Surgeons Often Warp Tumor Boards, Says Study

Medical Hierarchy Influences Treatment

Nick Mulcahy

April 21, 2020

Multidisciplinary tumor boards at teaching hospitals are often hailed as egalitarian gatherings where everybody can pitch in to formulate the best treatment plan for individual cancer patients.

But a new study suggests that these discussions — where surgical, radiation, medical oncologists, and others are present — commonly have another element that is undemocratic.

The study found that, at some of the tumor board meetings, discussion of "clinical considerations" were "secondary to power-status dynamics." As a result, the treatment decided upon was the one proposed by the specialist with the highest status, typically the surgeon.   

The study reported that this problem of "hierarchy" was present in 66% of 44 multidisciplinary tumor boards analyzed.

Hierarchy has long been established as stifling human interaction and is antithetical to the multidisciplinary approach, commented author Barbara Oureilidis-DeVivo, PhD, a social scientist at Westmont College, Santa Barbara, California.

Her study was detailed in a poster that was to have been presented at the 2020 annual meeting of the National Comprehensive Cancer Network (NCCN) in March. The conference was canceled because of the COVID-19 pandemic, and abstracts and posters from the meeting were released online instead.

I repeatedly saw all the cues of hierarchy — it was textbook. Barbara Oureilidis-DeVivo, PhD

Four years in the making, the study involved Oureilidis-DeVivo witnessing tumor boards at seven teaching hospitals (mid-sized and large) in the United States and United Kingdom. Many different tumor types (N = 35) were discussed, including breast, lung, prostate, and gastrointestinal. She listened to nearly 200 patient cases, and interviewed 28 clinicians.

"I repeatedly saw all the cues of hierarchy — it was textbook," Oureilidis-DeVivo told Medscape Medical News. For example, certain specialists, most notably surgeons, were more likely to speak longer and more frequently and to interrupt others who were speaking.

More damning, Oureilidis-DeVivo discovered via observational and interview data that "surgeons often use their power to direct tumor board [cases] towards surgical treatment."

The victims of these power arrangements are other specialists such as radiation oncologists and interventional radiologists. "A lot of the behavior is completely subconscious," meaning that clinicians were unaware they were doing it, said Oureilidis-DeVivo.

"Clinical considerations were always top of mind but the process of decision-making would often take a different turn — and would follow power dynamics of the group," she said.

Findings Are "Provocative"

Approached for comment, Heidi Nelson, MD, medical director of cancer programs, American College of Surgeons, called the findings "provocative." But she wondered "how representative" the new data were. The medical literature "shows many advantages of tumor boards for improving care of patients," she said.

Nelson asserted that tumor boards are regulated in the United States — via the American College of Surgeons' Commission on Cancer (CoC) and its standard on tumor boards. As a side note, the CoC is now referring to tumor boards as Multidisciplinary Cancer Case Conferences.

An "umbrella review" of boards published earlier this year concluded that the "multidisciplinary approach is the best way to deliver the complex care needed by cancer patients." However, proof of effectiveness is not robust, said the Italian authors. "Evidence on the impact of tumor boards on clinical practices is still lacking for many aspects of cancer care," they write. 

Capturing These Data

A portion of this study was first presented in 2018 at the International Conference on Cancer Research and Pharmacology in Edinburgh, Scotland. "After the presentation, I had so many folks come to me and say, 'Thank you for capturing this in a scientific way,' " said Oureilidis-DeVivo.

Medical professionals said they had observed and complained about medical social hierarchy and tumor board treatment decisions for a long time, noted Oureilidis-DeVivo. They also repeatedly said, "We thought it was unique to our tumor board."

Prior to academia, Oureilidis-DeVivo had a 14-year career as a marketing professional specializing in oncology for a number of companies, including CR Bard, a manufacturer of brachytherapy for prostate cancer. It was during these years that she developed a fascination with tumor boards.

Oureilidis-DeVivo's NCCN poster is part of a larger study of tumor boards performed when she was a doctoral student at Rockefeller College of Public Affairs & Policy, State University of New York, Albany.

The study, conducted from 2014 to 2018, included hundreds of pages of written field notes and interviews with interventional radiologists, radiation oncologists, nurses, patient care coordinators, medical oncologists, and surgeons.

Oureilidis-DeVivo coded the voluminous texts with categories until broad themes emerged — including hierarchy. 

She found hierarchy by specialty, with surgeons and medical oncologists as the two most powerful groups. Domination by surgeons comes, in part, via "historical pre-eminence," the study found.

In the words of one radiation oncologist who was interviewed in the study: "Surgeons own and control the patient because they think they know everything and everyone treats them as if they do. The rest of us little people just do what they ask us to do. It has always been this way."

ACS' Nelson acknowledged that surgery has historically been the most widely practiced cancer treatment; for solid malignancies, 70% of patients still undergo surgery. "It has had good cure rates and still does," she said.

"This poster raises the question about whether status and power play a role — and are present — in tumor boards. But you can't draw the conclusion, yet, that this is adversely impacting patient outcomes. We don't know that," said Nelson, who is an emeritus professor at the Mayo Clinic in Rochester, Minnesota.

Oureilidis-DeVivo agreed — the patient outcomes are unknown. But it was clear, she maintains, that treatment decisions were influenced by hierarchy, even if it was largely unconscious.

Nelson did not dismiss or endorse the study: "We can always do more to improve the human element of our care," she said, adding, "If there is power or status differential [with other specialties], that is something we should work on."

Oureilidis- DeVivo and Nelson have disclosed no relevant financial relationships.

National Comprehensive Cancer Network 2020 Annual Conference: Abstract 9. Presented online April 17, 2020.

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