Summary: Shamash and colleagues describe how their supra-regional germ cell tumour multidisciplinary team achieved standardisation of treatment and improved survival. We discuss some of the insights the study provides into prioritising complex patients, streamlining processes, the use of telemedicine, and the centrality of good data collection to continuous quality improvement

Green, James S. A.

Lamb, Benjamin W.

Sevdalis, Nick

Soukup, Tayana

PubMed

Shamash and colleagues describe how their supra-regional germ cell tumour multidisciplinary team achieved standardisation of treatment and improved survival. We discuss some of the insights the study provides into prioritising complex patients, streamlining processes, the use of telemedicine, and the centrality of good data collection to continuous quality improvement.</p

Green, James S.A.

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Quality improvement for cancer multidisciplinary teams:lessons learned from the Anglian Germ Cell Cancer Collaborative Group

Apollo (Cambridge)

EDITORIALQuality improvement for cancer multidisciplinary teams:lessons learned from the Anglian Germ Cell CancerCollaborative GroupShamash and colleagues describe how their supra-regional germ cell tumour multidisciplinary team achieved standardisationof treatment and improved survival. We discuss some of the insights the study provides into prioritising complex patients,streamlining processes, the use of telemedicine, and the centrality of good data collection to continuous quality improvement.British Journal of Cancer (2021) 124:313–314; https://doi.org/10.1038/s41416-020-01080-4MAINIn the months before the coronavirus disease 2019 (COVID-19)pandemic, multidisciplinary team (MDT) working in cancer carewas again on the stakeholder’s agenda. Interest had been piquedwith the Gore report,1 which called for a change in the wayMDTs worked to meet the challenges of increasing workload,while maintaining quality. Since the 1990s, the United Kingdom’ssystem of MDT working with networks of MDTs and cancer centres(and for rare tumours, of supra-network MDTs) has become thegold standard and a model for other countries.Shamash and colleagues2 describe the impact of a supra-network MDT (SMDT) on clinical decision-making and outcomesfor patients with germ-cell tumours in the east of England.Although all patients with a diagnosis of germ-cell tumour werediscussed at the MDT meeting, patients with favourable featureswere discussed briefly, permitting more time for discussion ofcomplex cases. Patients needing emergency treatment werediscussed with the chair outside the meeting to ensure timelyinitial therapy. MDTs across the region met weekly via videoconferencing. Oversight was provided through annual governancemeetings, which included reviews of operational policy andclinical trials. Importantly, a standardised proforma was developedand used for submission of patient details to the SMDT, which alsoformed the basis of data submitted for their manuscript.2Between 2007 and 2017, 2892 new cases of germ-cell tumourwere reviewed by the SMDT. Although changes to radiologicaland pathological reports and recommendations for patientmanagement were seldom made (3, 5.4, and 6.4%, respectively),other benefits of the supra-regional network are apparent.2Overall survival at lower-volume centres (87.8–93.3%) increasedto that of higher-volume centres (95%). Improvements arose fromstandardisation of chemotherapy regimens, increased adoption ofnovel regiments, and more equitable access to such treatments.18-Fluorodeoxyglucose positron emission tomography/computedtomography was found to be less useful than previouslydescribed. An additional benefit of the SMDT was as a focus toimprove the outcome of smaller centres as an alternative tofurther centralisation of services.2The data presented by Shamash and colleagues2 also gives aninsight into the organisation of a complex but well-functioningnetwork covering numerous sites and different specialists over asignificant geographical location. This group had put into practicethe suggestions set out in the Gore report1 years ahead ofpublication.Taking each of these individually:Focussing on complex casesThe greatest benefit of MDT working is seen in complex cases, e.g.unusual subtype of disease, failure of previous treatment,significant comorbidities, and social or psychological problems.2These patients often do not fit guidelines, are not eligible forclinical trials, and can be challenging to engage in healthcareservices. Shamash et al.2 highlight patients with learningdifficulties or mental health problems and those with late relapseseach present problem that are less commonly addressed andrequire tailored individualised treatment plans. These findings arein line with the recent study on what constitute a complex case forMDT discussion, mirroring those found to be indicators ofcomplexity across a range of tumour types.3 Although theyrepresent a small portion of cases, considerable amount ofadditional support is needed before and after diagnosis andtreatment.2Shamash and colleagues2 set out criteria for cases that may notneed full discussion in the MDT meeting. It may be desirable to gofurther and identify cases that are truly ‘complex’ and those thatare ‘simple’. Recently, Soukup and colleagues3 published work onthe development and validation of a tool for stratifying cases bycomplexity, which might allow teams to streamline their caseloadin a scientific manner. Further research is needed to assess itsimpact on patient care and the efficiency of MDT processes.The inclusion of information on patients’ comorbidities andpsychological and social factors that may impact care arepersistently, poorly represented in MDT meetings.4 Such informa-tion, as well as that which focusses on the disease in question, isnecessary for comprehensive clinical management planning.5These findings support the conclusions by Shamash andcolleagues,2 that patients with complicating features requireholistic discussion in order to develop tailored treatment plans.Using chair’s action to facilitate urgent treatmentThe time between meetings can present a significant period forpatients with rapidly progressing disease waiting for MDT reviewand recommendations.2 In such cases, the MDT chair is wellplaced to endorse management proposals of clinicians out withwww.nature.com/bjcReceived: 16 August 2020 Revised: 20 August 2020 Accepted: 4 September 2020Published online: 29 September 2020© Cancer Research UK 2020the MDT meeting in order to avoid delays.2 Such cases should stillbe registered with the MDT and could be reviewed post hoc. Theresponsiveness of an MDT to clinical or organisational pressures isan area fertile for improvement.The use of videoconferencing to improve collaborative decision-makingVideoconferencing has been controversial in MDT meetings, andShamash and colleagues2 discuss some of its advantages andchallenges. Regular SMDT meetings are not feasible without someform of remote contact.2 Technology failure and differences incommunication styles can present challenges to the quality ofMDT decision-making.6 Perhaps a lasting legacy of COVID-19 willbe the dramatic shift towards telemedicine, replacing many face-to-face interactions. Interestingly, Shamash and colleagues2 notethe benefits of a yearly meeting at which members of the SMDTcan interact and discuss matters of importance. Many MDTs nowmanage to operate remotely via video link. It may be desirable tosupplement this with periodic face-to-face interaction that permitmore nuanced communication regarding performance, opera-tional policy, challenges, and future directions.Data collection and auditThe careful, planned collection of clinical and process data wascrucial for assessing complex areas of healthcare, such as carepathways and organisational changes.2 Recent NHS England andNHS Improvement report7 has highlighted that data collectionand regular audit must accompany MDT transformation. AsShamash and colleagues2 showed, the collection and analysis ofsuch data might provide a resource to benchmark processes andoutcomes, thereby driving standardisation and convergencetowards best practice. Well-designed data collection supportsquality improvement and clinical research, driving the develop-ment of new and better standards of care. Ultimately, this willprovide high-quality information to patients and their doctors,enabling shared decision-making of the highest quality.AUTHOR CONTRIBUTIONSB.W.L. and T.S. conceived of and drafted the manuscript. J.S.A.G. and N.S. providedrevision of the manuscript.ADDITIONAL INFORMATIONEthics approval and consent to participate Ethical approval is not applicable forthis editorial piece.Data availability Not applicable.Competing interests B.W.L. and T.S. received funding for training multidisciplinaryteams in assessment and quality improvement methods in the United Kingdom. T.S.serves as a consultant to F.H.-L.R. Diagnostics providing advisory research services inrelation to innovations for multidisciplinary teams and their meetings. N.S. is theDirector of London Safety & Training Solutions Ltd, which provides patient safety andquality improvement training and advisory services on a consultancy basis tohospitals and training programs in the UK and internationally. J.S.A.G. is the Directorof Green Cross Medical Ltd that developed MDT FIT for use by National HealthService Cancer Teams in the UK. The other authors have no conflicts of interest toreport.Funding information N.S. is funded by the NIHR via the ‘Applied ResearchCollaboration: South London’ at King’s College Hospital NHS Foundation Trust,London, UK. N.S. is also a member of King’s Improvement Science, which offers co-funding to the NIHR ARC South London and comprises a specialist team ofimprovement scientists and senior researchers based at King’s College London. Itswork is funded by King’s Health Partners (Guy’s and St Thomas’ NHS FoundationTrust, King’s College Hospital NHS Foundation Trust, King’s College London, andSouth London and Maudsley NHS Foundation Trust), Guy’s and St Thomas’ Charity,and the Maudsley Charity. The funding agreement ensured the authors’ indepen-dence in designing the study, interpreting the data, writing, and publishing thereport. The views expressed are those of the authors and not necessarily those of theNHS, NIHR, or the Department of Health and Social Care.Note This work is published under the standard license to publish agreement. After12 months the work will become freely available and the license terms will switch toa Creative Commons Attribution 4.0 International (CC BY 4.0).Publisher’s note Springer Nature remains neutral with regard to jurisdictional claimsin published maps and institutional affiliations.Tayana Soukup 1, Nick Sevdalis1, James S. A. Green1,2 andBenjamin W. Lamb 31Center for Implementation Science, Health Service and PopulationResearch Department, King’s College London, London, UK; 2WhippsCross University Hospital, Barts Health NHS Trust, London, UK and3Department of Urology, Cambridge University Hospitals NHSFoundation Trust, Cambridge, UKCorrespondence: Benjamin W. Lamb(benjamin.lamb@addenbrookes.nhs.uk)These authors contributed equally: Nick Sevdalis, James S. A. GreenREFERENCES1. Gore, M. Transforming multidisciplinary team meetings (MDTMs). https://www.england.nhs.uk/south/wp-content/uploads/sites/6/2018/10/Transforming-MDTM-Martin-Gore-August-2017.pdf (2017).2. Shamash, J., Wendy, A., Alifrangis, C., Thomas, B., Wilson, P., Stoneham, S. et al.The impact of a supranetwork-multidisciplinary team (SMDT) on decision-mak-ing in testicular cancers: a 10-year overview of the Anglian Germ Cell CancerCollaborative Group (AGCCCG). https://doi.org/10.1038/s41416-020-01075-1(2020).3. Soukup, T., Morbi, A., Lamb, B. W., Gandamihardja, T., Hogben, K., Noyes, K. et al. Ameasure of case-complexity for streamlining workflow in cancer multidisciplinarytumor boards: mixed methods development and early validation of the MeDiCtool. Cancer Med. 9, 5143–5154 (2020).4. Lamb, B. W., Brown, K., Nagpal, K., Vincent, C., Green, J. S. A. & Sevdalis, N. Quality ofcare management decisions by multidisciplinary cancer teams: a systematicreview. Ann. Surg. Oncol. 18, 2116–2125 (2011).5. Soukup, T., Lamb, B. W., Sarkar, S., Arora, S., Shah, S., Darzi, A. et al. Predictors oftreatment decision in multidisciplinary oncology meetings: a quantitative obser-vational study. Ann. Surg. Oncol. 23, 4410–4417 (2016).6. Soukup, T., Lamb, B. W., Morbi, A., Shah, N. J., Bali, A., Asher, V. et al. A multicentrecross-sectional observational study of cancer multidisciplinary teams: analysis ofteam decision making. Cancer Med. 00, 1–17 (2020).7. NHS England and NHS Improvement. Streamlining Multi-Disciplinary Team Meet-ings: Guidance for Cancer Alliances (NHS England and NHS Improvement, London,2020).Editorial3141234567890();,:

Quality improvement for cancer multidisciplinary teams: lessons learned from the Anglian Germ Cell Cancer Collaborative Group

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Quality improvement for cancer multidisciplinary teams: lessons learned from the Anglian Germ Cell Cancer Collaborative Group

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