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Decisions and Challenges in Multidisciplinary Teams


Experts examine decision-makers in treatment selection and navigate challenges in organizing multidisciplinary team meetings, from institutional to wider practice perspectives.

David Carbone, MD, PHD: Dr Forde, who is actually making the decisions in your multidisciplinary tumor board? I've always struggled with how often we present a patient for a few minutes, everybody weighs in and the group thinks something should be done, but does the treating doctor, should they always do what that group recommends? Who’s responsible?

Patrick Forde, MBBCh: I think it's the same the world around. You know, I've been in and I've met in Europe and here and often it does default to the treating oncologists. But I would say that the patient is also central to it. You know, we're presenting a treatment recommendation to the patient in the end and I think explain to the patient why and how we came up with that decision or recommendation is important in explaining that it is not just the person sitting in front of them is making the recommendation, but there are all the other folks that we've mentioned. I think a lot of the time in our group, it is guided by the medical oncologists, for a more locally advanced or advanced disease. But radiation and surgery also play a very key role being guided by all of the other people we've mentioned pulmonologists, pathologists, everyone else who's present, and our nursing team who know the patients very well because they're running the MDT [multidisciplinary team] in some cases. I think it's a group decision, but a lot times it does still come down to the treating physician and the patient sitting in that clinic room…2 or 3 days later after the MDT has happened.

David Carbone, MD, PhD: I completely agree. The tumor board gets perspectives from all the specialties, but many of those people have never seen the patient. And really, when you sit in front of the patient, interact with them and find out what sorts of things may modify the treatment plan based on their social situation, their family situation, and their just desires. Some people just don't want chemotherapy or they don't want surgery. While the MDT is crucial for giving that 360-degree perspective, I really feel like it's the treating physician who writes that order that really has to make the decision in concert with the patient, but at least after an MDT, it’s an informed decision based on a group discussion. What obstacles are present when organizing MDTs, both within your institution and in broader practice? Anybody want to address that?

Erin A. Gillaspie, MD, MPH, FACS:Yeah, I’d be happy to tackle that a little bit. I think for us, 1 of the big challenges working at our huge medical center is we’re scattered all over campus, and trying to get everybody to be able to participate meaningfully in tumor boards was actually becoming really challenging as we got bigger. When the pandemic hit, we switched to Zoom because we weren't allowed to be in the same room and all of a sudden our tumor boards went from, you know, 7 to 10 people to 40 to 50 people. And then, oh, by the way, we find another silver lining that we can start to invite people from our satellite facilities to participate. Other hospitals in town that may not be well supported by certain specialties. For us actually to be able to get really, really meaningful participation as we've gotten bigger and bigger, it's been using those Zoom or tela-group platforms where we can all get together and talk about our patients. It's really been wonderful.

David Carbone, MD, PhD:Yeah, I totally agree. That's really given the opportunity for people in disparate locations, including their own homes, to participate in a tumor board and everyone is busy and finding a time that's convenient for everyone is difficult. Are there other challenges from anyone else?

Salma Jabbour, MD, FASTRO: A challenge for me is that I just find that the tumor board experience is so engaging and interesting and we can keep discussing a case probably for half an hour. We have so many cases and we have to get through them in an hour. I would say for me, the limitation is I wish we always had a lot more time to discuss every case and to spend half an hour on every case. But that doesn't happen in reality because we have to work with so many patients and cases and really thoroughly discuss each case. It's a balance for me of time and the full discussion.

David Carbone, MD, PHD: Anything to add, Dr Dietrich?

Martin Dietrich, MD, PhD: Well, I think another problem is if you have multiple providers from different institutions involved in the care, if you have a medical oncologist outside, but I do think that the multidisciplinary, even if it's done as a second opinion, is a very reassuring factor of both. For the treating oncologists as well as for the patient have basically the stamp of approval and ideally just to add for the execution of tumor boards, if the patient has been seen by all the specialties prior to tumor boards, you really add the art of medicine in addition to just the imaging and the pathology and really tailor what was recommended to the individual patient’s recommendations. I think there's a sequence of events that would idealize the opportunity to maximize tumor boards and also facilitate a little bit of a faster discussion and discussions around images and discussion around best treatment approach is also facilitated if it's not in a theoretical realm, but in 1 that has been done with the patients multiple times over and sharing different perspectives, gathering different pieces of information. I think it is very helpful and, in my opinion, should be done for every patient before treatment is initiated.

David Carbone, MD, PhD: Well, Dr Jabbour touched on this, too, but at least in my institution, it's completely impossible for us to discuss every patient. An obstacle is choosing who is appropriate to discuss at a tumor board. You know, if it's a fifth-line medical oncology patient where the answer is gemcitabine vs vinorelbine, there may not be a really ideal multidisciplinary tumor board patient, but if you have a new patient with unclear staging, that sort of thing is really very important. Or with a staging into 2 and 2 nodal stations; is this a neoadjuvant case or not, or a chemoradiation case? And often those the chemoradiation in the neoadjuvant surgical approaches are both reasonable and both sides need to be presented in that situation. Other obstacles people can think of? Time is always an obstacle too, like you said, having enough time to adequately discuss patients.

Transcript is AI-generated and edited for clarity and readability.

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