ABC of Cancer Care

Carlo Palmieri, Esther Bird, Richard Simcock, Carlo Palmieri, Esther Bird, Richard Simcock

• Publisher: BMJ Books
• Year: 2013
• ISBN:
  9781118526859
• Edition: 1
• Topic: Medicine
• Subtopic: Oncology

ABC of Cancer Care is a practical primary care guide to help health professionals better inform their patients, manage and recognize the common complications of cancers and their treatment, and understand the rationale and implications of decisions made in secondary and tertiary care.

It provides coverage of the diagnosis, management, treatment and on-going surveillance of common cancers within the multidisciplinary context of primary care. Individual chapters assess the different treatment options, including surgery, radiotherapy and chemotherapy, and examine their possible side effects. The contribution of clinical trials and new advances in cancer treatment including biological and targeted therapies, robotic surgery and advanced radiotherapy techniques are all described. Other aspects of cancer care, from nursing support and nutrition to psychological care and survivorship, are also covered. Edited by a specialist and general practitioner team, with multidisciplinary contributors, ABC of Cancer Care is ideal for general practitioners, practice nurses, cancer care nurses, medical students, and all healthcare professionals treating and supporting cancer patients.

This title is also available as a mobile App from MedHand Mobile Libraries. Buy it now from iTunes, Google Play or the MedHand Store.

Chapter 1

Multidisciplinary Care

Richard Simcock

Sussex Cancer Centre, Royal Sussex County Hospital, Brighton, UK

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OVERVIEW

• The multidisciplinary team (MDT) has become a vital part of the cancer patient's management
• The multidisciplinary team meeting (MDTM) should lead to improved decision making for the benefit of the patient
• Multidisciplinary teams will be constituted differently according to the cancer type
• Decisions on cancer treatment intent and modality depend on the cancer stage and patient performance status and fitness
• The MDTM allows for review of pathology and histology specimens in the diagnosis of the patient's cancer
• Cancer waiting time targets have increased the speed at which patients are treated for cancer in the UK

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Introduction

Cancer care is complex. The first treatments were either palliation or surgery. During the twentieth century nonsurgical oncology grew exponentially to provide radiotherapy and chemotherapy. In this century we have begun to see an explosion in biological and targeted therapies, as well as technical developments in the delivery of surgery and radiation. This has been accompanied by parallel improvements in imaging and pathology, and an increasing recognition of the roles of advocacy, support and survivorship. In order to deliver best care for a cancer patient, it has become necessary to form teams to provide all the requisite expertise.

Before the early 1990s, only a small proportion of cancer patients benefited from their care being managed by a team of cancer specialists, meaning that care was often not specialist and that staff worked in isolation. Data collection was poor, as was communication between primary and secondary care.

In 1995, the Calman–Hine report recommended a reorganisation of cancer services such that whenever possible, cancer was managed by a multidisciplinary team (MDT). The MDT is defined in the Department of Health (DH)'s Manual for Cancer Services as the meeting of a group of professionals at a given time or place to make decisions regarding treatment options for individual patients. In 2000, Cancer Networks were formed to bring together the providers of cancer care (organisations that deliver cancer services to patients) and the commissioners of cancer care (organisations that plan, purchase and monitor cancer services) in order that they could work together to plan and deliver high-quality cancer services for specific populations. There are currently 28 Cancer Networks in England.

Since 1995, the establishment of MDTs in the UK has been mandated by the requirements of peer review, a process led by the National Cancer Action Team and monitored by Networks. Over 95% cancers are now managed by an MDT.

Common cancers (e.g. breast and lung) are often managed by MDTs based at the local hospital. Rarer cancers (e.g. head and neck) may be referred to a Network specialist MDT based at the cancer centre within the Network. Very rare cancers (e.g. sarcoma) may be managed by a regional MDT serving several Cancer Networks.

The MDT will usually meet on a regular basis to discuss cases at a multidisciplinary team meeting (MDTM). The MDTM requires careful preparation and review of clinical materials before discussion by the wider team. Frequently, members from the wider team will use teleconferencing facilities to join discussions. Supporting a large team and investing in required the infrastructure is expensive; cost estimates range from approximately £90 per patient discussion in a high-volume local breast MDTM to more than double that for a regional specialist head and neck MDTM.

Membership of the MDT is determined by the needs of patients and will vary according to the disease. The MDT is made up of clerical and support staff, core members whose presence is essential to decision making and extended members who will have valuable input into the processes of the MDT and into occasional individual patients. Core members are expected to attend each MDTM (see Table 1.1).

Table 1.1 Core and extended members for breast and head and neck cancer MDTs. MDTs will be constituted differently according to the expertise required to give best care for each type of cancer.

	Breast MDT	Head and neck MDT
Common core members	Team secretary MDT coordinator Clinical nurse specialist Pathologist Radiologist Oncologist
Core members	Breast surgeon	ENT surgeons Maxillofacial surgeons Plastic surgeons Restorative dentist Speech and language therapist Senior ward nurse Palliative care specialist Dietitian
Common extended members	Social worker Psychiatrist/clinical psychologist Physiotherapist Occupational therapist
Extended members	GP Palliative care specialist Breast radiographer Plastic surgeon Clinical geneticist/genetics counsellor Lymphoedema specialist Orthopaedic surgeon with expertise in management of bone metastases Neurosurgeon	Anaesthetist with a special interest in head and neck cancer Gastroenterologist Ophthalmologist Pain management specialist Nuclear medicine specialist Therapeutic radiographer Maxillofacial/dental technician Dental hygienist

Evidence for MDT working

It has proved difficult to gain evidence for the effectiveness of MDTs due to their universal implementation (preventing control groups) and the concurrent changes in cancer treatment (complicating historical comparisons). Nonetheless, there are data which show improvements in cancer outcomes, including survival, in areas which implemented MDT processes compared to areas which did not. A large retrospective cohort study of nearly 14 000 patients in neighbouring areas in Scotland showed 18% lower breast cancer mortality in the area introducing MDTs (despite a higher mortality prior to MDT working).

MDT working also appears to increase work-related satisfaction in the team, as well as clinical trial recruitment.

Having a broader range of professional opinions available seems likely to benefit a patient. Teams are likely to generate higher-quality solutions and to have a wider sense of ‘ownership’ of the eventual decision. There are however problems inherent in the team decision-making process: it may dominated by individuals, or the team may be susceptible to ‘groupthink’ (defined as a deterioration in mental efficiency and moral judgement as a result of in-group pressure). Psychologists have also described ‘risky shift’, in which the decision made carries higher risk than that made by individuals, as the group feels reduced accountability.

A survey of over 2000 MDT members conducted by the National Cancer Action Team in the UK concluded that the most important aspects of MDT effectiveness were leadership, communication between members and time for preparation.

Databases

The MDT is the perfect forum in which to capture detailed disease data. These give epidemiological data and highlight regional a...

Table of contents

• Cover
• Series Page
• Title Page
• Copyright
• List of Contributors
• Preface
• Acknowledgements
• Chapter 1: Multidisciplinary Care
• Chapter 2: Cancer Imaging
• Chapter 3: Surgery
• Chapter 4: Surgery for Metastatic Disease
• Chapter 5: Chemotherapy
• Chapter 6: Toxicities of Chemotherapy
• Chapter 7: Radiotherapy
• Chapter 8: Toxicities of Radiotherapy
• Chapter 9: Endocrine Therapy
• Chapter 10: Biological and Targeted Therapies
• Chapter 11: Trials in Cancer Care
• Chapter 12: Oncological Emergencies
• Chapter 13: Cancer in the Elderly
• Chapter 14: Nutrition
• Chapter 15: Complementary and Alternative Medicine in Cancer Patients
• Chapter 16: Specialist Nursing Care
• Chapter 17: Cancer Survivorship
• Index