in Supplementary Table 4, available online (1)]. Briefly, we observed that our estimates for cancer risks after endometrial cancer were not substantially different from those for women without a previous diagnosis of endometrial cancer given the high degree of overlap in the confidence intervals—that is, we could not provide evidence that cancer risks for women with Lynch syndrome and history of endometrial cancer are higher than for women with Lynch syndrome but no history of endometrial cancer. Aung Ko Win Mark A. Jenkins
References
Funding AKW is supported by the Picchi Brothers Foundation Cancer Council Victoria Cancer Research Scholarship, Australia. MAJ is a National Health and Medical Research Council Senior Research Fellow.
Note The authors declare no conflict of interest. Affiliations of authors: Centre for Molecular, Environmental, Genetic and Analytic Epidemiology, The University of Melbourne, Parkville, Victoria, Australia. Correspondence to: Mark Jenkins, PhD, Centre for Molecular, Environmental, Genetic and Analytic Epidemiology, Melbourne School of Population and Global Health, Level 3, 207 Bouverie St, The University of Melbourne, VIC 3010 Australia (e-mail: [email protected]). DOI:10.1093/jnci/djt308 Advance Access publication October 29, 2013 ©The Author 2013. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: [email protected].
Re: Tumor Boards and the Quality of Cancer Care In a recent issue of the Journal, Keating et al. (1) examined the effect of tumor board (TB) meetings in the Veteran Affairs (VA) health system on a number 1838 Correspondence | JNCI
investigators need to fully understand the functioning, processes, and envisaged outcomes. Measurement of quality needs to include not only conventional health outcomes but also the indirect effects of the complex intervention, the processes involved, and cost effectiveness (6). We welcome the authors’ examination of TBs and agree that further research into measuring their effects using a broad range of quality parameters is warranted. Given the ubiquitous nature of TBs, it is unlikely randomized prospective studies can be conducted. Lessons can be learned; in the future, let us not miss the opportunity to design rigorous studies to evaluate complex health interventions prospectively. Bianca Devitt Jennifer Philip Sue-Anne McLachlan
References 1. Keating NL, Landrum MB, Lamont EB, et al. Tumor boards and the quality of cancer care. J Natl Cancer Inst. 2013;105(2):113–121. 2. Kesson EM, Allardice GM, George WD, et al. Effects of multidisciplinary team working on breast cancer survival: retrospective, comparative, interventional cohort study of 13 722 women. BMJ. 2012 April 26;344:e2718. 3. National Breast and Ovarian Cancer Centre. Multidisciplinary meetings for cancer care: a guide for health service providers. http://canceraustralia.gov.au/publications-resources/ cancer-australia-publications/multidisciplinarymeetings-cancer-care. Accessed January 18, 2013. 4. Wright FC, De Vito C, Langer B, et al. Multidisciplinary cancer conferences: a systematic review and development of practice standards. Eur J Cancer. 2007;43(6):1002–1010. 5. Devitt B, Philip J, McLachlan SA. Team dynamics, decision making, and attitudes toward multidisciplinary cancer meetings: health professionals' perspectives. J Oncol Pract. 2010;6(6):e17–e20. 6. Craig P, Dieppe P, Macintyre S, et al. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008 September 29;337:a1655. Affiliations of authors: Department of Oncology (BD) (SAM) and Centre for Palliative Care & Palliative Care Service (JP), St. Vincent’s Hospital, Fitzroy, Australia. University of Melbourne (BD, JP, SAM), Melbourne Australia. Correspondence to: Bianca Devitt, MBBS, FRACP, St Vincent's Hospital, Department of Oncology, PO box 2900, Fitzroy, Victoria 3065, Australia, 61392883155 (e-mail: [email protected]). DOI:10.1093/jnci/djt311 Advance Access publication November 1, 2013 ©The Author 2013. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: [email protected].
Vol. 105, Issue 23 | December 4, 2013
Downloaded from http://jnci.oxfordjournals.org/ at NERL on June 28, 2015
1. Win AK, Lindor NM, Winship I, et al. Risks of colorectal and other cancers after endometrial cancer for women with Lynch syndrome. J Natl Cancer Inst. 2013;105(4):274–279. 2. Win AK, Dowty JG, Antill YC, et al. Body mass index in early adulthood and endometrial cancer risk for mismatch repair gene mutation carriers. Obstet Gynecol. 2011;117(4):899–905. 3. Win AK, Young JP, Lindor NM, et al. Colorectal and other cancer risks for carriers and noncarriers from families with a DNA mismatch repair gene mutation: a prospective cohort study. J Clin Oncol. 2012;30(9):958–964.
of quality cancer measures extrapolated from national guidelines. They found little evidence that tumor boards positively improve quality of care or survival. We, however, believe this study may have underrepresented the benefits of TBs for a number of reasons. First, although we agree there is a lack of empirical evidence to support TB influence on quality measures such as overall survival, the authors did not note the recently published article by Kesson et al. (2). In that retrospective study of more than 13 000 women with breast cancer, the implementation of multidisciplinary cancer care, including TB discussion, was associated with an 18% reduction in breast cancer mortality compared with control areas. Although this is indirect evidence to support TBs, the results are compelling. Second, it is difficult to ascertain the proportion of the sample discussed at TBs given that Keating et al. did not report on this (1). If only a small proportion of patients were discussed, the results do not represent standard of care as outlined in Australian and Ontario guidelines, which advocate that all patients with a new diagnosis of cancer have their treatment managed through a TB (3,4). Consequently, the results may underestimate benefits of TB discussion. Third, although there was no reported interaction between the results and patient comorbidities, gains in the reported quality measures are difficult to show if patients are unable to receive potentially life-prolonging treatments. More than 50% of patients diagnosed with stage IV lung cancer did not receive palliative chemotherapy, and 39% (1) of patients with early-stage lung cancer did not undergo surgical resection, presumably because they were unfit or chose not to do so. Finally, the benefits of TBs may not be adequately captured through gross quality measures. TBs allow treating clinicians to tailor evidence-based guidelines to the individual patient discussed. Health outcomes are indirectly affected through decreased investigations and referrals to other specialists when it will not alter management. The indirect effects of TBs, such as improvements in efficiency, education, professional relationships, and the benefit of peer review, also cannot be underestimated (5). The implementation of TBs is a complex health intervention. Before evaluating the quality of such interventions,
References
Funding AKW is supported by the Picchi Brothers Foundation Cancer Council Victoria Cancer Research Scholarship, Australia. MAJ is a National Health and Medical Research Council Senior Research Fellow.
Note The authors declare no conflict of interest. Affiliations of authors: Centre for Molecular, Environmental, Genetic and Analytic Epidemiology, The University of Melbourne, Parkville, Victoria, Australia. Correspondence to: Mark Jenkins, PhD, Centre for Molecular, Environmental, Genetic and Analytic Epidemiology, Melbourne School of Population and Global Health, Level 3, 207 Bouverie St, The University of Melbourne, VIC 3010 Australia (e-mail: [email protected]). DOI:10.1093/jnci/djt308 Advance Access publication October 29, 2013 ©The Author 2013. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: [email protected].
Re: Tumor Boards and the Quality of Cancer Care In a recent issue of the Journal, Keating et al. (1) examined the effect of tumor board (TB) meetings in the Veteran Affairs (VA) health system on a number 1838 Correspondence | JNCI
investigators need to fully understand the functioning, processes, and envisaged outcomes. Measurement of quality needs to include not only conventional health outcomes but also the indirect effects of the complex intervention, the processes involved, and cost effectiveness (6). We welcome the authors’ examination of TBs and agree that further research into measuring their effects using a broad range of quality parameters is warranted. Given the ubiquitous nature of TBs, it is unlikely randomized prospective studies can be conducted. Lessons can be learned; in the future, let us not miss the opportunity to design rigorous studies to evaluate complex health interventions prospectively. Bianca Devitt Jennifer Philip Sue-Anne McLachlan
References 1. Keating NL, Landrum MB, Lamont EB, et al. Tumor boards and the quality of cancer care. J Natl Cancer Inst. 2013;105(2):113–121. 2. Kesson EM, Allardice GM, George WD, et al. Effects of multidisciplinary team working on breast cancer survival: retrospective, comparative, interventional cohort study of 13 722 women. BMJ. 2012 April 26;344:e2718. 3. National Breast and Ovarian Cancer Centre. Multidisciplinary meetings for cancer care: a guide for health service providers. http://canceraustralia.gov.au/publications-resources/ cancer-australia-publications/multidisciplinarymeetings-cancer-care. Accessed January 18, 2013. 4. Wright FC, De Vito C, Langer B, et al. Multidisciplinary cancer conferences: a systematic review and development of practice standards. Eur J Cancer. 2007;43(6):1002–1010. 5. Devitt B, Philip J, McLachlan SA. Team dynamics, decision making, and attitudes toward multidisciplinary cancer meetings: health professionals' perspectives. J Oncol Pract. 2010;6(6):e17–e20. 6. Craig P, Dieppe P, Macintyre S, et al. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008 September 29;337:a1655. Affiliations of authors: Department of Oncology (BD) (SAM) and Centre for Palliative Care & Palliative Care Service (JP), St. Vincent’s Hospital, Fitzroy, Australia. University of Melbourne (BD, JP, SAM), Melbourne Australia. Correspondence to: Bianca Devitt, MBBS, FRACP, St Vincent's Hospital, Department of Oncology, PO box 2900, Fitzroy, Victoria 3065, Australia, 61392883155 (e-mail: [email protected]). DOI:10.1093/jnci/djt311 Advance Access publication November 1, 2013 ©The Author 2013. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: [email protected].
Vol. 105, Issue 23 | December 4, 2013
Downloaded from http://jnci.oxfordjournals.org/ at NERL on June 28, 2015
1. Win AK, Lindor NM, Winship I, et al. Risks of colorectal and other cancers after endometrial cancer for women with Lynch syndrome. J Natl Cancer Inst. 2013;105(4):274–279. 2. Win AK, Dowty JG, Antill YC, et al. Body mass index in early adulthood and endometrial cancer risk for mismatch repair gene mutation carriers. Obstet Gynecol. 2011;117(4):899–905. 3. Win AK, Young JP, Lindor NM, et al. Colorectal and other cancer risks for carriers and noncarriers from families with a DNA mismatch repair gene mutation: a prospective cohort study. J Clin Oncol. 2012;30(9):958–964.
of quality cancer measures extrapolated from national guidelines. They found little evidence that tumor boards positively improve quality of care or survival. We, however, believe this study may have underrepresented the benefits of TBs for a number of reasons. First, although we agree there is a lack of empirical evidence to support TB influence on quality measures such as overall survival, the authors did not note the recently published article by Kesson et al. (2). In that retrospective study of more than 13 000 women with breast cancer, the implementation of multidisciplinary cancer care, including TB discussion, was associated with an 18% reduction in breast cancer mortality compared with control areas. Although this is indirect evidence to support TBs, the results are compelling. Second, it is difficult to ascertain the proportion of the sample discussed at TBs given that Keating et al. did not report on this (1). If only a small proportion of patients were discussed, the results do not represent standard of care as outlined in Australian and Ontario guidelines, which advocate that all patients with a new diagnosis of cancer have their treatment managed through a TB (3,4). Consequently, the results may underestimate benefits of TB discussion. Third, although there was no reported interaction between the results and patient comorbidities, gains in the reported quality measures are difficult to show if patients are unable to receive potentially life-prolonging treatments. More than 50% of patients diagnosed with stage IV lung cancer did not receive palliative chemotherapy, and 39% (1) of patients with early-stage lung cancer did not undergo surgical resection, presumably because they were unfit or chose not to do so. Finally, the benefits of TBs may not be adequately captured through gross quality measures. TBs allow treating clinicians to tailor evidence-based guidelines to the individual patient discussed. Health outcomes are indirectly affected through decreased investigations and referrals to other specialists when it will not alter management. The indirect effects of TBs, such as improvements in efficiency, education, professional relationships, and the benefit of peer review, also cannot be underestimated (5). The implementation of TBs is a complex health intervention. Before evaluating the quality of such interventions,
