The protocol for the consensuses of Chinese experts on glioma multidisciplinary team management :The National Glioma MDT Alliance National Center for Neurological Disorders, Ying Mao, Tao Jiang, Guoguang Zhao, Glioma

STUDY PROTOCOL
Year : 2022 | Volume : 5 | Issue : 4 | Page : 130--136

The protocol for the consensuses of Chinese experts on glioma multidisciplinary team management

The National Glioma MDT Alliance National Center for Neurological Disorders¹, Ying Mao², Tao Jiang³, Guoguang Zhao⁴,
¹ National Medical Center for Neurological Diseases, Beijing/Shanghai, China
² Department of Neurosurgery, National Center for Neurological Disorders, Huashan Hospital, Fudan University; Institute of Medicine, Huashan Hospital, Fudan University, Shanghai, China
³ Beijing Neurosurgical Institute, Capital Medical University; Department of Neurosurgery, National Center for Neurological Disorders, Beijing Tiantan Hospital, Capital Medical University; Center of Brain Tumor, Beijing Institute for Brain Disorders; China National Clinical Research Center for Neurological Diseases, Beijing, China
⁴ Department of Neurosurgery, National Center for Neurological Disorders, Xuanwu Hospital, Capital Medical University; Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China

Correspondence Address:
The National Glioma MDT Alliance National Center for Neurological Disorders
National Center for Neurological Disorders, No. 12 Wulumuqi Middle Road, Jing'an District, Shanghai
China

Abstract

Glioma is a highly heterogeneous disease with yet unknown mechanisms. It is imperative to provide individualized and precise treatment based on the multidisciplinary diagnosis and treatment model and the basic principles of evidence-based medicine for these patients. In 2018, the Glioma Society Affiliated to Chinese Medical Doctor Association led the development of the "Chinese Expert Consensus on Multidisciplinary Team (MDT) Management of Glioma," which significantly promoted the application of the MDT approach in China. To standardize the diagnosis and treatment of MDT for glioma in different regions and grades of hospitals, we plan to update the "Chinese Expert Consensus on MDT Management of Glioma" based on the currently available evidence-based medical evidence. This new version will update the standards of surgical procedures, clinical management, and quality control for the implementation of MDT for glioma to provide guidelines and recommendations for clinicians. The Consensus Committee will follow the policies of the Evidence-Based Clinical Practice Guidelines development, form a multidisciplinary expert team, and utilize Evidence-Based Management in line with the Oxford University Center for Evidence-Based Medicine Levels of Evidence and Grades of Recommendation to develop the evidence-based expert consensus on MDT for glioma. The proposal emphasizes the significance, purpose, members of the Consensus Committee, identification of clinical problems, evidence acquisition, evaluation and integration, and recommendation generation.

How to cite this article:
National Center for Neurological Disorders T, Mao Y, Jiang T, Zhao G. The protocol for the consensuses of Chinese experts on glioma multidisciplinary team management.Glioma 2022;5:130-136

How to cite this URL:
National Center for Neurological Disorders T, Mao Y, Jiang T, Zhao G. The protocol for the consensuses of Chinese experts on glioma multidisciplinary team management. Glioma [serial online] 2022 [cited 2023 Apr 2 ];5:130-136
Available from: http://www.jglioma.com/text.asp?2022/5/4/130/371293

Full Text

Introduction

According to the report on cancer epidemiology in China published by the National Cancer Center in 2019, which integrated data from 368 cancer registration organizations across the country, in the prevalence of malignant tumor incidence and mortality in China in 2015, the incidence of brain tumors was 7.72/100,000, ranking 9th; by gender, the incidence of brain tumors ranks 10th in both males and females, with an incidence of 7.04/100,000 for males and 8.43/100,000 for females.[1] The prognosis of malignant brain tumors is poor, and that of glioblastoma is the worst. According to the American epidemiologic survey data, the median survival time is about 15 months, and the 5-year overall survival (OS) rate is only 6.8%. Improvement of the prognosis remains an unmet medical need.[2]

The principles of standard treatment for newly diagnosed high-grade glioma are as follows: maximum safe resection of the tumor, concurrent adjuvant radiotherapy (60 Gy in 30 fractions), and temozolomide (TMZ) chemotherapy, and then, at least six cycles of adjuvant TMZ therapy or adjuvant TMZ are used until disease progression is halted. Under the above standard treatments, including surgery, radiotherapy, and TMZ, the median OS of patients strictly selected in clinical trials is about 15–18 months, and the 5-year survival rate is <10%.[3],[4] Previous studies have demonstrated that independent prognostic factors for high-grade glioma include age, sex, KPS score, primary tumor site, MGMT methylation status, and isocitrate dehydrogenase mutation status. These factors are clinical and pathological features, and the primary outcome predicted is OS.[4],[5],[6] These patients may have different consequences after receiving the standard chemotherapy and radiotherapy (Stupp regimen): some patients relapse in a short period, and some patients may have more prolonged progression-free survival, suggesting that glioma is a highly heterogeneous disease with yet unknown mechanisms.[7],[8] It is imperative to provide individualized and precise treatment based on the multidisciplinary diagnosis and treatment model and the basic principles of evidence-based medicine for these patients.

Through consultation and discussion with experts from different specialties, the multidisciplinary team (MDT) removes the limitations of a single discipline. It integrates the advantages of different disciplines to develop individualized diagnosis and treatment plans and provide optimal regimens to achieve standardized and individualized treatment, which will improve the patient's prognosis. The MDT mode is strongly recommended in modern medicine. Due to the high incidence, poor prognosis, rapid knowledge update of glioma, and multidisciplinary collaboration in the diagnosis and treatment process, the MDT is critical for the management of glioma patients. In 2018, the Glioma Society Affiliated to Chinese Medical Doctor Association, hereinafter referred to as "Chinese Glioma Society," led the development of the "Chinese Expert Consensus on MDT Management of Glioma,"[9] which significantly promoted the application of the MDT approach in China and standardized the diagnosis and treatment of glioma in different regions and grades of hospitals.

Recent years have witnessed new progress in the field of glioma diagnosis and treatment. The development of new technologies such as positron emission tomography, magnetic resonance spectroscopy, and multimodality imaging improves the diagnostic reliability of glioma; the update of the Fifth-edition Central Nervous System Tumors Volume of the WHO Classification of Tumors Series (WHO CNS 5) and the development of molecular pathology have improved the pathological diagnosis of neurological tumors; in the treatment of glioma, in addition to surgery, traditional radiotherapy, and chemotherapy, tumor-treating fields, targeted therapy, immunotherapy, and boron neutron capture therapy have potential clinical benefit. Nevertheless, the prognosis of high-grade glioma is still extremely poor. As such, we expect that MDT may maximize the benefit of patients under the current conditions. In addition, many centers have carried out clinical trials for the treatment of glioma, and the professional collaboration of multidisciplinary experts is of critical importance with respect to ethical and practical issues. Therefore, the National Center for Neurological Disorders plans to form a steering group to update the "Chinese Expert Consensus on MDT Management of Glioma (2nd Edition)," to further promote the application of MDT in the diagnosis and treatment of glioma by combining with the practical evidence of MDT of glioma. The application can achieve identical diagnosis and treatment to the greatest extent and benefit most patients.

Methods

The formulation of the consensus will draw on the "World Health Organization Guideline Development Manual" and the guideline guiding principles of the Chinese Medical Journal[10],[11] and meet the requirements of the Appraisal of Guidelines for REsearch and Evaluation II (AGREE II).[12] The guideline implementation plan and the full text of the consensus were developed according to the Guideline Development Checklist version 2.0 and the Reporting Items for practice Guidelines in HealThcare (RIGHT).[13],[14]

The initiators of the consensus

The National Medical Center for Neurological Diseases initiated the consensus. Lanzhou University provided the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). The Collaborating Center for Guideline Implementation and Knowledge Transformation of the World Health Organization and the Evidence-Based Medicine Center of Lanzhou University provide methodological support.

Consensus development working board

It comprises writing consultants, a consensus expert panel, a consensus methodology panel, a consensus secretariat, and a consensus external review panel [Table 1].{Table 1}

Registration of the consensus

This consensus has been registered in the National Practice Guideline Registration for transPARSEncy (PREPARE), registration number: PREPARE-2022CN795 (http://www.guidelines-registry.cn/guid/2160).

Purpose and scope of the consensus

This consensus aims to formulate recommendations based on the most reliable clinical evidence; enhance clinicians' understanding of MDT for glioma; formulate MDT-related implementation procedures, management norms, and quality control standards; and provide reference and guidance for clinicians. The proposed title of the consensus is "Chinese Expert Consensus on MDT Management of Glioma (2nd Edition)," which applies to the different levels of brain glioma diagnosis and treatment centers (teams) at national-regional-local levels and all member units for the National Glioma MDT Alliance of National Medical Center for Neurological Diseases. The clinical issues covered by the consensus mainly involve MDT construction, management, operating procedures, and quality control. The target population of the consensus is patients with clinically suspected or confirmed glioma.

Declaration and handling of interests

All the writing consultants, consensus expert panel, consensus methodology panel, consensus secretariat, and consensus external review panel are required to fill out the declaration of interest form [Supplementary file 1] before formally participating in the work related to consensus formulation. The coordination panel will sort it out, and the chief expert will review and judge the conflict of interest declaration. One can participate in the whole process without a conflict of interest. If there is a conflict of interest, the degree of participation will be judged according to the circumstances.

Construction of clinical questions and evaluation of importance

A preliminary list of clinical issues is formed through the review of the current MDT-related guidelines and consensus and the investigation of the members of the consensus expert panel. After deduplication and integration by the consensus methodology panel and the consensus secretariat, each issue is scored according to importance, with options including "important, relatively important, generally important, less important, and unimportant." Based on the results of the important survey research, the final clinical issues of this consensus will be determined by the consensus expert panel after discussion.

Retrieval of evidence

Chinese and English databases, including CNKI, Wanfang Full-text Database, China Biomedical Literature Service System, PubMed, Embase, Cochrane Library, and Web of Science, were searched by computer. The search keywords are composed of "glioma," "multidisciplinary diagnosis and treatment," "MDT," and other words combined with logical symbols. The search time is from the establishment of the database to December 2022, and the language is limited to Chinese or English. The search scope includes consensus, systematic reviews, or original studies related to clinical issues (including randomized controlled trials (RCTs), cohort studies, case–control studies, and single-arm clinical studies).

Evidence screening and data extraction

The literature was selected step by step according to the title, abstract, and full text. Then, the relevant information of the included literature was extracted according to the predesigned data extraction table. The screening and information extraction of each document were completed independently and then checked by two persons. If there was any disagreement, the third researcher was then consulted.

Methodological quality evaluation

The included guidelines and consensus were evaluated for quality by consensus methodology panelists using AGREE II.[12] A measurement tool to assess systematic reviews (AMSTAR) was used to assess the methodological quality of included systematic reviews and meta-analyses.[15] Evidence-based RCTs are considered to be high-quality evidence. Evidence-based observational studies are considered to be of low quality. RCTs were evaluated using the Cochrane Risk of Bias,[16] and cohort studies and case–control studies were evaluated using the Newcastle–Ottawa Scale.[17] The Canadian Institute of Health Economics Scale was used to assess case series and case reports.[18] Qualitative and survey research was evaluated referring to the JBI Critical Assessment tool.[19] The evaluation process was completed independently by two persons and then checked. If there was any disagreement, the third researcher was then consulted.

Literature inclusion criteria

When several high-quality guidelines have answered the clinical problems, and the recommendations are consistent, the supporting recommendations are directly included. When the recommendations are inconsistent, there is insufficient guideline support, or most of the guidelines are of low quality, systematic evaluation support is selected. When AMSTAR scores indicate that the methodological quality of the existing systematic review is high, recommendations supporting consensus are directly included. When AMSTAR scoring results indicate that the methodological quality of existing systematic reviews is low, or when screening results reveal no systematic review of a PICO issue, high-quality RCTs are selected to support the consensus recommendation. If there is no systematic review or RCT, observational studies are included to support the recommendations.

Grading of evidence quality and recommendation strength

The Consensus Approach Group intends to adopt an Evidence-Based Management evaluation tool[20] combined with the 2009 edition of the evidence-based medicine center at the University of Oxford evidence classification and recommendation[21] (https://www.cebm.ox.ac.uk/resources/levels-of-evidence/ocebm-levels-of-evidence) [Table 2]] to rate the quality of evidence and strength of recommendations.{Table 2}

Establish recommendations and consensus

After considering the preference of Chinese patients, the cost, and the pros and cons of intervention measures, the expert panel sets a preliminary recommendation. Methodologists and the coordination panel evaluated the initially proposed recommendation and gave feedback. After two rounds of feedback modification, members of the consensus expert group reached a consensus on all the key points and recommendations by the Delphi method and determined the final recommendation. If the consensus degree is over 75%, the consensus is considered to be reached, and the recommendation can be written into the consensus. Suppose the consensus degree is <75%. In that case, it is considered that no consensus has been reached, and the second round of consensus will be started after the modification according to the expert opinions. If the consensus degree is still less than 75% after the change, the recommendation opinion discussed by the expert panel will be deleted; if the consensus degree is more than 75% after the modification, the recommendation opinion can be written into the consensus.

The writing, external review, and approval of consensus

Based on the confirmed recommendations, the consensus expert panel shall write the first draft of the consensus. The draft shall be written using the reporting standard RIGHT as part of the international guidelines. After deliberation, the approved draft of the consensus will be submitted to the external consensus review panel. Based on feedback from the external consensus review panel, the consensus expert panel and the consensus coordination panel shall revise the first draft. In the end, the consensus expert panel shall discuss and approve the release of the consensus.

The release, dissemination, and update of the consensus

The consensus will be published in the form of journals and handbooks and disseminated through domestic and international glioma-related conferences and clinician training courses organized by regional glioma societies. The consensus will be updated in due course according to the situation of the latest evidence.

Discussion

In 2018, the Chinese Glioma Society took the lead in formulating the "Chinese Expert Consensus on MDT Management of Glioma," which has played an active role in clinical practice of glioma diagnosis and treatment in China. Since the establishment of the National Glioma MDT Alliance, in the framework of national-regional-local levels of glioma diagnosis and treatment centers, the members of the alliance have gradually increased. To ensure the homogeneity of glioma diagnosis and treatment among the members of the alliance, we plan to formulate the "Chinese Expert Consensus on MDT Management of Glioma (2nd Edition)." This consensus will be forged by the joint participation of multidisciplinary experts and will be constructed in strict accordance with AGREE II and RIGHT standards. The current research may not be able to address some significant issues. This consensus will also propose areas worth studying in the future, which will help researchers to conduct relevant studies.

Members of Consensus Editorial Board

*All authors are listed alphabetically by family names.

Writing consultants: Tao Jiang (Beijing Tiantan Hospital, Capital Medical University, China), Ying Mao (Huashan Hospital, Fudan University, China), Guoguang Zhao (Xuanwu Hospital, Capital Medical University, China).

Consensus expert panel: Yiqun Cao (Fudan University Shanghai Cancer Center, China), Fanfan Chen (The First Affiliated Hospital of SZU, China), Gao Chen (The Second Affiliated Hospital, Zhejiang University School of Medicine, China), Hong Chen (Huashan Hospital, Fudan University, China), Qianxue Chen (Renmin Hospital of Wuhan University/Hubei General Hospital, China), Zhongping Chen (Sun Yat-sen University Cancer Center, China), Liangzhao Chu (The Affiliated Hospital of Guizhou Medical University, China), Shuguang Chu (Shanghai East Hospital of Tongji University, China), Jian Duan (The First Affiliated Hospital of Nanchang University, China), Chuan Fang (Affiliated Hospital of Hebei University, China), Zhou Fei (The First Affiliated Hospital of Airforce Medical University, China), Xiwu He (The Fifth People's Hospital of Qinghai Province/Qinghai Province Cancer Hospital, China), Guanglong Huang (Nanfang Hospital, China), Hongming Ji (Shanxi Province People's Hospital, China), Xiaobing Jiang (Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, China), Xin Jiang (The First Bethune Hospital of Jilin University, China), Gang Li (Qilu Hospital of Shandong University, China), Yuehong Li (The second Hospital of Hebei Medical University, China), Xiaohua Liang (Huashan Hospital, Fudan University, China), Xiaomin Liu (Tianjin Huanhu Hospital, China), Yanhui Liu (West China Hospital of Sichuan University, China), Zhongqiang Lv (The second Hospital of Hebei Medical University, China), Chunxiao Ma (Henan Provincial People's Hospital, China), Hui Ma (General Hospital of Ningxia Medical University, China), Wenbin Ma (Peking Union Medical College Hospital, China), Qing Mao (West China Hospital of Sichuan University, China), Haozhe Piao (Liaoning Cancer Hospital&Institute/Cancer Hospital of Dalian University of Technology, China), Yueshan Piao (Xuanwu Hospital, Capital Medical University, China), Xueling Qi (Sanbo Brain Hospital, Capital Medical University, China), Zhiyong Qin (Huashan Hospital, Fudan University, China), Xiaoguang Qiu (Beijing Tiantan Hospital, Capital Medical University, China), Ke Sai (Sun Yat-sen University Cancer Center, China), Kai Shu (Tongji Hospital, Tongji Medical College of HUST, China), Zhipeng Su (The 1st Affiliated Hospital of Wenzhou Medical University, China), Xiaochuan Sun (The First Affiliated Hospital of Chongqing Medical University, China), Yan Sun (Beijing Cancer Hospital/Peking University Cancer Hospital, China), Jie Tang (Xuanwu Hospital, Capital Medical University, China), Jinghai Wan (Cancer Hospital of Chinese Academy of Medical Science, China), Bin Wang (Huashan Hospital, Fudan University), Yang Wang (Huashan Hospital, Fudan University, China), Jiapong Wang (Haikou Affiliated Hospital of Central South University Xiangya School of Medicine, China), Zhong Wang (The First Affiliated Hospital of Suzhou University, China), Jun Wu (Xiangya Hospital of Central South University China), Junxin Wu (Fujian Cancer Hospital, China), Jiankun Xu (Xuanwu Hospital, Capital Medical University, China), Peikun Xu (The First Affiliated Hospital of Anhui Medical University, China), Changxiang Yan (Sanbo Brain Hospital, Capital Medical University, China), Dongming Yan (The First Affiliated Hospital of Zhengzhou University, China), Xuejun Yang (Bejing Tsinghua Changgung Hospital, China), Xiaohong Yao (The Southwest Hospital of AMU, China), Yu Yao (Huashan Hospital, Fudan University, China), Yongping You (Jiangsu Province Hospital, China), Hongqi Zhang (Xuanwu Hospital, Capital Medical University, China), Jianning Zhang (Chine PLA General Hospital, China), Lan Zhang (Xuanwu Hospital, Capital Medical University, China), Ruijian Zhang (Inner Mongolia People's Hospital, China), Ye Zhang (Liaoning Cancer Hospital&Institute/Cancer Hospital of Dalian University of Technology, China), Yi Zhang (Huashan Hospital, Fudan University, China), Ming Zhao (Henan Cancer Hospital/Affiliated Cancer Hospital of Zhengzhou University, China), Ninghui Zhao (The Second Affiliated Hospital of Medical University, China), Zhigang Zhao (Beijing Tiantan Hospital, Capital Medical University, China), Qingjiu Zhou (The First Affiliated Hospital of Medical University, China), Xinli Zhou (Huashan Hospital, Fudan University, China), Dongxiao Zhuang (Huashan Hospital, Fudan University, China), Pin Zuo (Yunnan Cancer Hospital, China).

Consensus methodology panel: Yaolong Chen (Lanzhou University, China), Xufei Luo (Lanzhou University, China), Ling Wang (Lanzhou University, China).

Consensus secretariat: Secretary-General: Jinsong Wu (Huashan Hospital, Fudan University, China); Deputy Secretary-General: Ming Li (Henan Provincial People's Hospital, China), Zhiwei Tang (The Second Affiliated Hospital of Medical University, China), Zanyi Wu (The First Affiliated Hospital of Fujian Medical University, China), Zhirui Zhou (Huashan Hospital, Fudan University, China); Secretary of State: Linghao Bu (The First Affiliated Hospital, Zhejiang University School of Medicine, China), Song Chen (The First Affiliated Hospital of Chongqing Medical University, China), Yinsheng Chen (Sun Yat-sen University Cancer Center, China), Ye Cheng (Xuanwu Hospital, Capital Medical University, China), Ji Shi (Liaoning Cancer Hospital&Institute/Cancer Hospital of Dalian University of Technology, China), Wei Shi (Bejing Tsinghua Changgung Hospital, China), Fengping Zhu, (Huashan Hospital, Fudan University, China), Yourui Zou (General Hospital of Ningxia Medical University, China).

Consensus external review panel: Xiuwu Bian (The Southwest Hospital of AMU, China), Sameh Elmorsy Hassan (Shiekh Zayed Al-nahian Hospital, Egypt), Tareq A Juratli (Carl Gustav Carus University Hospital, Germany), Huiying Wang (Huashan Hospital, Fudan University, China), Liangfu Zhou (Huashan Hospital, Fudan University, China).

Acknowledgments

The authors sincerely thank all members of The National Glioma MDT Alliance of National Medical Center for Neurological Diseases for their support.

Financial support and sponsorship

This work was supported by Shanghai Hospital Development Center under project number SHDC22021208.

Conflicts of interest

There are no conflicts of interest.

Editor note: ZPC is the Chief Editor of Glioma. HP and XY are associate editors of Glioma. They are not involved in decisions about the paper which they have written themself or have been written by family members or colleagues or whoever relates to products or services in which the editor has an interest. The submission is subject to the journal's standard procedures, with peer review handled independently of the relevant editor and their research groups.

JW is an Editorial Board member of Glioma. He was blinded from reviewing or making decisions on the manuscript. The article was subject to the journal's standard procedures, with peer review handled independently of these Editorial Board and Editorial Office members and their research groups.

Supplementary material

Supplementary material is available at Glioma online (http://www.jglioma.com/).

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