Re: Tumor Boards and the Quality of Cancer Care
jnci.oxfordjournals.org
Nagi S. El Saghir Hussein A. Assi Katia E. Khoury AHMAD M. EL zawawy Jaber A. Abbas Toufic A. Eid
References 1. Keating NL, Landrum MB, Lamont EB, Bozeman SR, Shulman LN, McNeil BJ. Tumor boards and the quality of cancer care. J Natl Cancer Inst. 2013;105(2): 113–121. 2. Blayney DW. Tumor boards (team huddles) aren’t enough to reach the goal. J Natl Cancer Inst. 2013;105(2):82–84. 3. Mulcahy N. Are tumor boards a waste of time? Medscape. http://www.medscape.com/ viewarticle/776833. Accessed February 17, 2013. 4. Chang JH, Vines E, Bertsch H, et al. The impact of a multidisciplinary breast cancer center on recommendations for patient management: the University of Pennsylvania experience. Cancer. 2001;91(7):1231–1237. 5. Newman EA, Guest AB, Helvie MA, et al. Changes in surgical management resulting from case review at a breast cancer multidisciplinary tumor board. Cancer. 2006;107(10): 2346–2351. 6. Cohen P, Tan AL, Penman A. The multidisciplinary tumor conference in gynecologic oncology–does it alter management? Int J Gynecol Cancer. 2009;19(9):1470–1472.
7. El Saghir NS, Adebamowo CA, Anderson BO, et al. Breast cancer management in low resource countries (LRCs): consensus statement from the Breast Health Global Initiative. Breast. 2011;20(Suppl 2):S3–S11. 8. El Saghir NS, El-Asmar N, Hajj C, et al. Survey of utilization of multidisciplinary management tumor boards in Arab countries. Breast. 2011;20(Suppl 2):S70–S74. Affiliations of authors: Breast Center of Excellence (NSES, HAA, KEK), Department of Internal Medicine (NSES, HAA, KEK), Naef K. Basile Cancer Institute (NSES, HAA, KEK, TE), Department of General Surgery (JAA), and Department of Radiation Oncology (TAE), American University of Beirut Medical Center, Beirut, Lebanon; Clinical Oncology Department, Faculty of Medicine, Suez Canal University, Port Said, Egypt (AME). Correspondence to: Nagi S. El Saghir, MD, FACP, Professor of Clinical Medicine/HematologyOncology, Director, Breast Center of Excellence, Naef K. Basile Cancer Institute, American University of Beirut Medical Center, PO Box: 11–0236, Riad El Solh 1107 2020, Beirut, Lebanon (e-mail: [email protected]). DOI:10.1093/jnci/djt312 Advance Access publication November 1, 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 The article by Keating et al. (1) in a recent issue of the Journal concludes that tumor boards were not associated with higher rates of recommended stage-specific cancer care, survival, or care. We disagree. The study has substantial shortcomings in its design and execution, which do not allow the study’s conclusions to be supported. The survey was completed 28% of the time by a “chief of staff” who may have little knowledge of the structure of their facility’s tumor conferences. Similarly, surveys asking about the tumor board structure over the previous 5 years are highly susceptible to recall error. The authors also failed to categorize tumor boards as prospective or retrospective, to define the percentage of newly diagnosed cancer patients presented, and to specify what each facility’s conference frequency was during the study period. The latter two variables are obvious in their potential to introduce error, allowing JNCI | Correspondence 1839
Downloaded from http://jnci.oxfordjournals.org/ at Robertson Library University of prince Edward Island on July 19, 2015
In a survey of Veterans Affairs tumor boards (TBs) published in a recent issue of the Journal, Keating et al. concluded that multidisciplinary TBs had little association with measures of use, quality, or survival (1). In an accompanying editorial, Douglas Blayney stated that it should be no surprise that improved performance on the process or outcome measures of quality is not predicted by the existence of team meetings, and he added that TBs have too long a history to be abandoned (2). Both the article and editorial raised lots of eyebrows, and a comment at Medscape was even entitled “Are Tumor Boards a Waste of Time?” (3). The authors looked at measures of quality care for patients with lung, colorectal, prostate, or hematological cancers but did not include breast cancer because of a small numbers of cases. The absence of a group of breast cancer patients is a major limitation of this survey. Multidisciplinary management breast units and/or TBs are essential components for management of patients with breast cancer worldwide. Changes in 43% and 52% of diagnoses and/or surgical breast management at TBs have been documented (4,5). Important changes in chemotherapy and surgical management have been reported in gynecological cancer TBs (6). On another important note, limitations in diagnosis and management in suboptimal settings, such as those encountered in rural and low resource areas, can be improved at TBs. TB meetings can serve as an educational tool to make more optimal decisions and provide large benefits for management of patients in low- and middle-income countries (7). A survey of 338 practicing oncologists from various Arab countries showed that 60% of them attend TBs to seek group opinion and help in the management of their patients (8). Furthermore, almost all of them agreed that in the absence of experts from all disciplines, a mini-TB should be organized with whichever specialist is available (8). TBs can provide an opportunity for help in patient management and continuing education. TBs are a form of group second-opinion that includes case review, evidence-based recommendations, and expert opinions. Because
there can be no clinical trial for every particular patient’s condition, such group multidisciplinary opinions provide timely help for better oncology care. Every medical oncologist, surgeon, and radiation oncologist who takes care of cancer patients knows that many times he/she gets help in diagnostic and treatment plans from multidisciplinary TB group discussions. Benefit from TBs depends on the presence of qualified and effective faculty, as well as on the format of the meeting and efficient interactions among physicians present. Unlike clinical trials and evidencebased medicine, measurement of impact of expert opinion on progression-free survival, disease-free survival, and overall survival may be very difficult, if not impossible. We agree with the authors and the editorialist that TBs should not be thrown away and that we need more studies of structure and format that will lead to the highest quality care. Results of their survey may not apply to breast cancer patients. Multidisciplinary management improves the care of cancer patients, and tumor boards are definitely not a waste of time. Moreover, they are a necessity, not a luxury, in areas with limited resources.
jnci.oxfordjournals.org
Nagi S. El Saghir Hussein A. Assi Katia E. Khoury AHMAD M. EL zawawy Jaber A. Abbas Toufic A. Eid
References 1. Keating NL, Landrum MB, Lamont EB, Bozeman SR, Shulman LN, McNeil BJ. Tumor boards and the quality of cancer care. J Natl Cancer Inst. 2013;105(2): 113–121. 2. Blayney DW. Tumor boards (team huddles) aren’t enough to reach the goal. J Natl Cancer Inst. 2013;105(2):82–84. 3. Mulcahy N. Are tumor boards a waste of time? Medscape. http://www.medscape.com/ viewarticle/776833. Accessed February 17, 2013. 4. Chang JH, Vines E, Bertsch H, et al. The impact of a multidisciplinary breast cancer center on recommendations for patient management: the University of Pennsylvania experience. Cancer. 2001;91(7):1231–1237. 5. Newman EA, Guest AB, Helvie MA, et al. Changes in surgical management resulting from case review at a breast cancer multidisciplinary tumor board. Cancer. 2006;107(10): 2346–2351. 6. Cohen P, Tan AL, Penman A. The multidisciplinary tumor conference in gynecologic oncology–does it alter management? Int J Gynecol Cancer. 2009;19(9):1470–1472.
7. El Saghir NS, Adebamowo CA, Anderson BO, et al. Breast cancer management in low resource countries (LRCs): consensus statement from the Breast Health Global Initiative. Breast. 2011;20(Suppl 2):S3–S11. 8. El Saghir NS, El-Asmar N, Hajj C, et al. Survey of utilization of multidisciplinary management tumor boards in Arab countries. Breast. 2011;20(Suppl 2):S70–S74. Affiliations of authors: Breast Center of Excellence (NSES, HAA, KEK), Department of Internal Medicine (NSES, HAA, KEK), Naef K. Basile Cancer Institute (NSES, HAA, KEK, TE), Department of General Surgery (JAA), and Department of Radiation Oncology (TAE), American University of Beirut Medical Center, Beirut, Lebanon; Clinical Oncology Department, Faculty of Medicine, Suez Canal University, Port Said, Egypt (AME). Correspondence to: Nagi S. El Saghir, MD, FACP, Professor of Clinical Medicine/HematologyOncology, Director, Breast Center of Excellence, Naef K. Basile Cancer Institute, American University of Beirut Medical Center, PO Box: 11–0236, Riad El Solh 1107 2020, Beirut, Lebanon (e-mail: [email protected]). DOI:10.1093/jnci/djt312 Advance Access publication November 1, 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 The article by Keating et al. (1) in a recent issue of the Journal concludes that tumor boards were not associated with higher rates of recommended stage-specific cancer care, survival, or care. We disagree. The study has substantial shortcomings in its design and execution, which do not allow the study’s conclusions to be supported. The survey was completed 28% of the time by a “chief of staff” who may have little knowledge of the structure of their facility’s tumor conferences. Similarly, surveys asking about the tumor board structure over the previous 5 years are highly susceptible to recall error. The authors also failed to categorize tumor boards as prospective or retrospective, to define the percentage of newly diagnosed cancer patients presented, and to specify what each facility’s conference frequency was during the study period. The latter two variables are obvious in their potential to introduce error, allowing JNCI | Correspondence 1839
Downloaded from http://jnci.oxfordjournals.org/ at Robertson Library University of prince Edward Island on July 19, 2015
In a survey of Veterans Affairs tumor boards (TBs) published in a recent issue of the Journal, Keating et al. concluded that multidisciplinary TBs had little association with measures of use, quality, or survival (1). In an accompanying editorial, Douglas Blayney stated that it should be no surprise that improved performance on the process or outcome measures of quality is not predicted by the existence of team meetings, and he added that TBs have too long a history to be abandoned (2). Both the article and editorial raised lots of eyebrows, and a comment at Medscape was even entitled “Are Tumor Boards a Waste of Time?” (3). The authors looked at measures of quality care for patients with lung, colorectal, prostate, or hematological cancers but did not include breast cancer because of a small numbers of cases. The absence of a group of breast cancer patients is a major limitation of this survey. Multidisciplinary management breast units and/or TBs are essential components for management of patients with breast cancer worldwide. Changes in 43% and 52% of diagnoses and/or surgical breast management at TBs have been documented (4,5). Important changes in chemotherapy and surgical management have been reported in gynecological cancer TBs (6). On another important note, limitations in diagnosis and management in suboptimal settings, such as those encountered in rural and low resource areas, can be improved at TBs. TB meetings can serve as an educational tool to make more optimal decisions and provide large benefits for management of patients in low- and middle-income countries (7). A survey of 338 practicing oncologists from various Arab countries showed that 60% of them attend TBs to seek group opinion and help in the management of their patients (8). Furthermore, almost all of them agreed that in the absence of experts from all disciplines, a mini-TB should be organized with whichever specialist is available (8). TBs can provide an opportunity for help in patient management and continuing education. TBs are a form of group second-opinion that includes case review, evidence-based recommendations, and expert opinions. Because
there can be no clinical trial for every particular patient’s condition, such group multidisciplinary opinions provide timely help for better oncology care. Every medical oncologist, surgeon, and radiation oncologist who takes care of cancer patients knows that many times he/she gets help in diagnostic and treatment plans from multidisciplinary TB group discussions. Benefit from TBs depends on the presence of qualified and effective faculty, as well as on the format of the meeting and efficient interactions among physicians present. Unlike clinical trials and evidencebased medicine, measurement of impact of expert opinion on progression-free survival, disease-free survival, and overall survival may be very difficult, if not impossible. We agree with the authors and the editorialist that TBs should not be thrown away and that we need more studies of structure and format that will lead to the highest quality care. Results of their survey may not apply to breast cancer patients. Multidisciplinary management improves the care of cancer patients, and tumor boards are definitely not a waste of time. Moreover, they are a necessity, not a luxury, in areas with limited resources.
