THORACIC ONCOLOGY MULTIDISCIPLINARY TEAM MEETINGS: OPERATIONAL POLICY

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1 THORACIC ONCOLOGY MULTIDISCIPLINARY TEAM MEETINGS: OPERATIONAL POLICY EXECUTIVE SUMMARY 1. All patients in Lothian with thoracic malignancies should be discussed at designated times in pathway (see App 1). 2. Sufficient information should be provided before meeting for prepopulation on TRAK to require only confirmation of staging, histology and treatment decision to be recorded at MDM. Patients without this prior documentation will not be discussed. 3. This should be available 48 hours before meeting to allow coordinator, chair, radiologist and pathologist to decide whether presentation is feasible and safe. 4. Patients should ideally be presented by someone who has met patient and been involved in their care; if not a detailed handover must be given to a third party to allow them to present the patient. If this is not met, patient will not be discussed. 5. Sufficient information should be provided to complete audit, to allow the identification of patients suitable for clinical research and to allow early escalation of patients at risk of breaching treatment targets. REMIT The Thoracic Oncology Multidisciplinary Team Meetings take place at the Western General Hospital and Royal Infirmary. The remit of these meetings extends to all patients diagnosed with primary thoracic cancers referred or diagnosed in NHS Lothian and selected patients from other areas within the Southeast Scotland Cancer Network, as requested by members of the MDM. RESPONSIBILITIES To establish, record and review diagnoses for all new patients with lung cancer, mesothelioma, thymoma and other selected thoracic malignancies. To assess the extent and verify the stage of each patient s disease and discuss its probable course. To provide guidance for subsequent treatment for all new patients taking into account patients own views. To provide a forum for discussion for complex patients, including those on follow-up. To discuss the pathology of patients that have had resections for consideration of adjuvant chemotherapy. To consider patients other requirements such as palliative care or referral to other services. To support involvement in clinical trials and other research studies. To ensure registration of the required minimum dataset for the all cases of the relevant cancer within a specified area.

2 To ensure quality management of all patients. To ensure prompt, effective multi-disciplinary decision making, thus minimising delays in the patient s journey. To be aware of patients that have experienced delays, monitor where delays occur and report them via the MDM coordinator/tracker to the management. To act as a multi professional educational forum ensuring continuous professional development through regular MDM attendance. MEMBERSHIP The Multidisciplinary Team should comprise consultants and senior members within Respiratory Medicine, Thoracic Surgery, Clinical and Medical Oncology, Radiology, Pathology, Palliative Care, Clinical Nurse Specialists and Support nurses, Research personnel, Audit personnel, Radiography, Pharmacy and the Coordinator/tracker. Trainees and medical students are expected to attend as part of their training and other observers are welcome providing they have signed NHS confidentiality agreement and introduce themselves to the Chair at the start of the meeting. Responsibilities of the Team Members: Members should attend the majority of all meetings relevant to their site(wgh/rie). Members should always attend meetings at which their patients are discussed, or should ensure an appropriate, fully informed deputy is present. Patients will not be discussed unless this constraint is met. Decision making is likely to be unsafe in the absence of a team member knowing the patient. Specialist groups should ensure one member is available for each meeting ensuring cross-cover whenever possible. Members should arrive on time to participate fully in the meeting Members should fulfil any action for which they identified as responsible for during the meeting and as recorded in the minutes. Members should be respectful of the directions of the chair. Patients for discussion should be forwarded to the coordinator at least 48 hours before the meeting at which they will be discussed. Failure to do this provides insufficient time for radiology and pathology review, and renders the discussion and decision making unsafe. NAMED LEAD CLINICIANS FOR THE MDT s Professor Allan Price at WGH Dr Kris Skwarski at RIE Named deputies

3 Responsibilities of the lead clinician Work with coordinator/tracker to monitor attendance and follow up any issues. Work with Coordinator/tracker to monitor patients within the 62 day pathway to identify any delays and complex patients. Answering any written complaints specific to the MDM on behalf of the MDT. Ensure compliance with this SOP. This activity should be recognised within job plan; it is anticipated that review of referrals and consultation with coordinator will take an hour a week. REFERRAL PROCESS Referring clinician should inform the Coordinator (Lavinia Walsh or named deputy) of the name and date of birth of any patient to be discussed at the meeting at least 48 h before meeting. Currently this would be 4pm on Wednesday afternoon for RIE meeting and 12 midday on the Friday for the WGH meeting, with some modifications for holiday weekends. Referring clinician should ensure adequate data has been submitted for formatting on TRAK prior to the meeting. The adequacy of this data and the availability of radiology and pathology will be assessed by the chair in consultation with radiologist and pathologist the day before the meeting. To facilitate this, all referral forms must be submitted electronically. Paper referrals will not be accepted. Patients for whom information is inadequate will not be discussed and the referring clinician informed of this by the chair. Referring clinicians should document on referral form where the radiology to be reviewed has been performed to allow radiologists to review and download to worklist before meeting. Urgent late additions to the meeting should be reported to the chair and MDM coordinator at the start of the meeting; they will be discussed if chair, radiologist and pathologist think sufficient information is available with time for it to be reviewed safely. ORGANISATION OF THE MEETING The meeting will take place weekly on Tuesday 8.30am to 9.30am at WGH and Friday 8.30am to10am at RIE. The surgical half of the meeting at RIE will commence after discussion of non-surgical patients is completed but is anticipated to start after 9am. The meetings will be held in the Oncology Seminar Room, Western General Hospital and the Blackford Room in the RIE Postgraduate Centre where teleconferencing facilities are available. The meeting will be chaired by lead clinician or deputy at WGH and by a pathologist at RIE. It is felt that presentation and chairing is too onerous for one person.

4 A volunteer minute taker will record the minutes. This would usually be an oncologist at WGH and a CNS at RIE. The chair will summarise the stage, performance status, pathology and management decision after each individual patient to allow this to entered on TRAK in real time. The minute take will liase with the MDM coordinator/tracker after the meeting to enter any further issues of interest raised in the discussion on to the TRAK record. Responsibilities of the chair: Identify a minute taker at the start of each meeting. Ensure meeting runs to time. Ensure clear and full discussion of each patient s clinical history, results of investigations, review of imaging and review of pathology. Ensure equal opportunities for all disciplines to contribute to discussion. To summarise conclusions of discussion for minute, specificially stage, histology, performance status and management decision, and determine who should be responsible for actions decided. To review completion of key fields in the TRAK minute such as Date of referral, Urgency of referral, Stage, Performance status and any others required for SCAN audit. Make note of any delays and impending breaches of 62 day targets to be recorded in the minutes. These delays should be detailed in the minute on TRAK. Responsibilities of the minute taker: Ensure accurate concise recording of stage, performance status, pathology, and decision. To make brief comments to clarify the reason for the decision as well as recording the person responsible for actioning the decision. To note any deviations to the staging pathway for audit purposes. Record any reason for delays. Review TRAK minute with coordinator and forward to chair for approval. Regular minute takers should have this acknowledged in their job plan. PRESENTATION ARRANGEMENTS Referral forms for patients to be discussed at the meeting should be sent to the MDM Coordinator at least 48 hours before the meeting to allow sufficient time for pathology and radiology review. The adequacy of clinical information should be confirmed by the clinical lead, and the availability of radiology and pathology confirmed by the clinician rostered for the meeting.

5 Any patient not submitted to the MDM Coordinator by 48 hours before the meeting will only be discussed with the specific agreement of clinical lead, radiologist and pathologist. The presenting clinician will present an accurate clinical history and be familiar with the patient s performance status and social circumstances. The presenting clinician should be aware of the patients understanding of the diagnosis to date and any particular wishes the patient may have regarding their further management. The presenting clinician should be aware of all the available results of investigations. If it becomes clear this is not the case, discussion of the patient will be deferred until a subsequent meeting when such information is available, to avoid unsafe decisions and futile surgery or oncology appointments. The Chair should invite review of radiology and pathology. The Chair should lead the discussion to allow contributions from all relevant disciplines. The Chair should keep the discussion focussed to facilitate the running of the meeting to time. The information on the referral form should be validated during the meeting, and amended and completed as appropriate. At the end of each patient s discussion notes should be offered to the appropriate team for the patient s next appointment. The completed form on TRAK will function as a referral letter. Patients will not be offered appointments until this is on TRAK and adequately completed. The completed form will be sent to the patient s GP with a standard covering letter to indicate its provenance. ROLE OF THE MDT MEETING COORDINATOR The MDT meeting coordinator provides the support to enable the requirements of the meeting to be met by undertaking the following actions: Meeting Arrangements To work with clinicians to ensure that an operational policy for the meeting is prepared and implemented. To work with clinicians to ensure that optimal meeting room arrangements are in place and are maintained. To establish links with IT to ensure that any IT systems and teleconferencing facilities are available and in use where required. To record attendance at the meetings. To identify a deputy when the regular chair is unavailable. Preparation and support for meeting. To collate list of patients for the MDM and ensure that the pathologist and radiologist receive accurate lists of patients for review as soon as practicable once referrals closed 48 hours before meeting.

6 To record decisions on treatment on to TRAK as summarised by the meeting chair during the meeting and liaise with the minute taker to complete any gaps in the TRAK form at the end of the meeting. Provide information on patients monitored through 62-day pathway, list breach dates and flag up any patients at risk of breaching and any undue delays. To circulate minute to clinical lead (or deputy) for approval and then circulate electronically to all MDT members. Supporting patients progress To work with lead clinicians to track patients progress, using a structured recording system. Liase with secretaries to ensure follow-up actions (onward referrals; appointments) for patients are implemented. Data and reporting To record key data on the patients, ensuring that it is good quality, i.e. complete and accurate. To provide regular monitoring updates, especially on waiting times To assist clinical staff in monitoring and evaluating the effectiveness of the meetings/ processes used. CANCELLING THE MEETING The meeting may only be cancelled if falling on Christmas or New Year public holidays. If treatment delays are likely to arise, patients should be discussed at an earlier stage in their journey than might otherwise be the case so that decision trees can be constructed to avoid those delays.

7 Suspicion of lung cancer in primary or secondary care (see Scottish Cancer Referral Guidelines) Respiratory Physician (One Stop) Lung Cancer Clinic CT, assessment of fitness, performance status (biopsy procedure as below) Biopsy bronchoscopy or CT guided; EBUS if neither possible Potentially curable CS I-III, PS0-2 (LS) MDM Not potentially curable CS IIIB- IV, PS 3-4 (ES) Clinical Oncology (chemotherapy + radiotherapy) Medical oncology (chemotherapy for CS IIIB-IV, PS 0-3 ) or Palliative Medicine (symptom control for PS 3-4) Staging Pathway for Patients with Small Cell Lung Cancer

8 Suspicion of lung cancer in primary or secondary care (see Scottish Cancer Referral Guidelines) Respiratory Physician (One Stop) Lung Cancer Clinic CT, assessment of fitness, performance status (biopsy procedure as below) Biopsy bronchoscopy or CT guided; EBUS if neither possible Potentially curable CS I-III, PS0-2 Not potentially curable CS IIIB- IV, PS 3-4 PET PFT Surgical assessment including cardiac fitness, VITA and mediastinoscopy MDM EBUS Oncology (radiotherapy or chemotherapy for CS IIIB-IV, PS 0-3 ) or Palliative Medicine (symptom control for PS 3-4) Surgery Oncology (radiotherapy +/- chemotherapy) Staging Pathway for Patients with Non Small Cell Lung Cancer

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