Study types

There was no restriction on study design.

Participants

People with metastatic cancer without an identified primary in the period immediately after diagnosis.

Interventions

Assessment and investigation by a team with oncology expertise or dedicated MDT in the period immediately after diagnosis of metastatic cancer, prior to traditional oncology referral on tumour site-specific grounds.

Outcomes

Number and appropriateness of investigations, overall duration of pathway from initial presentation to treatment and treatment outcomes (including psychological morbidity).

Study selection

The literature search identified ten potentially relevant studies. All were ordered for appraisal but only one (Seve et al, 2006) was included as evidence. A high level search of Medline for systematic reviews of process of care in people with cancer identified several systematic reviews, two of which were included

Description of included studies

There was no direct evidence about the effect of early specialist oncologist in people presenting with metastases and an undiagnosed primary tumour. One Canadian cancer registry study (Seve et al, 2006) reported patterns of referral to cancer centres in patients with CUP. One systematic review (Grilli et al, 1998) examined the effect of specialisation on the care received by cancer patients. Another review (Gruen et al, 2009) summarised the evidence for link between hospital or physician case volume and mortality in patients with cancer.

References

• Grilli R, Minozzi S, Tinazzi A, Labianca R, Sheldon TA, Liberati A. Do specialists do it better? The impact of specialization on the process and outcomes of care for cancer patients. Annals of Oncology. 1998;9:365–374. [PubMed: 9636826]
• Gruen RL, Pitt V, Green S, Parkhill A, Campbell D, Jolley D. The effect of provider case volume on cancer mortality. CA: A Cancer Journal for Clinicians. 2009;59:192–211. [PubMed: 19414631]
• National Confidential Enquiry into Patient Outcome and Death. Systemic Anti-Cancer Therapy: For better, for worse? 2008.
• NHS Institute for Innovation and Improvement. Focus on: Cancer. Jun 1, 2009.
• Seve P, Sawyer M, Hanson J, Broussolle C, Dumontet C, Mackey JR. The influence of comorbidities, age, and performance status on the prognosis and treatment of patients with metastatic carcinomas of unknown primary site: a population-based study. Cancer. 2006;106(9):2058–66. [PubMed: 16583433]

References for included studies

Grilli 1998.

Grilli R, Minozzi S, Tinazzi A, Labianca R, Sheldon TA, Liberati A. Do specialists do it better? The impact of specialization on the process and outcomes of care for cancer patients. Annals of Oncology. 1998;9:365–374. [PubMed: 9636826]

Gruen 2009.

Gruen RL, Pitt V, Green S, Parkhill A, Campbell D, Jolley D. The effect of provider case volume on cancer mortality. CA: A Cancer Journal for Clinicians. 2009;59:192–211. [PubMed: 19414631]

NCEPOD 2008.

National Confidential Enquiry into Patient Outcome and Death. Systemic Anti-Cancer Therapy: For better, for worse? 2008. ()

NHSIII 2009.

NHS Institute for Innovation and Improvement. Focus on: Cancer. Jun 1, 2009. ()

Seve 2006.

Seve P, Sawyer M, Hanson J, Broussolle C, Dumontet C, Mackey JR. The influence of comorbidities, age, and performance status on the prognosis and treatment of patients with metastatic carcinomas of unknown primary site: a population-based study. Cancer. 2006;106(9):2058–66. [PubMed: 16583433]

Study types

Any study design.

Participants

The literature search was initially restricted to studies in those with unknown primary cancer, but did not return any relevant studies. The search was widened to include studies in people with any cancer.

Interventions

An identified key worker appointed to remain as a patient’s point of contact with throughout their clinical course. For example, the NICE Improving Outcomes Guidance for people with brain tumours defines the key worker as “[the] person who, with the patient’s consent and agreement, takes a key role in coordinating the patient’s care and promoting continuity, ensuring the patient knows whom to access for information and advice”.

Outcomes

Patient satisfaction with care, patient enablement, time taken to establish diagnosis, number of investigations, cost of hospital stay, overall duration of pathway from diagnosis to treatment, referral to appropriate site-specific team at first attempt and reduced morbidity resulting from more rapid diagnosis (including psychological morbidity)

Study selection

An initial list of studies was selected by the information specialist (SA). One reviewer (NB) then selected potentially relevant papers from this list on the basis of their title and abstract. These studies were ordered and each paper was check against the inclusion criteria. Reference lists of included papers were also checked for other relevant studies.

Data extraction and synthesis

One reviewer (NB) extracted data. Data extraction and critical appraisals of studies included in existing service guidance were used verbatim.

Quality assessment

Study quality was assessed using the NICE checklists for critical appraisal.

Heterogeneity Assessment

There was no statistical assessment of heterogeneity, differences in studies were recorded in the study characteristics tables.

Description of included studies

Two studies were identified from the literature reviews of the Improving Outcomes cancer service guidance series (see Table 1). A UK randomised trial of cancer care coordinators (Addington Hall et al, 1992) in patients with life expectancy of less than a year. The coordinators were nurses who continually assessed need for NHS and social services, provided a link between the patient these services if needed, and offered advice and help.

Table 2.1

Key workers in the Improving Outcomes cancer service guidance.

Another UK randomised trial examined the effectiveness of breast cancer specialist nurses (McArdle et al, 1996) who acted as a continuing source of advice and reassurance to women with breast cancer

An additional American randomised trial was found in the current literature search. Goodwin et al (2003) examined the effect of nurse case managers who coordinated care for older women with breast cancer.

Study quality

The included studies were well conducted and considered at moderate to low risk of bias.

Outcome 1: Patient satisfaction with care

Addington-Hall and co workers (Addington-Hall et al 1992 ) reported no difference between groups in satisfaction with care.

Outcome 2: Patient enablement

In the Addington-Hall et al study (Addington-Hall et al 1992) the two groups were equally likely to need help. There were no differences between groups in the sources of help, in the proportions having unmet needs for help or in the proportions who had aids and appliances for use at home.

Goodwin et al (2003) observed that women in the nurse case management group were more likely to report that they had a real choice in their treatment than women receiving standard care.

Outcomes 3,4 and 5: Time taken to establish diagnosis, the number of investigations and the overall duration of pathway from diagnosis to treatment

No evidence was found. The studies included only patients with an established diagnosis.

Outcome 6: Referral to appropriate site-specific team at first attempt

There was no direct evidence, but some studies attempted to measure the quality of coordination of care between healthcare professionals and patients.

Addington-Hall et al (1992) reported that frequency of contact with agencies and satisfaction with services did not differ significantly between groups.

Goowdin et al (2003) reported that women in the nurse case management group were more likely to receive breast conserving surgery and radiotherapy than those in the standard care group.

Outcome 7: Morbidity

In the Addington-Hall et al (1992) trial patients in the care coordination group were significantly less likely to have been suffering from vomiting, but there were no other significant differences in the symptoms experienced in the 24 hours before interview. There were also few significant differences in severity of symptoms, concern about symptoms and effectiveness of treatment: coordination group patients were more likely to be receiving effective treatment for vomiting (OR=0.04, 95% CI: 0.02–0.79) and were less likely to be concerned about having itchy skin (OR=3.7, 95% CI: 1.12–12.1). The control group patients were more likely to have died by the end of the study (OR=1.90, 95% CI: 1.01–3.58), but the authors considered this a statistical artefact of multiple comparisons.

There were few between group differences in the carers’ reports of the type, severity and effectiveness of treatment of the patient’s symptoms in the last week of life; carers of coordination group patients were more likely to report that the patient had had a cough, less likely to rate the patient’s difficulty with swallowing as severe, more likely to report effective treatment for constipation and less likely to report effective treatment for anxiety.

McArdle et al (1996) found that psychological morbidity scores (GHQ, HAD) were consistently better in patients offered routine care plus support from the breast care nurse compared with patients offered routine care from ward staff, routine care plus support from a voluntary organisation or routine care plus support from the nurse and the voluntary organisation.

Goodwin et al (2003) reported that, at two months after surgery, more women in the nurse case management group had normal arm function than those in the standard care group.

References for included studies

Addington Hall 1992.

Addington-Hall JM, MacDonald LD, Anderson HR, Chamberlain J, Freeling P, Bland JM, et al. Randomised controlled trial of effects of coordinating care for terminally ill cancer patients. BMJ. 1992;305(6865):1317–22. [PMC free article: PMC1883850] [PubMed: 1483075]

Chumbler 2007.

Chumbler NR, Kobb R, Harris L, Richardson LC, Darkins A, Sberna M, et al. Healthcare utilization among veterans undergoing chemotherapy: the impact of a cancer care coordination/home-telehealth program. Journal of Ambulatory Care Management. 2007;30(4):308–17. [PubMed: 17873662]
Chumbler NR, Mkanta WN, Richardson LC, Harris L, Darkins A, Kobb R, et al. Remote patient-provider communication and quality of life: empirical test of a dialogic model of cancer care. Journal of Telemedicine & Telecare. 2007;13(1):20–5. [PubMed: 17288654]

Goodwin 2003.

Goodwin JS, Satish S, Anderson ET, Nattinger AB, Freeman JL. Effect of nurse case management on the treatment of older women with breast cancer. J Am Geriatr Soc. 2003;51(9):1252–9. [PubMed: 12919237]

McArdle 1996.

McArdle JM, George WD, McArdle CS, Smith DC, Moodie AR, Hughson AV, et al. Psychological support for patients undergoing breast cancer surgery: a randomised study. BMJ. 1996;312(7034):813–6. [PMC free article: PMC2350687] [PubMed: 8608288]

Study types

Any comparative study.

Participants

Initial literature searches restricted to studies of people with cancer of unknown primary returned no studies, so the search was broadened to included people with any type of cancer.

Interventions

Multidisciplinary team (MDT) management. For the purpose of this review an MDT was defined as a group of health professionals meeting regularly to discuss the management of patients with cancer. Typical cancer MDTs include a surgeon, clinical oncologist, medical oncologist, radiologist, pathologist and specialist nurse. Other specialists might be included depending on the cancer site: the NICE Improving Outcomes cancer guidance series recommends membership for various cancer site specific MDTs.

Outcomes

Treatment outcomes, patient satisfaction with care, overall duration of pathway from initial presentation to treatment and the number and cost of investigations.

Study selection

An initial list of studies was selected by the information specialist (SA). One reviewer (NB) then selected potentially relevant papers from this list on the basis of their title and abstract. These studies were ordered and the reviewer checked each paper against the inclusion criteria. Reference lists of included papers were also checked for other relevant studies. The NICE Improving Outcomes cancer service guidance series was also searched for recommendations and evidence about MDTs.

Data extraction and synthesis

One reviewer (NB) extracted data.

Quality assessment

Study quality (risk of bias) was assessed using the NICE checklists for critical appraisal.

Heterogeneity assessment

There was no statistical assessment of heterogeneity, differences in studies were recorded in the study characteristics tables.

Description of included studies

Three systematic reviews were identified (Coory, 2008; Houssami et al, 2006 and Wright 2007). Houssami et al (2006) and Wright et al (2007) included few relevant studies, so the original studies from these reviews were appraised in their own right.

Stephens et al (2005, 2007) compared overall survival before and after the introduction of multidisciplinary team working in UK upper gastrointestinal cancer care. These studies tried to address the problem of using historical control groups (with generally poorer prognosis) by using multivariate analysis. Birchall et al (2004) used two UK audits to examine the effect of MDTs on the outcomes of people with head or neck cancer.

Morris et al (2006, 2008) used UK cancer registry data to compare cancer teams’ adherence to the MDT standards in the Manual for Cancer services with overall survival, in people with colorectal cancer (Morris et al 2006) or breast cancer (Morris et al 2008). Compliance was rated from 0% (no standards were met) to 100% (all standards met).

Study quality

The majority of the included studies were observational: a single randomised controlled trial was included in the Coory et al (2008) systematic review. Many of the studies used a “before-and-after” design, comparing outcomes before and after the introduction of MDT cancer teams. The use of historical controls introduces bias in favour of MDTs, because there has been a general improvement in the outcomes of people with cancer over time.

NICE Improving Outcomes guidance

All the service guidance publications recommended that people with cancer should have their treatment managed by MDTs. On the whole these recommendations were not based on direct evidence (see Table 3.1). This is not surprising since cancer MDTs were just beginning to emerge (sometimes as a result of the Improving Outcomes guidance).

Table 3.1

Multidisciplinary team recommendations in Improving Outcomes service guidance.

Treatment outcomes

Overall survival

Morris et al (2006, 2008) found for each 25% increase in MDT adherence score there was a 3% reduction in the risk of death within five years of diagnosis for colorectal cancer patients and 4% reduction for breast cancer patients. This effect was statistically significant in the colorectal cancer cohort but not in the breast cancer cohort. According to these figures, colorectal cancer patients treated by a team meeting none of the standards would have a 12% greater risk of 5 year mortality than patients treated by a team with full adherence to MDT standards.

Coory (2008) reviewed the evidence from five studies about the effect of MDT management on the overall survival of people with lung cancer. Two studies noted a modest survival benefit for patients managed by MDTs, and three studies reported no significant difference in survival

Stephens et al (2005, 2006) attributed large improvements in survival to MDT management (54% and 66% for patients with gastric and oesophageal cancer respectively).

Birchall et al (2004) reported two audits of UK head and neck cancer outcomes. In the earlier time period there was no statistical effect of MDT management on patient survival, but in the later audit MDT management was associated with 30% reduction in the risk of death within 2 years of diagnosis.

Table 3.2

Treatment outcomes.

Patient satisfaction

Two studies measured patient satisfaction, using questionnaires. Gabel et al (1997) reported that patients managed by MDT were more likely to report carers were encouraged to attend consultations and that the consultations helped them make a treatment decision, than patients managed in non-MDT settings. Another study (included in Coory et al 2008) found control group (non-MDT) patients were more likely to report the diagnostic process as too slow and that MDT patients were more likely to report a better care experience.

Table 3.3

Patient satisfaction with care.

Overall duration of pathway from initial presentation to treatment and number of investigations

Little evidence about the diagnostic process because studies were of patients with known primary tumours.

Grabel et al (1997) reported that the mean time from diagnosis to treatment was 30 days in patients managed by MDT compared with 42 days in those managed elsewhere. Chang et al. (2001) reported that the MDT review of cases would sometimes also lead to deferred radical treatment while further staging investigations were done.

The Coory (2008) systematic review included three studies reporting time from presentation to treatment. In all three the mean (or median) time from presentation to treatment was reduced by at least two weeks in the MDT group when compared to the non MDT group. Evidence from a single phase II randomised trial suggested this was due to quicker diagnosis in patients managed by MDT.

Table 3.4

Overall duration of pathway from initial presentation to treatment.

Number of investigations

There was little evidence about this outcome. Two studies suggested that additional staging investigations after diagnosis were more likely in patients managed by MDTs. Back et al (2007) study reported that post-operative imaging was more likely in patients managed by MDT. Chang et al. (2001) noted that MDT review of cases would lead to additional staging investigations before treatment in 31% of those destined for radical therapy.

In a randomised phase II trial of 57 patients with lung cancer (reported in Coory et al 2008) those managed by MDT made significantly fewer GP visits than those managed in a non-MDT setting (88 versus 164 respectively).

Table 3.5

Number and cost of investigations.

References for included studies

Back 2007.

Back MF, Ang EL, Ng WH, See SJ, Lim CC, Tay LL, et al. Improvements in quality of care resulting from a formal multidisciplinary tumour clinic in the management of high-grade glioma. Annals of the Academy of Medicine, Singapore. 2007;36(5):347–51. [PubMed: 17549282]

Birchall 2004.

Birchall M, Bailey D, King P. Effect of process standards on survival of patients with head and neck cancer in the south and west of England. Br J Cancer. 2004;91(8):1477–81. [PMC free article: PMC2409928] [PubMed: 15467772]

Chang 2001.

Chang JH, Vines E, Bertsch H, Fraker DL, Czerniecki BJ, Rosato EF, et al. The impact of a multidisciplinary breast cancer center on recommendations for patient management: the University of Pennsylvania experience. Cancer. 2001;91(7):1231–7. [PubMed: 11283921]

Coory 2008.

Coory M, Gkolia P, Yang IA, Bowman RV, Fong KM. Systematic review of multidisciplinary teams in the management of lung cancer. Lung Cancer. 2008;60(1):14–21. [PubMed: 18304687]

Gabel 1997.

Gabel M, Hilton NE, Nathanson SD. Multidisciplinary breast cancer clinics. Do they work. Cancer. 1997;79(12):2380–4. [PubMed: 9191526]

Houssami 2006.

Houssami N, Sainsbury R. Breast cancer: multidisciplinary care and clinical outcomes. European Journal of Cancer. 2006;42(15):2480–91. [Review] [27 refs] [PubMed: 16904313]

Morris 2006.

Morris E, Haward RA, Gilthorpe MS, Craigs C, Forman D. The impact of the Calman-Hine report on the processes and outcomes of care for Yorkshire's colorectal cancer patients. British Journal of Cancer. 2006;95(8):979–85. [PMC free article: PMC2360721] [PubMed: 17047646]

Morris 2008.

Morris E, Haward RA, Gilthorpe MS, Craigs C, Forman D. The impact of the Calman-Hine report on the processes and outcomes of care for Yorkshire's breast cancer patients. Annals of Oncology. 2008;19(2):284–91. [PubMed: 17785759]

Shylasree 2006.

Shylasree TS, Howells RE, Lim K, Jones PW, Fiander A, Adams M, et al. Survival in ovarian cancer in Wales: Prior to introduction of all Wales guidelines. International Journal of Gynecological Cancer. 2006;16(5):1770–6. [PubMed: 17009970]

Stephens 2005.

Stephens MR, Hopper AN, Blackshaw G, Barry JD, Edwards P, Hodzovic I, et al. Multidisciplinary team management is associated with improved outcomes after surgery for gastric cancer. Gut. 2005;54:A111.

Stephens 2006.

Stephens MR, Lewis WG, Brewster AE, Lord I, Blackshaw GR, Hodzovic I, et al. Multidisciplinary team management is associated with improved outcomes after surgery for esophageal cancer. Diseases of the Esophagus. 2006;19(3):164–71. [see comment] [PubMed: 16722993]

Wright 2007.

Wright FC, De Vito C, Langer B, Hunter A. Expert Panel on Multidisciplinary Cancer Conference Standards. Multidisciplinary cancer conferences: a systematic review and development of practice standards. European Journal of Cancer. 2007;43(6):1002–10. [Review] [56 refs] [PubMed: 17329094]