Information on public consultation

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Public consultation dates

These draft guidelines are open for public consultation from the period of 4 December 2014 to 16 January 2014.

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Preoperative assessment

Review of endometrial biopsies or curettings

The allocation of endometrial cancer to low and high risk is dependent on a number of features, only two of which are assessable pre-operatively, namely the histological type and grade. Histological review may change the preoperative diagnosis of the type and grade of tumour, from possibly low risk (grade 1-2 endometrioid tumours) to definitely high risk (grade 3 tumours, serous, clear cell carcinoma or to carcinosarcomas). Many gynaecological oncologists routinely review histopathological specimens from endometrial sampling with a gynaecological pathologist, prior to treatment. In many cases, the original diagnosis has been made in general pathology departments in regional or other metropolitan hospitals. Only one retrospective study has studied the frequency of change in diagnosis after review of endometrial curettings and biopsy in detail.[1] Of 182 specimens, 16 (8.8%) were reclassified from malignant to premalignant or benign; in another 16 cases (8.8%), the histological type of tumour was changed significantly. Eleven of these 16 cases involved a change between endometrioid carcinoma and serous carcinoma, with another five cases (2.7%) reclassified from carcinocarcinoma to other sarcomas or carcinomas. The primary site of disease was changed from endometrium to cervix in three patients (1.6%) and vice versa in one patient. Overall, 23.6% showed major discrepancies. A study by Khalifa et al showed a reclassification of endometrial cancer histological type in 9.4%,[2] consistent with data from the study by Jaques.


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Pre-operative radiology review

One study noted that a pre-operative review of imaging resulted in a new diagnosis or upstaging in 10%, while another noted a lower figure of 1.4%.[3] [4] The present evidence suggests that routine pre-operative imaging plays a minor role in defining treatment plans in the majority of patients.


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Post-operative assessment and further management

In the post-operative setting, there may be several options for further treatment available to patients. A multidisciplinary care approach ensures that all suitable options are discussed, thus ensuring the best care for the patient.

Multidisciplinary care team meetings may include input from gynaecological oncologists, medical and radiation oncologists, gynaecological pathologists, palliative care specialists, clinical geneticists, radiologists, trainee medical specialists, nursing and social work personnel, psychologists and research scientists. Treatment decisions may benefit from input from different perspectives, theoretically providing more patient-specific advice on treatment and follow up. Treatment delay may be shortened as waiting times for adjuvant, curative or palliative treatment are minimised where a treatment plan is made early in the process.

Multidisciplinary case conference decisions should be carefully documented and communicated to all personnel involved in the woman’s care. The woman’s involvement in decisions is usually via the primary treating clinician, often a gynaecological oncologist. The treatment plan should always consider individual patient circumstances and wishes.


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Clinical outcomes and multidisciplinary care

No randomised clinical trials have been undertaken to compare clinical outcomes for oncology patients managed by MDTs versus management by individual clinicians[5][6][7] and there are no studies related specifically to endometrial cancer. Two studies from the UK have shown implementation of MDT recommendations in gynaecological oncology and upper GIT and colorectal cancers varies, with between 7% and 15% of recommendations not being followed.[6][7] Similarly, a prospective study of gynaecological cancer cases in the US noted that 84% of recommendations were followed.[8] The authors concluded that the benefit to clinical outcome was actual rather than potential as most recommendations were followed. A retrospective study of 533 cases of ovarian cancer provided evidence that improved survival was associated with management by a MDT.[9] Studies of other tumour sites have shown that MDT management can result in positive patient outcomes, in terms of diagnosis, increase the proportion of patients staged, treatment planning , survival and patient satisfaction.[6][7][10]


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Other benefits of multidisciplinary care

Studies of MDT have also shown benefits for patients other than clinical outcomes.[11][6] They include:

  • Faster and more coordinated treatment with agreed treatment plans
  • Improved care through best practice through adoption of evidence based guidelines
  • Improved patient satisfaction with treatment
  • More consistent information to patient
  • Entry of eligible patients into trials of new therapies
  • Educational opportunities
  • Mutually supportive environment and reassurance from corporate decision making especially in complex cases
  • Improved well being of members
  • Communication between members improved

A UK survey, conducted between 2000-2004, showed increased patient satisfaction in breast, colorectal and lung cancer care, where MDT is more established.[7] Other reported benefits include improved professional performance (clinically appropriate care) through enhanced clinical expertise and improved coordination of care, resulting in positive effects on patient outcomes.[10]


Practice pointQuestion mark transparent.png

Patients may benefit from intervention at a number of points during their care, including: changes in major treatment modality (surgery, radiotherapy, chemotherapy) post-treatment survivorship care and decisions regarding palliative care.


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Recommendations

Evidence summary Level References
Pre-operative pathology review resulted in a change in histological type in 9%, downgrading of diagnosis to benign in 9%, change in differentiation (by 2 grades) in 1% and change in primary site in 2% of patients, resulting in significant changes in management. III-2 [1], [2]
Evidence-based recommendationQuestion mark transparent.png Grade
Pre-operative review of uterine curettings or endometrial biopsies by a specialist gynaecological pathologist is recommended to assist in the accurate tailoring of treatment.
C


Evidence summary Level References
Though evidence linking improved clinical outcomes specifically to multidisciplinary team management is hard to substantiate, several studies have shown that MDT care in breast, colo-rectal, lung, oesophageal and gynaecological cancers improves coordination of care, patient choice and, in some cases, outcome. No studies have looked specifically at MDT care and endometrial cancer patients. III-3, IV [6], [7], [8], [10]
One prospective study noted that 84% of the recommendations from a gynaecological cancer multidisciplinary conference were followed. IV [8]
Clinical input at multidisciplinary conference can provide pathologists with information that may alter tumour stage and site and therefore management. One study of gynaecological cancer patients found that 7% of patients discussed were upstaged, resulting in a change of management in 57%. A further study noted a change in diagnosis in 28%, which affected management in 75% of cases. III-3 [3], [4]
Current evidence suggests that routine pre-operative imaging plays a minor role in defining treatment plans in the majority of patients. III-3 [3], [4]
Evidence-based recommendationQuestion mark transparent.png Grade
All patients with endometrial cancer should have the benefit of multidisciplinary team management which includes, at a minimum, review of pathology and relevant imaging, and presentation of their case at a multidisciplinary team conference.
C


Public comments: Recommendations - Is there benefit for multidisciplinary care of women with low and high-risk apparent early stage endometrial cancer?

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Jutta von Dincklage15:17, 17 June 2011

I would really like to see it emphasised somewhere that the care of women with endometrial cancer is not purely surgical and that the benefit of Multidisciplinary care is that the 'whole' patient is looked after...as you say this includes psycho social and psychosexual care (surely this has been neglected in this whole document??!!),diet (very important in this group)/physio (ditto)/etc etc... MQ

165.228.90.7913:01, 8 July 2011

Dear Prof Quinn,

Thank you for providing comment on the draft guidelines.

The Working Party has recently met to consider all the public comments received and review the guidelines.

The following is their response to your comments above:

Text about pre-op review of pathology removed and added as a separate question “Histopathological review” under Pre-operative Investigations. Pre-op review of imaging deleted. Specific text added to reinforce whole person approach and about psychosocial and psychosexual care.

Christine Vuletich

Manager, Clinical Guidelines Network

Cancer Council Australia

Christine Vuletich16:58, 27 September 2011
 
 

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References

  1. 1.0 1.1 Jacques SM, Qureshi F, Munkarah A, Lawrence D. Interinstitutional surgical pathology review in gynecologic oncology. I. Cancer in Endometrial Curettings and Biopsies. Int J Gynecol Path 1998;17:36-41.
  2. 2.0 2.1 Khalifa MA, Dodge J, Covens A, Osborne R, Ackerman I. Slide review in gynecologic oncology ensures completeness of reporting and diagnostic accuracy. Gynecologic Oncology 2003;90:425-430.
  3. 3.0 3.1 3.2 Greer HO, Frederick PJ, Falls NM, Tapley EB, Samples KL, Kimball KJ, et al. Impact of a weekly multidisciplinary tumor board conference on the management of women with gynecologic malignancies. Int J Gynecol Cancer 2010 Nov;20(8):1321-5 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21051971.
  4. 4.0 4.1 4.2 Cohen P, Tan AL, Penman A. The multidisciplinary tumor conference in gynecologic oncology--does it alter management? Int J Gynecol Cancer 2009 Dec;19(9):1470-2 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19955920.
  5. Hong NJ, Wright FC, Gagliardi AR, Paszat LF. Examining the potential relationship between multidisciplinary cancer care and patient survival: an international literature review. J Surg Oncol 2010 Aug 1;102(2):125-34 Available from: http://www.ncbi.nlm.nih.gov/pubmed/20648582.
  6. 6.0 6.1 6.2 6.3 6.4 Fleissig A, Jenkins V, Catt S, Fallowfield L. Multidisciplinary teams in cancer care: are they effective in the UK? Lancet Oncol 2006 Nov;7(11):935-43 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17081919.
  7. 7.0 7.1 7.2 7.3 7.4 Taylor C, Munro AJ, Glynne-Jones R, Griffith C, Trevatt P, Richards M, et al. Multidisciplinary team working in cancer: what is the evidence? BMJ 2010 Mar 23;340:c951 Available from: http://www.ncbi.nlm.nih.gov/pubmed/20332315.
  8. 8.0 8.1 8.2 Petty JK, Vetto JT. Beyond doughnuts: tumor board recommendations influence patient care. J Cancer Educ 2002;17(2):97-100 Available from: http://www.ncbi.nlm.nih.gov/pubmed/12092861.
  9. Junor EJ, Hole DJ, Gillis CR. Management of ovarian cancer: referral to a multidisciplinary team matters. Br J Cancer 1994 Aug;70(2):363-70 Available from: http://www.ncbi.nlm.nih.gov/pubmed/8054286.
  10. 10.0 10.1 10.2 Bosch M, Faber MJ, Cruijsberg J, Voerman GE, Leatherman S, Grol RP, et al. Review article: Effectiveness of patient care teams and the role of clinical expertise and coordination: a literature review. Med Care Res Rev 2009 Dec;66(6 Suppl):5S-35S Available from: http://www.ncbi.nlm.nih.gov/pubmed/19692553.
  11. National Breast and Ovarian Cancer Centre. Multidisciplinary meetings for cancer care: a guide for health service providers. National Breast and Ovarian Cancer Centre: Sydney; 2005.


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Supporting material

*Note: It was decided to merge the initial clinical question "Is there a benefit to a histopathological review of currettings or biopsy prior to treatment in low and high risk apparent early stage endometrial cancer?" and "Is there a benefit to multidisciplinary team management in low and high risk apparent early stage endometrial cancer?" into "Is there a benefit to multidisciplinary team management and histopathological review of curettings or biopsy prior to treatment in low and high risk early stage endometrial cancer?". Both literature searches form the body of evidence for this question

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