| Literature DB >> 32005232 |
Maria Lucia Specchia1,2, Emanuela Maria Frisicale3,4, Elettra Carini3, Andrea Di Pilla3, Danila Cappa3, Andrea Barbara3, Walter Ricciardi5,3, Gianfranco Damiani5,3.
Abstract
BACKGROUND: Tumor Boards (TBs) are Multidisciplinary Team (MDT) meetings in which different specialists work together closely sharing clinical decisions in cancer care. The composition is variable, depending on the type of tumor discussed. As an organizational tool, MDTs are thought to optimize patient outcomes and to improve care performance. The aim of the study was to perform an umbrella review summarizing the available evidence on the impact of TBs on healthcare outcomes and processes.Entities:
Keywords: Diagnostic accuracy; Healthcare; Multidisciplinary team; Personalized medical care; Personalized treatment; Teleconsultation; Tumor board
Mesh:
Year: 2020 PMID: 32005232 PMCID: PMC6995197 DOI: 10.1186/s12913-020-4930-3
Source DB: PubMed Journal: BMC Health Serv Res ISSN: 1472-6963 Impact factor: 2.655
Fig. 1PRISMA Flow chart
Characteristics of the reviews included
| Authors, year, country | Databases and date range | Number of studies (studies quality) | Cancer types and population | Objective | Outcomes / outputs | Main results |
|---|---|---|---|---|---|---|
| Coory et al., 2008 [38] (Australia) | Ovid Medline, and snowball search. 1984 - July 2007. | 16 (studies quality: not assessed) | Lung cancer (both SCLC and NSCLC) | To evaluate and critically appraise the effectiveness of multidisciplinary teams to treat lung cancer and particularly to assess if the TBs, compared to traditional models of care, improves survival, and other outcomes such as practice patterns and waiting times. | Survival. Practice patterns. Waiting times. Satisfaction with care. Visits to GPs. Quality of life. | Weak evidence of a causal association in survival improvement. Stronger evidence of the effect of TBs on changing patient management: increase in the percentage of patients undergoing surgical resection and in the percentage of patients undergoing chemotherapy or radiotherapy with curative intent. Reduced waiting times. Improved patient satisfaction. Reduced number of visits to GPs. No-statistically significant differences in patients’ quality of life. |
| Lamb et al., 2011 [ | Embase, Medline, PsycINFO (using OvidSP), Cochrane database. 1999 - 15th May 2009 | 37 (studies quality: low to medium) | Breast, lung, gynaecology, urology, upper GI, colorectal, sarcoma, brain, head and neck cancer | To examine the literature on care management decisions in cancer TBs and assess the factors that enhance or impede effective decision-making | Diagnosis. Care management decisions. Adherence to guidelines. Treatment. Implementation of TB decisions. Survival. | Improvement in diagnostic accuracy. Changes in care management decisions (2–52% of cases). Improved adherence to clinical guidelines. More likelihood of patients being offered chemotherapy (7–23%). TB decisions not implemented in 1–16% of cases. Significant increase in survival for patients being offered chemotherapy (3.2–6.6 months). |
| Prades et al., 2015 [ | Medline database. November 2005–June 2012 | 51 (studies quality: not assessed) | Urological, pancreatic, rectal, head and neck, melanoma, oesophageal, prostate and genitourinary, colon, lung, breast, oesophageal, osteological, skin, gynaecological, and neurological cancer and bone metastases | To assess the impact of TBs on patient outcomes in cancer care and identify their objectives, organisation and ability to engage patients in the care process. | Diagnosis and/or treatment planning. Survival. Patient quality of life. Patient and clinician satisfaction. Waiting times. Care coordination for professionals and patients. | Improvement in diagnosis and staging accuracy; more appropriate treatment through preoperative review of imaging and pathology results; more up-to-date treatment; structured follow-up care plan. Improved survival. Patient quality of life improvement. Improved patient and clinician satisfaction. Reduced waiting times. Coordination and continuity of care improvement by reducing time from diagnosis to treatment; achieving early and appropriate referral patterns. Furthermore: teaching environment for healthcare professionals and junior doctors; increased enrolment in tumour registry; maintaining a commitment to research and clinical trials |
| Pillay et al., 2016 [ | OVID Medline, PsycINFO, and EMBASE databases. 1995 - April 2015 | 27 (studies quality: not assessed) | Colon or rectal, lung, oesophageal or gastric, urological, gynaecological, breast, hematologic and head and neck tumours. Mean or median age range: 54–71 years. Sample size range: 47–6760. | To summarise, integrate, and critically evaluate the literature regarding the impact of TBs on patient assessment, diagnosis, management and outcomes in oncology settings. | Patient assessment/diagnosis. Patient management/clinical practice. Waiting times. Survival, recurrence rates/remaining tumour after resection and rate of metastasis. | Changes in diagnostic reports after TB discussion (between 4 and 35% of patients discussed at TBs); more likelihood to receive more accurate and complete pre-operative staging for patients discussed at TBs. Changes in patient management/clinical practice after discussion reported in 4.5–52% of cases. More likelihood to receive neoadjuvant/adjuvant treatment and greater adherence to guidelines for patients discussed at TBs. Limited evidence for improved waiting times. Limited evidence for improved survival of patients discussed at TBs; little positive impact on local recurrence rates/remaining tumour after resection and incidence of metastases. |
| Basta et al., 2017 [ | PubMed, MEDLINE and EMBASE electronic databases. Until 30 November 2016. | 16 (studies quality: fair) | Gastrointestinal malignancies: oesophageal or gastric, colorectal, pancreatic or biliary, liver malignancy or neuroendocrine, other malignancies. | To assess whether the discussion in a multidisciplinary gastrointestinal cancer team meeting influences the diagnosis and treatment plan for patients with GI malignancies. | Diagnosis and staging. Treatment plan and adherence to guidelines. Implementation of the treatment plan. | Changes in the diagnoses formulated by individual physicians after TB discussion (18.4–26.9% of evaluated cases); accurate diagnosis in 89–93.5% of cases evaluated by TBs; more frequent complete staging evaluation for patients discussed. Treatment plan altered in 23.0–41.7% of evaluated cases; increased adherence to guidelines. TB decisions implemented in 90–100% of evaluated cases. |
TBs characteristics
| Coory et al., 2008 [ | Lamb et al., 2011 [ | Prades et al., 2015 [ | Pillay et al., 2016 [ | Basta et al., 2017 [ | |
|---|---|---|---|---|---|
| Definition | Team working among specialists with diagnostic and therapeutic intent, who meet to discuss the diagnosis and management of patients. | Group of different healthcare professionals, who meets together to discuss a patient. Each one is able to contribute independently to the diagnostic and treatment decisions about the patients. | Alliance of health care professionals related to a specific tumour disease. Approach to cancer care is guided by willingness to agree on evidence-based clinical decisions and to coordinate the delivery of care at all stages of the process, encouraging patients to take an active role in their care. | A regularly scheduled discussion of patients, comprising professionals from different specialties. The TB serves as a platform for the coordinated delivery of care through consultation amongst different professionals in a single setting. | Healthcare professionals from different medical specialties working together for specific diseases. |
| Intent | To discuss diagnosis, treatment and management of patients. | To discuss patients and contribute to the diagnostic and treatment decisions. To improve communication, coordination and decision-making between healthcare professionals. | Appropriate and up-to-date treatment, structured follow up plan. To improve coordination and continuity of care, to achieve early referral patterns. | Coordination of care within the team to ensure accurate staging, consideration of different treatment options, continuity of treatment, and follow-up. | To discuss and diagnose patients with complex diseases and formulate a treatment plan according to the guidelines. |
| Format | Meetings of specialists at specified time either in person, by video or teleconferencing. | Meetings of professionals at a given time, physically, by video or teleconferencing. | (1) Meetings of 30 min - 2 h including either all or a selection of diagnosed and/or referred patients. Patients selection by the specialist in charge on the basis of the case’s level of complexity or the wide range of therapeutic possibilities, prearranged team criteria, or triage by the clinical coordinator. (2) Clinics in which patients were seen and also simultaneously examined or remotely coordinated by all board members. (3) Online conferences within a given hospital or nationwide. Meeting presentations involving prospective reviews of new and recurrent cases, previously reviewed cases requiring additional follow-up, and second opinions. | TBs conducted either weekly or fortnightly (daily meetings reported in one study). | Team meetings at periodic intervals (i.e., daily or weekly). |
| Members | Thoracic physicians, thoracic surgeons, radiation oncologists, specialist radiologist, medical oncologists, pathologists, nursing and allied health staff and palliative-care specialists (there are different local configurations). | Several healthcare specialists. | Team members and attendance vary according to hospital size and medical specialty. Three levels of members involvement. (1) Core and (2) Allied: radiologists, pathologists, surgeons, radiation and medical oncologists, oncology nurses, palliative care physicians, head and neck specialists, nuclear medicine specialists, respiratory disease physicians, gastrointestinal disease physicians and anaesthesiologists; (3) Support: psychologists, nutritionists, dieticians, plastic surgeons, speech therapists, patients’ GPs, physiotherapists, practitioners of complementary medicine, orthopaedic specialists, medical physicists, odontologists, faith counsellors, biologists, data managers, genetic counsellors, hospital pharmacists, social workers and occupational therapists. | Surgeons, medical and radiation oncologists, radiologists, pathologists and nurse specialists. In addition, professionals from pharmacy, palliative medicine, mental health and other allied health disciplines may also be present. | Different medical specialists. |
Outcomes and outputs in the reviews retrieved. Main findings
| Outcome / Output | Author / Year | N. of studies | Results / Findings |
|---|---|---|---|
| Care coordination | Prades et al., 2015 [ | 22 | Format, data management and professional roles of TBs impacted positively on care coordination for professionals and patients. |
| Diagnosis (Patient assessment, diagnosis, staging) | Lamb et al., 2011 [ | 3 | Improvement in diagnostic accuracy was reported. |
| Prades et al., 2015 [ | 8 | Multidisciplinary setting improved diagnosis and staging accuracy. | |
| Pillay et al., 2016 [ | 15 | Diagnostic reports changed after the meeting in 4–35% of patients discussed. | |
| 6 | The impact of the TB on assessment and diagnosis was significant (higher accuracy in staging). | ||
| Basta et al., 2017 [ | 1 | No changes in diagnosis or stage were reported after validation by pathology or after follow-up. | |
| 4 | TBs changed the diagnoses formulated by referring physicians in 18.4–26.9% of cases. | ||
| 2 | TBs formulated an accurate diagnosis in 89 and 93.5% of evaluated cases. | ||
| 2 | Discussion during the TB influenced staging. After introduction of the TB, more patients underwent computed tomography (CT) before operation and patients discussed more often received a complete staging evaluation. | ||
| Treatment (Practice patterns, clinical practice, patient management, Implementation of treatment changes) | Coory et al., 2008 [ | 1 | A not statistically significant larger percentage of patients discussed in TB (43%) received radical treatment than the control group (33%). |
| 1 | A statistically significant increase in the percentage of patients older than 70 years receiving radical radiotherapy (from 3% in 1995 to 12% in 2000; | ||
| 1 | A statistically significant increase in the percentage of patients receiving chemotherapy (from 7% in 1997 to 23% in 2001; | ||
| 3 | Surgical resection rate was higher in MD groups. | ||
| Lamb et al., 2011 [ | 6 | Changes in care management decisions were reported in 2–52% of cases. | |
| 1 | TBs improved adherence to clinical guidelines. | ||
| 1 | Likelihood of patients being offered chemotherapy increased (from 7 to 23%) | ||
| 6 | Care management decisions by TBs were not implemented in 1–16% of cases due to contradictory patient choice or because of comorbidities. | ||
| Prades et al., 2015 [ | 21 | TBs ensured more appropriate treatment through preoperative review of imaging and pathology results; multidisciplinary approach guaranteed the most up-to-date treatment, and set up a structured follow-up care plan. | |
| Pillay et al., 2016 [ | 25 | Changes in patient management/clinical practice were measured. Three studies reported minimal change in clinical management (less than 9% of cases), four studies indicated that the percentage of patients who underwent changes in treatment plans ranged from 19 to 34.5%. Other studies reported that changes in patient management plan following a TB occurred in 4.5–52% of cases. | |
| 13 | Patients who were discussed were more likely to receive neoadjuvant or adjuvant treatment. Greater adherence to National Comprehensive Cancer Network (NCCN) guidelines was found in two studies. | ||
| Basta et al., 2017 [ | 9 | Treatment plan formulated by the referring physician was altered in 23.0–41.7% of evaluated cases. | |
| 5 | TB decisions on treatment plan were implemented in 90–100% of evaluated cases. The reasons for not following TB advice were comorbidity (45%) and patient preferences (35%), followed by new clinical information (10%), different opinion of the treating physician (5%), and unknown (5%). | ||
| 3 | TBs increased adherence to guidelines. Treatment plan more often adhered to national guidelines: 98% versus 83%. | ||
| Quality of life | Coory et al., 2008 [ | 1 | No statistically significant difference between groups was found |
| Prades et al., 2015 [ | 6 | Improvement of patients’ quality of life | |
| Recurrence and metastasis after resection | Pillay et al., 2016 [ | 2 | TB discussion had little positive impact on local recurrence rates of rectal cancer and incidence of metastases and remaining pelvic tumour after resection. |
| Satisfaction (patient or clinician) | Coory et al., 2008 [ | 1 | TBs resulted in better satisfaction for organisation of investigations and personal experience of care. |
| Prades et al., 2015 [ | 5 | TBs improved patient and clinician satisfaction as a consequence of team work communication and cooperation. | |
| Survival | Coory et al., 2008 [ | 2 | Two studies reported statistically significant survival improvement. 1 study reported an improvement of 3.2 months in median survival of patients with inoperable NSCLC, the other an increase from 18.3 to 23.5% in 1-year survival of lung cancer patients older than 70. |
| 3 | Three studies did not show a statistically significant improvement. | ||
| Lamb et al., 2011 [ | 1 | Patients being offered chemotherapy showed a significant increase in survival (from 3.2 to 6.6 months). | |
| Prades et al., 2015 [ | 10 | Improvements in survival were reported for colorectal, head and neck, breast, oesophageal, and lung cancer. | |
| Pillay et al., 2016 [ | 4 | TB discussion was not associated with overall survival. However, in one of these studies, rectal cancer patients discussed had improved post-operative mortality. | |
| 2 | Significant association was shown between TB discussion and survival of patients. | ||
| Visits to general practitioners | Coory et al., 2008 [ | 1 | Significantly fewer visits were reported for the MD group than the control group. |
| Waiting times | Coory et al., 2008 [ | 3 | In one study the median time from presentation to first treatment was 3 weeks in the MD arm (7 weeks in the control arm) but there was no difference in the time from diagnosis to radical treatment. Another study reported a reduction in mean time from presentation to surgery of 15 days. In the last study, a reduction of days from diagnosis to treatment from 29.3 to 18.8 was reported. |
| Prades et al., 2015 [ | 10 | TBs resulted in reduction of time from diagnosis to treatment, and achievement of early and appropriate referral patterns. | |
| Pillay et al., 2016 [ | 2 | In two studies patients discussed in TBs had fewer mean days from diagnosis to treatment. | |
| 1 | One study found an opposite trend. | ||
| Other | Prades et al., 2015 [ | 7 | TBs promoted the establishment of a teaching environment for healthcare professionals and junior doctors. |
| 9 | A commitment to research and clinical trials was maintained. | ||
| 1 | The enrolment in the tumour registry increased. |