Tumor Board: From Preparation to Practice Building

In this Q&A, Ripal Gandhi, MD, explains the best ways to prepare for a tumor board meeting and communicate with colleagues, particularly in areas that do not have high-quality data available. He also explains how the interventional oncologist can add value beyond therapeutic procedures, and how participation in tumor board can help to build your practice. Dr Gandhi practices interventional oncology at the Miami Cardiac and Vascular Institute and Miami Cancer Institute and is a Course Director for the Symposium on Clinical Interventional Oncology (CIO). He will be presenting on various interventional oncology topics at the 2018 Symposium on Clinical Interventional Oncology (CIO), which takes place February 3-4, 2018 in Hollywood, Florida

How do tumor boards help to optimize patient care?

Tumor boards are essential. With the multitude of systemic, locoregional, surgical therapeutic options available to patients, tumor board is the ideal setting to determine the appropriate treatment strategy for a given patient.  Medical oncologists, surgical oncologists, radiation oncologists, and interventional oncologists as well as pathologists and diagnostic radiologists will attend tumor boards and share their input, with the goal of developing a patient-centered approach to the management of care.

Any specialty can present a patient during the tumor board, and it’s through discussion and interaction between colleagues that we determine what the optimal treatment plan is for that individual patient. Tumor boards are truly critical in the management of cancer in the modern day where the complexity and diversity of therapies necessitates a multidisciplinary approach.

How much preparation time is needed before attending tumor board?

Preparing for tumor board does not mean that you need to review every case before the meeting, especially because you may not even have access to every case that will be presented. Good preparation means knowing the guidelines and most current data in the relevant area. For example, if you are attending a hepatobiliary tumor board, you need to know the diagnostic criteria for diagnosing hepatocellular carcinoma, transplantation criteria, the Barcelona Clinic Liver Cancer (BCLC) Staging and treatment algorithm as well as the medical, locoregional, and surgical therapeutic options and relevant data.

Obviously, you know your own data best of all, and this is where you serve as an expert and can help guide management decisions. However, I think you can provide added benefit by being knowledgeable of your colleagues’ data, too. You are not going to be an expert in medical/surgical/radiation oncology data, but you should definitely be knowledgeable enough to converse with your colleagues and to know any recent, landmark trials that will influence patient care. It is of key importance to keep the end goal in mind—you’re trying to deliver the most up-to-date care to patients.

Are there any challenges in explaining interventional oncologic options to colleagues?

The key to better communication is knowing and mastering the IO data, but some of the most challenging areas are those in which we don’t have a lot of data. I have no problem presenting interventional oncology treatment options in areas without robust data where it is appropriate, but the key here is to be honest, recognize our limitations, and allow for discussion. Keep in mind that your colleagues in other specialties may also be presenting potential options in areas without substantial data.

In fact, challenging cases without clear data are where multidisciplinary tumor boards provide the most added value. The key is to develop a personalized treatment plan and a multidisciplinary approach. This is especially helpful when there is a lack of clear guidelines and when a patient may have clinical features that do not fit standard algorithms.

Can you give an example of a hypothetical case in one of those areas without clear data?

One example is a patient with breast cancer with metastatic disease in the liver There are some recent data available on yttrium 90 (Y90) radioembolization as a treatment option, but there are no level 1 data, to my knowledge. For other types of cancer, such as colorectal cancer with liver metastases, there are abundant data for interventional oncology options, and those options are in the NCCN guidelines. That being said, there are some reasonable single-center studies looking at Y90 for breast cancer, predominantly in the salvage or chemorefractory setting.

When evaluating a breast cancer patient with liver-dominant metastatic disease, you need to consider systemic chemotherapeutic options. Where in the course of therapy do you add liver-directed therapy for a patient with breast cancer with hepatic-metastatic disease? Do you add it in a salvage setting only? Or do you add it earlier in their course?  We do not always have the answer and further studies will help us answer these questions. 

Can you elaborate on how attending tumor board helps to add value for patients?

There are many ways to add value at a tumor board, and they’re not always therapeutic procedures. One area is diagnosis. In addition to being experts in image-guided therapy, interventional oncologists are also diagnosticians.

For example, for hepatocellular carcinoma, we can help to establish whether we have a diagnosis on the basis of imaging or if we need a biopsy. In most cases, imaging is sufficient. We’re also involved in helping plan for biopsies. For example, do we have access to, or is this patient amenable to biopsy, or should the biopsy be done surgically or bronchoscopically?

We’re also involved in ancillary procedures, such as cancer-related palliative procedures, drainage procedures, pain management, vascular access, and inferior vena cava filter placement.

Of course, we also perform therapeutic procedures, including curative procedures such as ablation, portal vein embolization to allow for contralateral hepatic hypertrophy which might allow for a curative hepatic resection, and liver-directed therapy with chemoembolization, bland embolization, and Y90 radioembolization.

Finally, we are also problem solvers and are able to manage complications encountered during other therapies.  Because we have a role in so many different areas, it’s essential to attend tumor board and play a part in the decision making.

How can attending tumor board assist in building your practice?

Collaborating with colleagues helps to build your practice in the long term. Your peers get to know you and understand what you can offer patients. Colleagues might refer more patients once they have worked with you on a tumor board.

At my institution, we train fellows on how to build a practice, and we emphasize the three As: being available, being affable, and being able. Those are very important guidelines for tumor board and for growing a practice in general. For example, I give every referring physician my cell phone number and try to be available at all times.  If you’re available 24/7, people will call you. And if you’re affable and always happy to take a call, people are going to be willing to call you. And, of course, you also have to be able and competent.

Do you have any advice on growing in the profession beyond attending and participating in tumor board?

It’s important to become involved in research. Involvement in cutting-edge clinical research trials further cements your expertise and allows you to go beyond performing procedures and caring for individual patients to advancing the care of all cancer patients. There are many gaps in our knowledge, and additional studies will continue to transform oncologic diagnosis and treatment paradigms, allowing for less invasive IO options to play a larger role in cancer care.