A National Cancer Institute-funded multi-site study is lending evidence to the idea that multidisciplinary cancer care improves patient care processes and patient outcomes.
The Multidisciplinary Care Research Project, undertaken by the NCI Community Cancer Centers Program (NCCCP), investigated whether specific elements of multidisciplinary care—for example, case planning or care coordination—appear to influence treatment decisions, overall survival, and care processes such as time to initial treatment.
Speaking at the Association of Community Cancer Center's National Conference, which had the theme “Spotlight on Success,”' Nicholas J. Petrelli, MD, Medical Director of the Helen F. Graham Cancer Center & Research Institute in Newark, Del., reported that the pilot study found that:
* Patients treated for non-small-cell lung cancer (NSCLC) at institutions with higher levels of care coordination had a much higher likelihood of receiving multimodality therapy;
* Colon, rectal, and lung cancer patients have a much lower risk of death if treated at hospitals with high levels of care coordination;
* Colon cancer patients treated at cancer centers with a high degree of financial integration among caregivers were more likely to be evaluated for clinical trials; and
* Colon cancer patients seeking care at institutions with higher levels of physician engagement—one element of multidisciplinary care—tend to receive treatment sooner.
The pilot study also had some counterintuitive findings, in which higher levels of multidisciplinary care were associated with poorer patient outcomes. One of the study's coauthors, Andrew L Salner, MD, Director of the Helen & Harry Gray Cancer Center at Hartford Hospital in Connecticut, said he believes those findings reflect the fact that multidisciplinary care, which is still rare in community hospitals, is not yet standardized and that research into multidisciplinary care is in its infancy.
“It is likely that we need to refine some of our measurement tools to measure multidisciplinary care as well as how we collect some of the metrics that determine how effective it is,” he said.
Another team member, James D. Bearden, III, MD, Associate Director of Gibbs Cancer Center & Research Institute in Spartanburg, S.C., said the study's positive findings reinforced his conviction that multidisciplinary care should be widely adopted.
“I really think this has influenced the care of patients more than anything else I've seen happen within the hospital, and I've been in practice for 36 years. When you have a complicated patient, it is so reassuring to know you will bring that case to a multidisciplinary team and get all their input to collectively make the best decision regarding that patient's treatment. It is inconceivable to me now to practice medicine any other way.”
The research was undertaken by the NCCCP, a network of funded cancer centers in community hospitals across the country, as part of its work to identify ways to reduce cancer care disparities, increase accrual in clinical trials, and improve the quality of cancer care. Records for 1,077 patients with Stage III NSCLC, Stage III colon cancer, or Stage II or III rectal cancer treated at 14 cancer centers were analyzed.
Despite the growing emphasis on multidisciplinary care in recent years, the study marks the first time that the concept has been examined for multiple tumor types across multiple institutions. In doing so, the researchers acknowledged that multidisciplinary care is practiced differently from one institution to the next and, thus, saying that multidisciplinary care has a positive effect is meaningless unless the nuances of care delivery are understood.
To address that issue, the researchers developed a matrix that identifies five levels of multidisciplinary care based on the implementation of seven elements of care: case planning, physician engagement, coordination of care, infrastructure, financial, clinical trials, and medical records (see next page).
The aim was to learn how each of those elements were associated with five patient outcomes and processes of care:
* Receipt of multi-modality therapy (for stage III NSCLC);
* Overall survival;
* Time to receipt of initial therapy;
* Evaluation for enrollment in a clinical trial; and
* Adherence to National Comprehensive Cancer Network (NCCN) treatment guidelines.
“Intuitively, it just makes so much sense that the more you formalize the multidisciplinary care process, the better it's going to be for patients,” Salner said.
While that hypothesis was generally borne out, a few findings suggested just the opposite. The researchers hypothesize that comorbidities and other confounding factors at the patient level that were not captured in data collection may have influenced those findings.
“I just can't see how it doesn't improve the care,” Bearden said. “It adds peer pressure. If everybody in the room is saying a clinical trial or a certain guideline is the best thing to do, it's going to be hard to make a decision not to put them in a clinical trial, or not to follow NCCN guidelines.”
While more research is needed to fully understand which elements of multidisciplinary care yield the most benefits, the NCCCP matrix provides a framework for understanding multidisciplinary care, Salner said. “It does give cancer center leaders some good guidelines and suggestions about where they should be heading in terms of multidisciplinary care.”