Palliative care tumor board: a narrative review and presentation of a novel conference to enhance collaboration and coordination of pain and symptom management for patients with advanced cancer

Introduction

Background

Integration of palliative care into routine oncologic care is the gold standard for patients with metastatic solid tumors or advanced hematologic malignancies to help patients live as well as possible for as long as possible in the face of a cancer diagnosis (1). There is ample literature that supports early palliative care involvement in the care of cancer patients, yet many cancer patients have late or no referral to palliative care, so finding new approaches for the integration of the two disciplines is essential (2). In addition to assisting patients and their families achieve goal-concordant care, palliative care providers support colleagues across disciplines who must grapple with the challenging and emotionally onerous work of caring for patients with cancer.

Multidisciplinary tumor boards are groups of oncology providers that meet regularly to plan oncologic care for patients and serve as an opportunity for all involved parties (usually excluding the patient and the family) to discuss complex cases and propose an evidence-based plan of care for treatment. These panels are widely and routinely used in the care of patients with cancer because they promote collaborative care and improve patient outcomes (3,4). A 10-year review of the experience of patients with hepatic malignancies at the Veterans Affairs Hospitals revealed a 13% reduction in mortality for patients whose cases were presented at multidisciplinary tumor boards (5). Tumor boards usually include medical oncologists, radiation oncologists, surgical oncologists, radiologists, and pathologists, as well as representatives from other disciplines based on the disease site. Tumor boards enhance adherence to national guideline, increase enrollment in clinic trials, and improve survival (1-7). Large academic medical centers may have multiple tumor boards that specialize in specific disease sites, such as the gastrointestinal tumor board or the thoracic tumor board, while smaller institutions may have a single panel that discusses all cancer patients.

The American College of Surgeon’s Commission on Cancer accreditation board encourages but does not require multidisciplinary tumor boards to have palliative care representatives attend (8). Cancer centers must monitor specific elements discussed, including the options and eligibility for palliative and supportive care services. Despite the guidelines to include palliative care representatives and palliative care topics, multidisciplinary tumor boards rarely have consistent palliative care providers as members for a variety of reasons, including scarcity of palliative care personnel. While using the multidisciplinary discussion as a trigger for a palliative care consultation has been proposed, it is not consistently done, although these discussions typically do consider comfort care approaches and often encourage the primary oncologist to involve palliative care services (6,7,9,10).

Rationale and knowledge gap

Data on palliative care-focused tumor boards is limited. Chang et al. reported their experience with a palliative care tumor board where thirty-two patients were presented over twelve months. Their tumor board was well-received by clinicians and supported comprehensive management of pain and other symptoms. A mix of cases was discussed: multiple myeloma (n=11), gastrointestinal (n=9), genitourinary (n=5), breast (n=2), lung (n=2), skin (n=1), and unknown origin (n=2). Patients were briefly seen and managed by specialists after presentation (9). More recently, McNaughton et al. presented their experience creating a sustainable approach to implement a palliative care tumor board in a community setting. They concentrated on the methods of communication with patient and/or family. Their tumor board led to a total of 50 new referrals to inpatient and outpatient palliative care and 11 new advance care plans were documented in the electronic medical record (11).

Objective

Given the relative lack of incorporation of the palliative care perspective in the traditional multidisciplinary tumor board setting and the scarcity of palliative care-specific panels, our team saw an opportunity to weave the palliative care ethos more tightly into the fabric of the culture of oncology at our institution with the creation of a palliative care tumor board and determine whether this type of conference would fill the gap in providing a palliative care voice when determining how to navigate complex cancer patients. Understanding the robust data supporting early palliative care integration in oncology care and acceptance as gold standard treatment, a dedicated case conference seemed like the next logical step (1,12-20). We present this article in accordance with the Narrative Review reporting checklist (available at https://apm.amegroups.com/article/view/10.21037/apm-22-1366/rc).

Creation of a dedicated palliative care tumor board

Methods

We reviewed PubMed database to outline the scope of palliative care involvement in the standard oncologic tumor board structure. The search criteria are outlined in Table 1 and showed the team that there was very little precedent in the literature for a multidisciplinary case conference focused on symptom management in patients with advanced cancer. We used this information to create the Pain and Symptom Management Tumor Board (hereafter referred to as “tumor board”). The tumor board is a novel conference developed in 2021 at the Lifespan Cancer Institute of The Warren Alpert Medical School of Brown University. The twice-monthly conference brings together individual clinicians from multiple allied oncologic medical specialties who care for patients with cancer and pain. The panel includes representatives from palliative care, interventional radiology, radiation oncology, pediatric palliative care, psychiatry, physical medicine and rehabilitation, and medical oncology. To build support for the conference, the creators presented the concept at several oncology and radiation oncology division meetings and sent email calendar invitations to all members of the oncology division and cancer center staff, including nurses, oncology navigators, social workers, and chaplains. The tumor board coordinator created an email listserv that includes approximately one hundred people, and prior to each session, the coordinator solicits cases via email from the listserv. During each session, three to five patients are presented with typical discussions lasting for 15–20 minutes per patient. Each presentation starts with the medical oncologist sharing the history and medical details of the case, followed by a review of the pertinent imaging by the interventional radiologist. The discussion is then opened to the panel, and the members ask questions, offer ideas, suggestions, and treatment strategies, as well as validation for the challenging aspects of the case. The conference is a well-attended, well-received discussion that offers a novel space to discuss some of the most challenging aspects of caring for patients with complex pain and symptoms in the setting of an advanced cancer diagnosis. In addition to focusing on symptoms and the medical aspects of each case, the creators of the tumor board also intended that the conference could be a safe space in which providers could discuss the emotionally difficult parts of caring for patients with such complex symptoms and illnesses.

Tumor board structure

The core members of the tumor board include one palliative care physician, one radiation oncologist, one interventional radiologist, one psychiatrist and one pediatric palliative care physician. Other attendees include people from multiple disciplines. There are routinely several palliative care physicians present, as well as palliative care fellows, who are encouraged by the fellowship program leadership to attend. Many medical oncologists and medical oncology fellows attend, both those presenting patients and those who are not on the docket to present that day. The oncologists who routinely attend specialize in different fields, including head and neck oncology, thoracic oncology, gastrointestinal oncology, breast oncology, gynecologic oncology, neuro-oncology and hematology. Other radiation oncologists sometimes attend, and a physical medicine and rehabilitation physician who heads the cancer rehabilitation program at our institution has recently joined the panel. Each conference is typically attended by between 15 and 20 people. No surgeons have attended the tumor board, as the time of day has interfered with operating room schedules.

The coordinator of the tumor board is a nurse who manages other tumor boards and leads the quality initiatives for the cancer center. A written summary of each patient prepared by the coordinator is presented to the panel at the start of the session. After completion of the tumor board session, the palliative care nurse navigator enters a short summary of the tumor board’s recommendations in the electronic medical record. The summary in the patient’s medical chart was added 1 year after the tumor board started to ensure that the recommendations were clear to the care team, in the same way that many of the oncology tumor boards enter discussion notes into the medical record (Figure 1). This has also helped with tracking patients that have been presented.

Figure 1 Sample tumor board note in EMR. MS Contin, morphine sulfate extended release; TID, three times daily; MSIR, morphine sulfate immediate release; PRN, as needed; EMR, electronic medical record.

Patient demographics and details

In the first 15 months of the existence of the tumor board, 68 patients were discussed. Half of those patients have died as of September 2022. There were more than 30 types of cancer discussed and the three most common types of cancer presented were breast, lung and head and neck cancer. Half the patients [34] had a change in the medications that they were being prescribed for pain in the 4 weeks after presentation at tumor board. Eighteen patients underwent some type of procedure with seven patients receiving radiation in the 4 weeks after tumor board presentation. Twenty-seven patients did not have any procedures or immediate change in medication after presentation at tumor board (Table 2).

Twenty-seven different medical oncologists and hematologists presented patients at the tumor board, with one oncologist presenting 11 patients, averaging about one patient a month. The 27 different oncologists represent more than 70% of the medical oncologists and hematologists at the Lifespan Cancer Institute. Further analysis shows that 90% of medical oncologists presented at least one patient since the inception of the tumor board, and 22% of the hematologists presented patients. This suggests that patients with solid tumors tend to have more localized pain than patients with hematologic malignancies, except for patients with multiple myeloma and osseous disease. Patients with advanced hematologic malignancies do have significant symptom burden, though localized pain is less common. In addition, the culture of hematology tends to be different from medical oncology (21). Hematologists are more likely to provide all the care for their patients and oncologists are more likely to work with multiple providers, such as surgeons and radiation oncologists. At our institution, palliative care is well integrated into the routine care of patients with advanced hematologic malignancies, so we hypothesize that more medical oncologists presented patients than hematologists because medical oncologists are well versed in the use of an interdisciplinary approach to pain management given the frequent involvement of surgeons, radiation oncologists and other subspecialists into the care of oncologist patients (21-23).

Discussion categories

In the first 15 months of the tumor board’s existence, three categories of patient cases emerged from the discussions. The first category is patients who had pain in a concentrated area due to the specific location of the tumor, and discussion led to a targeted procedure, such as a course of radiation or an interventional radiology procedure. The second category that emerged were patients whose discussion revolved around the medication regimen. The third category of patients was that in which the medical plan of care was confirmed by members of the panel, but the conversation focused on certain psychosocial aspects of the case and the emotional toll of those details on the care team (Figure 2).

Figure 2 Representative cases of discussion categories. PCP, primary care provider; CT, computed tomography; ENT, otolaryngologist.

The first category of patients was the type of patients that organizers of the tumor board anticipated as the most common and had in mind when the tumor board was conceptualized. The types of procedures that were prompted from the tumor board discussions included palliative radiation, nerve blocks, steroid injections, and cryo-ablative procedures. When radiation was advised, the tumor board would typically recommend a hypofractionated course of radiation to minimize the burden of repeated radiation visits. Members of the tumor board, led by the representative radiation oncologist, discussed data showing that the pain effects of single fraction or other hypofractionated courses was equally beneficial in pain management of patients with limited life expectancy. Other patients were referred for interventional procedures, which included celiac plexus block, aorticorenal nerve block, and ablative procedures, as well as epidural steroid injections. Typically, such procedures were offered to patients with symptoms well localized to a specific nerve distribution (e.g., intercostal nerve for chest wall symptoms, pudendal nerve for pelvic symptoms) that was amenable to local image-guided therapy, whether by targeted administration of local anesthetic agents and/or steroids, or by focused chemical (e.g., ethanol) or thermal ablative (e.g., cryoablation) techniques. Case 1 in Figure 2 exemplifies this category of patients.

Other patients did not have any interventional options to manage pain based on the type or location of disease and prior treatments, and medications remained the mainstay of their care. These represented the second category of patients. Often the tumor board, led by the adult and pediatric palliative care physicians, suggested medication adjustments that would improve the pain control. Sometimes the patients’ plans changed entirely to include an opioid rotation, adjuvant medication or even a wean off opioids. This was an opportunity for members of the tumor board to learn more about certain medications, notably methadone, buprenorphine, and ketamine. These drugs are in the wheelhouse of many palliative care physicians, but typically not used by oncologists. While most patients for whom these medications were used or recommended did have palliative care involvement, the oncologists involved expressed appreciation for the rationales for using medications outside of the typical first-line opioids, like morphine and oxycodone. Many of the patients in this category included patients who had challenging-to-manage pain syndromes, and adjuvant medications, such as serotonin-norepinephrine reuptake inhibitors, gabapentinoids, non-steroidal anti-inflammatory medications, and muscle relaxants, were often recommended. Other patients in this category had opioid use disorders either in remission or actively problematic that affected the way their cancer pain was managed. The care for patients with opioid use disorder and cancer pain requires a nuanced approach to both effectively treat pain as well as prevent relapse and protect sobriety. Oftentimes these patients are labeled as “difficult” or “challenging”, and the presentations at tumor board frequently allowed the physicians to further understand the complexities of living with substance use disorders and cancer and how those two circumstances weave together to affect a person’s life and health. A representative case for this category of patients is case 2 in Figure 2.

The third and final category of patients has been perhaps the most interesting category, as well as the least anticipated. This category includes patients in whom no drastic procedural or medication adjustments were recommended, but about which a vigorous discussion occurred. The tumor board has discussed patients who have had unusual medical diagnoses but has also focused heavily on patients who have a social, emotional, or spiritual complexity that has led to challenging circumstances in their care. Throughout the past year, the discussions that have been eye-opening and fascinating include topics around chronic pain syndromes, the role of opioids in the management of patients’ pain long after their cancer has been cured, voluntarily stopping eating and drinking (VSED), end-of-life options and medical aid in dying, interpersonal conflict between patient and physician, prognostication and missed prognostic estimates, communication around serious illness, being fired by a patient, substance use disorders, and boundaries around emotional involvement in a patient’s care. Each of these topics has arisen organically during the conversations about a patient’s symptoms and has led to spirited and supportive discussions. Many oncologists have reached out to the tumor board coordinators to offer gratitude for the discussions, as there are few spaces in medicine and oncology where the emotions of the physician are valued and examined in this way. Case 3 in Figure 2 exemplifies the potential value for providers and this kind of collaborative arrangement dedicated to pain and symptom management in the oncology population.

This type of case has illuminated one of the most important aspects of the tumor board: the opportunity it provides for collaboration and support on an emotional and psychological level for the physicians, nurse practitioners and other providers involved. Medicine can be isolating, particularly when physicians are super-specialized as many are in academic institutions. While the role of the traditional multidisciplinary tumor board to serve as a clearing house for treatment plans, an opportunity to discuss the medical details of difficult diagnoses and to get second, third and fourth opinions before initiating treatments that can be life-sustaining as well as life-altering matters deeply, our novel tumor board has emerged as a space in which providers can share the cases that challenge them in an emotional way as well as an intellectual way. Some of the hardest topics in medicine are discussed during these sessions, thus making them easier to process and handle.

Streamlining care

Having cancer is devastating for most people. In addition to the emotional toll of the illness, the physical symptoms can be both overwhelming and disruptive. While treatments have improved, undergoing systemic therapy remains an arduous process that usually includes frequent clinic or hospital visits, regular blood work with either repeated needle sticks and IV placements or a port placement, and a demanding schedule that pulls patients and their caregivers away from their day-to-day lives. One of the additional benefits of the tumor board was limiting the number of physician visits that the patient had to attend to receive the consultation. Instead of going to the radiation oncologist, interventional radiologist, palliative care physician and psychiatrist, the patient’s medical oncologist was able to convey the recommendations to the patient and then make one or more appropriate referrals for the intended management plan.

Recommended strategies

Our experience has shown that the creation of a palliative care tumor board that brings together oncologic specialists from multiple fields is a beneficial entity to support a coordinated approach to managing complex symptoms. To create a similar conference, we recommend developing a core group of enthusiastic clinicians. Our interventional radiologist and palliative care physician worked together to conceptualize the tumor board and then proposed the idea to the cancer center administration, which was immediately supportive. The involved physicians reached out to a radiation oncologist, and then as the group coalesced, additional members were added organically over time—including a psychiatrist and physical medicine and rehabilitation specialist—to meet the evolving needs of the participating physicians and their patients. The tumor board nurse coordinator helped with establishing continuing medical education credits. Some weeks multiple patients are submitted when an email request is sent, and if no patients have been suggested 2 days prior to the discussion, the palliative care physician will solicit patients from specific oncologists (Table 3). Over the past year, the attendance at tumor board, as well as willingness to submit cases has increased. Future directions for our multidisciplinary tumor board include a clinic following the discussion where patients could meet with the appropriate physicians who offered strategies for their care, a more rigorous assessment of patient outcomes more formally regarding pain and symptom assessments, and surveying participating physicians regarding their satisfaction and take-aways from this conference.

Conclusions

In conclusion, the creation and implementation of the Pain and Symptom Management Tumor Board has led to both expected results and the unanticipated experience of providing a vigorous exchange of ideas, increased collegiality, and opportunity for transdisciplinary teamwork. While some of the changes in patient care and pain management that resulted from the tumor board discussion may have occurred due to a medical oncologist independently requesting a palliative care or radiation oncology consultation, the increased exposure to multiple physicians with varied expertise likely led to a broader range of care possibilities and certain management strategies that would not otherwise have been considered. In addition to changes in patient care, the collaboration and mutual support experienced by the physician members of the panel has been incredibly meaningful. Oncologists who routinely attend the conference report that the experience is both thought-provoking, medically helpful, and uplifting. Working in isolation can lead to physician burnout and moral injury. Creating a forum in which physicians and advanced practice providers can discuss challenging cases and validate their own emotional reactions is a promising way to improve physician experience and work satisfaction. Further research is needed to fully explore the potential benefits for patients and families and the medical professionals who care for them.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Palliative Medicine, for the series “Palliative Care in GI Malignancies”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://apm.amegroups.com/article/view/10.21037/apm-22-1366/rc

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-22-1366/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-22-1366/coif). The series “Palliative Care in GI Malignancies” was commissioned by the editorial office without any funding or sponsorship. K.A. served as the unpaid Guest Editor of the series. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Ferrell BR, Temel JS, Temin S, et al. Integration of Palliative Care Into Standard Oncology Care: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol 2017;35:96-112. [Crossref] [PubMed]
2. MacDermid E, Hooton G, MacDonald M, et al. Improving patient survival with the colorectal cancer multi-disciplinary team. Colorectal Dis 2009;11:291-5. [Crossref] [PubMed]
3. Goyal G, Young JR, Abeykoon JP, et al. Impact of a Multidisciplinary Tumor Board on the Care of Patients with Histiocytic Disorders: The Histiocytosis Working Group experience. Oncologist 2022;27:144-8. [Crossref] [PubMed]
4. Freytag M, Herrlinger U, Hauser S, et al. Higher number of multidisciplinary tumor board meetings per case leads to improved clinical outcome. BMC Cancer 2020;20:355. [Crossref] [PubMed]
5. Rabiee A, Taddei T, Aytaman A, et al. Development and Implementation of Multidisciplinary Liver Tumor Boards in the Veterans Affairs Health Care System: A 10-Year Experience. Cancers (Basel) 2021;13:4849. [Crossref] [PubMed]
6. Pillay B, Wootten AC, Crowe H, et al. The impact of multidisciplinary team meetings on patient assessment, management and outcomes in oncology settings: A systematic review of the literature. Cancer Treat Rev 2016;42:56-72. [Crossref] [PubMed]
7. Basta YL, Bolle S, Fockens P, et al. The Value of Multidisciplinary Team Meetings for Patients with Gastrointestinal Malignancies: A Systematic Review. Ann Surg Oncol 2017;24:2669-78. [Crossref] [PubMed]
8. Katz MHG, Francescatti AB, Hunt KK, et al. Technical Standards for Cancer Surgery: Commission on Cancer Standards 5.3-5.8. Ann Surg Oncol 2022;29:6549-58. [Crossref] [PubMed]
9. Chang S, Doshi A, Smith CB, et al. Multidisciplinary tumor board for improvement of oncology collaboration in advance cancer patients. J Clin Oncol 2016;34:175. [Crossref]
10. Wright FC, De Vito C, Langer B, et al. Multidisciplinary cancer conferences: a systematic review and development of practice standards. Eur J Cancer 2007;43:1002-10. [Crossref] [PubMed]
11. McNaughton C, Horenkamp E, Wilson W, et al. Implementation of a Palliative Oncology Tumor Board. J Pain Symptom Manage 2021;62:1245-51. [Crossref] [PubMed]
12. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010;363:733-42. [Crossref] [PubMed]
13. Kaasa S, Loge JH, Aapro M, et al. Integration of oncology and palliative care: a Lancet Oncology Commission. Lancet Oncol 2018;19:e588-653. [Crossref] [PubMed]
14. Haun MW, Estel S, Rücker G, et al. Early palliative care for adults with advanced cancer. Cochrane Database Syst Rev 2017;6:CD011129. [Crossref] [PubMed]
15. Hui D, Kim YJ, Park JC, et al. Integration of oncology and palliative care: a systematic review. Oncologist 2015;20:77-83. [Crossref] [PubMed]
16. Furman M, Harild L, Anderson M, et al. The Development of Practice Guidelines for a Palliative Care Multidisciplinary Case Conference. J Pain Symptom Manage 2018;55:395-401. [Crossref] [PubMed]
17. Engelhardt M, Ihorst G, Schumacher M, et al. Multidisciplinary tumor boards and their analyses: the yin and yang of outcome measures. BMC Cancer 2021;21:173. [Crossref] [PubMed]
18. Mano MS, Çitaku FT, Barach P. Implementing multidisciplinary tumor boards in oncology: a narrative review. Future Oncol 2022;18:375-84. [Crossref] [PubMed]
19. Okasako J, Bernstein C. Multidisciplinary Tumor Boards and Guiding Patient Care: The AP Role. J Adv Pract Oncol 2022;13:227-30. [Crossref] [PubMed]
20. Taberna M, Gil Moncayo F, Jané-Salas E, et al. The Multidisciplinary Team (MDT) Approach and Quality of Care. Front Oncol 2020;10:85. [Crossref] [PubMed]
21. LeBlanc TW, Roeland EJ, El-Jawahri A. Early Palliative Care for Patients with Hematologic Malignancies: Is It Really so Difficult to Achieve? Curr Hematol Malig Rep 2017;12:300-8. [Crossref] [PubMed]
22. Ruiz M, Reynolds P, Marranzini R, et al. Role of Early Palliative Care Interventions in Hematological Malignancies and Bone Marrow Transplant Patients: Barriers and Potential Solutions. Am J Hosp Palliat Care 2018;35:1456-60. [Crossref] [PubMed]
23. Hochman MJ, Yu Y, Wolf SP, et al. Comparing the Palliative Care Needs of Patients With Hematologic and Solid Malignancies. J Pain Symptom Manage 2018;55:82-88.e1. [Crossref] [PubMed]