Specialist multidisciplinary team working in the treatment of cancerBMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e2780 (Published 26 April 2012) Cite this as: BMJ 2012;344:e2780
Before 1995, treatment for all but a few patients with cancer was based on decisions that were made unilaterally, without necessarily following an evidence based approach. Specialist multidisciplinary teams for the treatment of cancer were generally found only in larger tertiary cancer centres. In 1995, an expert advisory group on cancer was set up with the aim of developing a framework that could achieve consistency in the delivery and outcomes of NHS cancer services in the UK.1 Over the ensuing years, the definition and composition of the multidisciplinary team has evolved, and such teams now provide a more structured and well documented system of care. In a linked study (doi:10.1136/bmj.e2718), Kesson and colleagues report outcomes for patients identified by the Scottish breast cancer registry who were treated contemporaneously in one of two regions,2 one of which used a multidisciplinary team approach and the other did not. In this way, the authors could directly compare the effects of a defined multidisciplinary team on breast cancer survival rates.
Management by a multidisciplinary team ensures that all patients with cancer benefit from the wisdom of a variety of specialist team members who can share their expertise, professional perspective, and knowledge. The advantages of such an approach over the more traditional unilateral one, which is prone to individual biases, seem obvious, but until now robust evidence on the benefits of a multidisciplinary approach has been lacking. Despite an absence of randomised trials, indirect evidence has shown a measureable improvement in outcomes since the introduction of multidisciplinary cancer care. Studies in breast, ovarian, gynaecological, and lung cancers have shown that multidisciplinary care has increased the use of chemotherapy, resulted in more patients being treated with radical intent, and optimised surgical management.3 4 5 6 In both lung and colorectal cancer, improved staging and specialist multidisciplinary review of imaging has improved curative resection rates.7 8 However, the ability to measure the true effect of multidisciplinary care on cancer survival is limited by the inability to disentangle the effects of confounders such as socioeconomic status and health service deprivation, heterogeneity of tumour stage when comparing patients before and after implementation of a multidisciplinary approach, and inherent improvements in cancer treatments over time.
Kesson and colleagues’ use of Scottish registry data enabled them to adjust for observed differences in age, stage of tumour, and health deprivation.2 The group of patients who were not exposed to a multidisciplinary approach received traditional care, with treating surgeons making unilateral decisions about surgery and adjuvant treatment, and delivery of care did not change during the study period. The introduction of multidisciplinary care had a significant initial positive effect on five year breast cancer specific survival for patients with incident cancers in 1996 and an ongoing positive effect on breast cancer survival. Breast cancer mortality was 18% lower in the region where specialist multidisciplinary breast cancer services were introduced than in the control region. Thus the authors report, for the first time, that lives were saved after the introduction of multidisciplinary cancer care.
By comparing contemporaneous populations of patients, Kesson and colleagues avoid the flaws inherent in historic comparisons, thereby strengthening their conclusion that gains in survival are attributable to the improved care offered by collective input of specialists. It is not surprising that care is improved when decisions are made by a team of experts who take time and effort to consider and discuss a patient’s prognostic risks and treatment options. In the face of an ever increasing array of diagnostic imaging and pathology tools, neoadjuvant and adjuvant treatments, prognostic classifications, surgical approaches, and potential tissue reconstruction, modern cancer teams that have multiple skills will become even more necessary.
The current study found that older patients benefited most in terms of survival from multidisciplinary care and undoubtedly gained from decisions to treat more intensively. Such decisions are more likely if specialists can share responsibility for treatment decisions and hold open discussions in which they can constructively question and challenge one another, because this can only serve to optimise unbiased decisions. This form of working is not without cost, and the quality of decisions is greatly influenced by several factors, including the information made available to clinical team members preparing cases for discussion before the team meeting; consistent attendance by the key members of the team; an effective working partnership between cancer units, treatment centres, and primary care; and administrative support that will ensure adequate documentation of information and decisions conveyed at the meeting and that ongoing measures of outcomes and audit enable quality assurance and benchmarking of the effectiveness of team decisions.9 10
Currently, healthcare systems that rely on reimbursement or insurance have found the implementation of effective multidisciplinary care to be more challenging. Barriers include defining and recognising specialist team members and ensuring input and attendance of relevant team members at any given time. Specialist multidisciplinary teams are now largely the standard of care throughout the United Kingdom, and similar models have been developed in other countries to a varying extent. Their success relies on the ongoing commitment of individual team members. However, the multidisciplinary team structure has enormous potential to harmonise and improve cancer care through improved documentation of radiological and histopathological cancer stage and prognosis, involvement of team members in clinical research, and audit of outcomes.
Cite this as: BMJ 2012;344:e2780
Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: funding from NIHR biomedical research centre; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.