Tumor board assessments sharpen treatment recommendations.
The diagnosis of pancreatic cancer became even more devastating to John “Bob” Williams when specialists at two hospitals deemed his tumor inoperable. Though the cancer was still at an early stage, they said it was too close to a major vein for surgery and that radiation and chemotherapy were his only options.
It seemed as though the doctors were saying they would do all they could, but that he should get his affairs in order, recalls Williams, 54, a writer for Consumers Union advocacy office in Washington, D.C. He says his work taught him to shop around for another opinion.
That led him to pancreatic cancer specialists at The Johns Hopkins Hospital in Baltimore, where his tumor was removed using a Whipple resection, a procedure that generally involves removing the gallbladder, part of the common bile duct, the first part of the small intestine and the head of the pancreas.
The change in treatment occurred after Williams’ case was discussed by a tumor board, a group of different specialists that assesses individual cases to determine the best course of treatment.
Tumor boards often are made up of a surgical oncologist, radiation oncologist, medical oncologist, radiologist and pathologist, who may seek input from other disciplines, such as hematology or pain management. The boards function in several formats, including:
> As part of a regularly held, multidisciplinary clinic where specialists personally evaluate patients, then meet as a board to discuss each case (they also may review cases requested by community-based clinicians);
> As stand-alone meetings to review cases complete with diagnostic imaging, biopsy findings and the patients’ medical histories; and
> As virtual meetings with visual and audio communication between multiple locations.
Services to patients may include genetic counseling, nutrition education, or guidance about social services and financial assistance. Multidisciplinary tumor boards sometimes give their treatment recommen-dations directly to the patient; in all other cases, to the requesting physician. Patients may then choose where to be treated.
If I were a patient, I would want as many people talking about me in a multidisciplinary setting as possible … Is it absolutely required? Probably not, but it’s nice to have another set of eyes making sure there isn’t anything complex going on.
Reviews by tumor boards increase the likelihood that the patient will be offered participation in a clinical trial. (In a given year, fewer than 5 percent of adults diagnosed with cancer receive treatment through clinical trials.)
Input from multiple specialties often can lead to a more personalized approach to treating pancreatic and other aggressive cancers, such as HER2-positive breast cancer. This input may also reveal new findings or interpretations of pathologic or imaging studies that could influence treatment recommendations.
“If I were a patient, I would want as many people talking about me in a multidisciplinary setting as possible,” says Kevin S. Scher, MD, a hematologist who was lead researcher in a 2011 Los Angeles-based study of physicians on tumor boards reviewing breast cancer cases. “Is it absolutely required in every case? Probably not, but it’s nice to have another set of eyes making sure there isn’t anything complex going on.”
Patients with complex cancers, in particular, could have cause to request a tumor board review, according to the results of studies showing boards often disagree with treatment plans initially recommended by patients’ physicians. Three studies of tumor boards reviewing either pancreatic, gynecologic or breast cancer cases, showed these results:
> Nearly one-fourth of the time, the tumor board within the Johns Hopkins Pancreas Multidisciplinary Cancer Clinic recommended treatment changes that affected 48 of 203 patients, according to a 2008 study.
> A study published in 2004 of 459 gynecologic cases presented at tumor conferences found 32 discrepancies with the original treatment plan—23 were major—that altered the final treatment plan, commonly resulting in surgery and chemotherapy as therapeutic changes.
> A study published in 2011 of Los Angeles physicians treating women with breast cancer credits tumor boards with the ability to improve coordination of care, enhance quality of care and potentially improve health outcomes by giving physicians actionable advice that alter plans of care. The survey showed 58 percent of physicians attended tumor board meetings weekly, and 25 percent monthly. The meetings deemed most helpful were when all participants’ cases were reviewed, with board recommendations serving the function of pretreatment planning, versus only considering unusual or controversial (teaching) cases.
Multidisciplinary clinics with tumor boards are resource-intensive and challenging for physician scheduling. For that reason, there are fewer of them, but the approach is much better for patients, says Timothy Pawlik, MD, associate professor of surgery and oncology at Johns Hopkins and a researcher on the 2008 pancreatic cancer tumor board study.
“It’s only one visit to the hospital, and the patient leaves with a consensus opinion of the entire multidisciplinary team, not the opinion of just one doctor,” Pawlik says.
The patient can be treated in their own community, with friends and family there to give assistance. They have access to new experimental and evolving treatments that are part of the UC Davis clinical trials portfolio.
Technology is extending academic medical center expertise to small city hospitals.
Sacramento, Calif.-based UC Davis Comprehensive Cancer Center began hosting virtual tumor boards to allow its Cancer Care Network oncologists in Pleasanton, Merced, Truckee and Marysville, Calif., to present cases in real-time.
Physicians post patient imaging scans and other data on the hosting software. All participants simultaneously see on-screen views as clearly as if in their own clinic, says Richard Bold, MD, professor and chief of surgical oncology.
The virtual setup extends best treatment recommendations to patients who can’t or won’t drive 250 miles to Sacramento for care, he explains. It gives local oncologists access to broader expertise and extends clinical trials into other regions.
“The patient can be treated in their own community, with friends and family there to give assistance,” Bold says. “They have access to new experimental and evolving treatments that are part of the UC Davis clinical trials portfolio.”
Williams considers his experience with a tumor board humbling.
“They said there’s absolutely no reason they couldn’t do the surgery and try to cure this thing,” Williams says. “That’s a long way from where I started.”
Although the procedure is considered standard for operable pancreatic tumors, only medical centers specializing in pancreatic cancer have the high-volume expertise to perform the surgery on patients such as Williams, says his surgeon, Christopher Lee Wolfgang, MD, PhD.
A long series of radiation and chemotherapy treatments also is required, but “Getting the tumor out was the biggest part,” Williams says. “I find it hard to use the word cure, but that’s what they think they can do.”
Boards within multidisciplinary clinics differ from stand-alone meetings because all specialists reviewing the case have also evaluated the patient, which expedites patient care that otherwise might take weeks of waiting to be seen by each of the many specialists required to treat cancer.
Stanford Cancer Institute in California has about a dozen multidisciplinary clinics and tumor boards for specific cancers, including cutaneous lymphoma and gastrointestinal cancers. The first was established 50 years ago as a lymphoma tumor board and a tumor clinic.
“Tumor boards aren’t new, but they’re still not used as much as they should be, especially in community settings,” says Richard Hoppe, MD, a radiation oncologist at the Stanford Cancer Institute.
Patient care in community medical oncology or radiation oncology groups commonly is supervised by an individual, without input from multiple disciplines or other specialists, he says.
“Ideally, if there were enough tumor boards, every cancer patient would be seen in that type of setting to get the opinion of all the disciplines,” Hoppe says. “But in general, the more complex the case, the more appropriate it is for a patient to be seen in a tumor board setting.”