The utilization of multidisciplinary tumor boards (MDT) in clinical routine: results of a health care research study focusing on patients with metastasized colorectal cancer

Cancer is a leading cause of death worldwide [1]. However, in the last 2 decades, numerous new treatment options including newly developed drugs, antibodies, and different local ablative therapies as well as extended indication for resection in metastatic disease have been implemented in clinical routine extending the armentarium to preserve quality of life and/or even prolong disease free (DFS) or overall survival (OS) in cancer patients. As a consequence of these numerous options and improvements, multidisciplinary tumor boards (MDT) have been advocated as standard of care in modern oncology. Recent national cancer guidelines demand pretherapeutical discussion of every cancer patient in these MDT [2‐4].

In order to improve cancer care in Germany, the Federal Ministry of Health, the German Cancer Society, the German Cancer Aid and the Working Committee of German Cancer Centers have initiated the National Cancer Act in 2008, a collection of numerous future goals and recommendations in all fields of cancer care including screening, quality improvement, cross-sectoral cooperation, and documentation [5]. In addition to the above described medical perspective of MDT necessity, this National Cancer Act argues not from the individual but from the societal perspective and demands high quality cancer care for every patient irrespective of age, sex, origin, habitation, and state of insurance. This goal should be reached by promoting high-quality oncological care on the one hand and reduction of inacceptable discrepancies in health care quality between regions on the other hand and thereby development of suitable health care structures including MDT.

Given that knowledge and attitude are not limited factors in the health care system of a developed country such as Germany, the aim of the present health care research study was to evaluate real life performance in terms of MDT discussion of cancer patients within a defined but representative region and focused on a frequent cancer type, namely metastasized colorectal cancer (mCRC). For this cancer, the German guidelines recommend to discuss every patient with colon cancer (CC) after primary tumor surgery and every patient with clinical stage IV CC as well as every rectal cancer (RC) patient prior to any therapy in a MDT. This recommendation includes that all patients with metastases of colorectal origin should be discussed in a MDT prior to any therapy [2].

Patients with mCRC and diagnosis of the first metastasis between 01/2011 and 12/2013 were eligible. National demography data including population of the 4 counties in 2011, 2012, and 2013 and raw CRC incidence rate ( www.destatis.de ) were used to estimate the number of CRC patients in the sample region resulting in 1.696 patients for the period 2011–13. Assuming no decrease in incidence rates over the last years and a proportion of 50% developing metastases during the course of disease [6], we calculated that 848 patients with mCRC would represent the maximal sample size for the study. A standardized patient report form (see supplementary material 1) was developed and anonymized data from patient charts were collected and stored in a GCP-conform EDC-system named secuTrial®. The study had been approved by the ethics committee of the University Medical Center Goettingen (AN 23/9/13), the ethics committee of the medical associations in Lower Saxony and Hesse and the data security officials of Lower Saxony and Hesse.

One university medical center, four teaching hospitals, one communal hospital, and 4 oncological focus practices participated in the study. All MDT consisted of at least a medical oncologist, a gastroenterologist, a visceral surgeon with experience in liver surgery and a radiologist. In total, 470 patients (CC n = 278, RC n = 192) representing 55% of the estimated sample maximum were enrolled.

As already stated MDT have been advocated as standard of care in modern oncology even though a direct benefit of MDT discussion in terms of improved patients’ survival has been demonstrated only in few studies [12]. However, previous studies have shown that MDT discussion leads to relevant improvements of interdisciplinary therapy such as more recommendations detached from the case-presenting discipline’s plan [13] and improved adherence to guidelines [14]. On the other hand, healthcare professionals, especially those working in university hospitals and large referral centers criticize feasibility of increasing numbers of time consuming MDT sessions. In this area of conflict, it is of major importance to gain knowledge about MDT utilization in clinical routine.

Different from other European countries and the US, the initiation of a nationwide clinical cancer registry has started not earlier than 2013 when the German Government adopted the Law for Early Cancer Diagnostics and Quality Assurance by Clinical Cancer Registries [15]. The corresponding standard report form includes notification of MDT date and timepoint of discussion (pretherapeutical, postoperative, or posttherapeutical) [16]. Unfortunately, the federal states did not harmonize their individual databases until today hampering nationwide analyses on MDT utilization on the basis of such registries. Therefore, the results of this study are of major interest.

Given the mentioned benefit of MDTs in previous publications as well as the significant differences in treatment decisions between MDT and non-MDT discussed cases as observed within this study, the overall low MDT utilization in all analyzed clinical scenarios in the present study raises relevant concerns. With 55% of estimated cases in the sample region involving most major players and a sample region layout applicable to many regions nationwide, it has to be assumed that comparable results would be obtained when other regions in Germany were investigated. As all participants in this study had access to at least one MDT, we can only hypothesize on the surprisingly low rate of MDT discussion in mCRC. One reason might be the supposed clarity of the clinical scenario in individual patients with clear guideline recommendations or strong conviction of the treating physician for the superior treatment and subsequent perceived needlessness for multidisciplinary discussion. Such thinking is underlined by our previous survey on experienced medical oncologists and surgeons who mainly stated that they were able to access correctly the complementary specialties’ treatment options in patients with mCRC [17]. However, there are prominent examples that even highly specialized experts do not homogeneously assess individual patient cases [18]. Very recently it has been shown by evaluation of 213 rectal cancer cases that MDT discussion led to a change in treatment schedule in 70 (33%) cases including 22 cases (10%) in which the presenting physician had a “definite plan” prior to MDT [19]. Furthermore, the ongoing elucidation of molecular subtypes in colorectal cancer [20] as well as treatment relevant clinical parameters such as localization [21] make even formerly simple clinical scenarios more and more complex requiring involvement of all available expertise in every treatment decision which can most easily be done within a MDT discussion. Another potential reason could be that single institutions actually never or only in selected scenarios discussed their patients within a MDT. This cannot be excluded because as part of the study policy the patient data were not linked to any institution code while transferred to the data base precluding inter-institutional comparison. However, the overall high number of patients not discussed in a MDT is unlikely generated by a single institutions performance.

Focusing on consequences of MDT utilization particularly in patients older than 70 years, it becomes obvious, that waiving the MDT discussion was not accompanied by restriction of therapy in general but less application of chemotherapy (Fig. 2). There is a huge discussion about how much therapy should be applied to older patients and it has been shown in other studies that the older patients are the less chemotherapy they get [22, 23]. However, biological age is not a straightforward parameter to trigger such treatment decisions. Unfortunately, data on ECOG status were not available for the majority of patients in our study, so other than planned any analysis considering ECOG status could not be done which would have been of great interest especially in older patients.

Once accepting that physicians do not inherit enough intrinsic motivation to discuss all their patients in MDT, other strategies to overcome the low rate of MDT discussion need to be developed. One of these could be a certification program for colorectal cancer centers which in Germany has been implemented by the German Cancer Society (DKG) beginning in 2006. Besides numerous other key figures monitored, the DKG has set the rate of pretherapeutical MDT discussion in RC patients to a minimum of 95%. From 2009 to 2011 this median rate of pretherapeutical MDT discussion in RC patients in all certified centers raised from 88.0 to 91.8% [24] showing two facts: first, certification resulted in higher MDT discussion rates than those observed in our sample region but second, even these certified centers did not meet the minimum requirements. Of note, none of the participating institutions in our study had been one of the 247 DKG-certified colorectal cancer Centers approved until 2013.

Concerning limitations, the results of this study might be biased by its retrospective design and related lack of MDT documentation as data were collected by chart review only. Furthermore, the study was not designed to evaluate a potential difference between the MDT recommendation and the actual treatment of patients. The reason for that is that every MDT had its own structure and some prefer to include patients’ preferences into the discussion process while others favor an interprofessional discussion first followed by a separate discussion on the recommendation with the patient as advocated by the British NICE guidelines [4]. In addition, the growing acceptance of MDT in general within the last years might have already resulted in an increased MDT utilization in the sample region and other parts of the country since 2013.

In conclusion, in clinical routine MDT discussion is not as established as advocated by national guidelines. Treatment decisions differ depending on MDT discussion especially in older patients and those with single organ metastases. Given the demonstrated benefits of MDT discussion concerning patient survival, efforts should be made to improve cancer care in terms of MDT utilization for which certification programs can be a reasonable option.