Abstract
Background/Aim: At present, multidisciplinary tumor boards (MDTB) are considered best practice in oncology. However, web-based virtualization of MDTB may increase participation in meetings, the number of cases discussed, and adherence to guidelines, deliver better treatment, and eventually improve outcomes for patients with prostate cancer. Patients and Methods: This is an observational study focused on exploring the structuring process and implementing a multi-institutional virtual MDTB in Sicily, Italy. Other endpoints included the analysis of cooperation between participants, adherence to guidelines, patient outcomes, and patient satisfaction. Results: Overall, 126 patients were referred to the virtual MDTB for a total of 302 cases discussed in an 18-month period. Nearly 45% of cases were referred from general hospitals or tertiary centers, 38% from comprehensive cancer centers, and only 17% from academic ones. Most health professional participants (95%) reported eliminating geographical barriers and consequently reducing costs and saving time as key advantages of virtual meetings over face-to-face ones. Using a specifically designed platform for virtual MDTBs was another excellent point, especially to geolocate clinical trials and time-lapse data storage. The majority of referred patients had stage T 3-4 prostate cancer (79%). Overall, 71% of proposals discussed were approved unchanged, while 19% changed after the virtual MDTB discussion. Debated points were mostly radiologic, surgical, medical, or radiation treatment-related issues. In particular, the prescriptive appropriateness of positron emission tomography with 68Ga-prostatic specific membrane antigen, newer drugs, radiation versus surgical approach, stage T3-4 cases, and adjuvant therapy represented the most debated issues. The proposed diagnostic and/or therapeutic options were controlled for adherence to the guidelines and/or updated scientific evidence. Overall, 98% of approved proposals and changes were in line with the guidelines. Overall, most participants felt virtual MDTB was very useful and case discussions led to a major change of strategy in 19% of cases. Conclusion: Virtual MDTBs are a very useful way to achieve best management of prostate cancer while saving time and fostering cooperation.
To date, multidisciplinary tumor boards (MDTBs) are considered the gold standard approach to achieve optimal management of patients affected by urological and other malignancies (1, 2). A recent exhaustive scoping review reported a relatively low number of published papers on MDTB focused on prostatic cancer and the need to implement multidisciplinary care due to the rapidly increasing complexity of cancer care in this setting (3). The growing armamentarium of antineoplastic agents, data from several prospective and real-life clinical trials, the availability of positron emission tomography with 68Ga-prostatic specific membrane antigen (PET-PSMA) scans, and the identification of oligometastatic patients make cooperation between different professionals necessary to achieved best management and improve patient outcomes (3).
The need for a multidisciplinary prostate unit is not a new issue. A decade ago, an editorial from the Thomas Jefferson University stressed the opportunity of a multidisciplinary approach to prostatic carcinoma (PC) (4). In 2015, a study of the Johns Hopkins Medical Institutions, reported critical changes in 25% of patients referred by tertiary centers with a 29% change in the stage or risk categories and a significant number of patients who undergone non appropriated imaging according to the NCCN guidelines (5). A recent European Cancer Organization article reviewed the critical points of PC care across the entire journey of a patient (6). Health professionals of different disciplines should cooperate in optimizing the multidisciplinary and patient-centered management of men affected by prostatic cancer, increasing adherence to clinical guidelines. Aside from establishing multidisciplinary teams, physicians and cancer experts should also support efforts to widen the impact or influence of MDTB collaboration.
The implementation of MDTBs leads to several positive effects for cancer patients, such as numerically significant changes in diagnosis and treatment strategies, improved disease staging, adaption of therapy to cancer risk, and, eventually, survival (7-10). Recent data from the MD Anderson Cancer Center showed that PC patients evaluated by an MDTB were more likely to receive guideline-adherent care than patients across the United States, with improved outcomes (8). Similar results have been reported by Chinese investigators, who showed that dynamic MDTB discussions at the time of prostatic cancer diagnosis and progression and throughout the disease positively impacted overall survival (9). Investigators from the MD Anderson Cancer Center reported superior overall survival of PC patients discussed in MDTB compared to the Surveillance, Epidemiology, and End Results (SEER) registry (11). MDTB discussions were a favorable independent indicator of more prolonged overall survival (9). Multidisciplinary teams are also felt to be a possible means to reduce discrepancies in the management of PC patients (12), and a higher number of MDTB meetings correlated with improvement in clinical outcome correlates (13). French researchers showed the reliability and reproducibility of decisions made at MDTM when guidelines are well defined. The therapeutic attitudes were less reproducible in locally advanced PC, but decisions concerning those cases should be made according to guidelines (14).
Despite such recommendations, the real world offers a different panorama with a low use of MDTBs for PC (15-17). Although some academic and comprehensive cancer centers have established MDTB-based care for PC, the majority of smaller or rural centers do not have such organizations, therefore offering patients fewer treatment options and a higher rate of non-adherence to guidelines or more advanced therapies (18-20).
From this perspective, telemedicine can break down the barriers linked to distance or the fragmentation of healthcare resources (21, 22). Consequently, in the last few years, informatic programmers developed web-based platforms to run virtual MDTBs. In fact, during the recent COVID-19 pandemic, virtualization of MDTB allowed the efficient, coordinated, and prospective discussion of cases among physicians (8, 10, 21, 22). Hopkins et al. reported a survey showing that most health professionals supported the use of a permanent virtual or hybrid MDTB format, which was considered more time-efficient and equally beneficial as face-to-face one by two-thirds of responders (23). Moreover, 90% of responders felt confident that virtual interaction did not affect decision-making. Virtualization of MDTB increases by 46% overall tumor board attendance and 20% in case presentations per meeting, allows additional weekly meetings and expansion to geographically distant sites (24). A recent review on the effects of MDTB on clinical practice reported that although the change in the decision could be as high as 45%, data are highly variable, and the number of studies is low (25). Based on this information, we report data from an observational study on virtual MDTB (vMDTB) for PC patients in a large area, including academic institutions, comprehensive cancer centers, and general and tertiary ones.
Patients and Methods
Study design. After approval by the Ethics Committee of the University of Palermo, a prospective, pragmatic, multicenter, clinical observational study [International Registered Report Identifier (IRRID): DERR1-10.2196/26220] on the implementation, effectiveness, and efficiency of vMDTB began in July 2020. The protocol was part of a larger research project on communication and multidisciplinary collaboration in oncology units and departments in the Sicily region. The study protocol was published in September 2021 and encompassed a pragmatic, observational, multicenter, noninterventional, prospective trial (26). The study was based on Bowen’s Framework and focused on exploring the structuring process and implementation of multi-institutional vMDTBs in Sicily, Italy (27). Other endpoints include analysis of cooperation between participants, adherence to guidelines, patient outcomes, and patient satisfaction. The study’s programmed duration was five years, with a half-yearly analysis of the primary and secondary objectives’ measurements.
The results of this study mainly focused on the organization of vMDTBs, involving oncology units in different hospitals spread in the area and creating a network to allow the best patient care pathways and a hub-and-spoke relationship. The present results also included data concerning organization skills and pitfalls, barriers, efficiency, number and types of clinical cases, and customer satisfaction.
Project structure. Participation of oncology care health professionals from various subspecialties at oncology departments in academic and general hospitals, tertiary centers, and community hospitals was nonhierarchical. vMDTBs employed an innovative, virtual, cloud-based platform to share anonymized medical data that were discussed via a video-conferencing system, satisfying security criteria and compliance with the Health Insurance Portability and Accountability Act (Navify, Roche, Basel, Switzerland). The platform allowed the geolocation of clinical trials, matching recommendations with updated guidelines, and accessing real-time relevant updated medical literature. Virtual meetings were held at 6:30 p.m. weekly or twice a month, depending on the availability of clinical cases and the needs of participants. vMDTB included medical oncologists, radiation oncologists, urologic surgeons, pathologists, molecular biologists, radiologists, nuclear medicine specialists, members of patient advocacy, and a case manager. All together represent the core team, but other specialists may also participate depending on the type and specialty of the tumor board; some vMDTBs may also include nutritionists, palliative care physicians, and research nurses. Only invited participants could attend the vMDTB by accessing the web platform via the URL link provided by the host.
After informed consent, patients’ records were anonymized and submitted by the case referrer through the platform. The workflow includes submitting cases by the presenting physician to the administrator, who collects and lists all items in a password-protected virtual room. Clinical cases are presented with relevant radiologic and pathologic findings and then discussed to obtain a proposed final recommendation. At the end of each case evaluation, the web platform allowed an anonymous electronic vote on the clinical decisions proposed during the meeting. If ≥75% of participants reached a consensus, each patient’s file was updated with the working group’s final recommendations. Patient data and decisions are then stored and can be rediscussed during follow-up. The shared recommendation can be scanned and uploaded to the electronic medical record system and rediscussed during follow-up. Figure 1 shows the vMDTB flowchart. The vMDTB organizers formed a steering committee to validate decisions and promote scientific research.
Flowchart of a multidisciplinary virtual meeting.
Population and enrollment. In a nonprejudicial manner, participation in the project was extended to all the centers and health professionals dealing with PC involved in a process with subsequent steps. Patient inclusion criteria were as follows: any patient with PC, age >18 years, written informed consent, and processing of personal health information. Exclusion criteria were life expectancy of fewer than six months, Eastern Cooperative Oncology Group performance status >3, and absence of informed consent and privacy. A crucial recommendation for the case presenters was to admit initially complex clinical cases and, once the vMDTB is functional, to expand the presentation to all possible cases.
Endpoints. The primary endpoints were the feasibility of vMDTB program implementation and health professionals’ acceptance of the vMDTB model. The establishment of the organizational steps (creation of the working groups, inter-group and interpersonal relationships, diagnostic and therapeutic pathways implementation and actions implementation, etc.) and the degree of adherence of the IMDB participants were measured using validated survey methods according to Delphi methodology. The degree of confidence at each meeting was measured using a 5-point Likert scale in which higher scores represent more positive responses.
Secondary endpoints included data on vMDTB program utilization and effectiveness in providing access to quality and equitable cancer care, including timely and appropriate multidisciplinary assessment of each case. The timely assessment occurred within two weeks of the initial consultation request. According to national and international guidelines, the appropriate multidisciplinary assessment matched all current oncology specialties/services with those recommended for each cancer type (AIOM, ESMO, NCCN). In addition, discussions and recommendations on each patient’s diagnostic and therapeutic plan were developed according to validated methods (Delphi and/or Grade) and their adherence to evidence-based medicine, national and international guidelines, or the availability of practice-changing data from recently published controlled trials.
Results
The vMDTB program was developed and carried out in Sicily, the largest geographical region of Italy, comprising 4,780,000 inhabitants, three academic institutions, and two public and three private comprehensive cancer centers plus a large number of tertiary centers.
Demand. Investigators assessed demand by recording the number of referrals to the program and the acceptance of those referrals to the program. From September 2020 to March 2022, a sequential observation period of 18 months, 36 meetings were held evaluating 126 patients with a median age of 69 years (range=41-86 years). Patients were also discussed each time they progressed throughout the disease management and follow-up. Therefore, overall, 302 cases were discussed during the observation time.
Implementation. The predominant resource was staff to run the program. In addition, the organization’s communications officer was key to program promotion, including direct contact with potential participants via phone call or email and review of medical data for each case presented. Overall, the vMDTB program involved 32 centers and 72 healthcare professionals comprising medical oncologists, radiation oncologists, urologists, radiologists, pathologists, nutritionists, patient advocacy members, and post-doctoral fellows. Participating institutions included three academic hospitals, five cancer centers, eleven general hospitals, and twelve tertiary centers. Figure 2 depicts referred patients according to the type of oncology centers involved. Overall, nearly 45% of cases were referred from general hospitals or tertiary centers, 38% from comprehensive cancer centers, and only 17% from academic ones.
The number and percentage of referred patients according to the type of Institution.
Acceptability, suitability, and feasibility. Three months after the beginning of the project, a survey on the acceptability, suitability, and feasibility of vMDTBs was distributed to the 72 clinicians who attended the virtual meetings. The survey helped assess participants’ feedback and whether this project could be a worthwhile alternative to traditional face-to-face meetings. Healthcare professionals in attendance had to answer questions regarding the acceptability and feasibility of switching to a vMDTB. Questions also included equity of access to treatment, cooperation among all health professionals, and data access and sharing. A 5-point Likert scale assessed acceptability, feasibility, and implementation. A proposal was voted on electronically and considered approved if it achieved at least 75% consensus. As shown in Table I, the survey highlighted the project’s impact, with the vast majority of participants agreeing to the items. In addition, most participants (95%) reported eliminating geographical barriers and consequently reducing costs and saving time as key advantages of virtual meetings over face-to-face ones. Using a specifically designed platform for vMDTBs was another excellent point, especially to geo-locate clinical trials and time-lapse data storage.
Survey results.
Overview and performance of vMDTBs. Table II depicts the main demographic and pathological characteristics of patients discussed. The majority of referred patients had stage T 3-4 PC (79%). Figure 3 describes significant clinical points debated during vMDTB conferences (number of patients/clinical issue). Based on the preliminary review of the in-progress evaluations, Figure 4 shows the significant decisions taken during the virtual multidisciplinary conference, including any following changes in the diagnostic-therapeutic plans. Overall, 71% of proposals discussed were approved unchanged, while 19% changed after the vMDTB discussion. Debated points were mostly radiologic, surgical, medical, or radiation treatment-related issues. In particular, the prescriptive appropriateness of PET PSMA scan, newer drugs, radiation versus surgical approach, stage T3-4 cases, and adjuvant therapy represented the most debated issues. The proposed diagnostic and/or therapeutic options were controlled for adherence to the guidelines and/or updated scientific evidence. Overall, 98% of approved proposals and changes were adherent to guidelines. Three cases were proposed for clinical trials.
Main demographic and pathological characteristics of discussed patients.
Description of significant points debated during virtual multidisciplinary tumor board conferences (number of patients/clinical issue).
Description of significant decisions taken during multidisciplinary tumor board conferences (number of referred patients).
Discussion
To date, MDTBs are considered the best approach to the increased complexity of cancer care (28, 29). Most health professionals widely accept using a cloud-based vMDTBs for PC. vMDTBs represent a unique opportunity to optimize patient management in a patient-centered approach. An efficient virtualization system is potentially a time saver, a data source, and a detector of possible critical clinical pathways. Hurwitz and coworkers showed that treatment proposal patterns by individual practitioners varied considerably from decisions of a MDTB representing an equal-access healthcare system, thereby reducing confounding because of varying levels of healthcare access (30). Moreover, MDTBs improve adherence to diagnostic and therapeutic guidelines and, eventually, patient outcomes (31, 32). Researchers at the Karolinska University Hospital showed that using a digital solution during preoperative MDTBs for PC decision-making improved the efficiency and quality of this multidisciplinary team meeting without impacting patient outcomes (33).
Besides the mere clinical care of PC patients, vMDTBs may also be an efficient tool for molecular tumor boards. This board may be important for patients who can benefit from molecular profiling, such as the expression of the androgen receptor splice variant 7 (AR-V7), which predicts nonresponse to next-generation AR-directed therapy like abiraterone or enzalutamide. Another setting may be the presence of homologous recombination defects that sensitize cancer cells to poly(ADP-ribose) polymerase (PARP) inhibitors or microsatellite instability, which may predict response to immunotherapy with PD-L1 inhibitors (34).
The need for an MDTB discussion for all patients with genitourinary cancers has been recently challenged (35). A prospective study evaluated the effectiveness of MDTBs in a series of 321 patients referred at a tertiary hospital showing that the predicted treatment plan by a single provider changed in 18% of cases after multidisciplinary discussion (35). Logistic regression analysis showed that only MDTB discussion with patients was statistically significant, while age, predicted plan, or provider experience were not. In 2013 an article from the Department of Health Care Policy at Harvard Medical School reported a low association of MDTBs with measures of use, quality, or survival. However, these disappointing data could be linked to poor structural and functional components and participants’ expertise (36).
In our study, after vMDTBs, nearly one-quarter of referred cases showed a major change in diagnostic and/or therapeutic work-up. Changes were introduced to the treatment plan proposed by the first provider, independently of changes in diagnosis, diagnostic work-up, and radiological or pathological findings in nearly 19% of referred cases. In addition, some diagnoses and some diagnostic methods changed. Remarkably, some radiological findings were changed, while additions were required in pathological findings. Finally, it is noteworthy that three specific highly specialized centers for PC neoplasms acted as a driving force for the homogenization of treatment plans, including the appropriateness of procedures and the application of diagnostic and therapeutic pathways. The observations and results of this study could help design nonclinical and organizational interventions to improve multidisciplinary decision-making in oncology.
In conclusion, vMDTBs offer undeniable advantages and benefits by reducing some already known critical issues compared to traditional ones (30-34, 37). For example, during the SARS-COV-2 pandemic, vMDTBs were undoubtedly sound systems in reducing interpersonal contact and containing the outbreak of the virus, on the one hand maintaining the circularity of clinical information among health care professionals, but above all, allowing patients to regain the equity of care that may have been threatened by it, especially regarding those who were geographically far from highly specialized centers. Furthermore, virtualization allows healthcare professionals to participate and communicate in a much more manageable way, as the time spent on travel does not facilitate engagement. However, virtual meetings cannot necessarily replace traditional meetings because there are still some advantages when participating members meet face-to-face. In addition, the interaction between different specialties and sharing information and decisions is critical to achieving optimal clinical recommendations.
Acknowledgements
The following health professionals participated in their availability to tumor boards. Medical oncologists: Francesco Verderame MD, Ospedale Cervello, Palermo; Helga Lipari MD, Ospedale Cannizzaro, Catania; Livio Blasi MD, ARNAS, Palermo; Daniele Galanti MD, Ospedale Fatebenefratelli, Palermo; Domenico Santangelo, Ospedali Riuniti, Sciacca, Agrigento. Urologists: Fulvio Piazza MD, Ospedale Villa Sofia, Palermo; Francesco Curto, Fondazione Giglio, Cefalù; Patient’s advocacy: Carmela Amato, Serena a Palermo, Europa Donna; Radiation oncologists: Gianluca Mortillaro, ARNAS, Palermo; Antonio Daidone, Ospedale Abele Aiello, Mazara del Vallo, Trapani.
Footnotes
Authors’ Contributions
Vittorio Gebbia, Vincenzo Serretta and Dario Piazza: conceptualization, data analysis, supervision. Maria Rosaria Valerio: reviewing and editing. Vittorio Gebbia: original draft preparation, statistical analysis. Demetrio Aricò, Ivan Fazio, Vincenzo Altieri, Sergio Baldari, Michele Pennisi, Andrea Girlando, Massimiliano Spada, Cristina Scalisi Gesolfo, Marco Messina, Carlo Messina, Leone Giorgia, Giovanni Sortino, Alfio Di Grazia, Rossella Guggino, Nicolo Borsellino: resources and reviewing.
Conflicts of Interest
The Authors have no relevant financial or non-financial conflicting interests to disclose.
- Received October 28, 2022.
- Revision received November 2, 2022.
- Accepted November 3, 2022.
- Copyright © 2023 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.
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