Health professionals who participate in cancer-related MDTMs report an overall positive attitude, but also identify key issues for improvement, which fits with reports from other health care systems [2, 4]. MDTMs are typically chaired by physicians and more recent inclusion of nurses and coordinators in the meetings has been reported to improve team performance . We identified differences between physicians and nurses/coordinators related to the estimated impact from MDTM on time to treatment, resource-efficiency and involvement in the case discussions. Nurses and coordinators did more often (28% vs 14%) refer to MDTMs contributing to shorter time to treatment, which may reflect that nurses and coordinators who participate in MDTM may immediately plan and book further procedures and treatments. Whereas the views on development of individual competence did not differ between physicians and nurses/coordinators, the latter group reported being less involved in the case discussions. An observing rather than an interacting role of nurses in MDT meetings has been reported also by other investigators with reports that the medical perspectives dominate over care perspectives during MDTMs [18, 19]. An important aspect of improvement of MDTMs relate to an appropriate skill mix of a multidisciplinary team and development and implementation of MDTM structures and procedures . These observations suggest that the roles of nurses and coordinators should be highlighted to improve MDTM function. Responsibilities that could be targeted to nurses include consideration of comorbidity, psychosocial aspects, rehabilitation and supportive care needs, patient preferences and relevant clinical trials . Cancer care coordinators could take responsibility for all relevant documentation being available prior to the case discussions [18, 20].
Though many MDTM groups struggle with how to best include patient-related perspective in the decision process, a limited focus on these aspects have been documented in several studies . Restivo et al. found that psychological, socio-demographic and relational aspects were discussed in 30% of the cases and patient’ preferences were discussed in 10% of the cases at MDTMs in French health care . Divergent treatment priorities between physicians and patients have been demonstrated in multiple studies and cancer types. If the MDTM aims to contribute to individualized treatment decisions and implementation of the MDTM’s recommendations, patient values and preferences need to be considered. Our data demonstrate that in Swedish health care 78% of health professionals agree that patient preferences should be commented on during the MDTMs, but only 1% of the respondents identify patient perspectives as a major benefit from MDTMs (Figs. 1 and 2). The need to consider comorbidities was supported by 87% of the respondent and 17% considered comorbidity to be a major barrier for a joint MDTM recommendation (Figs. 1 and 3). Leadership and interactions between the MDTM participants are central in this process. MDTM leaders often express a clear view on the optimal treatment recommendation. Team members may counteract this by providing additional patient-related information, which may influence the further discussion, though perhaps based on fragmented and selected information . Additionally, when the information is conveyed to the patient, it needs to be balanced, which requires that controversies and differences in opinion have been clarified. Current observations suggest that though the premises of multidisciplinary care involve addressing patients’ needs, routines for how this should be granted at the MDTM need to be developed and will likely require substantial revision of the current meeting structure [9, 23,24,25,26].
The MDTM may be a suitable and relevant time point to consider patients for inclusion into clinical trials. In our data, 74% of the respondents supported that the MDTM could be used for this purpose, but only 3% identified this as a key benefit of MDTMs. Training for multidisciplinary teams in communication around clinical studies has been implemented and evaluated in the UK with promising results related to ease of communication and understanding of the impact for trial inclusion .
The two most important benefits from MDTMs were reported to be treatment recommendations based on compiled clinical information and multidisciplinary evaluation, followed by adherence to guidelines, increased team competence and patient safety (Fig. 2). Reference to increased competence and strengthened team work fits well with data from an international survey that report that seeking advice on treatment recommendation and participation in multidisciplinary discussion were the main reasons for MDT attendance . The MDTM may also improve communication, positively influence the work environment and is an important part of continuous medical education . In our study, MDTMs were considered more valuable for training of younger colleagues/residents (93%) than for education of undergraduate students (65%) (Fig. 1). Health professionals at the university hospital did more often (34% vs 19%) than their colleagues in local hospitals refer to the MDTM contributing to an improved team competence. Pathologists did significantly more often (43% vs 7–11%) than other disciplines refer to teamwork as an important benefit of the MDTM, which most likely reflects differences in working cultures between pathologists, who independently diagnose cases, and other disciplines, where teamwork is part of the everyday clinical work.
Failure to reach a joint recommendation has been reported to occur in 6–52% of case discussions during MDTMs [16, 28]. Considering the increasing demand for meeting time, efforts to reduce this figure are important. The main barriers to reach a joint recommendation identified in our study were need for supplementary investigations and insufficient pathology, followed by no professional present who had seen the patient and complex cases (Fig. 3). Absence of key professionals was more frequently (17% vs 7%) reported from the university hospitals than the county hospitals, which may reflect a vulnerable access to highly specialized competences. The participants rated compiled clinical information as one of the most important benefits from MDTM, but at the same time identified insufficient clinical information as a main barrier for a joint recommendation, which is supported also by observations from other health care systems [16, 29]. Though poor leadership, insufficient teamwork, disagreement and time pressure were by the respondents identified as less important, other studies have documented that factors such as poor leadership, insufficient teamwork, disagreement and time pressure as barriers for efficient MDTM recommendations [17, 21]. MDTM case reviews have been shown to change the initial treatment plan in up to a third of the cases, with the highest likelihood in complex cases [22, 28, 30, 31]. In our study, complex cases were more often (33% vs 17%) identified as barriers for recommendations by MDTM members at the university hospital compared to county hospitals. This difference likely reflect case selection and underscores the need for highly specialized competences for high-quality case evaluations and the need for the MDTM team to define core competences and support these members in improvement initiatives related to efficient decision-making.
Guidelines for which patients should be discussed at MDTMs should regularly be reviewed since the benefit of multidisciplinary evaluation and the need for core expertise likely differs between cancer types, tumor subsets, disease stages and patient subgroups. Of the respondents, 61–64% were positive to targeted approaches, e.g. listing of standard cases without detailed discussion or mini-MDTMs with selected disciplines present. Alternative case discussion formats were in our study supported by teams in lung cancer and urological and gynecological cancer and support for prioritization has in previous studies been gained from e.g. urological and colorectal cancer [13, 30]. Though data on the use of mini-MDTM are scarce, this principle has been suggested to be time and resource saving compared to full MDTMs [28, 31].
Only 30% of the respondents reported work to develop the MDTMs, though use of e.g. independent observers or evaluation instruments have been shown to change case management and improve MDTM quality. Several instruments have been developed and have performed favorably related to validity and interrater reliability [11, 32,33,34]. Work to optimize MDTM recommendations need to consider the MDTM function as well as the implementation rate of the recommendations made with careful consideration of shortcomings and differences in views between the participants .
Strengths of the study include a population-based approach with participation from all MDTMs in our health care region, a 67% response rate and a large sample size, which allows for subgroup-specific analyses in relation to professions, disciplines, hospital type and cancer-specific MDTs. Weaknesses relate to our development of a questionnaire the results of which cannot readily be compared to other studies. The perceived benefits and barriers to MDTMs were largely restricted to issues previously identified in scientific studies. Use of select statements and predefined benefits and barriers risks overseeing less common perspectives, although the informants could provide free text comments. Furthermore, since standardized MDTM improvement programs have not been implemented in Sweden, the input from health professionals could not be studied in relation to whether the MDTM in question was well-functioning or not.