By Nagi S. El Saghir, MD, FACPImmediate Past Chair, ASCO International Affairs Committee
Professor and Director, Breast Center of Excellence, American University of Beirut Medical Center, Beirut, Lebanon
Watching soccer teams from nations from five continents compete at the World Cup reminded me of a comment about teamwork that Lesley Fallowfield, DPHIL, BSc, of the University of Sussex made at the Educational Session on Multidisciplinary Tumor Boards that we conducted along with Drs. Robert Carlson and Nancy Lynn Keating at the 2014 ASCO Annual Meeting in Chicago this past June. In fact, leadership and team play were recently exemplified by Lionel Messi, of Argentina, when he reached in front of the Swiss goalkeeper, decided not to throw the ball himself into the goal, but gave it as a pass to his own team member Angel di Maria who himself scored the winning goal of the game.
Oncology care is also increasingly a team effort. Every well-trained surgeon and oncologist would prefer to discuss the following case scenario with colleagues in order to come up with the best course of treatment: a patient in her early 40s has an abnormal 2.3 cm density in the UOQ of her left breast on a routine mammogram, proven to be malignant on an ultrasound-guided biopsy.
At the Tumor Boards, the radiologist shows the tumor. Residents are glad to learn that the radiologist inserted a clip at the site of the biopsy to guide the surgery, whether done before or after neoadjuvant therapy. When the radiologist says there are very small, shotty axillary lymph nodes, a nice demonstration follows on lymph-node assessment.
The pathologist then shows an infiltrating ductal carcinoma grade 2, ER-neg, PR-neg, HER2 ++. When he says that FISH results will be known after seven to 10 days, we all wish to have it earlier, but cost here is a reason and centralization of FISH analysis would not only improve results, but also reduce costs. The surgeon wants to do an MRI. An intense debate follows on the need for MRI, potential benefits, limited effect on margin assessment, and increased rates of mastectomy with increased use of breast MRI. Panel decides to proceed with a SLNB and breast-conserving therapy.
Tumor Boards discussions like this one improve communication between physicians, help teams make better decisions for patients, and contribute to better working environments. Sometimes, or many times, discussions go on and on forever, making people feel that their time is being wasted. This should be taken care of by ensuring that cases are well prepared and presented and that the Chair of the Tumor Boards is an efficient leader.
Tumor Boards are a forum for Multidisciplinary Teams (MDTs) of which benefit for patients has been taken for granted for decades and recommended by each and every medical authority and guideline committee, until that has been challenged by Dr. Nancy Keating and her team at Harvard who conducted a survey that found little effect on survival from participating at Tumor Boards.
Our Educational Session on Tumor Boards at this year’s ASCO Annual Meeting, “Tumor Boards: Optimizing the Structure and Improving Efficiency of Multidisciplinary Management of Patients with Cancer Worldwide,” was geared towards assessing the problems and promoting improvements for physicians and institutions that hold tumor boards, helping those who are in the process of setting up tumor boards to learn from other colleagues’ experiences, and promoting multidisciplinary management and evidence-based and worldwide resource-sensitive guidelines with Dr. Robert Carlson of the National Comprehensive Cancer Network (NCCN).
While multidisciplinary units are becoming common in Europe, multidisciplinary Tumor Boards are more commonly in place in North America and worldwide. Although only a few single-institution studies have shown their positive impact on patient management, by either changing a diagnosis or changing treatment plans, several regions and societies have recommended their utilization. The ASCO International portfolio includes Multidisciplinary Cancer Management Courses (MCMC), of which a great advantage has been the promotion and institution of multidisciplinary teams in low- and middle-income countries. A survey from Arab countries showed increasing but still insufficient utilization and reliance on Tumor Boards for decision-making. Preliminary results from a survey from the USA report reliance on MDT for collective decision making.
Efforts to improve case selection and presentations, optimize the structure and conduct of Tumor Boards, monitor performance, enhance team working, document recommendations, and follow up on implementation are essential. Our session emphasized needs in areas with suboptimal settings, such as small community hospitals, rural areas, and areas with limited resources, where Tumor Boards can help overcome limitations in diagnosis, management, and expertise. Videoconferencing is gaining momentum in remote areas. Special training of staff in multidisciplinary teams leads to better team dynamics and communication, improved patient satisfaction, and clinical outcomes, and also promotes healthier environments for practicing physicians and health care providers.
Benefits of multidisciplinary teams should be continuously fine-tuned and optimized in order to ensure efficiency and value versus efforts and time. By presenting data relevant to the entire oncology community, this ASCO Annual Meeting Educational Session, organized by the ASCO International Affairs Committee, published on PubMed (El Saghir NS, et al. Am Soc Clin Oncol Educ Book. 2014:e461-6. doi:10.14694/EdBook_AM.2014.34.e461) and available on ASCO University, is part of ASCO International’s vision to improve care of cancer patients worldwide, both in the USA and abroad.