Keywords
conference - multidisciplinary - rectal cancer - team
Introduction
Multidisciplinary team (MDT) discussions have become firmly established as the core of cancer care worldwide, significantly enhancing diagnosis, treatment planning, and outcomes.[1]
[2] Cancer guidelines typically recommend that patients be reviewed in the setting of an MDT. Due to the complex treatment strategies involved in rectal cancer, coordinated clinical decision-making between many specialties is essential. MDT meetings are crucial to this approach, bringing together health care professionals from different fields to collaborate and make well-informed decisions.[3]
An MDT approach in rectal cancer management helps standardize care with improved utilization of available resources. MDTs also improve the technical aspects of treatment, such as the quality of surgery, completeness of mesorectal excision, and negative circumferential resection margins (CRMs). This has improved patient outcomes, reflected by decreased recurrence rates and improved survival.
While there is evidence that MDTs improve treatment planning, adherence to clinical recommendations, patient outcome, and survival, few studies have specifically examined their impact on primary rectal cancer. This article aims to highlight the role of MDT meetings in rectal cancer management by providing insights into the conduct of an MDT, the decision-making and documentation process, and a surgeon's perspective on the role of a radiologist in the smooth conduct and steering of MDTs.
Structure of a Colorectal MDT
Structure of a Colorectal MDT
The U.K. Department of Health defines an MDT as “a group of people from different health care disciplines who meet at a designated time to discuss the care of individual patients.” The team members contribute independently to the diagnostic and treatment decisions of the patient.[2] Multidisciplinary cancer care is described using various terms—MDTs, multidisciplinary cancer conferences, or multidisciplinary tumor boards.[4]
The structure of an MDT is pivotal in delivering comprehensive care for patients with rectal cancer. The team includes core members like a surgeon (colorectal/surgical oncologist/gastrointestinal [GI] surgery), radiation oncologist, medical oncologist, and radiologist (with an interest in abdominal and pelvic imaging). Other members include a pathologist, a palliative care specialist, and a colorectal nurse specialist. Members from other disciplines like hepatobiliary surgery, gynecologic oncology, nuclear medicine, and clinical genetics are called in for opinions on a case-to-case basis ([Fig. 1]). Additionally, centers may have an MDT coordinator.[5]
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Fig. 1 Members of the rectal cancer multidisciplinary team (MDT).
MDT meetings initially started as face-to-face meetings, but there has been a shift to clinical meetings held via video conference.[8]
[9] These meetings are planned on specific dates at regular intervals convenient for the core members' attendance. The quality of MDTs improves when the meeting is scheduled, structured, prepared, attended by all core members, and guided by a qualified chairperson.[3]
[10] Dedicated time should be set aside for clinicians and radiologists to prepare for the MDT and discuss each case during the meeting.[3]
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Patients are referred to the MDT by the treating surgeon, radiation oncologist, or medical oncologist. The meetings comprise case presentations by a clinician, a review of imaging, and multidisciplinary discussions on the optimal management of each case.[5]
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The general framework of case discussions includes the following[3]
[13]:
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Opening: Identification of the patient
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Case presentation: Initial clinical evaluation, including treatment history
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Review of relevant imaging and investigations: The radiologist takes the team through the patient's imaging details, including a magnetic resonance imaging (MRI) of the pelvis. The imaging findings and the staging are summarized at the end. The pathologist sheds light on the histopathology report if available.
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Discussion: Interpretations or clarifications from other members of the team and any additional information are discussed. All specialists agree upon a treatment plan. There might be different opinions on a few occasions, and the various treatment options are explored.
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Articulation of treatment plan: The final treatment plan is documented.
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Closure: Attention is directed to the next patient.
Most MDT discussions are based on objective clinical, pathological, and radiological findings. Occasionally, subjective or qualitative information about patients or their social situation is also discussed (e.g., reluctance for surgery or radiotherapy [RT]). These help make an individualized plan for the patient and are documented in the discussion.[11]
Our Institutional Practice for a Colorectal MDT
Our Institutional Practice for a Colorectal MDT
At our institution colorectal MDTs were initiated in 2004. The colorectal MDT takes place once a week and runs for 1 hour and 30 minutes. While these meetings started as face-to-face, they have changed to an online format through Microsoft Teams. All patients with colorectal cancer are discussed at these meetings (both pre- and post treatment), with an average of 25 to 30 patients discussed every week.
Our MDT comprises colorectal surgeons, abdominal radiologists, radiation oncologists, medical oncologists, and colorectal cancer/stoma care nurses. In specific scenarios, the expertise of the hepatobiliary pancreatic surgeons, pathologists, and interventional radiologists is also sought.
Patients are referred to the MDT by the treating physician (surgeon, radiation oncologist, or medical oncologist). An in-house online computer program is used to list patients for the MDT. This program allows access to all relevant patient details, including outpatient details, investigations, and treatment details.
During the MDT, following the clinical presentation and a brief review by clinicians, the MDT radiologist (who is usually a dedicated senior GI radiologist) guides the team through the imaging, including discussion of the relevant anatomy, planes, and staging of the tumor. This is followed by a multidisciplinary discussion of the presented findings and available treatment options. The final MDT treatment recommendations are based on group consensus and standard institutional practice guidelines. Any deviation from standard guidelines and the reasons for deviation are documented. Any deviation or change in the treatment plan, especially in the light of new findings or specialist opinion, must be rediscussed in the MDT.
All new patients with colorectal cancer are discussed in the MDT. In addition, patients receiving neoadjuvant treatment are discussed again after completion of chemotherapy or RT (restaging scans). Patients are also reviewed after surgery to discuss the final histopathology report and plan adjuvant chemotherapy.
Documentation of MDT Decision-Making
Documentation of MDT Decision-Making
Documentation of the final MDT decision is an essential step in the management of the patient. The documentation should include a synopsis of the radiological and clinical findings followed by a detailed description of the proposed treatment. Neoadjuvant therapy, as well as timing for reassessment should be documented. An example for a patient requiring neoadjuvant chemotherapy followed by radiation followed by surgery would be: FOLFOX 4, reassessment with CT and rediscussing at MDT, long course chemoradiation, MRI at 9 weeks post-RT and rediscussing at MDT, and low anterior resection at 10 weeks.
This plan should be readily accessible to all members of the health care team involved in the treatment of the patient. This can be an online or a physical paper document kept in the patient's hospital records. The MDT plan is a ready reckoner for managing the patient and saves valuable time for the patient and doctor during busy outpatient visits.
The final treatment plan in our hospital is documented in the online hospital health care record. This is done by a member of the radiation oncology team or the colorectal team. The MDT plan is highlighted on the front page, along with the patient's clinical details.
Role of the Radiologist in a Rectal Cancer MDT
Role of the Radiologist in a Rectal Cancer MDT
MRI with high spatial T2-weighted images is the preferred modality for local staging of rectal cancer. A cross-sectional imaging of the chest and abdomen completes the staging. Accurate staging plays a key role in the evaluation of rectal cancer, both pre- and posttreatment. The smooth steering of MDT relies on an experienced radiologist who helps in staging the disease and offers additional inputs and clarification for interpreting the radiologic images.[7]
During the primary tumor staging in the preoperative setting, the radiologist can assist in several key areas apart from staging the disease. They help classify the tumor as low, mid, or high rectal cancers. Additionally, they provide information regarding the status of the sphincter and proposed CRMs. Furthermore, the radiologist offers vital insights for decision-making by interpreting poor prognostic factors. These include involvement of the mesorectal fascia, extramural vascular invasion, tumor deposits, lymph node involvement including pelvic side wall nodes, mucin content, and the involvement of pelvic organs and side walls.[14]
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The use of total mesorectal excision (TME) as the standard treatment for rectal cancer, along with the adoption of neoadjuvant chemoradiation and total neoadjuvant therapy (TNT) for patients with locally advanced rectal cancers has resulted in significant improvements in local disease control.[14]
[17] The radiologist's role in identifying patients with locally advanced disease and poor prognostic features is key for selecting patients for neoadjuvant chemoradiation or TNT.[15]
[16] The radiologist's interpretation additionally helps improve anatomical knowledge of planes and their relationship to adjacent structures, which helps in surgical planning.[7]
[18] In early rectal cancer, an accurate staging can help choose patients for upfront resection as well as local excision and transanal minimally invasive surgery.
In many instances, there is a change in staging and a subsequent treatment strategy following an MDT discussion. In a Korean study by Jeon et al,[7] a dedicated subspecialized radiologist in an MDT led to a change in radiologic interpretation in 30% and a change in treatment plans for 36.9% of cases.[18]
Another component of the MDTs is the reassessment and restaging of patients who have undergone neoadjuvant therapy. In this setting, the radiologist sheds light on tumor regression, residual tumor size, mucin response, fibrosis, and any local recurrence after a complete clinical response. Radiology is integral in assessing complete clinical response and helps monitor patients effectively for early recurrence.[14]
[17] The expert opinion of radiologists helps resolve many diagnostic challenges and refine decisions.[19] Radiologists are essential for identifying patients needing palliative care through accurate staging and assessing irresectable metastatic disease.[18]
The role of a radiologist extends beyond clinical decision-making; it also aims to enhance participants' knowledge over time.[19] In an MDT, as opposed to reading a report, there is improved communication with clinicians through a review of key radiology information, and peer learning also occurs.[2]
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Benefits of a Rectal Cancer MDT
Benefits of a Rectal Cancer MDT
Rectal cancer MDTs offer many benefits to patients with rectal cancer. As seen in studies done by Burton et al and Snelgrove et al, there is a striking reduction in positive CRM, a significant change in the treatment plans, and improved outcomes.[15]
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MDT conferences aim to make improvements in three key areas:
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Improvement of the treatment process
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Improvements in technical aspects of treatment
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Improvements in patient outcomes[22]
MDTs improve communication between different specialities, enhance the patient management process, and help prevent unnecessary investigations and interventions [19]. MDTs have introduced a standardization of care and improved utilization of the available resources. They enable multidisciplinary reviews of imaging such as MRI and CT, help decide the need for neoadjuvant chemoradiation, and ensure the accuracy and completeness of pathologic staging.[5]
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The second improvement is in the technical aspects of treatment, particularly in surgical quality, as demonstrated by the completeness of TME (R0) and negative CRMs. Incorporating expert feedback from radiologists and pathologists has improved the surgeon's ability to attain complete (R0) TME and clear CRM in a greater proportion of patients. The surgical approach has sometimes changed (wider excision, extra mesorectal TME, etc.) to get a negative margin. Junior doctors and other specialists also benefit from the training opportunities that MDTs offer. They have been shown to enhance team members' work lives.[24]
Finally, MDTs have been shown to improve patient outcomes, reflected by decreased recurrence rates and improved survival rates. The MDT process improves patient selection and overall survival in cancer patients. There is growing evidence that MDMs are associated with improved clinical decision-making, clinical outcomes, and patient experience. MDTs have also been shown to help better adhere to formulated treatment plans.[25]
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Barriers and Challenges of MDTs
Barriers and Challenges of MDTs
While MDTs have many advantages, concerns and barriers to implementation exist.[3]
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The absence of the clinician in charge of the patient and core members from the MDT has been identified as a negative factor affecting effective decisions.[28] A minimum quorum of key members should be present for the MDT to make effective recommendations. MDTs have often been criticized for not encouraging the participation and opinion of nurses and other nonmedical staff.[2]
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[4] It is also observed that junior doctors usually play a passive role in these meetings. MDTs should strive to be inclusive and be used as a training and learning opportunity by all members present.
Adequate preparation time for the presenter and the radiologist is a significant challenge identified by numerous studies.[29]
[30] Lack of preparation, unstructured case presentation, and lack of patient involvement are commonly reported hurdles. Interruptions during MDTs are common and have negatively impacted their effectiveness.[27]
[29] These interruptions may arise from participants in the meeting or from failures in technological equipment. MDT meetings are under pressure from the increasing number of patients needing discussion in a limited time. Cases discussed toward the end of meetings can be associated with lower decision-making rates, information quality, and teamwork. Adequate protected time should be provided to clinicians and radiologists to prepare for the meeting. Meetings should be planned to run without interruptions and proper time should be dedicated to each case discussed.
The MDT approach can become fragmented, resulting in poor provider communication and significant treatment delays. Another concern is the nonadherence to the MDT decision-making.[31] Reasons for not following MDT advice include patient comorbidities, unfitness for specified treatment, patient preferences, new clinical information, and differing opinions from the treating physician.[3]
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[32] In each scenario, the patient should be brought back to the MDT for a repeat discussion.
Conducting MDT meetings requires significant time and resources for medical personnel and hospitals. MDTs benefit from a more structured organization, clear meeting schedule, attendance of core members, especially the primary physician, streamlining cases, and structured evaluation.[3]
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Conclusion
MDTs are crucial in delivering high-quality cancer care and facilitating informed decision-making. A specialized rectal cancer-specific multidisciplinary conference that includes a review of imaging by expert radiologists and effective communication among clinicians significantly influences management plans.
As our understanding of tumor biology and treatment options improves, the need for a multidisciplinary approach to treating patients with rectal cancer continues to grow. Patients with rectal cancer benefit significantly from a review at an MDT conference, primarily through improved staging, therapeutic planning, and improved outcomes, including survival rates.
