Multidisciplinary teams in thoracic oncology-from tragic to strategic

The Journal has been constantly re-inventing itself since inception as is evidenced by randomly browsing at issues every successive year. Specific priority fields have changed over the years in parallel with novel developments emerging in the field of thoracic oncology and in several instances the subjects covered in the journal have even set the trend. Very clearly, methodology of the published papers has improved from mainly explorative retrospective work to more hypothesis-driven prospective approaches. Revolutionary new areas have been integrated such as the present article on Multidisciplinary Teams.

Multidisciplinary Care refers to practice in which physicians from multiple specialties attend to same patient population (1). Paramount importance has been given to multidisciplinary care due to ever increasing complexity of medical knowledge and huge wealth of information that is available for physicians, in addition to complexity of various medical procedures and interventions available in cancer care in thoracic oncology. Broad goals of Multi-Disciplinary Team (MDT) are: Collate, Homogenize and Distribute Information, Provide a platform for prospective discussions and to provide a framework to endorse existing and future endeavours.

Putting the pieces of the puzzle of the clinical scenario together requires significant and frequent interactions among the team members to reach the ultimate goal of cancer care and cure. Approach to a patient is depicted in the flowchart below with roles of different specialties (Figure 1).

Figure 1 Multidisciplinary pyramid.

The utility of MDTs in cancer care must be viewed in general and as specifically applicable to thoracic oncology. Data from other cancers would be applicable for thoracic cancers as well. The benefits of MDTs include reduction in time from presentation to treatment (from 42.2 to 26.9 days) as per a study (2). Treatment plans could get altered in about a third of patients as demonstrated by Gatcliffe et al. (3). There is an increase in rate of intervention and resection rates from 12.2% to 23.4% in lung cancer patients in favour of MDTs (4). An improvement in quality of life was demonstrated in lung cancer patients but was not statistically significant (5). Improved survival in lung cancer was shown when there was a change in outcome in a study (sample size 243) which showed a median survival difference of 3.2 months in favour of MDTs (6). Statistically significant improved patient Experience was shown in MDT group (6). Lawsuits are a major concern in today’s era and MDTs may be an answer for physician protection as more than 80% of the lawsuits have been attributed to communication failure (7). There could be improvement in accrual for trials to the tune of 29% (8) resulting in better research and publication of data. A change of 149% was seen in lung cancer cases in comparison to previous annual levels (1).

Although MDTs in thoracic oncology have shown to be of benefit both by logic and also by evidence it is not devoid of its share of controversies and misconceptions. These include loss of control of patients by primary physician. In addition, patient has to be seen by all physicians whether required or not hence not the efficient way of utilization of time. This could burden the patient with additional cost.

MDTs have come a long way with its share of challenges like establishing a mechanism for prospective assessment and implanting recommendations into clinical practice. MDTs would require ensuring evidence based treatment rather than those based on physician’s beliefs. The referring physician would be required to be part of patient management team. Other challenges include patient participation and balance between education, research and patient care. Minor challenges include data collection, management and staffing.

Regarding MDTs, have we reached the end, probably no. We have not even reached the beginning of the end; perhaps it would more be prudent to say that “we have reached the end of a beginning”.

MDTs present a wealth of opportunity for patients as well as physicians. The most important tool to possess is accepting it whole heartedly and working towards the change. It is time that we concentrate on how to take maximum leverage form such meeting rather than debating on whether to have one or not.

Acknowledgements

Disclosure: The authors declare no conflict of interest.

References

1. Horvath LE, Yordan E, Malhotra D, et al. Multidisciplinary care in the oncology setting: historical perspective and data from lung and gynecology multidisciplinary clinics. J Oncol Pract 2010;6:e21-6. [PubMed]
2. Gabel M, Hilton NE, Nathanson SD. Multidisciplinary breast cancer clinics. Do they work? Cancer 1997;79:2380-4. [PubMed]
3. Gatcliffe TA, Coleman RL. Tumor board: more than treatment planning--a 1-year prospective survey. J Cancer Educ 2008;23:235-7. [PubMed]
4. Martin-Ucar AE, Waller DA, Atkins JL, et al. The beneficial effects of specialist thoracic surgery on the resection rate for non-small-cell lung cancer. Lung Cancer 2004;46:227-32. [PubMed]
5. Murray PV, O'Brien ME, Sayer R, et al. The pathway study: results of a pilot feasibility study in patients suspected of having lung carcinoma investigated in a conventional chest clinic setting compared to a centralised two-stop pathway. Lung Cancer 2003;42:283-90. [PubMed]
6. Forrest LM, McMillan DC, McArdle CS, et al. An evaluation of the impact of a multidisciplinary team, in a single centre, on treatment and survival in patients with inoperable non-small-cell lung cancer. Br J Cancer 2005;93:977-8. [PubMed]
7. Levinson W. Physician-patient communication. A key to malpractice prevention. JAMA 1994;272:1619-20. [PubMed]
8. Pawlik TM, Laheru D, Hruban RH, et al. Evaluating the impact of a single-day multidisciplinary clinic on the management of pancreatic cancer. Ann Surg Oncol 2008;15:2081-8. [PubMed]