BENEFITS

Over the years, a solid body of literature has advocated the implementation of a multidisciplinary approach for adherence to clinical guidelines, outcome improvement, and cancer patient management.21 As such, the present evaluation on MTB advantages was performed focusing on these major aspects.

Adherence to Clinical Guidelines

Clinical guidelines help to define the best therapeutic strategy for each cancer patient, based on high-quality evidence. Adherence to guidelines is associated with an improvement in cancer patient outcome, preventing over- and undertreatment and reducing mortality.22 In the last few years, diagnostic and therapeutic options have increased significantly for cancer patients. Therefore, the creation of MTBs has become necessary for interdisciplinary cooperation and better optimization and integration of all therapeutic resources. In fact, several studies have shown that MTBs implement multimodal treatment, ensuring greater adherence to guidelines and as a result an improvement in patient outcomes.23


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MTBs offer benefits to patients, physicians, the community, and hospitals. In particular, they guarantee:

  1. uniformity of standards of care for cancer patients
  2. open communication lines to exchange information among physicians who can benefit from both the best scientific evidence and guidelines and the experience of others, improving the decision-making process thanks to case review, radiology- and pathology-report revision, and discussion of treatment options21
  3. a mechanism for review of the quality of professional care24

The aim of MTBs is improving patient management and outcomes. Most national and international guidelines recommend multidisciplinary management of cancer patients through the creation of MTBs. Adherence to MTB therapeutic indications to the best national and international guidelines is one of the most important parameters for assessing the quality of an MTB. Higher adherence to current guidelines has been observed for both staging and treatment.25

Several studies have analyzed the degree of adherence of MTB therapeutic decisions to guidelines, showing greater agreement compared to therapeutic decisions of individual clinicians. A retrospective study analyzed 3,815 cancer patient cases treated at the Centre for Integrated Oncology at the University Hospital Bonn. Therapeutic recommendations were formulated by three tumor boards, according to types of tumor and best guidelines. The study evaluated the degree of therapeutic recommendation implementation after MTB evaluation: 80% of all recommendations were implemented, with 8.3% of indications showing deviance, due to patient wishes (36.5%), patient death (26%), and physicians’ decisions, based to patient age, comorbidities, or adverse effects of the treatment (24.1%).26

A recent retrospective study on patients with head and neck cancers treated in a single urban academic medical center analyzed the level of concordance between a multidisciplinary team’s therapeutic indications and National Comprehensive Cancer Network (NCCN)-guideline recommendations. Adherence to NCCN guidelines was observed in about 98% of patients assessed in the MTB, while only 80% evaluated by a single specialist received a therapeutic indication in accordance with NCCN guidelines. Deviations from guidelines were mainly observed for a selected few patients, where MTB indication was based on patient age and comorbidities.27 Brauer et al conducted a prospective study aiming to evaluate the role of multidisciplinary teams in the management of patients with pancreatic or gastrointestinal cancer. They found an adherence rate to NCCN guidelines of 100%, while previous series had reported adherence by single physicians of 80%. However, clinician adherence to the treatment plan recommended by the MTB was not complete, due to the need for further diagnostic investigations or medical conditions.28

The therapeutic diagnostic algorithm of colorectal cancer patients is well specified in the guidelines, which suggest a multidisciplinary approach within an MTB to improve patient outcomes.29 A retrospective study analyzed the adherence of MTB decisions to NCCN guidelines on colorectal cancer, showing agreement of 97%. However, compliance of doctors with MTB recommendations was lower (87%), due to patient preference and doctor discretion.10 The management of patients with rare tumors is complex, and guidelines recommend management in expert centres within an MTB. A recent study evaluated the degree of concordance between MTB decisions on indication for postoperative radiotherapy andEuropean Society of Medical Oncology (ESMO) guidelines. MTB indications agreed with ESMO–Réseau Tumeurs Thymiques (RYTHMIC) guidelines in 92% of cases. However, only 85% of patients received postoperative radiotherapy, due to excessive delays after surgery for clinical conditions.30

In order to assess adherence to MTB therapeutic indications and guideline recommendations, an Indian group conducted a study evaluating the level of agreement between IBM’s Watson for Oncology (WFO) and MTB recommendations from the Manipal Comprehensive Cancer Center in Bangalore, India. WFO is an artificial intelligence (AI) system helping physicians in cancer-treatment decisions. WFO indications are processed from a body of knowledge comprising medical journals and textbooks, guidelines, and data on 550 breast cancer cases, including cancer characteristics and stage, patient characteristics and comorbidities, and laboratory exams. Treatment-recommendation concordance was demonstrated in 93% of breast cancer cases. Subgroup analysis showed greater agreement in patients with stage II and III, but low concordance for patients aged >75 years. Nonconcordance was observed especially in WFO indications of aggressive treatment approaches in frail patients. MTBs also considered demographic characteristics, comorbidities, patient preferences and level of social support in treatment choices. These aspects are not usually considered in guidelines, as there is a general lack of studies focused on these matters.31 Furthermore, the introduction of MTBs has been demonstrated to improveability to reach a decision, quality of information presentation, and quality of teamwork.32 In conclusion, MTBs ensure a high degree of concordance of therapeutic decisions with guidelines. However, the advantage of MTBs is to ensure individualized therapy, especially for the most complicated cases, taking into account patients’ clinical decisions and conditions. MTBs allow for the discussion, spread, application, and implementation of the best guidelines.1

In order to improve the decision-making power of MTBs, several instruments have been investigated. Shah et al investigated the quality of MTBs through an observational tool — Colorectal Multidisciplinary Team Metric for Observation of Decision-Making —evaluating quality and time used for presentation of patient history, radiological and pathological information, and contribution to decision-making of each team member. The authors identified areas for improving MTB procedures and optimizing the decision-making process.33 Another study used the MTB Metric for Observation of Decision-Making’ tool to evaluate the decision-making process of a MTB. This tool considered the quality of information presented at the MTB, team-member contributions, and number of case reviews. Analysis showed that psychosocial elements, comorbidities, and cancer nurses’ contributions should be used in decision-making processes and case reviews.34

Outcomes

Multidisciplinary teams increasingly provide treatment of cancer, but the effects of this approach on survival are unclear. Survival benefit from MTB meetings has been observed in a series of highly heterogeneous studies, usually with small numbers of patients included. There is a suggestion that multidisciplinary- and expert-care availability, particularly in cancer types where multimodal treatment is required, is crucial to optimize treatment choices and improve patient outcomes.

Serper et al performed a retrospective cohort study of all patients diagnosed with hepatocellular carcinoma (HCC) treated by 128 Veterans Affairs medical centers, demonstrating that MTB involvement was correlated with overall survival (HR 0.83, 95% CI 0.77–0.90).35 Agarwal et al reported a retrospective analysis comparing survival outcomes of 306 HCC patients managed in MTBs with survival outcomes for 349 patients who did not reach MTB discussion from 2002 to 2011. These patients were treated in a single tertiary-care center in Chicago. The two groups were essentially homogeneous, except that patients in the MTB group had less advanced HCC than those in the non-MTB cohort. The rate of treatment was higher among MTB patients (75%, OR 2.80, 95% CI 1.71–4.59) vs the others (61%; P<0.0001).The MTB seemed to be an independent predictor factor of better survival on multivariate analysis after stratification of tumor stage at onset. The MTB promoted a multimodal approach for HCC patients, allowing enhanced communication among the expert team and patient follow-up. This approach further reduced the potential of examination duplication and delayed or contradictory treatments.36

Liu et al conducted a retrospective analysis of 224 head–neck squamous-cell carcinoma patients treated at Temple University, Philadelphia, Pennsylvania between October 2006 and May 2015, comparing patients who were treated before introduction of an MTB in the hospital vs those who were discussed in MTBs. Median follow-up was 2.8 years, and a majority of patients were in the advanced stage (68%). Five-year overall survival and disease-specific survival were significantly better in the post-MTB cohort vs pre-MTB cohort (40% vs 61% and 52% vs 75%, respectively; P=0.008 and P=0.003).37 Blay et al examined the outcome of 9,646 sarcoma patients treated by a network of 26 reference sarcoma centers with specialized MTBs between 2010 and 2014. This research was funded by the French National Cancer Institute. Most cases presented to MTBs had a higher likelihood of having metastatic involvement at onset and more frequent unfavorable prognostic factors (ie, largerprimary tumors, greater depth, higher grading, and more retroperitoneal locations; all P<0.001). Presentation to MTBs before treatment was correlated with significantly lower 2-year local relapse-free survival (65.4% vs 76.9%, P<0.001) and 2-year relapse-free survival (46.6% vs 51.7%, P<0.001).38

Kesson et al included 13,722 breast cancer patients in a retrospective, comparative, nonrandomized interventional cohort study conducted at an NHS hospital in Scotland. Diagnosis of invasive breast cancer had been done between 1990 and 2000. After the introduction of multidisciplinary care, breast cancer mortality was 18% lower than neighboring areas performing traditional care (HR 0.82, 95% CI 0.74–0.91, P=0.004).39 Instead, Brauer et al analyzed the impact of MTBs on the outcomes of 470 prospectively collected cases of pancreatic and upper gastrointestinal diseases (presented during a 12-month period). Mean overall survival was not significantly different between cases with a change in plan as a result of MTBs vs no modifications in treatment choice (12.1±5.6 months vs 9.0±5.4 months, P=0.154).28 This concept was further confirmed by a wide-ranging literature review by Croke et al.21

Improvements in Clinical Decision-Making and Patient Management

Several studies have confirmed that MTB discussion results in a change in diagnostic or treatment plan in a considerable proportion of cases. Focusing on breast cancer, Newman et al retrospectively described a change in predefined surgical plans after MTB revision of pathological slides by dedicated breast pathologists in 13 patients (9%) pertaining to their center from an outside institution. Additionally, reexamination of previously acquired breast imaging led to surgery in 11% of cases where surgery was not considered a first option before MTB presentation. On the contrary, independently of pathological and radiological reevaluation, the MTB discussion suggested different surgical approaches in a remarkable portion of patients (32%) (eg, sentinel lymph–node biopsy vs axillary lymph–node dissection, mastectomy vs conservative surgery).40 Along these lines, a survey conducted by the Memorial Sloan Kettering Cancer Center showed that sharing individual surgical inclinations in a cross-sectoral setting might reduce unnecessary invasive procedures, such as the adoption of axillary lymph–node dissection in early breast cancer cases.11

With regard to other malignancies, Lee et al observed that modifications in formerly indicated diagnostic workup and treatment strategies at data evaluation occurred in almost half the gynecological tumors discussed within their MTB meeting. Interestingly, the authors found the percentage of recommended changes to be higher than previous findings from a head–neck tumor prospective study.41 In this respect, Wheless et al described a variation of approximately 27% in therapy, diagnosis, or diagnostic procedures. More importantly, a major proportion of patients (65%) experienced a multimodal intensification of their treatment strategy following MTB presentation.42 Similarly, both a cohort chart review and a prospective observational study respectively revealed change in management in 36% and 25% of gastrointestinal and pancreatic tumors after MTB discussion.28,43

According to a study on colorectal cancer patients with stage IV disease, recommendations for preoperative chemotherapy have increased significantly in cases of oligometastatic disease (limited to one site) due to input from MTB discussion. Lowes et al observed that after MTB confrontation, physicians were considerably more prone to refer elderly patients (>70 years) for treatment.44 A retrospective study by Pawlik et al investigated the role of a multidisciplinary approach in respect to pancreatic cancer. The study showed that some cases of declared unresectable disease profited from MTB-enriched surgical experience. Notably, radiological reevaluation caused an upstaging to metastatic disease in almost 70% of cases, requiring an adjustment of the patient’s plan of care.45 In a single-center experience reported by Jury et al, the value of implementing an MTB approach was marked by an increasing number of patients for whom multimodality therapy was indicated after access to their clinic.23 As stated by Ioannidis et al, gathering health-care professionals from different branches has been very beneficial in rectal cancers. Multimodal treatment constitutes the standard of care for these patients, and is partially accountable for outcome improvements achieved in this setting.29

Within this MTB framework, the opportunity to gain new and wide-ranging information is another central aspect to take into consideration. On this point, Deressa et al observed that patients discussed at MTB were characterized by exhaustive staging, resulting in more accurate treatment plans. In contrast, those who had undergone surgery prior to MTB discussion had inadequate and poor staging information.46 The quality of shared information (case history, radiological information) has been related to high-standard decision-making in terms of recommendations given,47 and team members are expected to cooperate as constant supervisors for the level of patient care provided by the group.24 Additionally, when formal consolidated guidelines are lacking, a multisectoral approach might guide health-care professionals in the decision-making process, as advocated by Wotman et al in papillomavirus-positive oropharyngeal squamous-cell carcinoma with incomplete postchemoradiation node response.48

A multimodal and interdiscipline-centered approach might similarly compensate, as underlined by Herlemann et al, the absence of consolidated recommendations on timing and best-treatment sequence in metastatic hormone-sensitive prostate cancer.49 To corroborate this, Fazio et al suggested that an integrated multispecialty strategy might be helpful also to optimize the management of lung neuroendocrine tumors, since the wider armamentarium available for this subgroup compared to the poorly differentiated counterpart.50 Furthermore, some evidence supports the implementation of MTB in surveillance. On behalf of the American College of Chest Physicians, Rubins et al highlighted the importance of multidisciplinary management for early detection of treatment complications, recurrences, or metachronous tumors in follow-up lung cancer patients after curative treatment.51 Taken altogether, the work of Gambazzi et al agrees on multidisciplinary radiological surveillance in posttreatment non-small-cell lung cancer.52 Finally, there have also been reports of increased clinical trial screening and patient recruitment in clinical settings where patient recommendations are discussed by an MTB, as opposed to trial accrual counting exclusively on a dedicated research team.45,53 As to standardizing multidisciplinary management of cancer patients in Europe, implementation of existing recommendations has been done through the creation of consensus documents based on the Delphi method.54––56

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