Tumor Boards May Not Really Impact Cancer Care (CME/CE)

By?Crystal Phend, Senior Staff Writer, MedPage Today

Published: December 29, 2012

Reviewed?by?Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco

Cancer treatment plans by multidisciplinary teams, or tumor boards, may not improve care or outcomes, an analysis of Veterans Affairs' data suggested.

Only one out of 27 measures of use, quality, and survival showed any significant advantage to tumor boards after adjustment for multiple comparisons, Nancy L. Keating, MD, MPH, of Harvard and the Brigham and Women's Hospital in Boston, and colleagues found.

Several measures of recommended care actually went in the wrong direction with cancer-specific tumor boards, such as lower use of white blood cell growth factors with cyclophosphamide, adriamycin, vincristine, and prednisone (CHOP) in diffuse large B-cell non-Hodgkin lymphoma, they reported online in the Journal of the National Cancer Institute.

While these group meetings are designed to better coordinate care among specialists and ultimately improve its quality, it's possible they just don't help, the group noted.

But "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," they wrote.

That should come as no surprise to anyone who has ever been part of a team huddle, agreed Douglas Blayney, MD, of the Stanford Cancer Institute in Stanford, Calif., agreed in an accompanying editorial.

"Execution of the plan is how we get to good outcomes regardless of the brilliance of the plan, the talent of the team, or the difficulty of the task," he wrote.

Although the study's results are disappointing, tumor boards have too long a history for them to go away, Blayney noted.

Instead, he suggested giving the boards feedback if their recommendations were followed, and why or why not, as a tool to improve them.

The researchers surveyed VA medical centers on their use of tumor boards and linked the answers to cancer registry and administrative data for patients with colorectal, lung, prostate, hematologic, and breast cancers diagnosed from 2001 to 2004 and followed through 2005.

Three-quarters of the centers (103 of 138) said they had at least one tumor board.

Of the 41% that had multiple tumor boards, all had one for lung cancer specifically, 95% had one for colorectal cancer, and 83% had a prostate cancer-specific tumor board (83%).

These boards almost always included medical oncologists, pathologists, and surgeons. Other participants were radiation oncologists (81%), radiologists (76%), social workers (31%), palliative care specialists (31%), and nutritionists (21%).

In the unadjusted analyses, seven of the 27 measures of care assessed were significantly linked to the presence of any tumor board:

• Stage I/II lung cancer not treated with curative surgery was more likely to get radiation if treated at a general tumor board compared with no tumor board or a lung cancer-specific tumor board.
• Stage IIIA lung cancer not treated surgically was more likely to get chemotherapy and radiation at centers with a general tumor board or a lung cancer?specific tumor board versus no tumor board.
• Limited-stage small-cell lung cancer was more likely to receive chemotherapy and radiation at centers with a general tumor board or a lung cancer-specific tumor board versus none.
• Metastatic prostate cancer was more likely to be treated with an oral antiandrogen before gonadotropin-releasing hormone agonist therapy if seen at a center with a prostate cancer-specific or general tumor board versus none.
• Non-Hodgkin lymphoma was more likely to be treated with the CHOP chemotherapy at centers with no tumor board, or with a hematologic cancer-specific tumor board, versus one with a general tumor board.
• CHOP chemotherapy was more likely to be given with white blood cell growth factor support at centers with a general tumor board or no tumor board versus with a hematologic cancer-specific tumor board.
• More than one emergency visit in the last 30 days of life was more likely without any tumor board, or with a tumor board that had a palliative care specialist, versus with a tumor board without a palliative specialist.

After multivariate adjustment for patient sociodemographic and clinical characteristics, the only significant association was that limited-stage small-cell lung cancer patients seen at VA centers with a general or a lung cancer-specific tumor board were still more likely to be treated with chemotherapy and radiation than when seen at centers without any tumor board (P<0.00185).

A possible explanation is that information about some types of recommended care are widely enough known without tumor boards, particularly in an integrated delivery system where care may be better coordinated than in other settings, Keating's group suggested.

Study limitations were a lack of data on format or frequency of tumor board meetings and whether the individual patients whose outcomes were analyzed were discussed by the tumor boards.

The analysis was funded by the Department of Veterans Affairs through the Office of Policy and Planning.

The study authors and Blayney provided no information on conflicts of interest.

Primary source: Journal of the National Cancer Institute
Source reference:
Keating NL, et al "Tumor boards and the quality of cancer care" J Natl Cancer Inst 2013.

Additional source: Journal of the National Cancer Institute
Source reference:
Blayney DW, et al "Tumor boards (team Huddles) aren't enough to reach the goal" J Natl Cancer Inst 2013.

Source: http://www.medpagetoday.com/HospitalBasedMedicine/GeneralHospitalPractice/36663

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