Multi-Disciplinary Meetings and Units

Introduction
Researching the effectiveness of multi-disciplinary units and meetings, most data has been done on breast units. This information can be extrapolated for other disciplines. Multi-disciplinary units are the backbone of effective multi-disciplinary meetings.

Specialization in general surgery has been evolving over the past few years. Indeed, surgeons with a specialty interest have generally had extra training in their specialty - hereby improving their skills and increasing their depth of knowledge and experience. These surgeons (with special training and expertise) should treat patients with breast cancer because surgical sub-specialisation in common cancers improves the standard of care, and outcome. Indeed, many studies have shown the benefits (ie, improved patient outcome) of sub-specialisation - when patients are treated by surgeons with a specific interest.

International MDM data
Many international reports state that patients treated in a Breast Unit have a better overall outcome. In a Breast Unit, although the primary care of breast cancer is the responsibility of surgeons, overall management also involves radiologists, pathologists, and oncologists (with a special interest and training in breast disease) - ie, a multidisciplinary approach.

Guidelines state: ‘Breast cancer is a complex disease requiring collaboration of a number of health disciplines for its diagnosis, treatment and follow-up. Multidisciplinary management can be best achieved by development of a multi-specialist clinic’.

Indeed, there is evidence that a specialist breast clinic improves efficiency of diagnostic work-up and there is also evidence from the United Kingdom (UK), showing that a lack of a multidisciplinary approach to breast cancer-management adversely affects prognosis.

In 1995, the British Association of Surgical Oncology (BASO) Breast Specialty Group published Guidelines for Surgeons in the Management of Symptomatic Breast Disease in the United Kingdom, which was revised in 1998. These guidelines state: ‘breast cancer care should be multidisciplinary, providing services as a team from the early detection through to the care of advanced disease’.

In the UK, the National Institute for Clinical Excellence (NICE) published an updated manual Improving Outcomes in Breast Cancer in August 2002. The key recommendations include ‘establishment of a multidisciplinary team’.

The Florence Statement’ demanded that all women have access to multidisciplinary breast clinics based on populations of around 250,000; also it called for mandatory quality assurance programmes for breast services.

Guidelines have been generally well received and have been influential in the introduction of multidisciplinary units working in several countries.

The importance of the establishment of multidisciplinary breast units was again stressed in ‘The Hamburg Statement’ which followed EBCC4. Approval was given to this in the European Parliament to make available for all women in Europe a high quality specialist Breast Service.

Current patient care in South Africa and local background
Unfortunately multi-disciplinary units that fit all the recommended criteria (see below ) are not the norm.

Problems
Establishing multi-disciplinary units in a country where financial and service diversity is huge in fraught with potential problems. Discrepancies in education, information and awareness in breast health result in women presenting with both early and locally advanced disease at initial presentation.

Access to health care let alone specialized breast units differs in urban and rural communities. Diagnosis of breast cancer is often made by Fine needle aspiration without radiology and treatment decisions based on sub-optimal information.

Access to specialized surgical units where reconstruction is offered is difficult for patients.  Radiation therapy and oncology units are often not based nearby to the surgical units. Supportive care for patients in their own communities is often not available.

Solutions
The first step to setting up multi-disciplinary units is ensure that like a few like minded physicians are prepared to work together, and concurrently a small dynamic group of patients must create media and patient advocacy around the value of multi-disciplinary units.

Usually the surgeon plays a central role - both in the coordination of this multidisciplinary team, and in the establishment of the Breast Unit itself. Indeed, the patient’s first contact is likely to be with a surgeon who (with the radiologist and pathologist) establishes the diagnosis, and subsequently provides the initial treatment.

The core members of the multidisciplinary team include: breast surgeons, breast care nurses, radiologists, pathologists, oncologists (medical and radiation), plastic and reconstructive surgeons, physiotherapists and psychologists.

Future Developments
The benefits of multidisciplinary management of breast cancer have been debated for some time. Multidisciplinary units in metropolitan centres are justified by their logistic advantages, by the opportunity to establish high standards with consistent peer review and by the small, but demonstrable, improvement in outcome.

Telephonic, computer based and specialist central referral units are all ways to improve peripheral cancer management.

The requirements of a specialist breast unit
Multi-disciplinary Unit/Meeting Composition.

The Breast Unit must have an identified Clinical Director of Breast Services.

Administration staff - they should all have close liaison with the patients and the doctors.

Breast Surgeons (In Europe this may include Gynaecologists performing breast surgery). Two or more nominated surgeons specially trained in breast disease, each of whom must personally carry out the primary surgery on at least 50 newly diagnosed cancers per annum and must attend at least one diagnostic clinic per week.

For an average sized unit the surgeons will need at least eight identified ca. 4 hr sessions per week in Breast Disease. These sessions will allow for operating time, participation in diagnostic clinics, a follow-up clinic and, where appropriate, screening assessment clinics. A session must be allowed for attendance at a weekly team case management and audit meeting.

A Unit team must provide breast surgical reconstruction when required for those patients not suitable for breast conserving therapy and be able to apply special techniques for patients with extensive local disease. The breast surgeons in the team should be able to undertake basic reconstruction or recontouring and there should be a standard arrangement or joint reconstruction clinic with one or two nominated Plastic Surgeons (non-core team member) who take a special interest in breast reconstructive and recontouring techniques.

Breast Radiologists
There must be at least two nominated radiologists, fully trained and with continuing experience in all aspects of breast disease and associated imaging, tissue sampling and localisation procedures under image control. Ideally any radiologist investigating breast patients should participate in the screening programme in countries in which this is established and must participate in a national or regional QA scheme. This involves reading a minimum of 1000 mammograms per year (5000 for those participating in a screening programme).They must attend multidisciplinary meetings for case management and audit purposes. They must be present in diagnostic assessment clinics with the surgeon. Each radiologist must attend at least one diagnostic clinic per week for symptomatic patients or screening assessment.

Breast Pathologists
A lead pathologist plus usually not more than one other nominated pathologist, specialising in Breast Disease, will be responsible for all breast pathology and cytology.

Pathologists carrying out these roles must have contractual sessions to attend team case management and audit meetings. They must be familiar with national and/or European performance quality standards and appropriate guidelines.

Breast Oncologists
A nominated radiation oncologist must arrange the appropriate delivery of radiotherapy. He/she must hold advanced disease clinics with other members of the breast team at the Breast Unit and must take part in the case management and audit meetings of the Unit.

In some countries, Clinical Oncologists carry out both radiation therapy and prescribe the chemotherapy. In centres in which a Medical Oncologist gives the chemotherapy he/she should be a member of the core team and take a full part in case management and audit meetings.

Breast Diagnostic Radiographers (Technicians)
Radiographers with the necessary expertise and training in mammography are essential members of the team. They must fulfil the training and working practice recommendations.

Size
A Unit must be of sufficient size to have more than 150, newly diagnosed cases of primary breast cancer (at all ages and stages) coming under its care each year.

Note: these are newly diagnosed breast cancers. They may have been diagnosed elsewhere but if they have received any prior treatment and have been transferred, for example, to receive radiotherapy, they should not be counted.

All primary treatment must be carried out under the direction of the Unit (operation must be in the unit, adjuvant therapies must be directed by the unit but may have been received in other settings e.g. RT and chemotherapy). Follow up should be under the control of the Unit.

The reason for recommending a minimum number is to ensure a caseload sufficient to maintain expertise for each team member and to ensure cost-effective working of the Breast Unit as the establishment of a clinic staffed by experts is expensive and must have a high through-put of patients.

Outreach
A Breast Unit should hold outreach clinics for symptomatic referred women, screening assessment and follow-up, in the smaller hospitals in the neighbourhood if these are at a distance from the Breast Unit.

Breast Units must provide care of breast disease at all its stages - from screening through to the care of advanced disease . There must be a system covering audit. A data manager must enter data on diagnosis, treatment, pathology and clinical outcomes contemporaneously.

Patient Support staff
Regular support (advice, counselling, psychological help) is given by Breast Care Nurses, in some countries or by professionally trained persons with expertise in psychology. These persons must be members of the core team. They must be available to counsel and offer practical advice and emotional support to newly diagnosed patients at the time the diagnosis is given, to aid  in explaining  treatment plans. They should also be available on demand from patients in the Primary Breast Cancer Follow up clinic and in the Advanced Breast Clinic. Particularly they must be present to support women when the diagnosis is given that the disease has become advanced.

Informing Patients
It may not be possible (now that core biopsy is most often used) or may not be considered appropriate by the unit to give the diagnosis of cancer at the initial visit. Women found to have breast cancer should receive that diagnosis within 5 working days. The diagnosis should be ideally communicated personally by the surgeon: if it is communicated by the radiologist, then the surgeon (±) the oncologist must personally advice the patient on treatment.

It is recommended that a breast care nurse (or) psychologically trained person be present to discuss fully with the patient the options for treatment and to give emotional support.

It may be more appropriate that an oncologist rather than a surgeon gives the diagnosis if the patient’s treatment does not involve surgery.

A suitable room with sufficient privacy must be available. In units in which preoperative irradiation or primary medical therapies are used, cases which might be suitable for these should be seen jointly by a surgeon and radiation or medical oncologist before treatment commences.

A diagnosis should not be given to a patient by letter or on the telephone, unless at the specific request of the patient given adequate and full informed choice.

Women must be offered clear written and oral information regarding their diagnosis and/or treatment options. The Breast Unit should also provide written information concerning local out patient support groups and advocacy organisations and should also respect the patients rights.

Communication

	A communications framework should be established which supports and ensures interactive participation from all relevant team members at regular and dedicated case conference meetings.
	Multidisciplinary input should be considered for all women with breast cancer, however, not all cases may ultimately necessitate team discussion.

Full therapeutic range

	Geographical remoteness and/or small size of the institution delivering care should not be impediments to the delivery of multidisciplinary care for women with breast cancer.
	The members of the team should support the multidisciplinary approach to care by establishing collaborative working links.

Standards of care

	All clinicians involved in the management of women with breast cancer should practice in accord with guideline recommendations.
	The treatment plan for a woman should consider individual patient circumstances and wishes.
	Discussion and decisions about treatment options should only be considered when all relevant patient results and information are available.
	In areas where the number of new cancers is small, formal collaborative links with larger units/centres should give support and foster expertise in the smaller unit.
	Maintenance of standards of best practice is supported by a number of activities which promote professional development.

Involvement of the woman

	Women with breast cancer should be encouraged to participate as a member of the multidisciplinary team in treatment planning.
	The woman diagnosed with breast cancer should be fully informed of her treatment options as well as the benefits, risks and possible complications of treatments offered. Appropriate literature should be offered to assist her in decision making. This information should be made available to the woman in a form that is appropriate to her educational level, language and culture.
	Supportive care is an integral part of multidisciplinary care. Clinicians who treat women with breast cancer should inform them of how to access appropriate support services.
	The woman with breast cancer should be aware of the ongoing collaboration and communication between members of the multidisciplinary team about her treatment.

Women are supported to have as much input into their treatment plan as they wish. All women should be fully informed about all aspects of their treatment choices.

All clinicians involved in the management of women with breast cancer should ensure that women have information about and access to support services.

Multidisciplinary Unit Running and Meetings
Units must record the basic data on diagnosis, pathology, primary treatment and clinical outcomes. The data must be available for audit and the Unit team should hold regular audit meetings inspecting separate topics and designing and amending protocols and QA systems. These meetings must be minuted.

Performance and audit figures must be produced yearly and set alongside defined quality objectives and outcome measures, such as those laid down in the EUSOMA Guidelines or in other suitable guidelines.

The Unit must have written protocols for diagnosis and for the management of cancer at all stages (primary and advanced cancer). All protocols must be agreed upon by the core team members. The following should be discussed at the weekly multi-disciplinary meetings.

	Cases in which the diagnosis is as yet uncertain e.g., following core biopsy.
	Cases in whom the diagnosis of cancer is confirmed and who may be considered for primary oncology (chemotherapy or endocrine)  therapy.
	All cases following surgery on receipt of the histopathology for discussion of further care and cases in follow-up who recently have undergone diagnostic investigations for possible symptoms of recurrent or advanced disease.

It is possibly more convenient to have two MDM’s per week:

	One for cases in diagnosis attended by surgeons, radiologists and pathologists and;
	One for post-operative consideration of prognosis and adjuvant therapies and for cases investigated for disease recurrence (oncologists, surgeons, radiologists and pathologists).

Relationship issues between collegues
An examination of the relationship between cancer teams and the quality of care delivered showed MDT working benefited patients through improved access to, and use of, standardised and up-to-date therapy (Landheer et al, 2001). Papers outline the necessity of a multidisciplinary approach for optimizing outcome in patients with cancer (Van Laethem et al, 2001; Blumberg and Ramanathan, 2002) and some evidence exists to show that specialized multidisciplinary units increase the efficacy and efficiency of the management of patients with cancer (Shankar et al, 2001; Soriano et al, 2002; Haward et al, 2003). However, quality of clinical care and team effectiveness has been shown to be related to team composition, working methods and workloads (Haward et al, 2003).

Found team leaders (who were invariably surgeons) and the nurses appeared prone to high levels of burnout on the emotional exhaustion subscale while it was the radiographers who had the greatest proportion (40%) reporting high levels of depersonalisation. Feelings of low levels of personal accomplishment were a pervasive problem for the histopathologists (69%) and a considerable proportion of the radiologists (43%). Women with breast cancer feel that their care is coordinated and not fragmented.

The final Data for multi-disciplinary units
The concept of a MDT should not merely be a group of professionals who work essentially independently and occasionally liase with one another (Miller et al, 2001). Effective interprofessional team working needs the evolution of a shared team culture, open communication, mutual respect for all the practitioners and equal value to be placed on their contribution to current team practices (Freeman et al, 2000). It is suggested that this can only be achieved when each member of the team understands the others' contributions to care, as well as understanding how and why they practise in the way they do and this requires group process to be nurtured (Miller et al, 2001). The expectation is that successful multidisciplinary teamwork is beneficial both for the patient and members of the team.

Combined modality therapy is emerging as the treatment of choice for patients with breast cancer leading the way to multidisciplinary management (Hortobagyi, 1994).

So in conclusion…. What are we waiting for…..Lets work together to ensure better patient care.