MULTIDISCIPLINARY CANCER CONFERENCES: EXPLORING OBSTACLES AND FACILITATORS TO THEIR ESTABLISHMENT AND FUNCTION. Nicole J.

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1 MULTIDISCIPLINARY CANCER CONFERENCES: EXPLORING OBSTACLES AND FACILITATORS TO THEIR ESTABLISHMENT AND FUNCTION. by Nicole J. Look Hong A thesis submitted in conformity with the requirements for the degree of Master of Science, Clinical Epidemiology Graduate Department of Health Policy, Management and Evaluation University of Toronto Copyright by Nicole J. Look Hong 2008

2 Abstract Multidisciplinary Cancer Conferences: Exploring obstacles and facilitators to their establishment and function. Nicole J. Look Hong Degree of Master of Science, 2008 Department of Health Policy, Management and Evaluation, Division of Clinical Epidemiology University of Toronto, Toronto, Ontario, Canada Background: Multidisciplinary cancer conferences (MCCs) provide an opportunity for health professionals to discuss diagnosis and treatment options with the goal of providing optimal patient management. No prior studies have explored the experiences of adopting and implementing MCCs in Canada. Methods: Using a grounded theory approach, interviews, participant-observation, and document analysis were triangulated to explore the experiences of implementing MCCs at four hospitals in Ontario, Canada. Constant comparative analysis was used to identify themes and assimilate them into a theoretical understanding of policy, administrative/organizational, and participant contributions to implementing MCCs. Results: Thirty-seven MCCs, in three hospitals, were observed, and 48 interviews were conducted. The core conceptual category was a perceived value for time balance, which was influenced by policy and administrative factors, and themes related to MCC structure and participant interaction. Conclusions: MCC implementation in Ontario is inconsistent. Future efforts should concentrate on a systematic implementation plan involving clinicians and administrators. ii

3 Acknowledgements I wish to express my thanks to my supervisory committee Lawrence Paszat, Frances Wright, Anna Gagliardi and Susan Bronskill - for supporting me and providing me with invaluable advice and mentorship throughout this project. Special thanks to Frances and to Anna, who have been key resources for this project since its inception. I look forward to meeting you all again as clinical and research colleagues. Thanks also to Lorelei Lingard and to Ross Gray, who graciously acted as my internal and external reviewers respectively. Lastly, thanks to my family for their support throughout the past two years. Your love and encouragement are, as ever, unwavering and inspirational. iii

4 Table of Contents Introduction / 1 Chapter 1: Multidisciplinary teams in cancer care / Incorporation of multidisciplinary teams into cancer care 1.2 Adoption and implementation of existing models for multidisciplinary cancer teams Chapter 2: Adoption and implementation of research in cancer care / 15 Chapter 3: Multidisciplinary cancer conferences / Defining multidisciplinary cancer conferences (MCCs) 3.2 Application of multidisciplinary cancer conferences 3.3 Obstacles to the establishment of multidisciplinary cancer conferences 3.4 Multidisciplinary cancer conferences in Canada 3.5 An approach to studying multidisciplinary cancer conferences in Canada Chapter 4: Theoretical framework and study objectives / Theoretical framework 4.2 Study objectives and questions 4.3 Study rationale Chapter 5: Methods / Rationale for a qualitative approach 5.2 Philosophical underpinnings and the symbolic interactionist grounded theory approach 5.3 Use of qualitative methodology in the study of teamwork 5.4 Sampling and recruitment 5.5 Data collection 5.6 Data analysis 5.7 Triangulation 5.8 Rigor 5.9 Reflexivity 5.10 Ethical considerations Chapter 6: Results / Describing MCC organization and function through participant observation iv

5 6.1.1 Site 1 (Academic) Site 2 (Community) Site 3 (Community) Site 4 (Community) Summary of participant observation 6.2 Interviews 6.3 Document analysis 6.4 Thematic analysis Defining MCCs and their primary purpose The evolution of MCC implementation The core category Policy factors Administrative & organizational factors MCC structure (task design) MCC function (team processes) 6.5 Global modifiers Unique attributes of community hospitals MCC adjuncts Cancer Care Ontario standards 6.6 Measures of MCC Success 6.7 Use of reflexive journals Chapter 7: Discussion / Revisiting the core category: the value for time balance 7.2 The evolution of MCC implementation 7.3 Multiple levels of coordination involved in implementing quality improvement 7.4 Developing communities of practice Chapter 8: Conclusions and study limitations / Conclusions 8.2 Study limitations Chapter 9: Implications for future practice and research / 129 Appendices / 136 References / 153 v

6 List of Tables and Figures Tables TABLE 1: Studies examining the association between multidisciplinary teams (MDTs) and survival. TABLE 2: Characteristics of the innovation and the innovation-decision process as defined by Rogers TABLE 3: Application of ITEM and diffusion of innovation theory to MCC context TABLE 4: Application of task design and team processes from the ITEM to MCC context TABLE 5: Sample entry of interview transcript and identified ideas according to the ITEM framework TABLE 6: MCC participant observation Dimensions of task design / MCC structure TABLE 7: MCC participant observation Cases discussed TABLE 8: Interview participants TABLE 9: Data Analysis: Summary of repeating ideas, themes & theoretical concepts TABLE 10: Comparison of Rogers five stages of the innovation-decision process with corresponding stages for MCCs TABLE 11: Estimated costs to provincial government for MCC function Figures FIGURE 1: Adopter categorizations based on Rogers theory of diffusion of innovation FIGURE 2: Integrated (Health Care) Team Effectiveness Model (ITEM) FIGURE 3: Illustrative representation of ITEM and diffusion of innovation theory to MCC adoption and implementation. FIGURE 4: Conceptual theory for MCC implementation vi

7 Appendices Appendix 1: Participant observation data collection template Appendix 2: Telephone/ script to request interview Appendix 3: Interview question template for multidisciplinary cancer conference participants, potential participants, coordinators and administrators. Appendix 4: Interview question template for Cancer Care Ontario representatives Appendix 5: Informed consent document for multidisciplinary cancer conference participants, potential participants and administrators. Appendix 6: Informed consent for Cancer Care Ontario representatives Appendix 7: Exemplar interview quotations for themes vii

8 Introduction A multidisciplinary approach to cancer care is becoming increasingly recognized internationally and in Canada, as it is a mechanism postulated to optimize patient care. One strategy used to bring key health professionals together is the multidisciplinary cancer conference (MCC). MCCs are regular meetings of cancer care providers (including surgeons, medical and radiation oncologists, pathologists, radiologists and supportive care staff) where the diagnosis and management of cancer patients is discussed and individualized. Evidence shows that MCCs encourage collaboration amongst cancer specialists, and likely improve patient care. However, it is unclear how multidisciplinary cancer conferences are being used in Ontario, and how they can more efficiently be incorporated into routine cancer care. The purpose of this study is to determine why and how multidisciplinary cancer conferences are being used in four Ontario hospitals, and to uncover barriers and facilitators to their establishment and function. This study is important because an understanding of these barriers and facilitators will help to target future strategies for cancer conference improvement, thereby supporting enhancement of patient care. 1

9 Chapter 1: Multidisciplinary Teams in Cancer Care 1.1 Incorporation of multidisciplinary teams (MDTs) into cancer care The importance of teamwork has been explored in many aspects of health care delivery. Primary care teams have been reported to increase staff motivation, and to improve the efficiency of disease detection, treatment, and follow-up in the management of hypertension (1). Similarly, in the surgical realm, interprofessional communication has been explored in the context of perioperative care, and has been reported to improve surgical team cohesion and to facilitate the articulation of patient concerns (2). A number of elements have also been identified as important contributors to the function of an effective team. Individuals should feel that their roles within a team are identifiable, meaningful, and personally and clinically rewarding. Team members have reported improved satisfaction when they share common objectives and enjoy ongoing feedback and professional education (3). However, one must also recognize that health care teams are embedded in mutable administrative organizations, including provincial and federal governments, as well as hospital institutions. Consequently, implementation of a successful team does not simply involve assembling interested individuals, but also necessitates aligning the team s goals with the organization s dynamic culture and philosophy, and continually adjusting for structural characteristics, such as the capacity for administrative support (4). Modern cancer management has largely assumed a multidisciplinary team approach, as diagnosis and treatment requires a collaborative, multimodal, evidence-based approach to optimize patient survival and quality of life. Strong communication within a cancer team has been shown to improve interactions between patients and providers, and to reduce error and injury (5). Furthermore, multidisciplinary teams have been endorsed as a mechanism to ensure [ ] a seamless service [ ] throughout the[ ] disease trajectory and across the boundaries of primary, secondary and tertiary care (6). As such, the smooth delivery of team-oriented care is the goal of many cancer programs. 2

10 3 The association of multidisciplinary teams with clinical endpoints There is increasing evidence that multidisciplinary cancer teams may potentially benefit patients in a variety of clinical settings. Multidisciplinary breast cancer clinics have been reported to contribute to patient satisfaction, and to decreased waiting times between diagnosis, evaluation, and treatment (7-9). Similar positive trends in patient and family satisfaction with team cancer care have been shown with multidisciplinary management of hepatocellular carcinoma (10). In the care of metastatic spinal cord compression treated with radiation therapy, multidisciplinary management resulted in enhanced ambulation and pain control when compared to usual care (11). Therefore, multidisciplinary management appears to contribute not only to patient-related outcomes such as satisfaction, but also to system efficiency by providing timely cancer care. The use of multidisciplinary cancer teams has also been associated with the occurrence of disease-specific clinically meaningful endpoints including staging accuracy and compliance with treatment guidelines. In a prospective case series of 431 patients with suspected thoracic malignancies managed by an Australian multidisciplinary clinic, diagnosis and treatment recommendations were correlated with internationally accepted clinical guidelines for diagnosis, staging, and management (12). Depending on stage and histologic subtype of the cancer, compliance ranged from %. Likewise, in a prospective case series describing the staging of 118 surgically resectable esophageal and gastric cancers, staging using imaging modalities (computed tomography scan, endoscopic and laparoscopic ultrasound), in conjunction with multidisciplinary discussion, was statistically better than using imaging modalities alone (13). Preoperative stage for each tumour was compared to its final stage after resection and pathological examination. Overall staging accuracy of 88% (gastric) to 89% (esophageal) was achieved using multidisciplinary discussion and radiologic staging, which was a statistically significant improvement when compared to the use of each imaging modality in isolation for ascertainment of nodal status and depth of tumour invasion. This study did not examine whether the treatment recommendations based on

11 stage were followed, nor whether various staging modalities, including multidisciplinary discussion, were associated with changes in patient outcomes. 4 Clinicians involved in multidisciplinary cancer teams also reported additional professional benefits. These included ongoing education for physicians and for allied health personnel, improved collaboration with colleagues, a degree of protection from risk of malpractice, and an auditing mechanism of hospital practices meant to reduce mortality and morbidity of cancer patients (14-17). Studies examining multidisciplinary cancer teams are largely descriptive and exploratory in nature, often reflect the experiences of single institutions, and target specific disease sites. For example, a single institution before-after series in the United States compared 162 breast cancer patients treated prior to the opening of a multidisciplinary breast cancer clinic (control group) with 177 patients who were subsequently seen in the clinic s first year of operation (7). The multidisciplinary nature of this clinic was meant to facilitate and to streamline the treatment process, and to provide a supportive and educational environment for women with newly diagnosed breast cancer. Outcomes explored included patient satisfaction (as determined by anonymous questionnaire) and timeliness of treatment (determined by retrospective chart review and defined as time from diagnosis to start of definitive local therapy). Patients participating in the multidisciplinary clinic reported increased satisfaction due to active involvement of family and friends in cancer management, and significantly decreased mean number of days between diagnosis and initiation of treatment. Multidisciplinary teams have also been suggested to impact patient survival. Appraisals of ovarian, breast, non small-cell lung, esophageal, and head and neck cancer patients have independently demonstrated association with improved survival when patients are treated in a multidisciplinary setting (18-24). Their methodologies and key results are briefly summarized in Table 1.

12 5 TABLE 1: Studies examining the association between multidisciplinary teams (MDTs) and survival Anatomic Study Design Population site Outcomes Junor et al. (1994) Sainsbury et al. (1995) Shylasree et al. (2006) Forrest et al. (2005) Gillis & Hole (1996) Stephens et al. (2006) Birchall et al. (2004) Population-based retrospective cohort Population-based retrospective cohort N = 533 Ovary N= Breast Retrospective cohort N = 287 Ovary Before - after series, single institution Population based retrospective cohort Retrospective before-after series, single institution Population based before-after series N = 117 (cohort 1, before MDT) N = 126 (cohort 2, after MDT) Lung N=3786 Breast N=77 (historical cohort) N= 67 (managed with MDT) N=566 (cohort 1) N=727 (cohort 2) Esophagus Head & Neck Overall 5-year survival: 23.6% Adjusted hazard ratio: 0.60 (95% CI , p < when attend multidisciplinary clinic) 5-year mortality: Volume adjusted risk ratio (ref <10 cases): cases/yr: 0.97 (95% CI ) cases/yr: 085 (95% CI ) >50 cases/yr: 0.86 (95% CI ) Overall median survival: 802 days Median progression free survival: 746 days 1-year survival: 65% 3-year survival: 60% Adjusted hazard ratio 1.79 (95% CI , p=0.012) if post-op care at peripheral hospital compared to gynecology oncology MDT at cancer centre (ref) Median survival 3.2 months in cohort 1 Median survival 6.6 months in cohort 2 (p <0.001) 5-year survival: 67% (specialist*) 58% (nonspecialist) 10-year survival: 49% (specialist), 41% (non-specialist) Adjusted hazard ratio: 0.84 (95% CI ) when managed by MDT Operative mortality: 26% (historical cohort) v. 5.7% MDT cohort) 5-year survival: 10% (historical cohort) v. 52% (MDT cohort), p<0.001 Median survival: 18 months (95% CI in historical cohort) v. 66 months (95% CI in MDT cohort), p< Adjusted hazard ratio: 0.34 (95 % CI , p<0.001) when managed by MDT Overall 2 year survival: Group 1: 64.1% (95% CI ) Group 2: 65.1% (95% CI ) Adjusted hazard ratio: 0.70, (p 0.02) when assessed by MDT in group 2 * Specialist defined as surgeon who woks in dedicated breast clinic, links to other disciplines and clinical trials, and has separate records for cancer cases In an attempt to summarize and to evaluate the literature describing the ability of multidisciplinary teams to influence survival in breast cancer, a systematic review was performed and included 14 case series and cohort studies after methodological appraisal (25). Overall, this review suggested that the evidence available to demonstrate that multidisciplinary patterns of care influenced survival was weak, as there was little direct evidence to link the processes of multidisciplinary care to outcomes. Four cohort studies examined the positive relationship between specialist case volume and survival, five cohort studies looked

13 6 at hospital case volume and its association with survival, and three cohort studies found a positive relationship between the presence of specialist surgical care and survival. Although specialists often work in treatment centres with large case volumes, and with available multidisciplinary care, it is imprudent to fully equate these surrogate measures with coordinated multidisciplinary care, as specialist clinicians may work independently to manage patients, irrespective of an available team-oriented practice environment. In addition, although all but one of these cohort studies included variables for risk adjustment based on patient and tumour characteristics, these studies used varying definitions of the term specialist and inconsistently included a defined comparison group without multidisciplinary care. Generalized conclusions about the effect of multidisciplinary teams on patterns of care or survival in breast cancer could therefore not confidently be made from this systematic review. There are three studies that reported improved survival in the presence of defined multidisciplinary teams. Two of these studies examined patients with ovarian cancer (18, 20), and one study examined the outcomes of patients undergoing esophageal cancer surgery (23). The first ovarian cancer study (18) used a Scottish cancer registry to retrospectively identify patients with ovarian cancer and to follow this cohort to determine 5-year survival. The second ovarian cancer study (20) used a questionnaire for data collection at 20 hospitals in Wales and examined survival at 3 years. The multidisciplinary setting in the latter study was identified as one where the gynecologist and medical oncologist together determined the most appropriate management plans for patients. Both studies examined referral patterns and treatments received and demonstrated increased survival with the receipt of platinum based chemotherapy, and with management by a multidisciplinary team. Similarly, in the single institution retrospective cohort study of 144 patients undergoing esophageal resection with curative intent, management by a multidisciplinary team conferred significantly improved operative (26% to 5.7%) and overall 5-year (52% to 10%) survival when compared with no multidisciplinary involvement. The multidisciplinary team in this study consisted of two consultant surgeons, two radiologists, a medical oncologist, two gastroenterologists, an anesthetist, a pathologist, and a specialist nurse. While patient comorbidity and intent of surgery

14 (palliative versus curative) were not accurately assessed in this study, the presence of a defined multidisciplinary team appears to confer significant benefit to patients. 7 At present, all published studies examining the impact of multidisciplinary teams on patient survival were conducted in the United Kingdom. These studies have therefore prompted reorganization and restructuring of the national cancer care system to facilitate the management of all cancer patients by specialist multidisciplinary teams. This reorganization is clearly highlighted by two studies examining patients before and after the implementation of changes in health care delivery. In a study of head and neck cancer patients, two patient cohorts were identified based on diagnosis either before (566 patients) or after (727 patients) cancer care reorganization (24). Each case was identified by clinicians in designated areas, and confirmed with the Cancer Register and through arbitrary case note sampling. This study demonstrated improved adherence to clinical standards of care, including referral to a multidisciplinary clinic, in the post-restructuring cohort. Overall, there was improved 2-year survival for patients seen at a multidisciplinary clinic. In a similar study of inoperable lung cancer patients in Scotland, two cohorts of patients were identified one before (117 patients) and one after (126 patients) the implementation of multidisciplinary teams (21). In this single institution, the multidisciplinary team consisted of respiratory physicians, surgeons, a medical and clinical oncologist, a palliative care physician, a radiologist and a specialist respiratory nurse. Information extracted from case notes in this study demonstrated an improved median survival in patients treated by a multidisciplinary team (3.2 months with no multidisciplinary team, 6.6 months with multidisciplinary team). However, it is important to note that these studies do not represent a randomized comparison of patients managed with and without multidisciplinary teams. Limitations to the interpretation of studies of multidisciplinary teams While there appears to be many potential benefits to the use of multidisciplinary cancer teams, some of the aforementioned studies contain methodological limitations. These limitations fall into four broad categories use of surrogate measures to define multidisciplinary teams, use of administrative data,

15 8 selection bias in the study cohort, and generalizability of the findings. These boundaries encourage the reader to interpret these studies caution. Surrogate measures to define multidisciplinary teams were seen in two of the studies included in the aforementioned systematic review examining survival in breast cancer patients (25). Multidisciplinary teams were implied in an indirect manner but linked with improved survival. In a study looking at 5-year survival of 12,861 breast cancer patients identified from the a cancer case registry, improved survival was observed in patients managed by surgeons treating 30 or more breast cancer cases per year, and with higher rates of chemotherapy (19). The latter result fueled the author s derived recommendation that a multidisciplinary setting, where chemotherapy is typically available, conferred improved survival for breast cancer patients. One cannot discount the possible effect of selection bias, whereby patients who received chemotherapy may have been specifically chosen due to their potential for a favourable response and in turn, a better survival rate. In a similar study examining 3786 registry-identified breast cancer patients in the West of Scotland, improved 5 and 10-year survival rates were reported when patients were treated by specialist surgeons (22). Specialist surgeons were identified by a single author in the study, and assumed to practice in a multidisciplinary environment due to their specialist nature. Since these two studies do not succinctly define the use of a multidisciplinary setting or team, the allusion of improved survival should be considered with prudence. With respect to the use of administrative data, four of the aforementioned studies (18, 19, 22, 24) used population based cancer registry data to identify the cohort of patients with ovarian, breast (2 studies) and head and neck cancers, respectively. Multidisciplinary team involvement in these cases was identified by subsequently consulting the case records of patients in two (18, 24) of these studies. While using registry data for patient identification prevents selection bias associated with questionnaires and clinician reporting of patients, this data source offers additional limitations. Registry data is often constrained by the completeness and accuracy of the administrative data, as well as the absence of supplementary information such as surgeon skill, patient comorbidity, performance status, and quality of life. In addition, temporal changes in clinical practice, such as doses and indications for radiation, chemotherapy, or hormone therapy, and changes in recommended surgical procedures, cannot be

16 9 differentiated in the survival models created from registry data. These limitations may have a significant and immeasurable effect on the practice patterns observed in these retrospective studies, as well as the observed survival outcomes. Selection bias was seen in a study examining the use of a multidisciplinary rural cancer program (14). The survey questionnaire methodology used to assess clinician attitudes introduced non-representative response rates and selection bias. In this study, 65 of the 90 (72%) targeted physicians responded, but there was no attempt to contact the non-respondents. There was no description of the proportion of respondents from each clinical specialty, nor any attempt to elicit responses from non-physician members involved in the cancer program, which may have included nurses, nutritionists, or social workers. Systematic exclusion of these members of the cancer team introduced a selection bias, since the perceived usefulness of the cancer program by these participants may have differed from the attitudes of physicians. Another example of selection bias was seen in a study looking at the timeliness of care in a multidisciplinary breast cancer clinic, where patients who were seen for a second opinion were systematically excluded (7). Selection bias resulted, as the inclusion of these patients would have increased the mean time between diagnosis and treatment, and thus reduced the apparent timeliness of treatment. This study also demonstrated a limitation in generalizability. Although this study illuminated innovative ways to function in a multidisciplinary oncologic practice, it described a clinic in which institutional support had already been granted in the form of physical space, and financial support for equipment and specialized personnel for organization and education. Therefore, recommendations and strategies gleaned from this investigation cannot necessarily be directly applied to other disease sites, or to diverse practice environments with developing clinics. In sum, multidisciplinary teams appear plentiful within the cancer realm. However, while they purport numerous potential benefits for patients and clinicians alike, one must be careful to interpret these studies within their methodological limitations. Furthermore, it is unclear at this point which aspects of multidisciplinary team care, namely specialist care, case volume, propensity to receive adjuvant therapies,

17 or improved cross-disciplinary collaboration, contribute most extensively to the suggested advantages conferred by the multidisciplinary setting Adoption and implementation of existing models for multidisciplinary cancer teams The proposed potential benefits of multidisciplinary teams have prompted attempts to formalize their organization, performance, and monitoring. MDTs have been supported by government health agencies and hospitals in the United Kingdom, the United States, and Australia as a vehicle to promote collaborative, evidence-based cancer care. United Kingdom (UK) In 1995, the Calman Hine report: A Policy Framework for Commissioning Cancer Services was released by the expert advisory group on cancer to the chief medical officers of England and Wales (26). This report was aimed at purchasers, planners and providers, and mandated the establishment of cancer care networks aimed at fully integrating cancer care between primary care physicians, cancer units, and cancer centres. This report emphasized the need for specialist care using multidisciplinary teams. Under the direction of the National Heatlh Services (NHS) Cancer Plan, published in 2000, major strategic reforms were made to cancer service delivery in England, including the formation of 34 cancer networks, the development of over 1600 multidisciplinary specialist teams, support from the Cancer Services Collaborative, and the introduction of standards for ongoing quality assurance (27). Under this plan, MDTs are required for cancer centre and cancer unit accreditation. Standards for MDTs were then subsequently published in the Manual for Cancer Serivces, most recently revised in 2004 (28). These revised standards draw on feedback from their original publication in 2000, and include MDT appraisal measures from Improving Outcomes Guidance, a guideline published by the National Institute of Clinical Excellence. Following implementation of the NHS Cancer Plan, audits have been conducted to examine the prevalence of MDTs in the UK. Results from these audits ranged from widespread use of MDTs for head and neck cancer (29), to inconsistent use in ovarian, endometrial, and anal cancers (30, 31). Preliminary

18 11 research is now identifying the challenges of implementing MDTs in the UK. Due to the high relative incidence of colorectal and breast cancers compared to other cancer sites, MDTs have been most intensively investigated in these areas. MDTs in breast cancer have been strongly promoted due to evidence that a shared team process results in more effective decisions and improved mental well-being of health professionals (32). In a 2006 audit, 98.5% of reporting breast units conducted weekly MDT meetings. These breast units found a local hospital MDT coordinator to be an essential keystone to MDT function (33). However, in the realm of colorectal cancer, in an audit of 11,548 colorectal cancer patients from the cancer registry, none of the responding nine colorectal MDTs followed all of structural team recommendations outlined in the Manual for Cancer Services (34). Although 90% of the cancer networks reported a functioning colorectal MDT, persisting organizational difficulties existed. These difficulties included lack of a coordinator, no fixed time, lack of venue and facilities, lack of interest, and inconsistent attendance of specialists (35). To further illustrate the latter deficiency, a recent audit looked at the 34 networks for the care of head and neck cancer in England. MDTs were evident in all centres but were frequently understaffed in the areas of pathology, radiology, reconstructive surgery, palliative care, and speech therapy (29). While audit data is useful for generating an overview of the use of MDTs in the UK, there are limitations to the conclusions that can be drawn concerning MDT function and efficiency. These audits were largely based on results of questionnaires (29, 32, 33, 35). While they achieved good response rates from 70-91%, the responses represented only opinions of the cancer unit lead personnel, and did not necessarily widely represent views of all MDT participants, administrators, or institutional policy-makers. These questionnaires were also subject to selection bias as it was not clear whether participants who did not respond had opinions and experiences that were unique. In addition, the reporting of national patterns of practice is descriptive in nature and does not relate presence of MDTs to resources and processes in cancer care (e.g. receipt of CT scan or MRI), nor to patient outcomes or cost measurements. Audits should to be complemented by long-term economic studies examining the cost of maintaining specialized treatment teams, and their relation to site-specific objective measures such as cancer recurrence, or

19 survival. Ongoing peer audits of MDTs in the UK continue to occur in order to promote development of accurate quality indicators and mechanisms for quality assurance. 12 United States A national US survey conducted by Henson, a pathologist, in 1990 indicated that more than 75% of all hospitals in the United States (academic and community) conducted regular MDT meetings focused on patient management (36). This survey, supported by the National Cancer Institute and the American College of Surgeons (ACS), examined 1700 American hospitals with multidisciplinary cancer teams, and subsequently identified nine factors common to the function of cancer conferences. These included: attendance associated with continuing professional development credit, discussion of treatment planning, presentation of tumour registry data, entry of discussion into medical records, patient case presentations, attendance of outside consultants, presence of medical oncologists, pathologists and surgeons, keeping of minutes, and completion of follow-up studies. Since then, multidisciplinary teams have steadily developed in scope and in prominence throughout the US. In 2004, the American College of Surgeons Commission on Cancer released standards stating that [c]ancer conferences are integral to improving the care of cancer patients by contributing to the patient management process and outcomes and providing education to physicians and other staff in attendance (37). These standards vary depending on the type of institution and the scope of cancer managed, but clearly delineate the required institutional responsibilities for multidisciplinary leadership and accountability. These standards recommend an array of multidisciplinary participants, an administrative monitoring system, and thresholds for the number of cases to be presented. At this time, in order to maintain accreditation with the ACS, all institutions are required to present at least 10% of their annual case volume at multidisciplinary meetings, and to discuss at least 75% of cases prospectively. Audits to ensure adherence to these standards are ongoing.

20 Australia 13 Multidisciplinary teams have been evolving in Australia since key cancer control groups highlighted the need for strategic organizational reform in the delivery of cancer services in From 2000 to 2002, using three breast cancer facilities as models, the Australian Department of Health and Ageing sponsored a study entitled Multidisciplinary Care in Australia: A national demonstration project in breast cancer (38). The principal goal of this project was to examine the process, impact, accessibility and cost of implementing multidisciplinary care in public and private institutions, using breast cancer as a disease model. The implementation of MDTs was one component of the care strategy, and was embedded within five principles of multidisciplinary care: establishment of a breast cancer care team, communication mechanisms to facilitate interaction among team members, access to a full therapeutic range of treatment options, maintenance of standards of care, and involvement of the woman (39). This project had two major components: (a) a cost analysis, statistical audit, observational study, and interviews with participants involved in multidisciplinary care and (b) a sustainability study (40). The principal findings from this project demonstrated that multidisciplinary care provided improved psychological support in breast cancer patients and a more comprehensive consideration of the full range of therapeutic possibilities for each patient. This study also uncovered barriers, enablers, motivators, and financial costs involved in implementing and sustaining multidisciplinary care in Australia. Of note, the major barriers to the implementation of multidisciplinary care included a resistance to change from health professionals, lack of infrastructure and technological resources, inadequate time and clinical interest, and large geographical areas requiring logistical coordination. These difficulties were also echoed by a parallel survey of both academic and community surgeons (41). Surgeons expressed hesitation in the ability to implement the recommendation that all breast cancer patients should be treated by a specialist who has access to a full range of treatment options in a multidisciplinary setting due to the diversity of health care environments in Australia. These studies informed and encouraged the National Breast Cancer Centre (NBCC) to release guidelines in 2005 to govern the establishment, implementation and maintenance of multidisciplinary care (42). These guidelines encouraged the use of MDTs and defined them as an integrated team approach to health care in which medical and allied health professionals consider all

21 14 relevant treatment options and develop, collaboratively, an individual treatment plan for each patient. Health professionals discuss[] options and mak[e] joint decisions about treatment and supportive care plans, taking into account the personal preferences of the patient. In 2006, the NBCC sponsored a set of state and territory forums to encourage further discussion of systemic, behavioural and environmental barriers to implementing multidisciplinary care (43). These forums resulted in a comprehensive set of local and national objectives and innovative solutions for improving the uptake of multidisciplinary care, including a desire to use MDTs as a benchmark for cancer centre accreditation in the near future, and the development of communication skills training for cancer care professionals. Recently, numerous administrative advances have taken place to address national issues related to maintenance of multidisciplinary cancer care. In November 2006, the Department of Health and Ageing introduced an item through the Commonwealth Medical Benefits Schedule to support cancer specialists attending multidisciplinary planning meetings (44). Two possible items may be billed: a) Item 871, a $71 fee billed by the practitioner who leads and coordinates the multidisciplinary meeting, and b) Item 872, a $33 fee billed by any practitioner participating in the MDT discussion, and formally involved (or anticipated to be involved) in the diagnosis or treatment of the patient within the 12 months preceding or following the discussion. Patients should not be discussed more than twice within a year, but there is no limit to the number of clinicians that may bill item 872 for each patient. Patients are charged directly, or through Medicare, depending on their health coverage. A telephone-based national audit of multidisciplinary care in breast, colorectal, gynecological, prostate, and lung cancers is also underway. Lastly, in March 2007, a workshop of clinical, legal, and ethical experts was conducted on the medicolegal implications of multidisciplinary care (45). This workshop addressed and provided guidance for cancer team members in the realms of informed patient consent (including financial consent), professional liability for MDT participants, need for documentation of patient plans and dissenting views, and the role of the patient in treatment planning. While Australia has previously recognized the potential benefit of MDTs as a surgical risk management strategy (46), the medico-legal advice provided, as well as ongoing audits, will provide a baseline framework of MDTs, and help to identify barriers and facilitators to their implementation.

22 Chapter 2: Adoption and Implementation of Research in Cancer Care The promotion of clinical and organizational practices grounded in evidence has become an important aspect in the evolution of health care systems and patient care. However, there are considerable challenges to delivering optimal care, and current practice often lags behind what is considered to be best practice (47, 48). The body of literature examining the implementation of evidence into practice is vast and purports a complex process that does not follow a linear path between research, implementation and practice. Broadly, some of the key issues enabling and mediating the implementation of evidence into practice relate to the nature and perceived benefit of the evidence (49), the fit of the evidence within the organizational context (50, 51), the presence of existing professional and social networks to promote new evidence (52, 53), and the existence of dedicated facilitators or opinion leaders to actively promote change (54, 55). However, these issues, when addressed in isolation, do not promote widespread change (56). Therefore, utilization and implementation of research into practice requires consideration of a variety of factors in order to be successful. Specifically in the cancer realm, a recent retrospective study in the United Kingdom globally looked at the barriers and facilitators to research utilization as perceived by nurses delivering care to breast cancer patients (57). Nurses identified that the major barriers to the use of research in clinical practice span the realms of communication and organization. Specifically, the communication issues include lack of contact with experts in the area in question, limited understanding of the concepts, and a fear of changing the politics of the existing breast cancer care culture. Organizational issues included a lack of teamwork, and insufficient time and support to implement new ideas. After recognizing these barriers, the next step lies in defining solutions to overcome them and to disseminate research effectively. The implementation and dissemination of research has been assessed in multiple contexts, including cancer care. In a recent systematic review of studies aimed in evaluating the dissemination of cancer control interventions into clinical practice, the authors were unable to recommend any specific 15

23 dissemination strategies as globally effective in promoting the uptake of these interventions (58). In this review, 41 systematic reviews of cancer control interventions and 30 primary studies of dissemination 16 strategies were included. However, these studies varied widely in their topic areas and in the interventions and outcomes evaluated. Included studies used interventions targeted at health care providers, individual patients, and workplace opinion-leaders, and examined outcomes that varied from physician knowledge and attitudes, to changes in patient behaviour. The authors of this review also commented that despite an abundance of cancer control innovations in the literature, that there was insufficient information to comment on the barriers to dissemination and the role of the local environment to the success of a dissemination approach. In sum, the implementation and dissemination of research into practice in cancer care is a complex process. However, despite knowledge and recognition of a multitude of factors influencing research utilization, the successful dissemination and uptake of new information, particularly in the cancer realm, is difficult to achieve, as implementation schemes are not generalizable. Attention must therefore be directed towards crafting carefully targeted and context-specific strategies to maximize the opportunity for optimal utilization of new evidence.

24 Chapter 3: Multidisciplinary Cancer Conferences 3.1 Defining multidisciplinary cancer conferences (MCCs) Multidisciplinary teams can flourish in many different formats. Diverse input on patient management can be achieved through multidisciplinary clinics (7-9, 12), organization of a hospital-wide multidisciplinary cancer program (10, 14, 59), creation of a prospective multidisciplinary diagnosis and treatment protocol (11), or formation of a cancer service collaborative (6). As an integral component of many of the abovementioned strategies, the multidisciplinary cancer conference (MCC) specifically provides an opportunity to maximize team communication. MCCs, often called tumour boards, are defined as regularly scheduled multidisciplinary meetings used to review individual cancer patients in a prospective manner, and to formulate appropriate management plans using evidence-based multimodal input (60). Depending on the institution, MCC participants typically include a variable selection of representatives from medical oncology, radiation oncology, surgery/surgical oncology, pathology, diagnostic imaging, nursing, nutrition, and social work. Hospital administrators and coordinators are required to ensure smooth function and accountability of the MCC. The suggested primary function of these conferences is to ensure that all appropriate tests, treatment options and recommendations are considered for each patient under discussion (60). Secondary potential benefits include continuing education for medical staff and trainees, ongoing patient care quality audit and improvement, development of patient management protocols, and appropriate referrals to tertiary centres, consultants and clinical trials. MCCs may also act as an important step in establishing coordination and continuity of care for patients. MCC structure The idea of discussing cases in a structured multidisciplinary format has been explored by clinicians by using different approaches. A single institution before-after series temporally compared two different MCC formats (61). The first group of patients, presented from , were discussed based on 17

25 18 their designation as an unusual or interesting case (fascinating case format). The second set of patients, presented from , were discussed due to their need for multi-specialty input (working case format). Based on a questionnaire, 17 of the 22 (77%) regular participants preferred the working case format, as it promoted increased support for patients through clinician collaboration, as well as improved treatment protocol enrollment and physician satisfaction. In addition, the institutional proportion of patients presented significantly (p<0.001) increased as the format changed from fascinating to working format (11% to 38%). However, this hospital did not compare both formats at the same time and therefore, it is unclear how many of the cases may potentially have overlapped between fascinating and working case formats, or whether an entirely different population of patient cases was being discussed. Other MCC formats have also been explored and described in the literature. These include variations in group composition, for example, inclusion of patients in MCC discussion (62, 63), and variations in decision-making strategies, for example, routine use of decision- making algorithms and computer-based decision trees (59). These strategies have not systematically been evaluated to determine their effect on participant satisfaction, team efficiency, and patient management or outcomes. 3.2 Application of multidisciplinary cancer conferences (MCCs) Evidence demonstrates that MCCs impact physician decision-making, thereby mediating patient management. In a retrospective cohort study examining a brain tumour board in Germany, 455 of 500 (91%) multidisciplinary recommendations were implemented within three months (64). This high rate of implementation was calculated from a random sample of 500 of the 1516 patients who were discussed over a six-year period. This article does not specify whether follow-up details were obtained through primary chart abstraction by the investigators, or by contact with the most responsible physician, as the latter may imply the possibility of reporting bias. However, recommendations from these conferences formed the basis of algorithms produced to manage many common brain tumour entities. A similar retrospective study of MCCs demonstrated an 84% implementation rate of cancer conference recommendations in the United States (65). Follow up data was obtained by the cancer registrar at each

26 19 hospital and involved contacting the primary cancer physician and inquiring whether the recommendation for each case had been followed. No detail was elicited about the final outcomes of the patients or reasons for noncompliance, if recommendations had not been followed. In this study, only six of the 18 (33%) hospitals initially contacted provided complete information about prospective MCC recommendations. In a recent study in the United States, consultation with a MCC was the only factor predictive of receiving appropriate (based on guidelines from the National Cancer Institute) treatment for stage II and III colorectal cancer patients, when accounting for patient comorbidities and physician decision-making (66). In this cross-sectional study, the investigators aptly used primary chart abstraction to supplement their cancer registry data to confirm tumour stage and treatment algorithms. However this study is limited by its setting in a Veterans Affairs hospital, where patient selection bias would play a large role in the interpreted results, as Veterans comprise a limited population that is not necessarily representative of the population in the United States. In England, where a prospective case series of 273 consecutive upper gastrointestinal cancers were discussed at MCCs and followed at a single institution, 232 (85%) of MCC recommendations were implemented (67). Reasons for non-implementation were highlighted and were commonly due to patient preference, comorbid health issues, or presentation of additional clinical information, such as discovery of metastatic disease. MCCs have also been used as an adjunct for decision-making, in combination with targeted diagnostic strategies. In a multi-centre before-after series of rectal cancer patients in the United Kingdom, the rate of positive circumferential resection margin was compared before (n=298) and after (n=98) institution of a combined strategy of mandatory preoperative MRI and subsequent MCC discussion (68). The circumferential resection margin was used as a quality indicator for surgery and an objective surrogate measure of clinical outcomes, as a positive margin has been shown to be a short-term marker of distant metastases, recurrence, and poor survival (69). Of the 259 patients with potentially curative rectal cancer, 62 (24%) underwent surgery alone without discussion at a MCC. Of these 62 patients, 16 (26%) had a positive circumferential resection margin. In contrast, 197 patients were discussed at a MCC. Of these, 115 (58%) underwent surgery alone and only one (1%) patient had a positive circumferential margin