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SFORL Guidelines

Guidelines (short version) of the French Otorhinolaryngology Head

and Neck Surgery Society (SFORL) on patient pathway organization in
ENT: The therapeutic decision-making process
S. Deneuveg, , E. Babina , J. Lacau-St-Guilyb , B. Baujatb , R.-J. Bensadounc , A. Bozecd ,
D. Chevaliere , O. Choussyf , F. Cunya , N. Fakhryh , J. Guigayi , M. Makeieffj , J.-C. Merolj ,
F. Mouawade , J. Pavilletk , C. Rebierel , C.-A. Righinim , M.-C. Sostrasn , M. Tournailleo ,
S. Vergezp
a

Service dORL, CHU, avenue de la Cte-de-Nacre, 14000 Caen, France

Service dORL, hpital Tenon, 4, rue de la Chine, 75018 Paris, France
Service doncologie et de radiothrapie, centre de Haute nergie, 10, boulevard Pasteur, 06000 Nice, France
d
Service dORL, institut universitaire de la face et du cou, 31, avenue Valombrose, 06100 Nice, France
e
Service dORL, hpital Claude-Huriez, rue Michel Polonovski, 59037 Lille cedex, France
f
Service dORL, hpital Charles-Nicolle, 1, rue de Germont, 76000 Rouen, France
g
Dpartement de chirurgie oncologique, centre de lutte contre le cancer Lon-Brard, 28, rue Laennec, 69008 Lyon, France
h
Service dORL et de chirurgie cervico-faciale, hpital de la Conception, CHU, 147, boulevard Baille, 13005 Marseille, France
i
Service doncologie mdicale, institut universitaire de la face et du cou, 31, avenue Valombrose, 06100 Nice, France
j
Service dORL, hopital Robert-Debr, avenue du Gnral-Koenig, 51100 Reims, France
k
Service doncologue mdicale, CHU, 38043 Grenoble, France
l
Service social, CHU, 14000 Caen, France
m
Service dORL, hpital Nord Michalon, BP 217, 38043 Grenoble cedex, France
n
Service social, hpital Tenon, 4, rue de la Chine, 75018 Paris, France
o
Service social, CLCC Francois-Baclesse, 3, avenue du Gnral-Harris, 14000 Caen, France
p
Service dORL, hpital Larrey, 24, chemin de Pouvourville, TSA 30030, 31059 Toulouse cedex 9, France
b
c

a r t i c l e

i n f o

Keywords:
Multidisciplinary team meeting
Therapeutic decision-making
Head and neck surgeon

a b s t r a c t
Objectives: The authors present the guidelines of the French Otorhinolaryngology Head and Neck
Surgery Society (SFORL) for patient pathway organization in head and neck cancer, and in particular for
multidisciplinary team meetings. The present article concerns the therapeutic decision-making process.
Methods: A multidisciplinary work group was entrusted with a review of the scientic literature on
the above topic. Guidelines were drawn up, based on the articles retrieved and the group members
individual experience. They were then read over by an editorial group independent of the work group.
The nal version was established in a coordination meeting. The guidelines were graded as A, B, C or
expert opinion, by decreasing level of evidence.
Results: It is recommended that: an organ specialist should contribute to all multidisciplinary meetings
on head and neck cancer; all members of the multidisciplinary meeting should have specic knowledge
in head and neck cancer; any referring physician who does not follow the multidisciplinary meetings
advice should justify that decision; there should be sufcient time to prepare, discuss and sum up the
cases dealt with in the multidisciplinary team meeting.
2015 Elsevier Masson SAS. All rights reserved.

1. Introduction

Corresponding author.
E-mail address: sophie.deneuve@lyon.unicancer.fr (S. Deneuve).

The therapeutic decision-making process comprises the various stages, following discovery of tumor, leading to a coherent
treatment proposal by the medical and paramedical team to the
patient and family, who should at least partly adhere to the proposal.

http://dx.doi.org/10.1016/j.anorl.2015.06.006
1879-7296/ 2015 Elsevier Masson SAS. All rights reserved.

Please cite this article in press as: Deneuve S, et al. Guidelines (short version) of the French Otorhinolaryngology Head and Neck Surgery
Society (SFORL) on patient pathway organization in ENT: The therapeutic decision-making process. European Annals of Otorhinolaryngology, Head and Neck diseases (2015), http://dx.doi.org/10.1016/j.anorl.2015.06.006

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Multidisciplinary team meetings (MDTM) were made mandatory in France under a Circular from the Health Ministry dated
February 22nd, 2005 [1], to bring together the patients le and
propose treatment. At least 3 physicians of different specialties are
required under the terms of the Circular, although it is often desirable that a larger number of specialties should be represented. The
MDTM is a therapeutic decision-making tool. A number of benets
have been reported:
positive impact on tumor staging [2] (level of evidence: 4);
impact on decision-making and treatment modication [3] (level
of evidence: 4): treatment as recommended by the MDTM tends
to be curative and more aggressive [4] (level of evidence: 4);
impact on the care pathway: the interval between rst consultation and treatment initiation is shortened [5] (level of evidence:
4).
A nationwide multidisciplinary work group was entrusted with
drawing up guidelines for the therapeutic decision-making process in head and neck cancer. The French Health Authority (HAS)s
methodology of formalized expert consensus for good practice
guidelines (http://www.has-sante.fr) was followed. A pilot group
organized the consensus conference logistics, choice of editorial
group members, and analysis of the literature based on a PubMed
search. Articles were graded A, B, C or expert opinion according
decreasing level of evidence, in line with the National Agency
for Evaluation and Accreditation in Healthcare (ANAES)s literature analysis and guidelines grading guide. A preliminary series of
guidelines was drawn up, based on a position paper, then assessed
by the editorial group, and recast by the work group following
feedback.
2. Results

Guideline 1
An organ specialist (head and neck or maxillofacial surgeon) should attend all head and neck cancer MDTMs. Expert
opinion.
Guideline 2
All MDTM members should have specic knowledge in
head and neck cancer. Expert opinion.

The following factors are mandatory in MDTMs [6] (HAS guideline):

statement detailing organization and functioning;
minutes of each meeting, with list of those present;
predetermined schedule: at least twice monthly [7] (level of evidence: 4).
All MDTM members should have specic knowledge of head
and neck cancer and general oncology [8] (European guideline). The
presence of a specialist organ surgeon is desirable [911] (level of
evidence: 3).
Each patient le is presented by a physician, whether or not usually an MDTM member: a physician not regularly present may come
to present a case or delegate an MDTM member, but it is preferable
that the physician in charge of treatment or treatment coordination
should be present. The person presenting the le should be familiar
with the case and able to discuss it and answer the questions and
arguments of those present.
Files for patients with new primary or recurrence should be
systematically presented, either for discussion or for treatment

validation [8] (European guideline). Each key step of treatment

should be dealt with in MDTM. Possible inclusion in clinical trials is
also dealt with (interest of presence of a clinical research associate
or clinician).

Guideline 3
The MDTM should have sufcient time to prepare, discuss
and sum up the cases presented. Expert opinion.

Ahead of the meeting, a standardized medical data form should

be lled out by the physician referring the case to the MDTM
[7] (HASINCA [National Cancer Institute] guideline). The medical
proposal must take account of the following factors, requisite to
decision-making:
TNM classication, essential before considering treatment: classication as local, regional or generalized;
pathology data not included in TNM classication. Certain pathology results are of recognized interest in tumoral assessment:
thickness, certain histologic forms, expression of certain antigens,
etc;
imaging le: usually, all examination results available will be
looked at during the meeting, as a nal check, which may reveal a
suspect element: metastasis, doubtful image, suspicion of second
tumor, etc;
general health status and assessment of capacity to withstand
treatment: analysis of all complementary examinations performed at initial assessment;
opinion of patients usual physician, provided directly or reported
to a MDTM member. The patients own physician is aware of the
patients socioeconomic situation, capacities and support;
epidemiological and social data: private and family life, support,
friends and relatives;
the possible interest of the patient being present at the MDTM is
a matter of debate [12,13] (level of evidence: 4).

Guideline 4
If the advice of the MDTM is not followed by the referring
physician, the latter should justify that position. Expert opinion.

After examination of the various elements:

either the le is sufcient for therapeutic decision-making, and
discussion leads to a team opinion;
or further examinations and/or consultations are needed and the
le is held over for consideration in a subsequent MDTM.
After free discussion in which each team member gives his or
her opinion, a consensus should emerge [14] (level of evidence: 4).
The MDTM report should include the date, treatment proposal and
names and qualications of those present [6] (HAS guideline) and
be kept in the patients le [15] (HASINCA guideline: charge book
for oncology communication les). The treatment proposal is to be
based on the guidelines used by the MDTM.
Once the MDTM has come to a decision, implementation is to
be considered: referral to specialist consultations in oncology, radiology, surgery, support cells and supporting care (physiotherapy,
nutrition, pain, psychology, social work). This enables the disease
to be considered globally, without adding to the anxiety inevitably
experienced by the patient and family, who often come up against
practical problems.

Please cite this article in press as: Deneuve S, et al. Guidelines (short version) of the French Otorhinolaryngology Head and Neck Surgery
Society (SFORL) on patient pathway organization in ENT: The therapeutic decision-making process. European Annals of Otorhinolaryngology, Head and Neck diseases (2015), http://dx.doi.org/10.1016/j.anorl.2015.06.006

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If the treatment implemented differs from the MDTMs recommendation, the reasons should be put forward in writing by the
patients physician and included in the le [6] (HAS guideline).
The MDTM is intended to offer the patient the best adapted
treatment [8] (level of evidence: 4). This form of organization is
particularly useful in rare tumors. To meet INCA requirements
for expert center organization [16] (INCA guideline), a national
bi-monthly back-up MDTM is held to deal with complex decisionmaking in rare head and neck tumors: the French Expert Network
for Rare Head and Neck Cancers (REFCOR) [17,18] (level of evidence: 4).
The patient may also wish to have other opinions on treatment,
and this should be facilitated by providing the patient with all relevant information.
3. Conclusion
The MDTM is intended to offer the patient the best adapted
treatment, and should apply to all cases of new primary or recurrence and to each key step in treatment, either for discussion or for
validation.
References
[1] Circulaire DHOS/SDO/2005/10102/2008/99 relative lorganisation des soins
en cancrologie. Direction de lhospitalisation et de lorganisation des soins.
2005.
[2] Wheless SA, McKinney KA, Zanation AM. A prospective study of the clinical
impact of a multidisciplinary head and neck tumor board. Otolaryngol Head
Neck Surg 2014;143(5):6504.
[3] Chang JH, et al. The impact of a multidisciplinary breast cancer center on
recommendations for patient management: the University of Pennsylvania
experience. Cancer 2001;91(7):12317.

[4] Forrest LM, et al. An evaluation of the impact of a multidisciplinary team, in a

single centre, on treatment and survival in patients with inoperable non-smallcell lung cancer. Br J Cancer 2005;93(9):9778.
[5] Murray PV, et al. The pathway study: results of a pilot feasibility study in
patients suspected of having lung carcinoma investigated in a conventional
chest clinic setting compared to a centralised two-stop pathway. Lung Cancer
2003;42(3):28390.
[6] HAS. Fiche mthode : runion de concertation pluridisciplinaire; 2014.
[7] INCA, HAS. Runion de concertation pluridisciplinaire en cancrologie. Une
dmarche damlioration de la qualit; 2006.
[8] Borras JM, et al. Policy statement on multidisciplinary cancer care. Eur J Cancer
2014;50(3):47580.
[9] Davies AR, et al. The multidisciplinary team meeting improves staging accuracy and treatment selection for gastro-esophageal cancer. Dis Esophagus
2006;19(6):496503.
[10] Houssami N, Sainsbury R. Breast cancer: multidisciplinary care and clinical
outcomes. Eur J Cancer 2006;42(15):248091.
[11] Martin-Ucar AE, et al. The benecial effects of specialist thoracic surgery on
the resection rate for non-small-cell lung cancer. Lung Cancer 2004;46(2):
22732.
[12] Butow P, et al. Health professional and consumer views on involving breast cancer patients in the multidisciplinary discussion of their disease and treatment
plan. Cancer 2007;110(9):193744.
[13] Choy ET, et al. A pilot study to evaluate the impact of involving breast cancer
patients in the multidisciplinary discussion of their disease and treatment plan.
Breast 2007;16(2):17889.
[14] Ruhstaller T, et al. The multidisciplinary meeting: an indispensable aid to
communication between different specialties. Eur J Cancer 2006;42(15):
245962.
[15] Haute Autorit de santINCA. Une dmarche damlioration de la qualit.
Runion de concertation pluridisciplinaire en cancrologie; 2006.
[16] INCA. Cancers rares de ladulte : lorganisation en centres experts Rapports et synthse. Plan Cancer 20092013. Mesure 20 et mesure 23;
2012.
[17] Badoual C, et al. [Pathologists and the French network of expertise on rare
cancers ENT: the REFCORpath]. Ann Pathol 2014;34(1):649.
[18] Baujat B, et al. [Rare tumors of the head and neck; on behalf of the
REFCOR, the French Network of rare head and neck tumors]. Bull Cancer
2014;101(5):41123.

Please cite this article in press as: Deneuve S, et al. Guidelines (short version) of the French Otorhinolaryngology Head and Neck Surgery
Society (SFORL) on patient pathway organization in ENT: The therapeutic decision-making process. European Annals of Otorhinolaryngology, Head and Neck diseases (2015), http://dx.doi.org/10.1016/j.anorl.2015.06.006