Uro-oncology multidisciplinary meetings at anAustralian tertiary referral centre – impact onclinical decision-making and implications forpatient inclusionKenny Rao*, Kiran Manya*, Arun Azad†, Nathan Lawrentschuk*‡¶, Damien Bolton*‡,Ian D. Davis†§ and Shomik Sengupta*‡¶

*Department of Urology and †Joint Austin-Ludwig Oncology Unit, Austin Health, ‡Austin Department of Surgery,University of Melbourne, ¶Ludwig Institute for Cancer Research, Austin Hospital, and §Eastern Health Clinical School,Monash University, Melbourne, VIC, Australia

ObjectivesTo analyse the impact of the uro-oncology multidisciplinarymeeting (MDM) at an Australian tertiary centre on patientmanagement decisions, and to develop criteria for patientinclusion in MDMs.

MethodsOver a 3-month period, all cases presented at our weeklyuro-oncology MDM were prospectively assessed, by asking thepresenting clinician to state their provisional managementplans and comparing this with the subsequent consensusdecision. The impact of the MDM was graded as high if therewas a major change in the management plan or if a plan wasdeveloped where there was none.

ResultsOver the study period, 120 discussions about 107 patientswere recorded. Prostate, urothelial, kidney and testis cancerrepresented 46 (38.3%), 36 (30%), 26 (21.6%) and 12 (10%) of

the discussions, respectively. The MDM made high impactchanges to the original plan in 32 (26.7%) cases. High impactchanges were nearly twice as likely to occur in patients withmetastatic disease as in those without metastases (P < 0.05).Primary cross referral between disciplines occurred in 40(33.3%) cases, including 66.7% of testicular and 42% ofbladder cancers but only 26% of prostate and 19% of kidneycancers (P < 0.02).

ConclusionsThe uro-oncology MDM alters management plans in aboutone-quarter of cases. Additionally, MDMs also serve otherpurposes, such as cross-referral or consideration for clinicaltrials. Patients should be discussed in MDMs if multimodaltherapy may be required, clinical trial eligibility is beingconsidered or if metastasis or recurrence is noted.

Keywordsmultidisciplinary team (MDT), multidisciplinary meeting(MDM), decision making, uro-oncology

Introduction

Internationally, patients with cancer are increasingly managedby multidisciplinary teams (MDTs), which include nurses, alliedhealth professionals, surgeons, radiation oncologists, medicaloncologists, pathologists and radiologists. Multidisciplinary careallows the use of varying professional skills in complex clinicalscenarios, with numerous putative benefits for the patient [1]. Inparticular, this may facilitate clinical decision-making and aid incoordinating management, thus improving quality of care. As aresult, multidisciplinary care has now been designated as a keypriority in cancer care at a government level in Australia [2].

The effective delivery of multidisciplinary care is contingentupon an appropriate mechanism for collaborative

communication between the MDT members. Very often, thistakes the form of a multidisciplinary meeting (MDM), whereindividual cases are discussed, with the aim of reviewing orreaching decisions on the further management of that patient.MDMs have been the subject of intense scrutiny, particularlyin relation to their implementation, composition, accessibilityand decision-making [3–7]. A recent review suggests thatMDMs generally have a significant impact on clinicaldecision-making for various cancer types [8].

However, there is currently limited data on the type andproportion of genitourinary cancers discussed at MDMs andconflicting evidence about the impact of these discussionson clinical decision-making. We have previously shown anincreased uptake of neoadjuvant chemotherapy for

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muscle-invasive bladder cancer after the initiation of auro-oncology MDM [9], while a North American study hasreported a greater adherence to treatment guidelines forpatients with prostate cancer [10]. Conversely, two Englishstudies have shown relatively infrequent change ofmanagement based on discussions at genito-urinary oncologyMDMs [5,6].

The aim of the present study was to prospectively investigatethe impact on clinical management decisions of theuro-oncology MDM at our tertiary-referral institution.Additionally, we aimed to develop criteria by which patientsmay be selected for MDM discussion.

MethodsAustin Uro-Oncology MDM

The Austin Health uro-oncology MDT consists of urologists,oncologists, radiation oncologists, radiologists, research nursesand trainees from various disciplines. Formal MDMs wereinitiated in 2007 as an adjunct to outpatient clinics [9], andhave developed over time to a more formalised meetingstructure, including prospective record keeping. Currently,meetings are held weekly with cases drawn from both AustinHealth and individual private practices. During the course ofthis study, patients were included in the MDM selectively atthe discretion of the treating clinician. This study wasconducted with approval from the Austin Health HumanResearch Ethics Committee.

Case Capture

As cases are selectively included in our MDM, we attemptedto estimate the proportion of eligible cases brought for MDMdiscussion by examining the subset diagnosed or treatedsurgically. A prospective database of urological procedures wasused to identify all newly diagnosed genitourinary cancerswithin the urology unit over a 3-month period in 2012. Thesewere then cross-referenced with the prospectively maintaineddatabase from the MDM to see if the case had been discussedat the MDM during a 12-month period either side of theprocedure.

Decision-Making

All cases discussed over a 3-month period at the AustinHealth uro-oncology MDM were prospectively evaluatedfor the impact of the MDM on clinical decision-making.Patient-specific data including age, sex, TNM stage, grade andtype of genitourinary cancer (i.e. prostate, kidney, bladder,testicular or other) were recorded. The source of the patient(private vs public) and seniority of presenting clinician(trainee vs consultant) was also noted. After presenting thecase details, the clinician was asked to specify the clinicalquestion/dilemma and state their individual management

plan, both of which were recorded. Subsequently, the MDTdiscussed the case and reached a consensus decision, whichwas also recorded.

The individual clinician’s plan and the MDM consensus planwere then compared and graded by a consultant urologist toassess the overall MDM impact as follows:

• Low impact: The clinician’s plan was endorsed orreinforced by the MDM discussion. Minor additions ormodifications were allowable, (e.g., change of surgicalapproach) but the essence of the proposed managementplan remained the same.

• High impact: The clinician’s plan was substantiallymodified (e.g., change of treatment method) or a plan wasdeveloped where none existed.

The impact of the MDM recommendation on resource usewas also assessed crudely based on whether additional orgreater interventions were needed.

Data Analysis

Data were entered into an Excel spreadsheet, and analysedusing online statistical software at www.statpages.org.Numerical data are presented as median (range) or mean (SD),as appropriate. Comparisons between groups were undertakenusing chi-square and Fisher’s exact tests, with statisticalsignificance ascribed to P < 0.05.

ResultsCase-Capture

Over the 3-month study period, 135 genitourinary cancerswere diagnosed/operated on at Austin Health, of which 46(34%) were discussed at the MDM. There were significantdifferences (Table 1) across tumour/procedure types in theproportion of patients discussed at MDM, ranging from 83%of patients undergoing cystectomy for invasive bladder cancerdown to only 23% of patients undergoing nephrectomy forkidney cancer or transurethral resection for bladder tumour(P < 0.002).

Patient Demographics

Over the 3-month study period, 120 discussions took placeat the MDM, involving 107 patients (seven patients werediscussed twice, three patients thrice) – in addition to patientsfrom the urology operating lists, this included patients fromurology, radiation oncology and medical oncology outpatientclinics and private consulting rooms. The median (range) ageof patients discussed was 63 (17–90) years, and 103 (85.8%)were males. The distribution of tumour types discussed at theMDM is shown in Table 2, with prostate cancer (46 cases,38.3%) and bladder cancer (36 cases, 33.3%) being the mostcommon.

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Decision-Making

Overall, high-impact changes were made to patientmanagement in 32 (26.7%) cases. This included a change oftreatment method in nine cases, a change from surgery tonon-intervention or diagnostic biopsy in three cases and adecision to operate in two cases. In addition, for the 18 caseswhere there was no original plan, the MDM developed a planin each case, often entailing cross-referral – to medicaloncology (seven cases), radiation oncology (two), urology(one) and a multidisciplinary sarcoma clinic (two) – or

commitment to a particular surgical (three cases) or aconservative (two) approach. Multimodal treatment wasrecommended in four cases, two being a change from singlemodality and two where a plan had not been developed. Therewere no instances of changing from multimodal tosingle-modality treatment.

For resource utilisation, when the clinician plan was endorsedor reinforced, there was necessarily no change, whereas whena plan was developed, it was necessarily increased. For thecases where the clinician’s plan was changed or added to,

Table 1 Capture of eligible cases from urology operating lists for MDM discussion.

Procedure Total, n N (%) discussed P (chi-squared)

Prostate cancer on TRUS biopsy 38 12 (31)Radical prostatectomy 27 7 (26)Nephrectomy 17 4 (23)Orchidectomy 10 6 (60)TURBT 31 7 (23)Cystectomy 12 10 (83)Total 135 46 (34) 0.002

TURBT, transurethral resection of bladder tumour; TRUS, trans-rectal ultrasound.

Table 2 Association of impact of MDM on clinical decision-making with clinicopathological features.

Feature Total, n N (%) high impact P

Sex:Female 17 6 (35) 0.37*Male 103 26 (25)

Age (median 63, range 17–90 years)<63 54 12 (22) 0.41*≥63 66 20 (30)

Disease:**Bladder 35 7 (19) 0.35*Kidney (renal & urothelial) 28 9 (38)Prostate 47 12 (26)Testis 12 4 (33)Other*** 2 1 (50)

Source:Public 82 18 (22) 0.086*Private 38 14 (37)

Metastasis:Yes 29 11 (38) <0.05*No/unknown 91 21 (23)

Non-metastatic by T-stage/disease:Bladder: 0.97*

T1–2 13 3 (18)T3–4 16 3 (19)

Kidney: 1.0†

T1–2 8 3 (38)T3–4 6 2 (33)

Prostate: 0.62†

T1 6 0 (0)T2 8 2 (25)T3 19 4 (21)

Testis: 1.0†

T1 5 1 (20)T2 5 1 (20)

*chi-squared test; **4 patients had dual pathology; ***includes 1 mediastinal germ cell tumour and 1 retroperitonealsarcoma; †Fisher’s exact test.

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resource use increased in 10 cases, decreased in five, wasunchanged in one and could not be assessed in the remainingfive (as they involved a change of method or timing oftreatment).

As shown in Table 2, most clinicopathological variables,including age, sex and tumour type, did not have a significantassociation with the impact of the MDM on decision-making.However, high impact changes to the management plan wereseen in twice as many patients with evident metastatic diseasecompared with those without (38% vs 23%, P < 0.05). Highimpact changes in management were also more likely to occurin cases presented from private practice than those from thepublic clinic (37% vs 22%), although this difference was notstatistically significant (P = 0.086). There were no differencesbetween the different specialities in terms of the impact of theMDM on decision-making.

In addition to decision-making, the MDM also served as avehicle for cross referral between disciplines in 40 (33.3%)cases, including six (5%) for inclusion in a clinical trial. Therewere significant differences across tumour types in the ratesof cross referral, occurring in eight of 12 (66.7%) testicularcancers, 15 of 36 (42%) bladder cancers, 12 of 46 (26%)prostate cancers and five of 26 (19%) kidney cancers(P = 0.014).

DiscussionIn the present prospective study, we analysed the workings ofa uro-oncology MDM at an Australian tertiary referral centre,thus gaining useful insights into both the capture of cases fordiscussion and the impact of discussions on decision-making.

We found that only about a third of newly diagnosed oroperated uro-genital cancers from the urology unit come toMDM discussion. Notably, invasive bladder cancers treated bycystectomy and testicular tumours treated by orchidectomyhad a high rate of MDM discussion, consistent with themultidisciplinary approach usually necessary for managingthese patients. In contrast, relatively few renal cancers treatedby nephrectomy or non-invasive bladder cancers treated bytransurethral resection were discussed at MDMs, as these areoften primarily managed surgically.

We also found that MDM discussion impacted significantly onclinical decision-making in over a quarter of cases discussed.In just under half of these, the treating clinician had a definedplan, which was changed substantially by the MDM discussion(e.g., change of treatment method or from a conservative to aninterventional approach or vice versa). In the remaining cases,the treating clinician did not have a definitive managementplan and the MDM developed a proposed treatment pathway.We have defined these changes as being ‘high-impact’, as theMDM is seen to have greatest clinical ‘value’ when it modifiesor develops the treatment plan for an individual patient.

For the other three-quarters of cases discussed, the MDMendorsed the clinician’s management plan, occasionally addingminor modifications, which we have classed as ‘low-impact’.However, it is important to acknowledge that, even in thesecases, the MDM has an important role to play in endorsingand validating the management plan, thereby giving it theimprimatur of the entire MDT. Our MDM also served animportant purpose in terms of facilitating cross-referralbetween disciplines, in some cases for inclusion in appropriateclinical trials. This was found to occur in a third of the casesstudied, although there were significant differences acrosstumour types. Consistent with their multidisciplinarymanagement, germ cell tumours and bladder cancers werecross-referred more frequently than prostate and kidneycancers. Notably, MDM recommendations generally resultedin greater multimodal treatment and increased resourceutilisation more often than not.

In assessing what factors determined the impact of the MDMon decision-making; the most important one was the presenceof metastatic disease, presumably reflecting the lack of definedtreatment pathways for many of these patients. In addition,there was a non-significant trend to a greater effect of theMDM on patients from private consulting rooms comparedwith public hospital patients. This observation may well bedue to a difference in selection, as only the more complexpatients may be brought for discussion from private rooms.Interestingly, patient age, sex or pathological features were notpredictive of the impact of the MDM on decision-making,although the small numbers may have limited the power ofour present study in this regard.

Numerous published studies have also sought to assess theimpact of MDM on clinical management [8], although onlytwo were conducted exclusively among patients withurological cancers [5,6]. As discussed previously, Acher et al.[5] found that only two of 124 patients had their clinicalmanagement altered at the MDM. These two patients wereamong 10 that had been identified by clinicians as possiblyrequiring changes to their management, indicating that amongsuch patients, the MDM impacted decision-making 20% of thetime. The other study examined the role of a central MDT,where cases were referred from a local MDT according towell-defined selection criteria [6]. In this context, clinicalmanagement was altered in five of 87 (6%) cases, but a furthersix (7%) patients were either offered enrolment in or excludedfrom clinical trials. Among non-urological cancers, the impactof MDM on clinical management has also been found to bequite variable [8].

As distinct from the UK, where all patients with cancer arereviewed at an MDM, patient inclusion at our institutionalMDM has to date been selective, but without defined criteria.Rather, this process has been left to a perceived indicationfrom the treating clinician. This process is likely to haveinfluenced the results of the present study, as the selective

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inclusion of more complex cases in the MDM is likely to beassociated with high impact changes. Although universalinclusion of patients for MDM discussion may be seen asdesirable, time and resource availability are limiting factors.Additionally, under those circumstances, the MDM appears toimpact on patient management less frequently [5]. Based onthe present study, we have now developed criteria for patientinclusion in the uro-oncology MDM (Table 3), reflecting thosemost likely to benefit from MDM discussion. Of course, thesecriteria are not intended to be exclusive, and additionalpatients may be included at clinicians’ discretion if indicated.We are currently investigating the impact of these selectioncriteria on the MDM.

Limitations of the present study included the short time-frameof 3 months, which limited the sample size. While largernumbers would be preferable in achieving greater statisticalpower, this was limited by pragmatic considerations of theimpact of the study on the running of the MDM. Nonetheless,the present study is, to our knowledge, the largest of its kind toinvestigate urological MDMs. Additionally, clinicians at theMDM were not ‘blinded’ to the management plan proposed bythe treating clinician or to the running of the study, both ofwhich may have influenced the decision-making process.Finally, the present study did not assess whether or not MDMmanagement recommendations translated to actual change inpatient care (although we have previously shown a 99%concordance between MDM recommendations and subsequentclinical management [9]), or ultimate patient outcome areas,e.g., survival, which require further prospective study.

In conclusion, the weekly MDM at our tertiary referralinstitution captures about a third of eligible genitourinarycancer cases, with over-representation of invasive bladdercancers and germ cell tumours. The MDM led to high impactchanges in patient management in over a quarter of cases,particularly for those with metastatic disease. In addition, theMDM also plays important roles in validation of managementdecisions, cross-referral and trainee education.

Conflicts of InterestNone disclosed.

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Correspondence: Shomik Sengupta, 292 Springvale Road, GlenWaverley, Victoria 3150, Australia.

e-mail: senguptaurology@gmail.com

Abbreviation: MD(M)(T), multidisciplinary (meeting)(team).

Table 3 Criteria for inclusion of uro-oncology patients for MDM discussion.

Multimodal treatment to be consideredHigh-grade non-muscle-invasive urothelial carcinoma of the bladderMuscle-invasive urothelial carcinoma of the bladderGerm cell tumours

Recurrent or metastatic diseasePotentially eligible for available clinical trial

e.g., pT3 tumours or positive surgical margins at radical prostatectomy for trial of adjuvant vs early salvageradiation

Rare tumoursPenile cancerNon-urothelial carcinoma of the bladderUpper tract urothelial carcinomaNon-adenocarcinoma tumours of the prostate, etc.

Cases with diagnostic uncertainty

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