“Relationship between multidisciplinary team meetings and patient survival in pediatric oncology settings”;
Examining the potential relationship between multidisciplinary team meetings and patient survival in pediatric oncology settings: a systematic review.
Abstract
Background
The organization of multidisciplinary team meetings (MTMs) has become standard practice in contemporary cancer care. They cost considerable time and resources. Although the impact of MTMs on survival in adult oncology has been well researched, the potential benefits on outcomes for pediatric cancer patients are still unclear. The aim of this systematic review was to examine the current literature regarding the impact of multidisciplinary team meetings on patient survival in pediatric oncology settings.
Methods
Relevant studies were identified by searching MEDLINE/PubMed, EMBASE, and the Cochrane Library databases from their inception up to March 2018. Additionally, the reference lists of all articles of which a full text was obtained were screened. Studies met the inclusion criteria if they (1) examined MTMs and (2) documented patient survival as an endpoint. All study designs were included.
Results
Of the 284 potentially relevant studies reviewed, the search yielded four studies that met the inclusion criteria. Of these, two were conference abstracts. All studies comprised original research. Together, the studies described over 811 patients and assessed children with retinoblastoma, neuroblastoma, and Ewing sarcoma. Three studies (one prospective and two retrospective cohort studies) described a difference in either overall or event-free survival rates when comparing patients discussed in the MTM to non-MTM patients. This association was statistically significant in two studies; one study did not describe tests of statistical significance. The remaining included study (a retrospective cohort study) did not observe a difference in survival rates. Quality of the studies was strongly affected by the observational design, use of before-after series, concurrent implementation of standardized treatment protocols, and univariate analyses. As the studies were not comparable with regard to patient populations, disease sites, and study designs, pooling of results was not possible.
Conclusions
Due to the small number of studies included and methodological limitations, this review was unable to definitively assert a causal relationship between MTMs and survival in pediatric cancer patients. However, there appeared to be a trend in favor of discussion in MTMs. Further research is needed to explore this relationship and to allow cost-benefit analyses to be made, so that time and resources are optimally spend to deliver the best care to childhood cancer patients.
1. Introduction
Over the past decades, tremendous progress has been made in the diagnosis, treatment, and survival of children with cancer. An increased understanding of tumor biology, improvement in treatment modalities, and the establishment of specialized treatment centers have led to survival rates exceeding 80% for many forms of childhood cancer.1 As part of this development, tumor board meetings have increasingly become part of standard practice in contemporary pediatric cancer care.2,3 In these multidisciplinary team meetings (MTMs), patients’ diagnoses and treatment plans are discussed on a regular basis by representatives from different specialties, such as pediatric oncology, radiation oncology, radiology, surgery, pathology, and nursing. Amongst participating professionals, it is widely felt that effective MTMs result in improved clinical decision-making, more coordinated patient care, improvement to overall quality of care, more evidence-based treatment decisions, and improved treatment.4 Nonetheless, the few large systematic reviews that were performed demonstrate scant evidence that MTMs improve survival in cancer patients.5–7 This begs the question whether these meetings, that require investment of considerable time and resources7–9, should continue in their current format.
These prior reviews, however, describe adult oncology patients.5–7 Characteristics of tumors occurring in children differ from those occurring in adults.10 Moreover, pediatric cancers are rare, leading to a relative inexperience with the disease. For example, in the Netherlands, the most common form of childhood cancer (acute lymphoid leukemia, ALL) has an incidence 114 per year11, in contrast to the incidence of breast carcinomas of 14,864 per year12. It is conceivable that discussion of patients with a rare disease leads to more new insights regarding diagnosis and treatment compared to discussion of patients with more common tumors. Thus, results from studies in adult oncology patients cannot be directly translated to pediatric oncology settings.
To better inform pediatric oncology centers and individual clinicians on the value of MTMs for their patients, research aimed exclusively at childhood cancer is needed. To our knowledge, no prior systematic reviews were conducted that have researched the benefits of MTMs on outcomes in pediatric cancer patients. Therefore, the aim of the present review was to examine the current literature regarding the impact of multidisciplinary team meetings on patient survival in pediatric oncology settings.
2. Methods
2.1. Search strategy
A literature search was conducted on the 1st of March 2018 using MEDLINE/PubMed, EMBASE, and the Cochrane Library. The following search terms were used:
Multidisciplinary team OR multidisciplinary meeting OR multidisciplinary discussion OR tumor board AND
Pediatric OR childhood AND
Oncology OR cancer OR neoplasms AND
Survival OR disease-free survival OR progression-free survival OR event-free survival.
Searches were limited to the English language. After employing the search strategy, abstracts of all articles yielded from the search were screened for relevance by a single individual (SD), based on the predefined eligibility criteria detailed below. The full texts of potentially relevant papers were obtained and further evaluated to ensure that they met the eligibility criteria. The reference lists of all articles of which a full text was obtained were screened to identify additional relevant studies.
2.2. Eligibility
Articles were included in this review if the study (1) examined multidisciplinary team meetings (meetings with a team of professionals from a range of disciplines, whose collective intent is individualized patient management) and (2) documented patient survival as an endpoint. To be included in this systematic review, each article had to meet both inclusion criteria. All study designs were included. Studies were excluded if they (1) did not concern pediatric oncology, (2) described a multidisciplinary approach and/or patient survival without investigating their relationship, (3) described a multidisciplinary approach, but not multidisciplinary team meetings specifically, or (4) did not have a comparison group (e.g. non-MTM group) or a pre- and post-test design as a control.
2.3. Data collection and critical appraisal
Data were extracted from the articles that met eligibility criteria based on full-text review. This information included study population, characteristics of the MTMs, and outcome measures. Data about the study design and limitations of each study were extracted as well. The methodological quality of each included study was assessed by examining study design, study population, follow-up, and adjustment for confounders or effect modifiers.
3. Results
3.1. Results of the search
Figure 1 shows retrieval and selection of included studies. Initially, a total of 315 potentially relevant articles were identified through database screening, of which 284 remained after removing duplicates. Screening of abstracts excluded 266 articles. After reviewing the reference lists of all full-text articles, one additional potentially relevant study by Qaddoumi et al.13 was found, but was excluded following review of the full text. A further 14 studies were excluded after full-text evaluation. Their characteristics are listed in
Table 1. Ultimately, only four studies satisfied the predetermined inclusion criteria and were included in this systematic review. Relevant information describing each of the studies included is summarized in Table 2.
3.2. Characteristics of included studies
Studies included were either retrospective (Chang et al.14, Dirksen et al.15, Elzomor et al.16) or prospective (Ashraf et al.17) cohort studies. No randomized trials or systematic reviews were retrieved. Two of the included studies were conference abstracts from the International Society of Paediatric Oncology (SIOP) conference in 2015.15,17 Studies were conducted in Pakistan17, Taiwan14, Germany15 and Egypt16. Three were single-center studies; the abstract by Dirksen et al.15 describes patients discussed in an interdisciplinary tumor board (ITB) offered by the trial office of the cooperative Ewing sarcoma study group, but does not specify the number of centers that were involved. The sample size ranged between 5814 and 48115, and mean or median age of patients ranged between two16 and fifteen15 years. Ashraf et al.17 did not report a sample size, nor mean or median age. Three of the included studies used a before-after design as a control, in which they compared patient survival before and after implementation of a regular MTM.14,16,17 Dirksen et al.15 compared patients that were discussed in the ITB with patients not discussed in the ITB. The studies assessed children with retinoblastoma16,17, neuroblastoma14, and Ewing sarcoma15.
3.3. Patient outcomes
Three studies found a difference in survival rates when comparing the patients before and after implementation of the MTM.14,16,17 Ashraf et al.17 found an increase in in overall survival (OS) from 23% to 48%. They did not specify the number of years after which the survival was measured. However, since the MTM was implemented in 2012 and the abstract was published in 2015, the maximum time period is four years. The patients in the study by Chang et al.14 demonstrated a better 3-year event-free survival (EFS), but not OS, after implementation of the MTM; the EFS increased from 41% to 73%. This difference was more apparent in patients with stage 4 disease, high risk stratification, and non-MYCN amplified tumors (MYCN amplification is an unfavorable prognostic factor in patients with neuroblastoma, as they tend to relapse more often and rapidly develop refractory disease18). Elzomor et al.16 found an increase in 3-year OS of 79% to 94%. Dirksen et al.15 did not observe a difference in 3-year EFS when comparing the patients that were discussed in the ITB with patients that were not discussed. In further subgroup analyses of patients with either primary localized disease or patients with metastases at time of diagnosis, no difference in 3-year EFS was found as well.