Interdisciplinary/Multidisciplinary Oncology Boards: The gold standard in the management of oncology patients

Summary
Interdisciplinary/Multidisciplinary Oncology Boards are the gold standard in the management of oncological patients. Through the boards, the coordination of the many health professionals involved in the care of the oncological patient is possible. It also allows for joint decision-making regarding treatment planning. The literature review shows that the implementation of the recommendations of a well-organized board results in a benefit for the patient, as an improvement in overall survival time and a reduction in the recurrence rate are observed. In addition, there are educational, occupational and legal benefits for doctors, as well as satisfaction for both doctors and patients, while reducing hospital costs and complications of the disease.

Introduction
The care and treatment of oncological cases is a complex process, in which many medical and paramedical specialties are involved. Due to the number of health professionals involved, there may be a gap in communication and coordination, two important parameters in the provision of high-quality oncological care. Multidisciplinary care (Multidisciplinary – Care) is defined as a multidisciplinary and team approach to patient care, in which the participating health professionals jointly study the treatment options and draw up the treatment plan. The health professionals involved in the care constitute the Multidisciplinary Team (MDT) which aims to improve communication, coordination and treatment planning.
The operation of MDTs was initially implemented in Western countries after the publication of the Calman-Hine report in the United Kingdom in 1995 and subsequently established internationally as good practice [1,2,4]. The Multidisciplinary/Multidisciplinary approach is currently the gold standard in the diagnosis and treatment of cancer [4]. The presentation of cancer cases in Multidisciplinary/Multidisciplinary Boards (MDTM) is recommended by medical professional bodies and recognized guidelines [5]. In the literature, Multidisciplinary/Multidisciplinary Boards are referred to as tumor boards, multidisciplinary cancer conferences, multidisciplinary case review or multidisciplinary team meetings without differentiation in their objectives and mode of operation [6].
Purpose: The purpose of the study is to clarify through the literature review whether there is a benefit from the operation of Interdisciplinary/Multidisciplinary Councils for patients and participating health professionals.

Method: This is a review of the literature via the internet using keywords such as “MDTM in Oncology”, MDTM Guidelines in Oncology”, “mdt streamlining”.

Impact of MDTM on the quality of oncology services
As shown by relevant studies, the recommendations of an MDTM can lead to a change in diagnosis and treatment in newly diagnosed cancer cases [3,6,7,8,9]. A review of 41 studies by
Kočo et al (2021) concerning the four most common types of cancer (colorectal, lung, prostate, breast) showed that the discussion of cases in MDTM changed the way of management by an overall percentage of 1.6-58%. On average, there was a change in 16.2% (6-29%) of cases of colon cancer, 53.2% (53-58%) of lung cancer, 21.1% (1.6-43%) of prostate cancer and 42.1% of breast cancer (only one study) [3]. Interestingly, Kočo et al (2021) found that MDTM varied the number and techniques of surgical procedures and increased the number of cases receiving chemotherapy (CMT) or radiotherapy (RT) as well as those requiring palliative care [3]. Another study from Scotland reported an increase in the proportion of patients with non-small cell lung cancer who received CMT and palliative care after a decision by the MDTM [10]. Rollet et al (2021) also found that presenting and discussing cases in MDTM is associated with the administration of more CMT in patients with metastatic cancer and more adjuvant CMT in patients with stage III colorectal cancer [11]. Furthermore, the MDTM recommendations, which are largely consistent with the guidelines [6,12], help in the early diagnosis and staging of the disease, and can lead to a readjustment of treatment based on the current guidelines [13,14]. An American study of 269 patients with urological cancer reports that after discussion in the MDTM, a change in diagnosis occurred in 23% of bladder cancer cases and in 17% of kidney cancer cases, while a change in treatment occurred in 44% of bladder cancer cases, in 36% of kidney cancer cases and in 29% of testicular cancer cases [10].
Improvements in diagnosis and treatment have increased the cure rate of cancer patients in many developed countries to more than 50%, with the best results reaching 60% [2]. The improvement in survival through MDTM recommendations is documented by many studies that demonstrate an improvement in the survival rate for some types of cancer such as lung, breast, gastrointestinal system, urinary system and sarcomas [4]. A Chinese study shows a 15.6% improvement in the 5-year survival rate in breast cancer after implementing recommendations from a well-organized MDTM [15]. Regarding the impact of organization on the quality and functioning of MDTM, Walraven, JEW et al (2022) after reviewing 74 studies report that although the dependence of the quality and functioning of an MDTM on its organization is not directly established, it is nevertheless clear that good organization is a prerequisite for its proper functioning [16]. A number of studies refer to the need for good organization and effectiveness of an MDTM, while guidelines and protocols have been recorded within the framework of the National Health System (NHS) of the United Kingdom to achieve this goal [2,17]. Kesson et al (2012) found an 18% reduction in deaths in breast cancer patients treated by MDTM, while Tsai et al (2020) in addition to the reduction in deaths also reported a reduction in the recurrence rate in breast cancer [18,19]. The literature also reports an improvement in overall survival time and a reduction in the recurrence rate after their management by MDTM in lung cancer cases [4,20]. A meta-analysis of 5 studies by Changyi Shang et al (2021) shows that the management of head and neck cancer cases by an Interdisciplinary/Multidisciplinary Team improves the overall survival rate [21]. A study by Yuan Chun Huang et al (2021) shows a reduction in the risk of death in patients with advanced esophageal cancer. Interestingly, the same study found that patients treated by physicians with experience in esophageal cancer and a high workload have a lower risk of death, which demonstrates the importance of specialization [22].
It is therefore clear that there is a benefit for oncological patients who are managed by an Interdisciplinary/Multidisciplinary Board. However, in addition to the improvement of therapeutic outcomes, which is the most important parameter, the operation of MDTMs results in educational, occupational (avoidance of double work and saving time) and legal (reduction of medical negligence cases) benefits as well as satisfaction for doctors. In addition, there is satisfaction and an increased sense of security for patients, who feel better when their case is discussed in an MDTM. Furthermore, the management of cases within the framework of an MDTM reduces hospital costs and complications [2,10,23,24,25].
The greatest benefit from discussion in MDTM appears to arise for complex cases such as advanced and metastatic, unusual subtypes of disease, cases after failed treatment, cases with significant comorbidities, and psychosocial problems [5].

Composition of the Interdisciplinary/Multidisciplinary Council (Multidisciplinary team meeting)

An Interdisciplinary/Multidisciplinary Oncology Board consists of permanent and non-permanent members. Permanent members include medical Oncologists (Pathologist and Radiation Oncologist), Surgeon (general surgery or surgical specialty related to the scope of the board), Radiologists and Histopathologists [1.4,5,26,27]. Walraven, JEW et al (2022) define as permanent members a Pathologist and Radiation Oncologist, Surgical Oncologist, Radiologist, Histopathologist and a specialist physician related to the scope of the board [16]. In some countries, the composition of the team does not require a Radiologist as a permanent member [6,28]. Non-permanent members usually include physicians with a specialty related to the subject of the board, as well as other involved health professionals such as nurses, physiotherapists, speech therapists, clinical dietitians, sociologists, etc. [1,4,26,28].
Keating et al (2013), studying 62 centers in which a tumor board operates, where almost all types of cancer are discussed, found that a Medical Oncologist participates in 95% of the boards, a Histopathologist in 97%, a Surgeon in 92%, a Radiation Oncologist in 81% and a Radiologist in 76%. Other health professionals such as sociologists, clinical dietitians and palliative medicine specialists participate to a much lesser extent [12]. Therefore, the participation as permanent members of physicians from the specialties of Pathological and Radiation Oncology, Surgery, Radiology and Pathological Anatomical (Histopathology) constitutes the internationally accepted composition of an Interdisciplinary/Multidisciplinary Team or otherwise an Interdisciplinary/Multidisciplinary Oncology Council.

Multidisciplinary/Multidisciplinary Team (MDT) and legal protection
The Multidisciplinary/Multidisciplinary Team (MDT) provides high-level recommendations in the diagnosis and management of oncological cases that lead to an improvement in the overall survival rate, which is why in the United Kingdom the National Health System (NHS) dictates the operation of the Multidisciplinary/Multidisciplinary Boards (MDTM). However, a prerequisite is the good organization and operation of the board since a poorly organized and inadequately framed MDTM can be dysfunctional and have poor results [15,29].
The question that arises is whether the recommendations of an Multidisciplinary/Multidisciplinary Team (MDT) provide legal protection to the participants and to the treating physician. Howard et al (2018) referring to English legislation note that in medical law the responsibility lies with the individual and not the group. As they state, the MDT has no legal identity and any recommendations it makes are based on individual opinions. In line with this logic, the authors note that [29]:

1. The health professional does not need to see the patient to perform their duty and incur legal liability.
2. An individual may be held responsible for that part of the decision that falls within their area of ​​expertise.
3. It is the primary physician’s responsibility to ensure that all relevant clinical information is available to the board and is accurate.
4. The recommendation, with any disagreements, should be explained to the patient in a way that allows them to make a decision.

Howard et al (2018) conclude that an Interdisciplinary/Multidisciplinary Council can act as a shield of legal protection if the correct and supportive information is placed before it and any discussions and decisions are clearly recorded in the minutes [29]. Belgium has legally established the Oncology Council in 2003 under the name MOC (multidisciplinary oncology consultation). Although the MOC is legally related to counseling to a patient and is convened by the personal physician, for practical reasons it took the form of an MDTM, in which a number of cases are discussed [6}. Greece has also proceeded with the legal enshrinement of the Interdisciplinary/Multidisciplinary Council [28].
In Cyprus, the issue of advisory opinions is regulated by Chapter 2, Article 6 of the Medical Professional Ethics Regulations “the Doctors (Associations, Discipline and Pension Fund) Law” which states that “the doctor is obliged to facilitate advisory medical opinions, as well as the formation of a medical council, as many times as the patient and his relatives request it” [30]. As in Belgium, the legislation concerns the consultation of a patient and is convened by the treating physician, but it can take the form of an Interdisciplinary/Multi-Thematic Council, in which a number of cases are discussed. The fact is that clinicians feel that the discussion in the Multi-Thematic/Interdisciplinary Council offers a certain degree of legal protection and security [5,16]. An interesting study from Korea found, based on a questionnaire, that 37% of respondents believe that the responsibility for the board’s decision lies with the treating physician, while 38% believe that the responsibility should be shared by all board members [27].

Factors affecting the functioning of a Council
As Walraven, JEW et al (2022) report after a review of 74 studies, improving the functioning and quality of a council depends on the planning, structure, preparation and participation of permanent members, dedicating enough time to discuss each case, avoiding interruption of the discussion by external factors, the guidance of a chairperson and secretarial support [16]. The absence of a guide/coordinator, poor preparation, poor presentation, lack of understanding of the question that the council is asked to answer, the preference for specialized treatments by the treating physician, time pressure as well as prolonged discussions that cause fatigue in the participants [5,16].
The reasons for the ineffectiveness of a council do not only concern the participating clinicians. They are also due to the increase in cases presented for discussion, which arise due to the increase in the incidence of cancer, the increase in the survival time of cancer patients. In addition, they are due to comorbidities, the increasing size of the population as well as the security that doctors feel when the case is discussed in MDTM. They are also likely due to unsatisfactory secretarial and technological support. They may also be related to unsatisfactory Radiological and Histopathological support since these two specialties deal with non-oncological cases on a daily basis [5].
The online participation that has been established during the Covid-19 pandemic ensures the participation of specialized doctors, reduces the travel of board members and reduces the time of the diagnostic course of the case [16]. At the same time, however, concerns are expressed about possible technical problems and differences in the technological method of communication, without telemedicine ceasing to be a challenge [5].

Οικονομική επίπτωση από τη λειτουργία Διεπιστημονικού/Πολυθεματικού Συμβουλίου
Αμερικανική μελέτη που αφορά σε ασθενείς με κακόηθες μελάνωμα αναφέρει ότι η διαχείριση περιστατικού από MDTM μπορεί να εξοικονομήσει $1600 (£969) ανά ασθενή [10]. Δημοσίευση των Ke, K.M., Blazeby, J.M., Strong, S. et al (2013) αναφέρεται σε δύο μη ταχαιοποιημένες μελέτες (non-randomized trials) που αφορούν σε ογκολογικούς ασθενείς που έτυχαν χειρισμού από MDTM. Η πρώτη που ήταν αναδρομική μελέτη περιστατικών με κακόηθες μελάνωμα που συζητήθηκαν ή δεν συζητήθηκαν σε MDTM ανέδειξε ότι το κόστος φροντίδας ήταν κατά 33-50% χαμηλότερο στους ασθενείς που έτυχαν χειρισμού από MDTM. Δεύτερη μελέτη που αφορούσε σε ασθενείς με αιματολογική κακοήθεια ανέδειξε μείωση του κόστους φροντίδας κατά 20% και μείωση των επιπλοκών [25].
Όπως διαφαίνεται βιβλιογραφικά δεν υπάρχουν αρκετά στοιχεία που να τεκμηριώνουν τη μείωση του κόστους φροντίδας ασθενών που τυγχάνουν χειρισμού από MDTM. Παρόλο ότι η θετική οικονομική επίπτωση παραμένει υπό αμφισβήτηση, εν τούτοις υπάρχουν στοιχεία που πιθανόν να δείχνουν κάποιο οικονομικό όφελος μέσω της βελτίωσης της παρεχόμενης φροντίδας [5]. Το θέμα χρήζει διερεύνησης αφού μόνο από τις αλλαγές που προκύπτουν στις διαγνώσεις και θεραπείες συμπεριλαμβανομένης της αποφυγής αχρείαστων εξετάσεων, χειρουργικών επεμβάσεων κλπ το πιθανότερο είναι να προκύπτει οικονομικό όφελος μέσω της διαχείρισης περιστατικών από συμβούλιο.

The institution of the Interdisciplinary/Multidisciplinary Oncology Council in Cyprus

The first Interdisciplinary/Multidisciplinary Oncology Council was established and operated in 2005 at the Bank of Cyprus Oncology Centre (BCOC) in Nicosia and concerned lung cancer and thoracic malignancies. The team initially consisted of a Radiation Oncologist, a Pathologist Oncologist and a Thoracic Surgeon, while the opinion of a Radiologist and a Histopathologist was sought where and when necessary. The above composition corresponds to the internationally applicable ones, which mention the participation of a Pathologist Oncologist, a Radiation Oncologist, a Surgeon, a Radiologist and a Histopathologist as permanent members [1,4,26]. The participation of a specialty relevant to the subject of the council is recommended, while the presence of the attending physician for the presentation of the case is essential [16,28,32]. In the process, Interdisciplinary/Multi-thematic Councils for a total of 10 groups of oncological diseases operated at the OKTK. Councils currently operate outside the OKTK, in public hospitals (OKYpY), at the German Oncology Center and at the Mediterranean Hospital of Cyprus in Limassol.
With the contribution of the Cyprus Oncology Society (OEK), the minimum requirements for the establishment and operation of an Oncology Council were recorded by the Health Insurance Organization (OAY) [1,4,16,26,28,32] while due to the absence of national guidelines, international guidelines were accepted on which the recommendations of the councils should be based, as is the practice internationally [4,6,12]. It is worth noting that Interdisciplinary/Multi-thematic Oncology Councils operate within hospitals, a practice that is valid internationally [10]. The operation of in-hospital councils was supported by a decision of the Council of Ministers of the Republic of Cyprus of 18 December 2019. This decision, which led to the establishment of the councils, linked the “positive opinion” of the Oncology Council to the provision of free medical care by state hospitals to oncology patients. The decision of the Council of Ministers provided for the continuation of this condition for the reimbursement of oncology services by the Health Insurance Organization (HIO) within the framework of the General Health Plan (GHS) [31].
For financial and quality control purposes, the HIO, in collaboration with the OEK, strengthened the institution of Oncology Councils. Based on the decision of the Council of Ministers, the OAY continued to link the reimbursement of medical oncological procedures to a “positive opinion” of an approved Oncology Board, making it a necessary condition for the reimbursement of doctors and hospitals [32]. The discussion of newly diagnosed oncological cases in Interdisciplinary/Multidisciplinary Boards is considered necessary or mandatory in many European countries such as the United Kingdom, France, Belgium, etc. [3,5,6,11,31].

Conclusion
The operation of Interdisciplinary/Multidisciplinary Boards in Oncology is currently the gold standard in the management of oncological cases. The implementation of the recommendations of a well-organized board shows that there is a benefit for the patient, since an improvement in overall survival time and a reduction in the recurrence rate are observed. In addition, the operation of MDTMs results in educational, occupational and legal benefits, as well as satisfaction for doctors and patients, while reducing hospital costs and complications of the disease.
Although no financial benefit has been established, the issue still needs to be investigated, since changes in diagnosis and treatment and the reduction of complications may result in financial savings. Concerns are expressed about the increasing volume of cases presented to boards, while online participation is increasingly being implemented. Cyprus implements internationally accepted good practice with the operation of in-hospital Interdisciplinary/Multidisciplinary Councils.