Volume 2 - Issue 7
Andrew C. Fenn*
Consultant Radiation Oncologist, Kauvery Hospital, Chennai, India
A multi-disciplinary tumor board (MDT) is a meeting of doctors and other health care professionals from different specialties to help formulate treatment plans for individual patients or to get second opinions on proposed treatment plans .
It is well known that tumor boards improve outcomes for patients. Almost all oncology guideline agencies such as NCCN, ASCO, ASTRO, ESTRO etc., recommend that all patients being planned for cancer treatment be discussed in a MDT. But what is the evidence? We will go through some of it.
Tumour boards have an impact on cancer care. A recent study showed "that the multi-disciplinary approach is the best way to deliver the complex care needed by cancer patients. But however, it was a challenge that requires organizational and cultural changes and must be led by competent health managers" . Freytag et al., did a study to assess whether number of tumour boards per patient improved outcomes. They found that "patients with three or more multidisciplinary tumour board meetings in their history show a significantly better overall survival than patients with no tumor board meeting" . Do tumour boards change treatment? A study by Wheless et al showed that "multi-disciplinary tumor board affects diagnostic and treatment decisions in a significant number of patients with newly diagnosed head and neck tumors. Change in treatment was significantly more common in cases of malignancy, occurring in 24% of patients versus 6% of benign tumors". With the advent of personalized medicine, there is a growing interest in the use of NGS (next generation sequencing) to help target tumour mutations that help in improving outcomes. But interpreting an NGS report can be a challenge to a physician who is not familiar with its nuances. Kato et al., showed that a molecular tumour board improves decision making for patients. They stated that" patients who receive MTB (molecular tumour board) based therapy are better matched to their genomic alterations, and the degree of matching is an independent predictor of improved oncologic outcomes including survival" . Thus, there is enough evidence to support the routine use of tumour boards in oncology practice.
We have a weekly tumour board at our hospital. Cases are added to our list as per preference of individual consultants. We try to discuss all new oncology cases to our hospital. There is a WhatsApp group where case details can be shared. At our tumour board, we involve oncologists - radiation, medical and surgical; radiologists, pathologists, nuclear medicine specialists and other specialties as the need arises. Case lists from our sister hospital at Trichy are also discussed. A typical case capsule would include a short history, relevant lab, endoscopy, PET CT and biopsy reports. If it's a case treated at another centre, details of previous treatment are presented to the level that is known. This is followed by relevant imaging or pathology discussion. After this, a short discussion among the clinical consultants is done and concurrence for the final plan is obtained. In case of areas where no opinion or consensus is obtained, treatment plans are suggested and therapy decisions are left to the discretion of the treating consultant. After the meeting, a decision list is shared for each patient. If there are clarifications or changes, it is made at that time.
I would like to discuss two patients who were recently discussed that demonstrate the utility of the tumour board
(1) A 78-year-old man with metastatic carcinoma prostate, who was initially diagnosed to have locally advanced disease (2015), underwent radiotherapy to the pelvis as well as orchidectomy at diagnosis (reasons not clear). His history was significant for radiation proctitis in 2017, requiring a colostomy which was closed later. He was recently found to have progressive/metastatic disease and started on second line hormonal therapy. He was brought to tumour board to discuss option of radiotherapy with palliative intent to a large para aortic node (Fig. 1). Due to its size, the decision was to defer radiotherapy in favour of hormonal therapy, considering the possibility of increased bowel toxicity due to radiotherapy.
Fig 1. Large para aortic nodal mass infiltrating right ureter and indenting/infiltrating the right kidney in a 78-year-old man with metastatic prostatic cancer.
(2) A 52-year-old female, presented with post-menopausal bleeding per vaginum for 3 months. She was evaluated and found to have a uterine cervical growth, biopsy of which was positive for squamous cell carcinoma - grade II. Clinical examination revealed a bulky cervical growth involving bilateral fornices and upper vagina as well as bilateral parametrium upto pelvic side wall. Rectal mucosa was free. PET CT/MRI showed locally advanced disease with bilateral iliac, para aortic and left supraclavicular lymph node metastasis. There was no visceral metastasis. She was planned for palliative chemotherapy with additional of local radiotherapy to the pelvis and para aortic regions after 3-4 cycles. Interim PET CT after 4 cycles showed good response in the primary and reduction in the size and activity of lymph nodes. She completed external beam radiotherapy (EBRT) to the pelvis and para aortic nodes and was being planned for brachytherapy boost. But due to patient/technical delays, brachytherapy/EBRT boost was not done at that time, and chemotherapy was continued. PET CT after 6 cycles (done 3 months after completion of radiotherapy) of chemotherapy showed complete response in the primary, with increase in activity in the left supraclavicular lymph node (Fig. 2). She was planned for EBRT boost to the pelvis and palliative radiotherapy to the left supraclavicular area. She was brought to tumour board for concurrence, where during discussion, it was opined that the value of adding EBRT boost 3 months' post completion of radiotherapy, may not be beneficial (to discuss the option of boost with the patient - EBRT Vs Brachytherapy boost Vs Observation) and to proceed with left supraclavicular radiotherapy and further systemic therapy. So, in this way, a treatment of questionable benefit was re discussed with the patient. The patient opted to not have boost radiotherapy to the pelvis and only supraclavicular radiotherapy was given.
Fig. 2. Whole body PET showing increased activity in the left supraclavicular lymph node (April 2021, after completion of 6 cycles of chemotherapy, EBRT to the Pelvis and Para aortic areas) as compared to the PET done earlier (Jan 2021, after completion of 4 cycles of chemotherapy) in a 52-year-old lady with carcinoma cervix stage 4.
We hope to discuss cases such as these in the future and give regular updates on the progress of the tumour board.
MDT has the potential to revolutionize cancer care, bringing the best care to our patients. We look forward to having more case discussions and also more of our sister institutions to join in the discussions, as well as share cases. We should strive to make MDT's as the avenue to discuss patient treatment plans, thus gifting our patients, the best possible course of action and this will surely help to improve outcomes; which is what we all strive to achieve.
I would like to thank all my seniors, colleagues and juniors who share cases for discussions, help prepare slides for presentation and participate in the discussions from oncology specialties, pathology, radiology and other specialties from Chennai as well as from Trichy.
I would like to thank our operations and IT team for making the arrangements for virtual as well as in person meeting.
I would like to thank the administration at Kauvery hospital for extending their support to tumour board meetings
Dr. Andrew C Fenn
Consultant Radiation Oncologist