Multicentre study of multidisciplinary team assessment of pancreatic cancer resectability and treatment allocation

Abstract

Background: Multidisciplinary team (MDT) meetings have been adopted widely to ensure optimal treatment for patients with cancer. Agreements in tumour staging, resectability assessments and treatment allocation between different MDTs were assessed.Methods: Of all patients referred to one hospital, 19 patients considered to have non-metastatic pancreatic cancer for evaluation were selected randomly for a multicentre study of MDT decisions in seven units across Northern Europe. Anonymized clinical information and radiological images were disseminated to the MDTs. All patients were reviewed by the MDTs for radiological T, N and M category, resectability assessment and treatment allocation. Each MDT was blinded to the decisions of other teams. Agreements were expressed as raw percentages and Krippendorff's values, both with 95 per cent confidence intervals.Results: A total of 132 evaluations in 19 patients were carried out by the seven MDTs (1 evaluation was excluded owing to technical problems). The level of agreement for T, N and M categories ranged from moderate to near perfect (46⋅8, 61⋅1 and 82⋅8 per cent respectively), but there was substantial variation in assessment of resectability; seven patients were considered to be resectable by one MDT but unresectable by another. The MDTs all agreed on either a curative or palliative strategy in less than half of the patients (9 of 19). Only fair agreement in treatment allocation was observed (Krippendorff's 0⋅31, 95 per cent c.i. 0⋅16 to 0⋅45). There was a high level of agreement in treatment allocation where resectability assessments were concordant.Conclusion: Considerable disparities in MDT evaluations of patients with pancreatic cancer exist, including substantial variation in resectability assessments.

Author response to: It is time for a biological definition of locally advanced pancreatic cancer

“…We thank Del Chiaro and Schulick for their interest in our recent paper on multidisciplinary team assessments of pancreatic cancer resectability and treatment allocation. We agree that our finding of only 64·1 per cent agreement in resectability assessment in pancreatic cancer patients is concerning.…”

Impact of Borderline Resectability in Pancreatic Head Cancer on Patient Survival: Biology Matters According to the New International Consensus Criteria

“…Fourth, the preoperative staging of PDAC improved over time thereby increasingly determining treatment proposals in multidisciplinary conferences, ultimately evolving the concept of multimodal neoadjuvant therapy for borderline resectable PDAC with considerable oncological benefit. 25 Given the fact that evaluation of patients with PDAC varies between different interdisciplinary conferences, 47 resection criteria for PDAC should be defined more precisely. Because the outcome of the so-called biological borderline group (preoperative CA 19-9 serum levels [ 500 U/ml) is so poor, new neoadjuvant regimens, including FOLFIRINOX, should be evaluated in randomized clinicals trials in this cohort of patients.…”

Value and Quality of Care in Head and Neck Oncology

“…They found that MDT treatment decisions were based on group consensus (92%), adherence to clinical practice guidelines (57%), or other evidence-based medicine sources (33%) [46]. Kirkegård et al showed a high heterogeneity in the staging of pancreatic tumors and in the definition of resectability between European MDTs [47]. Similar variability is to be expected between head and neck MDTs.…”