Abstract

Background:

The optimal management of patients with breast cancer (BC) requires the expertise of specialists from different disciplines. This has led to the evolution of multidisciplinary teams (MDTs), allowing all key professionals to jointly discuss individual patients and to contribute independently to clinical decisions. Data regarding BC MDTs in different regions and countries are scarce.

Methods:

The investigators of a large global phase III adjuvant BC trial being conducted by the Breast International Group were invited to respond to a questionnaire about the extent, structure, and function of BC MDTs.

Results:

One hundred and fifty-two responses from 39 countries were received, and remarkable differences were noted in different geographic regions. Sixty-five percent of the respondents from eastern Europe, 63% from western Europe, 35% from Asia, and 25% from South America declared that MDT was a mandatory part of BC care in their country. Ninety percent of the respondents from Europe stated their MDTs met weekly, compared with only half of the respondents from Asia.

Conclusion:

This survey is perhaps the first large-scale effort to collect information regarding BC MDTs from different parts of the world and provides objective information of frequency, composition, function, and working mechanism of BC MDTs.

introduction

Based on William S. Halsted's theory that breast cancer (BC) is initially a strictly local disease that spreads by orderly progression and is thus curable by radical surgery, early BC used to be managed almost exclusively by surgeons before the mid-1970s [1, 2]. The work of Bernard Fisher and Edwin Fisher [3] in the 1960s lead to the development of an alternative hypothesis that BC is a systemic disease and that patients with early BC destined to develop metastases have already had spread of undetectable tumor cells at the time of diagnosis. This contributed to a paradigm shift in BC management, and systemic therapies began to be used to treat patients with early-stage disease [4].

As a result of the evolution and refinement of BC diagnosis, staging, and management, the treatment algorithm gradually became more complex [5]. In contemporary practice, BC patient care requires the expertise of a wide range of specialists, and effective communication among them is crucial to formulate an optimal treatment strategy [6]. The effort to facilitate such communication has lead to the evolution of the multidisciplinary team (MDT), which is defined by the UK Department of Health as a “group of people of different health care disciplines, which meets together at a given time (whether physically in one place, or by video or teleconferencing) to discuss a given patient and who are each able to contribute independently to the diagnostic and treatment decisions about the patient” [7].

MDT meetings have become an integral part of cancer care in many countries worldwide. The main perceived benefit of an MDT is that it provides consistent, continuous, coordinated, and cost-effective care to the patient [8]. There is some evidence to indicate that decisions made by MDTs are more likely to conform to evidence-based guidelines than those made by individual clinicians [2, 9–11]. MDT meetings are perceived to be effective in the medical management of patients with advanced BC [12]. Breast MDTs contributed to a shorter mean time from diagnosis to treatment (29.6 versus 42.4 days; P < 0.0008), as well as increased patient satisfaction [13]. Importantly, this study also found that MDT referral resulted in a higher proportion of patients who either received neoadjuvant chemotherapy or underwent lumpectomy alone. Chang et al. [10] reported that MDT referral resulted in a change in treatment recommendation for 43% of the patients. However, it is to be noted that evaluating MDT benefits is quite difficult, given the heterogenous study designs, scanty data, etc.

The authors are not aware of any other global studies that have investigated the extent to which BC MDTs exist worldwide or attempted to describe the variability in MDT working between different regions and countries. It is critical to understand which particular characteristics of MDT structures and functions have an impact on clinical outcome so that MDTs can be adapted and modified in order to achieve better patient care, especially given the fact that MDTs are a very expensive resource. This study is a step in that direction and aimed to assess the prevalence of BC MDTs and to describe the similarities and differences between them in different regions, using the context of a multicenter international randomized BC clinical trial to survey investigators across the world.

methods

development of the survey

A series of discussions (face-to-face meetings, teleconference calls, e-mails) between the authors resulted in the development of a detailed online survey of the extent, structure, and functioning of MDTs in BC centers worldwide. The questionnaire consisted of 31 items and was in English.

participants

This survey involved investigators participating in a large global phase III trial involving women with early-stage human epidermal growth factor receptor 2-positive BC. The United States was not included in this analysis for administrative reasons.

procedure

From March to May 2010, 867 e-mail invitations including a link to the survey were sent to investigators from 885 centers in 50 countries, and responses were automatically saved in an electronic database.

statistical analysis

In this paper, Europe refers to the combined figures of Western and Eastern Europe, and percentages are presented only for regions where at least 10 respondents participated in the survey. A respondent refers to an investigator or his/her representative who filled out a questionnaire. Statistical significance of differences in binary variables between two regions was assessed using the Fisher's exact test and was considered as significant at a level of <0.05. For comparative analysis, the respondents were grouped into seven geographical regions, as shown in Table 1.

Table 1.

In this survey, responses from a total of 148 respondents from 39 countries were analyzed

Region Countries Number of respondents 
North America Mexico 
South America Argentina, Brazil, Chile, and Peru 15 
Western Europe Belgium, Denmark, France, Germany, Greece, Italy, The Netherlands, Spain, Switzerland, and UK 70 
Eastern Europe Bulgaria, Czech Republic, Estonia, Hungary, Poland, Romania, Slovakia, Slovenia, and Ukraine 22 
Africa South Africa 
Asia China, Hong Kong, India, Israel, Japan, South Korea, Malaysia, Pakistan, Philippines, Russian Federation, Taiwan, and Thailand 27 
Oceania Australia and New Zealand 
Region Countries Number of respondents 
North America Mexico 
South America Argentina, Brazil, Chile, and Peru 15 
Western Europe Belgium, Denmark, France, Germany, Greece, Italy, The Netherlands, Spain, Switzerland, and UK 70 
Eastern Europe Bulgaria, Czech Republic, Estonia, Hungary, Poland, Romania, Slovakia, Slovenia, and Ukraine 22 
Africa South Africa 
Asia China, Hong Kong, India, Israel, Japan, South Korea, Malaysia, Pakistan, Philippines, Russian Federation, Taiwan, and Thailand 27 
Oceania Australia and New Zealand 

To enable regional comparison, they were divided into seven groups as shown here. Refer to the text for a definition of ‘respondent’.

results

responses

One hundred and fifty-two responses from 39 countries were recorded in the electronic database (Figure 1). Multiple responses were received from three centers (three responses from an Italian center, two from an Australian center, and two from a UK center); only the first survey submitted by each of these centers was included in the analysis. Of these 148 unique respondents located in 39 countries (Table 1), 141 (95%) respondents reported that they had a BC MDT in their institution; only these surveys were subject to further analysis. One hundred and sixteen of 141 (82%) respondents were physicians. Of these, 71 specified their field of specialization: 58 medical oncologists, 6 gynecologists, 5 surgeons, 1 radiation oncologist, and 1 general practitioner.

Figure 1.

Flowchart showing the number of invitations sent and the responses received. Some investigators worked in more than one center and received only a single e-mail. MDT, multidisciplinary team.

Figure 1.

Flowchart showing the number of invitations sent and the responses received. Some investigators worked in more than one center and received only a single e-mail. MDT, multidisciplinary team.

extent of MDT presence in different parts of the world

One respondent each from six countries (Argentina, Malaysia, Slovakia, South Africa, Peru, and Ukraine) reported that their institution did not have an MDT. One respondent from Brazil did not answer this question. Only about half of the respondents (71 of 141) reported that it was mandatory for cancer institutions to have an MDT in their country: 65% of respondents in Eastern Europe, 63% in Western Europe, 35% in Asia, and 25% in South America. A list of the countries where MDT was reported to be mandatory is given in supplemental Table S1 (available at Annals of Oncology online).

structure and functioning of MDTs

Overall, 82% of respondents stated that their MDTs met every 7 days, 12% every 7–14 days, and 4% every 15–30 days (supplemental Table S2, available at Annals of Oncology online). Most (90%) respondents from Europe stated that their MDTs met weekly, compared with only half (50%) of the respondents from Asia. The MDT meetings were regularly attended by a medical oncologist (95%), surgical oncologist (95%), radiation oncologist (90%), pathologist (84%), radiologist (73%) and specialist nurse (49%). Fifty percent (10 of 20) of the respondents in Eastern Europe reported that patients attended MDT meetings, contrasting sharply with only 3% (2 of 70) in Western Europe (P < 0.001).

Fifty-one percent of the MDTs discussed BC patients of all disease stages, while 22% focused only on patients with early disease. Twenty-four percent of the MDTs discussed different tumor types (breast and non-breast) during their meetings. A greater proportion of respondents from South America reported that their MDTs discussed cases of different tumor types than their counterparts from Western Europe (50% versus 19%, respectively; P = 0.03).

clinical decision making

Thirty-eight percent of the MDTs were chaired by a designated chairperson, 12% by rotating chairpersons, 22% cochaired by more than one person, and in 26% there was no designated chairperson (Table 2). The duration of a typical MDT meeting was <1 (29%), 1–1.5 (52%), and >1.5 h (18%). When there was more than one opinion, either the chairperson made the final decision (13%) or there was a majority vote (67%). Almost half of the respondents (47%) declared that it was mandatory for the treating physician to implement the decisions and/or recommendations of the breast MDT (Table 2). However, 77% of the respondents were of the opinion that the recommendations made at the breast MDT were implemented by the treating physician most of the time.

Table 2.

Responses to various questions in the survey, especially pertaining to clinical decision making

 North America South America Western Europe Eastern Europe Africa Asia Oceania Total 
Who chairs the breast MDT sessions? 
    Designated chairperson (for fixed term) – 4 (33) 25 (36) 11 (55) – 7 (28)  
    Rotating chairperson (specified for a particular MDT session) – 2 (17) 10 (14) – – 4 (16)  
    Cochaired by more than one person – 1 (8) 20 (29) 3 (15) – 4 (16)  
    No designated chairperson – 5 (42) 13 (19) 6 (30) 9 (36) –  
    Other – – – – – –  
    Do not know or decline to answer – – 1 (1) – – 1 (4) –  
    Total 12 69 20 25  
Who makes the final decision/recommendation in case there is more than one opinion? 
    Chairperson – – 10 (14) 3 (15) – 4 (15) 18 (13) 
    Majority vote 10 (83) 44 (64) 14 (70) 17 (65) 94 (67) 
    Other – – 9 (13) 2 (10) – 3 (12) 16 (11) 
    Do not know or decline to answer – 2 (17) 6 (9) 1 (5) – 2 (8) 12 (9) 
    Total 12 69 20 26 140 
Is it mandatory for the treating doctor to implement the decision/recommendation of the breast MDT? 
    No 8 (73) 25 (36) 5 (25) 14 (54) 63 (45) 
    Yes – 2 (18) 36 (51) 15 (75) 12 (46) – 66 (48) 
    Do not know or decline to answer – 1 (9) 9 (13) – – – – 10 (7) 
    Total 11 70 20 26 139 
How often (in your opinion) is the decision/recommendation of the breast MDT implemented? 
    0%–25% – – 4 (6) – – – – 4 (3) 
    26%–50% – – – 1 (5) – 2 (8) – 3 (2) 
    51%–75% – 3 (25) 3 (4) 2 (10) – 6 (23) 15 (11) 
    76%–100% 8 (67) 56 (80) 16 (80) 17 (65) 109 (77) 
    Do not know or decline to answer – 1 (8) 7 (10) 1 (5) – 1 (4) – 10 (7) 
    Total 12 70 20 26 141 
In case of a lawsuit brought by a patient who underwent treatment according to the decision of the breast MDT, who do you think is/are legally responsible? 
    All members of MDT 3 (25) 18 (26) 5 (25) 8 (31) 37 (26) 
    The treating doctor – 6 (50) 34 (49) 11 (55) 11 (42) 71 (50) 
    Other – – 3 (4) 1 (5) – – – 4 (3) 
    Do not know or decline to answer – 3 (25) 15 (21) 3 (15) – 7 (27) 29 (21) 
    Total 12 70 20 26 141 
In your country, how is the opinion of the MDT perceived? 
    ‘Final’ 4 (33) 19 (27) 7 (35) – 3 (11) – 34 (24) 
    ‘Recommendation’ – 8 (67) 50 (71.5) 12 (60) 20 (77) 101 (72) 
    ‘Other’ – – – 1 (5) – 1 (4) – 2 (1) 
    Do not know or decline to answer – – 1 (1.5) – 2 (8) – 4 (3) 
    Total 12 70 20 26 141 
 North America South America Western Europe Eastern Europe Africa Asia Oceania Total 
Who chairs the breast MDT sessions? 
    Designated chairperson (for fixed term) – 4 (33) 25 (36) 11 (55) – 7 (28)  
    Rotating chairperson (specified for a particular MDT session) – 2 (17) 10 (14) – – 4 (16)  
    Cochaired by more than one person – 1 (8) 20 (29) 3 (15) – 4 (16)  
    No designated chairperson – 5 (42) 13 (19) 6 (30) 9 (36) –  
    Other – – – – – –  
    Do not know or decline to answer – – 1 (1) – – 1 (4) –  
    Total 12 69 20 25  
Who makes the final decision/recommendation in case there is more than one opinion? 
    Chairperson – – 10 (14) 3 (15) – 4 (15) 18 (13) 
    Majority vote 10 (83) 44 (64) 14 (70) 17 (65) 94 (67) 
    Other – – 9 (13) 2 (10) – 3 (12) 16 (11) 
    Do not know or decline to answer – 2 (17) 6 (9) 1 (5) – 2 (8) 12 (9) 
    Total 12 69 20 26 140 
Is it mandatory for the treating doctor to implement the decision/recommendation of the breast MDT? 
    No 8 (73) 25 (36) 5 (25) 14 (54) 63 (45) 
    Yes – 2 (18) 36 (51) 15 (75) 12 (46) – 66 (48) 
    Do not know or decline to answer – 1 (9) 9 (13) – – – – 10 (7) 
    Total 11 70 20 26 139 
How often (in your opinion) is the decision/recommendation of the breast MDT implemented? 
    0%–25% – – 4 (6) – – – – 4 (3) 
    26%–50% – – – 1 (5) – 2 (8) – 3 (2) 
    51%–75% – 3 (25) 3 (4) 2 (10) – 6 (23) 15 (11) 
    76%–100% 8 (67) 56 (80) 16 (80) 17 (65) 109 (77) 
    Do not know or decline to answer – 1 (8) 7 (10) 1 (5) – 1 (4) – 10 (7) 
    Total 12 70 20 26 141 
In case of a lawsuit brought by a patient who underwent treatment according to the decision of the breast MDT, who do you think is/are legally responsible? 
    All members of MDT 3 (25) 18 (26) 5 (25) 8 (31) 37 (26) 
    The treating doctor – 6 (50) 34 (49) 11 (55) 11 (42) 71 (50) 
    Other – – 3 (4) 1 (5) – – – 4 (3) 
    Do not know or decline to answer – 3 (25) 15 (21) 3 (15) – 7 (27) 29 (21) 
    Total 12 70 20 26 141 
In your country, how is the opinion of the MDT perceived? 
    ‘Final’ 4 (33) 19 (27) 7 (35) – 3 (11) – 34 (24) 
    ‘Recommendation’ – 8 (67) 50 (71.5) 12 (60) 20 (77) 101 (72) 
    ‘Other’ – – – 1 (5) – 1 (4) – 2 (1) 
    Do not know or decline to answer – – 1 (1.5) – 2 (8) – 4 (3) 
    Total 12 70 20 26 141 

All figures are in n (%), and percentages are only presented for the regions where at least 10 centers participated.

MDT, multidisciplinary team.

To the hypothetical question about who they thought would be legally responsible in case a lawsuit were filed by a patient who underwent treatment according to the decision of the BC MDT, half of the respondents replied that it would be the treating doctor while 26% thought that members of the MDT would be responsible. Seventy-two percent of the respondents stated that in their country, the opinion of the MDT was perceived as a ‘recommendation’, while in 24%, it was viewed as the ‘final’ decision. The perception of the MDT opinion being final was higher among European respondents than their Asian counterparts (29% versus 12%, respectively), although statistical significance was not reached (P value 0.08).

guidelines and training

Seventy-seven percent of the respondents indicated there were no national or regional guidelines for how MDTs should function in their country (Table 3). The same proportion of the respondents indicated that MDT members did not receive any specific training about functions or rules of the BC MDT before joining. According to 74% of the respondents, there was no specific financial compensation for participating in BC MDT meetings as it was considered a part of their normal work obligations.

Table 3.

Responses to various questions in the survey, especially pertaining to guidelines and training

 North America South America Western Europe Eastern Europe Africa Asia Oceania Total 
Are there any national or regional guidelines on MDT working in your country/region? 
    No 9 (82) 53 (77) 12 (60) 21 (81) 107 (77) 
    Yes – 2 (18) 12 (17) 8 (40) – 4 (15) 27 (19) 
    Do not know or decline to answer – – 4 (6) – – 1 (4) – 5 (4) 
    Total 11 69 20 26 139 
Do members receive any specific training about functions/rules of the breast MDT before joining? 
    No 9 (82) 54 (77) 12 (60) 21 (81) 108 (77) 
    Yes – 2 (18) 12 (17) 8 (40) – 4 (15) 27 (19) 
    Do not know or decline to answer – – 4 (6) – – 1 (4) – 5 (4) 
    Total 11 70 20 26 140 
How is the financial compensation of breast MDT participants taken care of? 
    Honorary (no specific payment, part of normal work obligation) 8 (67) 49 (70) 17 (85) 2 (67) 20 (77) 7 (78) 104 (74) 
    Patient is charged for MDT opinion – – 1 (1.5) – – 1 (4) – 2 (1) 
    Institution/hospital receives compensation – – 8 (11.5) 1 (5) – 1 (4) – 10 (7) 
    Other – 3 (25) 3 (4) 1 (5) 1 (33) 1 (4) 2 (22) 11 (8) 
    Do not know or decline to answer – 1 (8) 9 (13) 1 (5) – 3 (11) – 14 (10) 
    Total 12 70 20 26 141 
Which of the following statements about breast MDTs do you agree with? (multiple answers possible) 
    MDTs should be a mandatory part of cancer care 10 (91) 67 (97) 18 (90) 22 (85)  
    Members of MDTs should receive more training than available currently – 6 (55) 25 (36) 11 (55) 20 (77)  
    Decline to answer – – 2 (3) – – –  
    Total 11 69 20 26  
 North America South America Western Europe Eastern Europe Africa Asia Oceania Total 
Are there any national or regional guidelines on MDT working in your country/region? 
    No 9 (82) 53 (77) 12 (60) 21 (81) 107 (77) 
    Yes – 2 (18) 12 (17) 8 (40) – 4 (15) 27 (19) 
    Do not know or decline to answer – – 4 (6) – – 1 (4) – 5 (4) 
    Total 11 69 20 26 139 
Do members receive any specific training about functions/rules of the breast MDT before joining? 
    No 9 (82) 54 (77) 12 (60) 21 (81) 108 (77) 
    Yes – 2 (18) 12 (17) 8 (40) – 4 (15) 27 (19) 
    Do not know or decline to answer – – 4 (6) – – 1 (4) – 5 (4) 
    Total 11 70 20 26 140 
How is the financial compensation of breast MDT participants taken care of? 
    Honorary (no specific payment, part of normal work obligation) 8 (67) 49 (70) 17 (85) 2 (67) 20 (77) 7 (78) 104 (74) 
    Patient is charged for MDT opinion – – 1 (1.5) – – 1 (4) – 2 (1) 
    Institution/hospital receives compensation – – 8 (11.5) 1 (5) – 1 (4) – 10 (7) 
    Other – 3 (25) 3 (4) 1 (5) 1 (33) 1 (4) 2 (22) 11 (8) 
    Do not know or decline to answer – 1 (8) 9 (13) 1 (5) – 3 (11) – 14 (10) 
    Total 12 70 20 26 141 
Which of the following statements about breast MDTs do you agree with? (multiple answers possible) 
    MDTs should be a mandatory part of cancer care 10 (91) 67 (97) 18 (90) 22 (85)  
    Members of MDTs should receive more training than available currently – 6 (55) 25 (36) 11 (55) 20 (77)  
    Decline to answer – – 2 (3) – – –  
    Total 11 69 20 26  

All figures are in n (%), and percentages are only presented for the regions where at least 10 centers participated.

MDT, multidisciplinary team.

Table 4.

Responses to various questions in the survey, especially pertaining to benefits of MDTs

 North America South America Western Europe Eastern Europe Africa Asia Oceania Total 
How satisfied are you with the working of your breast MDT? 
    Very satisfied – 5 (42) 23 (33.5) 7 (35) 5 (19) 44 (31) 
    Satisfied 4 (33) 36 (52) 10 (50) 12 (46) 70 (50) 
    Somewhat satisfied – – 9 (13) 2 (10) – 6 (23) 18 (13) 
    Not at all satisfied – 2 (17) – – – 3 (12) – 5 (4) 
    Do not know or decline to answer – 1 (8) 1 (1.5) 1 (5) – – – 3 (2) 
    Total 12 69 20 26 140 
In your opinion, effective breast MDT working results in which of the following? (multiple answers possible) 
    Improved clinical decision making 10 (83) 68 (97) 20 (100) 26 (100) 137 (97) 
    More coordinated patient care 11 (92) 64 (91) 19 (95) 22 (85) 129 (91) 
    Evidence-based treatment decisions 11 (92) 62 (89) 18 (90) 24 (92) 128 (91) 
    Improved timeliness of tests/treatments – 6 (50) 46 (66) 15 (75) 17 (65) 90 (64) 
    Increase in proportion of patients being considered for clinical trials 7 (58) 50 (71) 12 (60) 16 (62) 98 (70) 
    Improved overall quality of treatment 10 (83) 67 (96) 16 (80) 25 (96) 131 (93) 
    Improved patient involvement in treatment decisions 2 (17) 4 (6) 4 (20) – 5 (19) – 16 (11) 
    Increased proportion of patients being staged – 2 (17) 2 (3) 2 (10) – 1 (4) – 7 (5) 
    Improved survival rates – 1 (8) 6 (9) 2 (10) – 3 (12) – 12 (9) 
    Total 12 70 20  141 
 North America South America Western Europe Eastern Europe Africa Asia Oceania Total 
How satisfied are you with the working of your breast MDT? 
    Very satisfied – 5 (42) 23 (33.5) 7 (35) 5 (19) 44 (31) 
    Satisfied 4 (33) 36 (52) 10 (50) 12 (46) 70 (50) 
    Somewhat satisfied – – 9 (13) 2 (10) – 6 (23) 18 (13) 
    Not at all satisfied – 2 (17) – – – 3 (12) – 5 (4) 
    Do not know or decline to answer – 1 (8) 1 (1.5) 1 (5) – – – 3 (2) 
    Total 12 69 20 26 140 
In your opinion, effective breast MDT working results in which of the following? (multiple answers possible) 
    Improved clinical decision making 10 (83) 68 (97) 20 (100) 26 (100) 137 (97) 
    More coordinated patient care 11 (92) 64 (91) 19 (95) 22 (85) 129 (91) 
    Evidence-based treatment decisions 11 (92) 62 (89) 18 (90) 24 (92) 128 (91) 
    Improved timeliness of tests/treatments – 6 (50) 46 (66) 15 (75) 17 (65) 90 (64) 
    Increase in proportion of patients being considered for clinical trials 7 (58) 50 (71) 12 (60) 16 (62) 98 (70) 
    Improved overall quality of treatment 10 (83) 67 (96) 16 (80) 25 (96) 131 (93) 
    Improved patient involvement in treatment decisions 2 (17) 4 (6) 4 (20) – 5 (19) – 16 (11) 
    Increased proportion of patients being staged – 2 (17) 2 (3) 2 (10) – 1 (4) – 7 (5) 
    Improved survival rates – 1 (8) 6 (9) 2 (10) – 3 (12) – 12 (9) 
    Total 12 70 20  141 

All figures are in n (%), and percentages are only presented for the regions where at least 10 centers participated.

MDT, multidisciplinary team.

benefits of MDTs

Thirty-one percent of the respondents were ‘very satisfied’ with the way their MDTs worked, while 50% were ‘satisfied’(Table 4). Most respondents reported that MDTs result in improved clinical decision making (97%), improved overall quality of treatment (93%), more coordinated patient care (91%), and evidence-based treatment decisions (91%). However, only 9% of the respondents reported that breast MDTs resulted in improved survival rates.

discussion

This unique survey provides us with objective information of frequency, composition, function, and working mechanism of MDTs in oncology with specific reference to BC. Results from this survey provide important new insights into BC MDTs that have been implemented in most parts of the world; however, there are countries that have still not adopted them.

For unknown reasons, this response rate (152 of 867, 18%) is significantly lower than previous online surveys conducted by the Breast International Group. There was a considerable variability in terms of structure and functioning of MDTs between different countries and regions. For example, MDTs met more frequently in Western European centers than in Asian ones, perhaps a reflection of the incidence of BC in the respective regions. Patients or their representatives attended MDT meetings more often in Eastern Europe and Asia than in Western Europe and South America. This was particularly striking in Eastern Europe, where patients or their representatives were more likely to be involved in MDT meetings (50%) than in other parts of the world. It is also striking that about half of the MDTs in South America discuss both BC and other cancer cases, perhaps a reflection of the fact that oncologists there treat a variety of cancer types in daily practice. The perception of the MDT opinion being final was higher among European respondents than their Asian counterparts (29% versus 12%).

In the present study, in half the MDTs, they did not have specialist nurses attend any meetings. Nurses are a key point of contact between oncologists and patients and are critical for the continuity of care of BC patients, thus their attendance in MDTs in an increasing frequency is desirable [13, 14]. Some MDTs encourage the patients’ families or friends to attend their meetings [13]. One study found that while the involvement of BC patients in MDT meetings was supported by 93% of patient advocates, only a minority of health care professionals (32% of surgeons, 25% of medical oncologists, and 24% of radiation oncologists) supported the idea, mainly because they felt that it would raise patient anxiety [15]. Similar findings were noted in a survey of >2000 MDT members in England, where most respondents felt that it was not practical or desirable for patients to attend MDT meetings [16]. However, a pilot study involving 30 BC patients concluded that patient attendance in MDT meetings is potentially acceptable to patients and health care professionals, without significantly raising patient anxiety [17].

Discussion of individual cases by experienced specialists at MDT meetings provides an excellent opportunity for training early-career doctors. In our study, trainees were present in substantial numbers in MDT meetings in most parts of the world, except in Eastern Europe, where they attended about one-third of such meetings. In contrast, the doctor in charge of the specific case was present in a surprisingly low number of MDT meetings (range 30%–65%) in all regions. The attendance of different specialists in MDT meetings is variable according to several studies reported in the literature [18–20].

Over the past two decades, cancer patients in Western countries are increasingly being managed under the purview of an MDT. Some countries have adopted guidelines for MDT functioning, and this could perhaps translate into a more consistent approach to patient care. For example, in the UK, the widespread introduction of MDTs began with the publication in 1995 of the Calman–Hine report [21]. Recommendations made in this report have been associated with improvements in processes and outcomes for BC patients [22]. It has been estimated that in 2004 >80% of all cancer patients in the UK were managed in the context of an MDT, up from <20% in 1994 [23]. A national survey completed by >2000 MDT members in England led to the publication of a document entitled ‘The characteristics of an effective MDT’ (National Cancer Action Team, England). This provides recommendations/guidelines for effective MDT working based on the clinical consensus achieved by the national survey. This work has also provided a springboard for a program of MDT development in England [16]. MDTs have been mandated to be the standard of care in many industrialized nations and are increasingly viewed as best practice [24]. Several Western countries have passed guidelines for the formation and running of MDTs (supplemental Table S1, available at Annals of Oncology online) and have deployed considerable financial, human, information technology, and administrative resources to set up and run them. This has increased the adoption of the MDT model. For example, it was estimated in 2004 that >90% of BC units in England held regular MDT meetings [23]. In Germany, a robust certification program provides quality assurance in multidisciplinary BC care [25].

However, data remain scarce regarding MDT decision-making processes, their functioning, and effectiveness in improving measurable health outcomes [26, 27]. Weak study designs, confounding factors, enforcement of standard practice guidelines, and changes in oncology practices over the recent past have made the evaluation of the impact of MDTs a very complex and inexact exercise [28]. There is an outstanding need to analyze and understand the key characteristics of MDT functioning, given that MDTs are a very expensive resource. There is paucity of high-quality data to support the notion that a breast MDT leads to improved BC survival.

A Swedish study involving >7600 patients found significant regional variation in BC survival, despite common guidelines, and concluded that strengthening of the multidisciplinary management of BC could improve survival [29].

Many developing countries have not formulated specific guidelines pertaining to MDTs, and some cancer centers do not have any formal MDTs at all [30]. For example, BC MDTs are only available at selected regional centers in India [31], and only 54% of the respondents to a survey of MDT utilization in Arab countries reported having dedicated BC MDTs [32]. While it is logical to expect variation in the structure and functioning of MDTs across different health care systems and populations, it is important to identify core characteristics that contribute to MDT effectiveness.

In an era of economic crunch, it is a challenge to tailor the MDTs to suit the geographical locations and the cultural and socioeconomic settings of diverse health care systems and thus facilitate interdisciplinary communication to optimize therapy and improve BC outcome [33]. While telemedicine-delivered BC MDTs may be a cost-effective and robust solution [34, 35], ‘mini MDTs’ may be useful in other contexts [32].

conclusions

This study shows that there are different models of BC MDTs across the world, with no standard guidelines in most places. The composition of the BC MDT is variable, mostly consisting of oncologists (medical, surgical, and radiation) and pathologists. The representation of specialist nurses is quite low in most BC MDTs worldwide. The content of these meetings is also quite variable, especially in terms of discussing tumor types and early-versus-late BC. This study supports previous findings that there is a high satisfaction from working in MDTs and that these BC MDTs are perceived to lead to better clinical decisions, evidence-based practice, and improved quality of treatment.

This study is an attempt to scrutinize BC MDT functioning worldwide, and insights gained from this survey should be validated and further explored in future studies. In this era of personalized medicine, there is a clear need for improvement in the MDT functioning worldwide.

funding

CP wishes to acknowledge the grant support (Grant number C20208/A8667) from Cancer Research UK and the Imperial College Healthcare Charity. The Division of Cancer at the Imperial College London/Imperial College HealthCare NHS Trust is an Experimental Cancer Medicine Center that is supported by funds from Cancer Research UK and the Department of Health.

disclosure

The authors declare no conflict of interest.

The authors would like to thank all the investigators who participated in this survey. In addition, they would like to thank Mona Ridderheim of GlaxoSmithKline for permission to contact the investigators of this phase III trial, Françoise Van Eenoo for assistance with preparation of the tables in this manuscript, Jaclyn Wallace for project management, and Carolyn Straehle and Anne Westcott for editorial support.

References

1.
Halsted
WSI
The results of radical operations for the cure of carcinoma of the breast
Ann Surg
 , 
1907
, vol. 
46
 
1
(pg. 
1
-
19
)
2.
Wilking
NKF
A Review of Breast Cancer Care and Outcomes in 18 Countries in Europe, Asia, and Latin America
 , 
2009
Stockholm, Sweden
Karolinska Institutet
 
3.
Fisher
B
Fisher
ER
The interrelationship of hematogenous and lymphatic tumor cell dissemination
Surg Gynecol Obstet
 , 
1966
, vol. 
122
 
4
(pg. 
791
-
798
)
4.
De Lena
M
Brambilla
C
Morabito
A
Bonadonna
G
Adriamycin plus vincristine compared to and combined with cyclophosphamide, methotrexate, and 5-fluorouracil for advanced breast cancer
Cancer
 , 
1975
, vol. 
35
 
4
(pg. 
1108
-
1115
)
5.
Kaufman
CS
Breast care is a team sport
Breast J
 , 
2004
, vol. 
10
 
5
(pg. 
469
-
472
)
6.
Ruhstaller
T
Roe
H
Thurlimann
B
Nicoll
JJ
The multidisciplinary meeting: an indispensable aid to communication between different specialities
Eur J Cancer
 , 
2006
, vol. 
42
 
15
(pg. 
2459
-
2462
)
7.
Department of Health
Manual for Cancer Services
 , 
2004
London
Department of Health
8.
Fleissig
A
Jenkins
V
Catt
S
Fallowfield
L
Multidisciplinary teams in cancer care: are they effective in the UK?
Lancet Oncol
 , 
2006
, vol. 
7
 
11
(pg. 
935
-
943
)
9.
Sainsbury
R
Haward
B
Rider
L
, et al.  . 
Influence of clinician workload and patterns of treatment on survival from breast cancer
Lancet
 , 
1995
, vol. 
345
 
8960
(pg. 
1265
-
1270
)
10.
Chang
JH
Vines
E
Bertsch
H
, et al.  . 
The impact of a multidisciplinary breast cancer center on recommendations for patient management: the University of Pennsylvania experience
Cancer
 , 
2001
, vol. 
91
 
7
(pg. 
1231
-
1237
)
11.
Vinod
SK
Sidhom
MA
Delaney
GP
Do multidisciplinary meetings follow guideline-based care?
J Oncol Pract
 , 
2010
, vol. 
6
 
6
(pg. 
276
-
281
)
12.
Chirgwin
J
Craike
M
Gray
C
, et al.  . 
Does multidisciplinary care enhance the management of advanced breast cancer?: evaluation of advanced breast cancer multidisciplinary team meetings
J Oncol Pract
 , 
2010
, vol. 
6
 
6
(pg. 
294
-
300
)
13.
Gabel
M
Hilton
NE
Nathanson
SD
Multidisciplinary breast cancer clinics. Do they work?
Cancer
 , 
1997
, vol. 
79
 
12
(pg. 
2380
-
2384
)
14.
Amir
Z
Scully
J
Borrill
C
The professional role of breast cancer nurses in multi-disciplinary breast cancer care teams
Eur J Oncol Nurs
 , 
2004
, vol. 
8
 
4
(pg. 
306
-
314
)
15.
Butow
P
Harrison
JD
Choy
ET
, et al.  . 
Health professional and consumer views on involving breast cancer patients in the multidisciplinary discussion of their disease and treatment plan
Cancer
 , 
2007
, vol. 
110
 
9
(pg. 
1937
-
1944
)
16.
 
National Cancer Action Team (England). The Characteristics of an Effective MDT 2010; http://ncat.nhs.uk/sites/default/files/NCATMDTCharacteristics.pdf (21 January 2011, date last accessed)
17.
Choy
ET
Chiu
A
Butow
P
, et al.  . 
A pilot study to evaluate the impact of involving breast cancer patients in the multidisciplinary discussion of their disease and treatment plan
Breast
 , 
2007
, vol. 
16
 
2
(pg. 
178
-
189
)
18.
Macaskill
EJ
Thrush
S
Walker
EM
Dixon
JM
Surgeons' views on multi-disciplinary breast meetings
Eur J Cancer
 , 
2006
, vol. 
42
 
7
(pg. 
905
-
908
)
19.
Whelan
JM
Griffith
CD
Archer
T
Breast cancer multi-disciplinary teams in England: much achieved but still more to be done
Breast
 , 
2006
, vol. 
15
 
1
(pg. 
119
-
122
)
20.
Harrison
JD
Choy
ET
Spillane
A
, et al.  . 
Australian breast cancer specialists' involvement in multidisciplinary treatment planning meetings
Breast
 , 
2008
, vol. 
17
 
4
(pg. 
335
-
340
)
21.
Calman
KC
Hine
J
A policy framework for commissioning cancer services. A report by the Expert Advisory Group on Cancer to the Chief Medical Officers of England and Wales, Department of Health: London 1995
22.
Morris
E
Haward
RA
Gilthorpe
MS
, et al.  . 
The impact of the Calman-Hine report on the processes and outcomes of care for Yorkshire's breast cancer patients
Ann Oncol
 , 
2008
, vol. 
19
 
2
(pg. 
284
-
291
)
23.
Griffith
C
Turner
J
United Kingdom National Health Service, Cancer Services Collaborative “Improvement Partnership”, Redesign of Cancer Services: a national approach
Eur J Surg Oncol
 , 
2004
, vol. 
30
 
Suppl 1
(pg. 
1
-
86
)
24.
ASCO-ESMO consensus statement on quality cancer care
Ann Oncol
 , 
2006
, vol. 
17
 
7
(pg. 
1063
-
1064
25.
Brucker
SY
Bamberg
M
Jonat
W
, et al.  . 
Certification of breast centres in Germany: proof of concept for a prototypical example of quality assurance in multidisciplinary cancer care
BMC Cancer
 , 
2009
, vol. 
9
 pg. 
228
 
26.
Lamb
B
Green
JS
Vincent
C
Sevdalis
N
Decision making in surgical oncology. Surg Oncol
 
2010 August 16 [Epub ahead of print]
27.
Houssami
N
Sainsbury
R
Breast cancer: multidisciplinary care and clinical outcomes
Eur J Cancer
 , 
2006
, vol. 
42
 
15
(pg. 
2480
-
2491
)
28.
Taylor
C
Munro
AJ
Glynne-Jones
R
, et al.  . 
Multidisciplinary team working in cancer: what is the evidence?
BMJ
 , 
2010
, vol. 
340
 pg. 
c951
 
29.
Eaker
S
Dickman
PW
Hellstrom
V
, et al.  . 
Regional differences in breast cancer survival despite common guidelines
Cancer Epidemiol Biomarkers Prev
 , 
2005
, vol. 
14
 
12
(pg. 
2914
-
2918
)
30.
Anderson
BO
Yip
CH
Smith
RA
, et al.  . 
Guideline implementation for breast healthcare in low-income and middle-income countries: overview of the Breast Health Global Initiative Global Summit 2007
Cancer
 , 
2008
, vol. 
113
 
8 Suppl
(pg. 
2221
-
2243
)
31.
Agarwal
G
Ramakant
P
Breast cancer care in India: the current scenario and the challenges for the future
Breast Care (Basel)
 , 
2008
, vol. 
3
 
1
(pg. 
21
-
27
)
32.
El Saghir
N
El Asmar
N
Hajj
C
, et al.  . 
Survey of utilization of multidisciplinary management tumor boards in Arab countries
Breast
 , 
2011
, vol. 
20
 
Suppl 2
(pg. 
S70
-
S74
)
33.
Jakesz
R
Breast cancer in developing countries: challenges for multidisciplinary care
Breast Care (Basel)
 , 
2008
, vol. 
3
 
1
(pg. 
4
-
5
)
34.
Kunkler
IH
Fielding
RG
Brebner
J
, et al.  . 
A comprehensive approach for evaluating telemedicine-delivered multidisciplinary breast cancer meetings in southern Scotland
J Telemed Telecare
 , 
2005
, vol. 
11
 
Suppl 1
(pg. 
71
-
73
)
35.
Kunkler
IH
Prescott
RJ
Lee
RJ
, et al.  . 
TELEMAM: a cluster randomised trial to assess the use of telemedicine in multi-disciplinary breast cancer decision making
Eur J Cancer
 , 
2007
, vol. 
43
 
17
(pg. 
2506
-
2514
)