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Introduction

The multidisciplinary team (MDT) meeting has been the cornerstone of cancer care over the last two decades and has been shown to improve survival for cancer patients.1 The majority of MDT meetings are centred on initial diagnosis and surgical care. Over a similar time period there have been many advances in systemic anticancer therapy (SACT) for patients with advanced cancer, which have improved overall survival and quality of life (QOL). The large number of new treatments significantly increases the complexity and challenge for oncologists.2 There is currently debate about the utility of the MDT meeting and the use of SACT in patients with metastatic disease.3 We describe work, developed in metastatic breast cancer but applicable to other cancers, that attempts to address these two issues.

Metastatic breast cancer, being a heterogeneous biological process, exhibits a varied and unpredictable response to treatment.2 Patients can have varying amounts and aggressiveness of disease, from minimal to extensive and slow-growing disease to rapidly progressive disease. The beneficial and harmful effects of treatment must be carefully balanced and regularly reviewed. Often during the active treatment phase, discussions around prognosis, goals of care, advance care planning and wishes for the future are seen as inappropriate and are not addressed until the patient is clearly at the end of life.

Recent developments

In an audit carried out at The Christie NHS Foundation Trust in the early 2000s we found that few patients being actively treated for metastatic breast cancer, with numerous lines of palliative SACT, had been identified as being in the last year of life. Furthermore, they had often become separated from support in the community. Consequently, admissions for supportive and terminal care were frequent. The experience of patients not accessing supportive care until they are nearing the end of life, possibly due to the negative connotations associated with palliative care, has previously been reported.2 Patients with a high symptom burden were poorly catered for in oncology clinics, occupying considerable time and many staff.2 Fifty-seven percent of breast care nurses report that they are unable to provide adequate provision of care for patients with metastatic breast cancer.4 Their expertise is around helping support patients undergoing treatment, from surgery through to chemotherapy, providing physical and psychological support and signposting to other services as needed; many feel inadequate to manage patients with progressive disease.4 It is vital that, alongside breast care nursing support, these patients receive specialist support from palliative/supportive care professionals who are skilled in managing patients with advancing disease.5 At The Christie we developed an advanced breast cancer MDT which includes an advanced nurse practitioner in supportive care as well as breast care and research nurses, and medical oncologists. This has greatly improved patient and staff experience and has improved health resource use and trial recruitment. The fulcrum is a metastatic breast cancer MDT meeting, where all new and ...

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