Impact of M.D.T. on Treatment Outcome For

Gynecologic Malignancies Emad Shash, MBBCh., MSc., MD.

Medical Oncology Department

National Cancer Institute, Cairo University

Disclosures Specific to Today’s Topic

• No Financial Disclosures

• I’m a medical Oncologist, not:• Gynecological Oncologist

• Surgical Oncologist

• Radiation/Clinical Oncologist

• I do believe that we need “Evolution” to adapt for OUR PATIENTS better care.

No Offense to any Specialty!

What we always hear about MDT?

• Multidisciplinary teams and/or clinics are associated with:

• Changes in staging/diagnosis

• Initial management plans

• Higher rates of treatment

• Shorter time to treatment after diagnosis

• Better survival

• Adherence to clinical guidelines.

Pillay et al., Cancer Treatment Reviews. 2016

MDT: Definition

Individual Specialties Together Either Physically or Virtually Discussing Therapeutic Strategy of a Given Patient

MDT in Oncology Setting

• The MDT meeting serves as a platform for the coordinated delivery of care through consultation amongst different professionals in a single setting.

• The MDT meeting can be defined as a regularly scheduled discussion of patients, comprising professionals from different specialties:

• Surgeons • Medical Oncologists • Radiation oncologists• Radiologists,• Pathologists • Nurse specialists

• In addition:• Pharmacy• Palliative medicine • Mental health• Other allied health disciplines

Pillay et al., Cancer Treatment Reviews. 2016

Is MDT a leisure or a MUST?

Background & History in UK!

• In the early 1990s, the EUROCARE study demonstrated poorer survival in the UK than in other European countries most types of cancer.

• Following this publication, it was proposed that all patients with cancer should be seen by MDTs

• 15 years ago less than 20% of patients with cancer in England were managed by a specialist team.

• Current National Institute of Health and Clinical Excellence (NICE) guidance and peer-review recommendations are that 95-100% of patients should be discussed at a MDT meeting.

N. Chinai et al. Clinical Radiology 2013

Estimated MDT Costs

N. Chinai et al. Clinical Radiology 2013

• Out of 47 cases (94 %) have a concurred results.• Does the clinical benefit gained weight the cost?• Do all patients need to be discussed in the MDT?

Do We really need MDT in Oncology?

B. Pillay et al. Cancer Treatment Reviews 2016

3 main Groups

patient assessment and

diagnosis

15 articles

patient management and clinician practice

25 articles

patient outcomes

7 articles

Pillay et al., Cancer Treatment Reviews. 2016

• Critically evaluate Current literature regarding the impact of MDT meetings on:

1. Patient outcomes2. Assessment 3. Diagnosis4. Management 5. Clinician practice.

Patient assessment/Management Changes

• Results indicated that 56% of studies (5/9) reported changes to diagnostic findings for • More than 10% of patients discussed at MDT meetings.

• Similarly, 54% of studies (7/13) reported that management plans were altered for • More than 10% of patients discussed at MDT meetings.

• Not all positive: Findings of 3 studies

• Did not support a strong association between MDT meetings and improvements in patient assessment and management.

• effectiveness of MDT meetings is dependent on a range of factors such as • Structural Components• Functional components • Expertise of participant

Pillay et al., Cancer Treatment Reviews. 2016

Patient Outcome Changes

• Few studies in this review evaluated patient outcomes.

• Those which did assess outcomes focused on survival rates, with a few studies assessing other clinical indicators (e.g. CRM rates for rectal cancer patients).

• The conduct of MDT meetings may indirectly lead to survival benefits through more efficient selection of treatment options for patients and by better case management.

• However, there is little evidence demonstrating a relationship between MDT meetings and survival.

Pillay et al., Cancer Treatment Reviews. 2016

What piece of information we still miss?

• Amongst the published studies, none evaluated how MDT meetings impacted upon aspects of patient satisfaction or quality of life.

• It is possible that patients experience:

• Sense of satisfaction or wellbeing if they are involved in decision-making during the MDT meeting process.

• Sharing of information regarding the outcome of the discussion and providing patients with support in making an informed decision regarding treatment options.

What about the role of MDT in Gynecological Malignancies?

Cohen et al. Int J Gynecol Cancer 2009

The aim of this study was to assess the impact of the twice weekly gynecologic oncology tumor conferences on the management of women with a diagnosis of or suspected of having a gynecologic malignancy

• The gynecologic tumor conference at Auckland City Hospital is consultative.

• All referrals comprise both preoperative and postoperative patients. • The meetings are multidisciplinary, with participants including:

• Gynecologic pathologist• Gynecologic oncologists• Medical oncologists• Radiation oncologists• Radiologists• Trainees in gynecology and oncology• Oncology nurses.

Change in tumor site, histological type, stage, or grade: Can Result in different patient management.

Summary of major diagnostic discrepancies after

histopathologic review at MTC

Summary of major diagnostic discrepancies after

radiological review at MTC

Cohen et al. Int J Gynecol Cancer 2009

• The rate of major discrepancies in this study is 5.9%• The involvement of specialized pathologist is a must

Do we need Tumor Biology Discussion Boards?

Classical Histological Endometrial Cancer Classification “as an Example”

Murali R, Lancet Oncol 2014

Endometrial Cancer

Type I

Endometrioid adenocarcinoma (80%–90%)

Type II

Non-Endometrioid subtypes (10%-20%)

Serous

Clear Cell

Undifferentiated Carcinomas

Carcinosarcoma/Malignant Mixed Mullerian tumor

The Cancer Genome Atlas (TCGA) website

G Getz et al. Nature 2013

Mutation spectra across endometrial carcinomas

Gene expression across integrated subtypes in endometrial carcinomas

Pathway alterations in endometrial carcinomas

The changing Landscape of Endometrial Cancer Prognostic Classification & Treatment Impact

Bokhman WHO The Cancer Genome Atlas

Basis Clinical and epidemiological features

Histological features Genome-wide genomic characterisation

Categories Type IType II

EndometrioidSerousClear cell

POLE (ultramutated), MSI (hypermutated), copy-number low (endometrioid), copy-number high (serous-like)Copy-number high (serous-like)NA

Right PatientRight

Treatment

Right TimeCost

Effectiveness

Every Physician’s Aim!

Take Home Message

• You need to be specialized & experienced enough to optimize your patients’ management.

• Learn to communicate effectively with your peers.

• Structural debates supported by evidence based medicine results in better patient outcomes.

• Future ahead: You need to engage your patient in the DECISION Making!

“Coming together is a beginning.Keeping together is a progress.Working together is a success”Henry Ford (July 30, 1863 – April 7, 1947) was an American industrialist, the founder of the Ford Motor Company, and the sponsor of the development of the assembly line technique of mass production.

Thank You