When oncologists and other clinicians come together to discuss a challenging cancer case, the hope is the patient will do better.
But that's not necessarily a certainty for a multidisciplinary tumor board.
Data evaluating tumor boards — particularly, the extent to which these conversations among specialists improve patient outcomes — remain mixed.
Some studies, for instance, have found a survival benefit, while others have found no such advantage. One analysis even revealed that a disorganized tumor board was associated with worse survival for patients.
But survival outcomes may not dictate the true impact a tumor board can have on patients or providers. These multidisciplinary groups often serve important functions that cannot be measured in a scan or patient chart, research suggests.
In addition to discussing treatment, tumor boards should be "making sure the logistics of treatment and life align," said Arif Kamal, MD, chief patient officer for the American Cancer Society and a medical oncologist at Duke Cancer Institute in Durham, North Carolina. A good tumor board can build patient trust, improve care coordination, and determine what factors may get in the way of patient adherence to a plan, he explained.
The Evidence Is Mixed
Multidisciplinary tumor boards have become a fixture of cancer care at many institutions.
Instead of individuals making decisions in a bubble, the group dynamic of a tumor board allows clinicians from different arenas to weigh in on a patient's care. The goal is to make better, more cohesive treatment decisions.
"I view it as a Justice League — each specialty has its own expertise in considering what is best for the patient," said Shearwood McClelland III, MD, a radiation oncologist at University Hospitals Seidman Cancer Center in Cleveland, Ohio. "My role on the tumor board is to bring the benefits and risks of radiation therapy. A surgical oncologist will be thinking about surgical indications."
Tumor boards typically work like this: A group of clinicians, which can include medical, surgical, and radiation oncology along with pathology, patient navigation, and financial counseling, meet weekly to discuss a handful of challenging cases. The physician responsible for the patient's intake — often the medical oncologist, surgeon, or radiation oncologist — will bring the case to the group. Tumor review boards can be small, with just a few specialists, or larger affairs with dozens of attendees.
"We tend to limit to patients for whom pathology is a little unusual, diagnostic imaging is a little unusual, or patients where the medical or surgical oncologist has questions about management," which is typically about 10% to 15% of patients, said Douglas Blayney, MD, a breast cancer specialist at Stanford Women's Cancer Center in Palo Alto, California.
Although research is limited, evidence on the effect tumor boards have 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 with a focus on gastrointestinal cancers.
One study, published in BMJ, found that after introducing multidisciplinary oncology care in hospitals in Scotland, breast cancer mortality was 18% lower among patients who received the team-based intervention. Another study concluded that these teams "enhance the multidisciplinary management of patients with cancer," providing feedback and sometimes leading to changes in diagnostic and treatment plans.
However, one analysis observed little association between multidisciplinary tumor boards and measures of quality or survival.
Perhaps some of the discrepancies come down to how well the tumor board functions. A 2019 analysis, for instance, indicated that the 5-year survival rate was 15.6% higher among cases in well-organized multidisciplinary tumor groups but almost 20% lower in disorganized groups compared with no tumor board.
"It should be no surprise that improved performance on the process or outcome measures of quality is not predicted by the existence of team meetings," Blayney wrote in an editorial. "Execution of the plan is how we get to good outcomes regardless of the brilliance of the plan, the talent of the team, or the difficulty of the task."
Benefits Outside of Clinical Decision-Making
Despite mixed data on patient outcomes, tumor boards can offer value outside of clinical decision-making.
In a recent study published in JAMA Oncology, Wren and colleagues uncovered several such functions: building trust, fueling continued education, as well as fostering greater understanding among specialists.
Patients may feel better with the treatment plan knowing that a panel of experts reviewed their case and came to a consensus, explained Wren.
Another major benefit of a tumor board: education. Cancer care has become very specialized over the last few decades. New recommendations and indications change frequently for some cancer types. It's too much for any one physician to track.
"The cognitive load for a general oncologist or even a specialized oncologist is very high. New indications for a drug or practice-changing pieces of evidence are coming out all the time," said Kamal.
Tumor boards rely on specialists keeping abreast of the latest developments in their fields, and then bringing that expertise back to the group so that everyone can stay informed.
Tumor boards also provide new avenues for interdisciplinary collaboration, and even camaraderie. That could mean increased physician satisfaction and decreased burnout, according to Wren and colleagues.
"Often it is just to feel like you're not making a decision in a vacuum," one participant in Wren's study said. "Like a gut check." "We learn from each other and we work together in research," another participant commented.
In addition to discussing treatment, a good tumor board will look at what's going to harm patient adherence to a treatment plan and what's going to help, said Kamal. That means identifying nondisease-related stressors, potential for financial toxicity, and caregiver concerns.
"If a patient comes to see us from 2 hours away, is there a place they could get their infusions locally so they would not have to miss a day of work?" said Kamal.
Getting the Most Out of Tumor Boards
But people may not always see eye to eye when bringing experts from different specialties together.
Disagreements about the best course of treatment may arise and this can stall decision-making.
"When a tumor board falls apart, it's usually because people are heated and feel very strongly about their position," said James Wurzer, MD, a radiation oncologist at AtlantiCare Cancer Care Institute and AtlantiCare Radiation Oncology, New Jersey.
For instance, a radiologist may want a patient to have a particular test done, but the surgical oncologist may feel it's unnecessary. "This can create a time-consuming back and forth," he explained. "Sometimes a discussion can't be resolved during the allotted time, and that key person needs to keep cases moving along."
Disagreements are natural, especially when there may be no one right answer for a person's care. Sometimes, according to Wren's study, treating clinicians will bring a cancer case to a tumor board to adjudicate a difference of opinion on a patient's treatment.
Most clinicians agree that the kind of decision-stalling disagreements described above is rare. That's especially true when participants understand that recommendations are by consensus and not unanimous, explained Blayney.
A tumor board's consensus statement can contain multiple recommendations. For instance, a tumor board may conclude that mastectomy is the best course of treatment for a patient with breast cancer but note that several surgeons may feel that lumpectomy is also a reasonable option. The treating physician can then take those recommendations back to the patient for discussion, Blayney said.
Aside from potential disagreements, time and attendance are two other key challenges to a tumor board's success.
Coordinating schedules may prove challenging among clinicians with busy schedules, and if all specialties are not present, the benefits of a tumor board really get lost, explained McClelland.
In addition, physicians typically aren't reimbursed for the time spent in tumor board meetings. "In a fee-for-service environment, a lack of reimbursement creates an unsaid tension around tumor boards. Taking an hour during the day may mean a clinician sees three or four fewer patients," Kamal added.
Zoom, Microsoft Teams, and other video conferencing platforms can now mitigate some issues with tumor board scheduling and attendance.
But to keep time management on track, someone must be committed to keeping the meeting organized and decisions moving forward. That involves making sure there aren't too many cases being presented and the mix of cases isn't overly complex, said Wurzer.
Tumor boards can provide value for both providers and patients, and potentially improve patient care when participants are open and engaged.
"A spirit of curiosity" is critical to a high-functioning tumor board, said Kamal. "It's important to remember that you're there to learn from 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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Cite this: 'A Gut Check': Do Tumor Boards Improve Care? - Medscape - Sep 15, 2022.