The influence of multidisciplinary team meetings on treatment decisions in advanced bladder cancer.

OBJECTIVES: To investigate the role of specialised genitourinary multidisciplinary team meetings (MDTMs) in decision-making and identify factors that influence the probability of receiving a treatment plan with curative intent for patients with muscle invasive bladder cancer (MIBC). PATIENTS AND METHODS: Data relating to patients with cT2-4aN0/X-1 M0 urothelial cell carcinoma, diagnosed between November 2017 and October 2019, were selected from the nationwide, population-based Netherlands Cancer Registry ('BlaZIB study'). Curative treatment options were defined as radical cystectomy (RC) with or without neoadjuvant chemotherapy, chemoradiation or brachytherapy. Multilevel logistic regression analyses were used to examine the association between MDTM factors and curative treatment advice and how this advice was followed. RESULTS: Of the 2321 patients, 2048 (88.2%) were discussed in a genitourinary MDTM. Advanced age (>80 years) and poorer World Health Organization performance status (score 1-2 vs 0) were associated with no discussion (P < 0.001). Being discussed was associated with undergoing treatment with curative intent (odds ratio [OR] 3.0, 95% confidence interval [CI] 1.9-4.9), as was the involvement of a RC hospital (OR 1.70, 95% CI 1.09-2.65). Involvement of an academic centre was associated with higher rates of bladder-sparing treatment (OR 2.05, 95% CI 1.31-3.21). Patient preference was the main reason for non-adherence to treatment advice. CONCLUSIONS: For patients with MIBC, the probability of being discussed in a MDTM was associated with age, performance status and receiving treatment with curative intent, especially if a representative of a RC hospital was present. Future studies should focus on the impact of MDTM advice on survival data.

Factors influencing the quality and functioning of oncological multidisciplinary team meetings: results of a systematic review.

BACKGROUND: Discussing patients with cancer in a multidisciplinary team meeting (MDTM) is customary in cancer care worldwide and requires a significant investment in terms of funding and time. Efficient collaboration and communication between healthcare providers in all the specialisms involved is therefore crucial. However, evidence-based criteria that can guarantee high-quality functioning on the part of MDTMs are lacking. In this systematic review, we examine the factors influencing the MDTMs' efficiency, functioning and quality, and offer recommendations for improvement. METHODS: Relevant studies were identified by searching Medline, EMBASE, and PsycINFO databases (01-01-1990 to 09-11-2021), using different descriptions of 'MDTM' and 'neoplasm' as search terms. Inclusion criteria were: quality of MDTM, functioning of MDTM, framework and execution of MDTM, decision-making process, education, patient advocacy, patient involvement and evaluation tools. Full text assessment was performed by two individual authors and checked by a third author. RESULTS: Seventy-four articles met the inclusion criteria and five themes were identified: 1) MDTM characteristics and logistics, 2) team culture, 3) decision making, 4) education, and 5) evaluation and data collection. The quality of MDTMs improves when the meeting is scheduled, structured, prepared and attended by all core members, guided by a qualified chairperson and supported by an administrator. An appropriate amount of time per case needs to be established and streamlining of cases (i.e. discussing a predefined selection of cases rather than discussing every case) might be a way to achieve this. Patient centeredness contributes to correct diagnosis and decision making. While physicians are cautious about patients participating in their own MDTM, the majority of patients report feeling better informed without experiencing increased anxiety. Attendance at MDTMs results in closer working relationships between physicians and provides some medico-legal protection. To ensure well-functioning MDTMs in the future, junior physicians should play a prominent role in the decision-making process. Several evaluation tools have been developed to assess the functioning of MDTMs. CONCLUSIONS: MDTMs would benefit from a more structured meeting, attendance of core members and especially the attending physician, streamlining of cases and structured evaluation. Patient centeredness, personal competences of MDTM participants and education are not given sufficient attention.

Preparing tomorrow's medical specialists for participating in oncological multidisciplinary team meetings: perceived barriers, facilitators and training needs.

INTRODUCTION: The optimal treatment plan for patients with cancer is discussed in multidisciplinary team meetings (MDTMs). Effective meetings require all participants to have collaboration and communication competences. Participating residents (defined as qualified doctors in training to become a specialist) are expected to develop these competences by observing their supervisors. However, the current generation of medical specialists is not trained to work in multidisciplinary teams; currently, training mainly focuses on medical competences. This study aims to identify barriers and facilitators among residents with respect to learning how to participate competently in MDTMs, and to identify additional training needs regarding their future role in MDTMs, as perceived by residents and specialists. METHODS: Semi-structured interviews were conducted with Dutch residents and medical specialists participating in oncological MDTMs. Purposive sampling was used to maximise variation in participants' demographic and professional characteristics (e.g. sex, specialty, training duration, type and location of affiliated hospital). Interview data were systematically analysed according to the principles of thematic content analysis. RESULTS: Nineteen residents and 16 specialists were interviewed. Three themes emerged: 1) awareness of the educational function of MDTMs among specialists and residents; 2) characteristics of MDTMs (e.g. time constraints, MDTM regulations) and 3) team dynamics and behaviour. Learning to participate in MDTMs is facilitated by: specialists and residents acknowledging the educational function of MDTMs beyond their medical content, and supervisors fulfilling their teaching role and setting conditions that enable residents to take a participative role (e.g. being well prepared, sitting in the inner circle, having assigned responsibilities). Barriers to residents' MDTM participation were insufficient guidance by their supervisors, time constraints, regulations hindering their active participation, a hierarchical structure of relations, unfamiliarity with the team and personal characteristics of residents (e.g. lack of confidence and shyness). Interviewees indicated a need for additional training (e.g. simulations) for residents, especially to enhance behavioural and communication skills. CONCLUSION: Current practice with regard to preparing residents for their future role in MDTMs is hampered by a variety of factors. Most importantly, more awareness of the educational purposes of MDTMs among both residents and medical specialists would allow residents to participate in and learn from oncological MDTMs. Future studies should focus on collaboration competences.

Digoxin treatment does not reinduce radioiodine uptake in radioiodine refractory non-medullary thyroid carcinoma.

Objective: Patients with non-medullary thyroid carcinoma (NMTC) that are refractory to radioactive iodine (RAI) have a poor prognosis. Strategies for restoring the ability to take up iodine, so-called redifferentiation, are promising but not suitable for all patients. Preclinical studies, in human cell lines just as in a murine model, have shown that the cardiac glycoside digoxin restored RAI uptake. This prospective single-center open-label study aimed to investigate whether treatment with digoxin could reinduce clinically relevant RAI uptake in patients with metastasized RAI-refractory NMTC. Methods: Eight patients with metastasized RAI-refractory NMTC were included between November 2022 and June 2023. Before treatment, a baseline [123I]NaI scintigraphy was performed. Thereafter, patients were treated with digoxin for 3 weeks. Starting doses depended on age and weight. For safety reasons, the usual therapeutic range was aimed for. After 1 week, the digoxin plasma concentration was measured, and the digoxin dose was adjusted if necessary. After 3 weeks of digoxin treatment, a second [123I]NaI scintigraphy was performed. RAI uptake was compared between the two scintigraphies. Results: Seven patients completed the digoxin treatment and were evaluable. None of the seven patients showed clinically relevant RAI uptake after digoxin treatment. No digoxin-related serious adverse events occurred during this trial. Conclusion: Contrary to results from preclinical trials, in this trial, 3 weeks of digoxin treatment did not reinduce RAI uptake in patients with NMTC. This highlights essential challenges regarding the approach toward optimization of studies aimed to restore the RAI uptake and its therapeutic efficacy through drug repurposing.

Development and Internal Validation of Nomograms for Survival of Advanced Epithelial Ovarian Cancer Based on Established Prognostic Factors and Hematologic Parameters.

Objective: To assess the association between pretreatment thrombocytosis, anemia, and leukocytosis and overall survival (OS) of advanced-stage EOC. Furthermore, to develop nomograms using established prognostic factors and pretreatment hematologic parameters to predict the OS of advanced EOC patients. Methods: Advanced-stage EOC patients treated between January 1996 and January 2010 in eastern Netherlands were included. Survival outcomes were compared between patients with and without pretreatment thrombocytosis (≥450,000 platelets/µL), anemia (hemoglobin level of <7.5 mmol/L), or leukocytosis (≥11.0 × 109 leukocytes/L). Three nomograms (for ≤3-, ≥5-, and ≥10-year OS) were developed. Candidate predictors were fitted into multivariable logistic regression models. Multiple imputation was conducted. Model performance was assessed on calibration, discrimination, and Brier scores. Bootstrap validation was used to correct for model optimism. Results: A total of 773 advanced-stage (i.e., FIGO stages IIB-IV) EOC patients were included. The median [interquartile range, IQR] OS was 2.3 [1.3-4.2] and 3.0 [1.4-7.0] years for patients with and without pretreatment thrombocytosis (p < 0.01). The median OS was not notably different for patients with and without pretreatment leukocytosis (p = 0.58) or patients with and without pretreatment anemia (p = 0.07). The final nomograms comprised established predictors with either pretreatment leukocyte or platelet count. The ≥5- and ≥10-year OS models demonstrated good calibration and adequate discrimination with optimism-corrected c-indices [95%-CI] of 0.76 [0.72-0.80] and 0.78 [0.73-0.83], respectively. The ≤3-year OS model demonstrated suboptimal performance with an optimism-corrected c-index of 0.71 [0.66-0.75]. Conclusions: Pretreatment thrombocytosis is associated with poorer EOC survival. Two well-performing models predictive of ≥5-year and ≥10-year OS in advanced-stage EOC were developed and internally validated.

Facilitators and barriers to conducting an efficient, competent and high-quality oncological multidisciplinary team meeting.

BACKGROUND: Optimal oncological care nowadays requires discussing every patient in a multidisciplinary team meeting (MDTM). The number of patients to be discussed is rising rapidly due to the increasing incidence and prevalence of cancer and the emergence of new multidisciplinary treatment options. This puts MDTMs under considerable time pressure. The aim of this study is therefore to identify the facilitators and barriers with regard to performing an efficient, competent and high-quality MDTM. METHODS: Semistructured interviews were conducted with Dutch medical specialists and residents participating in oncological MDTMs. Purposive sampling was used to maximise variation in participants' professional and demographic characteristics (eg, sex, medical specialist vs resident, specialty, type and location of affiliated hospital). Interview data were systematically analysed according to the principles of thematic content analysis. RESULTS: Sixteen medical specialists and 19 residents were interviewed. All interviewees agreed that attending and preparing MDTMs is time-consuming and indicated the need for optimal execution in order to ensure that MDTMs remain feasible in the near future. Four themes emerged that are relevant to achieving an optimal MDTM: (1) organisational aspects; (2) participants' responsibilities and requirements; (3) competences, behaviour and team dynamics and (4) meeting content. Good organisation, a sound structure and functioning information and communication technology facilitate high-quality MDTMs. Multidisciplinary collaboration and adequate communication are essential competences for participants; a lack thereof and the existence of a hierarchy are hindering factors. CONCLUSION: Conducting an efficient, competent and high-quality oncological MDTM is facilitated and hindered by many factors. Being aware of these factors provides opportunities for optimising MDTMs, which are under pressure due to the increase in the number of patients to discuss.

Impact of Sepsis on the Oncologic Outcomes of Advanced Epithelial Ovarian Cancer Patients: A Multicenter Observational Study.

OBJECTIVE: The sepsis-induced inflammatory response may potentially affect malignant cells. Recently, a case of spontaneous regression of a histologically confirmed International Federation of Gynecology and Obstetrics (FIGO) stage IIIC epithelial ovarian cancer (EOC) following sepsis was reported. The aim of our study was to assess the impact of sepsis on the oncologic outcomes of advanced-stage EOC patients. METHODS: Gynecologic oncologic patients admitted to the Intensive Care Unit of three oncologic centers between 2006 and 2019 were identified and patients who experienced sepsis following advanced-stage EOC diagnosis were selected. Survival outcomes were compared with advanced-stage EOC patients from the Netherlands Cancer Registry (NCR). To correct for case-mix differences, propensity score matching using 1:3 nearest neighbor matching was conducted after which survival analyses were repeated. RESULTS: A total of 18 of 215 patients with advanced-stage EOC experienced sepsis. Sepsis patients had similar distributions of patient, tumor, and treatment characteristics to 3988 patients from the NCR cohort. A total of 3 of 18 patients died from the complications of sepsis. While the remaining patients initially responded to treatment, 14/15 patients relapsed. The median (IQR) overall survival was 31 (24-44) and 35 (20-60) months for the sepsis and unmatched NCR cohort (p = 0.56), respectively. The median (IQR) progression-free survival was 16 (11-21) and 16 (11-27) months (p = 0.90), respectively. Survival outcomes did not differ following propensity matching (overall survival of 31 (24-44) vs. 36 (20-56) months, p = 0.40; progression-free survival of 16 (11-21) and 16 (12-21) months, p = 0.72). CONCLUSION: In this observational study, the occurrence of sepsis did not affect the oncologic and survival outcomes of advanced-stage EOC patients.

Pros and cons of streamlining and use of computerised clinical decision support systems to future-proof oncological multidisciplinary team meetings.

Introduction: Nowadays nearly every patient with cancer is discussed in a multidisciplinary team meeting (MDTM) to determine an optimal treatment plan. The growth in the number of patients to be discussed is unsustainable. Streamlining and use of computerised clinical decision support systems (CCDSSs) are two major ways to restructure MDTMs. Streamlining is the process of selecting the patients who need to be discussed and in which type of MDTM. Using CCDSSs, patient data is automatically loaded into the minutes and a guideline-based treatment proposal is generated. We aimed to identify the pros and cons of streamlining and CCDSSs. Methods: Semi-structured interviews were conducted with Dutch MDTM participants. With purposive sampling we maximised variation in participants' characteristics. Interview data were thematically analysed. Results: Thirty-five interviews were analysed. All interviewees agreed on the need to change the current MDTM workflow. Streamlining suggestions were thematised based on standard and complex cases and the location of the MDTM (i.e. local, regional or nationwide). Interviewees suggested easing the pressure on MDTMs by discussing standard cases briefly, not at all, or outside the MDTM with only two to three specialists. Complex cases should be discussed in tumour-type-specific regional MDTMs and highly complex cases by regional/nationwide expert teams. Categorizing patients as standard or complex was found to be the greatest challenge of streamlining. CCDSSs were recognised as promising, although none of the interviewees had made use of them. The assumed advantage was their capacity to generate protocolised treatment proposals based on automatically uploaded patient data, to unify treatment proposals and to facilitate research. However, they were thought to limit the freedom to deviate from the treatment advice. Conclusion: To make oncological MDTMs sustainable, methods of streamlining should be developed and introduced. Physicians still have doubts about the value of CCDSSs.

Hospital practice variation in the proportion of patients with esophagogastric cancer discussed during an expert multidisciplinary team meeting.

BACKGROUND: Multidisciplinary team meetings (MDTM) and especially MDTMs in which expert centres are involved (expert MDTMs) are a key element in adequate cancer care. However, variation among hospitals in the proportion of patients presented during an expert MDTM has been described. This study aims to investigate national practice variation in the proportion of patients with oesophageal or gastric cancer being discussed during an expert MDTM. METHODS: Patients diagnosed with oesophageal or gastric cancer in 2018-2019 were selected from the Netherlands Cancer Registry (n = 6,921). Multilevel logistic regression analyses were used to analyse the association between patient, and tumour characteristics, and the probability to be discussed in an expert MDTM. Variation was analysed according to the hospital and region of diagnosis for: all patients, patients with a potentially curable (cT1-4A cTX, any cN, cM0) or incurable tumour stage (cT4b and/or cM1). RESULTS: In total, 79% of patients were discussed during an expert MDTM, of whom 84% (n = 3,424) and 71% (n = 2,018) with potentially curable, or incurable oesophageal or gastric cancer, respectively. The proportion of patients discussed during an expert MDTM ranged from 54% to 98%, and 17% to 100% between hospitals for potentially curable and incurable patients, respectively (all p < 0.0001). Adjusted analyses showed significant hospital (all p < 0.0001), but no regional variation regarding the patients discussed during an expert MDTM. CONCLUSION: For patients with oesophageal or gastric cancer the probability of being discussed during an expert MDTM varies considerably according to the hospital of diagnosis.