impact of multidisciplinary discussion on treatment outcome for gynecologic cancers
TRANSCRIPT
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Impact of M.D.T. on Treatment Outcome For
Gynecologic Malignancies Emad Shash, MBBCh., MSc., MD.
Medical Oncology Department
National Cancer Institute, Cairo University
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Disclosures Specific to Today’s Topic
• No Financial Disclosures
• I’m a medical Oncologist, not:• Gynecological Oncologist
• Surgical Oncologist
• Radiation/Clinical Oncologist
• I do believe that we need “Evolution” to adapt for OUR PATIENTS better care.
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No Offense to any Specialty!
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What we always hear about MDT?
• Multidisciplinary teams and/or clinics are associated with:
• Changes in staging/diagnosis
• Initial management plans
• Higher rates of treatment
• Shorter time to treatment after diagnosis
• Better survival
• Adherence to clinical guidelines.
Pillay et al., Cancer Treatment Reviews. 2016
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MDT: Definition
Individual Specialties Together Either Physically or Virtually Discussing Therapeutic Strategy of a Given Patient
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MDT in Oncology Setting
• The MDT meeting serves as a platform for the coordinated delivery of care through consultation amongst different professionals in a single setting.
• The MDT meeting can be defined as a regularly scheduled discussion of patients, comprising professionals from different specialties:
• Surgeons • Medical Oncologists • Radiation oncologists• Radiologists,• Pathologists • Nurse specialists
• In addition:• Pharmacy• Palliative medicine • Mental health• Other allied health disciplines
Pillay et al., Cancer Treatment Reviews. 2016
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Is MDT a leisure or a MUST?
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Background & History in UK!
• In the early 1990s, the EUROCARE study demonstrated poorer survival in the UK than in other European countries most types of cancer.
• Following this publication, it was proposed that all patients with cancer should be seen by MDTs
• 15 years ago less than 20% of patients with cancer in England were managed by a specialist team.
• Current National Institute of Health and Clinical Excellence (NICE) guidance and peer-review recommendations are that 95-100% of patients should be discussed at a MDT meeting.
N. Chinai et al. Clinical Radiology 2013
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Estimated MDT Costs
N. Chinai et al. Clinical Radiology 2013
• Out of 47 cases (94 %) have a concurred results.• Does the clinical benefit gained weight the cost?• Do all patients need to be discussed in the MDT?
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Do We really need MDT in Oncology?
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B. Pillay et al. Cancer Treatment Reviews 2016
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3 main Groups
patient assessment and
diagnosis
15 articles
patient management and clinician practice
25 articles
patient outcomes
7 articles
Pillay et al., Cancer Treatment Reviews. 2016
• Critically evaluate Current literature regarding the impact of MDT meetings on:
1. Patient outcomes2. Assessment 3. Diagnosis4. Management 5. Clinician practice.
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Patient assessment/Management Changes
• Results indicated that 56% of studies (5/9) reported changes to diagnostic findings for • More than 10% of patients discussed at MDT meetings.
• Similarly, 54% of studies (7/13) reported that management plans were altered for • More than 10% of patients discussed at MDT meetings.
• Not all positive: Findings of 3 studies
• Did not support a strong association between MDT meetings and improvements in patient assessment and management.
• effectiveness of MDT meetings is dependent on a range of factors such as • Structural Components• Functional components • Expertise of participant
Pillay et al., Cancer Treatment Reviews. 2016
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Patient Outcome Changes
• Few studies in this review evaluated patient outcomes.
• Those which did assess outcomes focused on survival rates, with a few studies assessing other clinical indicators (e.g. CRM rates for rectal cancer patients).
• The conduct of MDT meetings may indirectly lead to survival benefits through more efficient selection of treatment options for patients and by better case management.
• However, there is little evidence demonstrating a relationship between MDT meetings and survival.
Pillay et al., Cancer Treatment Reviews. 2016
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What piece of information we still miss?
• Amongst the published studies, none evaluated how MDT meetings impacted upon aspects of patient satisfaction or quality of life.
• It is possible that patients experience:
• Sense of satisfaction or wellbeing if they are involved in decision-making during the MDT meeting process.
• Sharing of information regarding the outcome of the discussion and providing patients with support in making an informed decision regarding treatment options.
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What about the role of MDT in Gynecological Malignancies?
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Cohen et al. Int J Gynecol Cancer 2009
The aim of this study was to assess the impact of the twice weekly gynecologic oncology tumor conferences on the management of women with a diagnosis of or suspected of having a gynecologic malignancy
• The gynecologic tumor conference at Auckland City Hospital is consultative.
• All referrals comprise both preoperative and postoperative patients. • The meetings are multidisciplinary, with participants including:
• Gynecologic pathologist• Gynecologic oncologists• Medical oncologists• Radiation oncologists• Radiologists• Trainees in gynecology and oncology• Oncology nurses.
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Change in tumor site, histological type, stage, or grade: Can Result in different patient management.
Summary of major diagnostic discrepancies after
histopathologic review at MTC
Summary of major diagnostic discrepancies after
radiological review at MTC
Cohen et al. Int J Gynecol Cancer 2009
• The rate of major discrepancies in this study is 5.9%• The involvement of specialized pathologist is a must
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Do we need Tumor Biology Discussion Boards?
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Classical Histological Endometrial Cancer Classification “as an Example”
Murali R, Lancet Oncol 2014
Endometrial Cancer
Type I
Endometrioid adenocarcinoma (80%–90%)
Type II
Non-Endometrioid subtypes (10%-20%)
Serous
Clear Cell
Undifferentiated Carcinomas
Carcinosarcoma/Malignant Mixed Mullerian tumor
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The Cancer Genome Atlas (TCGA) website
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G Getz et al. Nature 2013
Mutation spectra across endometrial carcinomas
Gene expression across integrated subtypes in endometrial carcinomas
Pathway alterations in endometrial carcinomas
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The changing Landscape of Endometrial Cancer Prognostic Classification & Treatment Impact
Bokhman WHO The Cancer Genome Atlas
Basis Clinical and epidemiological features
Histological features Genome-wide genomic characterisation
Categories Type IType II
EndometrioidSerousClear cell
POLE (ultramutated), MSI (hypermutated), copy-number low (endometrioid), copy-number high (serous-like)Copy-number high (serous-like)NA
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Right PatientRight
Treatment
Right TimeCost
Effectiveness
Every Physician’s Aim!
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Take Home Message
• You need to be specialized & experienced enough to optimize your patients’ management.
• Learn to communicate effectively with your peers.
• Structural debates supported by evidence based medicine results in better patient outcomes.
• Future ahead: You need to engage your patient in the DECISION Making!
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“Coming together is a beginning.Keeping together is a progress.Working together is a success”Henry Ford (July 30, 1863 – April 7, 1947) was an American industrialist, the founder of the Ford Motor Company, and the sponsor of the development of the assembly line technique of mass production.
Thank You