The Fellowship Track
1. Kushner JH, Siris E, Sherman RS. Tumors in childhood and the role of a pediatric tumor board. J Am Med Womens Assoc. 1957;12(9):291-293.
As practitioners in oncology, our training typically extends beyond the scope of the specialty we initially chose after medical school. Whether that training was in pediatrics, internal medicine, surgery, or some other specialty, we all spent years focusing on a broader discipline before honing in on the oncology subspecialty. In my case, I spent 5 years training in general surgery prior to entering a surgical oncology fellowship. During that time, I strove to emulate the surgeons under whom I was training. I learned to think like a surgeon, operate like a surgeon, and care for patients, as a surgeon. Exposure to those mentors instilled in me a strong sense of the general surgeon’s role and responsibilities in medicine, and I established a support network for my future career.
Now, as a surgical oncology fellow, I find my scope of practice evolving and I look forward to embarking on a surgical career focused on oncology. Accompanying this evolution has been an expansion within my support network. Although my primary teachers and role models remain surgeons, these practitioners encompass a smaller portion of those whom I now strive to emulate. Who are these newest mentors and role models? They are the practitioners with whom I interact on a regular basis while attending interdisciplinary tumor boards and conferences.
Tumor Boards: A Review
Since the 1950s, tumor boards have been described as conferences dedicated to the topic of cancer.1 In a published review, John C. O’Brien, MD, detailed the inner workings of early tumor board meetings at Baylor Hospital in the late 1960s and regular breast tumor conferences at MD Anderson Hospital and Tumor Institute in the 1970s. Attendees included medical, radiation, and surgical oncologists, along with other subspecialized surgeons.2 Multidisciplinary tumor boards have slowly evolved from general case meetings into weekly focused gatherings on cancers affecting specific organs, “mini-tumor boards,” and even molecular tumor boards.3,4
It is no surprise that multidisciplinary meetings started at large hospital systems that could easily support the required subspecialty attendance. Today, with technologic advances, quality multidisciplinary meetings can be offered to hospitals and practitioners located in geographically remote settings.3 A pilot study in Germany set out to evaluate the feasibility of long distance, multicenter tumor board meetings, using the Internet as a platform. A total of 39 tumor board conferences were conducted between December 2004 and August 2006, and the results of the pilot were published in 2007. The authors concluded that online collaboration was indeed possible.5
Through a literature search, I discovered that efforts have been made by practitioners to investigate the role and efficacy of tumor boards in medical systems. The endpoints evaluated in these studies have included patient satisfaction, clinical outcomes, team dynamics, and communication.3
Results from a study conducted in the United Kingdom and published in Lancet Oncology demonstrated a greater than 60% increase in the percentage of patients with cancer managed by interdisciplinary teams over a 10-year period from the late 1990s to the mid-2000s.6 Despite this increase in coordinated case management, the tumor board conference, as an entity, has recently come under fire. A 2013 survey study reported in the Journal of the National Cancer Institute investigated Veterans Administration (VA) hospitals with established tumor boards. Investigators concluded that the VA hospitals’ multidisciplinary tumor boards had little effect on use, quality, and survival measures. Keating et al did note, however, that measuring the efficacy of a tumor board is complex and multifactorial, making it difficult to objectively quantify endpoints.7 This article fanned the flames of a question already being asked, “Are tumor boards a waste of time?”8
In a 2015 follow-up study from the same group, Kehl and colleagues published outcome results from patients with lung and colorectal cancer whose cases were discussed at multidisciplinary meetings. Despite concluding that the impact of tumor boards on survival, quality of care, and communication was not obvious, the authors did report an overall higher rate of clinical trial participation in those subjects whose cases were reviewed in a multidisciplinary setting. In addition, surgery was more often performed with curative intent on patients with stage 1 or 2 non-small cell lung cancer after tumor board review, and lower mortality rates were reported in cases of stage IV non-small cell lung cancer and extensive-stage small cell lung cancer reviewed in a multidisciplinary setting that discussed solely challenging cases. Kehl et al concluded that more focused investigations need to be undertaken with regard to the features of tumor boards most beneficial to patient care.9
A Surgical Oncology Fellow’s Perspective on Multidisciplinary Conferences
I lean forward, toward the edge of my seat; what I am witnessing has me captivated. The room is hushed and all eyes are directed toward the unassuming, soft-spoken medical oncologist seated at the end of a large conference table. She is speaking quickly and has been, by rote, for the last 3 minutes. Her diction moves fluidly from the results of one randomized trial to another as her encyclopedic knowledge of the literature effortlessly rationalizes various treatment approaches associated with a complicated cancer case. I audibly exhale and realize I’ve been holding my breath.
I remember the fascination I had as a medical student when first presented with the Whipple procedure. Surgery involving the head of the pancreas is analogous to doing roadwork on the East Los Angeles Interchange—that is to say, it is a complicated endeavor. Fast forward 7 years, and now as a second-year surgical oncology fellow who is well acquainted with the nuances of this procedure, my focus has globally broadened to include considerations regarding the treatment of these patients before and after operative intervention in order to obtain the best long-term outcome. Where can a practitioner obtain subspecialty guidance regarding ongoing care from multiple disciplines? The simple answer is a tumor board.
Cancer is a dynamic entity both in the literature and within the human body. It can take years for a and new information is constantly becoming available. Tumor boards offer an environment that not only fosters careful rationalization of cancer treatments, but also serves to educate the practitioners in attendance. Thus, a tumor board is a kind of melting pot for subspecialty fact sharing. Personally, I have enjoyed my increased exposure to tumor board conferences during fellowship, and through regular attendance, I have found inspiration from a new group of role models in this interactive environment.
Who are these new role models? They are the medical oncologists systemically attacking cancer, the radiation oncologists utilizing focused beams to treat the unseen and dampen recurrence, the radiologists scrutinizing with surgeons and endoscopists the resectability of a tumor, and the nurse navigators directing the board’s attention away from the raw facts and advocating for the patient’s emotional well-being. Important contributors to interdisciplinary conferences also include pathologists, other surgical and medical specialists, nurses, social workers, researchers, and in-training practitioners who are involved in the full gamut of cancer care, from the laboratory bench to post-treatment care and follow-up. We, as oncologists, can develop the perfect care plan, but it is the patient who needs to embrace this plan. The patient’s mental, emotional, and spiritual issues can easily be overlooked by a busy practitioner who is buried in the details of the case. All of these facets of care can be addressed by the tumor board.
The influence of these newest mentors will undoubtedly remain with me when I begin my practice of surgical oncology. I am certain that upon performing my first case that requires an intraoperative frozen section I will keenly remember the passion our director of pathology brought to conferences when discussing the importance of the handling and orientation of a pathologic specimen. “Pathology is low-hanging fruit to oncologists, Dr Flaherty. Take every opportunity to learn from it.” It is this kind of knowledge, knowledge obtained from and reinforced through multidisciplinary conferences, which will guide my practice patterns and make me a better oncologist.
As new oncology practitioners, we will also find that as medicine and standards of care evolve, so will tumor boards. For example, cancer genetics is a rapidly evolving field that requires specialist input, as oncology training has only recently started to incorporate dedicated rotations in this area. I always look reserves for the end of a discussion. With a growing focus on personalized cancer care, these practitioners offer a new layer to the prospective treatment of our oncology patients.
Finally, what about those cases that we just cannot win?
In a recent issue of Oncology Fellows, Dr Bollin offered timely and thoughtful insights into the importance of palliative care training during fellowship.10 Despite its importance, a publication in the Annals of Surgical Oncology highlighted the lack of palliative care training that fellows receive during surgical oncology fellowship. Program directors of surgical oncology and hepatobiliary fellowships were surveyed; the results revealed that only 60% of responding programs offered formal training in palliative care.11 As a future surgical oncologist, I appreciate the importance of this training because I recognize the nature of the foe we are battling. Inevitably, all oncologists will be placed in situations where palliative care training will allow them to appropriately and compassionately assist a patient and their family in accepting this new direction in care.
Granted, not all cases presented at tumor boards require palliative measures. There remains, however, a role for education regarding palliative care. Perhaps efforts should be made at those institutions without palliative care representation to reach out to these practitioners and encourage their participation in regular multidisciplinary conferences. Perhaps, as fellows, we can spur this initiative along by being advocates for the patients we present at tumor boards and personally extend an invitation to a palliative care practitioner when appropriate.
As a surgical oncology fellow, I have defined my new heroes. The interdisciplinary setting is a welcoming and comfortable environment that promotes a team approach to conquering cancer. There is so much knowledge and experience in one room, and everyone brings a different dish to the table that helps to create a full-course meal for all of us to share. And when the hour is up and the tumor board comes to a close, we all rise, sated and ready to continue the fight. Now, during fellowship, when we are sitting less on the periphery and are more involved in presentation and discussion, we should relish the opportunity to settle in and learn. Every week, I leave the tumor board inspired and count my blessings to be involved in this branch of medical care.
Recently, I contacted a friend who had just graduated from the complex general surgical oncology training program at my institution. Our conversation touched upon his move, the new city he was living in, and, finally, the manner in which he was preparing for his first day on the job. Expecting to hear about a planned busy clinic day or hours of electronic medical record training, I was surprised at his answer: “I am preparing for tumor board.” As new oncology practitioners, the tumor board setting will likely be one of our first opportunities to make an impact on patient care. We should all look forward to this opportunity and prepare for our role in this effective and necessary pillar of oncologic care.