Head & Neck

Head and Neck Multidisciplinary Team Meetings Change Patient Management

1,2

Markus Brunner, MD, 1Sinclair M Gore, MBBS, 1Rebecca L Read, PhD, 1Ashlin Alexander,

MD, 1Ankur Mehta,MBBS, 1Michael Elliot, MBBS, 1Chris Milross, MD, 1Michael Boyer, MD 1

1

Jonathan R. Clark, MBBS,MBiostat

Sydney Head and Neck Cancer Institute, The Sydney Cancer Centre, Royal Prince Alfred

Hospital, Missenden Road, Camperdown, New South Wales, 2050, Sydney, Australia. 2

Department of Otolaryngology, Head and Neck Surgery, Medical University of Vienna,

Währinger Gürtel 18-20, 1090 Vienna, Austria

Keywords: head and neck cancer; MDT, multidisciplinary Running title: MDT meetings in head and neck cancer.

Conflicts of interest: none.

Contact details: Dr. Markus Brunner Sydney Head and Neck Cancer Institute The Sydney Cancer Centre Royal Prince Alfred Hospital Missenden Road, New South Wales, 2050 Sydney, Australia Tel: +61295157537, Fax: +61295157483 E-mail: [email protected]

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process which may lead to differences between this version and the Version of Record. Please cite this article as an ‘Accepted Article’, doi: 10.1002/hed.23709

Head & Neck

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Abstract

Background In this study we prospectively audited the impact of head and neck multidisciplinary team meetings (MDM) on patient management. Study design: prospective analysis Methods We collected clinical data, the pre-MDM treatment plan, the post-MDM treatment plans, and follow up data from all patients discussed at a weekly MDM and we recorded changes in management. Results 172 patients were discussed in 39 meetings. In 52 patients (30%) changes in management were documented of which 20 (67%) were major. Changes were statistically more likely when the referring physician was a medical or radiation oncologist, when the initial treatment plan did not include surgery and when the histology was neither mucosal squamous cell cancer nor a skin malignancy. Compliance to the MDM treatment recommendation was 84% for all patients and 70% for patients with changes in their treatment recommendation. Conclusion Head and neck MDMs changed management in almost a third of cases.

Level of evidence: 2c

2 John Wiley & Sons, Inc.

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Head & Neck

Introduction Over the last 30 years, multidisciplinary team (MDT) meetings (MDM) have become an essential component of tertiary-level decision-making in the treatment of malignancy. It seems self-evident that the variety of specialist team members with their combined knowledge and expertise improve decision-making and therefore ultimately patient management and outcome. However, the evidence base for this assumption is not strong and is sometimes conflicting. The majority of the studies performed, in a wide range of malignancies other than head and neck cancer, show that MDT meetings change management and improve outcome [1-8], although these results could not be reproduced in all studies[9]. Data supporting the utility of MDMs in the management of head and neck cancer is scarce. In two studies Stalfors and colleagues [10, 11] focused on the impact of the use of telemedicine on the outcome of head and neck MDMs. They were able to demonstrate that presentation via telemedicine is cheaper and has comparable outcomes compared to traditional presentation. As yet, no study investigated the impact of MDMs on the management of patients with head and neck malignancies. The Sydney Head and Neck Cancer Institute has a longstanding head and neck MDM. Our hypothesis is that this meeting frequently changes patient management although a formal evaluation has never been performed. The purpose of this study was to prospectively document the impact of head and neck multidisciplinary meetings on patient management.

3 John Wiley & Sons, Inc.

Head & Neck

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Methods The study was performed in a prospective fashion between December 2011 and October 2012 at the Sydney Head and Neck Cancer Institute (SHNCI) at the Royal Prince Alfred Hospital, a tertiary care hospital in central Sydney. The proposed management plans of patients with head and neck tumors were documented before the MDM, the MDM recommended plan and potential changes to the initial plan were recorded after the meeting. Changes in the treatment plan were categorised as major or minor. Major changes involved a change in cancer treatment modality. Typical examples were the addition or omission of post-operative radiotherapy, the addition of chemotherapy to radiotherapy, recommendation of chemoradiotherapy rather than surgery, or observation instead of surgery following definitive chemoradiation. Minor changes consisted of alterations in the extent of a chosen modality (radiotherapy fields or dose, extent of surgical neck dissection), the addition of diagnostic tools (such as genetic testing and additional imaging studies) or research decisions (such as inclusion in a clinical trial). Consistent with these parameters, informing the clinician that a suitable trial existed was considered a minor change. However if the patients were actually included in the trial and received completely different treatment from that originally proposed, this was classified as a major change. Compliance with MDT recommendation was evaluated after completion of treatment Patients with recurrent disease were recorded with their new cancer location and staging. The MDM Process Consultants refer patients to the meeting by using a standardized form that contains demographic data (patient name, sex and age) and diagnostic data (pathological data including tumor location, TNM classification, stage and grade, and radiological data including all relevant imaging performed). In addition, and most importantly, the treating consultant’s management plan is outlined.

4 John Wiley & Sons, Inc.

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Head & Neck

A decision to refer to the MDM was at the treating physician’s discretion; hence not all head and neck malignancies treated at the SHNCI during this period were discussed at the meeting. Depending on the nature of the case and patient availability, patients may be reviewed clinically following discussion of the diagnostic findings, or alternatively discussed without subsequent clinical review. The meeting itself takes place once a week and is attended by surgeons, radiation oncologists, medical oncologists, radiologists, pathologists, nurses, speech and language therapists, dieticians, dentists and a data manager. In the first part of the meeting the treating physician presents each patient and available radiologic imaging and histology slides are discussed. In “discuss only” cases the MDT then either agrees on a treatment plan or alternatively may decide that clinical review of the patient is required. After all “new” patients are discussed, patients currently undergoing treatment are reviewed. Thereafter in the second part of the meeting new patients are clinically examined and discussion continues in a separate clinic room. Final documentation of the treatment plan is only recorded after all discussion regarding that patient has been completed. Statistical Analysis Data was recorded and filtered using Microsoft Excel (Microsoft, Seattle, USA). Statistical analysis was performed using Stata version 11.0 SE (StataCorp LP, College Station, TX). All statistics were 2-sided, and a value of p

Head and neck multidisciplinary team meetings: Effect on patient management.

The purpose of this study was for us to present our findings on the prospectively audited impact of head and neck multidisciplinary team meetings on p...
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