1. MDT Provision for Rare Cancer
Recommendation 40 of the Independent Cancer Taskforce Report

2. Agenda Welcome and Introductions (Jane Lyons)
Overview (Rupi Dev, NHS England)
CRUK Report/What we already know about rare cancer MDTs (Cath Taylor/James Green)
Q&A session/discussion
Summary and Next Steps

3. Overview NHS England

4. Background
Rare cancers are generally defined as those with an incidence less than 6 per 100,000 population.
In Europe, there are 186 types of rare cancer, accounting for 22% of all new cancer incidence
1 in 5 people with cancer have a rare cancer, and out of those with a rare cancer, 1 in 3 people have a particularly rare form of cancer (with an incidence less than 3 per 100,000 population).
Outcome data shows that the five year survival rate for people with rare forms of cancer is lower than that for people with more common cancers

5. Background cont…
In 2015, the Independent Cancer Taskforce Report made a series of recommendations to drive improvements in outcomes for patients with cancer
Recommendation 40 of the report was focused on the provision of multi-disciplinary teams and/or networks for rarer cancers
The recommendation references the use of national video conferences to enable local specialists to access national expertise and suggests the possibility of holding annual audits for rare cancers, where every death is discussed and performance metrics are produced for units allowing for comparison against the national average mortality rate

6. Recommendation 40
Recommendation 40 of the Cancer Taskforce Report states: “The Trust Development Authority, Monitor and NHS England should strongly encourage the establishment of national or regional MDTs for rarer cancers where treatment options are low volume and/or high risk. Clinical reference groups will need to play a key role in supporting these.”

7. Progress so far
Agreed scope of work with the Cancer Programme of Care Board (NHS England)
Engaged with individuals with experience of MDT effectiveness and specialist MDTs
Reviewed data from PHE regarding outcomes for rare cancer (in particular identifying cancers with low incidence/high mortality and high incidence/high mortality)

8. Progress so far cont…
Engaged with Clinical Reference Group Chairs within the Cancer Programme of Care
Observed national MDTs already in place for paediatric cancers
Engaging members of Cancer52 via a questionnaire and arranging workshop to gather views and feedback

9. Purpose of Today’s Workshop
To understand what works well currently in the provision of specialist MDT and networks of care
To get a better understanding of where good practice already exists for rare cancers and any learning from this
To understand where delays occur in the pathway for you patients (e.g referral, accessing specialist care)
To work with you all to identify potential tumour types and patient cohorts that would benefit from a national sharing of expertise

10. Cancer Research UK MDT Research

11. Cancer Research UK: Improving MDT effectiveness (2017)
Methods:
Survey of MDT members to identify key issues [2294 responses] and test recommendations [1258 responses]
Survey of patients [48 responses]
Observed 624 patient discussions [24 MDMs, across 10 sites]
Findings:
Not enough time to discuss complex patients
Current MDT meeting attendance is not optimal
The right information is often not used to inform discussions
MDTs are unable to fulfil their secondary roles (data validation, audit and education)
Not enough time to discuss complex patients
Mean length of patient discussion was 3.2 minutes, over half less than 2 mins long
Need to identify where protocolised pathways can be implemented e.g. to include a pre MDT triage meeting
Current MDT meeting attendance is not optimal
7-27 members (average 14) but only average 3 members contributed to discussions, and some decisions could not be made due to absent members. (need to determine who should be present and ensure spread of specialties)
The right information is often not used to inform discussions
7% decisions deferred due to either missing info (diagnostic) or missing people.
Only 14% of discussions involved non-tumour discussion (patient preference, comorbidities, other issues)
75% meetings no verbal contribution from nurse
Only 25% patients were satisfied with amount of contribution they had to MDT meetings
Only 8 of the discussions mentioned clinical trials
Solution: use a proforma. 54% use one but not standardised. 81% felt this would improve meeting efficiency.
MDTs are unable to fulfil their secondary roles
Less than half had process in place sufficient for improving MDT effectiveness
67% supported having a 4-6 monthly meeting regarding operation of MDT

13. CRUK Research – Findings
Received 2,300 responses to surveys
Most common raised was time to discuss patients (not enough time)
During MDT observations, it was noted:
Average length of discussion was 3.2 minutes
Over half discussions less than 2 minutes long
Meetings lasting up to 5 hours
74% agreed with the principle of streamlining MDTs

14. CRUK Research – Findings Cont…
Issues highlighted with MDT attendance
Individual members are required to attend 66% of all MDTs; this was noted to be very difficult for those working across multiple MDTs
In addition, individual member contribution in meetings varied
on average only 3 people out of the whole MDT were involved in discussions
in over 75% of meetings, Clinical Nurse Specialists did not speak at all
Feedback supported the need to move towards specialty cover in MDTs rather than individual attendance

15. CRUK Research – Findings Cont…
Issues identified with the use of information
7% of discussions were deferred due to either missing information (usually diagnostic imaging results) or missing MDT members
Only 25% of the patients surveyed were satisfied with the amount of information they were able to contribute to the MDT discussion
It was felt that MDT were unable to fulfil their secondary roles in data validation, audit and collection

16. What we already know about the provision of MDTs for rare and less common cancers

17. Common vs less common vs rarer or rare
COMMON (“BIG FOUR”)
Breast 55,000 F (M v rare) new cases per year
Prostate 40,000 M
Lung 46,000
Colorectal 41,000
NOT COMMON
Lymphoma NHL 17,000 HL 2,000 (rare)
Uterine (womb) 9,000 F
Ovarian 7,000 F
Brain
Pancreatic 9,600
RARE
Sarcoma soft 3,200 bone 600
Teenage Cancers 2,100
Cholangio carcinoma
Penile M
Myeloproliferative neoplasms 520
Waldenstrom’s macroglobulaemia a subtype of NHL

18. THIS IS ABOUT CANCER TEAMS what works and what can be improved

19. WHAT DO WE KNOW ABOUT TEAMS AND PATIENTS WITH RARER CANCERS ?

20. Winner: Digital Innovation in the Treatment of Cancer
MDT
FIT
IMPROVING CANCER TEAMS
Multi Disciplinary Team Feedback for Improving Teamworking
Winner: Digital Innovation in the Treatment of Cancer
Qic Oncology Award 2016
Web based Tool
Impeial, Barts Health, Kings, Surrey, UCLP
And over 100 NHS Trusts
Aims/purpose of presentation:
To provide an overview about what MDT-FIT is, how it has been developed and tested to-date, and our plans for further development and testing prior to national roll-out. 20

21. Recent CRUK SURVEY Data
WAS THERE A BIAS TOWARDS COMMON TUMOURS ?
ARE THERE DIFFERENCES ?
Depending on tumour type

22. Do you agree with the idea that some cases could be streamlined ?
Tumour Site
Yes No
Percentage in favour
Number of responses
What percentage of patients do you feel could be resolved outside of the meeting - for example, through clearly defined treatment protocols and review by a smaller group?
Overall
802
278
74%
1080
31.00%
Skin 80 10
89% 90
37.80%
Urology
116 17
87%
133
35.30%
Other (please specify) 25 6
81% 31
28.50%
Children and Young People 19 5
79% 24
31.40%
Lung 98 27
78%
125
26.90%
Gynaecology 60 77
28.20%
Upper GI 58
75%
30.70%
Breast
110 37
147
33.70%
Haematology 53 18 71
32.90%
Brain 26 9 35
26.70%
Sarcoma 8 3
73% 11
21.10%
Palliative Care 16
67%
42.90%
Colorectal 75 44
63%
119
27.90%
Head and Neck 48
50% 96
25.00%
CUP
43% 14
12.20%
Source: Online MDT follow up survey, data downloaded 27 May 2016

23. CANCER STRATEGY 3 recommendations on MDTeams38 39 40

24. MDT FIT 38 Self Assess to Improve
MDTs should be supported to use validated tools to self assess and improve their effectiveness.
MDT
FIT

25. Focusing of complex cases
MDT discussions should focus more on difficult cases and processes should be put in place to enable swifter decisions on patients going through standard treatment pathways.
Recommendation 38: NHS England should encourage providers to streamline MDT processes such that specialist time is focused on those cancer cases that don’t follow well-established clinical pathways, with other patients being discussed more briefly.

26. WHAT MAKES A CASE COMPLEX ?26

27. Elements that add complexity to Patients Cancer Cases
Mean Score
Level of complexity added
Number of respondents
5- Adds a significant amount of complexity 4 3 2
1- Does not add any complexity
Medical: Patient discussed in the meeting has unusual or rare tumour type
4.1
40%
42%
12% 4% 2%
1083
Treatment: There is a conflict of opinion regarding the best treatment option for a patient
39%
41%
15%
1075
Treatment: Guidelines/pathway do not account for patients' specific situation, (i.e. exceptional case)
3.9
27%
44%
20% 7%
1074
Psychological/Cognitive: Patient has a significant mental health or cognitive co-morbidity (e.g. they are sanctioned under the Mental Health Act, have schizophrenia, dementia from stroke or Alzheimer's disease)
3.7
21%
26%
10%
Treatment: Patient has treatment failure (i.e., there is cancer progression despite current treatment)
3.5
29%
Treatment: Patient experienced treatment toxicity and/or contraindications to standard treatment
3.4
11%
33%
13% 3%
1078
Medical: Patient has significant physical co-morbidity (e.g. diabetes, congestive heart failure, kidney or vascular disease, immunocompromised or suppressed).
31%
Surgical: Patient has a significant past surgical history (e.g. relevant previous surgeries that may affect surgical options) 9%
36%
14%
1081
Medical: Patient has a poor performance status (i.e., they are frail and/or need assistance with care/mobility)
3.1
30%
22%
1084
Social and Behavioural: Patient has socio-economic issues, such as for example, they are a sole parent with young children, there is a lack of social, family and/or financial support and/or housing issues
3.0
34%
1076
Social and Behavioural: Patient has lifestyle risks for the success of treatment, such as for example smoking, excess weight, alcohol/drug abuse
2.9
1080
Medical: Patient has significant drug history (e.g., polypharmacy)
2.8
19% 8%
1082
Source: Online MDT follow up survey, data downloaded 27 May 2016

29. Learning, Audit of End of Life
More emphasis should be placed on learning from patients who have gone through treatment, to improve decision-making.
For example, patients dying within weeks of active treatment.
Recommendation 39:
NHS England should require MDTs  to review a monthly audit report of patients who have died within 30 days of active treatment
to determine whether lessons can be learned about patient safety or avoiding superfluous treatment.

30. Recommendation 40 of the report was focused on rarer cancers The recommendation proposes the use of national video conferences to enable local specialists to access national expertise and suggests the possibility of holding annual audits for rare cancers, where every death is discussed and performance metrics are produced for units

31. Recommendation 40 of the Cancer Taskforce Report “The Trust Development Authority, Monitor and NHS England should strongly encourage the establishment of national or regional MDTs for rarer cancers where treatment options are low volume and/or high risk. Clinical reference groups (CRGs) will need to play key role in supporting these.

32. Q&A Session

33. Question 1. What works well?

34. Question 2. Any examples of best practice and learning?

35. Question 3. Where are the bottlenecks in service provision?

36. Question 4. Where do you think national MDT set-ups could have the biggest impact?

37. Next Steps
Collating feedback from workshop alongside all other evidence gathered
Identification of potential areas for focus and support through this piece of work
Feedback at Cancer Programme of Care Board end of April 2017 for sign-off and approval of next steps