As treatment options become more complex, real-time discussions among the physicians involved in care become more important. These discussions can also have an impact on the cost and value of care, making it either less expensive or more valuable, or, ideally, both. In this paper, we attempt to measure how often these discussions change the treatment recommendations for cancer care, an area with a vast number of treatment options where communications among physicians from multiple disciplines is particularly common and particularly important.
In cancer, multidisciplinary team planning conferences involving clinicians from numerous specialties, colloquially known as “tumor boards,” have become an integral part of care in leading centers in an effort to optimize patient outcomes. Surprisingly, there is little research on the value of such conferences, in regard to either the cost of care or its quality.
We tracked multidisciplinary team planning conferences in the Head and Neck Center at the University of Texas MD Anderson Cancer Center. The center holds a 75- to 90-minute multidisciplinary team planning conference every Thursday afternoon to discuss all new patients and consults. The conferences include about 50 clinicians — surgical, radiation, and medical oncologists; head and neck radiologists and pathologists; and clinicians involved in dentistry, speech pathology, and audiology — who discuss an average of 40 to 50 patients per week. The primary oncologist for each patient proposes a treatment plan, which the team discusses until consensus is reached.
In complex cancer care, reaching a consensus is essential both to deliver the best, evidence-based personalized cancer care, and to improve care coordination. Lack of care coordination may result in failure to deliver the right treatment, or the best sequence of multiple treatments, in a timely manner. For example, in a recent study of head and neck cancer patients, more than half of the patients failed to receive postoperative radiation therapy within 6 weeks of surgery, a recommendation strongly supported by the National Comprehensive Cancer Network guidelines.
The opportunity cost of the clinician time spent in these conferences, rather than on revenue-generating services, is significant — likely in excess of $10,000 for each weekly multidisciplinary team meeting. Yet the value of this multidisciplinary interaction has yet to be ascertained.
In this study, we monitored the impact of the Head and Neck Cancer Center’s multidisciplinary team conference on treatment recommendations for every patient treated at the center, at 10 weekly conferences held between January 12 and March 23, 2017. The primary attending physician’s proposed treatment plan, and the final disposition after group discussion, were recorded for each patient. Any changes made to the primary attending physician’s proposed treatment were recorded, along with the reasons for treatment plan alteration.
As multidisciplinary team discussions occur prior to treatment delivery, we could not determine actual cost of care. Therefore, we used cost “bundles,” employed in previous studies, to understand the potential effect of plan alterations on cost. Based on our previous work looking at drivers of overall treatment cost in head and neck cancer, we found that the number of modalities (surgery, radiotherapy, chemotherapy, plastic surgery reconstruction) was the most important determinant of cost. Thus, a patient recommended to undergo surgery alone would cost less than a patient recommended to undergo surgery and radiotherapy. We therefore categorized patients into cost “bundles” according to the number of modalities to be used in their treatment. Multidisciplinary team discussions could potentially increase the cost of treatment by recommending more modalities of treatment, or decrease cost of treatment by recommending fewer modalities of treatment.
The Patient Cohort
The multidisciplinary team meeting held a total of 415 discussions about 407 patients. (Eight patients were discussed twice over the study period.). The number of patients discussed per conference ranged from 31 to 57. The table below shows an overall summary of patient characteristics. All cases reached consensus. Multidisciplinary recommendations resulted in changes in patient treatment about a third of the time (or 129 of 415 cases). Patients with malignant tumors had a 4.4 times higher chance of having a change in treatment as a result of multidisciplinary discussion, compared with patients whose tumors were benign.
Patients with skin tumors were only a third as likely to have treatment changes, and patients with thyroid tumors were only a quarter as likely, compared with patients who had upper aerodigestive tract tumors (the most common type of tumor, and hence the type that we used as a baseline for comparison). These particular differences may be due to the often single modality of treatment required for early skin cancer and the detailed recommendations guiding thyroid cancer treatment published by the American Thyroid Association.
Thus, this study suggests that multidisciplinary team discussions are most useful in patients for whom treatment may involve multiple modalities, or tumors for which widely accepted, descriptive guidelines are unavailable. Of upper aerodigestive tract tumors, patients with metastatic disease from an unknown primary site were about one-tenth as likely to undergo treatment recommendation changes.
Duration of Discussion
Treatment plan discussions involved treatment choices important to optimal delivery of care, including the extent or sequence of treatment modalities such as surgery, radiotherapy, or systemic therapy (chemo-, immuno-, or targeted therapy). The presenting surgeon describes the proposed treatment plan. Either the plan is agreed upon by the group, or questions and suggestions are raised. Discussion durations ranged from less than 1 minute to 12 minutes, depending on the complexity of the patient. In 272 patients (65.5%), discussion lasted less than a minute and treatment decisions were made almost immediately. Even discussions lasting a minute or less resulted in changed treatment recommendations for 52 patients (19%). During these very brief discussions, physicians often identify a specific question about the treatment plan to present to the multidisciplinary group, or suggestions are straightforward and uncontroversial, such as possible eligibility for clinical trials.
Longer duration discussions unsurprisingly resulted in more treatment recommendation changes (90 patients, or 48% with discussions longer than 1 minute). Patients with discussion durations longer than a minute were about five times more likely to have a treatment recommendation change, compared with patients whose cases were discussed for a minute or less. As expected, we found that patients were more likely to have longer treatment plan discussions if they had malignant disease, or if the treatment was for disease that was previously treated.
Reasons for Treatment Plan Changes
Changes to treatment plans were recommended for a variety of reasons. The most common recommendation in 58 cases (45%) was to encourage clinicians to enroll patients into relevant clinical trials, a surprising but welcome outcome. Prior to multidisciplinary conference, only 19 patients had been proposed for evaluation for inclusion in clinical trials. In a large center such as MD Anderson, a multitude of trials with stringent inclusion criteria are open as options for patients. Clinicians were not always familiar with the newest trials, or were uncertain of their patient’s eligibility.
This 2.2-fold increase in clinical trial enrollment demonstrates the importance of having multiple clinicians involved in treatment decisions to maximize clinical trial involvement. Clinical trials are not only essential for supporting novel treatments in cancer, but participation in clinical trials has been demonstrated to be an independent predictor of survival.
The second most common change was to reduce treatment-related toxicity while maintaining efficacy by changing to a less toxic therapy. An example of this was a patient with advanced disease for which the primary treating physician initially recommend neoadjuvant chemotherapy followed by concurrent chemoradiotherapy. However, medical oncology experts felt that neoadjuvant chemotherapy would expose the patient to potential adverse events without improving disease outcome, and concurrent chemoradiotherapy alone would provide equally good outcome with less toxicity.
Recommendations for more effective therapy were the third most common reason for treatment recommendation change, in 35 patients (27.1%). An example of change in treatment recommendation was to recommend additional treatment for patients initially recommended to undergo surgery only. Review of imaging and pathologic characteristics could highlight adverse features, favoring additional treatment with adjuvant radiotherapy or radiation with concurrent chemotherapy in patients with high risk for cancer recurrence or metastasis. The additional treatment modalities were predicted to improve oncologic outcomes given current best available evidence.
Cost of Recommendation Changes
Using the cost estimates of various treatment bundles previously described, in the total of 129 treatment recommendation changes, 71 (55.0%), did not result in a difference in expected cost. Costs of recommended treatment decreased in 30 patients (23.3%), and increased in the remaining 28 (21.7%). In the 28 patients receiving more expensive care, the changes were most often made to improve effectiveness of therapy by adding a modality of treatment for 12 patients (42.8%).
It is important to note that the cost estimates are for acute treatment and do not include longer-term costs stemming from complications or recurrent disease. Thus even increased upfront treatment costs may result in lower downstream costs by improving the initial outcomes of patients treated and reducing disease recurrence. Most patients with changes in treatment recommendation that decreased cost of care were due to less intense treatment to avoid unnecessary toxicity (N=21, 70%).
Even in a specialized high-volume cancer center with highly experienced clinicians, multidisciplinary treatment planning conferences resulted in changes in treatment in one-third of patients. The effects of such changes in treatment can only be estimated based on best evidence, and there is no control group for comparison. However, implementation of multidisciplinary care in other care systems and different disease sites have demonstrated improvement in survival.
The long-term cost of care needs to be further investigated, but the treatment changes based on multidisciplinary team recommendations likely led to improved outcomes or reduced cost, including lower downstream costs from complications or poor disease outcomes, based on studies in other institutions. True cost of treatment is difficult to quantify in a retrospective fashion in our study and would require further prospective study. Though the precise value of multidisciplinary team discussions may be difficult to quantify, multidisciplinary team discussions result in improved disease outcomes and better coordination of care, and may decrease cost of cancer treatment.