Research Article
Improved Utilization of Resources as an Improvement of Outcome: the Effect of Multidisciplinary Team for Rectal Cancer in a District Hospital
Angela Maurizi* and Roberto Campagnacci
Department of General Surgery, Carlo Urbani Hospital, Italy
*Corresponding author: Angela Maurizi, Department of General Surgery, Carlo Urbani Hospital, Italy
Published: 26 Apr, 2017
Cite this article as: Maurizi A, Campagnacci R. Improved
Utilization of Resources as an
Improvement of Outcome: the Effect
of Multidisciplinary Team for Rectal
Cancer in a District Hospital. Clin Oncol.
2017; 2: 1267.
Abstract
Aim: Today, treatment decisions about patients with rectal cancer are increasingly made within
the context of a Multi-Disciplinary Team (MDT) meeting. The outcomes of rectal cancer patients
before and after the era of multi-disciplinary team was analyzed and compared in this paper. The
purpose of the present study is to evaluate the value of discussing rectal cancer patients in a multidisciplinary
team.
Methods: All rectal cancer patients diagnosed and treated in 2014-2015 in the General Surgery
Division of the “Carlo Urbani” hospital in Jesi (AN, Italy) were included. According to the national
guidelines, neoadjuvant chemo-radiotherapy should be administered to many rectal cancer patients.
Results: Sixty-five patients were included in this study: thirty patients in 2014 (pre-MDT) and
thirty-five patients in 2015. Improvements in the pathologic stage were seen in a rather big portion
of patients after the introduction of the MDT meetings, thanks to the increased adoption of the
neoadjuvant chemo-radiotherapy.
Conclusion: The vast majority of rectal MDT decisions were implemented and when decisions
changed, it mostly related to patient factors that had not been taken into account. Analysis of the
implementation of team decisions is an informative process in order to monitor the quality of MDT
decision-making.
Keywords: Rectal cancer; Multi-disciplinary team; Patient outcomes; Clinical stage; Pathological stage
Introduction
Rectal cancer represents a significant health care problem in terms of incidence, management complexity, and use of resources. Rectal cancer can have different patterns of presentation at diagnosis, which greatly influences both the prognosis and treatment choices. Treatment strategies vary depending on the level of the tumor, extension through the rectal wall in the mesorectum, presence of involved nodes inside and outside the mesorectum, presence of perforation, histological type and grade, and presence of distant metastases. The treatment of rectal cancer is extremely complex. The anatomy of the rectum presents a unique challenge and strict planes of dissection must be maintained to increase chances of healing. Basically, the management of rectal cancer has been changing over the past few decades, which has led to significant reductions in rates of local recurrence, increase in disease-free and overall survival, and reduction in permanent stoma rates [1]. However, surgical therapy is one aspect only of rectal cancer care. Treatment decision making for rectal cancer is challenging because of the inherent tradeoffs between effectiveness in terms of local recurrence and survival and functional outcomes in terms of bowel and sexual function [2-4]. This is further complicated by an increase in the number and type of available options for surgical treatment, as well as by changing paradigms for treatment based on response to preoperative chemoradiotherapy. Further complications are due to the importance of accurate preoperative staging, because under staging may result in primary surgery without neoadjuvant therapy, leading to increased risk of local recurrence, whereas over staging may lead to unnecessary radiotherapy and chemotherapy with poorer functional outcomes [5]. These various strategies in different combinations are aimed at improvement in care standards, improving quality of life with better local control and fewer complications, and improving survival. These decisions require communication between the surgeon, the pathologist, the radiologist, the medical oncologist, and the radiation oncologist. Indeed, the establishment of a multidisciplinary team to manage patients with rectal cancer attains just that. Further research has established the role of the pathologist and the radiologist in optimizing the multidisciplinary treatment of rectal cancer. Identification of tumor <1 mm from the circumferential resection margin proved to be a strong predictor of local recurrence, distant metastases, and survival, resulting in a new endpoint of rectal cancer treatment [6-9]. An optimal patient-tailored decisionmaking process requires adequate interdisciplinary communication and coordination. Hence, the complex treatment of rectal cancer requires a multidisciplinary approach [1,10-12]. To date, many studies have shown improvements in the standardization of care and an increased proportion of patients receiving this standard [13- 15]. Incorporating MDT into practice has resulted in an increase in the utilization of rectal cancer focused imaging, such as pelvic magnetic resonance imaging for preoperative clinical staging [16- 18], in the use of neoadjuvant chemo-radiotherapy [15,16,19] and in the accuracy and completeness of pathologic staging [16,19,20]. It is expected that immediate expert feedback from radiologists and pathologists will lead to improvements in the surgeon’s ability to achieve complete (R0) resection in a higher proportion of patients. Increasing complexity of multi-disciplinary management has led to the widespread adoption of the multi-disciplinary team meeting as a forum to direct treatment and improve quality of care [21,18]. In the past, rectal cancer treatment was primarily, and almost exclusively, surgical [22]. In fact, the notion that a multi-disciplinary approach improves medical management of cancer patients is becoming more prevalent. Many experts argue that the multi-disciplinary team approach presents a news standard of care, leading to a modern trend towards centralized and specialized centres for cancer management. Meaningful advances in imaging, staging, surgery, radiotherapy, chemotherapy and a growing arsenal of targeted therapies have all positively contributed to this notion. However, this multimodal approach demands for more time and resources, effective ongoing coordination between multiple specialties and can thus present formidable organizational challenges in a population where time can influence outcomes. There is some evidence that the introduction of rectal cancer MDT has improved outcomes for patients, but assessing the actual impact of MDT meetings is difficult, due to concurrent improvements in care brought in over time [19]. Ensuring that high quality treatment decisions are made requires discussion between experts in pathological and radiological data, information about patient related factors such as comorbid health status and patient treatment preferences and an effective decision-making process [23]. Rectal cancer treatment has become multi-disciplinary in nature involving at least surgeons, radiologists, radiotherapists, pathologists, and medical oncologists. This interconnection should commence at the time of the initial diagnosis. The preoperative handling of rectal cancer patients affects local recurrence and survival, and very often postoperative therapy schemes cannot compensate for any mistakes during the initial decision making. A multi-disciplinary team cans provide tailor-made treatment options for any given rectal cancer patient. Treatment out of the context of a MDT currently varies according to local dogma, facilities, and resources. In our hospital, before January 2015 patients with primary rectal cancer were initially examined by the surgeon who would assess the patient and make referrals at their discretion. There was no mandatory or formal review of the preoperative assessment or formal discussion of the patient among the surgeon, radiologist, radiation oncologist, and medical oncologist. For the reasons stated above, our institution decided to set up a multi-disciplinary team to discuss every case of rectal cancer. The objective of this study is to evaluate the improvements on rectal cancer treatments outcomes after the introduction of the MDT meetings.
Table 1
Table 2
Table 2
Appropriate use of postoperative adjuvant chemo-radiation therapy
decreased over the study period down to 37% of MDT group patients.
Materials and Methods
Design of the study
In our health institute, weekly multi-disciplinary team conferences
were initiated in January 2015. Patients with newly diagnosed rectal
cancer being treated in our institution between January 1, 2015, and
December 31, 2015, were presented at a specific rectal cancer multidisciplinary
team. Patients were identified by the treating surgeon.
Patient identifiers were forwarded to the multi-disciplinary team
coordinator, who was responsible for drafting and distributing the
patient list at each multi-disciplinary team meeting. To the purpose
of this study, only patients with primary rectal cancer were included.
Then, the data from rectal cancer patients since year 2014 were
evaluated, before the adoption of multi-disciplinary team and since
the year 2015 after the adoption of meeting. Multi-disciplinary team
meetings were held every week and attended by surgeons, radiologists,
radiation and medical oncologists and key nursing personnel
treating patients hired at our center. A chair facilitated the work of
the multi-disciplinary team and the treating physicians presented
the clinical history, physical and endoscopic findings, and imaging
results for each patient. After this, the treating physician indicated
his/her proposed treatment plan. Complete datasets regarding
demographics, tumor stage, treatment, and outcomes based on
pathology after operation were obtained. During an MDT discussion
patient history, clinical and psychological condition, co-morbidity,
modes of work-up, clinical staging, and optimal treatment strategies
were discussed. These weekly meetings were used for discussion of
proper patient management, concurrently, among all appropriate
disciplines. A database was created to include each patient’ s workup,
treatments to date, and for recommendations by each specialty. We
analyzed 30 patients associated to the year 2014 and 35 patients
associated to the year 2015. ‘‘Demographic variables’’ consisted of age
at diagnosis, sex, body mass index, comorbidities, American Society
of Anesthesiologists physical status classification system (ASA
score), clinical stage and pathological stage. Other analyzed variables
included baseline carcinoembryonic antigen (CEA), the type of
imaging, use of neoadjuvant chemo-radiation, restaging following
neoadjuvant therapy, distance from the anal verge, operation type
and use of adjuvant chemo-radiation. ‘‘Outcome variables’’ consisted
in a comparison for each group between clinical and pathological
stage.
Statistical analysis
Statistical analysis included Student t test of parametric variables
and chi-square test of proportions.
Results
There were 65 patients included in this study entered into the rectal MDT meetings at General Surgery Division of “Carlo Urbani” Hospital, Jesi, Ancona, Italy. These patients were split in MDT group (2015, no.35) and pre-MDT group (2014, no.30). Demographic data and their analysis are included in Table 1. The average age at diagnosis did not significantly differ between groups, as well as the variable “sex”. Comorbidities such as diabetes, coronary artery disease, congestive heart failure, body mass index, and American Society of Anesthesiologists physical status classification system did not differ significantly between groups. Preoperative clinical stages were similar between groups, except for that of clinical stage II, which was lower in the MDT group and statistically significant. Postoperative pathological stage did not differ between groups, except for that of clinical stage III, which was lower in the MDT group and statistically significant. Patients often arrive at our institution having completed their treatment, waiting for surgical operation only. The MDT did not exist before 2015. Baseline preoperative CEA measurement steadily increased, but did not reach significance. Colonoscopy and CT were high for both groups. Statistically significant increases were seen in the use of MRI but not for endoscopic rectal ultrasound to evaluate the depth of invasion. Complete metastatic imaging with CT to include imaging of the chest steadily increased. The majority of patients in the pre-MDT group included abdomen and pelvis imaging, but not chest. Proper neoadjuvant therapy was noticed to increase over time as did post-therapy preoperative restaging with MRI but they was no statistically significant difference. Appropriate use of postoperative adjuvant chemo-radiation therapy decreased over the study period down to 37% of MDT group patients (Table 2). Laparoscopic anterior rectum resection was performed in 18 patients in the MDT group and in 15 patients in the pre-MDT group.
Table 3
Table 3
As far as the outcomes we cannot verify the local and distant recurrence
because of the short follow-up of the 2 groups. But we can see (Table 3) that
thanks to the multi-disciplinary team and the increased use of the neoadjuvant
therapy, a statistically significant difference in reduction of the stage between the
clinical and pathological stage in the patients of the MDT group was verified, that
did not apply to the patients of the pre-MDT group.
Discussion
The multi-disciplinary team consists of primary team members
that include colorectal surgeons, radiologist, pathologist, oncologist,
meeting coordinator, and clinical nurse specialists. Other specialists
such as gastroenterologist, hepatobiliary surgeons, interventional
radiologist, clinical geneticist, stoma nurse, thoracic surgeon,
dietician, social worker, and research nurse are usually peripherally
involved. The meetings should occur weekly and be set up by the
team coordinator. Case notes, patient data, diagnostic data, staging,
and pathologic information should also be available during the
meeting. The cases to be discussed should include any new patient
with diagnosis of rectal cancer, all patients who have undergone
resection of a rectal cancer, patients newly identified with recurrent
or metastatic disease, and any other rectal cancer patients that
members of the team feel should be discussed. The clinical history
and imaging data in these patients are reviewed during meetings. A
radiologist reviews imaging with the team with particular focus on
operative planning. Also, histopathologic data are reviewed and in
many cases help to monitor the quality of surgery. Review of the raw
data serves to educate all members, gets all members well versed on
staging issues, and promotes the overall assessment and analysis of a
case. Postoperative cases are reviewed and the pathology is discussed.
In regard to rectal cancer, the pathologist provides valuable insight
into quality of total mesorectal excision which is reviewed grossly and
histologically. This can lead to an improvement in surgical technique.
The multi-disciplinary team accumulates information and opinions
so that management of decisions can be made on patient treatment. It
allows individualization of patient care so that care can be tailored for
any particular patient. Another key element of the multi-disciplinary
team is capturing the data on a database so that internal audits can
be performed to monitor outcomes. Improved coordination of care
and the opportunity to assess each patient from many viewpoints are
immediate benefits of a multi-disciplinary team. Multi-disciplinary
teams are typically associated with institutions with subspecialist
surgeons treating higher volumes of colorectal cancer patients. There
is growing evidence that high-volume colorectal cancer centers with
experienced subspecialty-trained surgeons have improved mortality
and have higher sphincter preservation rates [11,24-28]. Receiving
critiques or comments from experts in other fields can help surgeon
self-appraisal, specifically in reference to surgical margin review.
Audits of adequacy of total mesorectal excision with gross and
histopathologic review of the specimen can lead to improved surgical
technique [11,24]. Lately, an audit about the use of multi-disciplinary
team recommendations in Yorkshire, England, found out improved
survival in colon cancer patients treated with team recommendations,
and a trend toward increased survival in those with rectal cancer [19].
Inmulti-disciplinary team managed patients with rectal cancer, there
was an increased use of preoperative radiation and higher rates of
anterior resection. In our study, these decisions that changed after
any meetings were mainly due to patient co-morbidity that rendered
the recommended treatment as inappropriate or as not possible.
Other multi-disciplinary team decisions changed because they were
unacceptable to the patient. The high rate of implementation of
multidisciplinary team decisions recorded in this study suggests that
the colorectal multi-disciplinary team is an effective forum for making
management decisions that are acceptable to patients and can be
implemented. In this study, all the multi-disciplinary team decisions
that changed after a meeting resulted in final treatments that were more
conservative than originally planned. This highlights the need for up
to date information about the patient’s general health and preferences
to be available for the multi-disciplinary team meeting. Such
information might include relevant cardio respiratory or psychosocial
details. Information about patients’ preferences may also be difficult
to discuss routinely at meetings, either because patients may not have
particularly treatment wishes or because patients’ views frequently
evolve during the process of diagnosis and treatment [29]. Whichever
means is used to include more information about patient related
factors into multi-disciplinary team meetings, it is likely to require
investment, and evidence suggests that when patients are consulted
about the treatment decision, compliance is likely to be better [30,31].
For other cancers sites, it has been found out that MDT meetings
are useful in improving staging accuracy [32]. Recently a study has
shown that innovation in healthcare teams may reflect excellence
because it may mean that teams adapts to a changing environment
and increasing workload [33]. Others have shown that frequent and
voluntary interactions between team members increased opinion
sharing and ideas [23]. These are useful outcomes and it suggested
that by monitoring implementation of MDT decisions and studying
reasons why decisions change also provides useful clinical feedback
to teams. This process may also be a useful measure to peer review
the quality of MDT decision-making. This study suggests that there
is a need to develop pragmatic methods to allow the better inclusion
of information about co-morbidities and patient choice within MDT
meetings. If this could be achieved, it may lead to optimal treatment
decisions that can be subsequently implemented.
Multidisciplinary treatment of rectal cancer consists of accurate
imaging, meticulous surgery, and wise use of chemo-radiotherapy.
These elements are interconnected. Recently, Heald [34] proposed a
6-stage process for the management of rectal cancer after establishing
its diagnosis and excluding systemic disease. In the first stage, pelvic
MRI is performed, which provides the essential elements for the
preoperative decision making for rectal cancer. In the next stage, the
MDT discusses the patient’s case and the overall treatment plan is
formed. In stage 3, preoperative chemo-radiotherapy is administered,
when indicated. Selection for preoperative chemo-radiotherapy
principally is according to preoperative MRI. In the fourth stage, a
detailed precise surgical procedure is performed according to TME
concept. In stage5, pathologic audit of the specimen is performed
postoperatively. Finally, the case is evaluated thoroughly within the
MDT and decisions regarding postoperative treatment are made
along with surgical audit and feedback from the pathologists. The
MDT is responsible for choosing the tailor-made management for
all patients with rectal cancer and has to set up an algorithm for the
treatment of rectal cancer that is the backbone for any preoperative
decision making for colorectal cancer. The aim of the MDT is to
improve results and to offer state-of-the-art treatment. We consider
MDT discussion obligatory for all patients with rectal cancer.
The contribution of a MDT includes increased application of
neoadjuvant chemotherapy, careful patients election for primary
tumor resection (decreased surgical mortality rate), and increased
resection of metastatic lesions in the liver.MDT could not only
increase the communication between surgeons, oncologists,
radiologists, and pathologists, which undoubtedly increased the
tumor resection rate, but also simultaneously decrease the number
of unnecessary surgeries and the surgical mortality, thanks to more
careful patient selection [35,36]. The evolution in the management of
rectal cancer in our center reflects international best practice and has
allowed us to examine the effect of multi-disciplinary management of
rectal cancer.
Conclusion
Multi-disciplinary team care of patients with rectal cancer has been shown to improve process and oncologic outcomes. The process requires full commitment from all involved in the care of rectal cancer patients. To sum up, a multi-disciplinary approach can assist in providing seamless coordination of care and is crucial to achieving improved outcomes. Our responsibility as colorectal surgeons treating rectal cancer patients is to understand and coordinate the wide variety of modalities available to optimize survival, minimize morbidity, and maximize quality of life for those with this strict disease. It should become the standard of care in the future.
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