Multidisciplinary treatment (MDT) is considered to be beneficial for patients undergoing complex treatments for cancer. However treatment modalities for malignant diseases have become more and more sophisticated over the recent decade. Multiple prospectively randomized controlled trials have shown benefits not only for perioperative but also for non curative treatment modalities [1]. Thus a single specialist on whichever disease is no more able to know and perform all treatments considered to be beneficial for the respective patient. A team approach consisting of multiple specialists is supposed to improve patient’s outcome and prognosis after the treatment [2]. Those teams may improve communication coordination and decision making according to the recent literature and data available. Often time consuming referral to other colleagues may prolong necessary treatment and thus may influence the patients’ outcome. Several analyses on the outcomes of MDT have been published before. It was shown that MDT may lead to revised treatment plans with improved adherence to evidence-based guidelines [3-8]. Further it was demonstrated in the literature that MDT may reduce time from diagnosis to initiation of appropriate treatments. Not only patients but also health care specialists thus endorse those effective decision making processes. Besides higher patient’ satisfaction, MDT was reported to improve education of clinicians and increase inclusion rates to prospectively randomized controlled trials [3,9-11].

The efforts of MDT led to the initiation of nowadays well known trials in gastroesophagal cancer treatment [12-16]. Those trials changed the management of advanced stage gastric cancers and improved patient’s outcome throughout the world. However it was published before that a considerable amount of patients being eligible for multimodal treatment concepts have not been considered for such a therapeutic option [17,18]. Even among experts there is disparity in clinical management of certain situations. This was shown in a recent publication reporting on the results of a highly specialized panel of experts in gastric cancer treatment [1]. The major reason for this was considered to be the lack of evidence and also the drawbacks of clinical staging with the well known uncertainties to define clinical T- and N-stages. In contrast MDT meetings have shown to improve staging accuracy [19]. Compared to US and European countries, MDT is not mandatory in Korea so far. However, the importance of MDT has been recognized and efforts are being undertaken throughout the country in order to offer the benefits of MDT to local patients. In contrast to European countries the general practitioners system is not very common in Korea and patients usually report directly to the hospital where their treatment has taken place before. The National Cancer Center, Korea (NCCK) is one of the first institutions introducing MDT and implemented even for organizing administrative system. Here we report the experience of MDT of the Center for Gastric Cancer of NCCK. We show the management not only of oncologic treatment plans but also treatment decisions on perioperative oncologic therapy and multimodal management of postoperative and various treatment-related complications.

Despite the huge efforts undertaken, there is no strong evidence that MDT improves patients’ overall survival [5]. However it was revealed that MDT led to improved survival rates of breast cancer patients in Scotland [20]. Due to those findings MDT has become mandatory for breast cancer treatment in Germany [21]. Further it has become a mandatory prerequisite in order to become a certified comprehensive cancer center in several other countries [7,22-26]. Many national guidelines incorporated MDT modalities over the recent years [2,27-30]. Most of the guidelines suggest that a MDT team consists of representatives from surgery, medical oncology, radiation oncology, pathology and radiology. Further it is recommended to extend the team to nurses, dietitians, psycho-oncologists and trial specialists, who attend the frequent meetings. Despite common acceptance of MDT meetings, still many obstacles exist throughout the general practice. Those obstacles are mainly related to the workload in specialized treatment centers with consecutive lack of time as much as funding and reimbursement [2]. The key factors were poor staff attendance, scarcity of monetary and administrative support, ineffective recording and sometimes hierarchical boundaries [31]. It was reported that due to those barriers, treatment plans were not communicated to the general practitioners referring the patient. Therefore several requirements have to be met in order to establish MDT meetings. In a study from UK [29] the following requirements were outlined: appropriate infrastructure, meeting schedules, logistics and adherence to patient centered decisions. An Australian survey defined the following items in order to make MDT an effective tool: good leadership, core membership, team dynamics, administrative support, sufficient communication, adherence to guidelines and standards, appropriate recording, involvement of supporting stuff, protected time, adequate infrastructure, patient involvement, institutional funding and auditing of clinical activities. Especially leadership is supposed to play an important role [2,29,31]. Therefore an MDT leader is not only supposed to be a respected person (personally and scientifically) but also trained in communication, managing and listening skills. Further equality of the core team members is considered of utmost importance in order to avoid ineffective decision making. Another central issue should be so called “protected time” not only for the meeting itself but also for the preparation in order to obtain the relevant information for the respective patients [28,32].

The MDT conference at the Center for Gastric Cancer of NCCK was established when the hospital opened in 2001. Since then regular weekly meetings take place incorporating surgeons, gastroenterologists, medical oncologists, radiologists and specialized nurses (patient care, research and trials). Each case is presented according to treatment schedules and admission status. Out- and in-patients are discussed according to their respective diagnosis. All treatment decisions are taken in concordance with all MDT members. Due to its consistent character, MDT at NCCK fulfills the demands and requirements stated before. Protected time is warranted as much as appropriate infrastructure. All members are aware of their role within the team so that treatment decisions can be considered consistent. Further there is a strong adherence to national and international guidelines which is supported by the fact that all MDT members are exclusively specialized in gastric cancer treatment. Regular training is warranted by reviews of the recent literature shared between the team members. The described cases reveal that MDT does not only play a role in oncologic issues but also on perioperative problems. The case presentations reveal that treatment decisions are based on guidelines as recommended. Further on, review of postoperative findings led to changes in pathology reporting and treatment planning. This is consistent with reports that MDT not only may improve staging accuracy but also management of the therapeutic concept [2,19]. Review of postendoscopic and postoperative complications helped to avoid unnecessary and potentially harmful treatments such as redo-surgery. By active discussion among the members, difficult disease states such as conversion surgery were consented even without available guidelines on an individual basis. Recurrence cases were adequately scheduled for further treatment. Review of ongoing trials led to a high inclusion rate into prospectively randomized controlled studies. Further more specific clinical situations without available guidelines gave rise to study ideas and protocol development.

The local MDT conference can be considered as a fast and effective tool for adequate treatment and improving quality of the treatment. Therefore MDT is an essential component of cancer care to improve patient’s outcome. Further research on effectiveness of MDT and creation of objective data and evidence is needed to promote approval of insurance reimbursement in order to establish comprehensive cancer centers in Korea. Further, prospective and continuous evaluation of the patients treated within a MDT setting is going to provide improvements in outcome for gastric cancer.