Spotlight : The Medical Oncologist's Role in the Multidisciplinary Team - Observations from Around Europe

Multidisciplinary teams (MDTs) are commonly acknowledged as the gold standard of care for patients with cancer. To find out what role the medical oncologist plays within the MDT, we asked specialists from across Europe to explain how they see the situation in their own country.

  • Date: 27 Mar 2018

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Observations from France

What is the role of the MDT in the treatment of cancer patients in France? 

besse-benjamin

Benjamin Besse Institut Gustave Roussy, Villejuif, France; ESMO Faculty Member (Lung and Other Thoracic Tumours)

Fifteen years ago, the Plan Cancer initiative was launched by the French government and one of its directives was that all patients with cancer should have their treatment discussed in a tumour board, according to specified guidelines. Since this time, MDTs have been a mandatory part of cancer management. Following their cancer diagnosis, every patient's case is considered by the board to determine the global management strategy. Additional MDT discussions at different stages of treatment are optional. Whatever the decision of the MDT, it is only a recommendation. The final decision is the responsibility of the main treating physician.

Can you describe the role of the medical oncologist within the MDT? 

The role of the medical oncologist within the MDT in France may be a bit different to that in some other countries. This is because in addition to general medical oncologists and oncologists with expertise in a particular tumour type, we also have organ specialists who have undertaken additional training that allows them to be able to administer systemic chemotherapy. In France, an MDT must comprise at least three different specialists, often a medical oncologist/organ specialist, a radiotherapist and a surgeon, with input from other experts, such as a pathologist or radiologist, when they are required.

How would you like to see the role of the medical oncologist develop?

While the medical oncologist/organ specialist is generally involved in tumour board meetings, it doesn't happen in all cases. My view is that given their extensive knowledge not only of treatment options but also of associated toxicities, the medical oncologist's/organ specialist's role should be compulsory. Another area that is becoming more and more common in the era of targeted therapy is the molecular tumour board. In France, these take place if, following the initial MDT tumour board meeting, a decision to proceed with systemic therapy is made. We need to create other new MDTs that are related to the new specificities of oncology, that is immunotoxicity MDTs and elderly patient MDTs.

Observations from Germany

What is the role of the MDT in the treatment of cancer patients in Germany?

Carsten Bokemeyer

Carsten Bokemeyer University Medical Center of Hamburg-Eppendorf, Germany; ESMO Faculty Member (Genitourinary Cancer, and Supportive and Palliative Care)

In large university hospitals in Germany, there is usually a tumour board for each patient—this is generally routine in oncology care. Indeed, to become an officially accredited cancer centre, for example a centre for lung cancer or breast cancer, an institute must provide documented evidence that sufficient, good-quality tumour board discussions form part of patient care. Once accreditation is received, the centre is audited yearly to ensure that the standards remain high. In an ideal world, MDT discussions at tumour boards should be mandatory, but for this to be feasible we really need to define when these discussions should take place. Let me use my own centre as an example. One of Germany's leading cancer centres, my institute deals with 10,000 discussions per year for patients and each week we have around 16 tumour boards. Clearly, this entails a huge workforce. Part of the problem is that we can end up having multiple discussions for some patients. This doesn't generally happen with cases that are relatively straightforward and that can be managed according to established treatment guidelines. It is with the more complex cases, or those without existing treatment guidelines, that this can happen. Although this involves a lot of work, it is part of optimal patient management, particularly when the treatment situation changes throughout the course of the disease.

Can you describe the role of the medical oncologist within the MDT?

Within accredited cancer centres, the medical oncologist is one of the group sometimes called the big five of the MDT and comprising the medical oncologist, pathologist, radiologist, radiotherapist and surgeon. With an in-depth knowledge of systemic anticancer therapy and other aspects of treatment, for example, pain relief, the medical oncologist is likely to have more contact with the patient than other MDT members. However, while in the past the medical oncologist would probably have led the team, his or her role is now more of a core partner.

How would you like to see the role of the medical oncologist develop?

In some countries, there has been a move towards systemic therapy being delivered by an organ specialist rather than by the medical oncologist. I think we need to be very careful about this. A real advantage of the medical oncologist's training is that he or she can work across tumour types and so can apply knowledge from one tumour type to another. We are seeing this particularly with the molecular tumour boards, which are based around treating tumours according to molecular aberrations rather than by primary site. More often than not, these boards are led by the observations oncologist who generally has a greater knowledge than other team members of the effects of molecularly targeted treatments and immunotherapies across tumour types.

Observations from Italy

What is the role of the MDT in the treatment of cancer patients in Italy? 

licitra-lisa

Lisa Licitra Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy; ESMO Faculty Member (Head and Neck Cancer); ESMO Guidelines Committee Subject Editor (Head & Neck Cancers)

At the moment in Italy, there are really only vague recommendations for the use of MDTs. While just about everyone involved in cancer recognises that this is the optimum management approach, these teams have yet to become a requirement. Within my own area of expertise, head and neck cancers, we have come close to a mandate, but only in one particular circumstance; the use of an MDT is a criterion for those centres wishing to be endorsed by the Italian Ministry of Health for inclusion within the European Reference Network for rare solid tumours in adults ( EURACAN).

Can you describe the role of the medical oncologist within the MDT?

I can really only speak here about head and neck cancers and this is an area of oncology in which the medical oncologist has a valuable role to play in supporting other MDT members but—unlike with palliative care—is not usually at the centre of the team. Instead, because surgery and radiotherapy are often the primary treatment approaches, it is the surgeons and radiotherapy oncologists who have the greater experience and so will tend to lead the MDT. One of the problems is that the term 'head and neck cancer' hides the reality that this is actually a range of rare cancer subtypes, each with its own unique management issues, and so it is difficult to acquire sufficient clinical experience. Although the medical oncologist arguably has the greatest knowledge regarding chemotherapy drugs, his or her role is often restricted by a more limited level of understanding of this complex disease area. We need to remember that chemotherapy toxicity may not merely compromise radiotherapy administration it can lead to a patient losing his or her chance of cure.

How would you like to see the role of the medical oncologist develop?

If medical oncologists are to play a greater part within head and neck cancer MDTs there will have to be significant efforts to improve education, for example using preceptorships, management guidelines and practical exercises. In November last year, the Italian Head and Neck Oncologic Society (AIOCC) published a  guide for healthcare providers outlining the diagnosis and therapy pathway for patients with head and neck cancers. The document recommends that clinicians need to be exposed to at least 20 patients/year to become experienced in this area. You can see that this is quite a challenge!

Observations from Poland

What is the role of the MDT in the treatment of cancer patients in Poland? 

senkus-elzbieta

Elżbieta Senkus Medical University of Gdańsk, Poland; ESMO Faculty Member (Breast); ESMO Guidelines Committee Subject Editor (Breast)

MDTs were introduced in 2015 as a requirement necessary to obtain preferential financing of treatment within so-called ‘oncological packages’. Of course, it's a huge step forward, as before that MDTs were more the exception than the rule. However, the system is not perfect, because there are no regulations on quality requirements for specialists forming the MDT, which means that in some institutes MDT meetings are organised only to obtain the preferential financing and are being attended by physicians who are not experts in the particular field. Also, many patients are still treated outside of the ‘oncological package’, which means that there is no requirement for MDT-based decisions in these cases.

A major problem is that the treatment of cancer in Poland (in particular surgery) is being carried out in almost all hospitals and many doctors are reluctant to refer patients to specialised cancer centres, where multidisciplinary care is available.

Can you describe the role of the medical oncologist within the MDT?

The medical oncologist is crucial for the MDT in much the same way as are surgeons, radiation oncologists and ‘diagnostic’ specialists. In some ways, however, medical oncologists probably have the most comprehensive view of cancer as both a localised and a systemic disease, which naturally assigns to them the coordinating role in cancer treatment. It needs to be stressed that it shouldn’t be just ‘any’ medical oncologist (or ‘any’ surgeon, radiation oncologist, radiologist or pathologist), but a specialist with experience in particular tumours. This is facilitated by treating patients within specialised comprehensive units. As a breast cancer specialist, I represent the field that pioneered the development of specialised units and MDTs.

How would you like to see the role of the medical oncologist develop?

The role of systemic treatments in the management of cancers is growing and so is the role of medical oncologists. It is, however, crucial that all specialists involved in management have basic knowledge of the principles and possibilities related to treatments provided by other involved specialties. I’m also trained and working as a radiation oncologist and good understanding of the principles of both of these treatment modalities makes my treatment decisions easier and more comprehensive.

Another important issue is that, for the time being, in most places MDTs are limited to the management of patients treated for early disease and patients with advanced cancers are managed principally by medical oncologists. Their role is of course essential, but the benefit of MDT-based decisions should also be available for patients with advanced disease.

Observations from Slovenia

What is the role of the MDT in the treatment of cancer patients in Slovenia?

seruga-bostjan

Bostjan Seruga Institute of Oncology Ljubljana (IOL), Slovenia; ESMO Examination & Accreditation Working Group Member

At the IOL, which is the only comprehensive cancer centre in Slovenia, a multidisciplinary approach to cancer patient care is obligatory and members of different MDTs usually meet weekly at tumour boards. However, this approach does vary depending on the primary tumour type and location. For example, while it is mandatory for all women with early breast cancer to be discussed at a tumour board, this is not the case for patients with early prostate or bladder cancer. This is to some extent due to the availability of MDT specialists: the IOL has all MDT specialties for breast cancer onsite, whereas urologists and some other surgical oncologists practise in hospitals throughout the country.

I think that major obstacles for the evolution of MDTs are a rigid mindset among health professionals, ineffective health policies and poor leadership. Unfortunately, there have been no major developments in the ways MDTs function since they were first conceived. Other challenges to optimal MDT operation include the ever-increasing number of patients with cancer, shortages of relevant personnel and the establishment of secondary cancer centres within some regional hospitals.

Can you describe the role of the medical oncologist within the MDT?

There is a generally accepted rule that the medical oncologist should have at least five years' experience of working in the field before he/she becomes a member of the MDT. Within the MDT, the oncologist's role is to give advice on systemic anticancer therapy and corresponding supportive and palliative care. At my own institute, staff shortages and conflicting work schedules mean that treatment recommendations are frequently made solely by the medical oncologist. Only rarely is there the opportunity for the evidence and opinions of other MDT specialists to be discussed.

How would you like to see the role of the medical oncologist develop?

There is still a lot of room for improvement. Work schedules should be coordinated to allow all members of an MDT, including the medical oncologist, to be present at the tumour board. Furthermore, tumour boards themselves have to be based around the available evidence provided by all the healthcare professionals involved. We must also take care to ensure that we make equality of medical care a priority across the country, and I'm thinking here particularly of the newly developed secondary cancer centres we have here in Slovenia. It is paramount that medical oncologists within these centres have a pivotal role in the organisation and development of the MDT.

Observations from Spain

What is the role of the MDT in the treatment of cancer patients in Spain?

Enriqueta Felip

Enriqueta Felip Vall d’Hebron Institute of Oncology (VHIO), Vall d'Hebron University Hospital, Barcelona, Spain; ESMO Faculty Member (Lung and Other Thoracic Tumours)

In Spain, the use of an MDT is considered essential to ensuring the best management approach for each patient. The vast majority of cancer patients are discussed in MDT meetings, in which decisions are made regarding optimal staging and treatment. In addition to the main team, we also have a large number of very active cooperative groups dealing with different cancer types, which incorporate different oncology-related specialties and so further encourage a multidisciplinary approach.

Can you describe the role of the medical oncologist within the MDT?

The medical oncologist works very closely with the other professionals on the team. The oncologist must have a good understanding of current standard practices and be able to contribute information about not only the best therapeutic strategies but also other aspects of management, such as screening and prevention strategies, staging options and any molecular analyses required. In our centre, the medical oncologist is responsible for informing team members about any changes in the health status of patients who were previously discussed by the MDT. He or she is also expected to keep other MDT members up to date with any advances in medical oncology relevant to the patient's case.

 

How would you like to see the role of the medical oncologist develop?

We are now seeing the medical oncologist becoming involved in molecular tumour boards, in which the results of tumour molecular alterations and their potential clinical implications are discussed. This is becoming an increasingly important area and in my opinion, medical oncologists should work towards developing a closer relationship between the MDT and the biologists/pathologists involved in translational research.

Observations from the UK

What is the role of the MDT in the treatment of cancer patients in the UK? 

Jonathan Ledermann

Jonathan Ledermann UCL Cancer Institute and CR-UK & UCL Cancer Trials Centre, London, UK; ESMO Faculty Member (Gynaecologic Cancer)

In the UK, the role of the MDT is very clearly set out: all patients must have their treatment discussed in a multidisciplinary meeting by a board comprising key members of the clinical management team. The aim is to encourage evidence-based care, discourage or prevent treatments that cannot be clinically or scientifically justified, and ensure that the pathway of care that often involves different health professionals runs smoothly. While this is an admirable aim, it is in reality very expensive and not altogether practical to try to bring these healthcare practitioners together once or twice a week for a tumour board meeting. There is also a need to distinguish between patients with newly diagnosed cancer and those with recurrent disease, for whom management is often not so clear and may not require input from all members of the MDT. Frequently, the treatment approach for these patients is at the discretion of the individual team or institute. In our centre, it is often the medical or clinical oncologists who will discuss the options for patients with recurrent disease, only referring patients for a fuller discussion if required.

Can you describe the role of the oncologist within the MDT?

One of the great things MDTs have done is to encourage adherence to agreed protocols; clinical oncologists—who are trained in radiotherapy and drug administration—and medical oncologists, both of whom generally have a broad knowledge of current management strategies, have been key in helping to achieve this. Also, in our centre, a high proportion of patients are entered into clinical trials, and this tends to fall under the remit of the oncologist. However, while the oncologist's role is important, he or she is by no means the lynchpin. In fact, the MDT in the UK has a rather flat structure—compared with more pyramidal systems operated in some other countries—and this has been really helpful in aiding collaboration between members. One of the MDT members is generally appointed the team leader, but this is more of a managerial/logistical position rather than one of directing treatment decisions. In my area of gynaecology, the team leader is often the surgeon, simply because surgery or biopsy is often the first port of call for the patients we see.

How would you like to see the role of the oncologist develop?

There is no doubt that MDTs have improved patient care. However, in my opinion, there are still quite a few issues to be addressed about the most effective and cost-efficient way to use them. Oncologists need to be trained both in being a part of the team and in critically evaluating the model if we are to find the most efficient ways to run these teams. This is particularly important for the new generation of oncologists who are responsible for shaping care strategies for the future.

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