all diagnostic imaging is assessed by radiologists and nuclear medicine physicians with specific expertise in cancer imaging prior to the MDTM. An expert radiologist familiar with surgical principles may anticipate the expected organ involvement. Regular contact in the oncological network ensures that referring hospitals know which scan sequences and modalities that are required.
Table 2.1 Differences between hospitals caring for “regular” colorectal cancer patients and hospitals caring for locally advanced and recurrent pelvic cancer patients (Example from The Netherlands).
| Regular care for colorectal cancer | Specialized pelvic cancer care |
|---|---|
| Consultants with special interest in colorectal cancer | Consultants with special interest in locally advanced and pelvic cancer |
| Two radiologists | Two radiologists with verifiable expertise in evaluation of locally advanced and recurrent pelvic cancer, before and after neoadjuvant treatment |
| Two surgeons | Two surgeons with verifiable technical expertise in treatment of locally advanced and recurrent pelvic cancer. At least one surgeon with expertise in treatment of stage 4 colorectal cancer |
| One pathologist | Pathologist with specific expertise in evaluation of specimens of the pelvis and effects of neoadjuvant therapy |
| One radiation oncologist | Radiation oncologist with expertise in treatment of locally advanced and recurrent pelvic cancer. Expertise in IORT = Intra‐operative radiotherapy |
| One medical oncologist | Medical oncologist with specific expertise in curative treatment of patients with locally advanced and recurrent pelvic cancer |
| Extra: Oncological urologist with expertise in urinary deviation | |
| Extra: Oncological gynecologist with expertise in postoperative care and recovery | |
| Extra: plastic and reconstructive surgeon with expertise in reconstruction of large oncological defects | |
| 24/7 intervention radiology | Experience with acquiring tissue from the pelvis and placing drains in the pelvis, including transgluteal approaches |
| Stomatherapy nurse clinic | Stomatherapy nurse experienced in care of urinary stoma |
| protocol for referral for IORT | Provides IORT |
| MDTM operates according to national guideline | MDTM discusses many patients that cannot be treated according to national guideline |
| Includes all patients in Dutch Surgical Colorectal Audit (DSCA) | Includes only T4 in audit. Registers all patients in prospective databases, compares with other T4/locally recurrent rectal cancer (LRRC) centers, and publishes results |
Restaging
In patients who receive neoadjuvant treatment, response evaluation can be challenging due to the difficulties in distinguishing between malignant and fibrotic changes. Visualizing and assessing complete remission or downsizing of the tumor after neoadjuvant treatment, may alter the surgical planning in highly selected cases the surgical planning. Complete remission after (chemo)radiation cannot be predicted reliably with non‐invasive imaging techniques, because of the spatial limitations to detecting microscopic tumor residue [17]. Even magnetic resonance imaging (MRI) can result in false positive predictions. Addition of diffusion‐weighted imaging (DWI) to standard MRI makes detection more accurate. Overall, an experienced radiologist with considerable expertise is an essential part of the complex cancer MDTM [18–20].
Pathological Assessment
All resected specimens should be examined by an experienced histopathologist and results must be discussed in the complex cancer MDTM. The role of the pathologist includes advanced pelvic cancer specimen quality, lymph node and margin status. Reporting these findings should be done by the use of structured reports [21–22].
Complex Cancer MDTM Outcomes
All participants should have ample experience with this complex and heterogeneous group of patients. In the case of a treatment plan with curative intent, the surgeon proposes a strategy with as little harm as possible. This proposal often includes induction therapy with chemotherapy, radiotherapy, or both. The medical oncologist and radiation oncologist usually want specific aspects clarified, often involving prior medical history or imaging. The radiologist is frequently asked to specify some aspects of scans that were presented earlier. In cases of non‐curative treatment, the initiative lies with the medical oncologist. The possibilities for enrolment in a clinical trial should be discussed, and when enrolment is possible, the relevant trial will be included in the MDTM outcome advice. The discussion on an individual patient ends with the chair declaring what he or she thinks the consensus of the MDTM is, after which the secretary notes the final conclusion.
Summary Box
Increased complexity of modern cancer care requires a multidisciplinary approach.
Combining the knowledge of different specificities makes the MDTM an excellent learning environment enhance cancer care.
A lack of defined protocols in locally advanced and recurrent pelvic cancer endorses the necessity for a centralized multidisciplinary approach.
References
1 1 Fennell, M.L., Prabhu Das, I., Clauser, S. et al. (2010). The organization of multidisciplinary care teams: modeling internal and external influences on cancer care quality. J. Natl Cancer Inst. Monogr 2010 (40): 72–80.
2 2 Kelly, S.L., Jackson, J.E., Hickey, B.E. et al. (2013). Multidisciplinary clinic care improves adherence to best practice in head and neck cancer. Am. J. Otolaryngol 34 (1): 57–60.
3 3 Korman, H., Lanni, T.J., Shah, C. et al. (2013). Impact of a prostate multidisciplinary clinic program on patient treatment decisions and on adherence to NCCN guidelines: the William Beaumont Hospital experience. Am. J. Clin. Oncol 36 (2): 121–125.
4 4 Prades, J., Remue, E., van Hoof, E., and Borras, J.M. (2015). Is it worth reorganising cancer services on the basis of multidisciplinary teams (MDTs)? A systematic review of the objectives and organisation of MDTs and their impact on patient outcomes. Health Policy 119 (4): 464–474.
5 5 Raine, R., Wallace, I., Nic a’ Bháird, C. et al. (2014). Improving the effectiveness of multidisciplinary team meetings for patients with chronic diseases: a prospective observational study. Health Serv. Deliv. Res. 2.37.
6 6 Taplin, S.H., Weaver, S., Salas, E. et al. (2015). Reviewing cancer care team effectiveness. J. Oncol. Pract 11 (3): 239–246.
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