Translation of oncology multidisciplinary team meeting (MDM) recommendations into clinical practice.

BACKGROUND: Multidisciplinary team meeting (MDM) processes differ according to clinical setting and tumour site. This can impact on decision making. This study aimed to evaluate the translation of MDM recommendations into clinical practice across solid tumour MDMs at an academic centre. METHODS: A retrospective audit of oncology records was performed for nine oncology MDMs held at Liverpool Hospital, NSW, Australia from 1/2/17-31/7/17. Information was collected on patient factors (age, gender, country of birth, language, postcode, performance status, comorbidities), tumour factors (diagnosis, stage) and MDM factors (number of MDMs, MDM recommendation). Management was audited up to a year post MDM to record management and identify reasons if discordant with MDM recommendations. Univariate and multivariable regression analyses were performed to assess for factors associated with concordant management. RESULTS: Eight hundred thirty-five patients were discussed, median age was 65 years and 51.4% were males. 70.8% of patients were presented at first diagnosis, 77% discussed once and treatment recommended in 73.2%. Of 771 patients assessable for concordance, management was fully concordant in 79.4%, partially concordant in 12.8% and discordant in 7.8%. Concordance varied from 84.5% for lung MDM to 97.6% for breast MDMs. On multivariable analysis, breast and upper GI MDMs and discussion at multiple MDMs were significantly associated with concordant management. The most common reason for discordant management was patient/guardian decision (28.3%). CONCLUSION: There was variability in translation of MDM recommendations into clinical practice by tumour site. Routine measurement of implementation of MDM recommendations should be considered as a quality indicator of MDM practice.

Palliative care and psychosocial care in metastatic non-small cell lung cancer: factors affecting utilisation of services and impact on patient survival.

BACKGROUND: Palliative care (PC) and psychosocial care (PSC) are essential services, which can positively impact on quality of life in patients with metastatic lung cancer, when advanced disease and poor prognosis preclude the use of curative therapies. The aims of this study were to describe patterns of PC and PSC and identify factors associated with service utilisation and overall patient survival. METHOD: A retrospective Australian cohort of South Western Sydney residents with newly diagnosed stage IV non-small cell lung cancer (NSCLC) in 2006-2012 was identified from the Local Health District Clinical Cancer Registry. Supplemental information was sourced from the area PC database and hospital medical records. Cox regression models with robust variance identified factors associated with PC and PSC and examined patient survival. RESULTS: A total of 923 patients were identified. Eighty-three per cent of patients were seen by PC, with 67% seen within 8 weeks of diagnosis. PSC utilisation was 82%. Radiotherapy treatment and residential area were associated with both PC and PSC. Increasing age was associated with early PC referral. Median overall survival was 4 months. PC was associated with patient survival; however, the effect varied over time. CONCLUSION: The rate of PC and PSC in our metastatic NSCLC population was high when compared with published data. Despite this, there were gaps in PC and PSC provision in this population, notably with patients not receiving active treatment, and those receiving systemic therapy utilising these services less frequently. PSC and PC contact were not convincingly associated with improved patient survival.

Assessing guideline adherence and patient outcomes in cervical cancer.

AIM: To investigate adherence to clinical practice guidelines (CPGs) in cervical cancer and the correlation with clinical outcomes. METHODS: A retrospective analysis was conducted using patient information from a population-based cancer registry (2005-2011, n = 208). Compliance to 10 widely accepted CPGs was assessed. Univariate and multivariate analyses were performed to assess sociodemographic factors associated with CPG adherence. Multivariate Cox regression was performed to assess the relationship between CPG adherence and 5-year survival. RESULTS: Adherence to individual CPGs ranged from 47% to 100%. Compliance to all applicable CPGs was seen in 54% (n = 72) of patients, 62% of stage I and II patients and 22% of stage III and IV patients. Poorest adherence was seen with those with locally advanced disease receiving chemoradiotherapy. Patients who lived within 5 km of the treatment facility were more likely to be compliant. No difference was found for either age, country of birth or socioeconomic status group. Five-year survival was greater for stage I and II patients who received guideline adherent care (93.7% vs 69.7%, P = 0.002), and they had a significant lower risk of death on multivariate analysis (HR = 0.22, P = 0.015). There was no significant difference for those with stage III or IV disease. CONCLUSIONS: In this study, CPG adherence is variable between treatment modalities and only half complied to all applicable CPGs. There was better adherence in those with early-stage disease and this was associated with improved patient outcomes. CPG adherence may be a useful surrogate for quality of care.

Do patients discussed at a lung cancer multidisciplinary team meeting receive guideline-recommended treatment?

AIM: Clinical guidelines provide evidence-based management recommendations to guide practice. This study aimed to evaluate whether patients discussed at a lung cancer multidisciplinary team meeting received guideline-recommended treatment and determine reasons for not receiving guideline-recommended treatment. METHODS: All new lung cancer patients discussed at the Liverpool/Macarthur lung cancer multidisciplinary team meeting between 1 December 2005 and 31 December 2010 were included. Guideline-recommended treatment was assigned according to pathology, stage and ECOG (Eastern Co-operative Oncology Group) performance status as per the 2004 Australian Lung Cancer Guidelines. This was compared with actual treatment received to determine adherence to guidelines. For those patients who did not receive guideline-recommended treatment, the medical record was reviewed to determine the reason(s) for this. Survival was compared between those who did and did not receive guideline-recommended treatment. RESULTS: 808 new patients were discussed at the multidisciplinary team meeting. Guideline-recommended treatment could not be assigned in 2% of patients due to missing data. 435 patients (54%) received guideline-recommended treatment, and 356 (44%) did not. The most common reasons for not receiving guideline-recommended treatment were a decline in ECOG performance status (24%), large tumor volume precluding radical radiotherapy (17%), comorbidities (15%) and patient preference (13%). Patients less than 70 years who received guideline-recommended treatment had improved survival compared with those who did not. CONCLUSIONS: A significant proportion of lung cancer patients did not receive guideline-recommended treatment due to legitimate reasons. Alternative guidelines are needed for patients not suitable for current best practice. Treatment according to guidelines was a predictor for survival.

Do multidisciplinary team meetings make a difference in the management of lung cancer?

BACKGROUND: There is limited evidence regarding the effectiveness of multidisciplinary team (MDT) meetings in lung cancer. The objective of this study was to compare the patterns of care for patients with newly diagnosed lung cancer who were presented at a lung cancer MDT meeting with the patterns of care for patients who were not presented. METHODS: All patients who had lung cancer newly diagnosed in South West Sydney (SWS) between December 1, 2005, and December 31, 2008, were identified from the local Clinical Cancer Registry. Patient and tumor characteristics and treatment receipt were compared between patients who were and were not presented at MDT meetings. A logistic regression model was constructed to determine predictors for receiving treatment and survival. RESULTS: In total, there were 988 patients, including 504 patients who were presented at MDT meetings and 484 who were not presented at MDT meetings. The median patient age was 69 years and 73 years in the MDT group and the non-MDT group, respectively (P < .01). There was no pathologic diagnosis for 13% of non-MDT patients compared with 4% of MDT patients (P < .01). Treatment receipt for MDT patients versus non-MDT patients was 12% versus 13%, respectively, for surgery (P value nonsignificant); 66% versus 33%, respectively, for radiotherapy (P < .001); 46% versus 29%, respectively, for chemotherapy (P < .001); and 66% versus 53%, respectively, for palliative care (P < .001). In patients with good performance status, the MDT group had significantly better receipt of radiotherapy among patients with stage I through IV nonsmall cell lung cancer (NSCLC) and had significantly better receipt of chemotherapy among patients with stage IV NSCLC. MDT discussion was an independent predictor of receiving radiotherapy, chemotherapy, and referral to palliative care but did not influence survival. CONCLUSIONS: MDT discussion was associated with better treatment receipt, which potentially may improve quality of life for patients with lung cancer. However, it did not improve survival.