‘A Gut Check:’ Do Tumor Boards Improve Care?

When oncologists and other clinicians come together to discuss a difficult cancer case, the hope is that the patient will get better.

But this is not necessarily a certainty for a multidisciplinary tumor committee.

Data evaluating tumor committees — in particular, the extent to which these conversations between specialists improve patient outcomes — remain mixed.

Some studies, for example, have found a survival benefit, while others have found no benefit. One analysis even found that a disorganized tumor committee was associated with worse patient survival.

But survival outcomes may not dictate the true impact that tumor counseling may have on patients or providers. These multidisciplinary groups often perform important functions that cannot be measured in a CT scan or a patient chart, according to research.

In addition to discussing treatment, tumor committees should “make sure the logistics of treatment and life align,” said Arif Kamal, MD, patient manager for the American Cancer Society and medical oncologist at Duke Cancer Institute in Durham, North Carolina. Good tumor counseling can build patient confidence, improve coordination of care and identify what factors may hinder patient adherence to a plan, he explained.

Evidence is mixed

Multidisciplinary tumor boards have become a staple of cancer care in many institutions.

Instead of individuals making decisions in a bubble, the group dynamics of a tumor council allow clinicians from different fields to influence a patient’s care. The goal is to make better, more consistent treatment decisions.

“I think of it as Justice League – each specialty has its own expertise in determining what’s best for the patient,” said Shearwood McClelland III, MD, radiation oncologist at University Hospitals Seidman Cancer Center in Cleveland, Ohio. “My role on the Tumor Committee is to bring the benefits and risks of Radiotherapy. A surgical oncologist will consider the indications for surgery.”

Tumor counseling generally works like this: a group of clinicians, which may include medicine, surgery, and radiation oncology as well as pathology, patient navigation, and financial counseling, meet weekly to discuss a handful of difficult cases. The admitting physician—often the medical oncologist, surgeon, or radiation oncologist—will present the case to the group. Tumor review boards can be small, with just a few specialists, or larger cases with dozens of participants.

“We tend to limit ourselves to patients where the pathology is a bit unusual, the diagnostic imaging is a bit unusual, or patients where the medical or surgical oncologist has questions about management,” which typically accounts for about 10 to 15 percent of patients, Douglas said. Blayney, MD, a breast cancer specialist at the Stanford Women’s Cancer Center in Palo Alto, California.

Although research is limited, the evidence for the effect of anti-tumor panels on important clinical outcomes, such as patient survival, is mixed.

That’s largely because these effects are notoriously difficult to study in a controlled and critical way, said Sherry Wren, MD, a surgical oncologist at Stanford University who specializes in gastrointestinal cancers.

A study, published in BMJ, found that after the introduction of multidisciplinary oncology care in hospitals in Scotland, breast cancer mortality was 18% lower in patients who received the team intervention. Another study concluded that these teams “improve the multidisciplinary management of cancer patients”, providing feedback and sometimes leading to changes in diagnostic and treatment plans.

However, a analysis observed little association between multidisciplinary tumor committees and quality or survival measures.

Perhaps some of the discrepancies are due to the proper functioning of the tumor committee. A 2019 analysis, for example, indicated that the 5-year survival rate was 15.6% higher among cases in well-organized multidisciplinary tumor groups, but nearly 20% lower in disorganized groups compared to lack of tumor advice.

“It should come as no surprise that improved performance on process or outcome quality measures is not predicted by the existence of team meetings,” Blayney wrote in a editorial. “Executing the plan is how we get good results, no matter how brilliant the plan, how talented the team or how difficult the task.”

Benefits outside of clinical decision making

Despite mixed data on patient outcomes, tumor boards may offer value outside of clinical decision-making.

In a recent study published in JAMA OncologyWren and his colleagues discovered many of these functions: building trust, fueling ongoing learning, and fostering better understanding among specialists.

Patients can feel better about the treatment plan knowing that a panel of experts has reviewed their case and reached a consensus, Wren explained.

Another major benefit of a tumor board: education. Cancer care has become very specialized in recent decades. New recommendations and indications change frequently for certain types of cancer. It’s too much for one doctor to follow.

“The cognitive load of a general oncologist or even a specialist oncologist is very high. New indications for a drug or practice-changing evidence comes out all the time,” Kamal said.

Tumor councils rely on specialists who keep abreast of the latest developments in their fields and then bring that expertise to the group so that everyone can stay informed.

Tumor committees also offer new opportunities for interdisciplinary collaboration and even camaraderie. This could mean increased physician satisfaction and decreased burnout, according to Wren and colleagues.

“A lot of times it’s just to feel like you’re not making a decision in a vacuum,” said one participant in Wren’s study. “Like a gut check.” “We learn from each other and we work together in research,” commented another participant.

In addition to discussing treatment, a good tumor committee will consider what will hinder a patient’s adherence to a treatment plan and what will help, Kamal said. This means identifying non-disease stressors, the potential for financial toxicity, and caregiver concerns.

“If a patient comes to see us from 2 hours away, is there somewhere they can get their infusions locally so they don’t miss a day of work?” Kamal said.

Making the Most of Tumor Arrays

But people don’t always agree when bringing together experts from different specialties.

Disagreements about the best treatment can arise and this can block decision-making.

“When a tumor board collapses, it’s usually because people are overheated and very attached to their position,” said James Wurzer, MD, radiation oncologist at AtlantiCare Cancer Care Institute and AtlantiCare Radiation Oncology, New Jersey.

For example, a radiologist may want a patient to undergo a particular test, but the surgical oncologist may think it is not necessary. “It can create time-consuming back and forth,” he explained. “Sometimes a discussion can’t be resolved within the allotted time, and that key person has to move things forward.”

Disagreements are natural, especially when there is no right answer for a person’s care. Sometimes, according to Wren’s study, treating clinicians bring a cancer case before a tumor board to resolve a difference of opinion about a patient’s treatment.

Most clinicians agree that the type of decision-blocking disagreements described above are rare. This is especially true when participants understand that recommendations are made by consensus and not unanimous, Blayney explained.

A tumor committee’s consensus statement may contain several recommendations. For example, a tumor board may conclude that mastectomy is the best treatment for a patient with breast cancer, but note that many surgeons may think that lumpectomy is also a reasonable option. The treating physician can then bring those recommendations back to the patient for discussion, Blayney said.

Besides potential disagreements, time and attendance are two other key challenges to the success of a tumor board.

Coordinating schedules can be difficult for clinicians with busy schedules, and if not all specialties are present, the benefits of a tumor board are truly lost, McClelland explained.

Additionally, physicians are generally not reimbursed for time spent at tumor board meetings. “In a fee-for-service environment, a lack of reimbursement creates unspoken tension around tumor counseling. Taking an hour during the day can mean a clinician is seeing three or four fewer patients,” Kamal added. .

Zoom, Microsoft Teams, and other video conferencing platforms can now alleviate some of the challenges associated with scheduling and attending tumor councils.

But to keep time management on track, someone has to be committed to running the meeting and moving decisions forward. That involves making sure there aren’t too many cases presented and that the combination of cases isn’t too complex, Wurzer said.

Tumor counseling can provide value to both providers and patients, and potentially improve patient care when participants are open and engaged.

“A spirit of curiosity” is essential to a successful tumor board, Kamal said. “It’s important to remember that you are there to learn from your colleagues.”

Plus, “a dose of humility can help,” McClelland said.

Lindsey Konkel Neabore is a science journalist living in Haddon Township, New Jersey.

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