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MCC 2011 - Slide 21


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MCC 2011 - Slide 21

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