FOCUS ON RARE TUMORS
Rare cancers often require multimodal therapy. A few rare cancer types (Merkel-cell carcinoma, sarcoma, and HCC) require multidisciplinary management to offer the best treatment choice. On top of being discussed in MTBs, these cases should be referred to high-volume centres to tailor the best treatment strategy for each patient.57––61
A multidisciplinary approach certainly provides benefits in cancer patient management, mostly resulting from the sharing of decision-making processes in diagnostic and therapeutic settings. However, various aspects of the multidisciplinary approach might affect the applicability of MTBs in clinical practice, especially in suboptimal settings. These potential limitations still represent the subject of notable controversies and current debates.
In this systematic review, ten of the papers selected identified serious limitations regarding the multidisciplinary approach in cancer patients.24,28,30,32,44,60,62–65 Among these, the role of MTBs in patient outcomes might deserve special attention, and remains a matter of debate. In this regard, Brauer et al reviewed 470 cases of patients with benign and malignant pancreatic and gastrointestinal diseases that had led to MTB discussion and been recorded in a prospectively collected database. Despite strong adherence to NCCN guidelines, multidisciplinary discussion produced a change in patient management in a minority (about a quarter) of cases. Nevertheless, survival time was no different between these cases and patients without any variation in plan, suggesting that MTB discussion might not have a significant impact on outcome.28 In the same paper, the authors also focused on institutional resource utilization for MTBs, estimating total time expenditure of 16.5 hours and a cost of US$2,035 weekly.28 On the basis of these not-negligible expenses, MTBs should be available only in those settings where justified by a high number of cases that require critical decisions, and regular assessment of their effectiveness should be performed.
Another potential limitation of the multidisciplinary approach concerns the quality of the information presented to MTBs that might play a crucial role in team decision-making. Through a cross-sectional, observational study conducted at University Cancer Center Hamburg, a German hospital hosting 16 MTBs, Hahlweg et al evaluated the quality of single-case information using a scoring system with six main variables. Despite high variability among the 16 examined MTBs, data concerning comorbidities and psychosocial context were almost always missing or superficially presented, affecting teams’ final decisions and recommendations.62 Furthermore, low-quality information presented might render the MTB unable to make a decision, especially when there is a lack of fundamental reporting (ie, imaging performed at external centers), as deduced from an analysis of 68 consecutive cases presented at the Lung Oncology MTB of Peter MacCallum Cancer Centre (Melbourne, Australia) between March and May 2011. In three of 68 patients, inadequacy of administrative support in quickly finding missing information significantly reduced the effectiveness of a multidisciplinary approach.63 Lamb et al achieved similar results in their prospective longitudinal study evaluating the quality of decision-making processes in 1,421 urological cancer patients presented to MTBs of Whipps Cross University Hospital (London, UK) over 2 years (from 2009 to 2011). Despite significant growth in teamwork quality and effectiveness due to improvement interventions, lacking anamnestic, radiological, or pathological information still represented obstacles to reaching clinical decisions.32 On the other hand, an excessive amount of not strictly clinical information might lead to team members expressing contrasting opinions and the MTB producing more than one recommendation.63
Another potential limitation of the multidisciplinary approach is related to legal issues. MTBs represent an instrument of peer review for cancer patients. Due to the confidential nature of the relationship between patient and their physician, it might be not so simple to maintain the same confidentiality within an MTB. Already in 1987, Gross et al analyzed the prickly question of legal issues related to tumor boards, focusing on team members’ responsibilities in confidentiality and anonymity of every patient presented to an MTB.24
Furthermore, geographical barriers might represent concrete impediments to achieving an effective multidisciplinary approach in oncology settings. Regarding extra-European regions, MTBs still do not represent a common reality in Africa or the Middle East. A consensus of 22 urologists and oncologists from these areas firstly met in Quatar (February 2012) and then in Dubai (March 2013) to discuss local management of renal cell–carcinoma patients, frequently in the absence of an MTB. Zekri et al wrote a report on the consensus of opinion reached, identifying the main barriers to the multidisciplinary approach and interdisciplinary referral as financial issues, patients’ social conditions, and deficiency of surgeons.64
Geographical origin and socioeconomic conditions might limit accessibility to national networks and MTBs, even in European countries, with significant urban–rural inequalities, especially in the field of rare cancers. As reported in a recent paper by Lowes et al, MTBs are not yet widespread, despite national guidelines recommending a multidisciplinary approach in the majority of neoplasms, representing a real cornerstone in modern oncology.44 Fayet et al evaluated efforts of French sarcoma networks in reducing geographical disparities that still affect cancer patients.65 Despite centralization representing an essential requirement in rare cancer management, with a significant correlation with prognosis, Sandrucci et al focused on its disadvantages for patients, as the obligation to move to referral centers caused notable discomfort.60
Finally, a multidisciplinary approach might be associated with treatment delays due to MTB-meeting schedules and frequently longer waiting lists in referral centers. Basse et al wrote a retrospective analysis of 274 patients with thymic epithelial tumors discussed at the national RYTHMIC MTB focusing on postoperative radiotherapy. Despite MTB recommendations, several patients did not receive treatment, mostly due to excessive delays after surgery, suggesting that MTB decisions should be quicker, avoiding any waste of time30 (Table 1).
It has been said that humans make decisions by taking into account five variables at most. The increasing complexity in management of cancer patients has led to the development of computer systems that can help clinicians in choosing the most adequate diagnostic and therapeutic approach. In this context, Walsh et al provided a synopsis of decision-support systems: computer programs integrating all possible data, such as clinical history, imaging, genetics, and costs, to obtain validated predictive models and realize precision medicine.66
Somashekhar et al’s paper was based on the use of AI as a possible new approach to consider in multidisciplinary cancer patients care, too. They compared therapeutic choices made in a breast MTB of an expert panel of specialists in Bangalore, India to that suggested by IBM’s WFO. WFO is a unique system for oncology-therapy selection, deriving most of its knowledge from literature, protocols, and test cases from Memorial Sloan Kettering Cancer Center. The authors found a high level of agreement — up to 93%. According to stage, concordance was higher in stage II and III cancers. Including receptor status, final choices in triple-negative metastatic breast cancer patients showed less agreement than nonmetastatic HER2-positive cases. Different choices were adopted for patients aged 75 years older also. Nonconcordance could have derived from different drug availability in India and the US and differences in demographic characteristics, such as patient choice, comorbidities, and presence of caregivers. This study demonstrated how AI can help clinicians’ decisions in breast cancer treatment, notably if expert opinions are not easily achievable.31
Krupinski et al provided an overview of the use of a software platform — Navify Tumor Board — helping specialists improve workflow and preparation for MTBs. The authors reported on the experience of the breast cancer multidisciplinary team in Hospital del Mar, Barcelona. Navify is an oncology-informatics platform facilitating the coordination, preparation, scheduling, presentation, and extraction of clinical, biological, radiological, and other significant information during preparation of patient cases. Oncologists, surgeons, radiologists, and pathologists took part in this survey, revealing that using health-information technology can reduce time to provide recommendations for cases compared to current methods, rather pathologists take the same time. Moreover, it is undoubtedly a way of standardizing the presentation of cancer cases to be discussed in a multidisciplinary context.67
Finally, Gallagher et al proposed the realization of a clinical database to improve patient care and research, describing all phases requested in constituting the Genitourinary Oncology Database, created by the University of North Carolina. This project needed attention by all members of the MTB, accounting for their personal experience and reviewing literature. Indeed, there were several critical features, such as the security policy for patient data and reducing errors, in insertion of baselines and updating them. The authors hoped that their experience could mark the way for similar skills.68
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