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
Shomik Sengupta
Round 1
Reviewer 1 Report
Comments and Suggestions for Authors
This single centre retrospective review examines a uro-oncology multi-disciplinary meeting with particular focus on management change and adherence to recommendations.
The study is largely descriptive in nature, and the details included establishes a particular model of MDM implementation, but does not appear to provide any new information or learning points.
The authors' stated aims included assessing the impact on patient management, and in so far as changes to management were assessed, this aim would seem to be potentially addressed by this endpoint. However, it appears that a substantial proportion of patients were excluded from analysis. In many instances it appears that patients were included in the MDM at the time of receipt of referral rather than after clinical assessment and formulation of proposed management plan, which would seem a more logical timepoint to me.
The intro seems too brief, and doesnt really give the reader a good sense of the need & direction for the study
The data is spread across too many tables - clearly some if not all of the tables showing the distribution across tumour streams could be combined into one or two larger tables (1, 2, 3, 5, 6 & 7). Table 8 detailing specific cases would be better as a supplementary table
Comments on the Quality of English Language
Minor editing/correction required in places
Author Response
Please see the attachment.
Author Response File: 
Author Response.pdf
Reviewer 2 Report
Comments and Suggestions for Authors
In this manuscript the authors e conducted a review of a prospectively maintained database of all uro-oncology MDTMs helded over a 12-month period between 2020-2021 in a single-center setting. The MDTM facilitated cross referrals between different specialties and further promoted the entry into clinical trials. High adherence to MDT recommendations was also reported. Main oncological diseases were analyzed. Moreover, in one out of four pts a modified management was described. The effort of the authors is to be commended.
MDT meetings are changing our clinical daily practice and are going to be considered mandatory for uro-oncology indications.
Interesting key point: the result of MDT consultation was distributed to the patients general practitioner. Furthermore, after each meeting the patient was contacted by telephone to discuss the recommendations within 1 week. Thus, I presume that the patient was notified by the Consultant Urologist and not by the all MDT team. What do the authors think about the collegial delivery of the meeting results? Would it change the management of these patients even more? The authors should further develop this aspect in the appropriate section of the manuscript.
Another interesting point is the MDT discussion in the setting of localized disease. Historically, most of the pts enrolled for MDT discussion belonged to metastatic disease. This is an important paradigm shift with mentioned in the Discussion.
Author Response
Please see the attachment.
Author Response File: Author Response.pdf
Reviewer 3 Report
Comments and Suggestions for Authors
The authors proposed in the manuscript to demonstrate the importance and the impact of multidisciplinary team meetings on cancer patients. Although the study has some limitations that the authors mentioned, I consider the manuscript of great relevance to show/demonstrate that this type of scientific meeting can not only help with the treatment output but also help with the psychological/emotional state of the patient.
Very well done! I recommend the publication of the manuscript!
Author Response
Please see the attachment.
Author Response File: Author Response.pdf
Reviewer 4 Report
Comments and Suggestions for Authors
The authors aimed to investigate the role of uro-oncology multidisciplinary team meetings at an Australian tertiary centre, in order to analyse the impact on patient management and the adherence to MDTM plans.
The paper is well written even if not so innovative.
I suggest a re-editing of tables in order to achieve a easier understanding of the paper.
Moreover, please check the order and correspondence of tables’ lines (e.g.: table 8, last 2 lines)
Author Response
Please see the attachment.
Author Response File: Author Response.pdf
Reviewer 5 Report
Comments and Suggestions for Authors
This paper looks at changes in management in patients presented at an MDT and concludes the MDT discussion changed management. There are major issues is this hypothesis and conclusion.
1. The meeting only reviews selected cases. This means there was already questions about management as I assume only cases with questions are selected to be discussed. So although a management plan may have been documented prior to discussion, it is unlikely this management plan would have gone ahead without the treating doctor seeking further information, something which may have been achieved by phoning the pathologist or radiologist for clarification. So I doubt this was a true, change of management which arose from the MDT.
2. Some meeting had only one specialist for each treating speciality present but doesn't clarify how this may have impacted decision making. If a surgeon is presenting his or her own patient and is the only surgeon present, it creates a unilateral dynamic for management decision making.
4. 35% were prostate cancer, 6% were testicular cancer, yet 88% of patients discussed were male. Unless men are 3 times more likely to have a significant non-male cancer, this raises questions of gender bias in cases selected for discussion. This glaringly obvious disparity should have been addressed in discussion.
3. Cases which did not follow the MDT recommendations raise many questions about all management decisions. Although there is lack of information to make a conclusion there are important questions raised. For example:
a. Why a patient with localised ISUP 2 cancer was recommended for WW and not AS; and if the patient wanted treated, why a more definitive curative option was not offered (ie EBRT)
b. Was the patient with new diagnosis of mHSPC referred to a clinical trial or offered other upfront treatment other than ADT
c. Not only was the patient with a 4cm renal mass not recommended a biopsy (despite evidence it reduces surgical removal of benign lesions from 16 to 5% and is strongly recommended in EAU guidelines) but it appears they were also not offered a partial nephrectomy. Also, I would be interested to know what the biopsy result was.
d. The failing of the MDT meeting to consider the patients symptoms when recommending neo-adjuvant chemotherapy. This can create conflict and emotional distress in a patient when they now feel they are going against a whole committee when deciding on their own treatment. Also was neo-adjuvant chemo standard of care based on histopathology?
e. The conclusion (overridden by the consultant) to add bicalutimide to a patient with mCRPC was an odd conclusion when there are significantly better treatment options. How many other times was this recommended and not over-ridden?
Again, the paper lacks information which may allay the concerns I have above, but if I am asking these questions I am sure most readers of the paper will be doing the same.
The information provided in the paper leads to the conclusion the MDT meetings involve the presentation of cases were either clarification about investigations (imaging/radiology) is required or the presenting consultant is unsure on best manage plan. Then after discussion, which at times may be limited to a single voice from a speciality, a management plan is concluded. To concluded from this, that the MDT meeting significant changed patient management is not substantiated.
In addition, there is nothing to support the changes in management had a positive impact on patient care.
It should be a fundamental principal of any MDT to document and ensure any patient discussed is adhering to documented guidelines (ie EAU guidelines) and if not, why not. I appreciate, while it was not within the scope of this paper to show long term outcomes, there are still significant findings which can be presented within the time frame (ie histopathological outcomes from biopsies or surgery), which could have been added to show changes in management were beneficial to the patient. Otherwise the impression can be that patients are being advised to not follow guidelines and subsequently their outcomes are worse. A phenomenon negatively impacting 25% of patients discussed.
Author Response
Please see the attachment.
Author Response File: Author Response.pdf
