The multidisciplinary colposcopy meeting: recommendations for future service provision and an analysis of clinical decision making

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1 DOI: /j x Gynaecological oncology The multidisciplinary colposcopy meeting: recommendations for future service provision and an analysis of clinical decision making JE Palmer, a K Wales, b K Ellis, c N Dudding, c,d J Smith, d,e JA Tidy a a Department of Gynaecological Oncology/Jessop Wing Colposcopy Unit, Sheffield Hospitals NHS Trust, Sheffield, UK b Department of Obstetrics & Gynaecology, Sheffield Hospitals NHS Trust, Sheffield, UK c Department of Cytology, Sheffield Hospitals NHS Trust, Sheffield, UK d East Pennine Cytology Training Centre, Tingley, Leeds, UK e Department of Histpoathology, Sheffield Hospitals NHS Trust, Sheffield, UK Correspondence: Dr J Palmer, c/o Department of Gynaecological Oncology, Royal Hallamshire Hospital, Glossop Rd, Sheffield, S10 2JF, UK. palmer006@btinternet.com Accepted 26 May Objective In 2004 the NHS Cervical Screening Programme (NHSCSP) recommended that multidisciplinary meetings should be incorporated into patient management. No data has been provided since then regarding its functionality or benefits. We aim to address this issue. Design Retrospective review. Setting Jessop Wing colposcopy multidisciplinary meeting (MDM), Sheffield, UK. Population All women referred to the MDM from September 2003 to September Methods Retrospective review of the colposcopy database (Sept 2003 Sept 2009), cross-referenced with multidisciplinary team (MDT) letters, patient notes and the hospital results reporting system. Baseline statistics were used for data analysis. Main outcome measures Indications for MDT referral; concordance rates from cytopathology and histopathology review; concordance rates between MDT treatment decisions and final patient management. Results A total of 535 cases were discussed at 62 MDT meetings during the allocated study period. referral cytology and cervix punch biopsy was the most common referral (49%). Cytology and histology review concurred with the initial reports in 75.8 and 97.8% of cases, respectively; the MDT decision was concordant with the final patient management in 97% of cases. The main reason for discordance (67%) resulted from patient factors. Conclusions When significant discrepancies exist between colposcopy, cytology and histopathology, then MDT discussion seems pertinent as MDT discussion can lead to the avoidance of over-treatment. To improve timeliness of treatment, MDT meetings should occur at least monthly. The results of each case discussion should be recorded in the patient case notes, the minutes of each meeting should be circulated to all MDT members and a letter describing MDT recommendations must be sent to the colposcopist responsible for patient care. Keywords Colposcopy, cytology, gynaecology, multidisciplinary team, multiprofessional. Please cite this paper as: Palmer J, Wales K, Ellis K, Dudding N, Smith J, Tidy J. The multidisciplinary colposcopy meeting: recommendations for future service provision and an analysis of clinical decision making. BJOG 2010;117: Introduction Since the introduction of the Calman Hine report in 1995, 1 the importance of multidisciplinary team (MDT) working in cancer services has been repeatedly emphasised, resulting in an MDT approach to patient cancer management being widely adopted in the UK. In 2004 the colposcopy and programme management guidelines for the NHS cervical screening programme (NHSCSP) 2 recommended that multidisciplinary meetings (MDMs) should be incorporated into patient management, including histopathology, cytopathology and colposcopy review. It was suggested that MDMs should be held at least twice a year to discuss difficult cases, cases with significant mismatch between cytopathology and colposcopy, and borderline glandular and glandular smears. The new NHSCSP document 20 (Leusley D, Leeson S. NHS Cancer Screening Programmes unpubl data) will recommend that the MDT should meet often enough to allow for the timely care of women: once each month (best practice) or no less than once every 2 months. Whereas the Improving Outcomes Guidance 3 and the Manual for Cancer Services 4 provide direction with regard 1060 ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology

2 The multidisciplinary colposcopy meeting to the MDT function in gynaecological cancers, further guidance regarding the colposcopy MDT is yet to be provided. Research on the effectiveness of MDMs and MDTs in cancer management is lacking, 5 8 and, although suggestions have been made regarding the advantages and disadvantages of an MDT approach to cancer care (see Table 1), no systematic reviews have yet been performed. 9 Information regarding the function and benefits of the colposcopy MDT is even rarer, with, to date, only one publication reporting an activity review. 10 Assessing the effectiveness of an MDT is fraught with difficulty as the ultimate indicator in cancer care is improved patient outcome or survival. The ability to substantiate improvements in patient care purely consequential to MDT discussion, over the general improvements in patient management resulting from advances in surgery, and radiotherapy or chemotherapy techniques, is extremely difficult to ascertain, and, despite cancer MDTs being readily accepted and established within patient management protocols, very little information is available regarding improved outcomes arising from discussion at an MDM alone. In turn, assessing the benefits of a colposcopy MDT is also extremely difficult, and is even harder to establish as there are no set indicators of improved patient outcome. Blazeby et al. 11 proposed that one method of evaluating treatment decisions is to investigate whether or not those decisions are actually implemented. As data regarding colposcopy MDMs on the whole is lacking, we shall review the indications for colposcopy referral, the concordance rates from cytopathology and histopathology review and, in reference to the proposed methods of Blazeby et al., we shall consider the concordance between MDT treatment decisions and their final implementation in patient management within our own unit. Methods The colposcopy MDM at Sheffield Hospitals NHS Trust commenced in September The MDT group consists of colposcopists, cytopathologists and histopathologists, and has previously been and is currently led by a consultant in gynaecological oncology (JT and JP, respectively). For the purposes of this paper cytopathologists are taken to include either consultant medical staff and/or consultant biomedical scientists. The meeting is currently held on a monthly basis, with all attendees included in the discussions and all members of the MDT able to make referrals to the MDM via referral proforma sheets. Decisions made at the MDM are recorded by the colposcopy lead, and letters are written to the patients named colposcopist with details of the MDT discussion. Minutes of the meeting are also circulated to all MDT members, and over the last 12 months an MDM database has been established with data prospectively added from February 2009, and data from prior discussions added retrospectively following a review of minutes, letters and patient notes. The colposcopy database was retrospectively reviewed and cross-referenced with the corresponding MDM letters and, where appropriate, patient notes. All results were cross-checked against the hospitals clinical reporting results system. To assess concordance between MDT treatment decisions and their final implementation, patient letters, notes and results were again fully examined. Baseline statistics were used for the data analysis. Results Between September 2003 and September 2009 there were 62 colposcopy MDT meetings held at Sheffield Teaching Hospitals. From September 2003 to December 2004 meetings were held every 2 months, then monthly from thereon. All meetings were quorate (i.e. were attended by at least one histopathologist, a cytopathologist and a colposcopist). Five of eight colposcopists, all cytologists and all pathologists achieved a >50% attendance rate. During the study period 535 cases were discussed in total. An average of nine women were discussed at each meeting (range 3 16) with 1 hour allocated for each meeting. The mean age of the women discussed was 39 years (range years). Forty-six women (9%) were younger than 25 years of age, and seven women (1%) were older than 65 years of age. Women were referred to the colposcopy MDM by British Society for Colposcopy and Cervical Pathology (BSCCP) certified colposcopists (90%), trainee colposcopists (7%), histopathologists (1%) and cytologists (2%). Of the certified colposcopists, consultants made 44%, colposcopy practitioners made 25% and nurse colposcopists made 31% of the referrals, which was in keeping with the unit s clinical distribution of workload. Twentyseven women (5%) were discussed at more than one meeting, with a maximum of four discussions for one woman. The most common reason for MDM referral was because of a discrepancy between referral cytology and cervix punch biopsy (49%). In total, 433 cytology specimens and 372 histology specimens were reviewed during the allocated study period. Indications for MDM referral and concordance rates between referral cytology and histopathology review are illustrated in Table 2. Where an MDT review had been requested for purposes of further management discussion, the majority were cancer cases. Although this is a relatively small number of cancer cases, this purely reflects our policy of preferably discussing these cases at the gynaecological oncology MDM. Further management was discussed in 12 cases (13%) because of the presence of a glandular abnormality, nine (10%) for persistent low-grade dyskaryosis, eight (9%) ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology 1061

3 Palmer et al. Table 1. Proposed advantages and disadvantages of multidisciplinary teams and multidisciplinary meetings Advantages Disadvantages Patient centred Pooling of knowledge and expertise leading to higher quality diagnosis, 7 and evidence-based decision-making. 12 Inadequate communication between MDT members could lead to confusion for patients about diagnoses, prognoses and future management plans. 9 Optimum treatment planning. 6,7 Team discussion may not necessarily improve the quality of decision making overall. 12 Optimum delivery of care. 7 Decisions made at multidisciplinary meetings are not always implemented. 11,12 May be safer because a team creates an additional defence against error by monitoring and double-checking decisions. 8 Reduction in patient anxiety because the patient has the knowledge that treatment is based upon the opinion of several experts. 8 Provides continuity of care. 8 Shown to have a positive effect on patient outcome. 6 Pathology review has been identified as resulting in appropriate patient management. 14,15 In breast cancer there is evidence that improved survival was associated with management by an MDT, 16 and that patients cared for by an MDT rather than by a series of individuals have an improved survival 10 years post diagnosis. 17 Team centred Improved communication between different specialists. 8,18 Barriers to attendance leading to limited attendance: e.g. oncologists and pathologist having several site-specific meetings to attend. 24 Constraints of job plans. Beneficial to the mental health of members. 19 Types of cases selected and attendance by key staff vary. 25 Mutually supportive environment in complex cases. 7 Time constraints within the meetings. 8 Educational opportunities: learning about new developments and clinical trials. 13,18,20,21 Multidisciplinary decisions are sometimes not even documented. 26 Platform for recruitment into clinical trials. 21,22 Ever increasing numbers of referrals and need for quick response. In oncology cases, the presence of MDT clinicians provide pathologists with additional clinical Lack of administrative support. information that may alter or affect patient diagnosis. 13,23 Institution centred Enhance communication between primary-care health professionals and hospital-based specialists. 7 Institutional resistance. 7 Quality assurance role. Time consuming for clinicians leading to manpower & logistical difficulties. 28 May enhance implementation of protocols. 8 Resource expensive. Suggested increased recruitment into trials. 21 Constraints on job planning. Pathology review: identified as cost effective. 27 In gynaecological cancer, tumour boards have led to the identification of several major diagnostic discrepancies ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology

4 The multidisciplinary colposcopy meeting Table 2. Concordance between referral cytology and histopathology, and MDT review Histology review regarded as under-call Histology review regarded as over-call Histology review concordant Cytology review regarded as under-call Cytology review regarded as over-call Cytology review concordant Categories for MDT Referral n (%) 9 (39%) 0 5 of 5 (100%) (4%) 14 of 23 (61%) (one sample unavailable for review) cytology and colposcopy 261 (49%) 175 of 246 (71%) 71 (29%) of 224 (98%) 1 (0.4% 4 (1.6%) cytology and punch biopsy 25 (5%) 22 of 25 (88%) 3 (12%) 0 24 of 24 (100%) 0 0 cytology and loop/knife cone 17 (3%) 2 of 2 (100%) of 17 (94%) 1 (6%) 0 biopsy and loop/knife cone Review of cytology 95 (18%) 77 of 95 (81%) 17 (18%) 1 (1%) 18 of 18 (100%) 0 0 Review of biopsy/loop/cone 16 (3%) 2 of 2 (100%) of 16 (94%) 0 1 (6%) Discussion on further 93 (17%) 33 of 37 (89%) 4 (11%) 0 64 of 65 (98%) 1 (2%) 0 management Educational discussion 4 (1%) 3 of 3 (100%) of 3 (100%) 0 0 Totals (n) (%) 535 (100%) 328 of 433 (75.8%) 104 of 433 (24%) 1 of 433 (0.2%) 364 of 372 (97.8%) 3 of 372 (0.8%) 5 of 372 (1.4%) were immunocompromised with persistent cytological abnormality, five (5%) had persistent high-grade abnormality despite prior treatment, five (5%) had an inadequate colposcopic assessment, four (4%) had vaginal or vault lesions and nine (10%) were discussed for other reasons. The four cases discussed for educational purposes only were all referred by the lead pathologist (JS). The MDT cytology review concurred with the initial cytology report in 328 cases (75.8%). Where cytological overcall was identified, this was by at least two cytological grades (i.e. high-grade dyskaryosis downgraded to lowgrade dyskaryosis). The MDT histology review concurred with the initial histology report in 364 cases (97.8%). With regard to histology under-call, one punch biopsy had been reported as normal when high-grade cervical intraepithelial neoplasia should have been reported, but a secretarial typing error was identified at the MDM. Follow-up data was available for 509 of the 535 patients (95%), as 26 women awaiting colposcopy and/or repeat cytology at 6 or 12 months post-mdt discussion had not been seen by the end of the study period. The MDT decision was concordant with final patient management in 494 of 509 women (97%). Fifteen (3%) MDT decisions failed to comply with final patient management. Reasons for non-compliance with the MDT decision are provided in Table 3. In 67% of cases in which non-compliance was reported the reason for non-compliance with MDT decisions was because of a patient factor, and in 23% the reason was because of a clinician factor. Discussion Current NHSCSP guidelines suggest that multidisciplinary meetings (MDM) should be held at least twice a year. 2 We agree with Moss et al. 10 that this is not appropriate for the volume of workload undertaken in most colposcopy units. We recommend that best practice would be to meet on a monthly basis, and, where this is not feasible, meetings should occur at least every 2 months. When a gynaecological malignancy is detected through cervical screening or colposcopy services then we recommend that these cases are reviewed by the gynaecological cancer centre MDT, as such meetings tend to occur on a weekly basis, permitting the timely care of women in keeping with the 62-day pathway guidelines for cancers detected through the cervical screening pathway. 29 Alternatively, the colposcopy MDT could be held as a distinct part of the gynaecological cancer MDT. The NHSCSP colposcopy and programme management guidelines document upgrade (unpubl data) recommends that all colposcopists attend at least 50% of MDT meetings to ensure the timely management of difficult cases and discordant results. Three colposcopists (all gynaecological ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology 1063

5 Palmer et al. Table 3. Reasons for non-compliance with MDT decision in final patient management MDT decision Final management outcome Patient factor Clinician factor Recommend total abdominal hysterectomy: prior large loop excision of the transformation zone, now indicating severe dyskaryosis/invasion. Repeat colposcopy and smear in 6 months. Repeat smear in 12 months. Loop excision recommended. Recommend knife cone. Cervix excised only because of patient habitus. Three women did not attend. Patient deferred to private sector. Repeat punch biopsy only at patient request. Patient declined treatment and requested conservative management. Patient did not attend. Hysterectomy performed for medical reasons. Loop excision at patient request for persistent low-grade dyskaryosis. Repeat colposcopy and smear in 6 months (clinician not at MDM) three women. Colposcopy and biopsy in 3 months discretion of colposcopist as reported atrophic changes. Other Repeat colposcopy and smear in 12 months. Punch biopsy reported at the MDM after colposcopy showed invasion: referred to the gynaecological oncology MDT oncologists) were unable to attend 50% of meetings because of other commitments. This new recommendation means that job plans may need to be re-negotiated. As numerous barriers to MDT attendance may occur (see Table 1), we support the recommendation that the results of each case discussion are not only recorded in the patient case notes with the minutes of each meeting circulated to all MDT members, but that a letter describing MDT recommendations are sent to the colposcopist responsible for patient care. This is important as individual team members find it difficult to attend every MDM, and the decisions made by the MDT on behalf of their patients need to be clear during these periods of non-attendance. 12 We also recommend the use of a colposcopy database as a further quality assurance and service review measure. Designating referral criteria for a colposcopy MDM can be difficult. Although discussion regarding discrepancy between cytology and histology seems pertinent, 10 the inclusion of all mismatch is likely to result in an extremely large MDT workload. We therefore recommend that a mismatch of at least two grades between cytology, colposcopy and histology is included at the discretion of the colposcopist. We also recommend MDT discussion for patients younger than 25 or older than 65 years in age, in whom high-grade cervical intraepithelial neoplasia is detected, or where cytological abnormality persists. Glandular abnormalities should also be reviewed at the colposcopy MDT at the clinician s discretion as, although review of all cases might be ideal, this may also lead to a significantly increased workload. 10 The referral criteria that are most difficult to define is in patients where the clinician has requested further discussion regarding future management, as these cases are often less than straightforward. We therefore agree with Moss et al. 10 that additions to the colposcopy MDM falling outside of any standardised referral criteria should be allowed at the discretion of the team. In this study it is disappointing that only four cases (<1%) were specifically included on the MDM for educational discussion. Although every case discussed could be regarded as potentially educational, and discussion regarding new developments and clinical trials occur in our MDM, these latter discussions are not recorded in our minutes. Although educational opportunities are considered to be a benefit of MDT working (see Table 1), it remains difficult to assess the educational value of the MDM, especially on an individualised basis. Little has been discussed in the literature regarding the benefits of cytology review. Moss et al. 10 found a 79% concordance rate in cytology and a 92% concordance rate in histopathology when considering MDT referrals for a discrepancy between referral cytology and loop excision histology, and these results are similar to our own findings (75.8% concordance for cytology and 97.8% for histology). As 24% of our cytology reviewed at MDT was regarded as over-call, then MDT case review may have enabled the avoidance of over-treatment in some cases. The NHSCSP is a world leader in cervical screening, developing systems and guidelines to ensure a high quality of cervical screening throughout the UK. Sheffield also benefits from having a high diagnostic accuracy cytology laboratory exhibiting high specificity. In the international setting it is possible that there might be more cases of discordant cytology in laboratories with poorer sensitivities/ 1064 ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology

6 The multidisciplinary colposcopy meeting specificities, and in these circumstances MDT discussion might result in improved patient care. Anecdotally, there has been a degree of skepticism as to whether MDTs are of value, 29 yet assessing the value of an MDT is fraught with difficulty. In this case we have used Blazeby s 11 model, by investigating whether MDT treatment decisions were actually implemented. The MDT decision was concordant with final patient management in 97% of cases. The responsible clinician was not present at the MDM in all four cases of discordance with the MDT decision arising from a clinician factor. In future, we recommend that all such cases are re-discussed at the MDM. As in this study, MDT decision discordance is suggested to arise almost always from patients receiving a more conservative treatment than originally planned. 11 Patients may decline treatment, or patients and clinicians may opt for a more conservative approach to management. Whenever possible, however, patient wishes should be accounted for at the time of decision making. Conclusion Multidisciplinary team working has been widely incorporated into UK practice in cancer care, and more recently into non-cancer patient management, with the colposcopy MDT being one such example. There is little evidence, however, for any direct effect of MDT working on improved patient outcomes under any circumstances. Where significant discrepancies exist between colposcopy, cytology and histopathology, discussion at an MDM seems pertinent, as colposcopy, cytology and histopathology are well known to have associated false-negative and false-positive rates. An MDT discussion can result in the avoidance of over-treatment, and the safe and effective treatment of high-grade precancerous lesions. 30,31 In an aim to evaluate the treatment decisions made in our own colposcopy MDT, we investigated whether or not decisions were actually implemented. We found high concordance rates (97%). The majority of discordance came from patient factors, largely where patients wished for an alternative management approach to that planned by the MDT. If anything, this has highlighted that patient wishes need to be accounted for prior to discussion at the MDM, whenever appropriate. Disclosure of interests The authors state that they have no conflicts of interest: there were no affiliated sponsors and no funding for this article. Contribution to authorship JP conceived, designed and performed the study, analysed the data and wrote the paper. KW analysed the data and wrote the paper. ND, JS and JT conceived and designed the study, and wrote the paper. Details of ethics approval Ethical approval was not required for this study. Funding There was no associated funding. 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