Multidisciplinary care (MDC) is a collaborative approach to cancer care, whereby the treatment plan for the patient is discussed by health professionals in various fields of cancer treatment as an integrated team, considering all treatment options and the preferences of the patient.1,2 MDC has been shown to provide benefits to medical professionals1,3 as well as patients.4,5

The National Health and Medical Research Council (NHMRC) Clinical practice guidelines for the management of early breast cancer state that all patients with early breast cancer should have access to care from a range of disciplines.6

The National Breast Cancer Centre (NBCC) encouraged MDC as a new standard of cancer care, conducting large studies and forums.2,7 The results of these were formulated into guidelines on how to implement MDC.7 Few studies have looked at how these guidelines are followed by the medical community. The definition of MDC remains fluid in the literature and among health professionals, with no one interpretation being a perfect fit for all situations.1,7,8

We examined how MDC is being implemented by breast surgeons who are members of the Royal Australasian College of Surgeons (RACS) Section of Breast Surgery in Australia and New Zealand. We expected that the establishment of MDC may be dependent on a variety of factors including, at a fundamental level, the nature of practice, the environment in which it is set and the availability of health professionals and resources.

The National Breast Cancer Audit identified MDC as an important emerging area relating to quality patient care that is not included in the Audit’s dataset. Information on MDC was captured in a questionnaire consisting of 16 items based on the NBCC’s “Principles of multidisciplinary care”.7

The questionnaire and a covering letter were distributed in December 2006 to all 281 surgeons then listed as active full members of the RACS Section of Breast Surgery. Questionnaires were identified by the surgeon’s name and College identification number to allow for follow-up of missing replies, and consent was implied by the return of the surgeon’s survey. Surgeons who were not members of the RACS Section of Breast Surgery, who contribute around 10% of the National Breast Cancer Audit’s data, were not included.

The data were summarised and analysed in a Microsoft Access database and with Microsoft Excel (Microsoft Corporation, Redmond, Wash, USA), and Instat (GraphPad Inc, San Diego, Calif, USA). Questions not answered were treated as missing values. As the survey required separate answers for the participants’ public and private practices, most of the results presented refer to “teams” or “practices” to represent the separate sides of a surgeon’s practice. Therefore, an individual surgeon may be represented more than once in some results where public and private practice are treated separately, and P values provide a rough guide only to non-random findings, as multiple responses from the same surgeon cannot be assumed to be statistically independent. Surgeons identified their practice setting as metropolitan, regional or rural in response to a questionnaire item.

The overall response rate was 91.8% (258/281), although 19 of these surgeons replied that they were no longer practising breast surgery, were retired, or were no longer full members of the Section of Breast Surgery, and were excluded from our analysis. The valid survey responses used for analysis therefore gave a response rate of 91.2% (ie, 239/262). The distribution of participating surgeons in public and private practice, and in metropolitan, regional and rural settings is shown in Box 1.

The results of our survey show that the recommendations of the NHMRC and the NBCC are largely supported by the Australian and New Zealand breast surgery community; most surgeons had an MDC team established in their practice, whether private or public.

MDC teams operate differently in private and public practice, with private practice teams more likely to take an informal approach to case discussion. Private teams are less likely to discuss all their patients, have their meetings less frequently, and are more likely to have meetings on an ad-hoc basis or have no formal meeting, but consider personal communication a form of MDC. We speculate that this difference between public and private practices may be due to proximity of colleagues, availability of technology and resources, and the fact that private practices would be responsible for establishing and managing MDC teams at their own initiative and expense.

Our results also show that there was a marked difference between the performance of metropolitan and rural MDC teams, with the performance of regional teams falling generally between these. Rural teams were much less likely to have a communication framework in place, and most teams held meetings monthly or on a variable basis. Rural teams were also the most likely to have a protocol in place for selecting which cases would be discussed (rather than routinely discussing all cases). Options to help overcome the tyranny of distance and isolation for small-volume remote surgical practices have been explored.2,7,9 Additional comments from some surgeons indicated that, in areas where MDC is not well established, collaborations with major centres, continuing professional development meetings and use of video and teleconferencing may supplement care where formalised discussion is lacking. However, assuming that the evidence-based MDC guidelines represent the paradigm of best practice for breast cancer care, this raises the question of whether patients treated in some private and rural practices are being offered a lower standard of care.

The most commonly noted disciplines represented in teams were surgery, medical oncology, radiation oncology, pathology, radiology and nursing (supportive care), which accords with the NBCC recommendations for the six core team disciplines. Our study aimed to gain insight into the roles salient to a surgeon. It is interesting to note that no surgeons reported including the patient or their relatives in the core or expanded treatment teams.

The NBCC guidelines for MDC recommend that the patient be involved in her treatment plan. One study found that patients’ inclusion in the MDC meeting was generally supported by patients and health professionals.3 While the results of our survey do not suggest that the patient is not involved in decision making, they may reflect surgeons’ attitudes towards the role of patients, perhaps placing them outside the treatment team. There may be a similar attitude to patients’ GPs, given that so few GPs were included in either core or expanded MDC teams. More targeted research could examine the extent to which GPs and patients are being included in MDC meetings, attitudes among health professionals to their inclusion, and barriers to their inclusion.

The additional quality-of-life disciplines such as psychosocial care, allied health and rehabilitation, nursing, and plastic and reconstructive surgery were much less frequently included in rural teams, highlighting a lack of resources beyond the core services available to people with breast cancer in a remote area.

Overall, MDC is being heartily accepted as part of breast cancer care by members of the RACS Section of Breast Surgery. However, the results of our survey highlight deficits in rural practices implementing regular MDC collaboration, and this may require special attention by policymakers. The inconsistency between public and private practice may indicate a need for more pressure on surgeons in private practice to conform to the standards that public service surgeons are reaching to ensure all patients are receiving access to MDC.

3 Inclusion of the six recommended specialist disciplines and general practice in the core team by public and private practice and by setting

4 Inclusion of other specialist disciplines and general practice in the expanded team by public and private practice and by setting*

* 28.1% of surgeons with multidisciplinary care teams did not respond to these items in the questionnaire.