This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
Teams of professionals working together (multidisciplinary teams) have improved outcomes for people with many different conditions, including cancer. But a study found that this way of working may not support patient preferences. It calls for professionals to ensure that people with cancer take part in decisions about their treatment.
Multidisciplinary teams bring together different specialists involved in a patient’s care. In team meetings, professionals may discuss treatment options in a patient-centred way, but they rarely include patients themselves.
This study focused on head and neck cancer. Researchers observed multidisciplinary teams making treatment decisions and assessed patients’ engagement with their recommendations.
The study found that team meetings were frequently dominated by doctors’ opinions on the best treatment. Patients tended to be presented with the team’s preferred treatment option, rather than all treatment options; their preferences often did not inform treatment decisions. Patients may, for example, choose treatments that allow them to do things they love, rather than to live longer.
The researchers call for healthcare professionals to find ways to ensure that patient preferences inform decision-making. Training for professionals on shared decision-making could help; as could re-structuring team meetings. People could benefit from dedicated time or other support tools to help them fully explore their treatment options.
The issue: do multidisciplinary cancer teams support shared decision-making?
Shared decision-making is considered best practice. The patient and clinician discuss the risks, benefits and consequences of treatment alternatives; the patient’s preferences and values are explored.
However, in cancer care (and other specialisms), treatment approaches are often decided in multidisciplinary team meetings. The way these meetings are run has changed little since they were established in the 1990s and they rarely involve patients. There is little research on how far patients are involved in treatment decisions when they are under the care of multidisciplinary teams.
In head and neck cancer, treatment decisions are complex and may involve trade-offs. Some options will preserve quality of life but reduce survival, for example.
Researchers explored how the multidisciplinary team made decisions on treatments for head and neck cancer, and how patients engaged with treatment decisions after the meeting.
What’s new?
The study was carried out in 4 head and neck cancer centres in the north of England. Findings were based on 35 multidisciplinary team meetings and 37 clinic appointments. The meetings observed were attended by a range of staff (including surgeons, oncologists, radiologists, pathologists, speech and language therapists, dietitians, and administrative staff); no patients were present. Researchers interviewed 23 patients and 9 team members.
They found that multidisciplinary meetings tend to decide on treatment with the best outcome from the doctor's perspective (often better survival). Team members discussed several options but would agree on a single treatment option. One surgeon said: ‘[The team] need to leave the MDT [meeting] with the treatment options… prioritised. So a rank order of [the] best treatment clinically – slightly irrespective of the patient’s wishes.’
Following the meeting, a team member would generally present the patient with the team’s recommendation. The patient was often given little information about other options, or time to think about the implications of the treatment.
The researchers observed instances of treatment options being presented that did not reflect patient preferences. For example, options that would be practically difficult for a patient or impact their quality of life.
Patients usually accepted the team’s recommendation and were grateful for the treatment. This could give healthcare professionals the impression that patients wanted to be told what to do. But this approach did not enable patient preferences to inform decisions; it may just have reflected the disempowered position patients found themselves in. When asked if he felt the treatment decision should be up to the doctor, one patient said: ‘Oh, definitely, without a doubt. It’s got to be the doctor’s decision. How could I make a decision like that?’
The researchers described a ‘cycle of paternalism’ with grateful patients accepting firm recommendations from clinicians; and clinicians reassured that they are doing their best for their patients.
Why is this important for cancer teams?
Clinicians recognise the importance of including patients in decision-making. However, all major cancer treatment decisions are made in multidisciplinary meetings. This research suggests that these meetings do not support shared decision-making.
Clinicians and patients may not share the same view on what is most important. Clinicians tended to aim for the longest survival, but patients often preferred options that allowed them to do the things they love for longer. They might value their appearance more, for example, or the ability to speak or swallow.
Patients are better placed to make decisions about what is best for them, especially when thinking about treatments that have a serious impact on their everyday life. The researchers call for a new method of shared decision-making for multidisciplinary teams.
This study observed complex decision-making in choosing treatment options for head and neck cancer. The issues raised will not happen to the same extent at multidisciplinary team meetings for other conditions.
Recommendations
The researchers recognise that having patients attend multidisciplinary team meetings could be difficult. However, they recommend that clinicians:
- aim to understand as much as possible about patients' priorities in advance of the team meeting
- provide patients with decision-aids to help them make informed choices; pamphlets, videos and web-based tools can help explain the pros and cons of different options
- present the team discussion and decision flexibly; rather than giving the ‘best’ treatment option, a full discussion encourages patients' questions, corrects misunderstandings, and allows disagreement
- work with patients to co-design alternative models of team decision-making, which ensure that patient preferences are considered (the quality of decision-making will need to be evaluated).
You may be interested to read
This Alert was based on: Hamilton DW, and others. How do patients make decisions in the context of a multidisciplinary team: an ethnographic study of four head and neck cancer centres in the north of England. BMJ Open 2022;12:e061654.
The Calman-Hine report, which paved the way for multidisciplinary teams in cancer treatment in the UK: Calman K, Hine D. A policy framework for commissioning cancer services. April 1995.
An NHS handbook about multidisciplinary team working: Making it happen: multi-disciplinary team (MDT) working. Published in January 2014, updated in September 2018.
Research into the use of decision aids to improve patient involvement in the decision-making process: Stacey D, and others. Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews 2017: Issue 4.
Funding: This study was funded by the NIHR Doctoral Research Fellowship.
Conflicts of Interest: None declared.
Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
