Implementing consistent pretreatment multidisciplinary review for breast cancer: a quality improvement project.

Introduction
The facilitation of cancer treatment, especially for those patients with non-straightforward—or complex—cases, is rarely linear. Many medical conditions now require input from multiple disciplines, and although this creates more specialised care, a lack of seamless coordination between members at each step can result in avoidable obstacles in a patient’s journey. Many healthcare organisations and researchers around the world have implemented programmes that have been shown to prevent such challenges, as well as improve the quality and timeliness of care received from providers.15 This is exemplified by the multidisciplinary conference (MDC), a pioneering method of case review that has gained significant interest over the past few decades.
MDCs—often referred to as multidisciplinary teams, tumour boards or simply ‘rounds’—are processes in which healthcare providers meet to discuss cases. This organised method of communication allows a case to be evaluated by multiple perspectives from varying disciplines. This is especially important in cancer cases because treatment comprises several steps, involving many specialists—from primary detection by radiology, to diagnosis by pathology, to excision and reconstruction by surgery, to systemic therapy by medical oncology and locoregional therapy by radiation oncology.
The idea of MDCs was first described in Europe in 1995, and this movement has since gained international momentum.612 Many organisations around the world have guidelines of varying complexity for how best to facilitate MDC processes. In Canada, however, there is only one formally established set of guidelines—the one released in the early 2000s by Cancer Care Ontario.13 Since the release of this guide, the Pan-Canadian Standards for Breast Cancer Surgery, sourced from the review of current literature, has indicated that due to the multidisciplinary nature of breast cancer, surgeons must participate in regularly scheduled MDCs, whether virtually or in person.14
Studies show that not all provinces comply with these standards.15 16 In a study investigating young women with breast cancer in Canada, it was reported that although the large majority of Ontario sites comply with Cancer Care Ontario standards, very few sites in other provinces reported having regular MDC meetings.17 The lack of regular review is not the case for other countries.711 Studies based in the UK, the USA, continental Europe, Australia and Asia demonstrate a higher prevalence of review nationwide,18 19 perhaps due to earlier adoption of this process or because teams work at a common site.
These findings, coupled with the increased volumes and wait times for breast cancer cases at our centre, motivated us to implement a consistent pretreatment review (PTR) process targeting more complex breast cancer cases. With this, our goal was to create a more seamless patient care pathway to allow for early management recommendations from all specialties involved and define groups of patients with more complex breast cancer that would benefit from this approach. This project’s aim consisted of two phases: to increase the per cent of oncoplastic breast reconstruction (OBR) cases (a subset of complex cases) that have preoperative multidisciplinary review from 0% to 50% by May 2023, and to increase the per cent of all complex breast cancer cases reviewed to 50% by April 2024.

Methods

Patient and public involvement
Members of the public were not involved in the design, conduct, reporting or dissemination plans of this quality improvement (QI) project. However, input was sought from patient partners to ensure patient perspectives were included. By establishing a consistent pretreatment multidisciplinary review process, patients are directly benefitted through enhanced care coordination and more informed treatment decisions.

Context
Providence Breast Centre is among the highest-volume breast cancer surgery programmes in Canada performing approximately 850 breast cancer surgeries annually, which is 20% of procedures for our province. It is located in the third largest city in Canada at Mount Saint Joseph Hospital, a community hospital linked to the University of British Columbia. The centre receives referrals for patients with breast cancer in our catchment area of about 1 million as well as referrals for more complex cases from more remote communities that may not offer the full complement of breast cancer resection and reconstruction procedures. In our province, patients have investigations for breast abnormalities at community and hospital radiology facilities and are then referred to surgeons working in the regional hospitals. Medical and radiation oncology are coordinated through provincial programmes, usually outside of the hospitals where surgery occurs, and patients are referred to oncology either postoperatively for adjuvant treatment or preoperatively for neoadjuvant treatment.
At our centre, patients have breast investigations at 1 of 26 diagnostic facilities and are then referred to our centre by primary care physicians as the first step in breast cancer management. Referrals to the programme are triaged using a multidisciplinary algorithm that offers patients consultation with the surgeon that can accommodate the most appropriate operating room scheduling. Patients with breast cancer are seen by one of seven high-volume breast cancer surgeons, who help coordinate their care and individualised treatment plan. This plan can consist of immediate surgery, with or without reconstruction by plastic surgery, or begin with systemic treatment which occurs outside of our hospital.
MDCs in our region have been conducted using virtual meeting platforms since the COVID-19 pandemic, an innovation that has facilitated multidisciplinary representation as surgeons and oncologists work at different hospital sites. Additionally, there are four local breast diagnostic-focused MDC meetings—emphasising radiology, pathology and clinical correlation—and most also use virtual meeting platforms. Each MDC has a different focus and complement of clinicians, radiologists and pathologists. Due to breast imaging occurring at multiple sites, the radiology review may be asynchronous to the clinical discussions for some of the meetings.

Defining complex breast cancer cases for review
All of the aforementioned MDCs offered detailed review of cases by request, and routine review was not performed. After considering our case volumes and multiple diagnostic centres, we chose an aim of offering routine review of more ‘complex’ cases. Our initial definition of complex cases consisted of patients meeting criteria for neoadjuvant systemic therapy, patients with lesions that did not meet European Society of Breast Cancer Specialists (EUSOMA) criteria for breast conserving surgery, patients with recurrence, patients <40 and patients >80. Node-positive patients were added to the criteria in December 2023.
Some patients with larger lesions who are scheduled for immediate surgery may opt for OBR, a reconstructive plastic surgery procedure where the breast is reshaped using breast parenchymal displacement techniques following a large lumpectomy. This approach can remove up to 60% of the breast and is reported to have a lower rate of complications and results in fewer total surgeries, compared with the alternative of mastectomy.20 21 Since OBR is a lower-volume procedure and involves multiple specialists, it was selected as the first type of complex case targeted for PTR and became Phase 1 for our QI project. Phase 2 involved the review of all complex cases and was deliberately planned as a second step.

Interventions and study of interventions
This project had a total of eight plan-do-study-act (PDSA) cycles and consisted of two phases, one for each aim (figure 1). The first phase spanned PDSAs one through six, while the second spanned PDSAs seven through eight. The project lead—one of the surgeons at our hospital—began the first PDSA cycle in November 2022 by presenting an OBR case at an existing MDC at our local cancer centre. This served as a crucial first step, as this had been the only time that plastic surgery—a discipline that is generally under-represented at MDCs—had been present at MDC that year. Following a few case inquiries over email and another review at an existing diagnostic round at our hospital, other breast surgeons began presenting their OBR cases alongside the project lead. In February 2023, the seed localisation programme was implemented at our hospital, which led to the creation of a temporary MDC process between surgeons, radiologists and nurses. The goal of this seed round was to standardise the new method of localising breast lesions. This provided an opportunity for additional review of OBR cases, which often also require radiologic localisation. After completion of seed rounds in April 2023, breast surgeons began their own process, which included nurses, to aid in logistics of triage.
Following feedback and learning from the OBR PDSAs, the project pivoted to focus on the review of all complex cases. This was the second phase of the study, which we defined as Aim 2. PDSA seven began in September 2023 with the introduction of a weekly PTR process, to which all triaged ‘complex’ cases were brought and presented by the surgeon in charge of the case. These criteria encompassed over 50% of all patients with cancer being seen in consultation. At first, to work out logistics, the breast surgeons were the only ones involved, but the process evolved to include more disciplines in December 2023, starting with plastic surgeons and nurses. By April 2024, the disciplines involved included breast surgeons, plastic surgeons, nurses, medical oncologists and radiation oncologists.
To help facilitate this process during the initial QI project phase, a research coordinator would perform weekly reviews of triaged breast cancer patient data and schedule eligible patients for review. They would then send the case list 2 days in advance of the PTR to all specialties involved, providing physicians the opportunity to refine the case list or look up additional information for discussion. Following the two phases of the QI project, this role was assumed by staff at our centre. At each PTR, one of seven surgeons was assigned to be Chair, responsible for overseeing delegation of the discussion, filing of recommendations and completion of any relevant post-PTR paperwork.
For the two phases of the study, we prospectively collected data on 337 and 409 breast cancer cases, respectively, triaged to be seen by a breast surgeon. This allowed us to track the number and proportions of cases reviewed, along with the reasons for their review. In December 2023, we generated a comprehensive rounds recommendation form, on which the rounds Chair would indicate the changes proposed by the team for each case discussed.

Measures and analysis
To study the outcomes, prospectively collected data was analysed on a regular basis. This data consisted of date of triage, type of breast cancer, first treatment anticipated based on the triage algorithm, whether the patient was reviewed, date of review, reason for review and round at which reviewed. Measures included tracking the number of patients reviewed against the total number of triaged breast cancer cases.
Process measures included average time to PTR from the date of triage, number of disciplines attending each month, proportions of criteria being met for review and average case review and preparation times.
Outcome measures for Phase 1 were assessed up to May 2023, including the per cent of OBR cases reviewed and the per cent of total cancer cases reviewed. Outcome measures for Phase 2 were assessed up to April 2024, including the per cent of eligible cases reviewed and the per cent of total cancer cases reviewed.
Eight PDSA cycles were conducted across both phases. Each cycle represented a small, incremental change and was evaluated using the same predefined outcome measures. Process measures were collected continuously throughout the project to assess implementation and workflow changes, while balancing measures were used to monitor unintended effects on workload and feasibility. Findings from each cycle systematically informed subsequent adaptations.
Balancing measures included provider feedback, case preparation time and administrative time required. Feedback was collected through structured surveys and informal discussions with participants.
Google Forms surveys were distributed to conference members to assess perceptions of existing processes and satisfaction with PTR. The first survey was distributed in December 2022 to members of the diagnostic MDC at our hospital to gather feedback on existing workflows and inform early PDSA cycles. The second survey was distributed in March 2024 to all clinical PTR members to support discipline-specific sustainability planning.
To evaluate the sustainability of PTR implementation, two follow-up assessments were conducted in June 2025. These included a review of case volume data and an updated collection of physician feedback. All data were reviewed by members of a provincial QI team to ensure completeness and accuracy.

Results

Phase 1/Aim 1
This QI project comprised two phases with multiple interventions in the form of PDSA cycles (figure 1), each progressively impacting the implementation of PTR. The project lead encountered challenges in the time required and timeliness of responses when reviews were attempted via email, which, alongside phone calls, is the typical method of communication between members when bringing a case to an MDC is not an option. To address these issues, the project lead and other surgeons began presenting OBR cases at existing MDCs, which operate on a review-by-request model. This led to several changes in case management, including the cancellation of a liver biopsy for what was later identified as a haemangioma, changing of surgical procedure following a change in biopsy pathology and cancellation of a surgery altogether for someone reclassified as having metastatic disease. These cases, though not initially flagged for review, resulted in significant changes, further reinforcing our study objectives. The implementation of seed rounds facilitated the development of a clearer plan for optimum placement of the seed with respect to the target, reducing the need for extensive calls and treatment delays. Similar observations were made during triage reviews with surgical oncologists and nurses. As a direct outcome of these review processes, the project successfully achieved its initial aim, with 50% of OBR cases reviewed during Phase 1 (figure 2A).
Survey of our hospital MDC members showed an overall response rate of 71%. Regarding existing rounds, members suggested improvements in areas such as case scheduling, pre-rounds and post-rounds organisation through documentation, balance of responsibility between departments and case selection criteria. Among respondents, 80% acknowledged that rounds review had a positive impact on patient care. Regarding future rounds processes, 70% of responders believed there should be specific criteria for case review. When asked about potential challenges associated with implementation, concerns reported included the time spent on case preparation—estimated to be between 5 and 30 min per case—workload and lack of administrative support.

Phase 2/Aim 2
From May to August 2023, work on the project focused on reviewing and implementing the feedback and findings from Phase 1 and developing a plan to implement a sustainable PTR process for the clinic. Subsequently, the implementation of a consistent PTR process, coupled with a set of specific review criteria, allowed surgeons to review all complex cases on a weekly basis. Initially, patients were reviewed regardless of whether they had their initial surgical consult pre-PTR or post-PTR. However, due to the representing physician’s lack of information on the cases reviewed pre-consult, the process was adjusted to plan for review post-consult. With this method, the average time to review from date of triage was 9 days. The goal of reviewing 50% of all eligible triaged cases was achieved in the first month (figure 2B); however, there was a 3-month period lacking multidisciplinary representation. This allowed for refinement of the process in accordance with the results obtained from the first survey. During this period, treatment plans were informally documented and changes in management beyond treatment clarification were not formally recorded. In December 2023, before the addition of new disciplines, a post-rounds form was created to track reviewed cases, disciplines present at review and PTR recommendations. However, determining which cases had management changes as a result of review proved challenging. Consequently, the form evolved to include a checkbox asking whether changes had occurred—either post-triage or directly due to PTR. This allowed us to attribute the observed outcomes to the intervention of PTR implementation, with 23% of cases resulting in management changes. The number of cases reviewed remained consistently high, with an average of 94% of eligible cases being reviewed monthly since PTRs were first introduced (figure 2B).
After achieving consistent multidisciplinary representation, with plastic surgery, medical oncology, radiation oncology and nursing attending weekly, another survey was distributed to assess department-specific benefits, challenges and ideas for sustainability. This time, the response rate was 80%, and the overall feedback on PTRs was positive, with 80% of responders believing that PTRs have a positive impact on patient care. Reported benefits primarily focused on the ability to plan a patient’s entire care trajectory, along with increased educational opportunities. In contrast to previous survey responses, members noted that PTRs resulted in less time allocated per case when evaluated in a multidisciplinary setting compared with individual assessment, but it is acknowledged that this second phase used clinical discussion only. Challenges raised in the survey included high case volumes relative to allocated rounds time—with each case averaging a review time of 2–13 min—difficulty in keeping up with documentation, and increased workload.

Sustainability
Case volume data from April 2024 to May 2025 showed that an average of 32 cases were reviewed at PTR per month (figure 3). This is comparable to the 34 cases reviewed monthly during Phase 2 of the project, when PTR was initially implemented, suggesting sustained use of the rounds process over time. The same specialties continued to be represented at PTR and input from the hereditary cancer programme was added in 2025.
Physician feedback remained consistently positive, with perceptions largely unchanged from the previous survey conducted in March 2024. The benefit of input from the genetics team was noted. While some concerns persisted regarding documentation, case load and time commitment, 50% of respondents agreed that PTR continues to have a positive impact on the quality of patient care, while the remaining 50% reported uncertainty—rather than disagreement—about the extent of that impact.

Discussion
In this project, we effectively implemented a pretreatment MDC for patients with complex breast cancer, resulting in a more streamlined treatment process. By initially targeting a lower volume procedure requiring interdisciplinary coordination, we achieved our goal within a small and controlled setting. Starting reviews at existing MDC processes also provided insights into current practices and identified areas for improvement from members’ perspectives. Put together, these cycles allowed us to address challenges before implementing our PTR, thereby facilitating a smooth expansion of eligible case criteria. A gradual approach was further employed by only including breast surgeons in the first 3 months of complex case review, followed by slow integration of new disciplines each month thereafter. Additionally, key project members met approximately once a month to strategise data collection, refining methods with guidance from a QI advisor whenever obstacles were encountered, or the project focus shifted. Top of form.
Following the introduction of a recommendation form for PTRs, it was determined that, on average, 23% of cases underwent changes in management. This aligns with existing literature, which highlights the impacts that MDCs can have on a patient’s journey.12 2224 Two major themes emerged in terms of the types of management changes observed: diagnostic changes relating to pathology and radiology, and clinical changes in the sequence and refining of treatment options.
In addition to the changes associated with PTRs, this process limits presenter bias. Specifically, with few exceptions, all patients meeting criteria undergo review, even if the case may initially appear straightforward. In contrast, at other pre-existing MDCs in our area, physicians need to request reviews regardless of the category of criteria under which they fall. With the rapid change in modern cancer care, it is possible that a treating physician may not be aware of new options for their patient and routine review of complex cases offers patients the input of the whole team. Establishing a clear definition of ‘complex’ and appointing an independent staff member to schedule cases for review may introduce an additional layer of changes in management that might otherwise go unnoticed.

Implementation challenges and limitations
This project encountered some limitations and challenges. One challenge was how to measure changes due to the PTR process. During Phase 1, the project lead had prospectively tracked changes in patient management for their own patients, but we found it was difficult to classify whether management changes in other surgeons’ cases were attributable to the rounds review process or based on chart review alone. This led to the incorporation of a specific question for the rounds Chair in Phase 2, asking whether treatment was changed by review. We also found it was difficult to distinguish between changes from the triage plan—which was documented and made by the surgeon at consultation—and changes made to the treatment plan as a result of multidisciplinary review at PTR. We chose to ask both questions of the rounds Chair during data collection for Phase 2 in order to better understand where management changes originated. Another limitation is the documentation of data on hospital charts that are accessible regionally. Going forward, we plan to move from internal notes that include data on management changes to a more formal note in the regional hospital chart, in order to facilitate clear communication of management plans that are visible to all members of the care team. This note would not include all the data gathered for this project, and if further data is needed, it would need to be collected separately.
Another challenge that we encountered was the requirement for administrative and physician time and reimbursement to support the PTR process, as staff and physicians caring for patients with breast cancer at our centres are facing staffing shortages, prolonged wait times for patients and competing demands for their time. We were fortunate to be able to take advantage of donations to our centre in order to hire undergraduate research assistants who were able to take on the role of rounds organisation for this project. The project lead was supported through a provincial physician QI programme. Attendance at rounds is supported through service contracts and/or fee codes for MDCs. However, time required for review of cases, particularly for diagnostic specialists who work on a fee-for-service payment model, is not sufficiently reimbursed for time required, and for some of the more complex breast cancer cases this may take in excess of 30 min per case. Additionally, with diagnostic workups occurring at 26 different centres and limited time available for review, it is challenging to incorporate these centres into the PTR process.
When surveyed at all three time points, physicians highlighted several benefits of the PTR process, including timely interdisciplinary input without delays associated with formal consultations, more refined referrals for neoadjuvant therapy and plastic surgery, clearer surgical planning and increased uptake of genetic testing to inform treatment decisions. The finding of similar feedback over a year after implementation suggests that PTR continues to be a well-integrated and valued part of the centre’s clinical workflow, with sustained use and strong support from participating physicians.
From the feedback and results of the project, we have seen the impact of a PTR at our centre, and we have the support of our leadership to continue with PTR. We have been able to continue PTRs beyond the project timeline, and we will continue to implement improvements based on ongoing feedback. The results of the project will help guide development of a business case to ensure sustainability for all of the specialties involved. Expansion to involve different diagnostic centres will require additional administrative support and the additional time for review will need to be balanced with the volume of cases currently discussed. This implementation strategy may serve as a resource for other physicians seeking to implement a similar multidisciplinary process at their sites. Future studies may involve expanding the scope of data collected to encompass a broader trajectory of a patient’s journey, including whether patients reviewed at PTRs undergo additional reviews post-treatment. This will demonstrate whether PTRs influence long-term patient outcomes, as well as other downstream impacts.