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How to implement the multidisciplinary approach in prostate cancer management: The Belgian model

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Abstract

The Belgian oncology care system has been the subject of a major reorganization in recent years. The basis of this reorganization is the obligatory implementation of standardized care programmes in every hospital and the recognition of dedicated oncology specialists. Furthermore, health authorities created the multidisciplinary oncology consultation (MOC), as it was recognized that there was a need to organize and to reimburse the existing multidisciplinary approach. At MOC, a patient's case is discussed and a strategic plan is developed for diagnosis, treatment and follow-up. The conditions that have to be met for reimbursement of this MOC are strictly defined by law and include yearly follow-up meetings. The success of this multidisciplinary approach is partially attributable to legal requirements and reimbursement, but also to the willingness of the medical community to accept the concept that a multidisciplinary approach is the best investment to improve patient outcomes in cancer care.

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... Evidence of symptom development in integrated palliative care in oncology is scarce 38,39 . Depression is a frequent psychiatric condition in advanced cancer and is known to have an important negative impact on quality of life 40,41 . Studies of depression, however, most often relied on cross-sectional analysis techniques or were conducted prospectively but with a limited time scope 42,43 . ...
... Hematologic cancer is often characterized by acute exacerbations of the illness followed by highly technical therapies that can continue over many years. This, along with a rapid dying trajectory, results in difficulties in assessing the right time to refer to SPCS 19,41,42 . This rationale concurs which our findings of the treatment goal of hematologic cancer patients in the last week of life, since this was most often aimed at life prolongation or curation compared to solid cancer. ...
... This is concurrent with recent data that early palliative care has a beneficial impact on depression of cancer patients in some countries 23,29-31 . Access to specialized palliative care offered psychosocial support as part of usual oncology care 41 . This suggests that offering psychosocial care in oncology care alone is not enough, but that the additional support provided by a specialized palliative care team leads to further significant improvements in quality of life. ...
Thesis
Palliative care has evolved from a philosophy of care for dying patients to a professional discipline with expertise in symptom management, psychosocial and spiritual care, support for informal carers, complex decision making and end-of-life care. The World Health Organization stresses that palliative care is applicable early in the course of the illness, together with other therapies that are intended to prolong life. However, in routine clinical practice, specialized palliative care is often initiated late in the disease trajectory. By using quantitative survey methods and a randomized controlled trial, this dissertation gives insight into (1) the challenges of palliative care in oncology regarding symptom management (eg depression) and referral practices to specialist palliative care and (2) the benefits of early and systematic integration of palliative care in oncology for patients and their informal carers in the Belgian health care setting. The findings in this dissertation can be used to increase the awareness of the benefits of palliative care and to develop and promote timely and systematic integration of specialized palliative care in oncology.
... Seven oncology-specific laws have been put in place, the first defining the multidisciplinary oncology consultation (MOC), and allowing reimbursement for MOC care. 35 The law states that the MOC must be chaired by an oncologist and should comprise at least two other clinicians: a medical oncologist and/or a radiation oncologist and/or an oncology surgeon. Almost all innovative and expensive drugs are reimbursed only if all members of the MOC team agree that they would benefit an individual patient. ...
... Almost all innovative and expensive drugs are reimbursed only if all members of the MOC team agree that they would benefit an individual patient. 35 The success of this multidisciplinary approach to cancer care is partly attributable to its legal foundation and reimbursement, but also to the willingness of health professionals to accept the value of a multidisciplinary approach. Indirect evidence of the success of this multidisciplinary approach in Belgium is that they have one of the top five survival rates of cancer patients in Europe. ...
... Indirect evidence of the success of this multidisciplinary approach in Belgium is that they have one of the top five survival rates of cancer patients in Europe. 35 ...
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To develop a peer-review model for assessment and quality improvement of cancer multidisciplinary teams (MDTs) and qualitatively assess its feasibility and acceptability in Australia. A peer-review methodology was developed, based on the United Kingdom's National Health Service peer-review model and a comprehensive literature review. This was pilot tested in three mature MDTs in different settings. Semi-structured interviews were conducted between December 2012 and July 2013 with all five peer reviewers and 17 MDT members. Thematic analysis was undertaken using a framework approach. Peer reviewers and MDT members found the process reasonable, constructive and useful; however, those involved in the preparation for the review found it time-consuming. Most MDT members considered the final report accurate and reflective of their service. Recommendations in the report were met with mixed reactions: several MDT members perceived some recommendations to be particularly relevant, while others viewed the same recommendations as impractical or of limited value. Many participants were unsure if recommendations would be fully implemented. The majority saw value in the process and expressed support for its implementation locally and nationally; however, feedback suggests the most appropriate format is yet to be established. Peer review of cancer MDTs is feasible and acceptable. We describe valuable lessons learnt and recognise that further development of the proposed peer-review model and national benchmarking of MDTs against established outcome measures is required if this process is to be widely implemented.
... MDTMs are considered to facilitate communication between healthcare professionals by gathering the relevant specialties around the table to share their knowledge and expertise and make collective evidence-based recommendations for patient management [2]. The current literature provides evidence that MDTMs are achieving intended objectives [3,4]. MDTMs lead to significant changes in the way cancer patients are assessed and managed [1,5] and lead to improved outcomes [6][7][8]. ...
... For this study, we focus on the "multidisciplinary oncology consultation" (MOC), a formally regulated and financed type of MDTM in Belgian oncology since 2003. It aims to foster multidisciplinary consultations within oncological settings and to ensure a systematic transparent multidisciplinary approach across all Belgian hospitals providing oncological programs [4,15,28]. Within the MOC, the multidisciplinary team should agree on the diagnosis of the patient and recommend a treatment plan based on clinical treatment guidelines. ...
... The Belgian law states that the MOC must be chaired by a medical coordinator (preferably with oncological specialization). At least four different medical specialists (eg, radiotherapy, surgery, organ specialism, or pathology) from the hospital staff and one participant from outside the hospital (eg, the general practitioner or the treating physician of the patient if he/she is not part of the hospital team) participate [4,28]. ...
Article
Background: Multidisciplinary team meetings (MDTMs) have become standard practice in oncology and gained the status of the key decision-making forum for cancer patient management. The current literature provides evidence that MDTMs are achieving their intended objectives but there are also indications to question the positive impact of MDTMs in oncology settings. For cancer management to be patient-centered, it is crucial that medical information as well as psychosocial aspects-such as the patients' living situation, possible family problems, patients' mental state, and patients' perceptions and values or preferences towards treatment or care-are considered and discussed during MDTMs. Previous studies demonstrate that failure to account for patients' psychosocial information has a negative impact on the implementation of the treatment recommendations formulated during MDTMs. Few empirical studies have demonstrated the predominant role of physicians during MDTMs, leading to the phenomenon that medical information is shared almost exclusively at the expense of psychosocial information. However, more in-depth insight on the underlying reasons why MDTMs fail to take into account psychosocial information of cancer patients is needed. Objective: This paper presents a research protocol for a cross-sectional observational study that will focus on exploring the barriers to considering psychosocial information during MDTMs at medical oncology departments. Methods: This protocol encompasses a cross-sectional comparative case study of MDTMs at medical oncology departments in Flanders, Belgium. MDTMs from various oncology subspecialties at inpatient medical oncology departments in multiple hospitals (academic as well as general hospitals) are compared. The observations focus on the "multidisciplinary oncology consultation" (MOC), a formally regulated and financed type of MDTM in Belgian oncology since 2003. Data are collected through nonparticipant observations of MOC-meetings. Observational data are supplemented with semi-structured individual interviews with members of the MOC-meetings. Results: The protocol is part of a larger research project on communication and multidisciplinary collaboration in oncology departments. Results of this study will particularly focus on the input of psychosocial information during MDTMs. Conclusions: The concept of an MDTM should not merely be a group of care professionals who mostly work independently and occasionally liaise with one another. Interventions aiming to enhance the input of psychosocial information are crucial to ensure that MDTMs can benefit from their diverse membership to achieve their full potential. The findings from this study can be used to design nonclinical and organizational interventions that enhance multidisciplinary decision-making in oncology.
... 1,2 In Belgium, the multidisciplinary approach is mandatory and has been formally regulated since 2003. [3][4][5] Since the introduction of the legal framework, the proportion of cancer patient cases discussed within MDTMs continuously increases in oncology departments. 6,7 MDTMs are found to foster adherence to clinical practice guidelines 8 and can positively influence clinical decision-making. ...
... 5,[20][21][22]39 Comprehensive reforms were necessary to install and facilitate multidisciplinary care and have been completed in the organizational structure of healthcare delivery for oncology patients around the world, 22,[40][41][42][43] as in Belgium. 3,4 These changes transformed healthcare services formerly based on individual physicians' decision-making into institutionally supported team-based approaches to treatment and care. 21,44,45 To date, few articles have studied in real life how multidisciplinarity in cancer patient management and care may take form. ...
... The legal framework may have had a positive impact on the implementation of the multidisciplinary approach in Belgian oncology, 7 but the intentions of the policy-makers are not fully met or at least not as recommended in the guidelines for multidisciplinary cancer care. 3,5 The rather "procedural" approach in the MOC meetings and the organizational choice of pooling of MOCs at particular moments (weekly or fortnightly) reduces the meeting to a routine of collecting biomedical information and staging of the disease to ground treatment decisions in available guidelines. Hence, the legal obligation to install MOC meetings has enhanced multidisciplinarity but seems to have the unintended consequence that organizational practices induce routinization and dominance in biomedical terms more than an in-depth deliberation of the patients' cases in all aspects including psychosocial information. ...
Article
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Background: In current cancer care, multidisciplinary team meetings (MDTMs) aim at uniting care professionals from different disciplines to decide upon the best possible treatment plan for the patients based on the available scientific evidence. In Belgium, the multidisciplinary approach is mandatory and formally regulated since 2003. Current research indicates that MDTMs are not always truly multidisciplinary, ie, with a mix of medical as well as paramedical disciplines, and that the medical profession (physicians and medical specialists) tends to dominate the interaction in MDTMs. To ensure that MDTMs can benefit from their diverse membership to achieve their full potential, significant attention should be devoted to the multidisciplinary character of these meetings. The aim of this study is to explore and describe the multidisciplinary character in MDTMs and how it is actually shaped in practice in different Flemish medical oncology departments. Methods: For this study, we carried out an observational comparative case study. We studied 59 multidisciplinary team meetings at inpatient medical oncology departments in five different Belgian hospitals (academic as well as general) and explored multidisciplinarity and how it is actually shaped in practice. Results: The study is unique in identifying and analyzing three distinct types of MDTMs. The analysis of the three types revealed an inconsistent and, at times, contradictory picture of multidisciplinary team meetings. The findings also align with previous studies arguing that MDTMs in oncology are typically driven by doctors, with limited input of nurses and other nonmedical staff in which decisions are argued on biomedical information and far less consideration of psychosocial aspects. Conclusion: The concept of a MDTM should not merely be a group of care professionals who work essentially independently and occasionally liaise with one another. Yet, this study has shown a worryingly low awareness of the true character of multidisciplinarity, particularly among medical disciplines.
... The global movement towards MDC is also true of urological malignancies [2,3,[13][14][15][16][17][18]. Recent research has focused on the impact of these uro-oncology MDMs on patient care. ...
... MDC has become the standard of care for patients with cancer [1,6,10,11]. MDMs have flourished in the management of urological malignancy [13,[18][19][20][21][25][26][27], particularly of the prostate [2,3,[14][15][16][17]28,29]. Studies have shown that these MDMs change the clinician's initial management plan in 2-32% of cases (Table 4) [17,[18][19][20][21][22]. ...
Article
Objectives: To assess implementation rates of the consensus plans made at the uro-oncology multidisciplinary meeting (MDM) of an Australian tertiary centre, and analyse obstacles to implementation. Methods: A retrospective review was performed of all patients discussed at the uro-oncology MDM at our institution between 1 January to 30 June 2015. Rates of referral for MDM discussion following a new histological diagnosis of malignancy, categorised by tumour type, were assessed. Patient records were interrogated to confirm MDM plan implementation, with the outcomes examined being completion of MDM plan within 3 months and factors preventing implementation. Results: During the enrolment period, from 291 uro-oncological procedures 240 yielded malignant histology, of which 160 (67%) were discussed at the MDM. Overall, 202 patients, including 32 females, were discussed at the uro-oncology MDM. MDM consensus plans were implemented in 184 (91.1%) patients. Reasons for deviation from the MDM plan included delay in care, patient deterioration or comorbidities, patient preference, consultant decision, loss to follow up and change in patient scenario due to additional new information. Conclusion: The MDM is increasingly important in the care of uro-oncology patients, with about two-thirds of new diagnoses currently captured. There appear to be few barriers to the implementation of consensus plans, with nearly all patients undergoing the recommended management. This article is protected by copyright. All rights reserved.
... This position is partly supported by Asher and colleagues, they reported in 124 cases of urological cancer, MDTM changed therapeutic attitude in only 2% of cases, thus authors suggested that urologist could presented only few patients to MDTM which reduced significantly a working cost without compromising therapeutic patient's chance. (7) Van Belle (8) showed that MDTM established by the Belgian governmental program was a success thanks to specifically assigned budget. Authors reported also indirect evidence between MDTM and survival rate of cancer in Belgium, because it's within the five best European rates. ...
... Authors reported also indirect evidence between MDTM and survival rate of cancer in Belgium, because it's within the five best European rates. (2,3,8) This hypothesis was sustained by results of Sternberg and colleagues' study, they concluded of beneficial effect of MDTM on free recurrence survival of PCa in patients at high risk of recurrence, in particular phase III of TAX 3501 where was compared treatment with immediate or differed ADT with or without docetaxel after RP. (9) Our study showed reliability and reproducibility of decisions made at MDTM. This is valid in pT2 patients group in whom 100% of reproducibility was observed, while pT3a patients group showed 86% reproducibility (k= 0.74). ...
Article
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The prostate cancer (PCa) treatment is multimodal. Thus multidisciplinary team management (MDTM) decision-making process appears as a tool to answer all aspects of PCa treatment. Our aim was to evaluate the repro­ducibility of therapeutic decisions made at MDTM. We compared therapeutic decisions of PCa by presenting the same file of patient un­der a fake identity after 6 to 12 months from the first presentation. Forty-nine files of radical prostatectomy (RP) (28 pT2, 21 pT3) performed for clinical localized PCa were represented at MDTM which included urologist, on­cologist, pathologist and radiologist. Analysis of therapeutic decisions comprised criteria such as: TNM stage, Gleason score, margin status and comorbidities. The reproducibility was assessed statistically by Kappa coefficient. Study subjects included 49 patients who underwent radical prostatectomy (RP). The mean age was similar in pT2 and pT3 groups (P = .09). The mean serum PSA value was 8.32 ng/mL (range, 3.56-19.5) in pT2 group and 9.4 ng/mL (range, 3.8-22) in pT3 group. The margin status in pT2 and pT3 groups was positive in 25.0% and 47.6%, respectively. The decisions made at first and second MDTM for pT2 group were the same in 100% of cases with a per­fect kappa coefficient (k = 1). In the group of pT3 (n = 21), the decisions were different in 33% at the second MDTM in comparison to the first MDTM. Especially for pT3b only 29% were reproducible decision with a slight agree­ment (k = 0.1). Concerning pT3a, 86% of the decisions were reproducible with a substantial agreement (k = 0.74). We showed a reliability and reproducibility of decision made at MDTM when guidelines are well de­fined. The therapeutic attitudes were less reproducible in locally advanced PCa but decision concerning those cases should be made in the setting of guidelines.&nbsp.
... These include improved perceived satisfaction and psychological benefits for patients [1], comprehensive treatment decision-making by all involved specialists [10], improved integration of care for institutions and for health providers [5], ongoing education for health care providers [5,14], and increased access to clinical trials [11]. These benefits have prompted heath care organizations in the United Kingdom [15], Europe [16][17][18], the United States [19], Asia [7], and Australia [20] to formally promote and establish multidisciplinary care as a tenet of standard cancer management. In addition, the presence of multidisciplinary teams is a benchmark used for the attainment of accreditation and government funding [19]. ...
Article
Background and Objectives The aim of this review is to examine the relationship between multidisciplinary cancer care and patient survival.MethodsA literature review was undertaken between January 1950 and September 2009. Included studies described multidisciplinary cancer care and its relation to patient survival. Multidisciplinary care was defined as involvement of a team of clinical and allied specialists whose intent is individualized patient management. Studies were critically appraised for internal and external validity. All study designs were included.ResultsTwenty-one studies met eligibility criteria for this review, including two systematic reviews, one abstract, and 18 original studies. Pooling of results was not possible due to heterogeneity of patient populations, disease sites, measured outcomes, and follow-up periods. Twelve studies (one prospective and six retrospective cohort studies, five before–after series) reported statistically significant association between multidisciplinary care and patient survival.Conclusions Due to methodological limitations, this review is unable to assert a causal relationship between multidisciplinary care and patient survival. In order to better evaluate this relationship, the oncology community must first accept a common definition of multidisciplinary care. Future efforts can then elucidate which aspects of multidisciplinary care impact survival, with consideration of confounding patient and tumour factors. J. Surg. Oncol. 2010;102:125–134. © 2010 Wiley-Liss, Inc.
... Laryngeal carcinoma is a common head and neck malignancy with high incidence as it accounts for approximately 2.4% of new malignancies worldwide every year (Marioni et al., 2006;Papadas et al., 2010). Use of tobacco products and drinking too much alcohol can affect the risk of developing this cancer (Van Belle, 2008). The functional treatment of this condition poses a considerable challenge because it is resistant to chemotherapy and radiotherapy during advance stage. ...
Article
Previous evidence showed β1, 3-N-acetylglucosaminyltransferase 8 (β3GnT8), which can extend polylactosamine on N-glycans, to be highly expressed in some cancer cell lines and tissues, indicating roles in tumorigenesis. However, so far, the function of β3GnT8 in laryngeal carcinoma has not been characterized. To test any contribution, Hep-2 cells were stably transfected with sense or interference vectors to establish cell lines that overexpressed or were deficient in β3GnT8. Here we showed that cell proliferation was increased in β3GnT8 overexpressed cells but decreased in β3GnT8 knockdown cells using MTT. Furthermore, we demonstrated that change in β3GnT8 expression had significant effects on tumor growth in nude mice.We further provided data suggesting that overexpression of β3GnT8 enhanced the expression of matrix metalloproteinase-2 (MMP-2) and matrix metalloproteinase-9 (MMP-9) at both the mRNA and protein levels, associated with shedding of tissue inhibitors of metalloproteinase TIMP-2. In addition, it caused increased production of transforming growth factor beta 1 (TGF-β1), whereas β3GnT8 gene knockdown caused the reverse effect. The results may indicate a novel mechanism by which effects of β3GnT8 in regulating cellular proliferation are mediated, at least in partvia targeting MMPs/TIMPs and TGF-β1 in laryngeal carcinoma Hep-2 cells. The finding may lay a foundation for further investigations into the β3GnT8 as a potential target for therapy of laryngeal carcinoma.
... Internationally, the trend seems to be toward increased use of mandatory guidelines to ensure that cancer care is multidisciplinary. In Belgium, France and the Netherlands, the use of MDTs is mandatory [21][22][23]. The UK, Canada and Australia all have national or state-defined guidelines for the use of MDTs in cancer care [1,18,19]. ...
Article
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This article introduces palliative care to cancer patients in Middle Eastern countries. It considers the importance of the multidisciplinary team in providing an adequate service to the patient and his/her family. It provides views of professionals from the various countries with regard to the role of the nurse in such teams; whereby the three elements of palliative care nursing entail: 1. Working directly with patients and families; 2. Working with other health and social care professionals to network and co-ordinate services; and 3. working at an organizational level to plan, develop and manage service provision in local, regional and national settings. This article also details the challenges that nurses face in the Middle East and outlines the preferable ways to overcome such challenges. The latter include more focused educational activities at the undergraduate and graduate levels and continuous clinical training throughout their work as palliative care nurse specialists.
... A vision for radiotherapy. Canberra) and by cancer units in New Zealand (Stevens et al, 2012) and member states of the European union (Stalfors et al, 2005;Van Belle, 2008;Guillem et al, 2011;Mazzaferro and Majno, 2011). In the United Kingdom, the Cancer Reform Strategy (2007) emphasised that MDM working, as specified by NICE guidance, will remain the core model of cancer service delivery for hospitals in the future (Department of Health, 2000. ...
Article
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Background: The benefits of multidisciplinary working in oncology are now accepted as the norm and widely accepted as being pivotal to the delivery of optimal cancer care. Central to this are the multidisciplinary meetings (MDMs) and we have evaluated decision outcomes and financial costs of these. Methods: We reviewed the electronic patient records of 551 newly referred patients, discussed at 14 tumour site-specific MDMs for adult solid tumours and lymphoma (paediatric oncology and acute leukaemia were excluded) over a 1-month period, a total of 52 MDMs were studied. In addition, the records of a further 81 patients from 10 different MDMs were reviewed where the treating consultant had clearly recorded their opinion of how the patient should be managed and this was compared with the final MDM's consensus view. We also costed the MDMs utilising two different methodologies. Results: The mean age of the 551 patients in the study was 62 years. In all, 536 (97.3%) patients were treatment naive before MDM discussion and 15 (2.7%) had prior treatment. Median time to treatment after the MDM was 16 days. In 535 (97.1%) cases, the MDM discussions were clearly documented, 16 (2.9%) were not clearly documented. In total, 319 (57.9%) patients were discussed once, and 232 (42.1%) were re-discussed (one to six occasions). In 62 (12.7%) patients, there were delays in MDM discussion, 30 (48.4%) were related to radiology, 26 (41.9%) to histopathology and 6 (9.7%) a combination of both. Adherence to the MDM management plan decision occurred 503 times (91.3%) with 48 (8.7%) deviations. In the smaller cohort of 81 patients, the consultant management plan and MDM consensus was compatible 71 (87.6%) times. On four occasions, there were major alterations in management while six were minor. The cost per month of our MDMs ranged from £2192 to £10 050 (median £5136) with total cost of £80 850 per month and the cost per new patient discussed was £415. Conclusion: Adherence to MDM decisions by health-care professionals occurs in the majority of patients. MDMs are costly, which may have relevance in the currently challenged health-care financial environment. There is a need to improve MDM efficiency without losing the considerable benefits associated with regular MDMs.
... In our study, satisfactory partnerships were associated with the respect that cooperating physicians felt for their partners as well as the clear distribution of roles and responsibilities. In contrast to Belgium, where roles and responsibilities were clearly defined in laws that have restructured the oncological field, such clarity of role definition has not been a major focus in restructuring the German oncological field in community settings [36,37]. ...
Article
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Background Utilisation of multidisciplinary teams is considered the best approach to care and treatment for cancer patients. However, the multidisciplinary approach has mainly focused on inpatient care rather than routine outpatient care. The situation in private practice care and outpatient care is gradually changing. We aimed to 1), investigate interdisciplinary cooperations in the care of tumor patients among urologists and oncologists in the community setting, 2), establish an estimate of the prevalence of cooperation among oncologists and organ-specific providers in community settings in Germany and 3), characterise existing cooperations among oncologists and urologists. Methods We conducted simultaneously a cross-sectional survey with private practice urologists (n = 1,925) and a qualitative study consisting of semi-structured interviews with urologists and oncologists (n = 42), primarily with private practices, who had indicated cooperation the care of urological tumor patients. Results Most of the participants (66%) treated their own tumor patients. When physicians referred patients, they did so for co- and subsequent treatments (43%). Most cooperating urologists were satisfied with the partnership and appreciated the competency of their partners. Qualitative interviews revealed two types of collaboration in the community setting: formal and informal. Collaborations were usually ongoing with many physicians and depended equally on both patient preference and diagnosis. Conclusion Joint patient treatment requires clear delineation of roles and responsibilities and simple means of communication. Formal frameworks should allow for incorporation of patients’ critical role in collaboration decisions in treatment and care.
... The management of the progressive disease after primary treatments and that of the advanced PC requires a correct diagnostic evaluation and a therapeutic choice among radiotherapy, focal therapies, hormone therapies, chemotherapies or other novel target treatments [3]. Efficient organization of the national healthcare system can be a tool to help improve patient outcomes [4].The natural history of PC from asymptomatic organ-confined disease to locally advanced, metastatic and hormone-refractory disease describes the complexity of this tumor's biology and justifies the need for a fluid collaboration between expert physicians. Breast and Prostate cancer, respectively, are the most common cancers in women and in men, and different similarities have been underlined. ...
Article
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A Prostate Cancer Unit is a place where men can be cared for by specialists in prostate cancer (PC) working together within a multi-professional team .From October 2010 our hospital accepted the institution of a Prostate Cancer Unit. Our Prostate Unit was established in a large size hospital. The main aim of the Unit was to provide a continuum of care for patients from early diagnosis, through treatment planning in all stages of the disease, to follow-up, prevention and management of complications related to PC. The future of PC patients relies in a successful multidisciplinary collaboration between experienced physicians which can lead to important advantages in all the phases and aspects of PC management. The establishment of Prostate Cancer Units could provide financial savings avoid inappropriate procedures, improve outcomes delivering high-quality care to patients. These aspects are particularly relevant considering the high-incidence of PC as one of the most important medical problems facing the male population.
... Due to those findings MDT has become man-datory for breast cancer treatment in Germany [21]. Further it has become a mandatory prerequisite in order to become a certified comprehensive cancer center in several other countries [7,[22][23][24][25][26]. Many national guidelines incorporated MDT modalities over the recent years [2,[27][28][29][30]. ...
Article
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Multidisciplinary treatment (MDT) is considered to be beneficial for patients undergoing complex treatments for cancer. The efforts of MDT led to the initiation of nowadays well known trials in gastroesophageal cancer treatment. Here we report the experience of MDT of the Center for Gastric Cancer of the National Cancer Center, Korea. We show the management not only of oncologic treatment plans but also treatment decisions on perioperative oncologic therapy and multimodal management of postoperative and various treatment-related complications. Six cases from gastroenterology, hemato-oncology and surgery parts were presented to show function and effect of MDT conference. Those examples typically showed that even final pathological diagnosis was chnged after MDT conference for some cases, gives adequate decision for further treatment after compications, and offered optimal treatment decision for difficult metastatic disease. Also, management of complications are now more effectively resolved with multidisciplinay intervention with close communication. The local MDT conference can be considered as a fast and effective tool for adequate treatment and improving quality of the treatment. Therefore MDT is an essential component of cancer care to improve patient’s outcome. Keywords: Multidisciplinary treatment, Gastric cancer
... The purpose of the MDT meetings is to develop a strategic plan of diagnosis, treatment and follow-up and to discuss the overall care of an individual patient. 2 MDT meetings were identified as the best approach to organise cancer care in a way that consistently brings together all healthcare professionals involved in cancer diagnosis and treatment 3 and in 2014, the European Partnership Action Against Cancer (EPAAC) published a policy statement on multidisciplinary cancer care which was endorsed by the majority of European scientific societies, patient organisations and stakeholders. In this policy statement, MDT meetings are described as follows: ...
... 7,9,10 The observed benefit of early palliative care integration in oncology has been suggested to be due to the increased psychosocial support that patients receiving early palliative care have compared with those undergoing standard oncological care. 3 In Belgium, psychosocial care delivered by specialist nurses, social workers, dieticians, and psychologists specifically trained in oncological care is part of the routine oncology care and free of charge, 13 with 350 full-time equivalent (FTE) nurses, 350 FTE psychologists, and 175 FTE social workers available per 100 000 cancer cases (2009 data). 14 Hospital-based palliative care is also available without financial barriers, but resources are less extensive: hospital-based palliative care teams are formed by 0·5 FTE specialised nurses, 0·5 FTE palliative care physicians, and 0·5 FTE palliative care psychologists per 500 hospital beds. ...
Article
Background: The benefit of early integration of palliative care into oncological care is suggested to be due to increased psychosocial support. In Belgium, psychosocial care is part of standard oncological care. The aim of this randomised controlled trial is to examine whether early and systematic integration of palliative care alongside standard psychosocial oncological care provides added benefit compared with usual care. Methods: In this randomised controlled trial, eligible patients were 18 years or older, and had advanced cancer due to a solid tumour, an European Cooperative Oncology Group performance status of 0-2, an estimated life expectancy of 12 months, and were within the first 12 weeks of a new primary tumour or had a diagnosis of progression. Patients were randomly assigned (1:1), by block design using a computer-generated sequence, either to early and systematic integration of palliative care into oncological care, or standard oncological care alone in a setting where all patients are offered multidisciplinary oncology care by medical specialists, psychologists, social workers, dieticians, and specialist nurses. The primary endpoint was change in global health status/quality of life scale assessed by the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 items (EORTC QLQ C30) at 12 weeks. The McGill Quality of Life Questionnaire (MQOL), which includes the additional existential wellbeing dimension, was also used. Analysis was by intention to treat. This trial is ongoing, but closed for accrual, and is registered with ClinicalTrials.gov, number NCT01865396. Findings: From April 29, 2013, to Feb 29, 2016, we screened 468 patients for eligibility, of whom 186 were enrolled and randomly assigned to the early and systematic palliative care group (92 patients) or the standard oncological care group (94). Compliance at 12 weeks was 71% (65 patients) in the intervention group versus 72% (68) in the control group. The overall quality of life score at 12 weeks, by the EORTC QLQ C30, was 54·39 (95% CI 49·23-59·56) in the standard oncological care group versus 61·98 (57·02-66·95) in the early and systematic palliative care group (difference 7·60 [95% CI 0·59-14·60]; p=0·03); and by the MQOL Single Item Scale, 5·94 (95% CI 5·50-6·39) in the standard oncological care group versus 7·05 (6·59-7·50) in the early and systematic palliative care group (difference 1·11 [95% CI 0·49-1·73]; p=0.0006). Interpretation: The findings of this study show that a model of early and systematic integration of palliative care in oncological care increases the quality of life of patients with advanced cancer. Our findings also show that early and systematic integration of palliative care is more beneficial for patients with advanced cancer than palliative care consultations offered on demand, even when psychosocial support has already been offered. Through integration of care, oncologists and specialised palliative care teams should work together to enhance the quality of life of patients with advanced cancer. Funding: Research Foundation Flanders, Flemish Cancer Society (Kom Op Tegen Kanker).
... 7,9,10 The observed benefit of early palliative care integration in oncology has been suggested to be due to the increased psychosocial support that patients receiving early palliative care have compared with those undergoing standard oncological care. 3 In Belgium, psychosocial care delivered by specialist nurses, social workers, dieticians, and psychologists specifically trained in oncological care is part of the routine oncology care and free of charge, 13 with 350 full-time equivalent (FTE) nurses, 350 FTE psychologists, and 175 FTE social workers available per 100 000 cancer cases (2009 data). 14 Hospital-based palliative care is also available without financial barriers, but resources are less extensive: hospital-based palliative care teams are formed by 0·5 FTE specialised nurses, 0·5 FTE palliative care physicians, and 0·5 FTE palliative care psychologists per 500 hospital beds. ...
Article
We analysed the characteristics of patients included in our Prostate Unit (Group A), some results obtained from the early diagnosis programme and the distribution of prostate cancer (PC) cases in the different treatment options. These data were compared with those obtained in a monodisciplinary urological service (Group B). 292 cases were considered suitable and were included by our multidisciplinary team (MDT) in the Unit (Group A). 145 cases in which the diagnosis was unestablished started an early diagnosis programme for PC. Mean time for concluding all the initial programme till the histological diagnosis at prostate biopsy was 22.3 ± 5.4 days in Group A (32.7 ± 8.6 days in Group B). The rate of biopsy indications and that of PC positive biopsies were 64 % and 45 %, respectively, for cases included in Group A and 52 % and 41 % for cases included in Group B. A high percentage of cases (47.6 %) referred to our MDT were in the low-risk group. In the Prostate cancer Unit (Group A), the indications for primary therapies were more equally distributed between surgery (51.5 %) and radiotherapy (45.4 %). © 2014 Springer International Publishing Switzerland. All rights reserved.
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Prostate cancer (PC) is established as one of the most important medical problems affecting the male population. PC is the most common solid neoplasm and the second most common cause of cancer death in men. Its management involves several complex issues for both clinicians and patients. An early diagnosis is necessary to implement well-balanced therapeutic options, and the correct evaluation can reduce the risk of overtreatment with its consequential adverse effects. The paradigm of the patient consulting a multidisciplinary medical team has been an established standard approach in treating breast cancer. Such multidisciplinary approach can offer the same optional care for men with PC as it does for women with breast cancer. A multidisciplinary team (MDT) comprises healthcare professionals from different disciplines whose goal of providing optimal patient care is achieved through coordination and communication with one another. A Prostate Cancer Unit is a place where men can be cared for by specialists in PC, working together within a multi-professional team. The MTD approach guarantees a higher probability for the PC patient to receive adequate information on the disease and on all possible therapeutic strategies, balancing advantages and related side effects. The future of PC patients relies on a successful multidisciplinary collaboration between experienced physicians, which can lead to important advantages in all the phases and aspects of PC management. © 2014 Springer International Publishing Switzerland. All rights reserved.
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Cancer care can be complex with increased specialization within disciplines and more-sophisticated treatment techniques. Multidisciplinary care (MDC) is an integrated team approach to bring together a group of health professionals with appropriate skills to consider patient's treatment and care options. MDC are now conducted worldwide and is recommended as best practice for the management of patients with cancer. There is increasing evidence that MDC improves quality of care, treatment outcomes of patient with cancer and. other clinical outcomes, but concerns are raised over the paucity of good-quality evidence on their overall impact. In this review, we described available evidence on the impact of cancer MDC, and also reviewed focused on cancer MDC strategy depending on countries.
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The concept of multidisciplinary team meetings (MDTs) in cancer care is endorsed internationally, but its uptake varies considerably. In Belgium, MDT meetings were financially recognised in 2003 to encourage healthcare professionals to join their knowledge and competences to improve the quality and coordination of cancer care. This study aimed to evaluate for seven cancer types diagnosed between 2004 and 2011, the practices of MDT meetings in Belgium by means of population-based administrative databases. Results show a clear increase over time in the proportion of individual patients discussed at MDT meetings. Although this evolution may be partly explained by the legal implementation of several financial initiatives to stimulate MDT meetings, it also suggests an increase in specialists’ awareness of the importance of such meetings. Nevertheless, there is still room for improvement, for specific cancer types as well as for certain subgroups such as older patients. From the specialists’ point of view, reducing the administrative burden and time these meetings demand may entail a greater participation to MDT meetings. Further research is needed to identify the barriers to discuss more patients at MDT meetings and to elucidate the impact of MDT meetings on the quality of cancer care.
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Rationale, aims and objectivesTo develop a guideline with quality criteria for an optimal structure and functioning of a multidisciplinary team meeting (MTM), and to assess to what extent the Dutch MTMs complied with these criteria. MethodA literature search and expert opinions were used to develop a guideline for optimal MTMs. In order to assess adherence to the guideline, we conducted interviews with MTM chairs and observed general and tumour-specific MTMs in seven hospitals. ResultsThe new guideline included the following domains: (i) organization of the MTMs; (ii) membership of the MTM and roles and responsibilities of the members; (iii) the meeting itself; and (iv) documentation of meeting-recommendations. We observed good adherence to the quality criteria on the organization of the MTMs. Only the required coordinator/administrative support was often absent, particularly during general MTMs. Regarding membership of MTMs and roles, the recommended average attendance of 100% of the core disciplines was never reached and particularly the role of the chair needs improvement. Regarding the meeting itself, many interruptions took place and relevant information about the diagnoses of the cases was not available in 4-5% of the cases. Concerning the documentation of meeting-recommendations, only in a quarter of the meetings a specific form was used for the documentation. Conclusions We found a lot of diversity in the organization of MTMs. The variation in compliance with the quality criteria may decrease with better knowledge about the quality criteria around MTMs and by overcoming practical barriers for the effective organization of MTMs.
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This study aimed to assess the current effectiveness of Oncologic Multidisciplinary Groups (OMGs) meetings across central Tuscany through surgeons' reports and their individual perceived benefits on colorectal cancer management. One hundred and sixty-seven general surgeons received a questionnaire with 21 questions covering organizational characteristics of OMGs and the individual perceived benefits of OMGs. The responses were analyzed by hospital setting (teaching vs. community hospital). The reply rate was 62.8 %, and 82 respondent surgeons (49.1 %) were involved in the treatment of colorectal cancer patients. At community hospitals, there was a more frequent participation of medical oncologists, radiation oncologists and pathologists; a less selection of discussed cases was performed; and almost all decisions were inserted into official patient charts (p < 0.05). Community hospital surgeons perceived more of a benefit than academic surgeons: OMGs ensure that all treatment options are considered and improve timeliness of care, patient outcomes, patient satisfaction and communication with patients (p < 0.05). The surveyed surgeons reported that OMGs offer a modest degree of protection from malpractice but improve communications between colleagues and are an opportunity for personal professional development. Professionals regularly participating in well-conducted and well-organized OMGs for colorectal cancer felt that the multidisciplinary strategy may be advantageous to both patients and caregivers.
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Due to the mostly increasing incidence of cancers, rising survival rates and an overall increase in life expectancy, the number of tumor patients will significantly climb over the coming years. Health care needs of these patients are very complex, imposing high demands on coordination of health care providers and services. Taking this into account, an interdisciplinary and multidisciplinary approach is paramount. In oncology this approach has been considered standard for many years, e.g. interdisciplinary tumor boards. However, caring for patients in multidisciplinary teams is not currently practiced throughout the health care system. Especially coordination of care between different health professionals and at the interfaces of health care sectors may improve quality of care. Interdisciplinarity is also considered a criterion for high quality clinical practice guidelines (CPGs). Involving all relevant stakeholders enhances both acceptance and implementation into daily clinical practice. Based on the best available evidence, interdisciplinary oncological guideline groups define best medical practice as well as health care management, thus developing an ideal model for comprehensive cancer care. Using evidence and consensus-based CPGs as a foundation, health care services can be optimized according to regional or local needs.
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Prostate cancer (PC) is established as one of the most important medical problems affecting the male population. PC is the most common solid neoplasm (214 cases per 1000 men) and the second most common cause of cancer death in men. Its management involves several complex issues for both clinicians and patients. An early diagnosis is necessary to implement well-balanced therapeutic options, and the correct evaluation can reduce the risk of overtreatment with its consequential adverse effects. Breast and Prostate cancers, respectively, are the most common cancers in women and in men, and different similarities have been underlined. The paradigm of the patient consulting a multidisciplinary medical team has been an established standard approach in treating breast cancer. Such multidisciplinary approach can offer the same optional care for men with PC as it does for women with breast cancer. A multidisciplinary team (MDT) comprises healthcare professionals from different disciplines whose goal of providing optimal patient care is achieved through coordination and communication with one another. A Prostate Cancer Unit is a place where men can be cared for by specialists in PC, working together within a multi-professional team. The MTD approach guarantees a higher probability for the PC patient to receive adequate information on the disease and on all possible therapeutic strategies, balancing advantages and related side effects. The future of PC patients relies on a successful multidisciplinary collaboration between experienced physicians, which can lead to important advantages in all the phases and aspects of PC management.
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To evaluate differences and similarities in opinions on and expectations of prostate cancer management between physicians and patients. Two surveys on patientspecific opinions and expectations in prostate cancer management were done in 2011 among European prostate cancer specialists and patients with prostate cancer. Survey results were complemented with existing published data and with the authors' opinion. Most specialists spent 15-29 min on delivering the diagnosis, and about the same amount of time on explaining treatment options. This time was considered insufficient by 35% and 48% of patients, respectively. There was a large discrepancy between physicians' and patients' opinions about the type of provided prognostic and therapeutic information, indicating that patients may not have completely understood this information. Shared decision-making was preferred by both patients and specialists. Treatment efficacy was the most important factor determining treatment choice for both groups, while the physician's opinion or experience also had a great impact on patients' treatment choice. Patient-support groups have an important role in providing relevant information and in exchanging experiences between patients. The supportive role of partners/relatives was more appreciated when discussing treatment options than during diagnosis. Although patients' expectations are generally matched by their caring physician(s), physicians can still improve quality of care by taking adequate time for their patients, by using terminology that is easily understood by patients and by encouraging shared decision-making. A multidisciplinary team may be an important part of the treatment paradigm, with the individual patient's needs and preferences as the centre of care. © 2012 The Authors BJU International
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Multidisciplinary cancer conferences (MCCs) provide an opportunity for health professionals to discuss diagnosis and treatment options to optimize patient management. The purpose of this study was to explore the barriers and facilitators in implementing MCCs in Canada. This exploratory study used qualitative interviews and observation to explore the experiences of implementing MCCs in four hospitals in Ontario, Canada. Interviews were transcribed verbatim and analyzed using standard qualitative research methodology guided by grounded theory principles. Thirty-seven MCCs for gastrointestinal cancer were observed across three hospital sites, and 48 interviews were conducted among a range of clinical specialists and administrators. The dominant theme suggested that MCCs can most effectively be implemented if administrators and health professionals see value in MCCs, despite the time and effort required. A number of factors (eg, provincial policy, hospital administrative and clinician support, and an efficient MCC process) influenced whether MCCs were valued. Variation exists in the enthusiasm of health professionals and the administrative capacity of institutions regarding routine implementation of MCCs. A systematic implementation plan for MCCs is needed involving both cancer care providers and administrators.
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Cancer care is complex and multimodal therapy is now considered the standard of care. Multidisciplinary cancer conferences (MCCs) offer a venue to prospectively discuss cancer patients and plan treatment. MCCs are believed to improve patient outcomes and consequently have been internationally adopted. The purpose of this study was to describe the prevalence of MCCs in Ontario and identify individual and organizational barriers to their adoption. A cross-sectional, mailed questionnaire of general surgeons in Ontario, Canada who care for patients with cancer was used to assess prevalence, and organizational and individual barriers to MCC implementation. Responses were summarized overall, by hospital, and by academic status. The response rate was 44.2% (170/385). Respondents worked at 57 unique hospitals, of which 29 (52%) were reported to have MCCs, including all academic hospitals (7/7) and 22 of 50 (44%) community hospitals. Forty-nine MCCs were reported at 29 hospitals. MCCs occurred weekly at academic centers and biweekly or monthly at community hospitals. Few MCCs (28%) had a designated coordinator. Surgeons perceived that MCCs helped them to incorporate multidisciplinary opinions into their patient care plans, improved collegiality, and provided opportunity for continuing professional development. Despite the perceived benefits expressed by respondents, administrative support for MCCs may be minimal. In particular, surgeons at community hospitals may have limited access to multidisciplinary patient care planning. This information will be utilized to shape a provincial strategy for implementing MCCs. However, further research is required to understand barriers and enablers to establish and maintain MCCs, especially in community practice.
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In Europe, the vast majority of the costs of cancer therapy fall on third-party payers, normally the government, or sickness funds. Therefore, the main focus of cost-effectiveness studies is to assist payers in deciding whether new therapies are worthwhile, despite their high cost. Drug budgets are regulated in most European countries. The main form of central control is price setting, with some form of reference pricing being the most common approach. This sets the price of drugs, either to an international standard, or to a common price for drugs in the same group or cluster. At the hospital level, the main control over cancer drugs is the hospital formulary. Studies have shown a wide variation among European countries in access to cancer drugs. Explanations for these variations include differences in research funding, the drug approval process, the role of health economics in decision making, and budgetary issues. Several countries in Europe now require economic data in making decisions about the reimbursement of new drugs. An examination of decisions made by the National Institute for Health and Clinical Excellence in the United Kingdom suggests that cancer drugs have fared quite well, with most recommendations being positive. This could be because of the seriousness of the health condition and the lack of alternative therapies for some cancer patients. If the policy of requesting cost-effectiveness evidence for pricing and reimbursement decisions becomes more popular, a major implication for the pharmaceutical industry is that studies should be conducted during phase III of clinical development to generate the required data.
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Despite decreased perioperative morbidity and mortality and clinical trials suggesting improved outcomes with adjuvant therapy, national practice patterns in the management of pancreatic cancer remain poorly defined. The purpose of the current study was to evaluate multimodality therapy utilization and outcomes relative to hospital type and volume. Using the National Cancer Data Base, stage-specific treatment patterns were analyzed for 301,033 patients with pancreatic adenocarcinoma. Logistic regression was used to evaluate treatment utilization. Cox proportional hazards modeling was utilized to evaluate the effect of multimodality therapy on survival. Stage at presentation did not differ from 1985-1994 to 1995-2003; however, the percentage of patients receiving cancer-directed treatment increased from 45.1% to 51.8% (P < .001). Pancreatectomy for localized disease (AJCC 6th edition stages I and II) increased from 36.9% to 49.3% (P < .001). After resection, the use of adjuvant chemotherapy alone increased from 4.1% to 5.7% (P < .001), but the use of adjuvant radiation alone decreased from 7.0% to 4.6% (P < .001). Adjuvant chemoradiation use increased from 26.8% to 38.7% (P < .001). The use of surgery alone decreased from 62.1% (5213 of 8400 cases) to 49.9% (10,807 of 21,679 cases) (P < .001). Patients with localized pancreatic cancer were more likely to receive pancreatectomy and adjuvant chemoradiation at academic and high-volume centers (P < .001). Survival for localized disease was better after surgery with adjuvant therapy (hazards ratio [HR], 0.44; 95% confidence interval [95% CI], 0.42-0.47) and surgical resection alone (HR, 0.54; 95% CI, 0.52-0.57) compared with no treatment. To the authors' knowledge, the current study is the largest study regarding pancreatic cancer performed to date, and the first to investigate national practice patterns for multimodality therapy utilization. Multimodality therapy utilization has increased over time and appears to have a beneficial impact on survival.
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Background: Traditional cancer-survival analyses provide data on cancer management at the beginning of a study period, and are often not relevant to current practice because they refer to survival of patients treated with older regimens that might no longer be used. Therefore, shortening the delay in providing survival estimates is desirable. Period analysis can estimate cancer survival by the use of recent data. We aimed to apply the period-analysis method to data that were collected by European cancer registries to estimate recent survival by country and cancer site, and to assess survival changes in Europe. We also compared our findings with data on cancer survival in the USA from the US SEER (Surveillance, Epidemiology, and End Results) programme. Methods: We analysed survival data for patients diagnosed with cancer in 2000-02, collected from 47 of the European cancer registries participating in the EUROCARE-4 study. 5-year period relative survival for patients diagnosed in 2000-02 was estimated as the product of interval-specific relative survival values of cohorts with different lengths of follow-up. 5-year survival profiles for patients diagnosed in 2000-02 were estimated for the European mean and for five European regions, and findings were compared with US SEER registry data for patients diagnosed in 2000-02. A 5-year survival profile for patients diagnosed in 1991-2002 and a 10-year survival profile for patients diagnosed in 1997-2002 were also estimated by the period method for all malignancies, by geographical area, and by cancer site. Findings: For all cancers, age-adjusted 5-year period survival improved for patients diagnosed in 2000-02, especially for patients with colorectal, breast, prostate, and thyroid cancer, Hodgkin's disease, and non-Hodgkin lymphoma. The European mean age-adjusted 5-year survival calculated by the period method for 2000-02 was high for testicular cancer (97.3% [95% CI 96.4-98.2]), melanoma (86.1% [84.3-88.0]), thyroid cancer (83.2% [80.9-85.6]), Hodgkin's disease (81.4% [78.9-84.1]), female breast cancer (79.0% [78.1-80.0]), corpus uteri (78.0% [76.2-79.9]), and prostate cancer (77.5% [76.5-78.6]); and low for stomach cancer (24.9% [23.7-26.2]), chronic myeloid leukaemia (32.2% [29.0-35.7]), acute myeloid leukaemia (14.8% [13.4-16.4]), and lung cancer (10.9% [10.5-11.4]). Survival for patients diagnosed in 2000-02 was generally highest for those in northern European countries and lowest for those in eastern European countries, although, patients in eastern European had the highest improvement in survival for major cancer sites during 1991-2002 (colorectal cancer from 30.3% [28.3-32.5] to 44.7% [42.8-46.7]; breast cancer from 60% [57.2-63.0] to 73.9% [71.7-76.2]; for prostate cancer from 39.5% [35.0-44.6] to 68.0% [64.2-72.1]). For all solid tumours, with the exception of stomach, testicular, and soft-tissue cancers, survival for patients diagnosed in 2000-02 was higher in the US SEER registries than for the European mean. For haematological malignancies, data from US SEER registries and the European mean were comparable in 2000-02, except for non-Hodgkin lymphoma. Interpretation: Cancer-service infrastructure, prevention and screening programmes, access to diagnostic and treatment facilities, tumour-site-specific protocols, multidisciplinary management, application of evidence-based clinical guidelines, and recruitment to clinical trials probably account for most of the differences that we noted in outcomes.
Article
EUROCARE is the largest population-based cooperative study on survival of patients with cancer. The EUROCARE project aims to regularly monitor, analyse, and explain survival trends and between-country differences in survival. This report (EUROCARE-4) presents survival data for eight selected cancer sites and for all cancers combined, diagnosed in adult (aged >/=15 years) Europeans in 1995-99 and followed up until the end of 2003. We analysed data from 83 cancer registries in 23 European countries on 2 699 086 adult cancer cases that were diagnosed in 1995-99 and followed up to December, 2003. We calculated country-specific and mean-weighted age-adjusted 5-year relative survival for eight major cancers. Additionally, case-mix-adjusted 5-year survival for all cancers combined was calculated by countries ranked by total national expenditure on health (TNEH). Changes to survival were analysed relative to cases diagnosed in 1990-94. Mean age-adjusted 5-year relative survival for colorectal (53.8% [95% CI 53.3-54.1]), lung (12.3% [12.1-12.5]), breast (78.9% [78.6-79.2]), prostate (75.7% [75.2-76.2]), and ovarian (36.3% [35.7-37.0]) cancer was highest in Nordic countries (except Denmark) and central Europe, intermediate in southern Europe, lower in the UK and Ireland, and worst in eastern Europe. Survival for melanoma (81.6% [81.0-82.3]), cancer of the testis (94.2% [93.4-95.0]), and Hodgkin's disease (80.0% [79.0-81.0]) varied little with geography. All-cancer survival correlated with TNEH for most countries. Denmark and UK had lower all-cancer survival than countries with similar TNEH; Finland had high all-cancer survival, but moderate TNEH. Survival increased and intercountry survival differences narrowed between the data for 1990-94 and 1995-99 for, notably, Hodgkin's disease (range 66.1-82.9 [IQR 72.2-78.6] vs 74.0-83.9 [78.6-81.9]), colorectal (29.4-56.7 [45.8-54.1] vs 38.8-59.7 [50.7-57.5]), and breast (61.7-82.7 [72.3-78.3] vs 69.3-87.6 [76.6-82.7]) sites. Increases in survival and decreases in geographic differences over time, which are mainly due to improvements in health-care services in countries with poor survival, might indicate better cancer care. Wealthy countries with high TNEH generally had good cancer outcomes, but those with conspicuously worse outcomes than those with similar TNEH might not be allocating health resources efficiently.
Background: Health care organizations have begun to move toward a nonpunitive, or "blame-free," process when analyzing medical errors and near misses. The Dana-Farber Cancer Institute's (Boston) "Principles of a Fair and Just Culture," define for staff and managers behavioral expectations when an error occurs. Creating the principles of a fair and just culture: The principles focus not just on patient safety but on a culture of safety and transparency in all the organization's functional areas, including nonclinical departments such as information services, administration, and research. Incorporating the principles into practice: Introducing the principles is a gradual process, one that requires continual education and discussion among staff at all levels and a commitment to examining and changing many of the systems, policies, and procedures that guide the organization's work. A survey conducted in January 2007 revealed that the clinical areas had sustained higher-than-average scores and that the nonclinical areas showed improvement. Discussion: Changing a long-standing culture of blame, control, and disrespect to one that embraces principles of fairness and justice and standards of respectful behavior is a major undertaking. Educating and involving clinical and administrative leaders, who work directly with staff and play a pivotal role in translating the principles into practice, is especially important.
Multimodality therapy for pancreatic cancer in the U.S: utilization, outcomes, and the effect of hospital volume
  • Bilimoria
Guidelines for treatment of cancer by site in collaboration with the Belgian Health Care Knowledge Centre
  • Public Service
Estimates of the cancer incidence and mortality in Europe in 2006
  • Ferlay