The dream team: when will we make it a reality?
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GrandRound
The dream team:
when will we make it
a reality?
➜ Anna Wagstaff
Multidisciplinary teams provide the best quality cancer care, as specialists come
together to discuss diagnoses and plan treatments. They raise standards, improve
patient experiences and save lives. Sadly, most of Europe’s cancer patients never
have the chance to feel their benefits.
F
or the 2.9 million people accepted, the vast majority of these They got their evidence through a
in Europe who will be 2.9 million patients will never have meta-analysis of many trials,
diagnosed with cancer their cases considered by a group of conducted by the Oxford Early
during the coming year, experts in a multidisciplinary meet- Breast Cancer Collaborative Group,
evidence-based guide- ing. Many treatments will be sub- which marked the beginning of
lines will recommend a treatment optimal, patients will feel poorly sup- large-scale international cooperation
programme that is likely to involve ported and lives will be lost. on analysing clinical trials. This
complex combinations of surgery, Traditionally, most cancers were opened the way to the use of combi-
radiotherapy, systemic therapies and primarily the domain of the surgeon. nations of treatments in routine pri-
supportive care. Though radiotherapy has been used mary management and to generalise
Getting that treatment pro- to treat cancers for more than 110 the multidisciplinary approach to
gramme right for each individual years, and medical oncology has been other cancers, making possible many
patient, with their own specific diag- used for the best part of the last cen- of the improvements over the last
nosis and their own co-morbidities, tury, these treatments were seen as decades.
needs and preferences, is beyond the alternatives or even as rivals. Breast cancer still leads the way,
powers of any individual practitioner. It was in the early 1970s that the with a huge number of options com-
It needs a multidisciplinary approach value of adjuvant chemotherapy in bining surgical techniques with
to care, in which a team composed of breast cancer became established. chemotherapy, hormone therapy and
all relevant medical and allied health Gianni Bonadonna in Italy and radiotherapy administered in various
disciplines work with one another Bernie Fisher in the US recall battles sequences. However, other cancers
and with the patient to diagnose, to convince the medical establish- are rapidly catching up. So whether
treat and manage the cancer. ment (for which read “surgeons”) of the cancer is in the lung or the liver,
But while the principle of multi- the value of routine chemotherapy whether it is a glioma or a myosarco-
disciplinary treatment is widely following surgery for breast cancer. ma, the evidence shows – and the
16 ■ CANCER WORLD ■ MAY-JUNE 2006
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guidelines stipulate – that the patient with understandable information, and centres of excellence, prestigious
does best with careful selection of to listen to them. cancer institutes, major university
surgical, radiotherapy and systemic Branches of medicine dealing hospitals that offer high-quality multi-
treatments. with these aspects of care, including disciplinary care, are exceptions. The
Recent decades have also brought psycho-oncology, and palliative care, majority of Europe’s patients are diag-
a cultural change towards a far more have been steadily growing in most of nosed and treated by specialists who
patient-centred approach to medicine Europe over past decades, and in have little training or practice in a
in general, and cancer treatment in some countries specialist cancer multidisciplinary approach, and who
particular. More attention now tends nurses have taken on an increasing work within structures that discour-
to be paid to aspects of treatment role in areas such as symptom man- age or rule out multidisciplinary care.
such as control of pain, fatigue, nau- agement and the provision of infor- Patients with breast or ovarian
sea and other symptoms, and support mation. But there remains a major cancers may be treated at gynaeco-
SCIENCE PHOTO LIBRARY / GRAZIA NERI
in coping with the stress of a life- problem in integrating these aspects logy clinics, where their doctor’s
threatening disease, or in coming to into the routine care of patients; primary training is in surgery, and
terms with the potential loss of fertil- many patients who could benefit are where there are no specialist medical
ity or living with a stoma. Greater care not being referred to the specialists oncologists, radiation facilities or
tends to be taken to help the patient who could help them. The multidisci- supportive care. In a similar way,
play a role in decisions to do with plinary approach overcomes this many urology clinics routinely treat
their treatment, which entails taking problem by involving all specialists patients with prostate cancer.
the time and effort to provide them with a role to play in the patient’s care In some countries, a large
from the point at which the decision proportion of cancer patients are
on the treatment programme is made. treated at smaller general hospitals,
Unfortunately, most cancer serv- some of which lack radiotherapy.
ices in Europe cannot deliver. The They probably have one or two
specialist medical oncologists, but in
many cases they are not organ-based
specialists, as recommended for best
quality care.
GrandRound
Even in large, well-staffed, institu- cancer and the setting. In addition to nary discussion if there are addition-
tions, patients are shunted from one surgeon, medical oncologist and radi- al complications. “You can’t discuss
department to the next, without ever ation oncologist, the presence of every single case; that would be
having their cases considered by a histopathologist and radiologist is impossible,” he says, “unless you are
gathering of specialist disciplines. generally seen as essential, because at a teaching hospital, when the ‘eas-
Leading practitioners say that management decisions depend on ier’ and more common cases must
things are moving in the right direc- knowing details of tumour margins or also be discussed.”
tion, but that change is slow and location, or the exact proliferation Mike Richards, the UK National
largely confined to more prestigious index. Cancer Director, responsible for
sites. It seems that only the UK and The inclusion of additional clini- overseeing the national cancer plan,
France have strategies in place to cal staff may vary, case by case, says, “My own preference would be
ensure that every cancer patient, no according to the location of the can- to have every patient at least regis-
matter where treated, has his or her cer, or to the culture and tradition of tered at the meeting. Some can be
treatment planned and delivered by a the particular health service. In the discussed in under a minute – ‘This
multidisciplinary team (MDT). Both UK, clinical nurse specialists are is a patient with a completely
countries aim for 100% coverage commonly included in multidiscipli- straightforward breast cancer. I’ve
within a few years. nary teams, whereas in France this is talked to her. She wants breast con-
not the case. Teams treating gastro- serving therapy followed by x or y…
THE DREAM TEAM intestinal cancers may include gas- Has anybody any concerns?’
A multidisciplinary approach requi- troenterologists and specialist stoma Everyone can say ‘No that’s fine’ and
res that new cases are discussed at nurses; teams treating breast cancer you move on. But the nurse specialist
the point of diagnosis, in a setting in may involve reconstructive surgeons. may say, ‘Are you aware that the
which all specialists who have a role Palliative care nurses and psycho- patient’s husband has Alzheimer’s
to play in diagnosis and care con- oncologists may be involved accord- disease, and it will be very difficult
tribute towards a personalised, evi- ing to patient need. for her to get to radiotherapy.’ That
dence-based care programme, taking The extent of specialisation with- doesn’t take very long, but everyone
into account the patient’s co-mor- in the team will also vary. Surgeons in the team is then aware.”
bidities and preferences. all over Europe are becoming Christine Bara, director of the
Decisions should be efficiently increasingly specialised to a particu- Department for Innovation and
recorded and communicated, so that lar cancer, and often define the sub- Improving the Quality of Care at the
professionals understand their roles specialisation of the team. Medical French National Cancer Institute,
while the patient understands the oncologists or radiation oncologists says that, under the national cancer
plan and is clear about who is respon- may be involved in a number of mul- plan, a similar practice is mandatory
sible for what. Each step should be tidisciplinary teams dealing with two within the French system. “All cases
coordinated and monitored to ensure or more different types of cancers. are registered. Straightforward cases
that information, scans etc. are Specialists who are thin on the that require treatment with the stan-
passed on quickly and efficiently to ground have to spread themselves dard evidence-based protocol are sim-
the right people and that unnecessary across multiple teams. ply presented very fast. Only those
delays are avoided. who cannot be treated with a standard
Straightforward cases may be dis- PATIENT SELECTION protocol are really discussed. A stan-
cussed only briefly. Complex cases Methods to select patients for dis- dardised form is completed for each
may need to be reassessed by the cussion also vary. Bengt Glimelius, a patient, which is held by the cancer
multidisciplinary team to evaluate medical and radiation oncologist who network.”
the patient’s response to treatment, works as part of a colorectal cancer
and to agree on the next step. team in Uppsala University Hospital, VIRTUAL OR REAL?
Sweden, says that straightforward Variations also exist in the extent to
TEAM MEMBERS cases are simply treated according to which the team is a physical entity at
The precise make-up of a multidisci- protocol, and doctors only put a a single site, or is dispersed across
plinary team varies according to the patient on the list for multidiscipli- departments in different wings of a
18 ■ CANCER WORLD ■ MAY-JUNE 2006
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Michael Baumann, radiation oncologist and director of the Dresden Cancer Centre in Germany. The Centre was set up three years ago on the initiative
of the surgeons and medical and radiation oncologists at the Dresden University Hospital, and provides an environment where they can work side by
side. It has sparked great interest among other university hospitals, many of which have yet to adopt a multidisciplinary approach to treatment.
Multidisciplinary working has come late to Germany; even in breast cancer the proportion of patients who have their treatment planned in a
multidisciplinary team meeting is probably lower than 20%
hospital or even across two or more find medical oncologists, radiation need to treat a minimum number of
institutions. In the latter instance, oncologists and surgeons, sitting in patients each year to keep their skills
members travel to meetings or hold neighbouring rooms.” up to scratch. This has been shown
videoconferences. Single-site arrangements also to be the case for surgeons, not only
A good example of a single-site have clear advantages for patients, for difficult procedures such as pan-
team is the cancer centre at the Carl who have a single point of reference creatic and oesophageal resections,
Gustave Carus University Hospital in throughout all their stages of treat- but also for breast, colorectal and
Dresden, Germany. This centre was ment. However, such arrangements other cancers. There is growing evi-
set up three years ago on the initia- may not be feasible outside cancer dence that this holds true for other
tive of the doctors from the hospital’s centres, university hospitals or cen- disciplines.
surgical, medical and radiotherapy tres of excellence. Requiring multidisciplinary
departments who had worked closely It might be undesirable, as well teams to operate from a single site
together for many years, but who as financially and logistically impossi- while fulfilling minimum volume
wanted to establish multidisciplinary ble, to restructure cancer services requirements would result in patients
outpatient clinics. throughout Europe, so that every with less common cancers travelling
Director Michael Baumann says patient is treated by a specialist mul- enormous distances for treatment.
that they felt that this ideal would tidisciplinary team located at a single This may be the best option for cer-
only flourish in a physical centre. “I site, rather than at organ-specialist tain cancers or types of treatment,
am not a big believer in virtual cen- clinics or smaller general hospitals. but other treatments can be carried
tres. Ours is a real centre. You can go Individual practitioners and, by out closer to home.
there, there is a door and inside you extension, multidisciplinary teams A ‘virtual’ team may be the best
“Ours is a real centre… there is a door, and inside you
find medical and radiation oncologists and surgeons”
CANCER WORLD ■ MAY-JUNE 2006 ■ 19
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Jean-Pierre Gérard, director of the Antoine Lacassagne Cancer Centre in Nice, France. The Centre is one of the 20 cancer centres around which France’s
cancer services have been organised for decades, and has a long history of multidisciplinary working. Under the French Cancer Plan of 2003, all
centres treating cancer, whether public or private, are required to work in a multidisciplinary way, if necessary by cooperating with one another. Around
50% of all French patients are currently treated in a multidisciplinary setting; the aim is to extend this to 95% of patients by the end of 2007
option – particularly if it is supported ings are necessary, but they do take 80% of cancer patients. “It is a ques-
to overcome obstacles of distance time, and the geographical distribu- tion of time sharing and having
and to function effectively. The alter- tion of doctors can be a problem. videoconferencing, and also increasing
native is that team members travel to What we are trying to do, jointly with the number of these specialists,” he
locations closer to the patient. This the regional agencies and the cancer says.
can work across small distances, with networks, is to concentrate these
doctors based at one site attending meetings in fewer locations in order BETWEEN THEORY AND PRACTICE
team meetings at another site once a to guarantee their medical represen- The logic of using MDTs to plan and
week. However, there is already evi- tativity.” Providing videoconferencing deliver multidisciplinary treatment is
dence from many countries that find- facilities and effective electronic irrefutable. However, recent studies
ing time to attend multidisciplinary communications systems is set to looking at aspects of how teams func-
meetings is putting pressure on hard- play a key role in this. tion in the UK have revealed striking
pressed team members. Adding in Jean-Pierre Gérard is director of gaps between theory and practice.
long journeys would exacerbate the the Antoine Lacassagne Cancer One study (Macaskill et al, Eur J
situation. Centre in Nice, one of 20 cancer Cancer, in press), found that medical
Clearly, there is no single solu- centres around which the new oncologists were absent for some of
tion or blueprint. In both France and regional cancer networks are organ- the time in over half of all breast
the UK, the emphasis has been on ised. He says the problem is particu- meetings (55.9%). They did not
finding flexible, local solutions and larly acute for radiation oncologists as attend at all in 41.2% of cases and
allowing the system to evolve. there are no more than 500–600 in attended for only some of the meet-
Bara, of the French National France, and their involvement is ing in 14.7% of cases. Clinical oncol-
Cancer Institute, says, “These meet- needed in the discussion of around ogists (radiotherapists), by contrast,
More than half of the meetings take place over
lunch time… many don’t even provide lunch!
20 ■ CANCER WORLD ■ MAY-JUNE 2006
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Richards identifies good leadership as one of two
essential elements for effective team work
were present for the whole meeting be a problem. Fallowfield recalls one ed that they regularly discussed phys-
in 70% of cases, and surgeons in team meeting in a room so small that ical, functional, social and emotional
98.5% of cases. some members were left standing in wellbeing with patients, yet few of
One probable reason for this was doorway straining to hear what was their colleagues showed any aware-
that only a quarter (28%) of these said or see what was shown. ness of this. Some issues were dis-
meetings were held in ‘protected Another team held meetings in a cussed with the patient by several
time’ set aside for the purpose. More traditional lecture theatre with a top team members, while others – such
than half of the meetings took place table facing tiered rows of seats. as clinical trials and family history –
over lunch time, with a further quar- Predictably, she says, seats at the were recognised by only a few team
ter (26.5%) scheduled for breakfast table with microphones were occu- members as their responsibility.
time and 6.6% in the evenings. pied by surgeon, radiologist and Even amongst medical special-
Lesley Fallowfield, whose psycho- pathologist, while registrars and ists, working as a team and
oncology team at Brighton and others sat in the first row of seats respecting and valuing everyone’s
Sussex Medical School has been with breast specialist nursing staff contribution can be tricky. Baumann
researching the functioning of relegated to the back. “Not only were from the Dresden centre says, “One
MDTs, points out that many lunch the nurses rarely invited to contribute of the things that helps a lot is that
time meetings don’t even provide their opinion about patient care, but the leadership structure is on a rotat-
lunch! Breakfast and evening meet- even had they wished to, they proba- ing system. At the moment I am
ings can be particularly difficult for bly wouldn’t have been heard. One director as a radiation oncologist, but
staff with childcare responsibilities. recommendation we made was that it will rotate at some time to medical
Another problem is that medical and the nurses should at least have a rov- oncology or surgery or any other spe-
clinical oncologists often have to ing microphone.” cialty in the cancer centre. It is not a
cover a number of teams, often at dif- The problem of unequal status radiotherapy structure, or a surgeons’
ferent sites. must be tackled if every specialist structure, but something we carry
In the Macaskill study, respon- discipline is to make its contribution. together.”
dents were asked to choose from a Fallowfield says, “Most people have Mike Richards, the UK National
list of suggested improvements to the been brought up in an educational Cancer Director, identifies ‘good
system. Top of the list (72.8% of system that makes it very difficult to leadership’ as one of two essential
respondents) was more time to get over hierarchical boundaries. elements for effective team work (the
attend meetings or for them to be Without training, it is very hard for other being administrative support).
held in a protected session. people who have grown up in a world He recommends “an inclusive leader
Similar problems were highlight- where they make a decision and who will facilitate everybody to be
ed in a review of breast cancer serv- everybody fits in around that, to oper- part of the team and to make a
ices carried out by the Clinical ate in a way that will optimally bene- contribution.” He says that the last
Standards Board in Scotland two fit patients and also be helpful to the ten years have been about setting up
years ago. Their report recommended teams.” MDTs, and the next five “should be
that multidisciplinary meetings A recent study by her psycho- about making those teams work
should be considered of equal oncology research unit revealed that effectively”. Though he admits that
importance to clinics and operating team members often have a poor much work needs to be done to work
sessions, and should be included in awareness of the role their colleagues out how best to go about this,
individual job plans. play in providing information to the he mentions a two- to three-day
Finding a suitable venue can also patient. All the clinical nurses report- training course that has been run for
CANCER WORLD ■ MAY-JUNE 2006 ■ 21
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on the CRC programme, but word of
mouth has been very effective. Once
you get the first ten teams saying,
‘That was very helpful,’ then others
say, ‘Actually we want to do the
same.’ We reckon that within the next
few months almost all of the 186
CRC teams in England will have
been on that course.”
Richards believes this example
could be followed for other cancers.
“I’m sufficiently impressed that I
would like to encourage it for other
disease areas.”
SCIENCE PHOTO LIBRARY / GRAZIA NERI
OILING THE MACHINE
Another crucial area showing serious
gaps between theory and practice has
to do with the quality and complete-
ness of information, and procedures
for recording decisions and ensuring
they are implemented.
In some European countries, oncology nurse specialists regularly discuss physical, functional, social A review of decisions taken by an
and emotional wellbeing with patients. A multidisciplinary approach to treatment should ensure upper gastrointestinal multidiscipli-
that this sort of support is included as an integral part of every patient's care plan nary team published earlier this year
(Ann Oncol 17:457–460) found that
colorectal teams as an interesting ‘Now I understand why they want the in just over 15% of the cases, deci-
example. MRI scan done in a particular way.’ sions were not implemented. The
The course aimed to raise the The pathologist said, ‘Now I under- most common reason was that infor-
technical skills of teams around the stand why they want me to report the mation on the patient’s co-morbidity
technique of meso-rectal excision, but circumferential margins in a particu- had not been available or had been
Richards says it has proved to have a lar way.’ The nurse specialist said, given insufficient consideration
very helpful spin-off in bringing teams ‘Now I understand how to explain during the meeting. The report
together. It offered teams the oppor- this operation to a patient.’ And they recommended that methods be stan-
tunity to exchange ideas about how all said, ‘It has been valuable time dardised to ensure the inclusion of
they worked, which is something they working together and we feel we all co-morbidity data in MDT meetings.
would never usually do. know each other better and we will The other main reason for deci-
“I went to one of the courses, and work together better.’ We are begin- sions not being implemented was
talked to the team. The surgeon said, ning to get feedback that teams are patient preference. This raises com-
‘Now I really know how to do the pro- doing things differently, so we are plex issues. Is it feasible to find out
cedure properly. I thought I did seeing an evolution. about patient preferences before a
before I went.’ The radiologist said, “We never said people had to go multidisciplinary team meeting con-
The problem of unequal status must be tackled if
every specialist discipline is to make its contribution
22 ■ CANCER WORLD ■ MAY-JUNE 2006
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Extra resources for administrative staff will be key
to encouraging a multidisciplinary approach
siders the options? The report gave In Dresden, Baumann believes that decided at local level. “Some hospitals
an open verdict, saying simply that funding for infrastructure was essen- advertise for a separate post, while
the matter warrants further research. tial in making multidisciplinary care a others may allocate the task of servic-
Fallowfield identifies a problem reality. Without it, he says that man- ing MDTs to one of the nursing staff.
in ensuring that every member of the agement of patients would have con- Depending on the size of the team
team is aware of decisions, and that tinued to be driven by separate and the throughput of patients, you
patients receive a consistent mes- departments. His hospital struggled might be able to have a coordinator
sage. During an MDT training ses- to find funds from existing depart- who covers more than one MDT.
sion, a rectal cancer patient listened mental budgets. Baumann argues Alternatively, the person who coordi-
with dismay as a nurse explained that allocating extra resources for the nates team meetings might also
colostomies – what they look like, essential administrative staff is the navigate or track patients through the
how the patient should care for them. single most useful thing authorities system, knowing where the patients
The patient had been told that there can do to encourage hospitals to are and what is going on, and making
was no need for a colostomy, because move towards multidisciplinary care. sure the CT scan comes back and is
the MDT decided that sphincter- In France, the state allocates acted on, and the next appointment is
saving surgery would be safe, but the funding to all hospitals, clinics and made and so on.”
nurse had not been present at that cancer centres where cancer patients Many teams function well, but
meeting. are treated, whether they are in the Fallowfield has come across teams
MDTs must be well enough public or private sector. Funding is with no additional support that are
resourced to ensure that every meet- specifically for the establishment of struggling. The Macaskill study into
ing has access to a full set of infor- cancer coordinating committees – breast teams found that almost 6% of
mation (patient files, scans and other ‘the 3 Cs’ – whose role is to support MTD decisions were not recorded in
diagnostic results), that every team the delivery of care through specialist patient notes or on a special form.
member knows which patients are multidisciplinary teams, which is The study says that this raises
due to be discussed and where and being made mandatory under the questions about whether the decision
when meetings are held, and that French national cancer plan. is truly available for patients and staff
decisions are recorded and commu- Cancer coordinating committees members who were not at the
nicated effectively. are responsible not only for organising meeting. “It also raises the question
Getting the administrative side multidisciplinary meetings, recording of the relevance of the decisions
right was the second element identi- decisions, and computerising patient made at the MDM where they are
fied by Richards as vital for teams to information, but also for auditing not recorded.”
work effectively. His view is endorsed their effectiveness through systemat-
by others in different countries and ic reporting of a range of activity and NO TURNING BACK
different settings. Asked what single quality indicators, including patient While some studies have revealed
measure would most improve the outcomes. improvements from multidisciplinary
effectiveness of MDTs, Bengt In the UK, cancer services were working – including better diagnostic
Glimelius, clinical oncologist in the already being provided within a single practice, closer compliance with
colorectal team at Uppsala, Sweden, infrastructure – the National Health guidelines, a more consistent provision
says, “To have more time and not to Service. The cancer plan required of psychosocial support, a stronger
have to do all those extra administra- that infrastructure to be reorganised. input from nurses, and improved care
tive tasks that fall on you. We need Richards says that the nature of co-ordination – it places heavy pres-
more admin support.” administrative support for MDTs is sure on team members’ time and as yet
CANCER WORLD ■ MAY-JUNE 2006 ■ 23GrandRound
Bengt Glimelius, medical and radiation oncologist in the colorectal cancer team at Uppsala University Hospital in Sweden. Glimelius has conducted
patient consultations jointly with the colorectal surgeon for the past 25 years. More recently a radiologist and often a pathologist have also been
present. Though a large proportion of breast cancer patients are now treated in a multidisciplinary setting in Sweden, the figure for colorectal cancers
is closer to 40%, while for prostate, lung or gastric cancers, it is more like 10-20%. Multidisciplinary teams are likely to be included in new quality
indicators currently being drawn up for Sweden’s hospitals
there is little robust evidence to show nature of the institutions that have to RT department. But they like to have
that it improves clinical outcomes. work together – not least the mix of this cancer centre as a joint structure
However, ask any of the practitioners private and public – some level of that they can always go back to – they
in the UK or France who have been friction was to be expected. However, know their whole treatment is
obliged to start working in this way Bara of the National Cancer Institute steered by this structure.”
and, despite grumblings and misgiv- says the principle is now completely Surveys conducted in the UK in
ings, the principle is no longer in ques- accepted, and emphasises the role of 2000 and 2004 show patient satisfac-
tion and there is no mood to return to the regional networks in this success. tion increasing by 4 to 16 percentage
old ways. “Everybody is saying the same thing. points on issues ranging from, “Given
“I say at virtually every talk I give, ‘Multidisciplinary meetings are nec- written information at diagnosis”
that I believe the most important step essary and have a huge educational (from 45% to 61%), to communica-
we have taken in the last 10 years is value.’ Any resistance now only comes tion “Given completely understand-
to move to MDT working, and I from isolated persons. Doctors work- able explanations about side-effects”
never get anyone saying – Mike you ing in cancer today say they can no (from 63% to 76%), symptom control
are wrong about that,” says Richards. longer imagine working without “Felt everything had been done to
“I can assure you they can be vocal recourse to multidisciplinarity.” relieve pain” (from 81% to 85%) and
about things that they don’t like. For Patients also appear to be giving general issues “Always treated with
a lot of people, it is a source of job the system the thumbs up. The respect and dignity” (from 79% to
satisfaction because you get a lot of Dresden Cancer Centre conducts 87%). Richards believes that the
peer support from your group and systematic audits of patients, and MDT approach is responsible for a
you know you are doing the best you Baumann says the feedback has been large part of this improvement.
can for the patient.” very positive. “They understand that Multidisciplinary meetings also
In France, moves to extend we need specialists. We don’t want raise the overall quality of cancer
MDTs to cover all cancer patients generalists who think they can do services, not just in individual cases.
started three years ago, and already everything. And they understand that In effect they offer continual peer
they are reporting around 50% cover- for this reason they have to move to review, making it easier to detect and
age, with the aim of reaching 100% different places – to go for surgery to correct practitioners who consistent-
by the end of 2007. Given the diverse a surgeon and for radiotherapy to the ly stray from best evidence-based
24 ■ CANCER WORLD ■ MAY-JUNE 2006GrandRound
practice. They provide a superb believe it would be possible to extend That is not to say that this is an easy
setting for specialists to learn more MDTs to all treatment centres in the process. Former central and eastern
about the contribution of other disci- UK without some form of national European health systems may have
plines in the care of their patients, cancer plan. Bara agrees. The French unified structures in common with
and for younger practitioners to learn cancer plan has driven change, pro- the UK National Health Service, but
from more experienced hands. vided the policies and the finance to many have an acute shortage of
Glimelius says, “It takes time to implement them and supported pilot pathologists, medical oncologists or
have 10 or 20 people sitting there. schemes to get them right. “That’s radiation oncologists, constraining
You listen to ten cases, and are how it has been possible to move so moves towards MDT working.
involved directly in maybe only two. quickly, and I think that in 2007, Other European countries have
But listening to the others, and MDTs will be one of the measures no such single unified healthcare
understanding why a decision was [of the national cancer plan] we will provider. The French national cancer
made in one direction or other, helps achieve successfully.” plan is interesting because it encom-
your future patients. I’m not sure But what works in one country passes public and private provision
how a health economics study could may not in another. A working group within a single network. The MDTs
put a value on that.” in Australia has offered a useful con- at the Antoine Lacassagne Centre are
Jean-Pierre Gérard does venture tribution to this debate. Rather than open to private clinics within the
to put a figure on the impact on map out any particular organisational onc-Azur regional cancer network,
patient outcome. “It is usually said solution, they have drawn up a set of says Gérard, and some private doc-
that if the best treatment was applied “Principles of multidisciplinary care,” tors do attend. Conversely, in
to all patients, we would improve the (see Zorbas et al, Med J Aust Cannes, public hospitals work with
cure rate by between 5% and 10%. In 179:528–531), which “aim to accom- private radiotherapy clinics, because
France we have 150,000 deaths from modate a variety of delivery models they have no facilities of their own.
cancer every year, which would be and to enable clinicians to apply them But while this public–private mix
reduced by up to 15,000 if everybody according to the geographical, social is typical of many European health
got the best treatment. I think half of and cultural context in which they systems, not all of them have
this will be gained by MDTs.” work.” The principles emphasise the France’s tradition of a strong central
This, he says, will mainly come importance of the team approach, state. In Germany, responsibility for
about through raising standards in good communication, access to the health is devolved to a regional level
smaller establishments – public and full range of therapies, maintaining and doctors retain a high level of
private – closer to the standards standards of care, and involving the autonomy over how they organise
found in academic institutes. patient in decision-making. their work. Baumann believes they
Australia is a country of vast need the carrot rather than the stick.
THE CARROT OR THE STICK? distances, where the closest specialist He accepts that Germany has been
Sadly, the consensus on the principle radiation oncology services for breast slow to take on board MDTs, and
of MDTs among those who already cancer patients living in the city of that even among university hospitals,
work in this way will not benefit most Darwin, for instance, are located many are still not working in the new
of the 2.9 million Europeans who will 3,000 kilometres away, in Adelaide. If way. But he says there is a great inter-
be diagnosed with cancer in the com- Australia can map out how to organise est in what they have done in
ing year. They need the principle to a national network of specialist Dresden, and the most helpful thing
be put into practice in every location. MDTs, surely there is little excuse for would be for resources to be allocat-
Richards says that he does not failure in any European country. ed to support the change.
There is a need to inject a sense of urgency among
those who can influence Europe’s cancer services
CANCER WORLD ■ MAY-JUNE 2006 ■ 25GrandRound
MEP Karin Jöns is a breast cancer Though the German Cancer Society cancer they only realise during sur-
survivor and the German representa- accredits breast units, it has adopted gery that it is cancer. If they had done
tive for the European Breast Cancer quality criteria that are far less it in a multidisciplinary way and had
Coalition advocacy group, Europa stringent than both the EUSOMA known the diagnosis in advance, then
Donna. She says the German health- and the EU guidelines. Jöns says that the surgery would have been done in
care system is very fragmented and hospitals are pooling patient numbers the right way. Unfortunately this
there are few levers for effecting to show they treat a minimum of 150 is not the only problem with breast
change, no matter how strong the new cases a year, even though they surgery.”
evidence base. Health policy is are not working together as an Such monitoring can play an
organised in a federal way and is in integrated breast unit. Many so- important role in combating compla-
the hands of the 16 regional govern- called breast units, she says, have no cency and convincing the medical
ments (Länder), but it is the doctors, in-house pathologists, and have to get establishment of the need for
together with the health insurances the pathology done at another change. The Swedish government is
(there are no fewer than 55 of them), hospital, and are therefore unable to also developing quality indicators
who hold the real power. control the quality. Most don’t have which county councils will be obliged
She believes that, for Germany breast nurses – or even know what a to monitor. Glimelius expects MDTs
and other public healthcare systems, breast nurse should be. And while to feature. “It won’t be a law, but
the way forward lies in a system of the EU guidelines call for there will be the chance to check
reliable accreditation and re-accredi- multidisciplinary team discussions whether or not it has happened.”
tation for specialist units that offer pre- and post-treatment in 100% of Current and future cancer
diagnosis and treatment that comply cases, certification is being handed patients across Europe hope that a
with specified quality criteria. out in Germany to hospitals that combination of national cancer plans
Patients would then be able to make can show 20% of patient cases are and accreditation backed by EU
an informed choice about where to go considered at some point by an guidelines and recommendations will
for the best quality treatment, and MDT, so long as the hospitals deliver top-quality multidisciplinary
hospitals and clinics would have an give assurances they are moving care. But how long will it take?
incentive to raise their quality of care. towards 40%. Jöns points out the EU adopted
This approach has been pio- Jöns believes this provides win- guidelines on breast cancer screening
neered by the European Society of dow dressing without a commitment 15 years ago, but this service will not
Mastology (EUSOMA), which wants to real change. “Most hospitals want be available throughout Germany
to see all Europe’s breast cancer to get certified as a breast unit so that until the end of 2007. Women in
patients treated by multidisciplinary they get a better image. But often many other EU countries will have to
teams of breast specialists within they do not work in a serious multi- wait even longer.
accredited breast units fulfilling disciplinary way. Some doctors still There is a need to inject a sense
strict criteria on staffing of the med- believe they know everything and can of urgency among those who have an
ical team, treatment procedures and do as they please without reference influence over the shape Europe’s
minimum case loads. to any guidelines. They say ‘We’ve cancer services – the sense of urgency
Jöns played a key role in getting always done it in this way, and in our that convinced Jacques Chirac and
many of these criteria – particularly country everything is OK.’” Tony Blair to put some political clout
the multidisciplinary approach – That everything is far from OK is behind their countries’ respective
adopted by the European Parliament evidenced by a report into breast can- cancer plans.
as part of the European Breast cer operations compiled by the Currently 1.7 million European
Cancer Resolution in 2003. Since Bundesgeschäftsstelle Qualitäts- citizens die from cancer each year. If
then, she has been campaigning to sicherung. It found that in 622 of a Gérard at the Antoine Lacassagne
get the recommendations imple- sample of 691 hospitals, surgical Cancer Centre is right in estimating
mented throughout Europe, focusing ‘security’ margins were smaller than that MDT working could increase the
particularly on her own country, but evidence-based guidelines. Jöns cure rate by 2.5%–5%, that alone could
she is not satisfied with the pace of believes that this is largely a diagnos- save as many as 85,000 lives a year. As
change. tic failure. “In 50% of cases of breast Gérard himself put it, “Not bad eh?”
26 ■ CANCER WORLD ■ MAY-JUNE 2006You can also read
