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Chapter 1
Multidisciplinary Care
Richard Simcock
Sussex Cancer Centre, Royal Sussex County Hospital, Brighton, UK
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
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.
| 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...
