4. Specialised Multidisciplinary Care
You have a right to:
Receive care from a specialised multidisciplinary team, ideally as part of a cancer care network.
Three key questions that every cancer patient may choose to ask:
- Is my care discussed by a multidisciplinary team?
- Are my views and preferences clearly communicated to this team in a timely fashion?
- Is our cancer service part of a cancer network?
Explanation
European cancer patients’ care should be organised so that the best decisions about choices of treatment are made, ensuring best available care is delivered in the most effective and timely way, as close to the patient’s home as is safely possible. The two organisational structures recommended, the specialised multidisciplinary team (MDT) and the cancer network, are both well supported by evidence and experience.
Specialised Multidisciplinary Team (MDT)
A specialised MDT comprises all of the different healthcare professionals, whose combined knowledge ensures that the best treatment options are discussed with the patient and that Shared Decision-Making (SDM) takes place. All treatment options should be considered and can be advocated by the relevant specialists; all relevant doctors, nurses and other cancer care professionals should be informed and kept up-to-date through all stages of the patient’s journey.
Patients should be made aware of the MDT, its purpose, membership, when it meets, and that their case is being/has been discussed. They should receive the outcome of these discussions within a locally-agreed timeframe. A patient’s views, preferences and holistic needs should be presented to the MDT by a member of the team who has met the patient and discussed these aspects with her/him. Patients should be informed, in a consultation with the appropriate MDT member, of the results of MDT discussions, and its recommendations and the preferred options for treatment. Patients should receive information, consistent with their wishes, about their cancer, their diagnosis, and their treatment options, including therapies that may be available by referral to other MDTs in other cancer networks, ensuring a well-informed choice is made about their individual treatment and care.
Cancer Networks
It may not be possible to have all of the members of every MDT in every location where a cancer patient is diagnosed or treated. It may be necessary to centralise care by moving a diagnosed patient to a specialised centre. This might happen, for example, if the patient has a rare/very rare cancer and there is no expertise for treatment of this cancer in the patient’s closest institution. To ensure that care is integrated in a well-organised and streamlined way, the “Cancer Network” or the “Comprehensive Cancer Care Network” model has been developed. This involves different parts of the healthcare system including primary care, smaller community hospitals and large cancer centres working together, communicating effectively and ensuring that the patient’s travel to the specialised cancer centre is kept to the necessary minimum. In this approach, certain aspects of treatment are delivered in the specialised centre, while other aspects are safely provided closer to the patient’s home. Cancer care plans and long term survivorship plans should be shared between all parts of the network and regularly updated.
Supporting Literature and Evidence
Specialised multidisciplinary cancer care has an established position internationally and has been recommended by cancer organisations, governments, learned societies and patient advocacy organisations as best practice since the 1990s (67, 120-122). The benefits of organising cancer care into managed networks of healthcare providers have been identified as a key requirement for optimal quality cancer care (5, 11, 67, 82, 122). A key recommendation of the European Joint Action for Cancer Control (CanCon) is “Ensure equitable access to timely, high quality and multidisciplinary cancer care” (5). However, there remain challenges to ensure that cancer care is delivered efficiently and affordably, with the best possible impact and with the best modern supportive infrastructure and informatics (5, 7, 11).
The work of a Multidisciplinary Team (MDT) should result in (123):
- Treatment and care being considered by professionals with specialist knowledge and skills in the relevant aspects of that cancer type
- Patients being offered the opportunity to be entered into high-quality and relevant clinical trials
- Patients being assessed and offered the level of information and support that they need to cope with their condition
- Continuity of care, even when different aspects of care are delivered by different individuals or providers. The information provided by different team members must be consistent and clearly recorded, such that it can be readily transferred to other teams in hospitals or the community which may contribute to the patient’s care.
- Good communication among primary, secondary, and tertiary care
- Optimal data collection, for the benefit of the individual patient and for the purposes of audit and research
- Improved equality of outcomes as a result of better understanding and awareness of patients’ characteristics and through reflective practice
- Adherence to national and local clinical guidelines
- Promotion of good working relationships between staff, thereby enhancing their job satisfaction, mental health and QoL
- Opportunities for education/professional development of team members (implicitly through the inclusion of junior team members and explicitly when meetings are used to devise and agree upon new protocols and ways of working)
- Optimization of resources – effective MDT working should result in more efficient use of time, which should contribute to more efficient use of resources more generally
The evidence on the impact of MDTs on care and outcomes is extensive but uneven. Many studies are small and prone to case selection. However, in an important study, Kesson et al (124) compared the impact of the introduction of MDTs in a Scottish Health Board in Glasgow on breast cancer patient survival with survival in surrounding Health Boards that did not introduce MDTs for patients with breast cancer. They showed an improved survival and reduced variation in care in the region that introduced MDTs, in 13,722 women treated for breast cancer. Although the balance of studies in the literature support the value of MDTs, they must be kept efficient to justify the cost and staff time involved (125). Managing MDTs in clinical practice remains challenging. Human factors such as unequal participation by team members, varying quality of leadership, inconsistent communication, and decision-making fatigue in long meetings can all reduce the quality of the decisions made (126-127).
The European Cancer Organisation in its series of organisational specifications on “Essential Requirements for Quality Cancer Care” (36-43), explain the place of the MDT in cancer care and emphasise the varied nature of the impact of MDTs and the degree to which their value will vary between different cancer types and different groups of patients with a particular cancer.
Integrated Care within Cancer Networks is recommended by EU Member State Joint Actions, EPAAC and the recent CanCon studies (5, 11, 67, 82, 122). Specialised multidisciplinary cancer care requires a substantial team of cancer care professionals and significant infrastructure and supportive components. The experience of that team must be maintained by a sufficient number of patients under the team’s care. The number of patients required to maintain high quality and ensure cost effectiveness for an MDT will vary between different cancers. However, in general for uncommon or rare cancers (or paediatric/adolescent patients with cancer), to maintain the number of patients necessary for high quality care, a degree of centralisation of services and referral from one hospital towards a more specialised hospital for certain aspects of their treatment will be required. This process needs to be organised in an integrated and well-thought-out way so that patients can be referred to a specialist centre for the essential components of their care that depend on the expertise present only in that centre. The aspects of the care which tend to be better delivered at the centre often involve highly technical equipment such as specialised radiotherapy planning and treatment or expertise that is only relevant to a small number of patients with rare cancers such as testicular cancer - where cure rates are higher when such expertise is deployed. However, other parts of the patient pathway may be provided closer to home in district/community hospitals or primary care. Care delivered close to a patient’s home can include routine blood testing, routine X-rays, and increasingly the delivery of chemotherapy at home, often orally. The COVID-19 pandemic has also highlighted a place for video consultations in future cancer care. The organisation of integrated care in this way has been referred to as a “Cancer Network” or more recently as a “Comprehensive Cancer Care Network (CCCN)”. Integrated cancer care in networks, bringing together primary care and hospital care and forming closer links between institutions, can improve the quality of care and outcomes for patients (5, 11, 67, 82, 122).
Key factors in the successful integration of networks of cancer services across primary care and hospitals include the following:
- Excellent multidisciplinary cancer care
- Agreed and respected evidence-based pathways of care
- Shared ownership of healthcare and information systems by patients and professionals in primary care, in hospitals and in public health; co-production of new initiatives
- Commitment and engagement by healthcare professionals in all sectors
- Patient engagement in service development
- Excellent communications between all stakeholders
- Integrated information systems
- Governance clearly shared
- Routes to access service commissioners/payers
- Research and innovation intertwined with patient care
- Transparency and commitment to delivering and publishing outcomes
Cancer networks have developed across Europe at the local, regional and – in the case of rare cancers including paediatric/adolescent cancers – European levels, presenting considerable differences in terms of governance, management structures and degree of network maturity (128). Examples include the network in the Rhone-Alpes Region of France (129-130), the Catalonian cancer network in Spain (131) and Cancer Networks in England (67, 132-134). Prades et al (128) noted “The cancer network model, epitomised by the UK experience, has shown great potential to improve health outcomes by making better use of scarce clinical expertise, enhancing service coordination, and increasing patient access to services and clinical trials. From these promising results and early European experiences, the European Partnership for Action against Cancer (EPAAC), launched by the European Commission in 2009, promoted cancer networks as the optimal organisational strategy to strengthen comprehensive cancer care.” (11, 128) Cancer networks have been more recently explored and updated by the EU Joint Action on Cancer Control (CanCon), which characterised the Comprehensive Cancer Care Network or CCCN in Table 8 (5, 82, 122). Results from the CanCon 2015 survey of EU member states indicated that cancer networks do exist in many countries (122) and can adopt various configurations to fit individual country requirements. Given the apparent relationships between service volumes and outcomes, they suggested that a CCCN should serve a population of at least one to two million people (122). The European Experience has recently been supported by Australasian findings (135-136).
Table 8. Definition of a Comprehensive Cancer Care Network (CCCN) (122). The word unit is used to designate any component of a CCCN, whether an entire pre-existing institution or part of an institution. For example, a unit might be an entire cancer centre, an oncology department of a general hospital or a children’s hospital, a mammography facility, a pathology laboratory carrying out mutation analysis, or a hospice
