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Expanding the evidence for multidisciplinary team cancer careNick Sevdalis and James S. A. Green

Multidiscliplinary teams (MDTs) are increasingly used to aid decision-making in the care of patients with cancer, but their clinical value can be difficult to quantify. A prospective study has now assessed the use of MDTs for patients with urological cancers. Future refinement of MDT organization is required to optimize effectiveness.Sevdalis, N. & Green, J. S. A. Nat. Rev. Urol. advance online publication 14 October 2014; doi:10.1038/nrurol.2014.280

The past 20 years have seen the rise of the multidisciplinary team (MDT) as the main route for management of care and clinical decision-making in complex disease. Since their inception, care driven by MDTs has become the mainstay of cancer care delivery in the UK, so that all patients are reviewed by MDTs at various points in their care, including at diagnosis, treatment planning and following surgery. In other countries, such as the US and Australia, MDT-driven care is not mandatory, but is still practised in large cancer centres, with an increas-ing number of providers calling for its wider implementation.

The basic premise of MDT-driven care is that ‘two heads are better than one’, or more accurately, numerous heads are better than one, as cancer MDTs often consist of more than a dozen specialists teamed together. Historically, MDTs have been introduced to reduce unwarranted variation in clinical decision-making across geographic areas and specialists, and hence to improve care standards.1 This goal has been achieved by bringing together specialists to review and debate the pros and cons of different treat-ment options. In urology MDTs, these specialists can typically include urologists, oncologists, h istopathologists, radiologists and cancer nurses.

A prospective study by Rao et al.2 has now demonstrated that the use of MDTs makes a difference to clinical management of urologi-cal tumours: they analysed 120 genitourinary cases and found that the MDT had a demon-strable effect on more than a quarter of them, including arriving at a treatment plan where

previously there was none, and changing a treatment plan originally devised by an individual physician to one agreed upon by the team. Changes prompted by the MDTs, such as making a decision to operate, or to switch from surgical to noninvasive treat-ment, would undoubtedly have consider able effects on patients. This pattern replicates what we have found across a number of studies and tumour types—that MDTs change care- management plans in 2–52% of cases.3 Although many studies, including that of Rao et al.,2 do not evaluate the quality of such changes, in those that do so the overall pattern shows that decisions made by MDTs are better by some standard, including consistency with existing g uidelines, and d iagnostic accuracy.3

Further interesting findings of this study2 are that cross-referral between specialties occurred in 33.3% of the studied cases, and that the changes to the care plans triggered by the MDT were most significant in cases of metastatic disease. Cross-referral, improved coordination between clinical teams and consideration of multimodality treatment have long been espoused as benefits of MDT working,3 and this study provides further evidence to support this viewpoint, although a comparison group is lacking. Clinically, cross-referral and collabor ation seem to be more important in complex cases, such as advanced or metastatic disease, or where multimodal treatment is needed, as seen by Rao et al.2 Interestingly, in the UK there is no mandate for patients with recurrence to be re-reviewed by an MDT (except patients with breast cancer), and patients not eligible

for radical (curative) treatment are not eli-gible for specialist MDT discussion. Across cohorts, older patients are more likely to have advanced or recurrent disease, or to be ineligi ble for radical treatment. In com-plex cases or older patients, the influence of the disease goes beyond the physical, and the social and psychological welfare of the patient and their family can be negatively affec-ted. Considering the findings of Rao et al.2 together with existing evidence, it seems that these patients are precisely the ones who could benefit most from an MDT approach. An interesting dilemma therefore arises regarding which patients should be reviewed by an MDT. In the UK, with a long history of MDT implementation, all cases of new or suspected cancer are mandatorily reviewed by an MDT. In the study of Rao et al.,2 which was carried out in Australia, patient selec-tion criteria were narrower. The universal approach employed in the UK has triggered some concerns regarding the increased work-load of the teams, which can lead to rushed case reviews.4 In health-care systems with solid governance and standards of service, patients with urological cancers might be better served by a mixture of clearly defined, evidence-based care pathways for patients with straightforward early-stage disease, and MDT-driven case review for more complex, and possibly more elderly patients.

Importantly, an implicit assumption under-lying these clinical findings is that the MDT is doing ‘something’ right, such as the process-ing of available information on the biomedi-cal aspects of the disease and the history of the patient—including the presence of comor-bidities and their impact on care planning.5,6 The MDT should also consider the patient as a whole, and take into account their psycho-social circumstances and p references—this role is generally associated with the cancer nurse.7 With the focus being on the clini-cal outputs of the MDT, the team process that needs to take place for effective MDT decision- making to happen has remained largely undefined and underinvestigated.

‘‘…care driven by MDTs has become the mainstay of cancer care delivery in the UK…’’

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The debate as to whether MDTs have an effect on survival is ongoing. Although sur-vival seems to be a straightforward outcome to evaluate MDT effectiveness, it is a crude measure at best: in a complex disease such as cancer, a multitude of factors can affect sur-vival, and the MDT decision-making is only one of them. Randomized studies are not common in this area, because of methodo-logical complexity, existing policy (for example, in the UK, a trial on MDTs cannot take place because they are a mandatory part of care management and delivery), patient preference or financial counterincentives to MDT-driven care, which exist in some US health-care systems. The existing evidence base is, therefore, limited, and although some studies have found positive effects of MDTs, others have not.1,3,8,9

We take the view that a more clinically meaningful question to ask is “what needs to be in place for MDTs to improve the pro-cesses and outcomes of care?” MDTs are not a tablet that, once taken, will work well and improve cancer outcomes—their effective-ness depends on how they are carried out. In common with a range of recently proposed interventions to improve the safety and quality of hospital care, including the intro-duction of checklists and care plans, team briefings and standardized handovers, what

an MDT does is determined by people. These people have distinct skills, expertise and per-sonalities, and particular requirements in order to function at their best (Figure 1). The MDT brings inputs to the decision-making, which are typically processed during the team meeting, and produces outputs upon the completion of the meeting, which then have to be implemented and followed up.5,6 Breakdowns in any of these processes cause problems for the team, which can translate into delays for the patient, inappropriate decision- making or, when communication and c oordination after the meeting are defec-tive, lack of integration between secondary and primary care. Lack of information is a major barrier to MDT decision-making, but problems also arise in the logistical and managerial support of meetings. Prospec-tive studies that we have carried out have shown that overloaded meetings, which are a common occurrence in urology centres, mean that patients are reviewed within 2–3 min on average.4 Longer meetings also lead to increasingly fatigued and distracted attendees. We have demonstrated that team member interaction within an MDT can be objectively analysed and linked to the team’s decision-making.10 The impact of human factors on MDT d ecision-making requires further study.

Bringing specialists together to manage complex disease in an increasingly ageing patient population makes logical sense and is clinically necessary. Tellingly, MDT-driven care is now finding its way to other complex conditions apart from cancer, including car-diac disease and complex surgery. Scientific analysis of how best to organize and support MDTs is now required, so that we can under-stand what makes some teams work better than others, and generate implementable and clinically effective improvements.

Department of Surgery and Cancer, Imperial College London, St Mary’s Hospital, Wright Fleming Building (Room 507), Norfolk Place, London W2 1PG, UK (N.S.). Department of Urology, Whipps Cross University Hospital, Barts Health NHS Trust, London E11 1NR, UK (J.S.A.G.). Correspondence to: N.S. n.sevdalis@imperial.ac.uk

AcknowledgementsThis article was prepared on behalf of the Imperial Cancer MDT research group, which consists of (in alphabetical order): Sonal Arora, James S. A. Green, Rozh Jalil, Benjamin Lamb, Manmeet Matharoo, Somita Sarkar, Nick Sevdalis, Sujay Shah and Tajana A. Soukup. N.S. is affiliated with the Imperial Patient Safety Translational Research Centre (www.cpssq.org), which is funded by the UK National Institute for Health Research.

Competing interestsN.S. has been a paid advisor to Green Cross Medical Ltd, and delivers teaching and consultancy-based work on evaluating and improving MDT effectiveness and team processes for hospitals in the UK and internationally. J.S.A.G. has received funding from the National Cancer Action Team for the development of a team training/feedback system for cancer MDTs through Green Cross Medical Ltd.

1. Taylor, C. et al. Multidisciplinary team working in cancer: What is the evidence? BMJ 340, c951 (2010).

2. Rao, K. et al. Uro-oncology multidisciplinary meetings at an Australian tertiary referral centre—impact on clinical decision-making and implications for patient inclusion. BJU Int. http://dx.doi.org/10.1111/bju.12764.

3. Lamb, B. W. et al. Quality of care management decisions by multidisciplinary cancer teams: a systematic review. Ann. Surg. Oncol. 18, 2116–2125 (2011).

4. Lamb, B. W., Sevdalis, N., Benn, J., Vincent, C. & Green, J. S. A. Multidisciplinary cancer team meeting structure and treatment decisions: a prospective correlational study. Ann. Surg. Oncol. 20, 715–722 (2013).

5. Lamb, B. W., Green, J. S. A., Vincent, C. & Sevdalis, N. Decision making in surgical oncology. Surg. Oncol. 20, 163–168 (2011).

6. Fennell, M. L., Das, I. P., Clauser, S., Petrelli, N. & Salner, A. The organization of multidisciplinary care teams: modeling internal and external influences on cancer care quality. J. Natl Cancer Inst. Monogr. 40, 72–80 (2010).

7. Lamb, B. W. et al. Facilitators and barriers to teamworking and patient centeredness in multidisciplinary cancer teams: findings of a national study. Ann. Surg. Oncol. 20, 1408–1416 (2013).

8. Wright, F. C., De Vito, C., Langer, B. & Hunter, A. Multidisciplinary cancer conferences: a systematic review and development of practice standards. Eur. J. Cancer 43, 1002–1010 (2007).

9. Keating, N. L. et al. Tumor boards and the quality of cancer care. J. Natl Cancer Inst. 105, 113–121 (2013).

10. Jalil, R. et al. Validation of team performance assessment of multidisciplinary tumor boards. J. Urol. 192, 891–898 (2014).

Team inputs Team processes

Team outputs

■ Attendance■ Expertise■ Information■ Equipment

■ Expert review■ Teamwork■ Open discussion■ Leadership

■ Decision■ Implementation■ Documentation■ Communication■ Research

MDT meeting

Figure 1 | MDT cancer care.5,6 MDT health-care requires inputs of human resources, disease and patient information and equipment. These elements are processed at the MDT meeting, arriving at a treatment plan that can be implemented after discussion between the patient and the treating physician. Consistent documentation facilitates communication and research. Abbreviation: MDT, multidisciplinary team.

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