Mandatory tumour boards
The government of France takes cancer very seriously. With 150,000 deaths each year, this is the leading cause of mortality in the country. The national health system pays for 100% of the care.
Patients also have an enforceable right to the review of their diagnosis by a multidisciplinary team (MDT) as well as for the management of their treatment. Hospitals and clinics must meet national standards for care and prove they actually provide coordinated care by an MDT. More than half of the 2,000 cancer centres treating patients 10 years ago have been closed for not meeting these standards.
Trouble with numbers
Cancer care is well structured, at least in theory, by successive fiveyear plans that also cover initiatives for cancer prevention and screening. In September, the third Cancer Plan was submitted to the Health Ministry by Professor Jean-Paul Vernant, who had been personally asked by the President of the Republic to review progress of the first two plans and make his recommendations. Cancer Plan III will come into effect at the beginning of 2014, though it will likely be under-funded.
The universal requirement for MDTs, he wrote, ‘is a heavy action requiring significant medical resources that are often difficult to meet, and a systematic deployment for every patient is likely to pose problems, taking into account the increasing incidence of cancer and the expected decrease in the number of oncologists.’
The good news, Prof. Vernant reports, is that a review of 794 authorised cancer centres in 2011 showed a clear progression, with 70% of MDTs composed of at least three different specialists, compared to 38% the previous year.
Unequal access
Disparities remain, he noted, pointing out that there has never been an evaluation of the impact of this key component of the plan. Areas of concern include the unequal access across the regions for patients to MDT-supervised care, communication to the treating physician of the decisions proposed by the MDT, the time and resources dedicated to MDTs, and the lack of regional consulting boards with expertise that can be called upon for urgent decisions, for rare cancers and for unusual clinical issues.
There is also a need to set standards with a procedural manual for tumour boards spelling out roles, responsibilities, documentation requirements and especially communications with the patient’s physician.
Ignoring, for the moment, the lack of funding and resources, Prof. Vernant fulfils his commission by recommending three levels of MDTs in France: the first-line, or local, tumour board; a series of expert panels on the regional and the national level that can be called upon by the first-line team and, a MDT of last resort to manage patients where therapy has failed, either to supervise an alternative treatment or palliative care.
Prof. Vernant is especially critical of the failure to establish the networks for sharing files among MDT members. Considered key to the organisation of MDTs in the first Caner Plan in 2003, cancer files were to be linked with the national patient medical record, according to the second Cancer Plan in 2009.
A sophisticated, dedicated network
How many files-sharing networks were established in the first place is unknown, he notes, adding that MDT members do not use the few that exist to exchange information. Theoretically there could be 25 such networks, he wrote, each developed locally, and none able to communicate with another network. The initiative to link cancer files with a patient’s record remains stuck in a half-dozen regional pilot projects. Again in fulfilment of his commission, Professor Vernant spells out recommendations to rapidly deploy a national network to kick-start file sharing, to disconnect the cancer files from the national patient record, and to progressively build a more sophisticated, dedicated network that can include the referring physicians as well as general practitioners
29.10.2013
