MDT IMPROVEMENT PROJECT Professor Muntzer Mughal, UCLH
1995..assessment and management of rare cancers in multidisciplinary teams.. 2000 the care of all patients with cancer should be formally reviewed by a specialist team
More patients, more complex, more therapies
1600000 1400000 1200000 1000000 800000 600000 400000 200000 0 200 Activity (patient discussions) 2011-12 2012-13 2013-14 2014-15 Cost in million s 150 100 50 0 2011-12 2012-13 2013-14 2014-15
Challenges for cancer MDTs Time - increasing case-load & complex case-mix Increasing treatment options Demands on time of MDT Lead & members Preparation and attendance of MDMs Annual review meetings Leadership IT support Video links Data 5
1995 assessment and management of rare cancers in multidisciplinary teams 2000 the care of all patients with cancer should be formally reviewed by a specialist team 2015 Streamlining & more effective working 2017
MDT discussions should focus more on difficult cases and processes should be put in place to enable swifter decisions on patients going through standard treatment pathways. Recommendation 38: NHS England should encourage providers to streamline MDT processes such that specialist time is focused on those cancer cases that don t follow wellestablished clinical pathways, with other patients being discussed more briefly.
Identify protocolised treatment pathways. pre-mdt triage meeting to apply protocolised pathways. Minimum attendance based on quoracy. NHS England to run pilots to determine optimal attendance requirements. Develop referral proforma template to include minimum dataset including HNA, patient preferences, suitability for trials Real-time documentation of outcomes. Ensure regular morbidity & mortality meetings and quarterly operational meetings time in job plans 8
UCLH Cancer Collaborative MDT Improvement project MDT Improvement workshop July 2016 MDT visits (5 local, 8 specialist) Nov 2016 to March 2017 Questionnaires to MDT leads and co-ordinators Develop JD for MDT lead & co-ordinator Report published April 2017
Differences in MDTs Content Number of cases in the time available Information about the patient & preferences Stratification of cases Combination of benign & malignant Infrastructure Room, seating, screens, video-conferencing Process preparation and who does what Presentation of cases Recording of outcomes Consideration of cases for trials Chairing Involving team members Summarising discussion & outcomes Evidence of operational/review meetings 10
180 160 140 Length of meeting and number of cases Dur (mins) 120 100 80 60 40 20 0 1 2 3 4 5 6 7 8 9 10 11 12 13 11
21 Recommendations Leadership, infrastructure and attendance MDT lead & MDT co-ordinator JDs Quoracy Process Information about patient performance status & wishes Protocolised pathways Clear outcomes Governance & Improvement Morbidity & mortality SACT data Operational meetings Support Mentorship, support & development 12
Do MDT chairs have the time to prepare & lead? Does your job plan allow time for MDT preparation? 80% 70% 60% 50% 40% 30% 20% 10% 0% No Partly Yes Preperation is minimal due to the use of proformas Do you feel your role as MDT lead would benefit from a structured job description and recruitment process? 80% 70% 60% 50% 40% 30% 20% 10% 0% Yes no It would have been useful when I started JD would be beneficial but recruitment process would not We already have one (PAH) 13
120% % cases submitted with complete dataset 100% 80% 60% 40% 20% 0% Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 RLH BHRUT WXH HUH PAH Other/Private Total 15
Protocolised management
Tumour Site Percentage in favour What percentage of patients do you feel could be resolved outside of the meeting - for example, through clearly defined treatment protocols and review by a smaller group? Overall 74% 31.00% Skin 89% 37.80% Urology 87% 35.30% Other (please specify) 81% 28.50% Children and Young People 79% 31.40% Lung 78% 26.90% Gynaecology 78% 28.20% Upper GI 75% 30.70% Breast 75% 33.70% Haematology 75% 32.90% Brain 74% 26.70% Sarcoma 73% 21.10% Palliative Care 67% 42.90% Colorectal 63% 27.90% Head and Neck 50% 25.00% CUP 43% 12.20%
Analysis of single OG Cancer smdt meeting Clinical details Question for MDT MDT outcome Suitable for pre- MDT triage Next step after pre-mdt Metastatic gastric adenoca, CT scan Treatment options Palliative care Yes Palliative care Adenoca oesoph, neoadjuvant chemo Review CT Liver lesion - for MRI? Adenoca stomach, CT - T3N1, staging lap Results of staging lap Cytology - positive, for palliative chemo Yes Refer to oncology OPC Perforated adenoca oesoph, CT & PET Case review For neoadjuvant chemo-rad No Metastatic SCC oesoph treated with chemorad CT to determine disease progression Disease progression Yes Oncology review SCC oesoph treated with chemorad, OGD? Recurrence Review histology Recurrent disease, discuss salvage surgery No Perforated adenoca oesoph, SCLN biopsy Review histology Benign, consider oesophagectomy No Metastatic SCC oesoph treated with chemorad, interval CT CT to determine disease progression Stable disease Yes Oncology review SCC oesoph treated with chemorad, surveillance PET CTExclude recurrence No recurrence Yes Continue surveillance SCC oesoph, CT - T3N2M0 Next step PET scan Yes PET scan Referral from sarcoma MDT - oesophageal nodules biopsied Histology Repeat OGD with mapping biopsies No Adenoca oesoph, CT- T3N1M0, PET - staging lap clear Next step Neoadjuvant chemo Yes Refer to oncology OPC Adenoca oesoph, CT - R adrenal mass & suspicious liver lesions Review CT Metastatic disease, palliative chemo Yes Refer to oncology OPC Adenoca oesoph, CT/PET - T3N2M0, co-morbidities Case discussion Review in surgical clinic to discuss optiona No Resected gastric cancer Review histology For adjuvant chemotherapy No High grade dysphasia on surveillance OGD for Barretts Review histology Repeat biopsy but patient not keen for further invx Adenoca stomach, CT - T3N1M1, bleeding Review case & imaging For palliative DXT No Adenoca oesoph, CT - T3N2M0 Review CT For PET scan Yes PET scan Adenoca oesoph, CT - T2N1M0 Review CT For PET scan Yes PET scan Adenoca stomach, CT - TxN1M1 Review CT Metastatic disease, palliative chemo Yes Refer to oncology OPC No Elderly patient with gastric outlet obstruction from gastric ca Review CT T3N2M1 disease - stenting? Elderly patient with early adeno oesoph, EMR Review histology Complete resection, for surveillance OGD No Resected gastric cancer Review histology ypt3n2r1, for adjuvant chemo No 18
Cases suitable for protocolised pathway Clinical details Question for MDT MDT outcome Suitable for pre-mdt triage Next step after pre-mdt Metastatic gastric adenoca, CT scan Treatment options Palliative care Yes Palliative care Adenoca stomach, CT - T3N1, staging lap Results of staging lap Cytology - positive, for palliative chemo Yes Refer to oncology OPC Metastatic SCC oesoph treated with chemorad CT to determine disease progression Disease progression Yes Oncology review Metastatic SCC oesoph treated with chemorad, interval CT CT to determine disease progression Stable disease Yes Oncology review SCC oesoph treated with chemorad, surveillance PET CT Exclude recurrence No recurrence Yes Continue surveillance SCC oesoph, CT - T3N2M0 Next step PET scan Yes PET scan Adenoca oesoph, CT- T3N1M0, PET - staging lap clear Next step Neoadjuvant chemo Yes Refer to oncology OPC Adenoca oesoph, CT - R adrenal mass & suspicious liver lesions Review CT Metastatic disease, palliative chemo Yes Refer to oncology OPC Adenoca oesoph, CT - T3N2M0 Review CT For PET scan Yes PET scan Adenoca oesoph, CT - T2N1M0 Review CT For PET scan Yes PET scan Adenoca stomach, CT - TxN1M1 Review CT Metastatic disease, palliative chemo Yes Refer to oncology OPC 19
Pre-MDT meeting 7 patients for oncology review 1 patient for palliative care 3 patients for PET scan 12 cases for discussion 7 patients for oncology review 1 patient for palliative care 3 patients for PET scan AT LEAST 2 DAYS IN TIMED PATHWAY FEWER CASES FOR DISCUSSION 20
Introducing protocolised management Develop pathways with MDTs & Pathway Boards Each MDT to determine who will triage? E.g. MDT lead, MDT co-ordinator, radiologist Ensure direct to next step patients listed on MDT agenda Systematic study & audit
Implementation of recommendations JD & time for MDT leads & co-ordinators Make patient information mandatory Consider setting up MDT leads forum Develop & pilot protocolised management pathways Develop datasets to report patient outcomes regularly to the MDT QI programme to support MDTs 22