'Tumor boards' take team approach to breast cancer
From the October ACP Observer, copyright © 2007 by the American College of Physicians.
By Stacey Butterfield
A recent study has proven the adage that two (or more) heads really are better than one, at least in the case of breast cancer treatment.
In the 2006 study published in the journal Cancer, researchers reviewed the medical records of 149 patients who were seen by a multidisciplinary breast cancer clinic at the University of Michigan.
They found that in more than half the cases, the multidisciplinary review, also known as a tumor board, recommended changes to patients’ surgical treatment plans. The changes most often resulted from reinterpretations of imaging (11%), reinterpretations of pathology (9%) or discussion among specialists (34%).
At Beth Israel Deaconess Medical Center, cancer teams meet twice a week to discuss cases. Comparing ideas are: Abram Recht, MD, Radiation Oncology, Mary Jane Houlihan, MD, Breast Surgery, and Nancy Littlehale, RN, NP, Radiology.
Even in cases that did not appear at all complex, the tumor board’s review frequently resulted in major treatment changes, said study author Michael Sabel, MD, a surgical oncologist at the university.
“In many cases, it seemed like a very straightforward case, but when we reviewed the mammogram, there was another lesion that required a biopsy. In some of those cases, it was another cancer, so that obviously changed things dramatically,” said Dr. Sabel. Tumor boards have become the norm at comprehensive cancer centers and also many smaller hospitals, but this study confirmed the impact of the team method and the need for hospitals and physicians to adopt this approach in the treatment of breast cancer, noted Dr. Sabel.
By conducting the study, “I was trying to convince doctors to do this, more than I was trying to convince patients,” he said.
The physicians at Beth Israel Deaconess Medical Center in Boston are already convinced. There, the breast cancer specialists have been using the multidisciplinary approach for more than 10 years. “I absolutely do think it’s the best way. That’s what cancer care is now,” said Susan Troyan, MD, surgical director of the BreastCare Center at Beth Israel.
Twice a week, a surgeon, a medical oncologist and a radiation oncologist gather to meet with newly diagnosed breast cancer patients. The patients get three specialist visits in a single trip, as well as the psychological reassurance that their physicians agree on a treatment plan.
Once a week, the physicians meet for larger tumor board meetings, which include radiologists, pathologists, as well as additional oncologists, surgeons and other specialists. “You have so many heads in there. You’re getting a bazillion second opinions at once,” said Dr. Troyan.
Multidisciplinary sessions are particularly useful for determining which patients are eligible for neoadjuvant chemotherapy or clinical trials, but all kinds of other issues are often uncovered in the discussions, noted Dr. Troyan.
It was the wide variety of changes suggested by the tumor board that most surprised the Michigan researchers, said Dr. Sabel. “There was no single change that was most common. It was really right across the board. There was no area of the multidisciplinary setting that I could look at the data and say, well, this—for example, the pathology review—isn’t necessary.”
The review of pathology and radiology findings is a crucial aspect of the process and one that sets it apart from the typical second opinion, according to Dr. Sabel. “Often when you go to get a second opinion, that doctor uses the same lab results and radiology results that the first doctor made his opinion from,” he said. “Any time you’re getting a second reading, there’s a chance that something might be picked up that might have been missed.”
The success of the team approach to breast cancer has led to the development at many hospitals of similar programs for other conditions, particularly other forms of cancer. Beth Israel now has multidisciplinary thoracic, cutaneous skin, colorectal and prostate programs.
“I think it’s probably a good idea for anybody with cancer but if you have to limit it, and of course everyone with cancer can’t be seen by a team every time, certainly the most complex cases should always be referred to a multidisciplinary setting. I would hope that the first physician to see the patient would do that,” Dr. Sabel said.
Cost is one reason that not every cancer patient will see a tumor board. The time spent in the multidisciplinary meetings is usually not reimbursed, although many physicians who participate say that the system increases efficiency as well as improves patient care.
At Beth Israel Deaconess, efforts are underway to further ease access to the breast care team for primary care physicians and patients. Appointments for all of the medical center’s breast surgeons are scheduled through a central phone number, and oncology and radiology nurses are working together with primary care physicians so that patients are offered surgical appointments at the time they receive positive biopsy results.
Fortunately, access to this type of multidisciplinary care is no longer limited to urban areas and academic medical centers, noted Dr. Sabel.
“Even a rural hospital could set up a tumor board where the surgeons, medical oncologists and the radiation oncologists could all sit down at least once every two weeks and review a lot of the cases,” he said.
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