Abstract
Purpose
Multidisciplinary team (MDT) care is widely accepted as best practice for patients with head and neck cancer, although there is little evidence that MDT care improves head and neck cancer related outcomes. This study aims to determine the impact of MDT care on measurable clinical quality indicators (CQIs) associated with improved patient outcomes.
Materials and methods
Patients treated for head and neck cancer at Ipswich Hospital from 2001 to 2008 were identified. Comparisons were made in adherence to CQIs between patients treated before (pre MDT) and after (post MDT) the introduction of the MDT. Associations were tested using the Chi-square and Whitney U -test.
Results
Treatment post MDT was associated with greater adherence to CQIs than pre MDT. Post MDT had higher rates of: dental assessment (59% versus 22%, p < .0001), nutritional assessment (57% versus 39%, p = .015), PET staging (41% versus 2%, p < .0001), chemo-radiotherapy (CRT) for locally advanced disease (66% versus 16%, p < .0001) and use of adjuvant CRT for high risk disease (49% versus 16%, p < .0001). The interval between surgery and radiotherapy was shorter in the post MDT group (p = .009) as was the mean length of hospitalization (p = .002).
Conclusions
This study highlights the measurable advantages of MDT care over the standard, less formalized, referral process.
1
Purpose
Head and neck cancer is a significant medical burden with an annual global incidence of more than 500,000 cases and more than 300,000 deaths . Multidisciplinary team (MDT) care is widely accepted as best practice for patients with head and neck cancer , although there is little evidence that MDT care improves head and neck cancer related outcomes such as local control or survival .
A formal head and neck MDT meeting was introduced at Ipswich Hospital in June 2006. The team comprises two head and neck otolaryngologists, one radiation oncologist, speech pathologist, dietician, dentist, psychologist, cancer care coordinator (dedicated specialist nurse) and an affiliated medical oncologist. We studied the impact of the MDT approach on management of patients with head and neck cancer. The aim of this study was to compare care patterns of patients managed under the MDT model with a similar sized cohort managed immediately before the introduction of the MDT.
2
Materials and methods
This study is a retrospective review of head and neck cancer patients treated at Ipswich Hospital between January 2001 and July 2008. The patients were divided into two groups for comparison: pre and post MDT.
2.1
Patient eligibility
Pre MDT patients were those diagnosed between January 2001 and June 14, 2006. These patients were retrospectively identified using databases from hospital coding, medical records, pathology and operating theatres.
Post MDT patients were those seen or discussed at the MDT from June 15, 2006 onwards. Details of their care were collected in a prospective database which was supplemented by patient records.
2.2
Principles of head and neck cancer therapy
Head and neck surgery (including reconstruction) was performed by two otolaryngologists at Ipswich Hospital for the entire duration of the study.
One radiation oncologist provided radiotherapy (RT) to most patients from Ipswich Hospital, at the Mater Radiation Oncology Centre in South Brisbane. All treatments followed written departmental guidelines.
Concurrent chemotherapy was administered by one medical oncologist at the Mater Adult Hospital, co-located with Mater Radiation Oncology.
2.3
Structure of the MDT
The MDT meets on a fortnightly basis to discuss care of newly diagnosed patients, other patients of interest and post-operative results. Patients are seen and assessed by all MDT members and then discussed. This discussion generates consensus management plans as well as protocols and research initiatives.
2.4
Endpoints of quality care
The following clinical quality indicators (CQIs) were used to evaluate the process of patient treatment. These were common items of MDT discussion that were retrospectively identified as surrogates for improved patient outcomes, based on evidence of their efficacy.
- 1.
Was pre treatment dental assessment done?
- 2.
Was pre treatment nutritional assessment done?
- 3.
Was Positron Emission Tomography (PET) staging done where indicated?
- 4.
Was chemo-radiation (CRT) recommended for Stage III/IV disease?
- 5.
Was post-operative CRT recommended for extra capsular spread (ECS) or positive margins?
- 6.
Time from surgery to commencing RT.
2.5
Statistical methods
Patient data were analysed using SPSS v16.0. The association between the pre MDT and post MDT grouping and the CQIs was analysed using the Chi-square test. Fisher’s exact test was used when patient numbers were less than five. The Mann–Whitney U -test (two-tailed) was used to compare means of continuous data of skewed distribution.
2
Materials and methods
This study is a retrospective review of head and neck cancer patients treated at Ipswich Hospital between January 2001 and July 2008. The patients were divided into two groups for comparison: pre and post MDT.
2.1
Patient eligibility
Pre MDT patients were those diagnosed between January 2001 and June 14, 2006. These patients were retrospectively identified using databases from hospital coding, medical records, pathology and operating theatres.
Post MDT patients were those seen or discussed at the MDT from June 15, 2006 onwards. Details of their care were collected in a prospective database which was supplemented by patient records.
2.2
Principles of head and neck cancer therapy
Head and neck surgery (including reconstruction) was performed by two otolaryngologists at Ipswich Hospital for the entire duration of the study.
One radiation oncologist provided radiotherapy (RT) to most patients from Ipswich Hospital, at the Mater Radiation Oncology Centre in South Brisbane. All treatments followed written departmental guidelines.
Concurrent chemotherapy was administered by one medical oncologist at the Mater Adult Hospital, co-located with Mater Radiation Oncology.
2.3
Structure of the MDT
The MDT meets on a fortnightly basis to discuss care of newly diagnosed patients, other patients of interest and post-operative results. Patients are seen and assessed by all MDT members and then discussed. This discussion generates consensus management plans as well as protocols and research initiatives.
2.4
Endpoints of quality care
The following clinical quality indicators (CQIs) were used to evaluate the process of patient treatment. These were common items of MDT discussion that were retrospectively identified as surrogates for improved patient outcomes, based on evidence of their efficacy.
- 1.
Was pre treatment dental assessment done?
- 2.
Was pre treatment nutritional assessment done?
- 3.
Was Positron Emission Tomography (PET) staging done where indicated?
- 4.
Was chemo-radiation (CRT) recommended for Stage III/IV disease?
- 5.
Was post-operative CRT recommended for extra capsular spread (ECS) or positive margins?
- 6.
Time from surgery to commencing RT.
2.5
Statistical methods
Patient data were analysed using SPSS v16.0. The association between the pre MDT and post MDT grouping and the CQIs was analysed using the Chi-square test. Fisher’s exact test was used when patient numbers were less than five. The Mann–Whitney U -test (two-tailed) was used to compare means of continuous data of skewed distribution.
3
Results
One hundred and thirteen patients were treated for head and neck cancer at Ipswich Hospital between January 2001 and July 2008; 48 patients before the MDT started on June 15, 2006 (pre MDT) and 65 patients after this date (post MDT). Most patients were male (74.3%, 84 of 113) with squamous cell carcinomas (88.5%, 100 of 113). See Table 1 for patient and tumour demographics.
| Pre MDT (N = 48) | Post MDT (N = 65) | |
|---|---|---|
| Age (mean) | 58.77 | 63.26 |
| Sex | ||
| male | 35 | 49 |
| female | 13 | 16 |
| Histology | ||
| Squamous Cell Carcinoma | 43 | 57 |
| Merkel Cell Carcinoma | 0 | 2 |
| Lymphoma | 0 | 2 |
| Papillary Carcinoma | 1 | 2 |
| Adenoid Cystic Carcinoma | 2 | 0 |
| Other | 2 | 2 |
| Primary site | ||
| oral cavity | 11 | 10 |
| oropharynx | 13 | 14 |
| hypopharynx | 3 | 5 |
| supraglottis | 2 | 5 |
| glottis | 8 | 6 |
| parotid | 2 | 7 |
| thyroid | 1 | 2 |
| paranasal sinuses | 3 | 2 |
| skin | 1 | 5 |
| unknown primary | 1 | 8 |
| other | 3 | 1 |
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