Impact of a Virtual Multidisciplinary Lymphoma Tumor Board on Clinical Decision-Making

Abstract

Objective

To evaluate the impact of a virtual multidisciplinary lymphoma tumor board on clinical decision-making over time.

Patients and Methods

The Mayo Clinic Lymphoma Tumor Board, part of the International Mayo Clinic Care Network, conducted a retrospective review of 722 cases from January 1, 2014 to July 31,2024. The process includes review of clinical history, radiology, and hematopathology. In March 2020, the board transitioned to a fully virtual format. Recommendations regarding radiology, pathology, and treatment were tracked to compare pre-COVID (January 2014-February 2020) and post-COVID (March 2020-July 2024) eras.

Results

Of 722 cases, changes in care were identified in 423 patients. In the pre-COVID period (n=431), changes were recommended for 217 patients (50.3%, 217/431). Post-COVID (n=291), changes were recommended for 206 patients (70.8%, 206/291), representing a 40.6% relative increase (p < 0.001). Average recommendations per case rose from 0.64 (277/431) to 1.18 (343/291). Post-COVID increases were observed across all domains: radiologic interpretation changes rose from 2.1% (9/431) to 7.2% (21/291), pathologic diagnosis changes from 10.0% (43/431) to 18.6% (54/291), additional testing recommendations from 16.9% (73/431) to 29.2% (85/291), and clinical management alterations from 35.3% (152/431) to 62.9% (183/291).

Conclusion

The transition to a Virtual Tumor Board format coincided with increased tumor board–driven recommendations affecting diagnostic interpretation and clinical management. These results illustrate the potential of Virtual Tumor Boards to improve collaborative decision-making and adapt to evolving clinical needs.

The management of lymphoma, a diverse group of hematologic malignancies, is increasingly challenging due to ongoing advancements in diagnostics and treatment paradigms.1, 2, 3, 4, 5 The diagnostic landscape is complex, characterized by nuanced classification systems such as the 2022 International Consensus Classification and the 5th Edition of the World Health Organization Classification, which delineate over 100 distinct lymphoid neoplasms.^6,7 Accurate classification is crucial, as treatment strategies and prognoses vary significantly between subtypes, and the integration of genomic data (eg, whole exome sequencing and RNA sequencing) continues to identify clinically relevant molecular subtypes within established categories such as diffuse large B-cell lymphoma.2, 3, 4^,6,7 This biological complexity requires specialized expertise for clinical interpretation and application.

The treatment landscape for lymphoma has expanded significantly in the last decade beyond traditional chemotherapy.⁸ Treatment options include immunochemotherapy combinations, targeted agents, antibody–drug conjugates, bispecific antibodies, chimeric antigen receptor T-cell therapy, and checkpoint inhibitors, alongside radiation therapy and stem cell transplantation.8, 9, 10 Selecting the optimal sequence and combination of therapies requires careful consideration of disease subtype, molecular features, prior treatments, patient comorbidities, toxicity profiles, and evolving clinical trial data, underscoring the need for integrated multidisciplinary interpretation of clinical, radiologic, pathologic, and molecular data.^8,11,12

Multidisciplinary tumor boards (MDTs) are a cornerstone of modern oncology practice, providing a structured forum for collaborative discussion, evidence-based decision-making, and coordinated care planning, particularly for complex cases.^13,14 The value of MDTs lies in their ability to synthesize diverse expertise, resulting in more accurate diagnoses, comprehensive staging, and optimized treatment strategies compared with individual physician assessments.^13,15 Effective MDTs bring together experts from hematology/oncology, radiation oncology, radiology, pathology, pharmacy, and nursing to facilitate comprehensive case reviews and generate consensus recommendations.^15,16 Existing literature, including systematic reviews, indicates that MDTs can lead to significant modifications in diagnosis (reported in 4-45% of cases across various cancers),¹⁴ staging, and treatment plans (with modifications reported in 1.6-58% of cases).^14,17, 18, 19, 20 This impact often translates into improved adherence to established clinical practice guidelines.^14,17,21,22 However, demonstrating a consistent, direct impact on survival outcomes has proven more challenging, with mixed results reported in the literature.^{14,17,18,23,24} Despite these limitations, MDTs remain globally prevalent and highly valued for complex clinical decision-making.¹⁶

Recognizing the critical need for multidisciplinary input in lymphoma, the Mayo Clinic established a specialized lymphoma Virtual Tumor Board (VTB) in 2014 within the Mayo Clinic Care Network (MCCN).²⁵ The MCCN connects specialists at Mayo Clinic campuses with affiliated national and international sites. The VTB was designed to leverage videoconferencing technology, facilitating participation across diverse geographic locations.²⁵ An initial analysis of VTB’s first four and a half years (pre-pandemic, covering 309 cases) confirmed its substantial impact, with care recommendations modified in 45.3% of the complex cases presented. This early success underscored the utility of a structured, disease-specific, virtual format even prior to the global health crisis.²⁵ This established framework, with its inherent reliance on virtual technology, provided an opportunity to assess the impact of the further enforced virtualization mandated by the subsequent pandemic.

The COVID-19 pandemic in early 2020 mandated a rapid shift toward virtual healthcare delivery, profoundly impacting MDT operations globally and necessitating a fully virtual model for the Mayo Clinic Lymphoma VTB.²⁶ This study analyzes the impact of the COVID-19 pandemic on the Mayo Clinic Lymphoma VTB by comparing case characteristics, operational patterns, and the frequency and nature of care recommendations between the pre-COVID and post-COVID eras, building upon and extending previously published baseline data.²⁵

Patients and Methods

Study Design and Setting

This retrospective analysis utilized prospectively collected data from the Mayo Clinic Lymphoma Virtual Tumor Board, operating within the MCCN framework. Mayo Clinic Care Network comprises Mayo Clinic sites (Rochester, Arizona, and Florida) and affiliated healthcare organizations nationally and internationally. The VTB convenes biweekly via secure videoconference to discuss complex lymphoma cases referred primarily by physicians seeking expert multidisciplinary consultation for challenging diagnostic or management issues. This study was approved by the Mayo Clinic Institutional Review Board. The requirement for informed consent was waived due to the retrospective nature of the study.

Tumor Board Structure and Process

The VTB adheres to a structured, standardized format designed for efficiency and comprehensive review, consistently applied throughout the study period, as previously detailed.²⁵ Each 60-minute session typically involved the presentation of 3-4 preselected complex cases. Case selection was driven by the referring physician’s need for multidisciplinary input, often related to diagnostic uncertainty (eg, suspected rare subtype, discordant findings), challenging management decisions (eg, multiply relapsed/refractory disease, rare subtypes, significant comorbidities impacting treatment tolerance, transplant eligibility questions), or exploration of clinical trial options after standard therapies are exhausted. A dedicated nurse coordinator played an essential role, facilitating case submission and ensuring necessary materials (pathology slides/blocks, imaging files/links, and relevant clinical summaries) were received and distributed for review by Mayo Clinic specialists, ideally at least two weeks prior to the meeting. Case presentations included concise patient history, expert review of pertinent radiology images by a subspecialist radiologist (displaying key findings via screen share), detailed review of pathology slides (often via live microscopy feed or screen sharing of digital slides with annotation) by a subspecialist hematopathologist, deliberation on potential treatment options informed by current evidence and guidelines (often presented with brief supporting literature slides), discussion of relevant medical literature, and specific contributions from clinical pharmacists (eg, regarding dosing adjustments, drug interactions, and access programs) and other attendees (eg, radiation oncology input on field design/dose). Recommendations were formulated based on group consensus, guided by the VTB chair (TMH). Regular participants included physicians (hematologists, oncologists, radiologists, pathologists, and radiation oncologists), pharmacists, nurses, advanced practitioners, clinical research staff, and trainees (fellows). Pre-pandemic, participation modalities included in-person attendance at the Rochester site, MCCN site video conferencing, or nonparticipatory live-streaming. During the post-COVID period analyzed (March 2020 onward), participation transitioned exclusively to virtual formats (video conference or live stream), managed centrally by Mayo Clinic media services.

Data Collection

Data were systematically extracted from the VTB’s prospectively maintained operational database, which tracked case details and recommendations for quality improvement and MCCN reporting purposes. Two distinct periods were defined for comparative analysis based on the pandemic onset:

Pre-COVID: January 2014-February 2020 and Post-COVID: March 2020-July 2024.

Collected variables included the total number of unique cases presented, lymphoma subtype (classified according to contemporary World Health Organization/International Consensus Classification criteria^6,7 by the reviewing pathologist), patient disease status at presentation (newly diagnosed vs relapsed/refractory, where available in the database), referring site type (Mayo Clinic vs MCCN affiliate), and detailed records of all recommendations made by the VTB during case discussions, captured contemporaneously by the VTB coordinator and reviewed for accuracy.

Outcome Measures

The primary outcome measure was the change in the frequency and specific types of recommendations generated by the VTB between the pre-COVID and post-COVID periods. Recommendations were systematically categorized by trained abstractors (VTB coordinator, study personnel) into four main types based on established definitions used in the prior study²⁵:

• •Change in radiologic interpretation (clinically significant discrepancy or refinement of findings/staging compared with initial external read)
• •Change in pathologic diagnosis (clinically significant revision of subtype, grade, identification of transformation, or identification of composite/discordant lymphoma)
• •Recommendation for additional diagnostic testing (specific tests needed to clarify diagnosis or guide treatment, eg, specific molecular/genetic assays like fluorescence in situ hybridization or next-generation sequencing, specialized immunohistochemistry, flow cytometry, further imaging modalities, and repeat biopsy)
• •Change in clinical management (any alteration to the proposed or ongoing treatment/monitoring plan)

Recommendations involving newer therapeutic modalities, including chimeric antigen receptor T-cell therapy, were captured within the broader clinical management category because the prospective database was established before these therapies became routinely available and therefore did not include therapy-specific categories. Specific subcategories within clinical management changes were also analyzed, using predefined categories consistent with internal reporting metrics and the prior publication,²⁵ and informed by the updated results (eg, change from one systemic therapy to another, pathology change directly leading to treatment change, addition of radiation therapy, autologous stem cell transplantation recommendation, change from observation to testing/treatment, and observation to treatment). We calculated the proportion of cases resulting in any VTB-recommended change and quantified the total number of distinct changes made per period.

Statistical Analysis

Descriptive statistics (counts, percentages) were used to summarize patient case characteristics and the distribution of VTB recommendations. The chi-squared test was utilized to compare the proportion of patients experiencing VTB-recommended changes between the pre-COVID and post-COVID cohorts. A P<.05 was established as the threshold for statistical significance. Analyses were performed using IBM SPSS version 29.0.2.0.

Results

During the full study period (January 1, 2014-July 31, 2024), 722 unique patient cases were presented at the VTB and included in this analysis. The pre-COVID era (January 2014-February 2020,∼6.2 years) accounted for 431 cases, while the post-COVID era (March 2020-July 2024,∼4.4 years) included 291 cases. The case mix represented a broad spectrum of lymphoma types (see Figure). Common lymphoma types across the full cohort included diffuse large B-cell lymphoma (n=94, 13.0%), follicular lymphoma (n=49, 6.8%), marginal zone lymphoma (n=39, 5.4%), mantle cell lymphoma (n=29, 4.0%), and classical Hodgkin lymphoma (n=36, 5.0%). Other less common B-cell, T-cell (including angioimmunoblastic T-cell lymphoma and peripheral T-cell lymphoma, not otherwise specified), and histiocytic disorders were also represented. Based on the patients who experienced changes in either diagnosis or management in the whole cohort (n=423), 287 cases (67.8%) presented with a new diagnosis, and 136 (32.2%) presented with relapsed/refractory disease.

Figure.

Distribution of lymphoma subtypes among patients with changes in care following Virtual Tumor Board recommendations during the study period (n=423). cHL, classical Hodgkin lymphoma; DLBCL, diffuse large B-cell lymphoma; FL, follicular lymphoma; LPL, lymphoplasmacytic lymphoma; MCL, mantle cell lymphoma; MZL, marginal zone lymphoma; NLPHL, nodular lymphocyte-predominant Hodgkin lymphoma; PCNSL, primary central nervous system lymphoma; WM, Waldenström macroglobulinemia.

Comparison of Recommendation Rates Pre- vs Post-COVID

A statistically significant increase was observed in the proportion of cases for which the VTB-recommended one or more changes to the patient’s care plan. In the pre-COVID period (n=431), such changes were recommended for 217 patients (50.34%). In contrast, during the post-COVID period (n=291, data up to July 2024), changes were recommended for 206 patients (70.79%), representing a 40.6% relative increase (P<.001). Furthermore, the total count of distinct recommendations made by the VTB was 277 in the pre-COVID period and 343 (sum of categories below) in the post-COVID period (data up to July 2024). The average number of recommendations per case was 0.64 (277/431) pre-COVID and 1.18 (343/291) post-COVID.

Table 1 shows the breakdown of recommendation categories. The incidence of recommendations increased across all major domains when comparing the pre- and post-COVID periods.

• •Radiologic Interpretation Changes: The incidence was 2.1% (9 cases) pre-COVID and 7.2% (21 cases) post-COVID, a 242.9% increase.
• •Pathologic Diagnosis Changes: The incidence was 10.0% (43 cases) pre-COVID and 18.6% (54 cases) post-COVID, an 86.0% increase.
• •Additional Testing Recommended: The incidence was 16.9% (73 cases) pre-COVID and 29.2% (85 cases) post-COVID, a 72.8% increase.
• •Clinical Management Changes: The incidence was 35.3% (152 cases) pre-COVID and 62.9% (183 cases) post-COVID, a 78.2% increase.

Table 1.

Comparison of Virtual Tumor Board Recommendation Categories Pre- vs Post-COVID

Recommendation category	Pre-COVID (n=431 cases)	Post-COVID (n=291 cases)	% Increase of recommendation incidence (Post- vs Pre-COVID)
	No. of Cases (%)	No. of Cases (%)
Radiologic Interpretation Changes	9 (2.1%)	21 (7.2%)	242.9%
Pathologic Diagnosis Changes	43 (10.0%)	54 (18.6%)	86.00%
Additional Testing Recommended	73 (16.9%)	85 (29.2%)	72.80%
Clinical Management Changes	152 (35.3%)	183 (62.9%)	78.20%
Total Distinct Recommendations	277	343	23.8%

Data are presented as number (%). Percentages are calculated based on the total number of cases reviewed in each period. The rightmost column represents the relative increase in recommendations following transition to the virtual format.

A more granular analysis of clinical management alterations identified 152 specific types of clinical management recommendations in the pre-COVID period and 183 in the post-COVID period. For this specific breakdown, percentages are calculated based on the total number of cases presented in each period (n=431 pre-COVID, n=291 post-COVID), as detailed in Table 2.

• •The recommendation to change from observation to treatment applied to 2.1% of cases (9 changes) pre-COVID and 11.0% of cases (32 changes) post-COVID, a relative increase of 423.8%.
• •Changes in pathologic diagnosis that led to a treatment change occurred in 4.4% of cases (19 changes) pre-COVID and 11.7% of cases (34 changes) post-COVID, a relative increase of 165.9%.
• •Recommendations to change from systemic treatment alone to systemic treatment plus radiation therapy applied to 1.6% of cases (7 changes) pre-COVID and 3.8% of cases (11 changes) post-COVID, a relative increase of 137.5%.

Table 2.

Specific Clinical Management Changes Pre- vs Post-COVID

Specific clinical management change subcategory	Pre-COVID (N=152 changes from n=431 total cases)	Post-COVID (N=183 changes from n=291 total cases)	% Relative percent change, post- vs pre-COVID (%)
	No. of Changes (% of total period cases)	No. of Changes (% of total period cases)
Systemic treatment changed to a different systemic treatment	26 (6.0%)	26 (8.9%)	48.30%
Systemic treatment alone to systemic treatment plus radiation therapy	7 (1.6%)	11 (3.8%)	137.50%
Observation changed to recommendation for treatment	9 (2.1%)	32 (11.0%)	423.80%
Pathology change leading to a treatment change	19 (4.4%)	34 (11.7%)	165.90%
Systemic treatment changed to recommendation for ASCT	8 (1.9%)	9 (3.1%)	63.20%
Observation changed to recommendation for more testing	10 (2.3%)	10 (3.4%)	47.80%
Pathology change leading to no change in management	17 (3.9%)	20 (6.9%)	76.90%
Other clinical management changes	56 (13.0%)	41 (14.1%)	8.50%

Data are presented as number (% of total cases reviewed in each period). Percentages in the rightmost column represent the relative percent change in the frequency of each recommendation category in the post-COVID period compared with the pre-COVID period.

ASCT, autologous stem cell transplantation.

These totals (152 pre-COVID, 183 post-COVID) for specific management changes reflect a detailed count of individual alterations and may differ from the main category “Clinical Management” figures in Table 1.

Discussion

Our findings indicate that a specialized multidisciplinary virtual lymphoma tumor board maintained and increased its impact over time, including during the transition to a fully virtual format. The proportion of cases with VTB-recommended changes increased from 50.3% pre-COVID to 70.8% post-COVID (P<.001), representing a 40.6% relative increase, and the average number of recommendations per case rose from 0.64 to 1.18. The observed changes are likely multifactorial, reflecting both the maturation of the VTB model and increasing complexity in lymphoma care over time, rather than the effect of the pandemic alone. As detailed in Tables 1 and 2, post-COVID increases were most apparent in pathology-driven treatment changes and additional diagnostic testing recommendations, consistent with the growing diagnostic complexity of lymphoma. Together, these findings indicate a greater impact on clinical decision-making during the fully virtual era.

The marked increase in the overall rate of recommendations is a key finding. This rate also exceeds the 45.3% reported in the initial analysis focusing on the VTB’s first ∼4.5 years,²⁵ suggesting a possible acceleration of impact over time, perhaps further amplified during the pandemic period. This high rate of impact (70.8%) compares favorably with the ranges reported in systematic reviews of MDTs across various cancers, which often cite management change rates between ∼5% and 58%.^14,18 While direct comparisons are difficult due to differing approaches and case mixes, the lymphoma VTB appears highly influential. Several factors might contribute to this high and increasing rate. First, the pandemic itself may have altered referral patterns, potentially concentrating more diagnostically or therapeutically challenging cases toward expert review panels as routine care faced interruptions or as local resources were strained. Second, the universal adoption of the virtual format, while potentially posing challenges like “Zoom fatigue,” might also have inadvertently enhanced certain aspects of the meeting, such as accessibility for key specialists or fostering more structured, focused discussions. Third, the observed increase likely reflects the accelerating complexity inherent in lymphoma management itself over the full study period (2014-2024), driven by the factors outlined in the introduction (genomics, new classifications, novel therapies), inherently demanding more frequent and nuanced multidisciplinary input. This underlying trend toward greater complexity could have been further amplified by pandemic-related factors.

Specific increases were observed across several recommendation types. The substantial rise in instances where pathology changes directly led to a treatment alteration (from impacting 4.4% of total pre-COVID cases to 11.7% of total post-COVID cases in the granular analysis, Table 2) underscores the critical role of expert hematopathology review in establishing the correct diagnosis, which forms the foundation for all subsequent management. This function was clearly delivered effectively via virtual means (microscopy feed/digital slides). Similarly, the substantial rise in recommendations for additional testing (from impacting 16.9% to 29.2% of cases, Table 1) directly reflects the growing importance of molecular and genomic data (eg, next-generation sequencing panels, fluorescence in situ hybridization) in refining diagnosis, assessing prognosis, and identifying predictive biomarkers.^3,4,8 The increased recommendations for incorporating radiation therapy or proceeding to autologous stem cell transplantation suggest the VTB effectively addressed critical, evolving decision points regarding treatment intensification, consolidation strategies, or curative-intent approaches in appropriate patient subsets, navigating complex choices often requiring multidisciplinary consensus. This aligns with the concept that MDTs are particularly valuable for nonstandard cases where guidelines may be less prescriptive.^14,23

This study adds to the growing body of evidence supporting the effectiveness of virtual MDTs, particularly in specialized fields like hematologic oncology.^18,19,26,27 While necessitated by the pandemic, virtual models offer enduring advantages regarding accessibility (crucial for overcoming geographic barriers inherent in networks like the MCCN), potential efficiency gains (reduced travel time for participants), and scalability.^15,16 The Mayo Clinic Lymphoma VTB’s preexisting infrastructure and decade-long experience with virtual collaboration undoubtedly facilitated a more seamless adaptation compared with institutions newly implementing such formats during the crisis. High participant satisfaction reported previously,²⁵ with 100% rating the activity as excellent and 93% reporting improvements in knowledge and competence, supports strong user acceptance of the fully virtual model.

Because routine cases are managed in separate internal tumor boards within local healthcare systems, the VTB is reserved for complex diagnostic and therapeutic challenges. To allow sufficient time for detailed review of clinical history, pathology, and imaging for these difficult cases, sessions intentionally focus on 3-4 patients per hour. Future efforts to refine efficiency may include implementing formal triage processes to ensure live meeting time remains dedicated to the cases that benefit most from expert subspecialty consultation.

Although the present study was not designed to evaluate cost-effectiveness, virtual multidisciplinary review has the potential to improve healthcare efficiency by refining diagnostic accuracy, preventing redundant imaging and procedures, and optimizing overall treatment strategies. For network partners and international patients, the virtual format provides direct access to subspecialty expert consensus while sparing patients and providers the burden of travel, contributing to high overall participant satisfaction. Future studies evaluating healthcare resource utilization and cost-effectiveness will be important to further define the value of virtual MDTs.

The MCCN encompasses a diverse group of domestic and international member institutions across North America, Asia, Europe, and the Middle East, enabling virtual subspecialty consultation across wide geographic boundaries. Future expansion of the VTB through additional national and international institutional collaborations may further broaden patient access to expert multidisciplinary lymphoma care.

Several limitations must be acknowledged when interpreting these findings. The study’s retrospective nature, while based on prospectively collected data, and its origin from a single, albeit large and geographically diverse, network may limit the generalizability of findings to MDTs with different structures, specialist availability, resources, or patient populations. Consistent with the prior analysis and a common challenge in MDT research,^14,18,23 a major limitation is the inability to systematically track the implementation rate of VTB recommendations or assess their direct impact on patient outcomes (eg, survival, response rates, toxicity, quality of life).²⁵ This gap arises from the MCCN structure, where patients often receive subsequent care locally, outside the primary data systems accessible for this research. This lack of outcome linkage prevents a definitive assessment of the VTB’s ultimate clinical effectiveness, a point also raised by Keating et al²³ regarding the difficulty in demonstrating MDT impact on survival in the veteran affairs health system. Future prospective studies incorporating longitudinal follow-up across participating institutions will be important to determine whether implementation of VTB recommendations translates into improved patient outcomes. Furthermore, case selection for VTB presentation is inherently biased toward complexity, as routine or straightforward cases are typically managed locally without formal VTB review; thus, the high rate of recommendations observed may not reflect the potential impact on an unselected, general lymphoma patient population.¹⁴ Finally, isolating the specific effect of the mandatory virtual format from confounding pandemic-related variables (eg, potential shifts in patient demographics or disease severity due to care delays, concurrent evolution of treatment guidelines independent of COVID-19) is inherently difficult in observational study design. The lack of complete data on disease status (new vs relapsed/refractory) for the entire cohort represents another minor data limitation.

Conclusion

The COVID-19 pandemic imposed unprecedented operational demands on healthcare systems worldwide, forcing rapid adaptation in clinical practice, including the delivery of multidisciplinary cancer care. This analysis demonstrates that an established, specialized multidisciplinary virtual lymphoma tumor board successfully adapted to the period, not only maintaining its essential functions but also exhibiting an increased rate of impactful care recommendations. The VTB model proved resilient and highly effective for facilitating collaborative, expert-driven decision-making in complex lymphoma cases, even when operating under fully virtual constraints. This underscores the vital role that well-structured virtual MDTs can play in ensuring care continuity and quality, both during public health crises and as a sustainable model for future oncology practice, particularly within distributed healthcare networks or for rare tumor types requiring geographically dispersed expertise. Future investigations should prioritize the development of methodologies, potentially through prospective studies or enhanced data-sharing agreements within collaborative networks, to rigorously assess the implementation fidelity of virtual MDT recommendations and evaluate their correlation with measurable patient outcomes.

Potential Competing Interests

Arushi Khurana, Urshila Durani, Robert J. Levy, Muhamad Alhaj Moustafa, Allison C. Rosenthal, Robert Delaune, Daniel P. Larson, Matthew T. Howard, Namrata Shah, Brendan W. Lunn, Mike S. Bold, Scott C. Lester, William G. Breen, Lawrence Breitkreutz, Gregory A. Wiseman, Nneka I. Comfere, Caroline R. Hill, Valerie M. Kimball, Adrienne N. Nedved, and Rebecca L. King declare no competing interests.Thomas E. Witzig reports institutional research funding (Blood Cancer United, Predolin Foundation, Mayo Karolinska Foundation), royalties (Exact Sciences), speaker honoraria (Curio Science), and personal advisory board fees (AbbVie).Madiha Iqbal reports consulting fees (US Sanofi, ADC Therapeutics, Natera, BMS) and DSMB membership.Yucai Wang reports institutional research funding, consulting, and advisory board fees from AbbVie, AstraZeneca, BeiGene, BMS, Eli Lilly, Genentech, Genmab, Incyte, InnoCare, Janssen, Kite, Loxo Oncology, Merck, MorphoSys, Novartis, and TG Therapeutics.Brad S. Hoppe reports consulting fees (Mevion Industries) and an unpaid leadership role (NRG Hematologic Malignancies Working Group).Thomas M. Habermann reports institutional research support from Genentech, Sorrento, Bristol Myers Squibb, and GenMab, and Data Monitoring Committee participation for Eli Lilly & Co. (all payments to institution, no personal remuneration).

Ethics Statement

This retrospective study was approved by the Institutional Review Board of Mayo Clinic. Informed consent was waived.