A survey of Veterans Affairs (VA) medical centers recently reported by Nancy L. Keating, MD, MPH, and colleagues at Harvard Medical School in the Journal of the National Cancer Institute showed that the presence of multidisciplinary tumor boards had little association with rates of recommended stage-specific cancer care, differences in use of care, or survival among veterans with colorectal, lung, prostate, or hematologic cancer.1
In the study, 138 VA medical centers were surveyed for the presence of tumor boards and linked cancer registry and administrative data to assess receipt of stage-specific recommended care, use of care, and survival in patients with cancers diagnosed between 2001 and 2004 and followed through 2005. Of the centers, 35 (25%) had no tumor board, 62 (45%) had a single tumor board, and 41 (30%) had more than one board.
In centers with a single board, nearly all discussed all of the cancer types, including lung (97%), colorectal (92%), prostate (92%), breast (85%), and hematologic (84%) cancers. Of the centers with more than one board, 100% had a board specific for lung cancer, 95% for colorectal cancer, 83% for prostate cancer, 73% for hematologic cancer, and 66% for breast cancer.
Overall, 27 measures of quality, use, or survival were assessed in the categories of colorectal cancer (4 measures), lung cancer (9 measures), prostate cancer (5 measures), lymphoma/multiple myeloma (4 measures), and palliative and end-of-life care (5 measures). The number of patients with breast cancer was too small to accurately assess measures.
For colorectal cancer, comparison across centers with no tumor board, a single general tumor board, and a colorectal cancer–specific tumor board showed no significant differences in measures of adjuvant chemotherapy for stage III colon cancer (68.7%, 69.3%, and 70.4% of patients) or adjuvant chemotherapy and radiation for stage II/III rectal cancer (74.6%, 73.9%, and 74.6%). Likewise, no significant differences were seen in 3-year all-cause survival in patients with colon cancer (survival of 57.5%, 58.2%, and 60.2%) or patients with rectal cancer (survival of 52.5%, 56.2%, and 54.6%).
For lung cancer, comparison across centers with no tumor board, a general tumor board, and a lung cancer–specific tumor board showed no significant differences in the measures of curative surgery for stage I/II non–small cell lung cancer (NSCLC) (53.2%, 56.5%, and 61.9% of patients), mediastinal evaluation for stage I/II NSCLC (85.7%, 85.6%, and 89.3%), chemotherapy or radiation therapy for stage IIIA NSCLC patients undergoing surgery (79.6%, 74.8%, and 65.1%), or doublet chemotherapy for stage IV lung cancer (37.3%, 42.7%, and 42.8%; no chemotherapy in 56.0%, 52.3%, and 50.6%).
However, some significant differences were observed. Radiation therapy in patients with stage I/II NSCLC not undergoing curative surgery was more likely in patients treated at centers with a general tumor board than in patients at a center with no tumor board or a lung cancer–specific tumor board (70.8% vs 66.5% and 63.8%; overall P = .04). Chemotherapy and radiation therapy for unresected NSCLC stage IIIA patients was more likely in patients from centers with a general tumor board or a cancer-specific board than in patients from centers with no tumor board (39.5% and 35.6% vs 23.9%; overall P = .02). Treatment at a center with a general board or a cancer-specific board was associated with a greater likelihood of chemotherapy and radiation therapy for limited-stage small cell lung cancer (61.8% and 62.9% vs 28.4%; overall P < .001).
Comparison across centers with no tumor board, a general tumor board, and a lung cancer–specific tumor board found no significant differences in 1-year all-cause survival in NSCLC (41.3%, 39.5%, and 41.0%) or small cell lung cancer (25.2%, 26.2%, and 26.6%).
For prostate cancer, comparison across centers with no tumor board, a general tumor board, and a prostate cancer–specific tumor board showed no significant differences in the measures of primary therapy for local/regional prostate cancer (no radiation or surgery in 38.9%, 38.9%, and 37.7% of patients), androgen ablation for metastatic prostate cancer (77.2%, 70.7%, and 76.9%), adjuvant androgen-deprivation therapy for high-risk cancers treated with radiation therapy (2001–2002) (56.7%, 63.0%, and 68.6%), or use of three-dimensional conformal radiation therapy/intensity-modulated radiation therapy for patients receiving external-beam radiation therapy (61.0%, 59.3%, and 61.0%).
Patients treated at centers with a general tumor board or a prostate cancer–specific board were significantly more likely to receive an oral antiandrogen before starting gonadotropin-releasing hormone agonist therapy for metastatic disease (81.7% and 83.7% vs 71.1%; overall P = .03).
For lymphoma/multiple myeloma, comparison across centers with no tumor board, a general tumor board, and a hematology-specific tumor board showed no significant differences in the measures of CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) chemotherapy in diffuse large B-cell non-Hodgkin lymphoma (NHL) (80.7%, 75.4%, and 80.6% of patients) or bisphosphonate therapy for multiple myeloma (59.6%, 66.4%, and 66.2%).
Treatment with rituximab and CHOP in patients with diffuse large B-cell NHL was significantly less likely at centers with a general tumor board than at those with no tumor board or a hematology-specific tumor board (74.6% vs 89.3% and 87.1%; overall P = .003). White blood cell growth factor treatment with CHOP in patients with diffuse large B-cell NHL was less likely at a center with a hematology-specific board than at centers with no tumor board or a general tumor board (39.4% vs 56.4% and 61.3%; overall P = .002).
Palliative care specialists were included in only 31% of tumor boards. For palliative care and end-of-life care, comparison across centers with no tumor board, a tumor board without palliative care specialists, and a tumor board with specialists showed no significant differences in the measures of receipt of last dose of chemotherapy within 14 days of death (4.8%, 5.8%, and 5.4%), intensive care unit admission within 30 days of death (15.7%, 12.8%, and 13.1%), use of potent antiemetics for highly emetogenic chemotherapy (64.7%, 75.4%, and 66.4%; overall P = .10), or prescription of narcotic pain medication for pain in advanced cancer (69.6%, 68.6%, and 67.0%).
Patients treated at centers with a tumor board that did not include a palliative care specialist were more likely to have more than one emergency room visit within 30 days of death than patients treated at centers with no tumor board or with a tumor board including a palliative care specialist (12.0% vs 9.6% and 9.2%; overall P = .01).
After a Bonferroni correction for multiple comparisons, the only association that remained significant among all 27 measures included in the analysis was the greater likelihood of use of chemotherapy and radiation therapy for limited-stage small cell lung cancer at centers with a general tumor board or a lung cancer–specific tumor board.
The authors concluded, “We observed little association of multidisciplinary tumor boards with measures of use, quality, or survival. This could mean that tumor boards did not, in fact, influence quality of cancer care in the VA setting. It might also mean that tumor boards are only as good as their structural and functional components and the expertise of the participants, and because tumor boards likely vary in their efficacy depending on these factors, measuring only the presence of a tumor board may not be sufficient to understand their effects. Additional research is needed to understand the structure and format of tumor boards that lead to the highest quality care.” ■
1. Keating NL, Landrum MB, Lamont EB, et al: Tumor boards and the quality of cancer care. J Natl Cancer Inst 105:113-121, 2013.
By Nancy L. Keating, MD, MPH
In this large study examining care for patients with a variety of tumor types in the Veterans Health Administration (VA), we found no clear association of tumor boards with better quality of care or outcomes. It is unclear if our findings can be generalized outside of...