MDT meetings: an idea whose time has gone?

Alastair J MunroDundee & St Andrews

Questions

•  Why do we have MDT meetings?•  What resources do MDT meetings consume?•  What has been the impact of MDT meetings?•  Are MDT meetings necessary, or can we

escape?

Why do we have mdt meetings?

•  Prehistory–  Cancer registry –  Morbidity and Mortality Meetings–  Grand Rounds–  CPC–  “Tumor Boards”–  Combined clinics

•  Calman Hine Report 1995•  National Cancer Plan 2000•  Postcode Lottery•  Centralisation Paradox

WHAT RESOURCES DO MDTS CONSUME?

Breast CNS Colorectal CUPGynae H&N, Thyroid HBP LungSarcoma Melanoma Urology UGIHaematology

Total number 320,658Total patients for discussion per year (excluding NMSC)

62396

59784

69984

90476

33044

clinical oncol. radiologists pathologists surgeons etc. medical oncol.

total attendances p.a. by specialty

120540

329508

410850

267282

40584

clinical oncol. radiologists pathologists surgeons etc. medical oncol.

total mdt-asociated hours p.a. by specialty

0 5 10 15

surgeons

radiologists

pathologists

medical oncologists

clinical oncologists

% capacity % capacity (travel included)

Number of new patients per annum 320,658

MDT base cost £129.6m

MDT with an opportunity cost discounted by 75% £146.9m

Base cost per discussion £107

Average number of discussions per patient 4 (2.6 to 5.5)

Base cost per patient £428

Cost per patient with a discounted opportunity cost £485

WHAT HAS BEEN THE IMPACT OF MDT MEETINGS?

Colorectal MDT performance

•  Rate of compliance with standards: 91% (median)

•  Rate of “immediate risks” 8/165: 5%•  Rate of serious concerns 55/165: 33%

immediate risks and serious concerns

o  Lack of Clinical Oncology capacity, meaning that treatment decisions are taken without oncology input

o  Difficulties of collection of robust clinical MDT data, due to resource issueso  Anal cancer pathways outwith IOG agreed configurationso  Lack of CNS capacity, impacting on workload and availability at significant

points in pathwayo  Not all patients offered laparoscopic surgeryo  Inequities in patient pathway and support across MDTs within the same

Trusto  Impact of increased workload, including endoscopy capacity, theatre

capacity and surgical bedso  Cancelation of MDT meetings due to MDT coordinator absenceo  Surgeons not undertaking required 20 operative procedures with curative

intent

trus

t

10 20 30 40 50% respondents with stoma

PROMS 2015 survey

Public Health England Knowledge and Information Team (Northern & Yorkshire), University of Leeds, University of Southampton. Quality of Life of Colorectal Cancer Survivors in England. Report on a national survey of colorectal cancer survivors using Patient Reported Outcome Measures (PROMs). 2015.

0 10 20 30% respondents with stoma

Yorkshire and Humber SCN

West Midlands SCN

Wessex SCN

Thames Valley SCN

South West Coast SCN

South East Coast SCN

Northern England SCN

London SCN

Greater Manchester, Lancashire and S Cumbria SCN

East of England SCN

East Midlands SCN

Cheshire and Mersey SCN

data from colorectal PROMS survey 2015% with stoma by SCN

Public Health England Knowledge and Information Team (Northern & Yorkshire), University of Leeds, University of Southampton. Quality of Life of Colorectal Cancer Survivors in England. Report on a national survey of colorectal cancer survivors using Patient Reported Outcome Measures (PROMs). 2015.

E.J.A. Morris , P.J. Finan , K. Spencer , I. Geh , A. Crellin , P. Quirke , J.D. Thomas , S. Lawton , R. Adams , D. Sebag-Montefiore Morris EJA, et al., Wide Variation in the Use of Radiotherapy in the Management of Surgically Treated Rectal

Cancer Across the English National Health Service, Clinical Oncology (2016), http://dx.doi.org/10.1016/j.clon.2016.02.002

NRT, no radiotherapy; SCRT-I, short-course radiotherapy with immediate surgery; SCRT-D, short-course radiotherapy with delayed surgery; LCCRT, long-course chemoradiotherapy; ORT, other radiotherapy; PORT, postoperative radiotherapy

“All these observed variations in radiotherapy usage were seen despite the routine weekly colorectal MDT meetings, which occur across the NHS, in which clinical and radiological staging investigations, including pelvic MRI, are reviewed to determine the selection of patients for preoperative treatment. MDTs are, therefore, adopting very different treatment strategies. How can this wide variation in radiotherapy usage be explained?”

Morris EJA, et al., Wide Variation in the Use of Radiotherapy in the Management of Surgically Treated Rectal Cancer Across the English National Health Service, Clinical Oncology (2016)

http://dx.doi.org/10.1016/j.clon.2016.02.002

How Indeed?

0.1

.2.3

.4.5

.6A

PER

rat

e

0 .25 .5 .75 1Preop XRT rate

size of symbol is proportional to number of resectionsTrust Level 2013 - 2014

From NBOCA data

.15

.2.2

5.3

.35

APE

R r

ate

.2 .3 .4 .5 .6Preop XRT rate

size of symbol is proportional to number of resectionsSCN Level 2013 - 2014

From NBOCA data

586 patients diagnosed with colorectal cancerJanuary 2006 to December 2007

411 (70.1%) with documented evidence of an implemented MDT recommendation

175 (29.9%) with no documented evidence of an implemented MDT recommendation

134 (76.6%) survived >6w41(23.4%) died within 6w of

diagnosis

76 (91.6%) recommendation made and its lack of implementation clearly documented

7 (8.4%) impossible to tell if a recommendation was made

44 no discernible reason5 patients refused treatment that was offered

13 patients were too unfit for the recommended treatment 1 never seen after MDT

13 lack of implementation was for reasons other than above

407 patients who survived >6w and who had documented

implementation of MDT recommendation:

175 (42.3%) to see oncologist30 (7.4%) to have chemotherapy or

radiotherapy42 (10.3%) for further investigations

92 (22.6%) for surgery7 (1.7%) for palliative care

61(15.0%) for follow up only

51 (38.1%) never discussed at MDT

83 (61.9%) discussed at MDT but no documented implementation

22(53.7%) no MDT discussion

19 (46.3%) discussed at MDT

4 (1%) died within 6w of diagnosis

175/586 (29.9%) – either not discussed at MDT or recommendation not

implemented

45/586 (7.7%) - died within 6 weeks of diagnosis

Early

A or B 213

C 135

Neoadjuvant 38

Total 386

Advanced Advanced or metastatic 200

Factors used in MVA (adjusted)

AgeGenderGrade

SiteIncome deprivation

Co-morbidity

Factors independently influencing discussion and

implementation

•  Lower age•  Dukes stage C or neoadjuvant•  Survival >6w from diagnosis

0.00

0.25

0.50

0.75

1.00

surv

ivin

g fr

actio

n

0 12 24 36 48 60survival time (months)

MDT+ MDT-

Overall survival - all patients

Punadj <0.00001

0.00

0.25

0.50

0.75

1.00

surv

ivin

g fr

actio

n

0 12 24 36 48 60survival time (months)

MDT+ MDT-

Cause-specific survival - all patients

Punadj <0.00001HRadj = 0.73 (0.53 to 1.00)

0.00

0.25

0.50

0.75

1.00

surv

ivin

g fr

actio

n

0 12 24 36 48 60survival time (months)

MDT+ MDT-

Cause-specific survival - patients surviving >6w

Punadj = 0.0641HRadj = 1.00 (0.70 to 1.42)

0.00

0.25

0.50

0.75

1.00

surv

ivin

g fr

actio

n

0 12 24 36 48 60survival time (months)

MDT+ MDT-

Cause-specific survival - 'early' patients surviving >6w

Punadj = 0.1379HRadj = 1.85 (0.88 to 3.88)

0.00

0.25

0.50

0.75

1.00

surv

ivin

g fr

actio

n

0 12 24 36 48 60survival time (months)

MDT+ MDT-

Cause-specific survival - 'advanced' patients surviving >6w

Punadj = 0.0604HRadj = 0.89 (0.58 to 1.36)

Du

Lordan

McDermid

Munro

Palmer

Ye

Stud

y

-1 -.5 0 .5LnHR OS adjusted

supp. Figure 2

advantage from MDT discussion disadvantage from MDT discussion

ARE MDT MEETINGS NECESSARY, OR CAN WE ESCAPE?

Problem Proposal Intended effect

Costs Restrict face-to-face MDT discussions to complex or unusual problems

Decrease the direct and indirect costs

Limited evidence for effectiveness Randomised controlled trials using a step wedge design,  

Demonstrate relative effectiveness of different models

Recruitment to clinical trials and adherence to guidelines

Electronically mediated system would automatically capture information and make suggestions

Improved recruitment to clinical trials and adherence to guidelines.

Clinicians lack confidence

Use suitable gating mechanisms for referral to discourage the abuse of the MDT process by lazy clinicans

Ensure that the MDT is not a refuge for shirkers

Limited educational value Automatic capture of high-quality data generates an electronic archive of knowledge and experience: an educational resource.

An archive for each team that can be used for education and audit.

Medico-legal ambiguities Clarify the medico-legal position by insisting that the MDT process results in a recommendation, not a decision.

Ensure that MDTs operate within an appropriate legal framework

Committees for impersonalised medicine:

A web-based system would permit contributions from clinicians who actually know the patient 

Better representation of patients views

Unnecessary delay Discussions could take place at any timeReduction in the interval between diagnosis and starting definitive treatment

Flurry of emails following each MDT.

The emails (or other electronic communication) would be part of the MDT process Flexibility

Ritual and disengagement

Discussion is less likely to become formulaic: audit trail and the Hawthorne effect.

Discussions become more open and varied

Primary care excluded A more flexible web-based system would allow GPs instant access to, and (potentially) participation in, discussion.

There would be greater involvement of primary care

Problems

•  Conspicuous consumption of resources•  The Flying Dutchman syndrome•  Repeat business•  Decisive atrophy & sloth•  Delay•  Neither world enough nor time

THE LIGHT-BULB HAS TO WANT TO CHANGE