Quantifying the utility of a multidisciplinary neuro-oncology tumor board

Implementation of a student-run initiative to facilitate multidisciplinary cancer care in Pakistan: the Tumor Board Establishment Facilitation Forum

BACKGROUND

The lack of a multidisciplinary approach to the management of cancer patients in most parts of Pakistan is a long-standing and major concern. To overcome this disparity, we started a student-run initiative to facilitate the establishment of multidisciplinary tumor boards (MTBs) in oncology, titled "Tumor Board Establishment Facilitation Forum (TEFF)". The objectives of this study were to evaluate the clinical and academic impact of TEFF on cancer care for patients and student education, respectively.

METHODS

The formation of TEFF was based on the Theory of Change model. We conducted a needs assessment based on existing literature, physical evaluation of wards, and consultation with senior academic faculty members. The logic model was refined through multiple meetings between stakeholders. All engagements of TEFF described in this manuscript are limited to the Dow Medical College and its affiliated tertiary care hospital, Dr. Ruth K. M. Pfau Civil Hospital in Karachi, Pakistan. To gauge TEFF's impact, we used administrative data generated between October 2021 to March 2024 to evaluate predefined outcomes (number of MTBs, cases, educational interventions, and research).

RESULTS

The organizational structure comprised of 6 specialized departments: Communications, Operations, Media, Integrated Development, Research and Records, and Finance. We conducted 18 educational sessions for medical students about career guidance, research, cancer awareness; and 4 cancer awareness campaigns. TEFF facilitated the formation of 4 MTBs: breast, head and neck, gynecology, and pediatrics. Across these, 105 cases were discussed in 50 meetings. TEFF provided leadership opportunities, allowed familiarization with oncology, raised awareness of challenges associated with cancer care, allowed networking, and inculcated research-related skills and educational value through its MTBs.

CONCLUSION

Medical students can contribute significantly to clinical care at the undergraduate level. For countries/regions struggling to provide multidisciplinary cancer care, TEFF's model serves as a blueprint for a viable solution.

A nationwide provider survey of neuro-oncology tumor boards in a lower-middle-income country: Comparing centers with and without tumor boards

OBJECTIVES

To provide information about implementation, resources, practice patterns and prevalent perceptions regarding neuro-oncology tumor boards (NOTBs) in a lower middle income country.

METHODS

A nationwide survey was designed to include licensed neurosurgeons involving data on practice, structure, and perceptions of NOTBs with non-probability sampling, a pre-validated proforma, data analysis using SPSS v27, and geospatial mapping using Quantum GIS.

RESULTS

139 neurosurgeons were surveyed from 63 neurosurgical centers of a lower middle income country. 15/63 neurosurgical centers had dedicated NOTBs. Neurosurgeons from centers with NOTBs had better access to palliative care with radiation oncologists (70 %) and services (73 %) as compared to those without NOTBs (44 %, p = 0.012 and 44 %, p = 0.004). 76.3 % of neurosurgeons routinely prescribed postoperative CT scans with higher rate in centers without NOTBs (94 % vs. 80 %, p = 0.024). 57.6 % of neurosurgeons prescribed postoperative MRI scans within six weeks for intra-axial pathology, with higher rates in NOTB centers (63 % vs. 56 %, not significant). The perceived positive effects of NOTBs included improved patient outcomes (87.6 %), expedited centralized patient care (88.3 %), decreased referral times (74.4 %), increased uptake of adjuvant management (66.4 %), decreased mortality/morbidity (73.1 %), and significant treatment (78.5 %) and diagnostic plan changes (77.4 %) while perceived negative effects included the time-consuming nature (20.7 %), and suffering of patients due to wait associated with NOTBs (36 %). The perceived barriers included "lack of administrative support" (17.1 %), "limited resources" (15.2 %), and "lack of standardized protocols or guidelines" (13.8 %).

CONCLUSION

In this nationwide situational report from a lower middle income country, only a quarter of neurosurgical units had dedicated NOTBs. The centers with NOTBs were mostly education/training centers, and had better access/availability to palliative decision-making and care. The neurosurgeons from centers with NOTBs had lower rates of prescribing immediate postoperative CT scans while higher rates of prescribing MRI scans within 6 weeks for intra-axial pathology. Therefore, NOTBs can help advocate for judicious use of neuroimaging and increased uptake of adjuvant palliative treatment. While perceived effects were similar, the nature of perceived barriers was different for LMIC and HIC. Our study can aid policymakers, hospitals, and healthcare professionals, and can provide a roadmap for future in-depth studies with geospatial mapping of resources/services to fully elucidate the inequalities.

Implementing New Dementia Care Models in Practice

ABSTRACT

Care for patients with Alzheimer disease and related neurodegenerative causes of dementia is in the midst of a transformation. Recent advancements in diagnostics and therapeutics reflect a rapidly evolving knowledge base and represent positive steps for patients and clinicians facing these progressive diseases; however, the complexities of emerging biomarkers and treatment options present challenges that will require systematic adaptations to routine care to facilitate effective incorporation of these options. This article reviews ongoing updates in the assessment and management of neurodegenerative causes of dementia, focusing on practical models for innovation that practices and health care systems can use to implement these new tools. In particular, sustainable adaptation in the field will benefit from a comprehensive approach implemented at local levels, including (1) education of clinicians and communities to refine perceptions about dementia care, (2) multifaceted stakeholder engagement to optimize infrastructure and workflows to the new era, and (3) investments in personnel to address existing and exacerbated gaps.

SEOM-GEINO clinical guidelines for grade 2 gliomas (2023)

The 2021 World Health Organization (WHO) classification has updated the definition of grade 2 gliomas and the presence of isocitrate dehydrogenase (IDH) mutation has been deemed the cornerstone of diagnosis. Though slow-growing and having a low proliferative index, grade 2 gliomas are incurable by surgery and complementary treatments are vital to improving prognosis. This guideline provides recommendations on the multidisciplinary treatment of grade 2 astrocytomas and oligodendrogliomas based on the best evidence available.

Multidisciplinary neurofibromatosis conference in the management of patients with neurofibromatosis type 1 and schwannomatosis in a single tertiary care institution

OBJECTIVE

To evaluate the role of weekly neurofibromatosis (NF) multi-disciplinary conferences (MDC) on the diagnostic and therapeutic plan for patients with NF type 1 (NF1) and schwannomatosis (SWN).

MATERIALS AND METHODS

This retrospective study reviewed patients with confirmed or suspected NF1 and SWN discussed in weekly MDC from March to July 2021. Demographic data collected included patient age, sex, pre-conference and post-conference diagnosis, radiological studies reviewed, and provider specialties in attendance. Outcomes reported included changes in imaging interpretation and treatment plans, changes in post-conference diagnosis relative to pre-conference diagnosis, and time to completion of the recommended change in treatment.

RESULTS

Data from 17 MDC "pre-conference" lists included 75 patients (38 female, 37 males, mean age (years): 38 (range: 6-80)) with NF1 (52%, 39/75) and SWN (36%, 27/75) discussed over a total of 91 case reviews. 18.7% (14/75) of all patients had NF2-related SWN, and 17.3% (13/75) of all patients had non-NF2 SWN. The MDC led to changes in imaging interpretation in 18.7% and changes in patient management in 74.7% (diagnostic testing (n = 52), surgical plan (n = 24), medical treatment (n = 9), clinical trial status (n = 4), and radiation treatment (n = 1)) of cases. Among patients for whom a change in management was recorded, 91% (62/68) completed at least one recommendation (mean time to completion (days): 41.4 (range: 0-278)).

CONCLUSION

Weekly MDC changes the diagnostic and therapeutic management of the majority of patients discussed (74.7%) and promotes a high adherence rate to recommendations (91%).

Virtual multi-institutional tumor board: a strategy for personalized diagnoses and management of rare CNS tumors

PURPOSE

Multidisciplinary tumor boards (MTBs) integrate clinical, molecular, and radiological information and facilitate coordination of neuro-oncology care. During the COVID-19 pandemic, our MTB transitioned to a virtual and multi-institutional format. We hypothesized that this expansion would allow expert review of challenging neuro-oncology cases and contribute to the care of patients with limited access to specialized centers.

METHODS

We retrospectively reviewed records from virtual MTBs held between 04/2020-03/2021. Data collected included measures of potential clinical impact, including referrals to observational or therapeutic studies, referrals for specialized neuropathology analysis, and whether molecular findings led to a change in diagnosis and/or guided management suggestions.

RESULTS

During 25 meetings, 32 presenters discussed 44 cases. Approximately half (n = 20; 48%) involved a rare central nervous system (CNS) tumor. In 21% (n = 9) the diagnosis was changed or refined based on molecular profiling obtained at the NIH and in 36% (n = 15) molecular findings guided management. Clinical trial suggestions were offered to 31% (n = 13), enrollment in the observational NCI Natural History Study to 21% (n = 9), neuropathology review and molecular testing at the NIH to 17% (n = 7), and all received management suggestions.

CONCLUSION

Virtual multi-institutional MTBs enable remote expert review of CNS tumors. We propose them as a strategy to facilitate expert opinions from specialized centers, especially for rare CNS tumors, helping mitigate geographic barriers to patient care and serving as a pre-screening tool for studies. Advanced molecular testing is key to obtaining a precise diagnosis, discovering potentially actionable targets, and guiding management.

Cancer Care by Committee to be Superseded by Personal Physician-Patient Partnership Informed by Artificial Intelligence

Multidisciplinary tumor boards (MTBs) have become the reference standard of cancer management, founded upon randomized controlled trial (RCT) evidence-based guidelines. The inordinate delays inherent in awaiting formal regulatory agency approvals of novel therapeutic agents, and the rigidities and nongeneralizability of this regimented approach, often deny cancer patients timely access to effective innovative treatment. Reluctance of MTBs to accept theranostic care of patients with advanced neuroendocrine tumors (NETs) and metastatic castrate-resistant prostate cancer resulted in decades of delay in the incorporation of 177Lu-octreotate and 177Lu-prostate-specific membrane antigen (PSMA) into routine clinical oncology practice. Recent developments in immunotherapy and molecular targeted precision therapy, based on N-of-One individual multifactorial genome analyses, have greatly increased the complexity of decision-making. Burgeoning specialist workload and tight time frames now threaten to overwhelm the logistically, and emotionally, demanding MTB system. It is hypothesized that the advent of advanced artificial intelligence technology and Chatbot natural language algorithms will shift the cancer care paradigm from a MTB management model toward a personal physician-patient shared-care partnership for real-world practice of precision individualized holistic oncology.

Neuro-Oncology Multidisciplinary Tumor Board: The Point of View of the Neuroradiologist

Background: The multi-disciplinary tumor board (MTB) is essential to quality cancer care and currently recommended to offer the best personalized clinical approach, but little has been published regarding MTBs in neuro-oncology (nMTBs). The aim of the present paper is to describe our nMTB, to evaluate its impact on clinical management decisions, and to assess the role of neuroradiologists. Methods: The retrospective evaluation of the cases discussed at our nMTB from March 2017 to March 2020. From the electronic records, we extracted epidemiological, clinical and other specific data of nMTB. From the radiological records, we calculated data relating to the number, time for revision, and other specifications of MRI re-evaluation. Statistical analysis was performed. Results: a total of 447 discussions were analyzed, representing 342 patients. The requests for case evaluations came from radiation oncologists (58.8%) and neurosurgeons (40.5%), and were mainly addressed to the neuroradiologist (73.8%). The most frequent questions were about the treatment’s changes (64.4%). The change in patient treatment was reported in 40.5% of cases, 76.8% of these were based on the neuroradiologic assessment. A total of 1514 MRI examinations were re-evaluated, employing approximately 67 h overall. The median of the MRI exams reviewed per patient was 3 (min–max 1–12). Conclusions: Our study supported that the multidisciplinary approach to patient care can be particularly effective in managing brain tumors. A review by an expert neuroradiologist impacts patient management in the context of nMTBs, but has costs in terms of the time and effort spent preparing for it.

The role of anticoagulation for superior sagittal sinus thrombosis following craniotomy for resection of parasagittal/parafalcine meningiomas

OBJECTIVE

The safety and efficacy of anticoagulation in managing superior sagittal sinus (SSS) thrombosis remains unclear. The present study investigated the relationship between anticoagulation and cerebrovascular complications in parasagittal/parafalcine meningioma patients presenting with post-surgical SSS thrombosis.

METHODS

We analyzed 266 patients treated at a single institution between 2005 and 2020. Bivariate analysis was conducted using the Mann-Whitney U test and Fisher's exact test. Multivariate analysis was conducted using a logistic regression model. Blood thinning medications investigated included aspirin, warfarin, heparin, apixaban, rivaroxaban, and other novel oral anticoagulants (NOACs). A symptomatic SSS thrombosis was defined as a radiographically apparent thrombosis with new headaches, seizures, altered sensorium, or neurological deficits.

RESULTS

Our patient cohort was majority female (67.3%) with a mean age ([Formula: see text] SD) of 58.82 [Formula: see text] 13.04 years. A total of 15 (5.6%) patients developed postoperative SSS thrombosis and 5 (1.9%) were symptomatic; 2 (0.8%) symptomatic patients received anticoagulation. None of these 15 patients developed cerebrovascular complications following observation or anticoagulative treatment of asymptomatic SSS thrombosis. While incidence of any other postoperative complications was significantly associated with SSS thrombosis in bivariate analysis (p = 0.015), this association was no longer observed in multivariate analysis (OR = 2.15, p = 0.16) when controlling for patient age, sex, and anatomical location of the tumor along the SSS.

CONCLUSIONS

Our single-institution study examining the incidence of SSS thrombosis and associated risk factors highlights the need for further research efforts better prognosticate this adverse outcome. Conservative management may represent a viable treatment strategy for patients with SSS thrombosis.