ORIGINAL ARTICLE

Head and neck multidisciplinary team meetings: Effect on patient management

Markus Brunner, MD,1,2* Sinclair M. Gore, MBBS,1 Rebecca L. Read, PhD,1 Ashlin Alexander, MD,1 Ankur Mehta, MBBS,1 Michael Elliot, MBBS,1

Chris Milross, MD,1 Michael Boyer, MD,1 Jonathan R. Clark, MBBS, MBiostat1

1Sydney Head and Neck Cancer Institute, The Sydney Cancer Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Sydney, Australia, 2Department of Otolaryn-gology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria.

Accepted 4 April 2014

Published online 11 July 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.23709

ABSTRACT: Background. The purpose of this study was for us to pres-ent our findings on the prospectively audited impact of head and neckmultidisciplinary team meetings on patient management.Methods. We collected clinical data, the pre-multidisciplinary teammeeting treatment plan, the post-multidisciplinary team meeting treat-ment plans, and follow-up data from all patients discussed at a weeklymultidisciplinary team meeting and we recorded the changes inmanagement.Results. One hundred seventy-two patients were discussed in 39 meet-ings. In 52 patients (30%), changes in management were documentedof which 20 (67%) were major. Changes were statistically more likelywhen the referring physician was a medical or radiation oncologist,

when the initial treatment plan did not include surgery, and when thehistology was neither mucosal squamous cell cancer nor a skin malig-nancy. Compliance to the multidisciplinary team meeting treatment rec-ommendation was 84% for all patients and 70% for patients withchanges in their treatment recommendation.Conclusion. Head and neck multidisciplinary team meetings changedmanagement in almost a third of the cases. VC 2014 Wiley Periodicals,Inc. Head Neck 37: 1046–1050, 2015

KEY WORDS: head and neck cancer, multidisciplinary team, multi-disciplinary team meetings

INTRODUCTIONOver the last 30 years, multidisciplinary team meetingshave become an essential component of tertiary-leveldecision-making in the treatment of malignancy. It seemsself-evident that the variety of specialist team memberswith their combined knowledge and expertise improvedecision-making and, therefore, ultimately patient man-agement and outcome. However, the evidence base forthis assumption is not strong and is sometimes conflict-ing. The majority of the studies performed in a widerange of malignancies other than head and neck cancer,show that multidisciplinary team meetings change man-agement and improve outcome,1–8 although these resultscould not be reproduced in all studies.9

Data supporting the utility of multidisciplinary teammeetings in the management of head and neck cancer isscarce. In 2 studies, Stalfors et al10,11 focused on theimpact of the use of telemedicine on the outcome of headand neck multidisciplinary team meetings. They wereable to demonstrate that presentation via telemedicine ischeaper and has comparable outcomes compared to tradi-tional presentation. As yet, no study investigated the

impact of multidisciplinary team meetings on the manage-ment of patients with head and neck malignancies.

The Sydney Head and Neck Cancer Institute has alongstanding head and neck multidisciplinary team meet-ing. Our hypothesis is that this meeting frequentlychanges patient management, although a formal evalua-tion has never been performed. The purpose of this studywas to prospectively document the impact of head andneck multidisciplinary meetings on patient management.

PATIENTS AND METHODSThe study was performed in a prospective fashion

between December 2011 and October 2012 at the SydneyHead and Neck Cancer Institute at the Royal PrinceAlfred Hospital, a tertiary care hospital in central Sydney,Australia. The proposed management plans of patientswith head and neck tumors were documented before themultidisciplinary team meeting, the multidisciplinaryteam recommended a plan, and potential changes to theinitial plan were recorded after the meeting.

Changes in the treatment plan were categorized as majoror minor. Major changes involved a change in cancer treat-ment modality. Typical examples were the addition oromission of postoperative radiotherapy, the addition ofchemotherapy to radiotherapy, recommendation of chemo-radiotherapy rather than surgery, or observation instead ofsurgery after definitive chemoradiation. Minor changesconsisted of alterations in the extent of a chosen modality(radiotherapy fields or dose, extent of surgical neck

*Corresponding author: M. Brunner, Sydney Head and Neck Cancer Institute,The Sydney Cancer Centre, Royal Prince Alfred Hospital, Missenden Road, NewSouth Wales, 2050, Sydney, Australia.E-mail: markus.brunner@meduniwien.ac.at

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dissection), the addition of diagnostic tools (such as genetictesting and additional imaging studies), or research deci-sions (such as inclusion in a clinical trial). Consistent withthese parameters, informing the clinician that a suitabletrial existed was considered a minor change. However, ifthe patients were actually included in the trial and receivedcompletely different treatment from that originally pro-posed, this was classified as a major change.

Compliance with multidisciplinary team recommenda-tion was evaluated after completion of treatment.

Patients with recurrent disease were recorded with theirnew cancer location and staging.

Multidisciplinary team meeting process

Consultants refer patients to the meeting by using astandardized form that contains demographic data (patientname, sex, and age) and diagnostic data (pathologicaldata including tumor location, TNM classification, stageand grade, and radiological data including all relevantimaging performed). In addition, and most importantly,the treating consultant’s management plan is outlined.

A decision to refer to the multidisciplinary team meet-ing was at the treating physician’s discretion; hence, notall head and neck malignancies treated at the SydneyHead and Neck Cancer Institute during this period werediscussed at the meeting. Depending on the nature of thecase and patient availability, patients may be reviewedclinically after discussion of the diagnostic findings, oralternatively discussed without subsequent clinical review.

The meeting itself takes place once a week and is attendedby surgeons, radiation oncologists, medical oncologists, radi-ologists, pathologists, nurses, speech and language therapists,dieticians, dentists, and a data manager. In the first part ofthe meeting, the treating physician presents each patient andavailable radiologic imaging and histology slides are dis-cussed. In “discuss only” cases, the multidisciplinary teamthen either agrees on a treatment plan or alternatively maydecide that clinical review of the patient is required. After all“new” patients are discussed, then the patients currentlyundergoing treatment are reviewed. Thereafter, in the secondpart of the meeting, new patients are clinically examined anddiscussion continues in a separate clinic room. Final docu-mentation of the treatment plan is only recorded after all dis-cussion regarding that patient has been completed.

Statistical analysis

Data were recorded and filtered using Microsoft Excel(Microsoft, Redmond, WA). Statistical analysis was per-formed using Stata version 11.0 SE (StataCorp LP, Col-lege Station, TX). All statistics were 2-sided, and a valueof p < .05 was considered statistically significant. Cate-gorical data were compared using the chi-square test orFisher’s exact test when appropriate.

RESULTSOne hundred seventy-two patients were discussed dur-

ing the study period. Details on their clinical informationare summarized in Table 1.

Thirty-nine meetings were performed in the studyperiod and, on average, 4 new patients were discussed permeeting (1 to 7). In 52 of 172 patients (30%), changes in

management as a result of the multidisciplinary teammeeting process were documented. Major treatmentchanges occurred in 35 patients (20% overall). A signifi-cant association was found between the frequency ofchanges in treatment plan and the following: (1) the refer-ring consultant’s specialty: referrals by a medical or radi-ation oncologist were more likely to be altered by themultidisciplinary team than those from surgical oncolo-gists (34% vs 18%; p 5 .05); (2) the initial treatmentplan: similarly treatment plans not including surgery weremore likely to be changed than those containing surgery(25% vs 10%; p 5 .01); (3) the histological tumor source:treatment plans for mucosal tumors were least likely tobe changed, whereas those for “other” tumors were mostlikely to be altered (7% vs 24%; p < .01).

Details on the changes are summarized in Table 2.Data on subsequent compliance with multidisciplinary

team meeting recommendations were available in 158

TABLE 1. Clinical information.

SexMale 118 (61%)Female 54 (39%)

Age, yMean (min–max) 65 (25–93)

SiteOral cavity 29 (17%)Oropharynx 30 (17%)Sinus/nose 15 (9%)Nasopharynx 16 (10%)Hypopharynx 9 (5%)Larynx 9 (5%)Salivary glands (large) 13 (7%)Skin 39 (23%)Other 12 (7%)

Tumor originMucosa 107 (62%)Skin 40 (24%)Other 18 (10%)Unknown 7 (4%)

HistologyMalignant 160 (93%)Benign 12 (7%)Mucosal SCC 97 (56%)Cutaneous SCC 34 (20%)Other 41 (24%)

Proposed treatmentSurgery 42 (25%)Surgery 1 RT 42 (25%)Chemoradiotherapy 29 (17%)RT 24 (14%)Diagnostic procedures 11 (6%)Undecided 11 (6%)Observation 6 (4%)Palliation 4 (2%)Chemotherapy 3 (1%)

DiseasePrimary tumor 120 (70%)Recurrent disease 52 (30%)

Presenting locationPrimary site 1/- metastatic disease 150 (87%)Lymph node metastasis (unknown primary) 22 (13%)

Abbreviations: SCC, squamous cell carcinoma; RT, radiotherapy.

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patients (92%). The proposed plan was enacted in 132patients (84%). In 50% of the 26 cases in which the planwas not followed, a more aggressive treatment option waschosen by the treating physician, whereas in 40% of thecases, a less aggressive treatment was delivered. In 10%of the cases, surgery was replaced with radiotherapy (RT)or vice versa. The reasons cited for these changes wereunexpected findings in the surgical specimen, patientpreference, and/or change in the patient’s functional statusbetween the multidisciplinary team meeting and the startof treatment. Details on the changes are summarized inTable 3.

DISCUSSIONMultiple factors make treatment decisions in head and

neck cancer very complex.12 Different medical specialtiesand professions are involved in the treatment protocols,patients are often elderly with medical comorbidities, andthe close proximity of functionally important anatomicstructures makes it difficult to predict side effects of ther-apy. In addition, evidence-based treatment is not availablefor every combination of histology, site, staging, andcomorbidity. In fact, there is almost no level I evidenceto guide choices between surgery and radiation-based pro-tocols for head and neck cancer. These variables make itdifficult to have a strongly algorithmic approach to treat-ing patients; rather, they necessitate an individually tai-lored treatment plan based on tumor factors, patientfactors, and treatment factors, including institutional

expertise. Given this complexity, we hypothesize that theuse of multidisciplinary team meetings in head and neckcancer are likely to benefit patient care.

Our results demonstrate, we believe for the first time,that head and neck multidisciplinary team meetings leadto changes in management in almost a third of cases.Published changes in management have ranged from 30%in breast cancer and sarcoma,2 to 77% in gastric cancer.3

At odds is a study of 124 urological cancer cases reportedby Acher et al9 identifying no change in management inover 98% of patients.

Unfortunately, equating change in management to animprovement in patient care is much more difficult. At themost basic level, a study on rectal cancer reportedimproved preoperative tumor staging after multidisciplinaryteam meetings,6 it could then be argued that the subsequenttreatment must have been more stage appropriate at thevery least. Despite the lack of evidence, multidisciplinaryteam meetings are considered the standard of care for mostmalignancies and, hence, finding a valid control group isalmost impossible. In a recent study on 13,722 patientswith breast cancer, Kesson et al8 partially overcame thisproblem by comparing outcomes of Scottish health districtsbefore and after introduction of multidisciplinary teammeetings. They were able to demonstrate that multidiscipli-nary team meetings are associated with improved survivaland reduced variation in survival among hospitals.

Interestingly, in our study, major changes wererecorded more frequently than minor changes. The major

TABLE 2. Details on changes in management.

Variables No change Minor change Major change p value

New malignancies T classificationT1 18/80% 0/0% 2/20%

.19 (any change)T2 25/66% 4/10% 9/24%T3 17/77% 2/9% 3/14%T4 15/60% 1/4% 9/36%

All malignancies N classificationN0 61/67% 9/10% 21/23%

.17 (any change)N1 13/62% 1/5% 7/33%N2 38/86% 3/7% 3/7%N3 3/75% 0/0% 1/25%

Referred bySurgeon 105/72% 15/10% 26/18% .15 (any change)Medical/radiation oncologist 15/58% 2/8% 9/34% .05 (major change)

Initial planSurgery 6 (C)RT 34/80% 4/10% 4/10%

.001 (any change)(C)RT alone 40/71% 2/4% 14/25%Tumor site

Mucosa 73/68% 11/10% 23/22%Skin 28/70% 4/10% 8/20%

.89 (any change)Other 13/72% 1/5% 4/23%Unknown 6/86% 1/24% 0/0%

HistologyMucosal SCC 69/83% 8/10% 6/7%

< .001 (any change)Cutaneous SCC 25/68% 3/8% 9/24%< .001 (major changeOther 26/50% 6/12% 20/38%

PhasePrimary 84/70% 10/8% 26/22% .52 (any change)Recurrent 36/69% 7/14% 9/17%

Abbreviations: (C)RT, (Chemo) Radiotherapy; SCC, squamous cell carcinoma.The figures in bold indicate statistical significance.

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changes included both changes in the intensity of treat-ment as well as complete changes to the principal treat-ment modality. Therefore, we conclude that the majorityof changes introduced by our multidisciplinary teammeeting were not just diagnostic additions but were defin-itive changes in the chosen treatment modalities. It islikely that our study underestimates the true value of mul-tidisciplinary teams because we did not consider the roleof routine histological review in which subtle differencesin pathological definitions (such as perineural invasion ormargin characteristics) may determine the use of adjuvanttherapy. Furthermore, all initial treatment recommenda-tions before the multidisciplinary team meeting weremade by clinicians who regularly form part of the multi-disciplinary team. Hence, to determine the true rate ofchange one would need to evaluate patients referred byclinicians who do not routinely attend a multidisciplinaryteam meeting.

No published data are available on the average rate ofcompliance to head and neck multidisciplinary teammeeting treatment recommendations. In this study, thetotal compliance rate was 84%, whereas the compliancerate for patients with changes in the treatment recommen-dation was 70%. Given the complex and mutilating natureof head and neck squamous cell carcinoma treatment pro-tocols and the advanced age and frequent comorbiditiesof our patients, we consider this to be a high compliancerate. In the patients in whom the plan was not compliedwith, we observed both changes to more and less aggres-sive treatment regimens, indicating that there was no gen-eral trend by treating clinicians to change treatmentintensity in a certain direction. Despite this, it is concern-ing that even when a treatment plan was agreed on, inmore than 15% of cases the plan was not carried through.

In addition to the clinical benefits discussed above,multidisciplinary team meetings could also be used as anaudit and databasing process.

Although multidisciplinary team meetings do havemany agreed advantages, it is also true that they mayhave potential disadvantages. First, there is a potentialdelay in commencing treatment as patients wait for themultidisciplinary team meeting to occur. This can be miti-gated to some extent by meeting on a weekly basis and,in many cases, the referring doctor’s proposed treatmentstrategy can be scheduled before the multidisciplinaryteam meeting. Another often mentioned disadvantage ofmultidisciplinary team meetings is that they are verytime-consuming and expensive. It is certainly true thatdiscussing patients in a large forum usually takes longerthan 1 person making a decision. In our own unit, approx-imately 20 professionals spend 3 hours every week dis-cussing and reviewing patients in our multidisciplinaryteam meeting. Although we would not advocate clinicianswho are not involved in multidisciplinary teams treatingpatients with head and neck cancer, it is likely that cer-tain “routine” patients do not benefit from attending amultidisciplinary clinic or even being discussed if the cli-nician is a regular multidisciplinary team member. This islikely to vary across institutions; however, our data wouldsuggest that changes in management occur less frequentlyin the patients for whom the initial plan is surgery forcommon malignancies (mucosal and cutaneous SCC).Interestingly, we could not demonstrate a correlationbetween tumor classification or site and the frequency ofchanges.

Limitations

Our study was not designed to detect differences in dis-ease or functional outcomes between patients with andwithout a multidisciplinary team meeting. Patients werepresented in the multidisciplinary team meeting at thetreating physician’s discretion and, hence, the rate ofchanges may be increased because of selection of morecomplex cases.

The influence of the surgeons on the multidisciplinaryteam may be influenced by the institution and personal-ities and this may not be translatable across institutions.

CONCLUSIONSHead and neck multidisciplinary team meetings

changed management in almost a third of the discussedcases, however, a clinically important proportion ofchanges recommended are not enacted. Institutionsshould audit their treatment compliance and outcomes todetermine whether the recommendations are being fol-lowed and consider how the multidisciplinary teammeeting process can be improved. We think that thepotential benefits of multidisciplinary team meetingsoutweigh their disadvantages and therefore we suggestthat they are an essential part of head and neck cancertreatment.

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TABLE 3. Noncompliance to multidisciplinary team meetingrecommendation.

Multidisciplinary team meetingrecommendation

Treatmentreceived

No. ofpatients

Surgical primary treatment 20Surgery CRT 1Surgery Surgery 1 RT 3Surgery 1 RT Surgery 1 CRT 3Surgery 1 RT Surgery 5Surgery 1 CRT Surgery 1 RT 1Surgery RT 2Surgery Palliative therapy 2Surgery Observation 1Diagnostic EUA Surgery 1Diagnostic EUA Observation 1

Nonsurgical primary treatment 6RT CRT 1CRT RT 2CRT Surgery 1RT Surgery 1 RT 1RT Palliation 1

Abbreviations: CRT, chemoradiotherapy; RT, radiotherapy; EUA, examination underanesthesia.

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