Gunnar Baatrup (ed.)Multidisciplinary Treatment of Colorectal Cancer10.1007/978-3-319-06142-9_1

1. Organizing the Multidisciplinary Team

Gunnar Baatrup^{1, 2}

(1)

Institute of Regional Health Science, University of Southern Denmark, Svendborg, Denmark

(2)

Department of Surgery A, Odense University Hospital, Svendborg, Denmark

Gunnar Baatrup

Email: gunnar@baatrup.com

Abstract

The multidisciplinary colorectal cancer team (CRC MDT) decides the treatment strategy after the disease has been diagnosed, classified, and staged by the team members. It also executes quality control after the treatment has been completed. The core MDT team consists of colorectal surgeons, oncologists, radiologists, and pathologists [3]. Some institutions also include patient care representatives and other disciplines in the team as they take on other obligations concerning the patient’s way from referral to discharge from the last follow-up visit [3].

The team should ensure that decisions are evidence based whenever possible and the decisions are based upon all necessary preoperative diagnostic and staging modalities. It is further ensured that diagnostics and staging procedures are of high quality and that no unnecessary procedures are delaying the treatment. The team defines guidelines to ensure that the patient flow is efficient, fast, and without dropouts. The team meetings are learning platforms for younger doctors in specialist training.

Organizing the Team

In organizing the CRC MDT, there are local matters to consider. The meetings can be organized in many different ways. The team has to define the tasks they want to take responsibility for. Not all teams will take responsibility for all the jobs listed below, but it may serve as a list from which you can choose those necessary to deal with in your hospital. It is a suggestion for those who have not yet found a satisfactory organization and may act as a checklist for those who have. Weekly meetings are to be recommended. Even if the patient number is low, it is not advisable to prolong the patients’ way through the system. The very complex diagnostic, staging, and treatment lead the patient through many consultations and periods of waiting before the treatment is completed. A study conducted in the Section of Colorectal Surgery, Haukeland University Hospital, through 2006–2008 revealed that the patient or the patient’s papers are transferred from one person to another 15 times before the patient is operated on in the case of rectal cancer and 6 times for colon cancer patients (not published). For psychological and possibly for outcome reasons [1, 2], the team must strive for an efficient and fast handling in every step toward end of treatment. More national guidelines are now indicating maximum times for the preoperative handling of these patients [3–5], and accidental dropouts have recently made headlines in the Norwegian newspapers. The team must consider cost-effectiveness of their algorithm for the preoperative handling of the patients. Unnecessary procedures should be identified and omitted from the routine. The team setting is, on the other hand, ideal for evaluating new procedures and defining research protocols. The team should, after some time, be able to answer questions as: Are we performing acceptably as compared to national results? Is transrectal ultrasonography or MRI of the pelvic region more accurate for T staging in our hands? Could we restrict MRI investigations to the large cancers? By omitting unnecessary procedures, we may be able to find time and resources to conduct investigations and research.

The team shall be responsible for:

Tailoring treatment

Deciding the general procedures for diagnostics, staging, and treatment

Conducting routine quality control

Organizing patient flow

Conducting research and quality control studies

Training younger doctors and nurses

The team consists of one or more dedicated representatives from colorectal surgery, medical oncology, radiotherapy, radiology, and pathology but serves also as an open meeting for training and education of younger colleagues. The team meets to demonstrate the clinical, radiological, and histological data obtained and from these data decide a treatment strategy. Each specialty takes responsibility for the data they obtain and offers a treatment best fitted to the individual patient. The team decision emerges from these facts. It might therefore seem unnecessary for the team members to have any detailed knowledge about the background for suggestions and decisions taken by their colleagues. The practical experience from the daily work clearly reveals that this is not the case. The quality of the discussion and decisions taken is very much dependent on the team member’s transdisciplinary knowledge and insight.

The UK guidelines [3] are defining a more extended MDT group to handle further aspects of the patient’s disease and treatment. They recommend the participation of a palliative team, dedicated nurses, physiotherapists, medical coordinator, and a team secretary. Further they describe the staff involved in an “extended MDT” from gastroenterology, liver surgery, thoracic surgery, interventional radiologists, GPOs/primary care teams, diarists, liaison psychiatrist, social worker, clinical genetics, and research nurse.

The participation of a geriatric specialist may be useful to many colorectal cancer cases.

The entire staff taking care of the patient throughout his hospital contact consists of many other specialties and professions. Indeed, the patient may remember his hospitalization as mainly managed by professionals who are not members of the CRC MDT. The CRC MDT is not meant to be a forum for all professionals involved in the treatment and care of the CRC patients, and it is critical for the team to focus on well-defined tasks. The team aspect of problem solving may add further complexity to the administration of the patient flow. The aspects handled by the team should therefore primarily be those which benefit from the team approach.

In larger centers also dealing with surgical treatment of liver metastasis, the CRC MDT is often additionally handling these patients at the same meeting. Alternatively the liver MDT may be held immediately before or after the CRC MDT meetings as some of these patients will need discussion between the two teams. This may be even more important as the “liver-first strategy” is becoming more widespread in the case of synchronous liver metastasis¹. The entire strategy for resection of the primary tumor and resection or destruction of liver metastasis and oncological adjuvant and neoadjuvant treatment will have to be coordinated.

Ad hoc groups may be formed to discuss the rare cases for intended curative treatment of cancers involving other organs.

Tailoring Treatment for the Individual Patient

During the meetings, easy access to all results, photo-documentation, and radiologic demonstration is ensured. In high-volume centers, it is important that the demonstration is well organized and all relevant data immediately accessible. One appointed member is responsible for the demonstration and the accessibility of data during the meeting. It should be allowed to include patients for demonstration until shortly before the meeting, and the preparation should be done by all team members immediately before the meeting. The file containing data of the patients of the week should therefore be accessible to all team members. The presentation of each patient is often performed by the surgeon who has been talking with the patient about options and preferences. A decision on the treatment strategy is agreed upon for each patient based upon the patient’s physical performance and age, the stage and grade of the disease, and the available facilities for treatment. The motivated decision is documented together with the name of the doctor in charge of the patient. This is the main focus of the weekly meeting regarding the treatment of the patient.

If the team has taken responsibility for individualized care and support as well, nurses and physiotherapists will offer a plan for introducing the patient to the facilities for the course of his postoperative recovery and mobilization and to scrutinize the patient’s resources and preferences and prepare him in the case a stoma may be necessary.

Some teams also perform quality control and feedback on a weekly basis at these meetings. The final histology of tumors from patients operated earlier is compared with the results from the preoperative staging. Photos documenting the quality of the operation specimen are shown to adjust the patient’s prognosis [6] and decide upon any further oncological treatment. Other centers have monthly or rarer meetings for quality control to allow a higher number of patients to be evaluated at the same time.

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