Uro-Oncology Multidisciplinary Team Meetings at an Australian Tertiary Centre: A Detailed Analysis of Cases, Decision Outcomes, Impacts on Patient Treatment, Documentation, and Clinician Attendance

Abstract

Objectives: There is currently limited local and international literature on the characteristics of uro-oncology multi-disciplinary team meetings (MDTMs) and their impact on clinical decision making. The aims of this study were to provide a comprehensive descriptive analysis of MDTMs at an Australian tertiary hospital over a 12-month period and their impacts on patient management, and to evaluate adherence to MDTM plans. Methods: We conducted a review of a prospectively maintained database of all uro-oncology MDTMs held within the Northern Adelaide Local Health Network (NALHN) over a 12-month period in 2020–2021. Results: During this 12-month period, 24 MDT meetings were conducted, in which 280 patients were discussed. Overall, MDTMs resulted in modifications to the management of 25.7% of patients, which was consistent across all three major tumour streams (24% for prostate cancer, 29% for renal cell carcinoma, and 22% for urothelial carcinoma). MDTMs also facilitated cross referrals between specialties for 105 patients (37.5%), including 5 patients who were considered for entry into clinical trials. There was a high acceptance rate, with adherence to MDT recommendations for 270 of the 278 patients discussed (96.4%). MDTM plans were fully implemented within a 6-month period. Conclusions: We provided a detailed analysis of uro-oncology MDTMs at an Australian tertiary referral centre, demonstrating that MDTMs facilitate optimal cancer management for patients with urological cancers.

1. Introduction

The multidisciplinary team meeting (MDTM) model in cancer care has expanded from being utilised for only specific tumour streams to include all cancers. The aims of MDTMs are to review patients’ diagnoses and results, and to help establish the best treatment plans according evidence-based medicine. MDTMs have been demonstrated to improve various clinical outcomes in cancer care, including adherence to clinical guidelines, survival, quality of life, and patient satisfaction [1,2,3]. Various cancer frameworks in Australian states and territories emphasise the importance of multidisciplinary cancer care and have instituted measures to increase their uptake [4]. Despite this, there is currently limited local and international literature regarding the characteristics of urology-specific oncology MDTMs and whether they make meaningful changes in patient care and clinical outcomes, which would be the ultimate indicator of their utility. With this in mind, the urologists of our unit sought to review the practices of our MDTMs.

The aim of this study was to provide a descriptive analysis of uro-oncology MDTMs meetings convened at our Australian tertiary hospital over a 12-month period to gain an understanding of characteristics of the patients and tumour streams discussed. In addition, this study aimed to assess the impact of our institution’s uro-oncology MDTMs on patient management decisions and to evaluate adherence to MDTM plans to ensure their effective implementation.

2. Methods

A database of all patients discussed at our uro-oncology MDTMs is maintained as part of our unit’s standard audit practice. This database consists of information on patient demographics, key imaging findings, histopathology results, clinical questions being posed to the multidisciplinary team, MDTM recommendations, and consultant attendance. Meetings are held every fortnight, and attended by consultant urologists, radiation oncologists, oncologists, radiologists, a uropathologist, urology nurse practitioners, and junior medical officers. There are no set criteria for patient inclusion; however, all new prostate cancer diagnoses and all new testicular cancer diagnoses were discussed as part of the practice of the unit. MDTM cases were put forward for discussion either directly from triage by the Urology Head of Unit, by other consultant urologists from within the unit, following histopathology clinics performed by registrars, or from other specialties (e.g., medical oncology or radiation oncology). The unit’s accredited urology trainee reviewed patient cases awaiting discussion and collated a list of patients prior to distribution via secure internal email to everyone involved in the meeting. Patients were notified by the clinic or on the ward that their care would be discussed in this setting; patients added from triage were not directly notified.

Recommendations were documented by the chair of the meeting (the unit’s urology registrars) into a document on a secure internal drive. The unit’s resident medical officers then prepared formal documents within our health system’s electronic medical records, which upon being published were automatically distributed to each patient’s general practitioner. After each meeting, patients, or in some cases representative family members, were contacted by telephone to discuss recommendations within 1 week by the urology registrar who chaired the meeting.

Implementation of recommendations was confirmed by reviewing patients’ medical records at up to 6 months post-discussion, confirming commencement of recommended treatments. A few cases did not adopt the recommended treatment; brief clinical vignettes explaining these deviations follow below.

From our prospectively maintained database, we analysed 24 consecutive MDTMs between July 2020 and June 2021. Data obtained from the database included demographic details, tumour streams, cancer stages/grades, times from diagnosis (pathological/imaging) to discussion, instances of treatment before MDTM discussion, and post MDTM correspondence to GPs. Additional data were extracted from patients’ electronic records when required. To assess the impact on management decisions, we identified cases in which a preferred treatment strategy was documented, either in a patient’s records or within the clinical question submitted to the MDTM chair as part of our MDTM template. When there was no documented preferred treatment option specified, patients were excluded from this analysis. In many cases this was because a formal discussion had not yet taken place regarding a preferred treatment strategy (e.g., cases were added for MDTM discussion by registrars reviewing results in a pathology results clinic) or because documentation in pre-MDTM clinic notes was either unclear as to a preferred treatment strategy or there was no treatment strategy documented. Significant impact was defined as a change in treatment modality (i.e., active surveillance vs. active treatment), treatment intent (i.e., palliative vs. active), or when further investigations were requested to guide treatment (e.g., biopsy, imaging, or genetic testing).

Data were managed via an Excel spreadsheet. Numerical data are presented as medians (ranges), means, or percentages.

3. Results

In total, there were 24 MDTMs conducted during this 12-month period, in which 280 patients were discussed. The median (range) age was 65 (20–93) years, and most patients discussed were male 245 (87.5%). Most cases were submitted for discussion by urologists (273, 97.5%), with the remaining from radiation oncologists and medical oncologists.

The breakdown of cases by tumour stream is shown in

Table 1. Proportion of urological cancers discussed (total, (%)), time from diagnosis to MDTM discussion (median, (range)), extent of disease by tumour stream (total, (%)), impact on management (number modified, (%)), and adherence to MDTM consensus by tumour stream (proportion, (%)).

Tumour Stream	Number of Patients	Time to Discussion	Extent of Disease			Impact on Management	Adherence to MDTM Conensus
			Local	Metastatic	Equivocal
Prostate	99 (35.4%)	4 weeks (1–12)	72 (72.7%)	9 (9.1%)	18 (18.2%)	Endorsed = 46 (76%) Modified = 15 (24%)	93/99 (95.9%)
Renal	87 (31.1%)	4 weeks (1–24)	68 (78.2%)	6 (6.9%)	13 (14.9%)	Endorsed = 44 (71%) Modifed = 18 (29%)	85/87 (97.7%)
Urothelial cancer	54 (19.3%)	4 weeks (1–12)	45 (83.3%)	4 (9.3%)	5 (7.4%)	Endorsed = 28 (78%) Modified = 8 (22%)	53/54 (98.1%)
Testicular	18 (6.4%)	3 weeks (1–4)	8 (44.4%)	10 (55.6%)	0 (0%)	-	17/18 (94.4%)
Dual	16 (5.7%)	-	-	-	-	-	-
Adrenal	2 (0.7%)	-	-	-	-	-	-

. Prostate cancer (99 cases, 35.4%) and renal tumours (87 cases, 31.1%) were most frequently discussed. Other tumours, in order of frequency, were urothelial cancer (19.3%), testicular cancer (6.4%), and ‘dual’ tumours (5.7%—examples included patients with concurrent urological tumours (e.g., a renal mass and prostate cancer); lymphadenopathy in the setting of urological cancers and haematological malignancies; new lung lesions in the setting of urological malignancy and concern for concurrent primary lung malignancy; and concurrent urological and non-urological malignancies (e.g., colorectal cancer), for which a decision regarding priority of treatment was required). Apart from testicular cancer, cases from all other tumours had predominantly localised disease (Table 1).

The median time from diagnosis (imaging or histopathology) to MDTM discussion was 4 weeks across all tumour streams (Table 1). There were between 6 and 16 cases discussed at each MDTM. Renal tumours had a wider range of waiting times for MDTM discussion, with a preponderance of elderly patients with low-risk small renal masses on imaging, triaged by the MDTM chair as non-urgent. The average attendances by specialist clinicians was 9 (range 7–12). Every meeting had at least one representative from Urology, Pathology, Medical Oncology, and Radiology. Respective attendances by specialty are summarised in

Table 2. Attendance by specialty (mean, range).

Overall	9.26 (7–12)
Urology	3.35 (3–4)
Oncology	2.09 (1–3)
Radiation Oncology	1.61 (1–2)
Pathology	1 (1–1)

.

In total, 33 patients were discussed more than once (27 twice, and 6 patients three times). This was either due to further investigations being required, further specialty opinions being required on the suitability of different treatment options (e.g., a high-risk anaesthetics clinic), response to a treatment being reviewed, or patients discussed in both pre- and post-operative settings.

To assess the impact of the MDTM process on patient management, we analysed data from 159 of 280 patients who had a clearly documented management plan in either their patient notes or in MDTM correspondence to the chair, as per our template. Reasons for non-inclusion included being added directly to an MDTM discussion from triage, resulting in discussion at an MDTM prior to the formulation of a treatment plan from a referring surgeon; being added to an MDTM discussion from a registrar results clinic without a formal discussion about preferred management; or lack of documentation regarding a preferred treatment plan in the clinic or from the ward prior to MDTM discussion. Overall, MDTMs resulted in a modification to management in greater than 20% of patients across all three major tumour streams. This was most apparent in patients with renal tumours (29%) (Table 1). MDTMs also facilitated cross referrals between specialties for 105 patients (37.5%). This process resulted in five patients being considered for clinical trials, as well as six patients (4.3%) being referred to palliative care. There was a significant difference in rates of referrals across tumour streams, with prostate cancer having the highest rate of cross referral (59.1%). A complete breakdown by tumour stream is shown in

Table 3. Cross referrals from MDTMs.

Tumour Stream	Radiation Oncology	Medical Oncology	Intervention Radiology	Palliative Care	Total (Percentage)
Prostate n = 99	43	12	0	0	55 (59.1%)
Renal n = 87	7	7	8	1	23 (26.4%)
Urothelial Cancer n = 54	6	5	1	5	17 (31.5%)
Testicular cancer n = 18	0	7	0	0	7 (38.9%)
Total n = 258	56	32	11	6	105 (40.7%)

. Notable impacts of the MDTM process included two patients who had their pathology upgraded after specimen re-review by an experienced uropathologist.

There was a high adherence to MDTM recommendations, with 270 of 278 patients (96.4%) having their MDTM plans fully implemented within a 6-month period. This was consistent across all major tumour streams, as shown in Table 1. Most patients who did not have plans implemented as per the MDTM process had prostate cancer (6/10). The reasons for this are summarised in Supplementary Table S1. Seven patients’ cases required re-discussion due to incomplete information—four of these patients’ cases did not have adequate staging studies, and three had inadequate clinical information. An “MDTM summary” was published in the electronic patients’ record system and sent to general practitioners for 276 of 280 patients (98.6%).

4. Discussion

In this study, we provided a comprehensive analysis of uro-oncology MDTMs at an Australian tertiary referral centre. We analysed all MDTMs over a 12-month period consisting of 24 MDT meetings and discussion of 280 cases. Most cases (97.5%) were submitted for MDT discussion by urologists, and prostate cancer represented the highest proportion of cases discussed (35.4%). The median time to discussion was 4 weeks for all major uro-oncological tumour streams, and there were no outliers who waited a clinically inappropriate time. A majority (87.5%) of cases discussed were male patients, which was appropriate for the number of male-only cancers and the known disparity in incidences of urothelial cancer and renal cell carcinoma. With the exception of testicular cancer, the other tumour streams discussed at our MDTMs were localised at the time of review, when traditionally, cases discussed were often more advanced. This could reflect changing practices to ensure all patients receive multidisciplinary input that allows the best available evidence; however, these types of data were not measured in this study.

A recent review found that MDTM discussion generally has an impact on management decisions in patients with cancers [5]. In our study, we found that 25.8% of patients had their management modified at an MDTM. Greater than 20% of patients in all three major tumour streams had a modification to their original management plan. Management changes in our study were similar to those of previous reports from the US (32%) [6], UK (12.6%) [7], and Australasia (8.9% [8] and 26.7% [9]). When interpreting these results, it must be noted that there is a significant heterogeneity in the inclusion criteria for various MDTMs around the globe, which affects the interpretation of these percentages (for example, seeking clarification for a radiological or pathological finding that affects a patient’s management plan could be performed outside an MDTM setting; however, this was routinely performed in an MDTM setting in our cohort). In contrast to the UK, our institution does not mandate MDTM discussion for all patients with cancer, and discussion of a case at an MDTM is at the treating clinician’s discretion. In addition, we were only able to provide analyses of treatment impact for 159 of the 280 patients discussed at our MDTMs, which is a significant proportion and needs to be considered when interpreting our results. Nevertheless, this proportion of changes highlights the value of the MDTM process in altering management through a collaborative decision-making process. Whether changes in management plans led to positive, clinically meaningful improvements in cancer outcomes was not measured by this study; however, as has been demonstrated in previous studies, cases discussed at MDTMs are more likely to have more complete staging, neo-adjuvant or adjuvant treatment, and treatment in line with evidenced-based guidelines [10,11], which should translate into improved cancer treatment outcomes.

Attendance at our MDTMs was high overall, and well represented by our units’ four urologists (at least three attended every meeting); however, oncologists and radiation oncologists were at times only represented by one clinician. Most patients for discussion were put forward by urologists; however, for the few patients put forward for discussion by other specialties, there was a small risk of an MDTM opinion being provided by both the sole treating clinician and representative of their specialty, which was unlikely to result in a change in patient treatment or the MDTM opinion that the treating clinician sought. Mandating that multiple clinicians attend from each representative specialty may navigate this problem.

The uptake of MDTM recommendations is a key performance indicator. Our study confirmed that 270 of 280 patients (96.4%) had their MDTM plans fully implemented within a 6-month period. A key strength of our MDTMs was the high rate of publishing and distributing MDTM summaries to general practitioners, which is a key recommendation set by Cancer Australia and in the Australian national optimal care pathways [12,13]. Studies have shown that when an MDTM recommendation is formally documented, treatment concordance increases from 76% to 95% [14]. At our centre, 276 of 280 cases (98.6%) discussed were published on our electronic system and distributed to general practitioners. This was significantly higher than percentages noted in other similar reports, which found that only one third of MDTM recommendations were communicated to the patient’s general practitioner [15]. We believe a key reason for this at our centre was the allocation of an ‘MDTM clinic’ to the chair within 2 days of the meeting to (i) document and publish the MDTM discussion, (ii) communicate results to patients, and (iii) organise further investigations where indicated. In addition to this, our use of an electronic MDTM database, which serves as a template and includes a post MDTM checklist, ensures all tasks are carried out for each meeting. We believe that having the urology registrar chair MDTMs and carry out the post meeting ‘MDTM clinic’ reduces ambiguities in plans/recommendations, as they are the best equipped to accurately summarise the complex discussions that took place. Although having these complex discussions via the telephone is not ideal (particularly if the news is quite serious), it was the fastest way to communicate outcomes to patients, which, anecdotally, we found reduced their anxiety. In most cases, it allowed patients to prepare questions prior to meeting in a consultant clinic to formalize their management plan.

Our MDTMs also promoted cross referrals between specialties for 105 patients (37.5%), which for 5 patients resulted in enrolment in clinical trials. The value of having clinicians with a sub-specialty interest in genitourinary tumours was highlighted by the re-staging of pathology specimens and re-grading of imaging reports. For example, a 68-year-old man with organ-confined prostate cancer had his biopsy report modified from a highest grade of Gleason 3 + 4 = 7 to Gleason 4 + 4 = 8 on review. Similarly, a multiparametric MRI prostate report from an external radiology centre had an upgraded PIRADS score after secondary review.

Limitations of our study include its retrospective nature and single-institution focus. Furthermore, the assessment of ‘impact of MDTMs on management’ focused on a subset of patients who had clearly documented management plans; this was largely due to triaging practices in our unit, which help streamline patient care through our service and justify costs of performing robotics cases (required by our finance department) for which our unit currently needs to ‘rent’ time on another hospital’s robotics system, which comes at a significant cost. A metric we did not capture was whether, when following our MDTM assessments, patients’ management plans were in line with international guidelines (e.g., EAU), which could be performed as part of an audit in the future.

Although we provided numerous significant objective findings, the impact of having nurse practitioners and specialist cancer nurses was not captured by our data. We also did not assess important qualitative measures of MDTMs’ functions, such as communication and each team member’s input and involvement in the decision-making process. Strengths of our study include a long 12-month period with a 6-month lag time afterward, enabling assessment of adherence to and implementation of MDTM recommendations. Although our study data were analysed retrospectively, maintaining an electronic database of MDTM discussions with a pre-set template that included “question to MDTM/management options” enabled our data to be collected in a prospective manner with clinicians ‘blinded’ to the study.

There is potential for further interrogation of the performance of the unit’s MDTMs by utilising various MDTM quality assessment tools, including the first, developed in 2010, Multidisciplinary Tumor Board Metric for the Observation of Decision-Making (MDT-MODe) [16]. Several other assessment tools have been produced, and were summarised in a recent systematic review [17]. A question for further research could investigate whether patients whose information performed better, according to these quality assessment tools, experienced a greater number of changes in their treatment plans.

5. Conclusions

This study provided a detailed analysis of the uro-oncology MDTMs process at our institution, highlighting its key role in the management of urological cancers. Collaborative multi-specialty input resulted in changes to management plans at the diagnostic, staging, and treatment stages of patient care.