Dr Chris Parker: ..and explain what they are for and give my personal view as to how good a job they are doing and then we will see a real life MDT in action.
So first of all what is an MDT? Well the composition of a urology MDT was laid down in this document The improving outcomes guidance in 2002 and is shown there, and the guidance also stipulated that all men with Prostate Cancer in the NHS would be managed under the care of an MDT. And this was regarded as a very major change and has been recognised as such by for example Mike Richards who will be speaking to us later. Now the idea is that we get away from the old system where an individual consultant usually the urologist would be in charge and make the decisions, moving towards a team all working together with different expertise.
What were the reasons for this change? Well these were the three reasons stipulated in that document, and the first was to promote specialisation, so the care of men with prostate cancer should be managed by experts who specialise in the disease rather than by general urologists who did a bit of prostate cancer amongst their general work.
And the evidence base for that is well established, and this is one paper. This has nothing to do with the physical stature of your surgeon. Surgeon volume here refers to the number of radical prostatectomy's he performs each year, and what it shows is that the risk of complications at least in the short term was roughly halved in this study if the surgeons performed more than 40 radicals a year, compared with those surgeons who performed fewer than 40. And similarly there seemed to be an improvement perhaps in strictures, and also in the duration of the inpatients stay.
Now sadly in this country there was a very major problem in this regard. This is data from the late 1990's showing the number of the radical prostatectomy's and radical cystectomies performed in each hospital in the UK and what you can see is that the vast majority of hospitals at that time were performing fewer than 20 or 30 such operations. And so clearly this was a problem that needed to be fixed.
Moving on then, the second reason for MDTs is to try and reduce geographical variation. I think we would all agree that men should be receiving the same sort of care no matter where they live. And the hope was the MDT's would help that. Here is data published two days ago, how is that for being bang up to date, on geographical variations on patterns of care in the US . This is data on over 100,000 men and what you can see it's the first treatment of men with localised prostate cancer in different parts of the country and you can see major variations. The popularity of surgery differs by more than 100%, two fold from one part to another, and the same for watchful waiting, now that doesn't mean to say there is necessarily a problem but the study also showed that your ethnicity and your socioeconomic status was an important factor in determining what treatment you received. So this is suggestive of a major issue that should be tackled. As far as I know we have got no UK data on this, I guess your survey is perhaps the best there is. But I think that we could all agree that there is likely to be major geographical variation in the UK as well.
The third reason for MDTs is to try and improve treatment decision making, and we know from the work of Howard Cohen who is here today that your clinicians recommendation is perhaps the most important factor in deciding your choice of treatment. And we all know that that is a major problem, it is a very well known study from the US when they surveyed over 1000 prostate cancer specialists, roughly half urologist, half radiation oncologists: And they gave them a raft of different scenarios and asked for their treatment recommendations: If you look about half way down, patients with a Gleeson score of 7 and a PSA of 5 you can see that 91% of urologists recommended surgery, and surprise, surprise, 91% or radio oncologist, recommended radiotherapy.
And we do have data from the UK - patients surveys commissioned by the Department of Health - suggesting that patients' main priority is greater involvement in decision making. So how good have MDTs been? They've been up and running for one or two years, what difference have they made? Well in terms of promoting specialisation I think there has been a very major improvement. And so hospitals can no longer perform radical prostatectomy unless they are doing more than 50 such major operations a year. And those few surgeons that were doing fewer than 5 a year have stopped. That's a major improvement, have we gone far enough? I think that's a very good question.
The one study I showed you suggested that surgeon volume was more important than hospital volume, and it suggested a cut point of 40. And I suspect that there are still many surgeons well below that in the UK at the moment, but none the less it is a major step forward.
What about reducing geographical variation? Have MDTs reduced that?
I have no idea. I don't think any body knows, I don't think anybody has looked at it as far as I am aware. What I can say is that MDTs will do nothing to reduce this aspect of geographical variation. This is prostate cancer incidence and mortality in different parts of the country. If you look on the right you can see the mortality statistics, the areas in white have average prostate cancer mortality, the areas in pink slightly higher, and blue slightly lower. Overall that's a fairly even distribution there is no more than 20 % variation in Prostate cancer mortality in different parts of the country.
But look at incidence here you can see deep pink and deep blue areas, this is more than 100% variation in prostate cancer incidence different parts of the country.
I think we all know the main reason its nothing in the water in the South East's that's predisposing men, it's the PSA tests. The point I want to make here is that MDT's will do nothing to lessen this very major cause of geographical variation.
And then moving on - what about improving treatment decision making?
And my own opinion is that MDT's probably are very helpful for improving decision making in very complex cases, but of course the meat and drink if you like of MDT's is early Prostate Cancer, and I would maintain that MDT's do little to help in that regard, because essentially its my belief that if patients got it right the choice of what treatment to have for localised prostate cancer, is when it boils down to it not largely a medical decision, it's a value judgement, and an MDT can't make value judgements, or shouldn't, now this is a simple point but I want to labour it so bear with me.
Let's imagine a hypothetical scenario a man is newly diagnosed with low risk prostate cancer, and let's suppose that if he had no treatment what so ever he has a 10% chance of dying from his disease and lets just suppose he's trying to decide whether to have a treatment that would halve his risk of dying from prostate cancer from 10% to 5% , and lets suppose for the sake of argument that that treatment has a 50% risk of impotence and a 2% risk of urinary incontinence. Now some of us would choose to go for treatment others would choose not to go for treatment. I think we would all agree that it's not a medical decision it's a value judgement.
That's the point I want to emphasise I think it's a major limitation of MDTs and treatment decision making. The one person who is not on the MDT is the patient. How could we improve the decision making? Well I think there are two good ways which should be emphasized, one we hear about earlier and that's specialist nurses. This is data from the National Audit Office survey published earlier this year, showing that only half of men with prostate cancer have access to a named nurse. It seems to me in my opinion, likely that having that access to a specialist trained, experienced nurse would likely improve the quality of decision making, would make those decision more congruent if you like, with the patients own individual values.
And the second way that's been proven in randomised trials to improve the quality of decision making, improve patient satisfaction, reduce regret about wrong decisions is patient decision aids; and there do exist patient decision aids to help men decide whether to have treatment for prostate cancer, what treatment to have? Those should be emphasised and made more widely available.
In summary then; those are the three reasons for the introduction of MDTs, I think they've been very successful in promoting specialisation but I think there is a long way to go, particularly in the other two areas that I have mentioned.
I am now going to hand over to a real live MDT from Birmingham and we are going to see them in action.
Vivienne Parry: I think what we are going to do, is first of all let s everybody introduce themselves.
Professor Nick James: We are going to run through four cases two of the cases the patients are actually here. The second of the two cases, we are actually going to invite the patient to join us up on stage to hear his take on his input into the decision making process.
I think I'll start by saying the point that Chris makes about the patient with early Prostate cancer and his treatment is a personal one we can entirely accept and we don't spend any time discussing what the options should be for a patient if they've got all the options available. We focus our discussion as a team today on the cases where the treatment is contentious, that doesn't fall into a neat pigeon hole.
So the people we've got today are Dr Flynn Chan, the consultant pathologist. Dr Peter Guest the consultant radiologist. Mike Wallace who is the urology team leader, consultant urologist, and Richard Gledhilll who's our Prostate Cancer Nurse Specialist, funded by The Prostate Cancer Charity.
So I will hand over to Mike.