E1 – Multidisciplinary care

E1 – Multi-disciplinary care: Cancer diagnosis and treatment committees

Key Messages 

•    Tumour-specific Cancer Diagnosis and Treatment Committees (CDTCs) are available across the RCN.
•    The majority of the CDTCs occur weekly or biweekly, have participation from multidisciplinary specialists and meet the RCN structural target.
•    All patients that require complex multidisciplinary treatment, such as those with tumours of the head and neck, should be presented at a CDTC. The percentage of head and neck cancer patients presented at a CDTC across the RCN is over 80%.


Background

CDCTs are the cornerstone of multidisciplinary cancer care. These are regularly scheduled meetings that provide a forum for clinicians from different disciplines to review individual patients’ results and achieve consensus regarding an optimal treatment plan. Patients discussed at a CDTC are more likely to be treated according to best evidence, have a shorter pathway from diagnosis to treatment, and have better coordination of interventions. Also, they are more likely to have access to emerging treatments and have improved outcomes.1-4 

As per the Collège des médecins du Québec guidelines, an effective CDTC requires the participation of a multidisciplinary team, typically including surgeons, medical oncologists, radiation oncologists, pathologists, diagnostic imaging specialists, pharmacists, nurses and other allied healthcare professionals, although the composition may differ depending on the tumour type. The committee can specialize in one tumour type or can cover a range of cancers.  

To assess the structural quality of CDTCs across the RCN, we used a framework for measurement developed by Cancer Care Ontario (CCO), in which an “adherence to standards” score is determined based on nine criteria.5   These include:

•    prospective review of patient cases
•    weekly or biweekly meetings (a CDTC must occur a minimum of 5 times every 3 months)
•    assignment of a CDTC coordinator
•    assignment of a CDTC chair
•    attendance by a surgeon, medical oncologist, pathologist, radiation oncologist, and radiologist ≥75% of the time

The aim of the RCN was that CDTCs achieve an “adherence to standards” measure of at least 75%.

While there is no formal target denoting the percentage of new patients that should be discussed at a CDTC, all patients with complex cancers requiring interventions by multiple disciplines should be presented. For example, all head and neck cancer patients should be formally reviewed by a multidisciplinary specialist team prior to treatment. This CDTC may also be attended by dentists, speech pathologists and dieticians. Evidence indicates that for head and neck cancer patients, CDTCs alter the initial planned course of treatment in almost a third of cases.6  

Charts + Tables

Fig 1: Percent adherence to CDTC standards


 

Data represent the average of three measurement periods for tumor specific CDTCs occurring at the JGH and/or MUHC over 2 fiscal years (2014-16). The grey bar represents the CDTC at SMHC, which is not tumor-specific.
 

Fig 2: Percentage of new patients with head & neck cancer presented at a CDTC across the Rossy Cancer Network

 

What Do the Results Mean?

CDTCs generally adhere to structural standards (Fig 1) 

Some CDTCs are better structured than others, but most of the CDTCs meet organization and participation standards. The melanoma CDTC is below the target, principally due to lower attendance by pathologists and radiation oncologists.

Most patients with head and neck cancers are presented at a CDTC (Fig 2)

The results show that across the RCN, over 80% of patients with head and neck cancers are presented at a CDTC. While this represents a high percentage of patients, an analysis of cases not presented is currently underway to determine the cause.

Efforts

•    The RCN is working to improve the collection of information through the use of CDTC electronic templates for summary notes. The aim is that CDTC reports be accessible in the patients’ medical record immediately after sign-off by the CDTC chair. Electronic reports will facilitate the collection of information by cancer registries and allow for auditing of recommendations. 

•    Head and neck cancer patients that were not presented at the CDTC have been reviewed. An effort is in place to both improve documentation and to emphasize the importance of presenting new eligible cases to CDTCs. 

Notes

Data Specifications - Figure 1

DEFINITION

% adherence to CDTC standards, as defined by Cancer Care Ontario

ADHERENCE SCORE  

For a 12-week measurement period, 1 point is allotted for the following:

  • cases generally discussed prior to treatment (1 point)
  • weekly or biweekly meetings (a CDTC must occur a minimum of 5 times in a 12-week period) (1 point)
  • assignment of a CDTC coordinator (1 point)
  • assignment of a CDTC chair (1 point)
  • attendance by a surgeon (1 point), medical oncologist (1 point), pathologist (1 point), radiation oncologist (1 point), and radiologist (1 point) 75% of the time

The total score is between 7 to 9 points, depending on the tumour type. Some tumour types require all specialists to be present, whereas others only require three of the five specialists.

% ADHERENCE TO STANDARDS

 =    Total score over 12-week evaluation period     x 100 
        Total possible score (7-9) 

SOURCE  

MUHC: Cancer registry
JGH, SMHC: CDTC administrator by tumour type

MEASUREMENT TIMEFRAME

Two times yearly, 12-week time periods (April-June, October-December)

NOTES 

The following evaluation periods were used in the analysis
2016: April-June, October-December 
2015: April-June, October-December
2014: Oct-Dec 

Data Specifications - Figure 2

DEFINITION

 % new patients presented to Head and Neck CDTC

NUMERATOR  

Number of new patients with head and neck cancer who were presented at any RCN CDTC

DENOMINATOR

Total number of new patients with head and neck cancer, per fiscal year

% ADHERENCE TO STANDARDS  

 =    Numerator     x 100 
        Denominator

SOURCE  

Cancer registry

MEASUREMENT TIMEFRAME

 Yearly 

References

1.     MacDermid E1, Hooton G, MacDonald M, McKay G, Grose D, Mohammed N, Porteous C. Colorectal Dis. 2009 Mar;11(3):291-5.

2.    Stephens MR, Lewis WG, Brewster AE, et al. Multidisciplinary team management is associated with improved outcomes after surgery for esophageal cancer. Dis Esophagus. 2006;19:164–71.

3.    Coory M, Gkolia P, Yang IA, et al. Systematic review of multidisciplinary teams in the management of lung cancer. Lung Cancer. 2008;60:14–21.

4.    Taylor C, Munro AJ, Glynne-Jones R, et al. Analysis: multidisciplinary team working in cancer: What is the evidence? BMJ. 2010;340:c951.

5.    Brar, S.S., Provvidenza, C., Hunter, A. et al. Improving Multidisciplinary Cancer Conferences: a population-based intervention. Ann Surg Oncol (2014) 21: 16.

6.    Brunner M, Gore, SM, Read RL et al. Head and neck multidisciplinary team meetings: Effect on patient management. Head Neck 37: 1046–1050, 2015.

 

Disclaimer: The Rossy Cancer Network has attempted to ensure the accuracy of the data that it is reporting for each of its hospitals. Values posted on this web page may change as new information becomes available or corrections are made; this may alter accumulated values.

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