Virtual Tumor Boards for Remote Learning in Head and Neck Surgical Oncology

This survey study assesses use of American Head and Neck Society Virtual Tumor Board videos as virtual learning for head and neck surgical oncology trainees.

Key Points

Question

Is a virtual education series using a tumor board format an effective learning tool for head and neck surgical oncology trainees?

Findings

This survey study examined the structure and content of 42 American Head and Neck Society (AHNS) Virtual Tumor Board sessions and assessed engagement with and strengths and weaknesses of the sessions via survey. Each recorded session was viewed a mean of 217 times, and most survey respondents (69%) felt that the sessions were excellent for learning.

Meaning

The AHNS Virtual Tumor Board was well-attended and well-reviewed by trainees and may represent a useful model of remote learning.

Abstract

Importance

In addition to their patient management value, multidisciplinary tumor boards have been recognized as effective learning tools. However, the value of using a virtual tumor board as a learning tool for head and neck surgical oncology fellows has not been studied.

Objective

To describe the structure and content of the American Head and Neck Society (AHNS) Virtual Tumor Board and assess its educational value as perceived by attendees.

Design, Setting, and Participants

All sessions of the AHNS Virtual Tumor Board from April 8, 2020, to June 1, 2022, were reviewed. Topics, presenters, participants, and viewership data were collected as of October 15, 2022, from session recordings posted to an online video sharing and social media platform. Additionally, an anonymous, 14-question online survey was designed to elicit feedback from head and neck surgery trainees on virtual tumor board engagement, strengths, and weaknesses. The survey was electronically distributed in June and July 2022 to the 101 fellows enrolled in AHNS-accredited programs between July 1, 2020, and June 30, 2022.

Main Outcomes and Measures

The primary aim was to tabulate online viewership of the sessions. The secondary aim was to qualitatively assess the experience of head and neck trainees with the AHNS Virtual Tumor Board using a survey.

Results

Forty-two sessions of the virtual tumor board were held between April 8, 2020, and June 1, 2022. Almost all sessions (41 [98%]) were case based. One hundred and sixteen cases were presented, representing 2 to 3 cases per session, by 75 unique faculty members. Each session was viewed a mean of 217 times (range, 64-2216 views). In the 2021 to 2022 academic year, a mean of 60 viewers (range, 30-92 viewers) attended each live session. In all, 29 survey responses were collected from 101 fellows in AHNS-accredited programs (29% response rate). Most respondents felt the format allowed for excellent teaching (18 of 26 respondents [69%]) and discussion (19 of 26 respondents [73%]). Most respondents (22 of 29 respondents [76%]) believed that practicing head and neck surgeons would benefit from the sessions.

Conclusions and Relevance

This survey study found that the AHNS Virtual Tumor Board was well-attended and well-reviewed by head and neck surgical oncology trainees. The virtual tumor board format could be used as model of remote learning for other organizations.

Introduction

Participation in regular multidisciplinary tumor boards is a useful aspect of head and neck surgical oncology training. The traditional purpose of tumor boards is to facilitate discussion of diagnosis, staging, and management among the various practitioners involved in the complex management of patients with head and neck cancer. Previous work has found that tumor boards have value in both altering treatment plans for these patients and coordinating care among practitioners.^1,2 It has also been established that discussion at multidisciplinary tumor boards is associated with improved survival in patients with squamous cell carcinoma of the head and neck.³ Trainees (residents and fellows) are commonly involved in tumor boards to become more familiar with the presentation, workup, and evidence-based treatment of patients with head and neck cancer. However, the value of using a multidisciplinary tumor board format as a learning tool for head and neck surgeons-in-training has not been studied.

The educational value of tumor boards is reflected by the fact that many institutions offer continuing medical education credit to attendees.⁴ When surveyed, most tumor board attendees in nonotolaryngologic disciplines, including postgraduate trainees,⁵ have reported that the sessions have enhanced their learning.^6,7 While tumor boards have traditionally been held within a single center, the rise of virtual platforms has allowed for collaboration between practitioners across institutions and geographic regions. Recently, a multi-institutional group of gastrointestinal oncologists reported on the use of a virtual panel to discuss challenging cases for educational purposes.⁸ To our knowledge, there have been no previous efforts to implement a remote tumor board program to educate head and neck surgery trainees.

The American Head and Neck Society (AHNS) Curriculum Development and Management Service established a virtual tumor board series in April 2020 to provide continued education to fellows in the context of the COVID-19 pandemic. Each session was conducted via an online platform and focused on a particular discipline of head and neck cancer. By reviewing case scenarios, content experts were able to discuss strategies for management of specific pathologies. To explore the educational value of these sessions, we surveyed current and past fellows at AHNS-accredited fellowship programs. This study presents the structure of the AHNS Virtual Tumor Board program and attendees’ perceived strengths and weaknesses of the format.

Methods

This survey study was approved by the Institutional Review Board of the NYU Grossman School of Medicine. Written informed consent was not obtained from survey respondents, although the survey indicated that the results were intended to be used for a study.

Virtual Tumor Board Format

Each session of the AHNS Virtual Tumor Board was dedicated to a specific content area related to head and neck surgery and oncology. Sessions were presented live via Zoom (Zoom Video Communications) to fellows enrolled in AHNS-accredited programs, and then made available on the AHNS YouTube page (Google, Inc), where they could be publicly viewed.⁹ Members of the AHNS Curriculum Development and Management Service typically acted as moderators for the sessions and invited content area experts to serve as case presenters and discussants. The format comprised a clinical case presentation (selected by the presenter), review of relevant imaging, discussion of treatment options, description of the treatment applied, and summary of teaching points. The session moderator then facilitated a discussion of the case with faculty members. Case scenarios were designed to be completed in 20 minutes. Attendees were invited to pose questions via the chat feature on Zoom. Sessions were held weekly during the 2019 to 2020 fellowship year, biweekly during the 2020 to 2021 fellowship year, and monthly during the 2021 to 2022 fellowship year.

Analysis of Session Recordings

We reviewed the Virtual Tumor Board’s page on the AHNS website to view videos of all sessions that were presented to AHNS fellows from April 2020 through June 2022.¹⁰ Recordings were analyzed by 2 of us (M.R.P., M.C.) to sum the number of cases discussed in each session, the number of faculty discussants, and the number of faculty participants. All session recordings were accessed on October 15, 2022, to collect online viewership data. Live viewership data were available for the 2021 to 2022 academic year.

Survey Format

In addition to the objective data collected from the recordings, we designed a survey to explore how attendees viewed the experience. The survey was designed by 2 of us (M.R.P., M.C.) and was reviewed and edited by the rest of us (D.W., J.C.L., A.F.B., M.G.M., M, B.G). The anonymous survey was constructed via Qualtrics (Qualtrics Software Company) and consisted of 14 questions addressing demographics (1 question), engagement with tumor board (2 questions), viewership (2 questions), and evaluation (9 questions). Radio buttons displayed available options. Questions to evaluate the quality of the sessions were limited to a single response, whereas questions about how to improve the sessions allowed for multiple responses. Responses to the evaluation questions were rated on a scale of 1 (poor) to 5 (excellent). Respondents were also invited to share their thoughts on the most helpful and least helpful aspects of the case-based format and how to improve the sessions via a free-text box.

All AHNS fellows from the 2020 to 2021 and 2021 to 2022 academic years were invited to complete the survey via an email from AHNS administration. The survey was first distributed on June 10, 2022, and a second time on July 10, 2022, to facilitate completion. Responses were evaluated from June 11 through August 18, 2022.

Statistical Analysis

Survey output was automatically compiled in Excel (Microsoft Corp) and was analyzed using Prism (GraphPad Software). Linear regression was used to study trends over time. To quantify differences between the means of multiple independent groups, η² with 95% CIs was used as a measure of effect size.

Results

Session Recordings

In all, 42 sessions of the AHNS Virtual Tumor Board were held between April 8, 2020, and June 1, 2022. Almost all sessions (41 [98%]) were case based, while 1 was held in a quiz show format. A total of 116 cases were presented over the 42 sessions, for a mean (SD) of 2.8 (0.6) cases per session. Most cases were presented by faculty (109 cases [94%]), while a minority were presented by fellows (4 cases [3%]) or residents (3 cases [3%]) on behalf of faculty. Seventy-five unique faculty members presented cases. Over the 42 sessions, 17 nonotolaryngologic faculty participated in the virtual tumor board. Represented specialties included radiology (8 faculty [47%]), radiation oncology (3 faculty [18%]), medical oncology (2 faculty [12%]), oral surgery (2 faculty [12%]), thoracic surgery (1 faculty [6%]), and ethics (1 faculty [6%]). Disciplines covered by the virtual tumor board included reconstruction (6 sessions [14%]), oral cavity and oropharynx (6 sessions [14%]), endocrine surgery (6 sessions [14%]), general head and neck (5 sessions [12%]), cutaneous cancer (5 sessions [12%]), rhinology or skull base (4 sessions [10%]), laryngeal cancer (4 sessions [10%]), salivary gland (3 sessions [7%]), general fellowship information and orientation (2 sessions [5%]), and ethics (1 session [2%]) (Table).

Table. Disciplines Covered in 42 American Head and Neck Society Virtual Tumor Board Sessions.

Discipline	Sessions, No. (%)
Endocrine surgery	6 (14)
Oral cavity and oropharynx	6 (14)
Reconstruction	6 (14)
Cutaneous cancer	5 (12)
General head and neck	5 (12)
Rhinology or skull base	4 (10)
Laryngeal cancer	4 (10)
Salivary gland	3 (7)
General fellowship information and orientation	2 (5)
Ethics	1 (2)

Each session had a median (range) of 217 (61-2216) views on YouTube. The 3 sessions with the most views were about sinonasal neoplasms: open vs endoscopic approach (2216 views), oropharynx (386 views), and nonmelanoma skin cancers (349 views). Live viewership data were available only for the 2021 to 2022 fellowship year. During this period, a mean (range) of 60 (30-92) viewers watched each session live.

The average number of YouTube views per recorded session was similar between the 3 fellowship years (2019-2020, 210 views; 2020-2021, 268 views; 2021-2022, 117 views; η² = 0.04 [95% CI, 0-0.17]). Within each fellowship year, only the most recent (2021-2022) demonstrated a decline in viewership over the course of the year (from 221 to 70 views, r² = 0.86). There was an association between content area and the number of session views (η² = 0.19; 95% CI, 0-0.23), but the number of sessions in each content area was small (Table).

Survey Data

Surveys were distributed to 101 fellows who were enrolled in AHNS-accredited fellowship programs between July 1, 2020, and June 30, 2022. Adequate survey responses were obtained from 29 respondents (demographic data were not requested), for a response rate of 29%. At the time of survey completion, most respondents (26 [90%]) identified as fellows, while the remainder were attending physicians (3 [10%]). Most respondents (26 [90%]) heard about the virtual tumor board through an email communication from the AHNS. Most respondents attended 1 to 5 sessions (12 respondents [41%]) or 6 to 10 sessions (12 respondents [41%]); a minority attended more than 10 sessions (5 respondents [17%]). It was more common to exclusively attend sessions live (10 respondents [34%]) and less common to exclusively view recorded sessions (5 respondents [17%]). The majority of respondents felt that the frequency of sessions (24 respondents [83%]) and the breadth of the topics discussed (28 respondents [97%]) were appropriate.

Most respondents reported that the case-based format of the virtual tumor board fostered excellent (19 of 26 respondents [73%]) or above average (6 of 26 respondents [23%]) discussion. Three respondents did not select answers to questions about the format. The majority found that the format allowed for excellent (18 of 26 respondents [69%]) or above average (7 of 26 respondents [27%]) learning. Most respondents were in favor of maintaining the format (16 of 29 respondents [55%]), while some (13 of 29 respondents [45%]) felt it would be beneficial to include a debate format in which faculty argue for and against a topic.

Of 5 respondents who identified limitations of the format, 3 (60%) felt that the robust discussion surrounding a given case was often cut short by the need to move on to subsequent scheduled cases. Of 13 respondents who identified advantages of the format, 5 (38%) highlighted the diversity of cases presented and variety of perspectives shared.

While most respondents felt that nonotolaryngologic specialists were appropriately represented in the sessions (16 of 29 respondents [55%]), many requested the presence of a radiation oncologist at more sessions (13 of 29 respondents [45%]). When asked to identify other groups that could benefit from the education provided at the sessions, the most identified group was practicing head and neck surgeons (22 of 29 respondents [76%]). Specific free-text responses about how to improve the sessions overall included adding “how I do it” sessions to showcase surgical technique, extending invitations to former fellows, and more clearly defining learning objectives at the start of each session.

Discussion

Many traditional tumor boards transitioned to a virtual format during the COVID-19 pandemic, and the benefits related to increased attendance and participation have been documented.¹¹ The differentiating factor for the AHNS Virtual Tumor Board series was the intention to use the format as a novel teaching tool to educate trainees. This strategy was based on our findings from interviewing experts in head and neck surgery, who agreed that the tumor board is an effective learning tool.¹² After operationalizing this opinion for more than 2 years, we investigated the educational value of this format. Viewership data presented in this study suggested that the sessions were well-attended, and survey results indicated that attendees found the sessions to be educational. The mean number of online views for each AHNS Virtual Tumor Board session (217) showed that engagement with the sessions extended beyond fellows currently enrolled in AHNS-accredited programs. We also observed similar viewership across the various content areas, suggesting that the selected topics were equally interesting to most audiences.

By design, the topics reviewed during traditional multidisciplinary tumor boards are driven by the cases that are slated for discussion. Because the curriculum can be intentionally designed, a virtual tumor board expands the educational potential of the conventional tumor board format. In a study of a gastrointestinal oncology virtual tumor board series, 58% of participants felt that the virtual case scenarios offered more educational value than the tumor boards at their own institutions.⁸ A strength of the AHNS Virtual Tumor Board curriculum identified by attendees was the varied nature of the session topics. This allowed participants to hear directly from experts representing a diverse range of head and neck subspecialty areas. This is an additional educational benefit of virtual tumor conferences: trainees are offered consistent and convenient opportunities to be exposed to management strategies practiced by experts at other institutions.

The AHNS Virtual Tumor Board primarily used a case-based format. Most survey respondents reported that this format supported excellent discussion (19 of 26 respondents, or 73%) and teaching (18 of 26 respondents, or 69%). Nonetheless, 45% (13 of 29) of respondents suggested the addition of a formal debate format. Inclusion of this format could be helpful, especially when multiple management options exist. In the current case-based format, the session moderator typically elicits input from multiple faculty members present at the session in addition to the presenter, which can highlight differing management strategies. Many respondents (13 of 29 [45%]) also requested the presence of a radiation oncologist at additional sessions. This request suggested an interest in hearing opinions of nonsurgical radiation options and could be an avenue for improvement in future iterations. When the most recent academic year (2021-2022) was analyzed, there was a decline in online viewership over the course of the year. It is possible that not enough time elapsed before data analysis to see viewership in the later months increase. However, other possibilities include meeting fatigue as well as the chance that there is decreased interest in virtual conferences as in-person conferences resume. Continued monitoring of viewership and evaluation of content will be necessary to drive continued interest and engagement. A more interactive format in which the audience has an opportunity to respond to questions has been tested in a limited number of sessions. Effective implementation of this concept requires adequate infrastructure that can complete and broadcast the results in a timely fashion. In the current format, the participants can use the chat feature of the video conference platform to post questions or comments. In the AHNS Virtual Tumor Board sessions, a dedicated person monitors the communication board to respond to and or relay the messages.

The virtual tumor board format has potential uses in addition to the education of fellows enrolled in AHNS-accredited programs. The remote nature of the sessions could allow for international fellows-in-training to participate. The sessions could also be used to provide otolaryngology residents with additional exposure to the specialty of head and neck surgical oncology. This exposure could be helpful with career decision-making and could help prospective head and neck surgery applicants identify mentors in the field. In a study of medical students, tumor board attendance was shown to provide more education and exposure to a field than traditional clinical shadowing.¹³ Respondents to our survey also highlighted that the sessions would be valuable to attending physicians, who could remain abreast of contemporary practice trends at peer institutions. In addition to head and neck surgeons, general otolaryngologists who incorporate head and neck care into their practice and maintain board certification could also benefit from the programming of the virtual tumor board. One possible method to incentivize additional head and neck surgeon (nontrainee) participation in the AHNS Virtual Tumor Board would be to offer continuing medical education credit for attendance.

The standard channels for fellows to be exposed to techniques performed at other institutions include courses, national meetings, and publications. Leaders in head and neck surgery education agree there is a need for a standardized national curriculum.¹² This need was accelerated in the context of the COVID-19 pandemic, when many existing educational programs housed at host institutions were paused. Findings of the present study suggest that a remote tumor board can be an effective remote learning tool with a national and international reach. As the AHNS and other fellowship bodies seek to create standardized curricula, inclusion of a virtual tumor board series, such as the one described here, could be considered.

In the process of creating this case-based learning series, we identified several key points that may be useful to other groups seeking to establish similar programs. It is important to have well-recognized experts in the field of head and neck oncology participate in sessions relevant to their area of expertise. We have found that their inclusion maximizes attendee interest in the sessions. It is also crucial to ensure a diverse group of expert presenters, not only in gender, race and ethnicity, and academic affiliation, but in specialty as well. In head and neck oncology, this includes featuring specialists from radiation oncology, medical oncology, radiology, and endocrinology. Consistency in the format of the sessions and limiting the frequency to once a month has been helpful in assuring quality and maintaining the interest of the audience. Moderating the sessions requires expertise in head and neck oncology and skills as a session moderator. It is important not only to ask relevant questions and direct the conversation, but also to keep a good pace and assure that all cases are discussed and that panelists have an opportunity to share their experience of managing similar clinical scenarios. During these sessions, we avoided dedicating time to literature reviews and presenting large amounts of data and instead focused on clinical pearls and the nuances of clinical decision-making.

Finally, society support of the virtual tumor board was a key component of this remote learning program. From conception to execution and continuation of the program, the program organizers leaned heavily on the expertise and resources of the AHNS. The AHNS provided the telecommunication platform account, advertised upcoming sessions, and hosted the previous sessions on its website, which can be viewed, free of charge, anywhere in the world.¹⁰ We believe that these resources and support have been invaluable and that this effort would not have been possible without the backing of the AHNS.

Limitations

Limitations of survey studies include recall and response bias. The response rate for this survey was 29%, and the responses may have not be representative of the views of all attendees. It would also be helpful to study the implications of this series for the clinical practice of attendees. While live viewership data were reflective of the engagement of the main target audience (head and neck surgery fellows), it is not possible to study who viewed the sessions online and if the sessions have been used as an educational tool. Despite these limitations, we believe that this study provides valuable insight into the educational value of the virtual multidisciplinary tumor board format and describes a program that could be implemented in other specialties and settings.

Conclusion

The AHNS Virtual Tumor Board series was well-attended and well-reviewed by head and neck surgeons-in-training. The survey participants expressed high satisfaction with this program’s format, contents, and educational value. This novel, case-based, discussion-oriented teaching format could be used as an effective learning model for other organizations and should be continued.

Supplement.

Data Sharing Statement