Patients participation in multidisciplinary management in gastric cancer: regulation comparison and expert survey among major countries

Article information

Korean Journal of Clinical Oncology. 2025;21(3):143-149

Publication date (electronic) : 2025 December 31

doi : https://doi.org/10.14216/kjco.25365

Kyoyoung Park ¹^,²

, Hyuk-Joon Lee ¹^,²^,³

, Seong-Ho Kong ¹^,²^,³

, Do Joong Park ¹^,²^,³

, Hyunsoo Chung ⁴

, Soo-Jeong Cho ⁴

, Seock-Ah Im ³^,⁴

, Yoonjin Kwak ³^,⁵

, Hye Seung Lee ³^,⁵

, Eui Kyu Chie ³^,⁶

, Jimmy Bok Yan So ⁷

, Zekuan Xu ⁸

, Narikazu Boku ⁹

, Jiafu Ji ¹⁰

, Yuko Kitagawa ¹¹

, Raul J Rosenthal ¹²

, Takeshi Sano ¹³

, Han-Kwang Yang ¹^,²^,³^,¹⁴

¹Department of Surgery, Seoul National University Hospital, Seoul, Korea

²Department of Surgery, Seoul National University College of Medicine, Seoul, Korea

³Cancer Research Institute, Seoul National University, Seoul, Korea

⁴Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea

⁵Department of Pathology, Seoul National University Hospital, Seoul, Korea

⁶Department of Radiation Oncology, Seoul National University Hospital, Seoul, Korea

⁷Division of Surgical Oncology, National University Cancer Institute, Singapore

⁸Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China

⁹Department of Oncology and General Medicine, IMSUT Hospital, Institute of Medical Science, University of Tokyo, Tokyo, Japan

¹⁰Department of Gastrointestinal Surgery, Peking University Cancer Hospital, Beijing, China

¹¹Department of Surgery, Keio University School of Medicine, Tokyo, Japan

¹²Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Weston, FL, USA

¹³Department of Surgery, Cancer Institute Hospital, Tokyo, Japan

¹⁴National Cancer Center, Goyang, Korea

Correspondence to: Hyuk-Joon Lee, Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul 03080, Korea, Tel: +82-2-2072-2318, Fax: +82-2-766-3975, E-mail: appe98@snu.ac.kr

Received 2025 August 7; Revised 2025 October 2; Accepted 2025 October 17.

Abstract

Purpose

In Korea, the Health Insurance Review and Assessment Service (HIRA) mandates patient participation in outpatient multidisciplinary team (MDT) meetings as part of national cancer quality assessment. However, the necessity of involving patients and families in MDT discussions remains debatable. This study explored international expert perspectives on patient participation in gastric cancer MDTs.

Methods

A cross-national expert survey was conducted in September 2021 among 15 gastric cancer specialists from Korea, China, Japan, Singapore, and the United States. The survey assessed the frequency of patient and family member attendance, perceived pros and cons, and preferences regarding mandatory versus selective involvement. Additionally, MDT structures and policies were reviewed by countries.

Results

Most respondents reported that patients and families rarely or never attend MDT meetings: nine stated that patients are never included, three reported “usually not,” and three indicated “sometimes.” None consistently included patients. The most cited benefits were sharing opinions with patients and families simultaneously, followed by improved explanation of treatment and legal protection. Major concerns included hindered discussion, inefficiency, and logistical challenges. Only four respondents supported routine participation, while 11 favored case-dependent involvement.

Conclusion

International experts do not widely support mandatory patient participation in MDT meetings. A flexible approach that allows MDTs to operate with or without patient involvement may better reflect actual clinical practice.

Keywords: Multidisciplinary team; Stomach neoplasms; Patient participation

INTRODUCTION

According to the global cancer statistics from 2022, gastric cancer was the fifth most common malignant tumor and the fifth leading cause of cancer-related death worldwide. Japan and South Korea show a high incidence of gastric cancer among East Asian countries [1]. Surgical resection remains the cornerstone of treatment for resectable gastric cancer, however, optimal outcomes require a comprehensive approach that includes accurate staging, pathological assessment, chemotherapy, and, in selected cases, radiotherapy. While early-stage gastric cancer is often managed using well-established protocols, treatment strategies for advanced gastric cancer remain controversial, with significant variation across clinical guidelines and institutions [2–4].

To address this complexity and ensure consistent, evidence-based care, multidisciplinary teams (MDTs) have emerged as a critical framework [3,5]. By integrating expertise from various medical specialties, MDTs facilitate individualized and standardized treatment planning and are increasingly recognized as essential to improving the quality and coordination of cancer care [5,6]. The MDT approach is broadly defined as a collaborative effort to develop individualized treatment plans through enhanced communication, coordination, and decision-making among healthcare professionals [7]. MDTs thoroughly discuss the diagnosis and management of complex diseases, such as cancer, and formulate treatment strategies by current clinical guidelines [8,9].

Since the Calman–Hine Report in 1995 first recommended MDTs in the United Kingdom to standardize cancer treatment practices [10], the 2016 National Comprehensive Cancer Network (NCCN) guidelines marked the first instance where principles of MDT-based care for esophagogastric cancers were supported by Category 1 evidence. Most recently, the 2022 update of the NCCN guidelines further refined these recommendations [3], and today, the MDT approach is widely regarded as the gold standard in cancer care.

Numerous studies have demonstrated that the implementation of MDT care in gastric cancer—as well as in other malignancies—offers a range of clinical and systemic benefits. One of the most significant advantages is the improved adherence to evidence-based treatment guidelines [11–14], which enhances consistency and quality of care across institutions. MDT discussions have also been shown to reduce unnecessary diagnostic testing, improve staging accuracy, and shorten the interval from diagnosis to treatment initiation [14,15]. In addition, MDTs frequently lead to revised or optimized treatment plans, especially in complex cases, ensuring that care strategies are personalized and aligned with the most current clinical standards. Beyond these clinical improvements, MDTs have been associated with increased participation in clinical trials [16], enhanced clinician education, and improved patient satisfaction [17,18]. Importantly, some studies suggest that MDT implementation may ultimately contribute to improved survival outcomes [14,15], highlighting its value as a core component of high-quality oncologic care.

This study reviewed and compared the MDT systems and structures of major countries and, based on this context, aimed to explore international expert opinions on the necessity of patient and family member participation in MDT meetings for gastric cancer. Specifically, it sought to assess the current frequency of patient involvement, the perceived advantages and disadvantages, and expert perspectives on whether such participation should be mandatory or selective.

METHODS

A survey was conducted in September 2021 among 15 gastric cancer specialists from Korea, China, Japan, Singapore, and the United States. The survey included questions regarding the frequency of patient and family member participation in MDT meetings, the perceived advantages and disadvantages of such involvement, and expert opinions on whether participation should be mandatory or selective. Participants were selected from specialists attending the 2021 MDT commemorative conference, who had at least 5 years of clinical experience in the management of gastric cancer and prior involvement in MDT discussions. The survey was administered in printed paper format and distributed individually in a face-to-face manner during the conference. All responses were collected with participant names identified, rather than anonymously. A total of 15 completed questionnaires were collected and analyzed, and all respondents answered every item. The actual survey form is provided in Supplementary Table 1.

Additionally, this study reviewed and compared the MDT systems and structures of major countries, including legal mandates and policy frameworks. No statistical analyses were performed in this study. This study does not constitute human subject research. All survey responses were collected solely from the study authors. No identifiable personal or patient data were included, and Institutional Review Board approval was therefore not required.

RESULTS

Expert survey responses

An expert survey was conducted among experts in gastric cancer from five countries: Korea, China, Japan, Singapore, and the United States. A total of 15 experts participated in the survey, including eight surgeons, four medical oncologists, two pathologists, and one radiation oncologist. Supplementary Table 2 summarizes the characteristics of the respondents by country, years of practice, academic position, and institution type, demonstrating that the majority were senior faculty members at tertiary university hospitals or national cancer centers. The results are presented and discussed in the following paragraphs, organized by each survey question (Q1–Q5).

Q1. In your MDT conference, do the patients and their guardians participate?

When asked whether patients or family members participate in MDT meetings, most respondents reported that such participation is rare or nonexistent: four institutions, accounting for nine respondents, indicated that patients are never included; three reported “usually not”; and three answered “sometimes.” Notably, no respondent indicated that patients or family members are always included in MDT discussions (Fig. 1). Among those who answered “sometimes,” two were affiliated with hospitals in China, and one was from the United States. These responses align with the national-level overview in Table 1, which notes that in China, MDT meetings are partially recommended in major centers and patient participation is only occasionally required.

Fig. 1

Expert responses on patient participation in multidisciplinary team (MDT) conferences, following questions: (1) In your MDT conference, do the patients and their guardians participate?; (2) What is the potential advantage of the participation of patients/guardians in the MDT conference, in your opinion?; (3) What is the potential disadvantage of the participation of patients/guardians in the MDT conference, in your opinion?; (4) What is your opinion on the routine participation of patients/guardians in your MDT?; (5) What is your opinion on the selective participation of patients/guardians in your MDT?

Table 1

Summary of MDT implementation characteristics across nine countries

Q2. What is the potential advantage of the participation of patients/guardians in the MDT conference, in your opinion?

When asked about the potential advantages of having patients or family members participate in MDT conferences, the most frequently cited benefit was the opportunity to communicate with both patients and family members simultaneously (n=11). Other reported advantages included an enhanced explanation of treatment plans and potential side effects (n=4), as well as legal protection (n=1). These responses allowed for multiple selections, including write-in options (Fig. 1). One additional comment highlighted the benefit of patient participation when numerous treatment options exist. Notably, the single response mentioning legal protection came from a participant based in the United States, reflecting the country’s emphasis on medicolegal considerations in clinical practice.

Q3. What is the potential disadvantage of the participation of patients/guardians in the MDT conference, in your opinion?

Next, respondents were asked about the potential disadvantages of patient or family members participation in MDT conferences. Ten respondents indicated that such participation hindered open and candid discussions, particularly regarding surgical resectability and poor prognosis. Other reported drawbacks included inefficiency, prolonged meeting duration, difficulties in effective communication, and significant logistical barriers—such as the need to coordinate the schedules of multiple specialists to convene during a single patient’s outpatient visit (Fig. 1).

Q4–5. What is your opinion on the routine or selective participation of patients/guardians in your MDT?

Regarding the preferred policy on patient or family members participation in MDT conferences, only four respondents (27%) supported routine participation—1 selected “strongly agree” (USA), and three chose “somewhat agree.” In contrast, 11 respondents (73%) favored selective, case-dependent involvement, with one selecting “strongly agree” (China) and 10 selecting “somewhat agree” (Fig. 1). These findings reflect a broad consensus among experts in favor of maintaining flexibility rather than enforcing a standardized approach.

Comparison of MDT systems across countries

The implementation of MDTs varies substantially across countries, reflecting differences in healthcare infrastructure, legal mandates, and institutional policies. In the United Kingdom, MDT discussions have been legally mandated since the publication of the Calman–Hine Report and the National Health Service Cancer Plan [10]. France also legally requires RCP (Réunion de Concertation Pluridisciplinaire) meetings, which involve at least three physicians and documented clinical decisions [21,22]. Italy implements MDTs at the regional or hospital levels, with varying standardization across regions [23]. In Germany, MDTs are required as part of cancer center certification, with regular audits ensuring compliance [24]. In the United States, MDTs are not legally mandated but are strongly recommended by bodies such as the NCCN and Commission on Cancer [3]. Singapore encourages MDT implementation through institutional guidelines [25], and in Japan, cancer boards are required by the Ministry of Health for designated cancer hospitals [26]. China broadly conducts MDTs in tertiary hospitals, where patient participation is optional [27]. The core features of each country’s MDT implementation are summarized in Table 1.

In Korea, MDT implementation is not legally required, but it is effectively mandatory because it is included as a key performance indicator in the national gastric cancer quality assessment program. For reimbursement to be approved, the MDT must involve the simultaneous, face-to-face participation of at least three board-certified specialists from different departments, along with the patient [19]. However, in practice, this structure presents significant logistical challenges, as coordinating multiple specialists for a single outpatient session is often difficult [20]. Moreover, hospitals that strictly follow the standard of care by ensuring that surgery and adjuvant treatments are managed by the respective specialized departments often lack sufficient time for face-to-face MDT meetings with patients. In contrast, some institutions where a single department handles both surgery and chemotherapy—contrary to ideal division of roles—may have more time to conduct frequent MDT meetings, potentially giving the false impression of higher quality care. It is important to note that, particularly for cases such as borderline resectable tumors or post-EMR (endoscopic mucosal resection) decisions in early gastric cancer, specialist-only MDT discussions without patient presence can provide essential value by enabling prompt, evidence-based consensus. Furthermore, to our knowledge, Korea is the only country where patient participation is explicitly required as a condition for MDT reimbursement, which may hinder open discussion among clinicians and reduce the overall efficiency of the process.

DISCUSSION

MDT care plays a crucial role in managing complex diseases, such as cancer, by facilitating timely and evidence-based decision-making through collaborative input from various specialists. MDTs aim to improve patient outcomes by enabling structured communication, shared decision-making, and adherence to guideline-based care [28].

At Seoul National University Hospital, the Gastric Cancer Center has held formal MDT conferences every 2 weeks since 2005, involving specialists from gastroenterology, radiology, pathology, nuclear medicine, and medical oncology. As of July 2025, a total of 472 MDT meetings have been conducted, providing a platform for in-depth, multidisciplinary decision-making in the care of gastric cancer. A cumulative total of 3,685 patients have been discussed. For nearly two decades, the MDT has consistently provided solutions for complex cases without involving patients or their family members, ensuring the delivery of optimal care. The survey presented in this study was also conducted in conjunction with a conference commemorating the 400th gastric cancer MDT meeting at Seoul National University Hospital.

The National Cancer Center of Korea has also reported favorable treatment outcomes through a similar multidisciplinary conference system. In some cases, final pathological diagnoses were revised as a result of MDT discussions. Furthermore, these meetings facilitated appropriate treatment decisions in response to complications arising during therapy and enabled the formulation of optimal strategies for managing complex metastatic disease. Overall, MDT conferences have proven effective in supporting timely and informed clinical decision-making, ultimately contributing to the improvement of care quality [18].

This study aimed to explore multinational expert perspectives on the necessity and appropriateness of patient participation in gastric cancer MDTs. The findings indicate that mandatory participation of patients and family members in MDT meetings is not widely supported among gastric cancer experts across countries. Instead, a flexible, patient-centered approach—allowing for both physician-only and patient-inclusive MDT formats depending on the clinical context—may more accurately reflect real-world practice.

The gastric cancer experts who participated in the survey identified the ability to communicate simultaneously with both patients and family members as the most significant advantage of their participation, citing improved communication efficiency as a key benefit. However, how frequently this benefit can be realized in actual clinical practice may vary depending on factors such as the structure of the MDT meeting, time constraints, and patient receptiveness [28]. In some countries, participants also noted potential legal protection as an advantage, although the need for such protection varies significantly depending on national legal and medical systems [29].

When patients directly participate in MDT discussions, the most anticipated issue is the difficulty in conducting frank and open conversations. Many respondents expressed concern that patient presence could inhibit candid exchanges, particularly regarding sensitive topics such as dismal prognosis or surgical resectability. Moreover, aligning the schedules of multiple specialists with those of the patient and family members requires considerable resources, making the process highly resource intensive [20]. The necessity of direct communication with the patient may also lead to redundant explanations and prolonged meeting durations, raising concerns about time efficiency and overall workflow. Taken together, these findings suggest that patient inclusion could compromise the core objective of MDTs—facilitating in-depth, professional discussions among specialists—and potentially dilute the essence of multidisciplinary collaboration.

Although the number of respondents was relatively small (n=15), the participants were leading experts from five major countries, offering meaningful insights into international perspectives on MDT participation. Rather than mandating patient presence across all MDTs, a more flexible and context-dependent approach may be more appropriate. These findings have policy implications, suggesting the need to reconsider whether patient attendance should remain a strict requirement for MDT reimbursement and performance evaluation.

This study has several limitations. First, the survey exclusively reflects physicians’ perspectives, without incorporating the views of patients or caregivers. Considering that patient-reported outcomes and satisfaction are increasingly emphasized in oncology, future studies should include patients and family members, ideally through a mixed-methods design, to capture their experiences and evaluate the impact of patient-inclusive MDTs on treatment satisfaction, shared decision-making, and clinical outcomes. In addition, objective outcome data comparing pre- and post-implementation of mandatory patient participation were not available within the scope of this study, limiting direct evaluation of its clinical impact.

In the Korean healthcare setting, where patient participation is currently required for MDT reimbursement, adopting a revised framework may be warranted. Selective patient involvement—based on case complexity, institutional resources, and patient preference—could improve both the efficiency and the quality of MDT discussions while preserving patient-centered care.

Notes

Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Funding

None.

Author Contributions

Conceptualization: KP, HJL, HKY. Methodology: KP, HJL. Formal analysis: KP. Data curation: KP, HJL. Writing–original draft: KP, HJL, SAI, EKC, JJ. Writing–review and editing: all authors. Visualization: KP. Supervision: HJL, HKY. Project administration: KP, HJL. All authors contributed to the manuscript and approved the final version for publication.

Institutional Review Board Statement

No identifiable personal or patient data were included, and Institutional Review Board approval was therefore not required.

Data Availability Statement

Data analyzed in this study are available from the corresponding author upon reasonable request.

Supplementary Materials

Supplementary materials are available at the Korean Journal of Clinical Oncology website (http://www.kjco.org/).

kjco-25365-Supplementary-Table-1.pdf

kjco-25365-Supplementary-Table-2.pdf

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Table 1

Summary of MDT implementation characteristics across nine countries

Country	Legal mandate	Patient participation	MDT composition criteria	Reimbursement/incentives	Notable features
Korea	Not legally mandated (included in quality assessment)	Mandatory	3 Board-certified specialists from different departments, face-to-face	Reimbursed under HIRA criteria; max 3 claims per patient/disease	Must occur within ±8 wk of diagnosis; outpatient-based MDT
Japan	Required for designated cancer hospitals	Not mandatory	3 Specialties required in cancer boards at designated centers	Conference fees partially reimbursed	Required for hospital accreditation under JGCA standards
China	Partially recommended in major centers	Occasionally required	Tier III-A hospitals organize MDTs	Hospital-driven; some incentive mechanisms	Often used for educational and quality purposes
Singapore	Not legally required	Not mandatory	Standard operating procedures encourage MDT use	No public reimbursement; institutional variation	MDTs are encouraged within 1–2 wk of diagnosis
United States	Not mandatory (recommended by NCCN, CoC)	Not mandatory	Institutional discretion; NCCN recommends cross-specialty	Covered by hospital budgets or private insurance	Lacks standardization; variable by hospital
United Kingdom	Legally mandated (NHS Cancer Plan)	Not mandatory	Weekly MDT required for all new cases; cross-specialty	Covered by NHS institutional resources	Based on the Calman–Hine Report, mandatory listing and case review
France	Legally mandated (Cancer Plan I, RCP)	Not mandatory	3 Physicians; mandatory documentation	Publicly funded under national insurance	Central registry and strict documentation (RCP) required
Italy	Regional/hospital-level mandate	Not mandatory	Defined by regional guidelines; variable criteria	Public health service (SSR) funded	Heterogeneous implementation depending on the region
Germany	Mandated for certified cancer centers (DKG)	Not mandatory	MDT required for certification; structured audit	Incentivized via structural reimbursement	Reviewed as part of regular cancer center accreditation

MDT, multidisciplinary team; HIRA, Health Insurance Review and Assessment Service; JGCA, Japanese Gastric Cancer Association; NCCN, National Comprehensive Cancer Network; CoC, Commission on Cancer; NHS, National Health Service; RCP, Réunion de Concertation Pluridisciplinaire; SSR, Servizio Sanitario Regionale (Italian Regional Health Service); DKG, Deutsche Krebsgesellschaft (German Cancer Society).