INTESTINAL SURGERY I

The colorectal cancermultidisciplinary team andthe interlinked role of theclinical nurse specialistMichael J Kelly

Jacquette Masterman

AbstractIn order to continue to treat patients with colorectal cancer it is an official

requirement (Peer Review Standard) that all cases are managed by a desig-

nated multidisciplinary team (MDT) which must meet regularly, usually

weekly, to discuss them. This team must have written policies, it must

keep records, and it must download them annually into the National

Bowel Cancer Database (NBOCAP). There must be clinical nurse specialist

input. This article summarizes best practice in all of these areas.

Keywords Clinical nurse specialist; CNS; colorectal cancer; MDT; MDT

meetings; multidisciplinary team

History

Before 1999 in the UK only breast cancer patients in the better

units had their progress determined by a formal multidisciplinary

team meeting (MDTM). The Calman-Hine report (1995) together

with the Improving Outcomes Guidance (1996, taken over by

NICE in 2000) laid down that the individual strategic direction of

the case management of all patients diagnosed with having cancer

should be managed by an MDT. This was a revolutionary concept

and, apart from breast cancer, there were few precedents in either

the UK or abroad on how it should be done.

The Cancer Services Collaborative (CSC) was set up and given

significant sums of money on an annual basis assured for 5 years

which it used to commission nine pilot sites (including Leicester),

with the remit that they had to invest, develop, assess and imple-

ment MDTs in the five commonest cancers (lung, breast, bowel,

prostate and ovary). To this later was added upper gastrointestinal

(GI) cancer.

The hallmark of each MDT in every pilot site was that there

should be a part-time medical lead clinician with a full-time

administrative project manager (often coming from a nursing

Michael J Kelly MChir FRCS MRCP(UK) is a Colorectal Surgeon and MDT

Chairman 1999e2009, National Lead Clinician (now Advisor) for

Colorectal Cancer to NHS-Improvement, Leicester General Hospital,

Leicester, UK. Conflicts of interest: none declared.

Jacquette Masterman RGN BA is a Clinical Nurse Specialist for Colorectal

Disease at Leicester General Hospital, Leicester, UK. Conflicts of

interest: none declared.

SURGERY 29:1 29

background). In this way a vast amount of trial and error was

undertaken until systems emerged that were ‘proven at the coal

face’ and really did work. At the same time the Cancer Peer Review

system for inspection of cancer units was set up (from 2001) which

required NHS trusts treating cancer to have their MDTs up and

running.

In 2002 under Professor Richards (now Sir Mike Richards),

cancer tsar, national lead clinicians (NCLs) were chosen from

among the nine pilot sites’ lead clinicians, and the NCLs con-

ducted a series of sub-regional, regional and national meetings to

roll out the MDT system to all 160 NHS trusts treating cancer in

England and Wales.

Sir Mike Richards introduced a series of targets, the 2-week

wait, 1 month from diagnosis to treatment, 2 months from GP

referral to treatment and his office monitored compliance. The

NCLs carried out a series of visits and inspections to secure

improvement in those units which were consistently falling short

of these targets, so that by 2009 some 90% of NHS trusts in

England andWales were seeing urgent cancer referrals in less than

2 weeks and treating them in less than 31 days after diagnosis.

The colorectal MDT in 2010

Most colorectal cancer (CRC) MDTs meet weekly and we have

recently published a detailed account from Leicester of how ours

is run.1 The basic requirements are laid down in the Peer Review

Standards.2 The personnel involved are as follows:

Core members

Surgeon: a minimum of two who must each undertake at least

20 CRC resections per year with curative intent. This concept is

supported by the National Bowel Cancer Audit Programme

(NBOCAP).

Histopathologist: ideally a specialist GI pathologist. The larger

centres often have more than one.

Oncologist: at least one. Nationally these are separating into

those who use radiotherapy (radiotherapists) and those who

offer chemotherapy (medical oncologists).

Clinical nurse specialist (CNS): this may be either a desig-

nated colorectal cancer nurse or a stoma nurse or both (see

below).

Clerk coordinator: this is a layperson often with a medical/

secretarial background who collects and collates referrals, runs

the database and coordinates the logistics of meetings and

supports subsequent executive actions (onward referral, GP and

patient notification etc.)

GI physician: this is a controversial category. On the one hand it

is highly desirable that GI physicians remain ‘in touch’ with

cancer MDTs, but their input varies considerably between

different cancer types. In lung cancer MDTs they play a very

major role, whereas in colorectal MDTs their input is much

smaller. The idea is growing that a representative of the GI

physicians needs to attend each meeting, but individuals only

need to attend from time to time.

� 2010 Elsevier Ltd. All rights reserved.

INTESTINAL SURGERY I

Non-core members

Hepatobiliary (HPB) surgeon: ideally an HPB surgeon should

attend for part of the meeting and cases requiring their input can

be ‘saved up’ for their arrival. In practice, in smaller units this

cannot be achieved.

Palliative care: an intermittent attendance is very helpful.

Junior surgical staff: it is both helpful and desirable for senior

house officers (SHOs) and specialist registars (SpRs) to attend,

although it is difficult to fit into their schedules (see below).

Dieticians and total parenteral nutrition nurses: attend on an

ad hoc basis.

Room layouts, videoconferencing

It is generally agreed that ‘board room’ style (round a central

table) is greatly to be preferred over ‘lecture theatre’ style

(important people at the front facing a room full of others). Eye

contact between participants is to be encouraged.

Some form of display for the X-ray scans and reports is highly

desirable and the Picture Archiving and Communications System

(PACS) is becoming the near universal norm.

Videoconferencing is increasingly being used so that individ-

uals in different hospitals can participate without a need to

travel. It is particularly helpful for pathologists and oncologists

who each have to service several (sometimes up to 10) MDTs

and who are at risk of spending an inordinate amount of their

time in travelling from hospital to hospital.

Administrative preparation

MDT meetings are very expensive for hospital trusts to run

because they tie up the services of a dozen senior clinicians and

Printout of the report without the summary

Table 1

SURGERY 29:1 30

nurses for an hour or more each week. It is therefore hugely

important that they are run efficiently and effectively with the

time not being squandered chasing results and flicking through

case notes.

Liaison between the MDT chairman and the clerk/coordinator

is the key to a slickly run effective MDT meeting. Several days

before each meeting the clerk/coordinator needs to supply the

participants with lists of patients to be discussed. This is espe-

cially important for pathologists (who will look up their slides

and reports), radiologists (who will look at their films) and

oncologists (who will check on dates, diaries and progress).

Ideally the chairman and clerk/coordinator need to have a ‘dry

run’ through the meeting on the day before to make sure (as far

as possible) that all the reports, results and paperwork will be

readily available for the meeting the next day. We spend an hour

doing this each week.

The database

Having a well-run detailed informative database is essential

(Table 1). All these data are entered beforehand by the clerk/

coordinator and this is the basis of the ‘paperwork’ that is

available on the day to everyone. Cases are discussed on several

occasions as follows:

� Once when the diagnosis has been made and they are

‘registered’ as a new case.

� Once when the results of the staging tests are available and the

mode of treatment needs to be agreed (immediate surgery,

preoperative chemotherapy with later surgery, palliative

chemo/radiotherapy etc).

� Once when the surgery has been completed, the histology is

available and further (oncological) treatment is planned.

� Complex cases are discussed many times more than this and

simple cases less often.

� 2010 Elsevier Ltd. All rights reserved.

INTESTINAL SURGERY I

� At ‘sign off’ from theMDT it is important that formal follow-up is

agreed (i.e. doctor-led, nurse-led, GP-led, minimal follow-up

etc).

Best practice suggests that at the conclusion of the discussion on

each case the chairman should read out or display an agreed

summary to be entered on the computer and in the case notes

(Box 1). This has the great advantage that it can be used as part of

a form letter used to notify GPs and to confirm subsequent

arrangements to relevant parties (e.g. oncologists, palliative

care etc).

The dictated summary

Colorectal multidisciplinary team meeting, 27th May 2008

Patient’s name: Unit Number, DOB

Outcome: this 69-year-old man came up on the 2-week wait to the

physicians and has a biopsy-positive carcinoma of themiddle rectum

at 12 cmon FOS. CTchest clear, liver one small metastasis in the right

lobe. MRI suggests radiological T2 N1 M1. He has been put forward

for short course preoperative radiotherapy followed by anterior

resection with a view to interval liver resection þ/� chemotherapy.

Colorectal MDT Coordinator: Tracy Cook

Box 1

Post-meeting administration

The chairman needs to have a post-meeting session on the next

day with the clerk/coordinator (we spend half an hour) signing

off all the letters generated above and generally confirming the

various arrangements.

Policy decisions

In general (because they are very busy and time stressed) MDT

meetings are not the best occasions for discussing policy issues

involving cancer patients and their care. These discussions are

best referred to a separate multidisciplinary group meeting and

we hold one of these every 6e8 weeks.

Annual data trawl

The MDT database contains a wealth of detailed accurate validated

information and can, and should, be used for audit and research. At

Leicester we conduct an open meeting once a year and trawl our

database. We therefore know all of our own mortalities, leak rates,

readmission rates, length of stay etc. We can identify if any partic-

ular consultant is an ‘outlier’, whether good or bad, at an early

stage. This system also facilitates the now compulsory uploading of

local hospital results into the national audit database system

(NBOCAP).

Junior medical staff input

Approached sensibly the MDT meeting can be one of the major

learning experiences for all grades of junior surgical staff enabling

them to gain a grasp of how the common presentations of colo-

rectal cancer are diagnosed, staged and treated. In addition during

eachmeeting a handful of difficult cases will be covered. SpRs and

occasionally SHOs will need to deputize for consultants who are

on leave and this too can be a major learning experience.

SURGERY 29:1 31

The CNS role in the MDT

One of the significant developments of the MDT coordination of

case management has been the emerging prominence of the CNS,

who has become the pivotal link person for both patient and the

treating team. In our hospital the CNS will have met new cancer

patients during their outpatient visit, in endoscopy or in a separate

consultation. Patients are given their telephone number to act as

a contact point and through them contact is made with the stoma

department. Time and again during MDT meetings it is the CNS

who acts as the patient’s advocate, for example asking whether the

patient has been informed of the diagnosis, the plan, a repeat scan,

operation date etc. They are also responsible for giving patients

written information (there is a multiplicity of leaflets available).

Likewise through the CNS, potential problems with discharge

arrangements can be identified before even the patient is admitted

for surgery.

The CNS role in general

Preoperative: in most units, including ours, the CNS has an

extended outpatient interview/consultation with all elective

cancer patients. Frequently they will reveal additional informa-

tion (family history etc) that may have been overlooked at their

shorter surgical consultation. They are often more likely to voice

their fears and worries to a nurse rather than to a doctor. CNS in

some departments are authorized to prescribe drugs to patients

from an agreed limited list.

In endoscopy: in our unit, the CNS (or, in their absence,

a stoma nurse) is ‘on-call’ for endoscopy sessions. When a CRC

is visually identified and biopsied the CNS is summoned to the

department in order to meet the patient, establish rapport,

explain the implications and explain that they are the named

individual for contact. They will then immediately arrange and

coordinate staging tests and the follow-up outpatient

appointment.

The CNS/stoma nurse interface: some CNS started as stoma

nurses, others did not. In smaller units these two roles may be

combined. Where they are separate it is important that the two

parties forge a good working relationship arising out of mutual

respect, with a fair amount of cross-cover in individual cases.

Both groups deal with cancer and non-cancer patients. The stoma

nurses provide a straightforward management service for ileos-

tomies and colostomies (the bags, spillages, skin problems)

which carries on into the community, whereas the CNS provides

a more longitudinal strategic oversight (the plan, milestones,

after care and follow-up). Availability of a dedicated CNS-stoma

nurse service is one of the essential Peer Review Standards, and

the CNS has to prepare their own dossier for these regular

3-yearly official inspections.

Inpatient involvement: it is helpful for the ward staff to

understand that they run the day-to-day care of patients, whereas

the CNS is available both to the patients and the nursing staff

team for rather longer term strategy. The CNS will visit cancer

patients in the ward most days during the working week. They

are connected to the surgical team, the pain control team and the

oncologists and they will become the patient’s link with these

teams on discharge home.

� 2010 Elsevier Ltd. All rights reserved.

INTESTINAL SURGERY I

Post-discharge role: in our unit a member of the colorectal

nursing team telephones CRC patients approximately 48 hours

after discharge to make sure ‘all is well’ and transmits informa-

tion, where appropriate, about the histology, if it has become

available.

The ‘big event’ for all patients with cancer is the arrival of the

definitive histology of a cancer specimen.Has therebeena complete

removal?What is its stage and grade?What does this mean andwill

chemo- or radiotherapy be necessary? Liaising with the MDT

coordinator, the CNS will be among the first to receive this infor-

mation. They will be at the MDT to participate in the therapeutic

discussions and supply nursing input. Often they will be chosen to

telephone patients and tell them what the MDT is recommending

and what further clinic arrangements have been made for them.

Sometimes, where there is a genuine choice between treatment

options, the CNS role is crucial in helping patients and their families

come to a satisfactory decision.

If there are postoperative problems at home, the GP surgery

and the hospital CNS are usually the two first places where

patients seek advice.

The CNS and the oncology department: when patients live close

to the oncology centre, its own dedicated CNS usually takes over

the support of patients as they undergo chemo- or radiotherapy.

On the other hand when patients live at a distance, especially in

a different town, many of these duties devolve onto the local CNS

who needs to form a relationship with the oncology outreach

nurses at the centre.

The CNS and nurse-led follow up: it is generally accepted that

whereas the scientific basis for cancer follow-up is by no means

rigorous, and different hospitals are running very different regimens

and schedules, there is little value in a cancer patient attending

a series of outpatient consultations where they see junior SHOs

whose involvement, knowledge and commitment is at best variable.

SURGERY 29:1 32

Into this gap has stepped the CNS. In most hospitals the MDT will

have laid down and agreed follow-up protocols of tests and clinic

visits, and the CNSwill manage and runmost of these in close liaison

with the consultant teams. The backbone for this is the planned

schedule of tests, scans and endoscopies. Many units have formal

‘paper clinics’ where the CNS sorts out the negatives and telephones

the patient with their results. Thus the consultant clinic only needs to

see follow-up patients who are in difficulties or where there are

problems.

Continuity of care: althoughmuch lip service is paid to this concept,

in reality over a 5-year period for the patient often the only constant

members of staff remaining in post are the consultant surgeon,

oncologist and the CNS.

Tumour recurrence: it therefore follows that patient’s first ‘port

of call’ if they develop untoward symptoms or when a routine

follow-up scan proves positive, is the CNS. This is an important

onerous role that may later blend into palliative care and end of

life management. A

REFERENCES

1 Kelly MJ, Cook Tracy. The colorectal MDT: how we do it at Leicester.

Colorectal Dis 2010; 12: 596e600.

2 www.dh.gov.uk cancer section; Peer Review Manual 2010.

Acknowledgement

Both Table 1 and Box 1 are reproduced by kind permission of the

Editor of Colorectal Disease.

� 2010 Elsevier Ltd. All rights reserved.