To our knowledge, this is the first European survey on the role of the radiologist and the related issues in MTBs.
Most of the respondents worked in a university hospital (59.2%), and only 11% (32/292) of them were not involved in MTBs (of whom 65.6% because not formally invited, and only 12.5% because not interested in participating). This is in line with the fact that currently the radiologist has a fundamental role in the MTB as a “core member”. According to the RCR document, all “core members” must personally attend two out of three MTBs [11]. Moreover, the radiologist needs adequate time to review images before the meeting to provide a robust radiological opinion of the cases and avoid errors. In order to do this, it is necessary to have the list of patients to be discussed during the MTB, at an agreed minimum time in advance, and all the imaging studies performed by the patient (also at other hospitals) should be available.
The time required for a radiologist to review the images of a case reported by him/herself is different from that necessary to review a case reported by another colleague, or even multiple examinations performed in different hospitals. For this reason, examinations performed at other hospitals should be available within an appropriate length of time before the meeting. However, our findings show that only 43.9% of radiologists reviewed over 70% of exams prior to MTB meetings, and imaging studies are reviewed by one-third of radiologists in less than 50% of cases. Possible explanations for this include the fact that only 66.5% of respondents received the list of patients and the imaging studies before the meeting, the lack of time due to a busy schedule for imaging and reporting (46.6%), and the difficulty of reviewing poor-quality imaging studies performed elsewhere (18.1%). In this context, an inaccurate or lacking review of imaging studies before the meeting can lead to significant errors in patient care.
According to the RCR document [11], there should be at least two radiologists designated for each site-specific meeting to provide continuous support, but our findings show that in 73.1% of cases, the MTB meeting is attended by one radiologist only. In general, radiologists deal with different types of cancer and therefore have to attend several meetings in a week, which can make their time commitment especially hard. In addition, many meetings are outside normal working hours or during lunchtime, and in different locations from the normal working place, with consequent problems related to travelling and time management. Problems in MTB attendance have been emphasised in the literature [2], and to this regard it is worth mentioning that an American Society of Clinical Oncology (ASCO) survey showed that although multidisciplinary attendance occurred 70% to 86% of the time, many respondents still did not have access to MTBs and/or lacked certain types of specialists at their institutions, with a small but significant fraction of respondents (24.6%) attending MTBs at nearby institutions [1]. A potential solution might be the implementation of dedicated hardware and/or software platforms to manage MTBs from remote locations, but meeting rooms should be equipped with appropriate technology, and in any case, the issues of lack of time and inconvenient meeting times would remain unresolved [12]. According to our survey, meetings were held mainly in the morning (28.5%) or early afternoon (31.5%), or during lunchtime (19.2%), probably in relation to the needs of the members of the different MTB meetings.
All of the time spent reviewing images, writing supplementary reports and attending meetings should be accounted for as regular working hours and addressed in the appraisal process of the department. However, according to our survey, only in 71.9% of cases the radiologist’s involvement was accounted for in normal working hours and in 66.9% of cases, it was addressed in the appraisal process of the department.
From the radiologist’s point of view, meeting rooms need to have appropriate technology to project high-resolution images (55%), as well as PACS facilities with image reviewing workstations to display imaging studies and eventually retrieve prior examinations (32.7%).
According to the RCR paper [11], the radiologist who has reviewed the images must document that he has done so, independently of whether his/her opinion is in agreement or not with the previous report. This supplementary report, which could influence the clinical decision-making of patients, should be available to MTB members, either at the time of the decision or in the next days before the beginning of treatment. However, our survey shows that only 40% of respondents provide a supplementary report when their opinion differs from the primary imaging report, although in 81.9% of cases radiologists are included in the final multidisciplinary report.
Another important point concerns the presence of patients during meetings. In a survey of over 2000 cancer health professionals in the UK, the majority of them felt that it was neither desirable nor practical to include patients in MTB meetings [13]. However, it is important to ensure that patients are informed about MTBs in a way that allows them to be actively engaged in the decision-making process [14, 15]. Based on our findings, patients did not participate in MTB discussions in 90.4% of cases.
In the respondents’ opinion, the participation of radiologists in MTB meetings is mandatory (58.8%) or very useful (41.2%), and its most important benefits are surgical and histological feedback (86.9%), improved knowledge of cancer treatment (82.7%) and better interaction between radiologists and referring clinicians for discussing rare cases (56.9%). Actually improved communication between health professionals is a recognised putative benefit of MTB working [2], which enables radiologists to assume a more active role in patient care by taking part in team decision-making and allows clarifying the diagnostic strategy or refining therapeutic decisions of clinician members [16]. In the respondents’ view, the attendance of radiologists at the meetings could change the diagnostic strategy or refine the therapeutic decisions in a range of 25–50% of cases discussed (50%). This finding is in line with data from the ASCO survey, revealing that MTB working led to a change of 1% to 25% in treatment plans for 44% to 49% of patients with breast cancer and for 47% to 50% of patients with colorectal cancer. The same survey showed that MTBs were associated with 25% to 50% changes in surgery type and/or treatment plans for 14% to 21% of patients with breast cancer and for 12% to 18% of patients with colorectal cancer [1].
Moreover, involvement in MTB meetings is a good opportunity for trainees to learn, and for members to update their professional knowledge, yet in 85% of cases, they are not CME accredited. Involvement in MTB meetings is essential for both improved patient care and medical research, as well as for continuing education. Members who are actively involved in multidisciplinary discussions have the opportunity to keep themselves updated with ongoing developments of state-of-the-art oncology and clinical studies conducted at their centre. Also, the vast majority (96%) of respondents to the ASCO survey agreed that MTBs can have a teaching value [1]. However, currently, the significant time expenditure required for preparation and performance of MTB sessions finds no counterpart in adequate reimbursement and CME accreditation. Since the demand for MTB sessions will be further increasing, considerable efforts are urgently needed to ensure that the radiology service is adequately acknowledged.
A limitation of our survey is that its specific nature might have led to a selection bias due to collecting data solely from members of a subspecialty radiological society, leaving out opinions from a potentially much larger number of radiologists sharing the same activities and related issues. This might limit the generalisability of our findings and possibly underestimate any shortcomings related to MTB organisation that could occur outside the working institutions of the radiologists involved in our survey. A further potential limitation is the relatively higher prevalence in our survey of respondents from one country (i.e. Italy) compared with other countries, which might introduce a bias in the results towards the Italian system.
In conclusion, our survey (conducted within a selected group of radiologists with a special interest in oncologic imaging) has revealed several criticisms that need to be solved in order to ensure that the presence of a radiologist in MTBs can yield a real added value both to the radiologist and the entire MTB team.