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UNHPC
L'utilité des réunions pluridisciplinaires en oncologie
remise en cause
Stéphanie Lavaud
21 janvier 2013
Boston, Etats-Unis - Plébiscitées par les autorités sanitaires et désormais incontournables en termes de
bonne pratique, les réunions de concertation pluridisciplinaires (RCP) ont-elles une utilité ? Favorisentelles le suivi des bonnes pratiques de soins, ont-elles au final un impact sur la survie des patients ? Pour le
savoir, Barbara J. McNeil et ses collègues (Havard Medical School) ont mené une étude dans 138 centres
de soins américains pour les Anciens combattants (Veterans Affairs) [1]. Et les résultats sont édifiants : il
y a peu voire pas de liens entre la tenue de ces RCP et la qualité des soins, voire la survie des patients. Un
résultat obtenu sur la base des 27 critères retenus, donc pas exhaustifs, loin s'en faut. L'étude a été publiée
le 28 décembre dernier dans le Journal of the National Cancer Institute.
75% des établissements organisent des RCP
En pratique, les chercheurs ont colligé les données de 138 hôpitaux américains dédiés aux anciens combattants (où les soins prodigués sont similaires ou meilleurs que dans les hôpitaux publics, est-il précisé). Ils
se sont intéressés à l'existence de RCP dans ces établissements et ont rapporté les données administratives
et cliniques de patients atteints de cancers colorectaux, pulmonaires, prostatiques, hématologiques et du
sein diagnostiqués entre 2001 et 2004 et suivis au long de l'année 2005.
Ils ont ainsi établi que 75% des établissements de soins organisaient des RCP. Soixante-deux avaient une
équipe dédiée aux différents types de cancer et 41 établissements disposaient de plusieurs équipes pluridisciplinaires fonction de la localisation des tumeurs. Les RCP comprenaient la plupart du temps des oncologues (95%), des anatomopathologistes (97%), des chirurgiens (92%) et des radiologues (76%). Les autres
intervenants, comme les assistantes sociales (31%), les spécialistes de soins palliatifs (31%) et les nutritionnistes (21%) pouvaient aussi être présents mais plus rarement.
1 seul critère de qualité des soins associé à la présence de RCP
Au final, pour l'ensemble des cancers, 7 critères sont apparus associés à la présence de RCP dans l'établissement mais après ajustement avec la méthode de Bonferonni, 1 seul critère de qualité des soins sur les 27
testés a été retrouvé : il s'agit de la mise en route d'une chimiothérapie et de radiothérapie dans le cancer
du poumon à petites cellules localisé.
C'est peu quand on sait que sur les 7 critères, certains allaient plutôt à l'encontre de ce que l'on aurait pu attendre : ainsi les facteurs de croissance des globules rouges dans les protocoles CHOP dans les lymphomes non hodgkinien (LNH) à cellules T étaient moins fréquemment donnés dans les établissements disposant d'une RCP spécifique à ce type de cancer que dans les hôpitaux sans RCP spécifique ou sans RCP
tout court.
L'analyse par type de cancer est plus nuancée, mais ne change pas véritablement la donne. Pour les patients atteints de cancer colorectal, par exemple, aucune association n'a pu être mise en évidence. Pour le
cancer de la prostate, 1 des 5 critères recherchés a pu être relié à la présence de RCP : les patients métastatiques étaient plus susceptibles de recevoir un traitement anti-androgène avant une thérapie de castration
chimique avec les agonistes de la GnRH (hormone libératrice des gonadotropines).
Tenir compte des limites de l'étude
Ces résultats ont de quoi surprendre tant il est admis que les réunions de concertation pluridisciplinaires
jouent un rôle important dans la formation des médecins et les soins des patients, en partant du principe
qu'une meilleure coordination des soins entre spécialistes conduira à une meilleure qualité de ceux-ci. Ces
réunions font d'ailleurs désormais partie intégrante des préconisations des sociétés savantes et Autorités
sanitaires en termes de bonne pratique en oncologie, tant aux Etats-Unis qu'en France. Elles sont mises en
place dans la plupart des établissements hospitaliers.
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De précédentes études américaines, plus petites et se limitant souvent à un établissement, avaient semblet-il confirmé ce bénéfice des RCP. Ici, tout l'intérêt de ce travail tient à son ampleur et à sa relative homogénéité sur tout un système de soins mais les auteurs ne sont pas sans pointer des limites. Ils mentionnent
des inconnues sur la fréquence des RCP, l'individualisation de la discussion pour chaque patient, ou encore sur le fait que le médecin suive le patient dont il est question en RCP. Par ailleurs, les auteurs reconnaissent que les RCP peuvent avoir favorablement amélioré des aspects du soin, non pris en compte par
les critères choisis. Enfin, cette étude n'a pas tenu compte de l'appréciation des patients sur leurs soins ou
le type de soins, ce qui, bien sûr, peut avoir de l'importance.
Garder les RCP mais les améliorer
Alors au final, « les maigres bénéfices obtenus sont-ils à la hauteur de l'énergie, en temps et en compétence investis dans ces RCP ? Le jeu en vaut-il la chandelle ? interroge le Dr Douglas Blayney (Stanford
Cancer Institute) dans un éditorial accompagnant l'article [2]. Oui, indéniablement, pas question d'abandonner les RCP car la prise en charge du cancer aujourd'hui est nécessairement multidisciplinaire, répond
l'oncologue. En revanche, il est possible de l'améliorer : l'utilisation de la vidéo et donc de la télémédecine
pour augmenter la présence des médecins, la spécificité et la multidisciplinarité de ces réunions est une
piste. Mettre en place un « feedback » afin de comprendre pourquoi certaines recommandations n'ont pas
été appliquées en est une autre.
Références
-
Keating NL, Landrum MB, Lamont, Bozeman SR, L. Tumor Boards and the Quality of Cancer Care.
Journal of the National Cancer Institute, 2012; DOI: 10.1093/jnci/djs502 2.
-
D. W. Blayney. Tumor Boards (Team Huddles) Aren't Enough to Reach the Goal. Journal of the National Cancer Institute, 2012; DOI: 10.1093/jnci/djs523
Union Nationale Hospitalière Privée de Cancérologie
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http://jnci.oxfordjournals.org/content/105/2/113
Documentation
UNHPC
Tumor Boards and the Quality of Cancer Care
Nancy L. Keating, Mary Beth Landrum, Elizabeth B. Lamont, Samuel R. Bozeman, Lawrence N. Shulman, Barbara J. McNeil
Manuscript received June 15, 2012; revised October 29, 2012; accepted October 31, 2012.
Correspondence to: Nancy L. Keating, MD, MPH, Department of Health Care Policy, Harvard Medical School, Boston, MA 02115 (e-mail: [email protected].
harvard.edu).
Background
Despite the widespread use of tumor boards, few data on their effects on cancer care exist. We assessed whether
the presence of a tumor board, either general or cancer specific, was associated with recommended cancer care,
outcomes, or use in the Veterans Affairs (VA) health system.
Methods
We surveyed 138 VA medical centers about the presence of tumor boards and linked cancer registry and administrative data to assess receipt of stage-specific recommended care, survival, or use for patients with colorectal,
lung, prostate, hematologic, and breast cancers diagnosed in the period from 2001 to 2004 and followed through
2005. We used multivariable logistic regression to assess associations of tumor boards with the measures, adjusting for patient sociodemographic and clinical characteristics. All statistical tests were two-sided.
Results
Most facilities (75%) had at least one tumor board, and many had several cancer-specific tumor boards. Presence
of a tumor board was associated with only seven of 27 measures assessed (all P < .05), and several associations
were not in expected directions. Rates of some recommended care (eg, white blood cell growth factors with
cyclophosphamide, adriamycin, vincristine, and prednisone in diffuse large B-cell lymphoma) were lower in centers with hematologic-specialized tumor boards (39.4%) than in centers with general tumor boards (61.3%) or no
tumor boards (56.4%; P = .002). Only one of 27 measures was statistically significantly associated with tumor
boards after applying a Bonferroni correction for multiple comparisons.
Conclusions
We observed little association of multidisciplinary tumor boards with measures of use, quality, or survival. This
may reflect no effect or an effect that varies by structural and functional components and participants’ expertise.
J Natl Cancer Inst 2013;105:113–121
Care for cancer is increasingly complex and often requires specialized expertise from multiple disciplines. Tumor board reviews
provide a multidisciplinary approach to treatment planning that
involves doctors from different specialties reviewing and discussing the medical condition and treatment of patients (1). They serve
to educate providers, to increase shared appreciation of different
specialists’ perspectives on the approach to specific cancers, and
to assist in management decisions for specific patients, although
the functions may vary. Tumor boards have been an accepted and
established part of the care of cancer patients for decades (2). They
are perceived to be so important that the American College of
Surgeon’s Commission on Cancer Program accreditation requires
cancer programs to have a multidisciplinary cancer conference that
prospectively reviews cases and discusses management decisions (3).
Despite their widespread use, few data are available about the
effects of tumor boards on cancer care (4). We studied cancer care
in the Veterans Affairs (VA) health system, the largest integrated
delivery system in the United States, to explore the association of
tumor boards and measures of cancer care quality and use. Cancer
is the second leading cause of morbidity and mortality for veterans,
and data suggest that the care delivered to veterans with cancer
is generally similar to or better than care delivered to individuals insured under fee-for-service Medicare (5–7). Specifically, we
assessed if the presence of a tumor board, either general or cancer
specific, was associated with higher rates of recommended stagespecific cancer care or differences in use of care for veterans with
colorectal, lung, prostate, hematologic, and breast cancers.
Methods
Data
The Department of Veterans Affairs Central Cancer Registry
(VACCR) collects uniformly reported information on all patients
who were diagnosed with and/or received their first course of
treatment for invasive cancer at one of the VA medical centers. For
all incident cancers, registrars collect information about patient
demographics, tumor characteristics, and primary treatment.
We linked the registry data with VA administrative data on
hospitalizations, outpatient visits, contracted care, laboratory
data, inpatient and outpatient pharmacy data, and all Medicare
administrative data for Medicare-eligible patients. We obtained
National Death Index data to ascertain vital status through
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2005. Data were linked using social security numbers. Patients
were assigned to the hospital that reported their cancer to the
VACCR. We also surveyed 138 VA medical centers in December
2005 (response rate 100%) using a web-based instrument about
availability of tumor boards, cancer providers, cancer screening
and diagnostic services, chemotherapy, radiotherapy, and
palliative care. The survey was supported by VA leadership, and
the instrument was directed to veteran integrated service network
chief medical officers (and the designated point of contact for each
center to complete the survey using the following hierarchy: cancer
committee chairpersons (21% of facilities), chief staff oncologist/
hematologist (39% of facilities), chief of staff (28% of facilities), or a
different physician (eg, surgeon; 12% of facilities). This survey was
also presented during two veteran integrated service network chief
medical officer conference calls to encourage participation. The
study was approved by the Harvard Medical School Committee on
Human Studies.
Cancer and Stage-Specific Cohorts
We studied patients with colorectal, lung, prostate, hematologic,
and breast cancers. For each cancer type, we identified all patients
diagnosed with a first diagnosis of that cancer type during the
period from 2001 to 2004. As previously described (5), we excluded
small numbers of cases with histology that suggested alternative
primary cancers, patients diagnosed at autopsy or by death certificate only, and patients for whom data were incomplete (eg, missing
month of diagnosis, no administrative data between 45 days before
diagnosis through 195 days after diagnosis). These initial exclusions were to ensure that included patients actually had the cancers of interest and could be treated and that data were complete.
Additional inclusion criteria were developed for individual cancer
type and stage-specific cohorts, as described below.
Tumor Boards
The facility survey asked each facility to report if they had one or
more than one tumor board. If they reported at least one tumor
board, they reported whether the tumor board(s) discussed lung
cancer, colorectal cancer, prostate cancer, breast cancer, and/
or hematologic cancers. They also reported participants at each
tumor board, including surgeons, medical oncologists, radiation oncologists, pathologists, social workers, and palliative care
specialists.
For each facility and each cancer type with sufficient numbers of
patients (lung, colorectal, prostate, hematologic), we characterized
if they had no tumor board, a general tumor board, or a cancerspecific tumor board. We also characterized each facility based on
the presence or absence of palliative care specialists at the tumor
board(s).
Cancer Care Measures
We identified measures of high-quality care and use of care for
patients with lung, colorectal, prostate, or hematologic cancers
(there were too few breast cancer patients to accurately assess
breast cancer measures) (5–7). These process and outcome measures were developed based on national guidelines available during
the study period (8–29). Table 1 displays the measures and eligibility criteria.
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Control Variables
We also collected information on other patient and tumor factors
that might influence receipt of cancer treatments. Information
on age, marital status at diagnosis, race/ethnicity, tumor characteristics, and history of previous cancer was included in the registry data, based on medical record abstraction. We characterized
comorbid illnesses based on inpatient and outpatient administrative data in the year before diagnosis using the Klabunde modification of the Charlson score (30,31). We linked data with year
2000 Census data for area-level information on the proportion of
residents with a college degree. Although there are limitations to
the use of area-level measures of socioeconomic status as proxies
for individual measures (32), they are nevertheless associated with
cancer care and outcomes (33).
Statistical Analyses
We first described the presence and types of tumor boards across
the VA facilities. Next, we assessed the association of tumor boards
and each indicator using multivariable logistic regression analyses
with generalized estimating equations to account for clustering by
VA medical center. We used separate models for each indicator.
The primary independent variable, availability of tumor boards,
was specified with two indicator variables for availability of general tumor boards and availability of cancer-specific tumor boards
(with no tumor board as the reference category). We tested for the
joint significance of these two variables and present the overall,
two-sided P value for the effect of tumor board and type of tumor
board on the measure of interest, adjusting for all other variables.
P values less than .05 were considered statistically significant for
primary analyses. All analyses were adjusted for patient age, sex,
race/ethnicity, marital status, quartiles of the proportion with a college degree in the zip code of residence, history of previous cancer,
Charlson comorbidity score, year of diagnosis, tumor grade, and
veteran integrated service network. We included stage or cancer
type in analyses with patients of more than one stage. We included
tumor size in models assessing survival. We included information
on availability of services at the reporting facility in relevant models, including radiation in assessing radiation, thoracic surgeons
in lung cancer models, urologists in prostate cancer models, and
hospice and palliative care services in models assessing palliative
care or end-of-life measures. Analyses were conducted using Stata
statistical software, version 11 (StataCorp, College Station, TX).
For each category of the tumor board variables, we calculated the
adjusted rate with each measure using direct standardization (34).
We also used a Bonferroni correction to adjust for multiple comparisons (P < .05/27) and considered only values less than .00185 to
be statistically significant.
Results
Overall, 103 (75%) of the 138 VA medical centers reported having
at least one tumor board (Table 2). Sixty-two centers had a single
tumor board that discussed cases from multiple cancer sites, and 41
centers had more than one disease-specific tumor board.
Among the 62 centers with a single tumor board, nearly all
discussed all of the cancer types we inquired about, including
colorectal (92%), lung (97%), prostate (92%), breast (85%), and
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Table 1. Measures of cancer care use, recommended processes of care, and outcomes*
Measure
Colorectal cancer
Adjuvant chemotherapy for stage
III colon cancer (9)
Adjuvant chemotherapy and
radiation therapy for stage II/III
rectal cancer (10)
Three-year all-cause survival for
colon cancer patients
Three-year all-cause survival for
rectal cancer patients
Lung cancer
Curative surgery for stage I/II
NSCLC (11)
Definition
Cohort
Measure type
At least 1 dose of adjuvant 5
fluorouracil or capecitabine
administered within 90 days
of the date of curative-intent
resection of stage III colon
cancer
At least 1 dose of adjuvant
chemotherapy with 5 fluorouracil
or capecitabine AND at least 1
treatment with radiation therapy
before or within 140 days of the
date of curative intent resection
for stage II, III rectal cancer
Patients alive 3 years after the date
of diagnosis
Patients alive 3 years after the date
of diagnosis
All patients with stage III colon cancer who underwent
curative-intent resection. Patients were required to
be alive and not in a Medicare HMO through 90 days
from surgery.
Quality
All patients with stage II/III rectal cancer who
underwent curative-intent resection. Patients were
required to be alive and not in a Medicare HMO
through 180 days from surgery.
Quality
All patients with colon cancer
Outcome
All patients with rectal cancer
Outcome
Receipt of pneumonectomy, lobec- All patients with stage I/II lung cancer. Patients were
tomy or wedge or segmental
required to be alive and not in a Medicare HMO
resection within 180 days of
through 180 days from diagnosis. Patients were also
diagnosis
included if they died within 180 days but underwent
surgery.
Receipt of at least 1 treatment with All patients with stage I/II lung cancer who did not
Radiation for unresected
radiation therapy within 180 days
undergo pneumonectomy, lobectomy, or wedge
stage I/II NSCLC (11)
of the diagnosis date
or segmental resection within 180 days of
diagnosis. Patients were required to be alive and
not in a Medicare HMO through 180 days from
diagnosis.
Mediastinal evaluation for patients Receipt of mediastinal evaluation
All patients with stage I/II NSCLC who underwent
undergoing lobectomy or pneufrom 45 days before date of diag- lobectomy or pneumonectomy. Patients were
monectomy for stage I/II NSCLC
nosis through date of lobectomy
required to be alive and not in a Medicare HMO
(11)
or pneumonectomy
through 180 days from surgery.
Chemotherapy or radiation for
At least 1 dose of adjuvant
All patients with stage IIIA NSCLC who underwent
stage IIIA NSCLC patients who
chemotherapy and/or at least 1
lobectomy or pneumonectomy or wedge resecreceived surgery (11)
treatment with adjuvant radiation tion. Patients were required to be alive and not in a
therapy from 30 days before date Medicare HMO through 90 days from surgery.
of diagnosis through 90 days
from date of pneumonectomy,
lobectomy, or wedge resection
for NSCLC
Doublet chemotherapy for stage IV Receipt of at least 1 dose of
All patients with stage IV NSCLC. Patients must surNSCLC (11)
platinum-based doublet
vive 45 days from diagnosis and not be enrolled in
chemotherapy, nondoublet
Medicare HMO through diagnosis through death or
chemotherapy, or no
180 days, whichever comes first.
chemotherapy within 180 days of
diagnosis
Chemotherapy and radiation for
Receipt of at least 1 dose of
VA patients were required to be alive through 45 days
limited-stage small-cell lung
cisplatin or carboplatin and VP-16
from diagnosis and not in a Medicare HMO through
cancer (17)
with concurrent radiation therapy 180 days from diagnosis.
within 180 days of diagnosis;
chemotherapy must start
between the start and end dates
of radiation therapy
One-year all-cause survival for
Patients alive 1 year after the date All patients with NSCLC
NSCLC
of diagnosis
One-year all-cause survival for
Patients alive 1 year after the date All patients with small cell lung cancer
small-cell lung cancer
of diagnosis
Prostate cancer
Primary therapy for local/regional
Radical prostatectomy vs radiation All patients with local/regional prostate cancer. Patients
prostate cancer
vs neither within 180 days of
were required to be alive and not in a Medicare
diagnosis
HMO through 180 days from diagnosis.
Quality
Quality
Quality
Quality
Use
Quality
Outcome
Outcome
Use
(Table continues)
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Table 1 (Continued).
Measure
Definition
Androgen ablation within 4 months Androgen deprivation therapy
of diagnosis for stage IV prostate with at least 1 dose of a GnRH
cancer (13,15,16,19)
agonist or bilateral orchiectomy
within 120 days of diagnosis
Oral antiandrogen before initiating Among men with metastatic cancer
GnRH agonist therapy for metawho are started on GnRH agostatic prostate cancer (8)
nist, evidence that they also filled
a prescription for an oral antiandrogen for at least 2 weeks, with
the date of the prescription fill at
least 1 week before first dose of
GnRH agonist
Adjuvant androgen deprivation ther- Proportion of patients with highapy for high-risk cancers treated
risk prostate cancer (Gleason
with radiation therapy (8)
8–10 or PSA >20 or stage T3 or
greater) treated with at least 1
radiation treatment who also get
hormonal therapy (adjuvant or
neoadjuvant)
3D-CRT or IMRT if treated with
Receipt of 3D-CRT or IMRT among
external-beam radiation for local/
men with local-regional prostate
regional prostate cancer (8,14,18) cancer who received external
beam radiation therapy within
180 days of diagnosis
Hematologic cancers
CHOP chemotherapy for diffuse
At least 1 dose of each agent of
large B-cell non-Hodgkins lymCHO-based chemotherapy from
phoma (22)
15 days before date of diagnosis
through 60 days after diagnosis
Rituximab with CHOP chemoAt least 1 dose of rituximab with
therapy for diffuse large B-cell
CHO-based chemotherapy (as
non-Hodgkins lymphoma (21)
defined above) from 15 days
before date of diagnosis
through 60 days after diagnosis
White blood cell growth factor
Receipt of at least 1 dose of white
with CHOP chemotherapy in
blood cell growth factor from 14
diffuse large B-cell non-Hodgkins
days before date of first CHOlymphoma (29)
based chemotherapy through
21 days after
Bisphosphonates for myeloma
At least 1 dose of intravenous
(12,20,23)
pamidronate or zolendraic acid
from 15 days before date of
diagnosis through 180 days after
diagnosis
Palliative care and end-of-life care
Last dose of chemotherapy within Receipt of last dose of chemother14 days before death (24,25)
apy within 14 days of death
Cohort
Measure type
All patients with stage IV cancer at diagnosis. Patients
were required to be alive and not in a Medicare
HMO through 120 days from diagnosis.
Quality
All patients with stage IV cancer at diagnosis who
started a GnRH agonist
Quality
All patients with high-risk, nonmetastatic tumors
treated with radiation therapy within 180 days of
diagnosis. Patients were required to be alive and
not in a Medicare HMO through 180 days from diagnosis. Included only cases in 2001–2002 because
Gleason 7 tumors could not be distinguished from
Gleason 8 in 2003–2004.
All patients with local/regional prostate cancer at
diagnosis who had evidence for external beam radiation therapy in administrative data. Patients were
required to be alive and not in a Medicare HMO
through 180 days from diagnosis.
Quality
All patients with diffuse large B-cell lymphoma.
Patients were required to be alive and not in a
Medicare HMO through 60 days from diagnosis.
Quality
CHO(P)-treated patients with diffuse-large B cell lymphoma with outpatient claims for chemotherapy in
2002–2004 (patients from measure above)
Quality
CHO(P)-treated patients with diffuse-large B cell lymphoma. Patients could not be in a Medicare HMO
during the time of interest.
Quality
All patients diagnosed with myeloma. Patients were
required to be alive and not in a Medicare HMO
through 180 days from diagnosis.
Quality
All patients diagnosed with stage IV NSCLC or colorectal cancer who died. Patients could not be enrolled in
a Medicare HMO in the last 30 days of life.
Admitted to an intensive care unit Admission to the ICU in the last
All patients diagnosed with stage IV NSCLC or
(ICU) within 30 days before
month of life
colorectal cancer who died. Patients could not be
death (24,25)
enrolled in a Medicare HMO in the last 30 days
of life.
More than 1 emergency room
More than 1 emergency room visit All patients diagnosed with stage IV NSCLC or colorecvisit within 30 days before death
in the last month of life
tal cancer who died. Patients could not be enrolled in
(24,25)
a Medicare HMO in the last 30 days of life.
Use of potent antiemetics for
Receipt of at least 1 dose of a 5HT All VA patients with any cancer treated with one of the
highly emetogenic chemotherapy blockade among patients treated
highly emetogenic chemo drugs, including adria(26,28)
with highly emetogenic chemomycin, cisplatin, carbo-platin, cyclophosphamide,
therapy. 5HT blockade assessed
ifosphamide, idarubicin, epirubicin, daunorubicin.
from 30 days before date of first
Patients could not be in a Medicare HMO during the
dose of a highly emetogenic
time window of interest.
chemotherapy through 30 days
following last dose of the same
chemotherapy
Quality
Use
Use
Use
Quality
(Table continues)
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Table 1 (Continued).
Measure
Prescription of narcotic pain
medication for advanced cancer
patients in pain (27)
Definition
Cohort
At least 1 opioid prescription filled
among stage IV patients with
2 consecutive pain scores ≥5.
Script must be filled during
the period between the 2 pain
scores.
Measure type
All patients with any cancer diagnosed at stage IV
who have 2 consecutive pain scores of ≥5 from 3
to 30 days apart with no lower pain score between
and no hospitalization. Patients could not be in a
Medicare HMO during the time window of interest.
Quality
* 3D CRT = 3-dimensional conformal radiation therapy; 5HT = 5-hydroxytryptamine receptor; CHO = cyclophosphamide, adriamycin, vincristine;
CHOP = cyclophosphamide, adriamycin, vincristine, and prednisone; GnRH = gonadotropin-releasing hormone; HMO = health maintenance organization;
IMRT = intensity-modulated radiation therapy; NSCLC=non-small-cell lung cancer; PSA = prostate-specific antigen; VA = Veterans Affairs.
Table 2. Tumor boards in Veterans Affairs medical centers
Tumor board features
No.
%
Among all 138 facilities
Tumor board present
No tumor board
Single tumor board
More than one tumor board
Among 62 facilities with a single tumor board
Presentation of patients with these cancer
types
Colorectal cancer
Lung cancer
Prostate cancer
Breast cancer
Lymphoma/hematologic cancer
Tumor board participants
Medical oncologist
Pathologist
Surgeon
Radiation oncologist
Radiologist
Social worker
Palliative care specialist
Nutritionist
Among 41 facilities with more than one tumor
board
Has tumor board specifically for
Colorectal cancer
Lung cancer
Prostate cancer
Breast cancer
Lymphoma/hematologic cancer
138
100
35
62
41
62
25
45
30
100
57
60
57
53
52
92
97
92
85
84
59
54
57
50
47
19
19
13
41
95
97
92
81
76
31
31
21
100
39
41
34
27
30
95
100
83
66
73
hematologic cancers (84%). Most of these tumor boards (n = 48
of 62) discussed all five of these cancer types. Participants in these
tumor boards nearly always included medical oncologists (95%),
pathologists (97%), and surgeons (92%) and typically also included
radiation oncologists (81%) and radiologists (76%). Other providers, such as social workers (31%), palliative care specialists (31%),
and nutritionists (21%), were less often included (Table 2).
Among the 41 centers with more than one tumor board, all
had a lung cancer–specific tumor board, and nearly all (95%) had
a colorectal cancer–specific tumor board. Most also had a prostate cancer–specific tumor board (83%), a hematologic cancer–
specific tumor board (73%), and a breast cancer–specific tumor board
(66%) (Table 2). Most (n = 22 of 41) had tumor boards for all five
of the cancer types we discussed. Another eight centers had tumor
boards for lung, prostate, colorectal, and hematologic cancers; three
had tumor boards for lung, prostate, colorectal, and breast cancers;
two had tumor boards for lung, colorectal, and breast cancers; one
had tumor boards for lung, prostate, and colorectal cancers; three
had tumor boards for lung and colorectal cancers; and two had a
tumor board for lung cancer.
Table 3 presents the adjusted proportion of patients with each
indicator by tumor board status. Overall, the presence of a tumor
board was associated with only seven of 27 measures assessed (all
P < .05). Among patients with colorectal cancer, none of the process or outcome measures were associated with the presence or
type of tumor board. For patients with lung cancer, three of the
nine measures were associated with the presence or type of tumor
board. Patients with stage I/II non-small-cell lung cancer who did
not undergo curative surgery who were treated at centers with a
general tumor board were more likely than patients at a center
with no tumor board or a lung cancer–specific tumor board to
undergo radiation. Patients with stage IIIA lung cancer who did
not undergo resection who were at centers with a general tumor
board or a lung cancer–specific tumor board were more likely than
those at a center with no tumor board to undergo chemotherapy and radiation therapy. Patients with limited-stage small-cell
lung cancer who were at centers with a general tumor board or a
lung cancer–specific tumor board were more likely than patients
at a center with no tumor board to undergo chemotherapy and
radiation.
One of the five measures of prostate cancer care was associated
with tumor boards; patients at a center with a prostate cancer–
specific or general tumor board were more likely to receive oral
antiandrogen therapy before initiating gonadotropin-releasing
hormone agonist therapy for metastatic prostate cancer. Two of
the four hematologic measures were associated with tumor board
status. Receipt of rituximab with cyclophosphamide, adriamycin, vincristine, and prednisone (CHOP) chemotherapy for nonHodgkins lymphoma was highest among patients at a center with
no tumor board or with a hematologic cancer–specific tumor board
compared with patients at a center with a general tumor board.
Receipt of white blood cell growth factor among patients receiving CHOP chemotherapy was highest among patients treated at
a center with a general tumor board (61.3%) or no tumor board
(56.4%) compared with a hematologic cancer–specific tumor board
(39.4%; P =.002) (Table 3).
For the palliative care and end-of-life care measures, we
assessed whether the general tumor board or at least one of the
cancer-specific tumor boards of interest had a palliative care specialist participating. Only one of these five measures was associated
with the presence of a tumor board; patients at a center without a
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Table 3. Adjusted proportion of each cancer care process by availability of tumor boards
Colorectal cancer
Measure
Adjuvant chemotherapy for stage III colon cancer
Adjuvant chemotherapy and radiation for stage II/III rectal
cancer
3-year (all-cause) survival in colon cancer patients
3-Year (all-cause) survival in rectal cancer patients
Lung cancer
Curative surgery for stage I/II NSCLC
Radiation for unresected stage I and II NSCLC
Mediastinal evaluation for stage I/II NSCLC
Chemotherapy or radiation therapy for stage IIIA NSCLC
patients who received surgery
Chemotherapy and radiation therapy for unresected NSCLC
stage IIIA patients
Doublet chemo for stage IV lung cancer
None
Doublet chemo
Nondoublet chemo
Chemotherapy and radiation therapy for limited-stage smallcell lung cancer
1-year (all-cause) survival, NSCLC
1-year (all-cause) survival, small-cell lung cancer
Prostate cancer
Primary therapy for local/ regional prostate cancer
No radiation or surgery
Radiation
Surgery
Androgen ablation for men diagnosed with metastatic
prostate cancer
Oral anti-androgen before initiating GnRH agonist for
metastatic prostate cancer
Adjuvant androgen deprivation therapy for high-risk cancers
treated with radiation therapy (2001–2002)
Use of 3-D CRT/IMRT for men treated with external beam
radiation therapy
Lymphoma and multiple myeloma
No. patients
No tumor
board, %
1738
801
68.7
74.6
69.3
73.9
70.4
74.6
.83
.97
4995
1389
57.5
52.5
58.2
56.2
60.2
54.6
.24
.37
No. patients
No tumor
board, %
General tumor
board, %
4291
1666
2191
370
53.2
66.5
85.7
79.6
56.5
70.8
85.6
74.8
61.9
63.8
89.3
65.1
.14
.04
.37
.27
1305
23.9
39.5
35.6
.02
1062
56.0
37.3
6.7
28.4
52.3
42.7
5.0
61.8
50.6
42.8
6.6
62.9
<.001†
21 123
3493
41.3
25.2
39.5
26.2
41.0
26.6
.22
.88
No. patients
No tumor
board, %
General tumor
board, %
Palliative care and end-of-life care
P*
P
.15
Prostate cancer–specific
tumor board, %
32 533
P
.37
1582
38.9
35.4
25.6
77.2
38.9
38.1
23.0
70.7
37.7
36.0
26.4
76.9
.24
1459
71.1
81.7
83.7
.03
1537
56.7
63.0
68.6
.25
7898
61.0
59.3
61.0
.94
No tumor
board, %
General tumor
board, %
766
431
350
80.7
89.3
56.4
75.4
74.6
61.3
80.6
87.1
39.4
.31
.003
.002
899
59.6
66.4
66.2
.18
No. patients
Receipt of last dose of chemotherapy within 14 days of
death
ICU admissions within 30 days of death
More than one ER visit within 30 days of death
Use of potent antiemetics for highly emetogenic
chemotherapy
Prescription of narcotic pain medication for advanced
cancer patients in pain
Lung cancer–specific
tumor board, %
5853
No. patients
CHOP chemotherapy in diffuse large B-cell NHL patients
Rituximab with CHOP in diffuse large B-cell NHL patients
White blood cell growth factor with CHOP in diffuse large
B-cell NHL patients
Bisphosphonate therapy for multiple myeloma patients
General tumor Colorectal cancer–specific
board, %
tumor board, %
No tumor
board, %
Hematologic cancer–
specific tumor board, %
Tumor board
without
palliative care
Tumor board with
specialist, % palliative care specialist, %
P
P
9796
4.8
5.8
5.4
.47
9796
9796
11 256
15.7
9.6
64.7
12.8
12.0
75.4
13.1
9.2
66.4
.36
.01
.10
2813
69.6
68.6
67.0
.76
* We assessed the association of tumor boards and each indicator using multivariable logistic regression analyses with generalized estimating equations to account
for clustering by Veterans Affairs medical center. We used separate models for each indicator. The primary independent variable, availability of tumor boards, was
specified with two indicator variables for availability of general tumor boards and availability of cancer-specific tumor boards (with no tumor board as the reference
category). We tested for the joint significance of these two variables, and present the overall two-sided P value for the effect of tumor board and type of tumor
board on the measure of interest, adjusting for all other variables. 3D CRT = 3-dimensional conformal radiation therapy; CHOP = cyclophosphamide, adriamycin,
vincristine, and prednisone; ER = emergency room; GnRH = gonadotropin-releasing hormone; ICU = intensive care unit; IMRT = intensity-modulated radiation
therapy; NHL = non-Hodgkin lymphoma; NSCLC = non-small-cell lung cancer.
† This was the only statistically significant association after applying a Bonferroni correction for multiple comparisons (P < .05/27 or P < .00185).
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tumor board or with a tumor board with a palliative care specialist
were less likely than those at a center with a tumor board but no
palliative care specialist to have more than one emergency room
visit within 30 days of death (Table 3).
After applying a Bonferroni correction for multiple comparisons, only one of the 27 indicators was statistically significant
(P < .00185): patients with limited-stage small-cell lung cancer
who were at centers with a general tumor board or a lung cancer–
specific tumor board were more likely than patients at a center with
no tumor board to undergo chemotherapy and radiation.
Discussion
The VA health system is the largest integrated delivery system
in the United States, caring for more than 6.1 million veterans.
Cancer is second to cardiovascular disease as a cause of morbidity
and mortality for veterans, and data suggest that the care delivered
to veterans with cancer is generally similar to or better than care
delivered to individuals insured under fee-for-service Medicare (5–
7). We surveyed all 138 VA medical centers to learn about the availability of tumor boards to discuss cancer care and assessed whether
the presence of general or cancer-specific tumor boards was associated with various measures of use, quality, or outcomes. Most facilities (75%) had at least one tumor board, and many had a number
of cancer-specific tumor boards. Yet, we found that only seven of
27 measures we assessed were associated with tumor boards; and
if we applied a Bonferroni correction for multiple comparisons,
only one of the measures was statistically significantly associated.
Moreover, several of the seven associations were not in expected
directions, with, for example, rates of some recommended care (eg,
white blood cell growth factors with CHOP in diffuse large B-cell
non-Hodgkins lymphoma) lower in centers with cancer-specific
tumor boards than in centers with general tumor boards or no
tumor boards.
Tumor boards are widely seen as serving an important role in
physician education and patient care, with the aspiration that care
will be better coordinated among specialists and ultimately will be
of higher quality. The American College of Surgeon’s Commission
on Cancer Program accreditation requires all accredited cancer
programs to have a multidisciplinary cancer conference that meets
at least monthly and prospectively reviews cases and discusses
management decisions (3). A national survey of 1700 US hospitals
in the late 1980s documented that tumor boards are widely used,
with substantial variability in the format, participants, and function of tumor boards (2). This survey also estimated that more than
50 physician hours per month are devoted to tumor board meetings (2). With person-time investments such as this, it is surprising
how little data are available about the impact of tumor boards on
cancer care.
Some small studies have demonstrated the potential for tumor
boards to influence clinical care. One study of eight tumor boards
in six hospitals in Oakland assessed care on 97 patients for which
153 specific prospective recommendations were made and found
that 84% of the recommendations were followed (35); similar
findings were evident for a brain cancer tumor board (36). Another
study of a breast cancer tumor board at a single cancer center
found that more than half of patients discussed at a tumor board
over a 1-year period had changes in their recommended surgical
treatment based on review. Modest evidence from single institutions suggests that presentation of a case at a multidisciplinary
tumor board was associated with higher rates of guideline-recommended care for patients with rectal cancer (37), lung cancer (38),
or esophageal cancer (39).
We found relatively modest and contradictory associations of
tumor boards with care received. With three lung cancer measures (including the one that was statistically significant after the
Bonferroni correction for multiple comparisons), we observed
higher rates of care that involved consideration of multiple treatment modalities associated with tumor boards: radiation for
unresected patients with stage I/II non-small-cell lung cancer,
chemotherapy and radiation for unresected stage IIIA non-smallcell lung cancer, and chemotherapy and radiation for limited-stage
small-cell lung cancer. Nevertheless, we did not observe effects
for other measures of multimodality therapy, including adjuvant
chemotherapy for colon cancer, chemotherapy and radiation therapy for rectal cancer, chemotherapy or radiation for resected stage
IIIA non-small-cell lung cancer patients, or adjuvant androgen
deprivation for high-risk prostate cancers treated with radiation.
Moreover, we found high rates of some measures (eg, rituximab
with CHOP and white blood cell growth factor with CHOP
for lymphoma) among patients at sites with no tumor boards.
Information about some types of recommended care may be disseminated effectively without tumor boards. This may be particularly true in an integrated delivery system where care may be
better coordinated than in other settings. It is also possible that
cancer specialists working at centers without tumor boards may
also have appointments at other hospitals where they may have
access to tumor boards.
Our study’s strengths include the ability to study care within
a large, integrated delivery system for patients treated at 138 VA
medical centers that varied in their use of tumor boards. We had a
100% response rate to our facility survey, and we studied a variety
of indicators for all eligible patients with the cancers of interest
over the study period. Nevertheless, some limitations should be
noted. First, although we had information on the focus of the tumor
board (general or cancer specific) and participants, we did not know
the format or frequency of the tumor board or whether individual patients (including patients in our measures) were discussed
nor did we have any information about group dynamics or group
experiences. We also did not know to what extent each patient’s
physician(s) participated in the tumor boards or if any medical
centers initiated quality improvement initiatives or research network participation during the study period. Second, there may be
aspects of care influenced by tumor boards that our measures did
not capture. Third, we did not collect information about patients’
perceptions of care; some data suggest that breast cancer patients
seen at centers with regular multidisciplinary case conferences may
have better perceptions of comprehensive cancer care (40). Finally,
we asked about tumor boards in late 2005 and studied care in the
period from 2001 to 2005; to our knowledge, the presence of tumor
boards in the VA was stable in the early 2000s.
In conclusion, we observed little association of multidisciplinary
tumor boards with measures of use, quality, or survival. This could
mean that tumor boards did not, in fact, influence quality of cancer
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care in the VA setting. It might also mean 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.
References
1. National Cancer Institute. Definition of Tumor Board Review. http://www.
cancer.gov/dictionary?cdrid=322893. Accessed June 1, 2012.
2. Henson DE, Frelick RW, Ford LG, et al. Results of a national survey
of characteristics of hospital tumor conferences. Surg Gynecol Obstet.
1990;170(1):1–6.
3. American College of Surgeons/Commission on Cancer. Cancer Program
Standards 2012: Ensuring Patient-Centered Care V1.0. Chicago: American
College of Surgeons; 2011.
4. Wright FC, De Vito C, Langer B, Hunter A. Multidisciplinary cancer conferences: a systematic review and development of practice standards. Eur J
Cancer. 2007;43(6):1002–1010.
5. Keating NL, Landrum MB, Lamont EB, et al. Quality of care for older
patients with cancer in the veterans health administration versus the private sector: a cohort study. Ann Intern Med. 2011;154(11):727–736.
6. Landrum MB, Keating NL, Lamont EB, et al. Survival of older patients
with cancer in the Veterans Health Administration versus fee-for-service
Medicare. J Clin Oncol. 2012;30(10):1072–1079.
7. Keating N, Landurm M, Lamont E, Earle C, Bozeman S, McNeil B. Endof-life care for older cancer patients in the Veterans Health Administration
versus the private sector. Cancer. 2010;116(15):3732–3739.
8. National Comprehensive Cancer Network. Clinical Practice Guidelines
in Oncology: Prostate Cancer. Version 1. Fort Washington, PA: National
Comprehensive Cancer Network, Inc.; 2001.
9. National Comprehensive Cancer Network. Clinical Practice Guidelines in
Oncology: Colon Cancer. Version 1. Fort Washington, PA: National Comprehensive Cancer Network; 2001.
10. National Comprehensive Cancer Network. Clinical Practice Guidelines in
Oncology: Rectal Cancer. Version 1. Fort Washington, PA: National Comprehensive Cancer Network; 2001.
11. National Comprehensive Cancer Network. Clinical Practice Guidelines in
Oncology: Lung Cancer. Version 1. Fort Washington, PA: National Comprehensive Cancer Network; 2001.
12. National Comprehensive Cancer Network. Clinical Practice Guidelines in
Oncology: Multiple Myeloma Cancer. Version 1. Fort Washington, PA: National
Comprehensive Cancer Network; 2001.
13. Medical Research Council Prostate Cancer Working Party Investigators
Group. Immediate versus deferred treatment for advanced prostatic
cancer: initial results of the Medical Research Council Trial. Br J Urol.
1997;79(2):235–246.
14. Dearnaley DP, Khoo VS, Norman AR, et al. Comparison of radiation sideeffects of conformal and conventional radiotherapy in prostate cancer: a
randomised trial. Lancet. 1999;353(9149):267–272.
15. Huggins C, Hodges CV. Studies on prostate cancer. I. The effects of castration, of estrogen, and of androgen injection on serum phosphatases in
metastatic carcinoma of the prostate. Cancer Res. 1941;1:293–297.
16. Huggins C, Stevens RE, Hodges CV. Studies on prostate cancer. II. The
effects of castration on advanced carcinoma of the prostate gland. Arch
Surg. 1941;43(2):209–233.
17. Laurie SA, Logan D, Markman BR, Mackay JA, Evans WK. Practice guideline for the role of combination chemotherapy in the initial management
of limited-stage small-cell lung cancer. Lung Cancer. 2004;43(2):223–240.
18. Pisansky TM. External-beam radiotherapy for localized prostate cancer. N
Engl J Med. 2006;355(15):1583–1591.
19. Bahnson RR, Hanks GE, Huben RP, et al. NCCN practice guidelines for
prostate cancer. Oncology (Huntingt). 2000;14(11A):111–119.
120 Articles
|
20. Berenson JR, Lichtenstein A, Porter L, et al. Efficacy of pamidronate in
reducing skeletal events in patients with advanced multiple myeloma.
Myeloma Aredia Study Group. N Engl J Med. 1996;334(8):488–493.
21. Coiffier B, Lepage E, Briere J, et al. CHOP chemotherapy plus rituximab
compared with CHOP alone in elderly patients with diffuse large-B-cell
lymphoma. N Engl J Med. 2002;346(4):235–242.
22. Fisher RI, Gaynor ER, Dahlberg S, et al. Comparison of a standard regimen (CHOP) with three intensive chemotherapy regimens for advanced
non-Hodgkin’s lymphoma. N Engl J Med. 1993;328(14):1002–1006.
23. Hortobagyi GN, Theriault RL, Porter L, et al. Efficacy of pamidronate
in reducing skeletal complications in patients with breast cancer and lytic
bone metastases. Protocol 19 Aredia Breast Cancer Study Group. N Engl J
Med. 1996;335(24):1785–1791.
24. Earle CC, Park ER, Lai B, Weeks JC, Ayanian JZ, Block S. Identifying
potential indicators of the quality of end-of-life cancer care from administrative data. J Clin Oncol. 2003;21(6):1133–1138.
25. Earle CC, Neville BA, Landrum MB, Ayanian JZ, Block SD, Weeks JC.
Trends in the aggressiveness of cancer care near the end of life. J Clin
Oncol. 2004;22(2):315–321.
26. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered
to adults in the United States. N Engl J Med. 2003;348(26):2635–2645.
27. National Comprehensive Cancer Network. Clinical Practice Guidelines in
Oncology: Cancer Pain. Version 1. Fort Washington, PA: National Comprehensive Cancer Network; 2001.
28. National Comprehensive Cancer Network. Clinical Practice Guidelines in
Oncology: Antiemesis. Version 1. Fort Washington, PA: National Comprehensive Cancer Network; 2001.
29. National Comprehensive Cancer Network. Clinical Practice Guidelines in
Oncology: Non-Hodgkins Lymphoma. Version 1. Fort Washington, PA: National
Comprehensive Cancer Network; 2001.
30. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and
validation. J Chronic Dis. 1987;40(5):373–383.
31. Klabunde CN, Potosky AL, Legler JM, Warren JL. Development
of a comorbidity index using physician claims data. J Clin Epidemiol.
2000;53(12):1258–1267.
32. Geronimus A, Bound J, Wagner E. On the validity of using census geocode
data to proxy individual socioeconomic characteristics. J Am Stat Assoc.
1996;91(434):529–537.
33. Singh GK, Miller BA, Hankey BF, Feuer EJ, Pickle LW. Changing area
socioeconomic patterns in U.S. cancer mortality, 1950–1998: Part I—all
cancers among men. J Natl Cancer Inst. 2002;94(12):904–915.
34. Little RJ. Direct standardization: a tool for teaching linear models for
unbalanced data. Am Statistician. 1982;36(1):38–43.
35. Petty JK, Vetto JT. Beyond doughnuts: tumor board recommendations
influence patient care. J Cancer Educ. 2002;17(2):97–100.
36. Lutterbach J, Pagenstecher A, Spreer J, et al. The brain tumor board: lessons
to be learned from an interdisciplinary conference. Onkologie. 2005;28(1):
22–26.
37. Abraham NS, Gossey JT, Davila JA, Al-Oudat S, Kramer JK. Receipt of
recommended therapy by patients with advanced colorectal cancer. Am J
Gastroenterol. 2006;101(6):1320–1328.
38. Freeman RK, Van Woerkom JM, Vyverberg A, Ascioti AJ. The effect of
a multidisciplinary thoracic malignancy conference on the treatment of
patients with lung cancer. Eur J Cardiothorac Surg. 2010;38(1):1–5.
39. Freeman RK, Van Woerkom JM, Vyverberg A, Ascioti AJ. The effect of
a multidisciplinary thoracic malignancy conference on the treatment of
patients with esophageal cancer. Ann Thorac Surg. 2011;92(4):1239–1242;
discussion 1243.
40. Komatsu H, Nakayama K, Togari T, et al. Information sharing and case
conference among the multidisciplinary team improve patients’ perceptions of care. Open Nurs J. 2011;5:79–85.
Funding
This work was funded by the Department of Veterans Affairs through the Office
of Policy and Planning.
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Notes
Data assembly and analyses and manuscript writing were conducted by
researchers at Harvard Medical School and Abt Associates. A team of persons
from the Veterans Affairs Office of Policy and Planning and Veterans Health
Administration clinicians reviewed the measures and the research findings, provided feedback to the investigative team, and approved the final manuscript.
The views in this paper reflect those of the authors and not the Department of
Veterans Affairs.
We are grateful for helpful feedback from the VA Oncology Program Evaluation
Team, especially members with extensive clinical oncology experience within the
VA system, including, Dr Albert Muhleman (Cincinnati VAMC), Dr Nirmala
Bhoopalam (Hines, IL VAMC), Dr Paulette Mehta (VHA), Dr Dawn Provenzale
(VA HSR&D researcher in Durham, NC), Dr Michael Kelley (Chief of Oncology,
VHA), Dr Robert Kerns (National Program Director for Pain Management,
VHA), and the chief VACCR registrar, Raye Anne Dorn (VHA – DC VAMC). We
also thank Marshall Amesquita and Barbara Stephens, COTR, and the rest of our
VA Oncology Program Evaluation Team: Stanlie Daniels (VHA), Heidi Martin
(VHA), Diana Ordin (VHA), Karen Pane (VA), Dr. Archna Sharma (VHA), Anecia
Thibodeau (VHA), and Patricia Vandenberg (VHA OP&P).
We also thank Jeffrey Souza for expert programming assistance and Garrett
Kirk for research and administrative assistance.
Affiliations of authors: Division of General Internal Medicine (NLK) and
Department of Radiology (BJM), Brigham and Women’s Hospital, Boston,
MA; Department of Health Care Policy, Harvard Medical School, Boston, MA
(NLK, MBL, EBL, BJM); Massachusetts General Hospital Cancer Center,
Boston, MA (EBL); Abt Associates, Cambridge, MA (SRB); Dana-Farber
Cancer Institute, Boston, MA (LNS).
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Documentation
UNHPC
Tumor Boards (Team Huddles) Aren’t Enough to Reach the Goal
Douglas W. Blayney
Correspondence to: Douglas W. Blayney, MD, Stanford Cancer Institute, Stanford School of Medicine, 875 Blake Wilbur Dr, CC 2213, MC 5827, Stanford,
CA 94305–5827 (e-mail: [email protected]).
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. 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 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
82
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regardless of the brilliance of the plan, the talent of the team, or the
difficulty of the task.
Contemporary cancer care is multidisciplinary. Tumor boards
are team meetings of the multidisciplinary team. Typically, patients
with newly diagnosed cancer are formally discussed by representatives of various cancer care specialties. Medical, surgical, and
radiation oncologists, as well as pathologists and diagnostic imaging specialists, attend. Palliative care, social work and chaplaincy
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are often represented. A short history of the patient’s illness and
course is recited, pertinent histopathology and radiological images
are reviewed, and relevant disciplines are given an opportunity to
suggest further diagnostic and therapeutic maneuvers. The patient
is not usually present.
Studies of tumor board efficacy have mostly come from single
institutions. The study by Keating et al. published in this issue of the
Journal expands observations to include a large, integrated health
system, the Veterans Health Administration (VA) (1). Previously,
these investigators found that VA Healthcare System cancer care
is sometimes better than that of the less integrated fee-for-service
Medicare (2). Their current work suggests that existence of tumor
boards is not a meaningful contribution to quality care in the VA.
They surveyed all of the 138 VA medical centers on availability of
either general or cancer-specific tumor boards for discussion of
patients diagnosed in 2001–2004. Tumor board infrastructure was in
place in 75% of the VA Medical Centers. They identified 27 measures of quality and linked cancer registry and administrative data
to assess receipt of stage-specific care and outcome. The measures
evaluated were mostly those related to adherence to care process.
Disappointing findings show that the presence of some kind
of tumor board was correlated to only one of the process of care
measures. Moreover, availability of a tumor board did not correlate
with improvement in any of the four survival outcome measures.
As a result of these findings, we should ask: Is the minimal benefit described by Keating et al. (1) worth the costly investment of
organizational time, energy, and talent? Should tumor boards continue as a feature of organized cancer programs? Is the juice worth
the squeeze?
The approach proposed by Donabedian (3) to understand inferences about quality provides a path to improvement. In his 1988
publication, Donabedian suggested dividing quality into inferences
about the structure, process, and outcomes involved (3).
As a structural measure, Keating et al. (1) have shown that the
presence or absence of the tumor boards, in a large integrated
health system, does not influence quality in a meaningful way.
Smaller studies of tumor boards have shown that they can influence treatment recommendations (Keating’s references 34–38). An
additional small study at a referral center in which tumor boards
incorporated expert pathology and radiology review showed recommendation changes for surgical management in 52% of patients
evaluated (4). In a study of physicians whose patients participated
in a population-based sample of women with incident breast cancer, the Los Angeles Women’s Health Study (LAWHS), physicians’
self-reported breast cancer case volume predicted tumor board
attendance (5). The LAWHS investigators hypothesized, but did
not demonstrate, that tumor board attendance by physicians might
lead to collaborative decision making about type of surgery between
specialist and patient and physician, as well as to increased use of
evidence-based adjuvant chemotherapy, hormonal therapy, and
radiation. Physicians with an interest in cancer care attend tumor
boards, and these boards can change treatment recommendations.
Incremental changes in the tumor board infrastructure may
increase the value of these team meetings and extend their potential benefits to low-volume physicians. The application of technology to create the “virtual” or telemedicine tumor board should
be explored. Synchronous audio and video presentations that link
physicians in remote areas with disease-specific expert clinicians,
as well as asynchronous (“store and forward”) discussions, which
focus on patient-specific management issues, are a potential infrastructure enhancement (6). One example is the “Cure4Kids,” a
tele-oncology service linking providers in low- and middle-income
countries with experts in high-income countries (6).
Twenty-three of the 27 measures studied describe adherence to
care process. Process adherence measures are designed to predict a
desirable future outcome, that is, survival years after application of
the process. Process adherence measures are derived from clinical
trial results, from which care guidelines are developed. In cancer
care, a formal analysis of process adherence tools—whether guideline
adherence or rigorous application of clinical trial results—has not
been done. However, in cardiovascular disease, a meta-analysis of the
ability of guideline and clinical trial results to predict mortality has
demonstrated only modest accuracy (7). The link between process
adherence and improved outcome remains to be proven when
applied to routine cancer care, in either large integrated government
or academic systems, or in the oncologist’s office.
Current adherence-to-care-process measures may be too insensitive to detect differences in care and to guide improvement. For
instance, 5 years of tamoxifen after surgery for hormone-sensitive
breast cancer has been shown to meaningfully improve survival.
Current quality measurement systems measure the recommendation to begin treatment but do not yet measure patient compliance with the treatment for the full 5 years. To be useful, quality
measurement systems should evolve to more fully measure process
adherence.
Survival is the most important outcome measure in cancer care.
Presence of tumor boards did not influence any of these outcome
measures. Four explicit survival measures were studied by Keating
et al. (1)—all-cause mortality in colon, rectal, small cell lung, and
non–small cell lung cancer. Arguably, chemotherapy within 14 days
of death and intensive care unit admission and emergency department visits within 30 days of death could also be characterized as
outcome measures. Again, outcome measures were not affected by
tumor board presence.
With the exception of perioperative mortality, public reporting
of cancer survival data is problematic. Overcoming both political
and technical limitations is necessary before survival information
can be meaningfully used. Survival data produced by single institutions are loaded with potential bias. Biases that might artificially
inflate survival include differences in cancer screening methods
employed, differences in the underlying health of patients referred
to one center compared with another, differences in the rigor
of staging applied, and differences in the willingness to publicly
release the results (8).
Until there is carefully constructed public reporting of process
adherence and outcome, we are left to hope that cancer doctors,
their leaders, and the systems that they build will use recognized
measures of structure and process and work toward superior outcomes. As the efforts by Keating and colleagues (1) highlight, more
work is needed. We should also expand Donabedian’s (3) construct
of structure, process, and outcome to include a feedback loop.
The Donabedian construct is adequate for quality measures with
a short interval between intervention and outcome (eg, 30-day operative mortality). A fourth measure that incorporates the presence
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and efficacy of feedback may be helpful. Most naturally occurring
biological and physical systems have feedback loops. These loops
can dampen or amplify changes as they move through the system.
The tumor board or team meeting might be a much more powerful tool if its recommendations were actually carried out and if the
reasons why or why not were known. Feedback loops for processes
with a short time constant already exist (eg, chemotherapy dose
adjustments based on toxicity), and we should also incorporate
feedback loops with longer time constants.
Tumor boards have too long a history for them to be easily
abandoned. Much like the “hurry-up” offense changed the conduct of huddles in football, tumor boards should also adapt to the
changing times and technology. In the system studied by Keating
et al. (1), there are only huddles and no feedback loop. Their measurement work provides a reason to change tumor board conduct.
References
1. Keating NL, Landrum MB, Lamont EB, Bozeman SR, Shulman LN,
McNeil BJ. Tumor boards and the quality of cancer care. J Natl Cancer Inst.
2013; doi:10.1093/jnci/djs502.
84
Editorials
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2. Landrum MB, Keating NL, Lamont EB, Bozeman SR, Krasnow SH,
Shulman L, et al. Survival of older patients with cancer in the Veterans
Health Administration versus fee-for-service Medicare. J Clin Oncol.
2012;30(10):1072–1079.
3. Donabedian A. The quality of care. How can it be assessed? JAMA.
1988;260(12):1743–1748.
4. Newman EA, Guest AB, Helvie MA, Roubidoux MA, Chang AE,
Kleer CG, et al. Changes in surgical management resulting from
case review at a breast cancer multidisciplinary tumor board. Cancer.
2006;107(10):2346–2351.
5. Scher KS, Tisnado DM, Rose DE, Adams JL, Ko CY, Malin JL, et al.
Physician and practice characteristics influencing tumor board attendance: results from the provider survey of the Los Angeles Women’s Health
Study. J Oncol Pract. 2011;7(2):103–110.
6. Hazin R, Qaddoumi I. Teleoncology: current and future applications for
improving cancer care globally. Lancet Oncol. 2010;11(2):204–210.
7. Siontis GM, Tzoulaki I, Ioannidis JA. Predicting death: an empirical evaluation of predictive tools for mortality. Arch Intern Med.
2011;171(19):1721–1726.
8. Berry DA. Comparing survival outcomes across centers—biases galore.
Cancer Lett. 2011;37(11):7–10.
Affiliation of author: Stanford Cancer Institute, Stanford School of Medicine,
Stanford, CA (DWB).
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Contact: Zachary Rathner z [email protected] z 301-841-1286
Tumor Boards Linked to Little Association with Effects
on Cancer Care
There is little association of multidisciplinary tumor boards with measures of use, quality, or survival, and measuring
only the presence of tumor boards may not be adequate in determining their effects on cancer care, according to a study
published December 28 in the Journal of the National Cancer Institute.
Tumor board reviews offer a multidisciplinary approach to treatment planning, which encompasses doctors from many
specialties reviewing and discussing the medical condition and the treatment of patients. Even though the use of tumor
boards is widespread, there is little data on how it affects cancer care.
In order to determine the effects tumor boards have on cancer care, Nancy L. Keating, M.D., M.P.H., Department
of Health Care Policy, Harvard Medical School, and colleagues gathered information about tumor boards from 138
Veterans Affairs (VA) medical centers and linked cancer registry and administrative data to gauge receipt of stage-specific
recommended care, survival, or use for patients with colorectal, lung, prostate, hematologic, and breast cancers diagnosed
during 2001–2004 and followed through to 2005.
The researchers found only a modest association between the presence of tumor boards and the types of treatments that
patients received. Most types of care for lung, prostate, hematologic, and breast cancers were unaffected by the presence
or types of tumor boards. For seven measures, the rates of some types of care were higher (lung cancer and prostate
cancer) whereas others were lower (lymphoma and palliative care). “This could mean that tumor boards did not, in fact,
influence quality of cancer care in the VA setting,” the authors write. “Additional research is needed to understand the
structure and format of tumor boards that lead to the highest quality care.”
In an accompanying editorial, Douglas W. Blayney, M.D., Stanford Cancer Institute, Stanford School of Medicine, notes
that tumor boards may not influence quality in a large, integrated health system such as the VA as much as they might in
smaller centers and writes that measures of adherence and survival are difficult to track and therefore while it is tough to
determine the overall efficacy of tumor boards, they “have too long a history for them to be easily abandoned,” adding
that, “until there is carefully constructed public reporting of process adherence and outcome, we are left to hope that
cancer doctors, their leaders, and the systems that they build will use recognized measures of structure and process and
work toward superior outcomes.”
Contact Info:
H Article: Nancy L. Keating, M.D., M.P.H., [email protected]
H Editorial: James Larkin, [email protected]
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NCI Cancer Center News
Little association of multidisciplinary tumor boards
with effects on cancer care
http://www.cancer.gov/newscenter/cancerresearchnews/2012/TumorBoardsCancerCare
There is little association of multidisciplinary tumor boards with measures of use, quality, or survival, and
measuring only the presence of tumor boards may not be adequate in determining their effects on cancer
care, according to a study published Dec. 28 in the Journal of the National Cancer Institute. Tumor board
reviews offer a multidisciplinary approach to treatment planning, which encompasses doctors from many
specialties reviewing and discussing the medical condition and the treatment of patients. Researchers from
the Harvard Medical School (a component of the Dana-Farber Cancer Institute), and colleagues gathered
information about tumor boards from 138 Veterans Affairs (VA) medical centers and linked cancer registry and administrative data to gauge receipt of stage-specific recommended care, survival, or use for patients with colorectal, lung, prostate, hematologic, and breast cancers diagnosed during 2001-2004 and followed through to 2005.
Press release :
Science News
... from universities, journals, and other research organizations
Tumor Boards Linked to Little Association
With Effects On Cancer Care
Dec. 28, 2012 — There is little association of multidisciplinary tumor boards with measures of use, quality, or survival, and measuring only the presence of tumor boards may not be adequate in determining their
effects on cancer care, according to a study published Dec. 28 in the Journal of the National Cancer Institute.
Tumor board reviews offer a multidisciplinary approach to treatment planning, which encompasses doctors from many specialties reviewing and discussing the medical condition and the treatment of patients.
Even though the use of tumor boards is widespread, there is little data on how it affects cancer care.
In order to determine the effects tumor boards have on cancer care, Nancy L. Keating, M.D., M.P.H., Department of Health Care Policy, Harvard Medical School, and colleagues gathered information about tumor boards from 138 Veterans Affairs (VA) medical centers and linked cancer registry and administrative
data to gauge receipt of stage-specific recommended care, survival, or use for patients with colorectal,
lung, prostate, hematologic, and breast cancers diagnosed during 2001-2004 and followed through to
2005.
The researchers found only a modest association between the presence of tumor boards and the types of
treatments that patients received. Most types of care for lung, prostate, hematologic, and breast cancers
Union Nationale Hospitalière Privée de Cancérologie
Documentation à l'usage des adhérents
17 / 17
were unaffected by the presence or types of tumor boards. For seven measures, the rates of some types of
care were higher (lung cancer and prostate cancer) whereas others were lower (lymphoma and palliative
care). "This could mean that tumor boards did not, in fact, influence quality of cancer care in the VA setting," the authors write. "Additional research is needed to understand the structure and format of tumor
boards that lead to the highest quality care."
In an accompanying editorial, Douglas W. Blayney, M.D., Stanford Cancer Institute, Stanford School of
Medicine, notes that tumor boards may not influence quality in a large, integrated health system such as
the VA as much as they might in smaller centers and writes that measures of adherence and survival are
difficult to track and therefore while it is tough to determine the overall efficacy of tumor boards, they
"have too long a history for them to be easily abandoned," adding that, "until there is carefully constructed
public reporting of process adherence and outcome, we are left to hope that cancer doctors, their leaders,
and the systems that they build will use recognized measures of structure and process and work toward superior outcomes."
Story Source:
The above story is reprinted from materials provided by Journal of the National Cancer Institute.
Note: Materials may be edited for content and length. For further information, please contact the source cited above.
Journal References:
N. L. Keating, M. B. Landrum, E. B. Lamont, S. R. Bozeman, L. N. Shulman, B. J. McNeil. Tumor
Boards and the Quality of Cancer Care. JNCI Journal of the National Cancer Institute, 2012; DOI:
10.1093/jnci/djs502
D. W. Blayney. Tumor Boards (Team Huddles) Aren't Enough to Reach the Goal. JNCI Journal of the National Cancer Institute, 2012; DOI: 10.1093/jnci/djs523
Need to cite this story in your essay, paper, or report? Use one of the following formats: Journal of the National Cancer Institute (2012, December 28). Tumor boards linked to little association with effects on cancer care. ScienceDaily. Retrieved January 26, 2013, from http://www.sciencedaily.com- /releases/2012/12/
121228203158.htm
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