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  • The MERCURY Study is the Magnetic……………..
  • Transcript

    • 1. Quality and Organization of Care Value of a Multidisciplinary Team (MDT) Brendan Moran 15 th February 2011
    • 2. Multidisciplinary Team (MDT)
      • All complex medical care requires a team of people
      • Medical care is multidisiplinary in nature
    • 3. MDT in Cancer
      • Cancer care in particular requires MDT input
      • Colorectal Cancer – particularly relevant
    • 4. MDT in Colorectal Cancer
      • Mandatory in UK – NHS reimbursement and Association Coloproctology GB an d Ireland
      • Particularly relevant in rectal cancer
    • 5. Why Rectal Cancer ?
      • Proven benefit of neodajuvant therapy, in selected cases
      • Variations in surgical technique - Reconstruction versus a permanent stoma
      • Rectal function
      • Bladder and sexual function
    • 6. Why Rectal Cancer ?
    • 7. Members MDT
      • Core (Essential)
      • Additional
    • 8. Core Members Colorectal MDT
      • Two (or more) Surgeons
      • Radiologist
      • Radiation Oncologist
      • Medical Oncologist
      • Clinical Nurse Specialist (Stoma Care)
      • Pathologist
      • MDT Co-ordinator
    • 9. Additional Members Colorectal MDT
      • Gastroenterologist
      • Nutritionist
      • Palliative Care Specialist
      • Liver Surgeon
      • Psychologist
      • Etc etc
    • 10. “ All patients with colorectal cancer should be managed in a hospital with a colorectal MDT”
    • 11. NHS England 2011
      • “ Cancer care should be under the jurisdiction of a cancer specific MDT and follow the principles of “
      • “ No decisions about me without me”
    • 12. “ No decisions about me without me” ??
    • 13. “ No decisions about me without me” ??
      • Ideally patient at the MDT ?
      • Real world – Patient representative at the MDT
    • 14. Patient Representative
      • Surgeon
      • Clinical Nurse Specialist
    • 15. Rectal Cancer
      • Common
      • Curable – Mainly by surgery
      • Technically challenging
    • 16. <6cm 12-15 cm - upper Definitions of upper, middle and low rectal cancer 7-11 cm – middle
    • 17. Anterior resection Most Permanent stoma Except specialist units ? And slightly higher ! <6cm 7-11 cm 12-15cm Restorative anterior resection Rectal Excision For Cancer
    • 18. Significant Advances in Management of Rectal Cancer
      • Surgical technique
      • Pathology
      • Neoadjuvant therapy
      • MRI
      • MDT
    • 19. “ The mesorectum in rectal cancer surgery -the clue to pelvic recurrence” Heald, Husband, Ryall Br J Surg 1982
      • Anecdote
      • 5 cases
    • 20. How were these results achieved in Basingstoke in 1980’s ?
      • MDT – Heald (Surgeon), Ryall (Radiation Oncologist) , Husband (Pathologist), Clark (Nurse Specialist)
      • Focussing on surgical technique/ specimen
    • 21. “ The MDT” Basingstoke 1980’s
    • 22. “ The MDT” Basingstoke 1980’s
    • 23. “ The MDT” Basingstoke 1980’s
    • 24. Significant Advances in Management of Rectal Cancer
      • Surgical technique
      • Pathology
      • Neoadjuvant therapy
      • MRI
      • MDT
    • 25. The rectal cancer story
    • 26.  
    • 27.  
    • 28. Phil Quirke –Subset analysis Quality and p lane of surgery MRC CR07 n=1119 Mesorectal Intra-mesorectal Muscularis propria n=596 53% n=382 34% n=141 13%
    • 29. Disease free survival by plane of surgery 72% 79% (p=0.29)
    • 30. Significant Advances in Management of Rectal Cancer
      • Surgical technique
      • Pathology
      • Neoadjuvant therapy
      • MRI
      • MDT
    • 31. Pelican (Pelvic and liver cancer) Centre Basingstoke The M.E.R.C.U.R.Y. Study M agnetic RE sonance Imaging and R ectal C ancer E UR opean Equivalence Stud Y
    • 32. MERCURY - MRI and The Concept
    • 33.  
    • 34.  
    • 35.  
    • 36. Bad
      • MRI of 32 year old woman with Rectal cancer – Dec 1996
      mrT3/T4 mrN1
    • 37. Bad
      • ?
      • MRI of 32 year old woman with Rectal cancer – Dec 1996
      mrT3/T4 mrN1
    • 38. pT3, pN2 and baby 20 weeks later
    • 39. 2006  2010
    • 40. MERCURY- Multi-centre observational trial 429 patients
      • CRM involved:
        • APE 32%
        • AR 13%
    • 41. Problems associated with APR
      • Tumour involved circumferential resection margin significantly more common after APR (CRM +ve)
      • AR APR
      • Dutch TME Trial 12% 29%
      • MERCURY Trial 12% 33%
    • 42. Lower tumour (<6cm) Difficulties!!
      • Embryological/Anatomical
      • Surgical Access
      • Staging –EOUS/MRI/Clinical
      • Function
      • Tumour characteristics
    • 43. Biopsy proven Rectal Cancer
      • 34 year old woman
      • 3cms (max) from anal verge
      • What op ??
    • 44. Multiple choice
      • 1 APE
      • 2 AR
      • 3 SCRT +APE
      • 4 SCRT + AR
      • 5 CRT +APE
      • 6 CRT +AR
    • 45. Upper Rectal Low rectal
    • 46. Significant Advances in Management of Rectal Cancer
      • Surgical technique
      • Pathology
      • Neoadjuvant therapy
      • MRI
      • MDT
    • 47. Indications Neoadjuvant therapy
      • Definite - Tumours fixed (Involving resection margin)
      • Consider – High risk tumours – low rectal cancer and adverse features
    • 48. Neoadjuvant therapy (Pre-operative RT/CRT
      • Reduces local recurrence – Grade A (Metanalysis RCT
      • May improve survival BUT
      • Increased peri and post op morbidty and mortality
    • 49. Side-effects preoperative radiotherapy: Lange MM Br J Surg 2007 P <0.001 Faecal incontinence
    • 50. Purpose MDT
      • Review clinical details/ relevant imaging
      • Develop a treatment plan
      • Advise on options
    • 51. COLORECTAL MDT
      • Major advance in management of colorectal cancer
      • Increasingly important due to complexicity of management
      • Improves outcomes for patients
      • Role is to “Advise Surgeon”
    • 52. Evidence Base
      • No RCT
      • Case series
      • “ Good Practice”
      • “ Parachute evidence”
    • 53.  
    • 54. “ Parachutes reduce the risk of injury after gravitational challenge, but the effectiveness has not been proven with randomized controlled trials” MDT
    • 55. Royal Marsden London
      • “ MRI directed multidisciplinary pre-operative decision making for rectal ccancer: the way to eliminate positive circumferential margins ?
    • 56. Royal Marsden London
      • Cases discussed at an MDT compared to those not discussed
      • Histological CRM +ve rates
    • 57. Surgery alone Group -178/259 (69%)
    • 58. Conclusion
      • MDT essential in optimal care colorectal cancer
      • Surgeons should lead/have major input MDT
      • Imaging focal point in MDT
      • Surgeon and Nurse Specialist represent patient
      • Team work crucial
    • 59. Team- work Crucial

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