Colorectal cancer: are multidisciplinary team meetings

a waste of time?

In this edition of the Journal, Wichmann et al. outlined their expe-rience in treating colorectal cancer in a rural setting.1 This commonsense, practical publication reassuringly demonstrates that excellentresults can be achieved by non-specialists in treating this condition,which affects around 1 in 20 Australians, and often presents as anemergency many miles from metropolitan specialists. An interestingaspect of this publication is that in the last three years of the study,all plans have been ‘discussed and approved by an institutionalmultidisciplinary tumour board’. This raises the important questionof the rise of the multidisciplinary team meeting (MDTM), which isworth reviewing.

In 1995, in response to perceived inferior cancer treatment in theNHS, the Calman and Kline report was published.2 It suggested,without any supporting evidence, that the answer was more meetingsand that the treatment of colorectal cancer should be coordinated bya multidisciplinary team (MDT). MDTs became standard of care,and by 2007 in the Guidelines for the Management of ColorectalCancer by the Association of Coloproctology of Great Britain andIreland, it was stated that ‘All patients with colorectal cancer shouldhave the benefit of a suitably informed surgical opinion and theirmanagement should be discussed by the multidisciplinary team –GCP’.3 While there were 468 references in the total document, therewere none supporting this statement – it was proclaimed as GCP,that is, ‘Some recommendations cover topics which are not amena-ble to formal studies (e.g. informed consent) but represent goodclinical practice’.

Through a strange mix of politics and medicine, MDTs started tobecome enshrined in government policy, again without reference toevidence or debate. For example, in Western Australia in a Depart-ment of Health publication entitled Colorectal Cancer Model ofCare, it is stated that ‘All patients should have access to a MDT toplan the management of their cancer. It is essential that a cancerspecialist lead the MDT approach and it is available to all patients nomatter where they live’.4 It states the MDT should be composed of amedical oncologist, nurse coordinator, pathologist, radiationoncologist, radiologist with expertise in MRI, social worker, surgeon(colorectal for rectal cancer) and stomal therapist, with access to avariety of others including dietitians, as well as video link-ups andassisted travel arrangements.

Regarding colorectal cancer, one of the first publications address-ing MDTs reviewed retrospectively the rate of involved circumfer-ential resection margins (CRMs) in rectal cancer before and one yearafter the introduction of MDTs.5 One hundred seventy-eight patientsunderwent surgery alone, while 81 had neoadjuvant therapy. Theauthors found that 62 of 178 in the surgery alone group did not havemagnetic resonance imaging (MRI)-based MDT discussion, result-

ing in positive CRM in 16 cases (26%), compared to 1 out of 16(1%) in those patients who had MDT discussion of their MRI. Thisfinding has been cited 105 times in the literature, generally tostrongly support the role of MDTs. It is not mentioned in the abstractof the article that in the original audit, only 13% of patients weredeemed palliative as compared to 24% on ‘re-audit’, or that in thenon-MDT group, some cases were operated on because of obstruc-tion, or that many of the non-MDT MRI reports were by different,less experienced radiologists who underreported 50% of cases. Theeffect of surgeons knowing that ‘their’ CRM rate is being measuredmay also have had a major impact. Perhaps most importantly, manywould question the inference that if a patient’s case is unfortunatelyleft off the list and not discussed at a MDT, then that patient’slikelihood of having a positive CRM therefore increases by 2500%.This is not common sense.

A more recent, larger study from Holland found no difference inthe involved CRM rate between those discussed at a MDT meetingand those not discussed.6

In a journal editorial in 2009, it was stated that MDTs ‘have beenimplemented almost universally in many European countries andtoday stand as the gold standard for the selection of surgicaland oncological management of patients with all forms of cancer’,and ‘. . . in this issue of the journal, we are presented for the first timeby a study which demonstrates that the MDT-conference results in asignificant improvement in survival’.7 In the actual study, 310patients undergoing treatment by one surgeon before and after theintroduction of MDTs are analysed, with the abstract concluding‘MDT status was shown to be an independent predictor of survivalon hazard regression analysis (P = 0.044)’.8 The reason for thisincreased survival was the introduction of the appropriate use ofchemotherapy. More patients were given chemotherapy in the MDTgroup (P = 0.00023) and survival for patients with Dukes’ C cancersimproved from 58% in the pre-MDT group to 66% in the MDTgroup (P = 0.023). Perhaps, MDTs did influence the inappropriatelyinfrequent use of adjuvant chemotherapy, but there are other ways todo this, and these results do not mean that every case of colon cancerhas to be presented at a MDT for evermore.

Particularly in rectal cancer, it must be asked what is the goldstandard adjuvant treatment protocol that is being ensured byMDTs? For example, in one study, the use of radiotherapy in rectalcancer was analysed in four different cancer centres in NorthwestEngland and North Wales.9 Different MDTs, based on their interpre-tation of the literature, gave different advice. For example, in T2 N1tumours of the lower rectum, two of the centres gave short-courseradiotherapy, whereas the other two centres advised long-coursechemoradiotherapy. This is in contrast to another UK MDT group

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where their own data support routine avoidance of any radiotherapyfor rectal cancers stages T1, T2, T3a and T3b (<5 mm spreadthrough muscularis propria) with MRI-predicted safe margins irre-spective of N stage, with 5-year local recurrence rate in thesepatients of 3%.10 Conversely, in Holland, almost all patients withrectal cancer, irrespective of stage, are given radiotherapy.6 Withsuch variance in the approach of different MDTs, one logically hasto question their value.

There are numerous other publications concluding that MDTsmust be good. For example, in a Spanish study, 90 patients discussedin a MDT and given preoperative chemoradiotherapy were pre-sented, with no control group. Fifty-four per cent had side effects,2% severe, 8% had anastomotic leaks, 34% had perineal complica-tions and disease-free survival was 64%.11 It was therefore con-cluded, much as other ‘studies’ on MDTs conclude, ‘. . . neoadjuvanttreatment results in low local recurrence rates and optimal survivalrates, with no increase in morbidity or mortality. A systematic evalu-ation by a MDT in the context of a clinical protocol offers better curerates’. The worldwide MDT bandwagon rolls on, apparently encour-aged by referees and editors.

Other studies are able to extol the worth of MDTs without evenneeding to look at patient outcome. For example, at the University ofHull, a questionnaire of doctors and nurses found that of the 55% ofMDT participants who responded, 97% considered MDTs improvedpatient care, 79% thought MDTs were good for their morale, 73%thought they were cost-effective, but half of surgeons and a third ofnurses thought that their job plan did not contain adequate time toattend MDTs.12

Even when MDTs are analysed by systematic reviews, the con-clusions can appear to be less than scientific. In a review of all 16publications on MDTs in lung cancer, the authors stated in theabstract ‘Statistical pooling was not possible due to clinical hetero-geneity. Only two of the primary studies reported an improvement insurvival. Both were before-and-after designs, providing weak evi-dence of a causal association’.13 Yet, the authors were able to com-fortably defend MDTs, concluding ‘It seems intuitively obvious thatMD teams should improve outcomes for lung cancer patients andperhaps they should be universally implemented on this basis alone’.There were no references quoted to support this memorable state-ment. Who needs science when we have intuition?

In an international review of MDTs in colorectal cancer, 133international cancer centres responded to a questionnaire.14 Therewas significant variation in the use of preoperative investigations;55% used computed tomography scan, 35% MRI, 29% endorectalultrasound, 12% digital rectal examination and 1% positron emis-sion tomography scan in all rectal cancer cases. Seventy-four percent consider a threatened CRM an indication for neoadjuvant treat-ment. The authors found ‘A significant difference in practice existsbetween the US and non-US surgeons: poor histological differentia-tion as an indication for chemoradiotherapy (25% versus 7.0%, P =0.008), chemoradiotherapy for stage II and III rectal cancer (92%versus 43%, P = 0.0001), MRI for all RC patients (20% versus 42%,P = 0.03), and ERUS for all RC patients (43% versus 21%, P =0.01)’. The authors concluded that ‘There was little consensus onstaging, neoadjuvant treatment, and preoperative management ofrectal cancer. Regular multidisciplinary team meetings influence

decisions about neoadjuvant treatment and staging methods’.Despite this marked variation in the recommendations of differentMDTs, the authors were able to state, relying on belief rather thanintuition, ‘We believe that regular MDT meetings will improveguideline adherence and quality of rectal cancer care’.

In a rigorous review of the literature regarding multidisciplinarycare and cancer survival, 21 studies meeting the entry criteria wereanalysed.15 The authors concluded ‘this review is unable to assert acausal relationship between multidisciplinary care and patient sur-vival’. They went on to state ‘Multidisciplinary cancer care isgrowing in international prominence and exploration of its effects onoutcomes is plentiful within the literature; however, at the presenttime, there is no clear evidence that multidisciplinary care improvessurvival’.

There are a number of issues regarding MDTs not stressed in theliterature. Firstly, one must ask what highly complex, somewhatsecret information does a medical or radiation oncologist possessthat will change the mind of the MDT? The literature regardingadjuvant therapy is not that complicated and, as shown in the MDTliterature, there is considerable interpretational disagreementanyway. At present, MDTs are an unproven very expensive inves-tigation; readers are invited to add up the wages of those at theirnext meeting, and then try requesting an extra hour or two of oper-ating time. Furthermore, how should decisions at MDTs be made?Should it be democratic and, if so, who votes? Should the finaldecision be by the treating surgeon? In reality, is it often the alphamale or female who decides? With regard to teaching, MDTshave often replaced weekly colorectal unit meetings where abroad array of conditions were discussed and taught, while teach-ing at current MDTs often has a low priority. Moreover, whyjust limit MDTs to elective cancer patients? Why not haveMDTs for every patient with conditions including inflammatorybowel disease, diverticular disease, constipation, haemorrhoids andwhy not call the MDT team together at 2 am for patients withobstructing cancer to discuss stenting, stomas, etc.? What is theeffect on survival of delay in treatment of cancer patients if man-datory MDT presentation is implemented, as it is in some centres?Finally, is a well-trained surgeon who has read the literature, hada long interview with and examined the patient more likely toaccept the onus of responsibility for that patient’s care than aroomful of often distracted people hearing a selective 1-min pres-entation of a client followed by radiology films and pathologyslides?

Clearly, difficult, complicated patients do exist and we often helpthese patients and ourselves by discussing their treatment with col-leagues. However, such patients are not all that common. We allcarry mobile phones and should make our time available.

It is easy to be critical of studies, and original data demonstratingthat MDTs are bad have not been presented here. Nonetheless,MDTs were only introduced because, like the Euro, they were obvi-ously a good idea. The recent introduction of MDTs and theirfuture is well worth questioning. Time is a valuable resource. Manywould think (or intuitively believe) that in the future we will notstill be expected to sit in a room crowded with medical staff todiscuss the treatment of every 85-year-old patient with Dukes’ Bcaecal cancer.

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References

1. Wichmann MW, Beukes E, Esufali ST, Plaumann L, Maddern G. Five-year results of surgical colorectal cancer treatment in rural Australia.ANZ J. Surg. 2013; 83: 112–7.

2. Expert Advisory Group on Cancer. A policy framework for commission-ing cancer services – the Calman–Hine Report. A Report by the ExpertAdvisory Group on Cancer to the Chief Medical Officers of England andWales. London: Department of Health, 1995.

3. Association of Coloproctology of Great Britain and Ireland. Guidelinesfor the Management of Colorectal Cancer. London, UK: Association ofColoproctology of Great Britain and Ireland, 2007; 117 p. [Cited August2012.] Available from URL: http://www.mccn.nhs.uk/userfiles/documents/Nat%20Ass%20of%20Coloproctology%20Guidelines%281%29.pdf

4. Department of Health, Western Australia. Colorectal Model of Care.Perth: WA Cancer & Palliative Care Network, Department of Health,Western Australia; 2008.

5. Burton S, Brown G, Daniels IR, Norman AR, Mason B, Cunningham D.MRI directed multidisciplinary team preoperative treatment strategy: theway to eliminate positive circumferential margins? Br. J. Cancer 2006;94: 351–7.

6. Swellengrebel HAM, Peters EG, Cats A et al. Multidisciplinary discus-sion and management of rectal cancer: a population-based study. WorldJ. Surg. 2011; 35: 2125–33.

7. Wille-Jørgensen P, Bülow S. The multidisciplinary team conference inrectal cancer – a step forward. Colorectal Dis. 2009; 11: 231–2.

8. MacDermid E, Hooton G, MacDonald M et al. Improving patient sur-vival with the colorectal cancer, multi-disciplinary team. Colorectal Dis.2009; 11: 291–5.

9. Scott NA, Susnerwala S, Gollins S, Sun Myint A, Levine E. Preoperativeneo-adjuvant therapy for curable rectal cancer reaching a consensus.Colorectal Dis. 2009; 11: 245–8.

10. Taylor FGM, Quirke P, Heald RJ et al. for the MERCURY Study Group.Preoperative high-resolution magnetic resonance imaging can identifygood prognosis stage I, II, and III rectal cancer best managed by surgeryalone. A prospective, multicenter, European study. Ann. Surg. 2011; 253:711–9.

11. Priego P, Sanjuanbenito A, Morales V et al. Multidisciplinary approachto the treatment of rectal cancer: the benefits of neoadjuvant therapy.Rev. Esp. Enferm. Dig. 2008; 100: 393–9.

12. Sharma A, Sharp DM, Walker LG, Monson JRT. Colorectal MDTs: theteam’s perspective. Colorectal Dis. 2007; 10: 63–8.

13. Coorya M, Gkolia P, Yangc IA, Bowmanc RV, Fongc KM. Systematicreview of multidisciplinary teams in the management of lung cancer.Lung Cancer 2008; 60: 14–21.

14. Augestad KM, Lindsetmo R, Stulberg J et al. International preoperativerectal cancer management: staging, neoadjuvant treatment, and impactof multidisciplinary teams international rectal cancer study group(IRCSG). World J. Surg. 2010; 34: 2689–700.

15. Look Hong NJ, Wright FC, Gagliardi AR, MSc MLS, Paszat LF. Exam-ining the potential relationship between multidisciplinary cancer careand patient survival: an international literature review. J. Surg. Oncol.2010; 102: 125–34.

Alan P. Meagher, FRACSSt Vincent’s Hospital, Sydney, New South Wales, Australia

doi: 10.1111/ans.12052

Superdocs of the 21st century: can they really fly?

The shift in modern medicine towards a patient-centric approach hasevolved rapidly in the clinical, ethical and legal spheres. Gone arethe days of the doctor as the bespectacled deity who handed medi-cines without explanation across a desk almost as vast as the powerdifferential in the doctor–patient relationship. The emphasis has nowlanded firmly and squarely (and rightly so) on the patient. The resulthas been a drastic rise in patient demands and expectation. With thisshift in paradigms, it pays to stop and consider the affect this ishaving on our medical students and doctors in specialty training.

Patients are now encouraged to advocate for their own health andto be integral in decision-making processes regarding medical treat-ment. With the freedom and accessibility of information, patientstoday are generally better informed than their counterparts ofdecades past.1 Such ready access to knowledge leads to more ques-tions, more concerns and more expectation, keeping clinicians ontheir toes. Clinicians must stay current with relevant advances in themedical field, an attribute commonly labelled as ‘continuing profes-sional development’.

The approach behind compensation disputes is likewise undergo-ing a shift in favour of better patient care. The thinking behindnegligence has shifted from the Bolam test (did the doctor act in away that other practitioners would consider reasonable) to a focus onmaterial risk (what would a reasonable patient expect).2 With this

changing tide, doctors must be aware of medico-legal implicationsin the domains of medicine appropriate to their practice to avoidleaving themselves open to prosecution.

The spotlight is also broadening its vista to include ethics as acentral part of modern medical practice. While ethics has alwaysbeen assumed intrinsic to medical practice from the days ofHippocrates, today ethics has evolved into a discipline in its ownright. There are almost as many buzz words and neologisms crop-ping up as there are emerging ethico-legal complexities.3

In addition, expectation does not rest here. Doctors are expectedto be capable teachers while they themselves are yet studying, topresent and publish while they are yet learning, and to work asintegral members of high-fidelity teams as both as members and asleaders. Today’s doctors are challenged to provide optimal healthcare for their individual patients while also advocating for the healthof the community as a whole.

Such changes have been paralleled by diversification of modernmedical curricula. Medicine has shifted from the study of a scienceand the practice of a trade to become much more. Indeed, these arenow merely components of the expected educational achievements.Other common pillars of medical curricula now include such enti-ties as population medicine and personal and professional develop-ment, encompassing health advocacy, ethics and legalities. The

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