Refocusing cancer multidisciplinary team meetings in the United Kingdom: comparing urology with other specialties

Abstract

Introduction

Multidisciplinary team (MDT) meetings have been the gold standard of cancer care in the UK since the 1990s. We aimed to identify the views of urology cancer MDT members in the UK on improving the functioning of meetings and compare them with those of other specialties to manage the increasing demand on healthcare resources and enhance the care of complex cancer cases.

Methods

We analysed data from 2 national surveys distributed by Cancer Research UK focusing on the views of 2,294 and 1,258 MDT members about cancer MDT meetings.

Findings

Most breast, colorectal, lung and urology cancer MDT members felt meetings could be improved in the following areas: time for meeting preparation in job plans, streamlining of patients, auditing meeting decisions and prioritising complex cases. Most urology respondents (87%) agreed some patients could be managed outside a full MDT discussion, but this was lower for other specialties (lung 78%, breast 75%, colorectal 64%).

Conclusions

To facilitate decisions on which patients require discussion in an MDT meeting, factors adding to case complexity across all tumour types were identified, including rare tumour type, cognitive impairment and previous treatment failure. This study confirms that urology MDT members are supportive of changing from reviewing all new cancer diagnoses to discussing complex cases but managing others with a more protocolised pathway. The mechanisms for how to do this and how to ensure the safety of patients require further clarification.

Introduction

Cancer multidisciplinary team (MDT) meetings were first set up in the UK in the 1990s to improve and standardise cancer care. The benefits of MDT working, such as improved governance, joined-up care between oncologists and surgeons, and use of specialist nurses and allied health professionals to support patients, have been well described,¹ but without conclusive evidence of their efficacy.^2,3 Similar models exist internationally.

Guidance in the UK is for all patients with new cancer diagnoses to be discussed in an MDT meeting. Meetings are typically held once a week.^1,4 Many patients require several discussions, for instance to review updated investigation results or treatment failures. Over the past three decades, the number of treatments available to each patient and the comorbidities of patients have increased. This has resulted in long meetings and concerns about the time and attention afforded to each patient.

This is a particular problem in urology. The incidence of prostate cancer in the UK is high, at 47,700 new cases per year.⁵ There are also four other cancer types to consider (renal, bladder [including upper tract urothelial cancer], testicular, penile). Research suggests the average time spent discussing each patient is three to four minutes.^6,7 Fatigue towards the end of meetings is an issue, potentially impacting on decision making.⁸

MDT meetings require the coordination of several senior members of staff, including surgeons, physicians, radiologists, oncologists, pathologists and specialist nurses. Other nurses, allied health professionals, trainees and administrative staff such as MDT coordinators may also be involved. The cost of the meetings is high, with estimates in the UK of more than £150 million per year.^6,9 As a consequence, recommendations to streamline MDT processes have been made.¹⁰ Guidance published by the NHS Cancer Programme in January 2020 provides a framework for introducing streamlining.¹¹

We analysed the responses from cancer MDT members to two national surveys sent to all MDT members in the UK in 2017.⁶ Previous analysis of these data showed urology to be an outlier in relation to support for streamlining MDT discussions but did not explore this further.¹²

We compared the views of urology MDT members with those of MDT members for breast, lung and colorectal cancers. This analysis examines responses in relation to current practices and suggestions for refocusing MDT meetings.

Methods

Cancer Research UK (CRUK) sent two surveys to all MDT members in the UK in 2017.⁶ Distribution was via a mixture of modalities, primarily through respective professional institutions such as the Royal College of Pathologists, the Royal College of Radiologists and the Royal College of Surgeons of England.

The first survey asked respondents to provide their opinion on the importance of 13 key areas to MDT working (Table 1) and the current compliance of their MDT with each of these on a 6-point Likert scale (1 = not very important or never done to 6 = extremely important or always done). Our data focus on the current implementation of these areas.

Table 1.

Suggested key areas for cancer multidisciplinary team working

Stratify patients based on risk

Prioritise more complex cases

Incorporate discussion on patient preferences

Have results present for patient discussions

Audit decisions made by team

Discuss patients on 14-day pathway if investigations do not show cancer

Discuss patients at all stages in pathway

Enter patient details into database in real time

Ensure all required members are present

Ensure sufficient time to discuss patients

Circulate agenda in advance of meetings

Meeting owner takes charge of discussions

Time allocated for preparation in job plans

The second survey asked respondents to rank on a 5-point Likert scale the degree to which they agree or disagree with several recommendations for changes to MDT working (1 = strongly disagree to 5 = strongly agree). We divided 48 questions into 4 categories (Table 2). The second survey also included questions that required written free text answers; the qualitative analysis of these responses is beyond the scope of this article and has been published elsewhere.¹² (Please contact the corresponding author for a detailed breakdown of the individual questions.)

Table 2.

Categories considered for refocusing of cancer multidisciplinary team (MDT) working

Changes to current compulsory attendance levels

Streamlining patients discussed in full MDT

Ensuring patients are ready for discussion

Non-case discussion benefits of MDTs

CRUK designed the surveys with the assistance of a steering group including clinicians, academics and a patient representative. Further information on the survey content and methods has been published.⁶

We included responses to both surveys from all core and extended urology MDT members for analysis.¹³ We included responses from members belonging to MDTs for other common cancers in the UK (breast, colorectal, lung) for comparison. If participants were a member of more than one MDT, they were asked to respond for only one team.

Data were checked for anomalies and cleaned as described previously.¹² We calculated means, medians and ranges and generated box-and-whisker plots using SPSS version 25 (SPSS Inc., Chicago, IL, USA).

Findings

Characteristics of respondents

The first survey had 2,294 responses, of which 267 were from urology MDT members from a range of professional groups. The second survey had 1,258 responses, of which 162 were from urology MDT members. Table 3 shows the number of respondents from other major cancer types for comparison. Respondents covered all regions in the UK and were from all MDT levels (local, regional, supraregional).

Table 3.

Number of survey respondents for major cancer types

Tumour type	Number of respondents (% of total)
	Survey 1	Survey 2
Breast	326 (14.1%)	177 (13.9%)
Colorectal	297 (12.9%)	134 (10.6%)
Lung	264 (11.5%)	141 (11.1%)
Urology	267 (11.6%)	162 (12.8%)

Current practice

We identified no differences in the extent of current practice between urology and other major cancer MDT members for any of the 13 questions in the first survey. For factors considered potential targets for future improvement (clinician attendance levels, streamlining, meeting preparation), there was considerable variation in the extent that they are implemented (Fig 1). The auditing of MDT decisions is highly variable for all specialties (Fig 2).

Figure 1.

Extent of implementation of key areas of multidisciplinary teams (MDTs). MDT members ranked on a Likert scale their current level of implementation of the following factors (1 = low to 6 = high): (a) required attendance, (b) streamlining patients and (c) patients ready for discussion.

Bold bar represents median; boxes represent interquartile range; whiskers represent overall range.

Figure 2.

Level of auditing of multidisciplinary team (MDT) decisions. MDT members ranked on a Likert scale their current level of auditing MDT decisions (1 = low to 6 = high).

Bold bar represents median; boxes represent interquartile range; whiskers represent overall range.

Compulsory attendance

Urology MDT members agreed that attendance at a minimum of two-thirds of meetings should be a requirement for core members, in line with current guidelines (Fig 3).

Figure 3.

Percentage of meetings that core multidisciplinary team (MDT) members should attend. Views of urology MDT expressed by professional groups.

Bold bar represents median; boxes represent interquartile range; whiskers represent overall range.

Streamlining patients

Most urology MDT members (87%) agreed some patients could be streamlined (‘specialist time focused on those cancer cases that do not follow well-established clinical pathways, with other patients being discussed more briefly’⁶) or reviewed outside the MDT; this was similar across all professions within urology (Fig 4a). Percentages were lower for other specialties (lung 78%, breast 75%, colorectal 64%) (Fig 4b). A majority (76%) of urology MDT members suggested 20–50% (median 30%) of patients could be discussed outside the MDT, which could include the use of protocolised pathways. Similar proportions were seen for the other major cancer types, although the median for colorectal cancer was only 20% of patients (Fig 5).

Figure 4.

Views on use of streamlining. Percentage of multidisciplinary team (MDT) members who thought some patients could be streamlined. (a) Views expressed by professional groups within the urology MDT and (b) overall comparison between MDT members of common cancer types.

Figure 5.

Proportion of cases that could be resolved outside the multidisciplinary team (MDT) meeting. MDT members were asked what percentage of patients they thought would be suitable for streamlining out of the main MDT meeting.

Clinicians were uncertain (median Likert score 3) about making decisions alone outside the urology MDT (Fig 6a), although urology MDT members held slightly more favourable views compared with other specialties (median Likert score 3 versus 2 for all others) (Fig 6b).

Figure 6.

Should clinicians be able to make treatment recommendations directly for newly diagnosed patients without referring to the multidisciplinary team (MDT)? MDT members ranked on a Likert scale (1 = strongly disagree to 5 = strongly agree): (a) views of each profession within the urology MDT; (b) overall views of MDT members.

Bold bar represents median; boxes represent interquartile range; whiskers represent overall range.

Identifying case complexity

Participants were asked to identify the importance of a number of potential issues that could increase case complexity and require discussion in a full MDT. Factors considered important (Likert score ≥4) to urology MDT members included unusual or rare tumour types, significant mental health or cognitive comorbidities, treatment failure, treatment toxicity or contraindication to standard treatment, conflict of opinion regarding best treatment, and exceptional cases not fitting standard guidelines. The views of the urology MDT members were similar but not identical to those of the other major cancer groups (Fig 7).

Figure 7.

Factors increasing case complexity. Multidisciplinary team (MDT) members were asked to individually score 12 factors that contribute to case complexity on a Likert scale (1 = not very important to 5 = very important)

Discussion

Current issues

People with lung, colorectal, breast and prostate cancers make up the majority of patients with newly diagnosed cancer in the UK. Other cancer types are rarer than these four combined. It is useful to see whether MDT members with comparable high-volume teams overseeing these tumour types have similar views on whether MDT meetings should remain as they are or modernise. The aims and standard operating procedures of MDT meetings have not been reviewed significantly since their inception.

A 2017 CRUK survey posed a series of questions to address this. Despite several years since the implementation of MDT meetings, many members, in particular pathologists and radiologists, are still challenged with having inadequate time in their job plans to prepare for and attend MDT meetings. Agreeing on radiology and histology opinions outside the MDT meeting could reduce meeting attendance for these members and should be actively encouraged. Nonetheless, time outside the meetings would still need to be factored into the job plans for these individuals.

Stratifying patients so that MDT members discuss more complex cases at the start of meetings was popular, as fatigue can affect decision making. Not many MDTs are organised in this way, however. Auditing MDT decisions and analysing whether treatments recommended ever took place were also thought to be sensible but were not universal.

An alternative approach

Views on whether patients could be streamlined to earlier treatment without waiting for an MDT discussion were interesting. Our analysis of the CRUK surveys suggests there is support for UK cancer MDTs to move away from the model of discussing all new cancer diagnoses. This view is endorsed by all professional groups within the urology MDT, and in other specialties to a lesser extent. Previous research has supported this view and indicated that patients with low-risk prostate, bladder or renal cancer could be managed with predefined pathways outside an MDT.¹⁴ These protocols would need to be defined by the MDT, in consultation with the wider cancer network. Auditing of their implementation would need to be more robust than current MDT auditing practices. Similar approaches are taken internationally.

Protocols should be designed from a combination of national and international guidelines and a retrospective review of how these patients have previously been managed by the full local MDT. The auditing process should aim to confirm protocols were adhered to, that streamlining of cases was appropriate, and whether any changes need to be made. Following any changes to the streamlining protocol, audits by a senior clinician or MDT core member should take place at least annually to maintain accountability for these patients.

Although some differences between UK MDT specialties have been identified previously regarding the effectiveness of discussions,¹⁵ it is unclear why some specialties are more interested in streamlining than others. In our data, more of the urology MDT members (87%) compared with the colorectal MDT members (64%) would consider streamlining. Several factors could account for this, including clearer standard treatment protocols, less complex cases, a larger caseload driving the need for change, or differing concerns regarding patients not discussed. Further identification of the differences between specialties and interspecialty collaboration is required.

Benefits of streamlining

The removal of non-complex cases from the full MDT will allow more time for complex case discussions. Our data suggest complex cases are not prioritised to the start of meetings on a regular basis for urology or other major cancer groups. Previous evaluation of MDT working has demonstrated the quality of decision making reduces at the end of long meetings.^8,16 The discussion of only complex cases could shorten meetings and enhance the quality of decisions for all patients discussed.

Identification of complex cases

MDT members identified several factors that could help to define a complex case and hence warrant full meeting discussion. It remains uncertain who would be responsible for reviewing all cases to determine whether they meet the criteria for inclusion in MDT meetings, and how they would do this. The Measure of Case-discussion Complexity (MedDiC) tool is a 27-point checklist to assist with this decision making process.¹⁷ It is unclear who would implement such a tool, but it could be a single clinician such as the MDT chair, or a representative from each of the key professional groups in a pre-MDT meeting. Further work to identify how this would impact on overall efficiency is needed.

Patients not discussed in the MDT

Previously published qualitative analysis of the surveys used in our study has identified concern from some clinicians regarding the safety of patients not discussed in MDT meetings.¹² Our quantitative data suggest there is a wide range of opinions on the proportion of urological cancer patients who can be managed outside the MDT (0–80%). Decisions on which patients do not require discussion is likely required at a local level or within the cancer network. A suggestion is to manage these patients in dedicated MDT clinics led by senior clinicians with specialist nurse support. This is supported by the recent NHS Cancer Programme streamlining guidance.¹¹ Treatment plans should be audited regularly by the MDT.

Limitations

As with all voluntary survey-based studies, there is a risk of non-response bias. While the views of those who did and did not respond may be the same, it is possible that the non-responders are completely satisfied with current cancer MDT practices and do not wish to consider future change, making them a very different group from those who have responded. Respondents were from a wide geographical spread and a mixture of local, regional and supraregional meetings, suggesting a representative cohort.

According to the 2018 workforce report from the British Association of Urological Surgeons, the response rate from urologists was approximately 5% of the total UK consultant body (1113 consultants).¹⁸ Although not all the consultants are part of cancer MDTs, as urology has many benign subspecialties, the true percentage would be much higher. Small sample sizes mean it is difficult to compare the views of different professional groups within the urology MDT. Nonetheless, the inclusion of the full range of stakeholders enables a true reflection of the challenges at the local level to implementing potential changes.

Conclusions

This study highlights current practices and opinions on future developments to the working of MDTs. We have demonstrated that urology cancer MDT management in the UK is in a similar position to other specialties. By identifying factors that contribute to case complexity and protocols for managing standard care pathways, urology can be at the forefront of refocusing UK cancer MDT practices into supporting more complex cases, whereby patients will benefit from a multidisciplinary discussion. The concept of streamlining has support from urology MDT members, but the challenge is implementing this while retaining exemplary governance.