Tumor boards, outcomes, and quality of cancer care


If I happened to be a U.S. military veteran with or at risk for cancer (which I am not) or a senior official with the Veterans Administration, I would likely be more than a little distressed by a recent article in the Journal of the National Cancer Institute. The article suggests that the presence or absence of specific types of tumor boards at VA medical centers has little to no impact on the continuing improvement of treatment, quality of care, or survival of veterans with cancer.

For those readers who don’t know what tumor boards are, we should explain that they are organized, regular gatherings of physicians, nursing staff, and others at hospitals and other institutions, specifically designed to coordinate multi-disciplinary discussion of the treatment and outcomes of patients with any type of tumor (benign or malignant). However, tumor boards are considered so important to the continuing education of physicians and others who treat cancer that the American College of Surgeon’s Commission on Cancer Program accreditation requires all cancer programs to have “a multidisciplinary cancer conference that prospectively reviews cases and discusses management decisions” and, in fact, tumor boards of this type have been an established element of the continuing education of cancer specialists for decades. It is also relevant to note that tumor boards may be general (e.g., encompassing all types of cancer) or specific (e.g., focused specifically on a single cancer type, such as ptrostate cancer).

The new article by Keating et al. (the full text of which is available on line) should be read in concert with the editorial commentary by Blaney in the same issue of the journal. What the two articles say is that, to all intents and purposes, the current use of tumor boards at most VA medical centers appears to make little to no difference to the way in which patients get treated at these centers, and therefore has no effect on the quality of care provided to patients or to their long-term survival. Blaney goes on to observe that, in fact, he doesn’t find this in the least bit surprising.

We should be clear that this assessment of the utility of tumor boards as a continuing education vehicle within VA medical centers specifically includes prostate cancer as one of the major cancer types examined (along with lung cancer, colo-rectal cancer, breast cancer, and blood cancers).

Keating and her colleagues note that despite the fact that there was no evidence that tumor boards influence quality of cancer care in the VA setting, this may have nothing to do with the presence or absence of specific types of tumor boards in specific institutions. Rather, it may be that

… tumor boards are only as good as their structural and functional components and the expertise of the participants, and because tumor boards likely vary in their efficacy depending on these factors, measuring only the presence of a tumor board may not be sufficient to understand their effects. Additional research is needed to understand the structure and format of tumor boards that lead to the highest quality care.

Blaney concurs with this assessment, accurately observing that

Anyone who has ever played a team sport, worked with a laboratory team, led a clinical trial team, or led a patient care team soon realizes that [team] huddles, lab meetings, cooperative group meetings, or attending physician rounds don’t get the job done. Huddles are a necessary but not sufficient feature of high-functioning teams. 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.

What is clear is that if tumor boards are to continue to be a key component of the continuing education of cancer physicians (in VA medical centers or at any other cancer institution for that matter), it is essential that their design and implementation be carefully tied to the execution of behavioral change by participants that is designed to achieve a high quality of care and improvement in measurable outcomes of the patients treated.

In the case of U.S. veterans at risk for, diagnosed with, and treated for prostate cancer at VA medical centers around the country, some of those measurable outcomes might well include:

  • Appropriate application of PSA testing based on well-established guidelines
  • Avoidance of unnecessary biopsies when possible
  • Minimization of rates of post-biopsy infection
  • Avoidance of over-treatment (particularly in older men with concomittant morbidities) and under-treatment (in younger, healthy men with long life expectancies)
  • Minimization of side effects and complications of treatment
  • Reduced time to recovery of continence (in  surgical patients) post-treatment
  • High rates of recovery (or maintenance) of sexual function post-treatment in men with localized disease who had good sexual function prior to treatment
  • Overall and prostate cancer-specific survival

We would again emphasize that, while the study by Keating and her colleagues was carried out based on data from a survey of 138 VA medical centers (and the VA system is the largest integrated health care system in the USA), there is good reason to believe that its findings may be applicable way beyond the VA health system. While tumor boards at some institutions may be much more closely tied to continuing improvement in delivery of quality of care, it seems likely that such institutions are the exception rather than the rule. It would be interesting to know if tumor boards at other, significant, integrated health care systems in the USA (e.g., Kaiser Permanente, Partners Healthcare, Intermountain Healthcare, Geisinger Health System) were more closely tied to improvements in quality of care over time.

4 Responses

  1. The study seems not to say that there is no result but no measurable result of “tumor boards.” This seems unsurprising, if the boards tend to assure (presumably their purpose) that information about treatments spreads broadly in the treatment communities. The wide and to some extent obligatory presence of the boards would seem to assure that useful information about treatment spreads sufficiently, even beyond the membership of the boards, perhaps to the extent that no measurable such result can be expected.

    Of course physicians with similar practices need to (and should be expected to) communicate and compare notes with each other to the extent possible.

    Whether “tumor” is the best or even a well-defined focus of such boards, vs. other foci, is another matter.

    Indeed, yes, there should be research always to improve the effectiveness of such practices, because it must be basic that physicians have difficulty prioritizing their access to information about new treatments — and maybe especially these days concerning hormone-refractory prostate cancer.

  2. Perhaps it’s me … but the logic and intent of this comment escapes me.

  3. Sorry, but I was questioning the Sitemaster’s comment that “What the two articles say is that, to all intents and purposes, the current use of tumor boards at most VA medical centers appears to make little to no difference to the way in which patients get treated at these centers, and therefore has no effect on the quality of care provided to patients or to their long-term survival.”

    I appreciate very much the info at NPCI and certainly the critical comments of the Sitemaster, but thought this one was perhaps unnecessarily on the negative side.
    Don’t be offended.

  4. Dear Grover:

    I am not offended at all, but we may have to disagree about what the paper is suggesting.

    Here is another quote from Dr. Blaney’s editorial:

    The “current work suggests that existence of tumor boards is not a meaningful contribution to quality care in the VA.”

    That seems pretty blunt to me.

    Mike

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