Year: 2017
Type: article
Abstract: The delivery of head and neck (H&N) cancer care continually is expanding. The rapid growth of complex multimodal treatment options and the emergence of new areas of cancer care intervention have allowed for potentially more efficacious therapeutic options. Given the complex functional and anatomic sites of H&N cancer, diagnosis, treatment, and long-term support require seamless, team-based, and specialist-driven continuity of care. Increasing specialization in the treatment of H&N cancer patients has led to the introduction of multidisciplinary teams (MDTs), the demand for which rapidly has increased in recent years. Composed of physicians (H&N surgeons, medical and radiation oncologists) and nonphysician members (speech/occupational therapists, psychologists, and social workers), the MDT conference combines the perspective of a diverse group to improve the diagnostic and treatment plan for each patient. The benefits of group discussion, care coordination, and shared decision making are apparent, and they frequently are addressed in review and opinion publications. However, despite literature that has shown MDTs to improve cancer staging, and subsequently the patient outcomes, a large proportion of newly diagnosed H&N cancer patients still are managed without MDTs due to perceived costs and inefficiencies. Opinions expressed include the potential impact on cost and time, which may cause some clinicians to argue that MDTs are not practical for all patients. Therefore, we sought to investigate the literature for evidence detailing the impact of H&N cancer outcomes in relation to the costs associated with the implementation of MDT conferences. A literature search in the Medline and PubMed database was performed using the keywords “multidisciplinary head and neck cancer” and “head and neck tumor board.” Numerous review, opinion, and editorial reports have touted the theoretical benefits of the MDT approach in H&N surgery. Efforts have been made to only include investigative, data-driven, retrospective, prospective, and systematic review publications. Amid growing medical literature that demonstrated improved treatment planning and decision making with MDTs in cancer primaries outside the H&N, Friedland et al. produced the earliest H&N study that retrospectively analyzed the survival outcomes of H&N cancer patients who were treated within or outside the MDT setting from 1996 to 2008.1 When controlling for cancer stage and year treated, patients presented in MDT conference (n = 395) had more synchronous treatment with chemoradiation therapy (CRT) (P = 0.004) and were more likely to have advanced disease (P < 0.001). Furthermore, the non-MDT group (n = 331) had significantly more radiotherapy (RT) as a single modality (P = 0.002). These findings resulted in the first study to demonstrate significantly improved 5-year overall survival (OS) outcomes in stage IV H&N cancer patients presented at MDT conference (hazard ratio = 0.69, P = 0.004), in contrast to those not discussed at MDT conference. In the first prospective H&N MDT study, Wheless et al. captured 120 consecutive new patients presented at tumor board, through February 2010, to investigate the effects of MDT case presentation on treatment planning.2 The results were significant: 32 patients (27% of the cohort) had some change in either tumor diagnosis (type/stage/grade) or treatment plan following MDT conference. Of these, 68% patients (18.3% of the total cohort) had a change particularly affecting the management of malignant lesions. The majority of the patients (65%) received treatment escalation, with the addition of another treatment modality (P = 0.02). In an effort to identify the factors associated with improved survival, Kelly et al. retrospectively studied adherence to treatment planning in the pre-MDT period (n = 48) with prospectively collected data in the post-MDT period (n = 65).3 All patients who were treated following implementation of MDT had improved rates of adherence to clinical quality indicators, which included higher rates of dental and nutritional assessments, completion of pretreatment positron emission tomography, and referral for radiation or CRT (P < 0.01). Furthermore, the time from surgery to radiation therapy initiation, as well as the inpatient hospital duration, also were significantly shorter in the post-MDT group (P < 0.01). The authors reflect that the average length of hospitalization decreased by more than a week post-MDT due to the “efficiency of the MDT process in diagnosis, staging, and pretreatment evaluations.” Although remarkable for quality of life and costs to health providers, there is a gap in cancer literature across specialties in the analysis of costs of MDT implementation to the savings from more efficient care delivery; therefore, a systematic review by Prades et al. set forth to investigate the efficacy of MDT care in balancing patient outcomes.4 From 2005 to 2012, 29 studies were published on MDT patient management and outcomes. Most noteworthy was that patient survival, when compared to that of patients not assessed by an MDT, was significantly improved (P < 0.05) in all reported accounts, which included those of breast, colorectal, esophageal, and H&N cancer patients. Additionally, 14 original reports were found to improve patient care beyond diagnosis to include follow-up, palliative care, and clinical trial coordinators. Despite the excellent outcomes, a uniform operational framework of the MDT is not consistent among published studies and would aid in resource allocation and team management. Since publication of this review, the largest single subsite, MDT-directed, H&N cancer study was performed in a consecutive patient population. Liao et al. investigated 1,616 patients with primary oral cavity, squamous cell carcinoma (OC-SCCA) undergoing surgical resection. The study cohort demonstrated significantly improved 5-year rates of cervical regional control (P < 0.05), OS (P < 0.01), and disease-specific survival (P = 0.01) in those presented at MDT compared to the non-MDT group. Significant association of MDT with improved survival rates across all stages (1–4) was identified.5 These findings were associated with the extended role of MDT on patient coordination and follow-up in that the MDT group demonstrated 90% rates of completion of adjuvant RT or CRT, as originally planned, compared to only 71% and 57% of those not presented (P < 0.001). Overall, this study is the first to indicate that MDT may serve as an independent predictor for survival in OC-SCCA patients. In summary, MDT improves cancer care delivery that advances patient care coordination and helps optimize a complex treatment plan in a physiologically active and highly morbid anatomically setting. Further studies to understand the factors that lead to cost-effective care are required. Despite the lack of standardization among MDT groups at a variety of institutions, all reported literature supports a positive relationship between improved care coordination, adherence to clinical guidelines, reduced time to treatment, and improved survival following MDT discussion. This, taken in conjunction with the plethora of similar survival results among non-H&N (i.e., breast, lung, colorectal) cancers, has resulted in a new standard of care advocating for MDT for all H&N cancer patients. Further studies are required to better assess resource allocation, cost-effectiveness, and quality-of-life outcomes. Thus, all H&N cancer patients requiring single or multimodality therapy for advanced H&N cancer should be presented at MDT conference. Recommendations for the use of MDT conference in guiding H&N cancer care is based on a prospective cohort study (level 2 evidence),2 retrospective reviews (level 3 evidence),1, 3, 5 and a systematic review of the literature (level 5 evidence).4
Source: The Laryngoscope
DOI: 10.1002/lary.26919
Language: English
Topic: Head and Neck Cancer Studies
Subfield: Otorhinolaryngology
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2766761043