During the Triological Society session “Tumor Board: Multidisciplinary Care of Head and Neck Cancer Patients,” veterans of the head and neck cancer field discussed how they use tumor boards, a treatment planning approach that involves experts from multiple specialties who review and discuss the condition and management options of a patient.
The panelists focused on how the approach has helped improve care quality and increased the value of care provided at their respective centers.
Tumor Board Value
Randal Weber, MD, chair of head and neck surgery at the University of Texas MD Anderson Cancer Center in Houston, discussed how his center is examining its own multidisciplinary tumor care to make sure it is providing value to patients.
Value, he reminded the audience, can be seen as a simple calculation proposed by Harvard economist Michael Porter, PhD: outcome divided by the cost of care.
An important metric to look at, Dr. Weber said, is “treatment package time”—the time between surgery or the start of radiation-chemotherapy and the final treatment. A 2002 study concluded that, in cases involving multi-modality therapy, treatment that extends beyond 100 days can have a negative effect on prognosis and survival (Head Neck. 2002;24:115-126). “These are the types of metrics that we try to capture to make sure that we are delivering care efficiently and within the prescribed treatment time,” Dr. Weber said.
They’ve also looked at performance indicators, divided into high-acuity and low-acuity cases—numbers such as hospital stays of two or more days for low-acuity cases and more than 11 days for high-acuity, blood use, and readmissions within 30 days. MD Anderson presented each of its surgeons with their own numbers in these types of categories and, anonymously, with those of their peers.
A year later, when the hospital examined those numbers again, they’d improved—often significantly—or at least had not gotten worse. One finding was that even though metrics such as length of stay and return to the operating room improved, blood use increased. The center is now conducting research to determine the reasons for that increase.
When it comes to cost, the main drivers are the treatment modalities and co-morbid conditions, not disease site or stage, Dr. Weber said. “You have to know your cost of care before you can enter into a bundled payment scheme, and you have to maintain a reasonable margin because if there’s no margin, there’s no mission,” he said. MD Anderson has built in a stop-loss on cases that are extreme outliers, he said.
Palliative Care Specialists
Jonas Johnson, MD, professor and chair of otolaryngology at the University of Pittsburgh School of Medicine, made powerful remarks on acknowledging when patients may have hit the end of the line with aggressive treatment. In those cases, having a palliative care representative on a tumor board is immensely helpful, he said.
“One of the most important changes in our tumor board that’s occurred over the last decade or so is we bring patients to tumor board who have failed, who have persistent, recurrent disease,” he said. It was, in part, a practical consideration, he added, because patients would ask the surgeon, who would say that no more surgery should be done; then they would see the radiation therapist, who would say there were no more options. This way, everyone is talking about a case together.
—Carol Bradford, MD
“The patients and their families need to be part of the decision to treat,” he said. “The elephant in the room is this business of treating people with interventions that are potentially harmful, which you just can’t expect to work. The patient needs to understand the potential for harm. We need to recognize this and move on to symptom relief.”
“There are patients who we see every week who can’t be helped by any [non-palliative] intervention. And this is the intervention that helps: Somebody should help at home. Somebody should help them with their nutritional needs and their pain needs and their anxiety needs…. It is so essential to multidisciplinary care.”
Cherie-Ann Nathan, MD, professor and chair of the department of otolaryngology-head and neck surgery at Louisiana State University in Shreveport, called total laryngectomy “the most feared surgical procedure.” A team approach to the care of patients who face this procedure is vital, with surgery, radiation, oncology, pathology, nursing, social work, tobacco cessation, nutrition, speech, and swallow rehabilitation all represented, she said.
The choice of laryngeal preservation or laryngectomy should involve a variety of factors, she said. Her group’s research has found that tumor size, co-morbidities, and malnutrition are independent significant risk factors for disease recurrence in patients who undergo chemo-radiotherapy for laryngeal squamous cell carcinoma (Laryngoscope. 2012;122:565-571).
In a study published this year, patients at her center had better overall survival compared with those in the National Cancer Data Base, even though her center’s patient population had inferior socioeconomic factors and more advanced tumor stage (JAMA Otolaryngol Head Neck Surg. 2015;141:169-173). “We believe that this was because we continued to perform total laryngectomies for T4 disease patients,” Dr. Nathan said.
“Laryngeal preservation [should be chosen] only if it offers improved function and quality of life without compromising survival,” she said. Selection should depend on patient factors and co-morbidities, local expertise, and support and rehab services, she added.
After the session, Miriam Lango, MD, an oncologist at the Fox Chase Cancer Center in Philadelphia, asked, “What do you do with the patient with a T4 larynx cancer who has a dysfunctional larynx but refuses total laryngectomy? All the surgeons may agree that the patient needs a total laryngectomy, but there’s no shortage of medical and radiation oncologists who would consent to trying primary chemoradiation.”
Panelist Carol Bradford, MD, professor and chair of otolaryngology at the University of Michigan Comprehensive Cancer Center in Ann Arbor, said the patient’s wishes and goals of care are very important. “I think our job as physicians is to present the various treatment modalities and our recommendation and help patients understand to the best of their ability.”
She suggested that the patient meet with a speech pathologist or those who have previously had laryngectomies. “You inform as best as you can, but at end of the day, the patient gets to choose,” she said.
Melanoma Tumor Boards
Dr. Bradford said a patient education focus is one element that has come out of the melanoma tumor boards at her center. “One of the things we do that’s really interesting is to teach our patients how to follow themselves,” she said. “They all get an instructional DVD that demonstrates self skin and lymph node exams. We do not recommend highly expensive surveillance testing, but we do recommend regular visits with a dermatologist and a primary care doctor twice a year for three years.”
Those visits involve a history and physical and a careful review of systems, with more tests ordered only when those screening tests are positive.
Her university also convenes a tumor board for Merkel cell carcinoma, a rare malignant tumor now known to be potentially related to a virus and one that results in worse outcomes for immunosuppressed patients. “We developed an algorithm of how we would treat these patients,” she said. The university also kept a registry of their results, which may later be published.
“I think that the role of the multidisciplinary tumor board is important,” Dr. Bradford said. “It really fostered part of my own scholarship and the scholarship of many others…. The collaboration is how we really improve care for our patients.”
Thomas Collins is a freelance medical journalist based in Florida.Multi-Page