Abstract
Background
Few studies have examined the impact of multidisciplinary tumor board (MDT) discussion on pancreatic cancer treatment and diagnosis. We aimed to determine whether these patients who are presented at MDT meetings have improved outcomes compared with those who are not presented.
Methods
A retrospective chart review was performed of patients diagnosed with pancreatic cancer at our tertiary referral center between 2019 and 2022.
Results
Of the 190 patients included in the study, 166 (87.4%) were presented at MDT. Patients presented were more likely to receive appropriate pretherapy workup (81.9% vs 37.5%, P < 0.001) and posttreatment surveillance (52.4% vs 20.8%, P = 0.004) and had fewer postoperative complications (30.7% vs 58.3%, P = 0.008) compared to patients who were not presented.
Conclusion
All patients diagnosed with pancreatic cancer should be discussed at MDT meetings.
Keywords: Multidisciplinary tumor board, pancreatic adenocarcinoma, pancreatic cancer, tumor board
Pancreatic cancer is the third overall leading cause of cancer deaths in the United States; an estimated 51,980 patients will die of pancreatic cancer in 2025.1 Furthermore, with its rising incidence, pancreatic cancer is projected to become the second leading cause of cancer deaths by 2030.2 Though multiple types of pancreatic tumors exist, pancreatic adenocarcinoma accounts for over 90% of all pancreatic cancers. Pancreatic cancer tends to present late, with most patients having metastatic disease at the time of presentation. As such, while surgical resection is the mainstay of curative treatment for pancreatic cancer, most patients will have unresectable disease at presentation. Thus, most treatment options for patients with newly diagnosed pancreatic cancer will be palliative, not curative.
Treatment of complex, aggressive cancers like pancreatic adenocarcinoma requires a multidisciplinary approach. Multidisciplinary tumor board (MDT) meetings have been established as standard of care in complex cancer treatment at most major academic centers. MDT meetings involve detailed discussion of complex patient cases among multiple different specialties—most commonly involving surgical, medical, and radiation oncologists, gastroenterologists, and radiologists. Previous studies have demonstrated that presentation at MDT meetings increases the proportion of patients undergoing appropriate diagnostic workup and may lead to changing reports in 4% to 45% of patients on existing diagnostic studies or pathology.3–6 Additionally, MDT meetings have been shown to alter treatment plans in up to 58% of patients.7 Though MDT discussion on hepatobiliary and gastrointestinal cancers have been well studied, only a few studies exist on the impact of MDT meetings on pancreatic cancer treatment and diagnosis.8–11 The present study aimed to determine whether patients undergoing pancreatectomy who are presented at MDT meetings have more appropriate diagnostic workup, comprehensive treatment, and overall improved outcomes compared to those who are not presented.
METHODS
After institutional review board approval, a retrospective chart review was performed of patients diagnosed and treated with pancreatic cancer at our tertiary referral center between 2019 and 2022. These patients were identified by retrospective review of pathological records from biopsy, surgical resection, or by records from MDT meetings held at our institution.
Patients were included in the study if they were diagnosed with pancreatic cancer and treated at our institution between 2019 and 2022. Eligible patients needed to have complete data available on key variables such as age, sex, race, preoperative comorbidities, tumor stage, diagnostic and treatment sequence, postsurgery outcomes, and disease progression. Patients were then separated by those presented at MDT meetings and those not presented. Patients treated at facilities other than our institution and those without available data on presentation at the MDT board were excluded from the study. Additionally, patients undergoing enucleation procedures were excluded from the present study.
Patient charts were retrospectively reviewed during data collection. Variables collected included demographic information (gender, race, ethnicity, age at presentation), diagnostic workup, disease information (histology, stage at diagnosis), treatment characteristics (surgical resection, neoadjuvant chemotherapy, neoadjuvant radiation), patient outcomes (postoperative complications, appropriate oncological resection, appropriate pretherapy workup, appropriate posttreatment surveillance), and follow-up status (patient alive or deceased). Postoperative complications included organ space infection, dehiscence, reintubation, ventilator dependence or failure to wean for >48 hours, acute renal insufficiency or failure, pneumonia, stroke, coma, cardiac arrest, myocardial infarction, venous thromboembolism, sepsis or septic shock, return to operating room, and clinically relevant postoperative pancreatic fistula. Appropriate oncological resection was defined as R0 resection with standard lymphadenectomy (≥17 lymph nodes harvested) according to National Comprehensive Cancer Network guidelines.12 Appropriate pretherapy workup was defined as proper staging including CA 19-9 with staging imaging such as computed tomography of the chest, abdomen, and pelvis, or computed tomography of the chest with magnetic resonance imaging of the abdomen and pelvis. Similarly, appropriate posttreatment surveillance was defined as surveillance imaging with computed tomography of the chest, abdomen, and pelvis and CA 19-9 every 3 to 6 months for at least 2 years after treatment.
Continuous and categorical variables were compared between groups using two-sample t tests and chi-squared tests, respectively. Categorical variables were presented as numbers, and continuous variables were presented as means with ranges. A P value <0.05 was considered significant. All statistical analyses were performed using STATA SE version 14 (Stata Corp).
RESULTS
The study included 190 patients. Of these, 166 (87.4%) were presented at a MDT meeting, while 24 (12.6%) patients were not. Patient demographics are shown in Table 1. The mean age of patients presented at MDT meetings was 62.6 years, compared to 68.2 years for patients not presented. Most patients were male. A malignant diagnosis was found in 139 (87.3%) patients presented and in 24 (100.0%) patients not presented (P = 0.003). Final pathology included pancreatic ductal adenocarcinoma, duodenal adenocarcinoma, cholangiocarcinoma, malignant intraductal papillary mucinous neoplasm (IPMN), solid pseudopapillary neoplasm, mucinous cystic neoplasm, serous cystadenoma, metastatic lesions, benign IPMN, serous cystadenoma, ampullary adenocarcinoma, and other benign lesions.
Table 1.
Demographics of patients with oncologic pancreatic surgery based on presentation at a multidisciplinary tumor board
| Variable | Presented at MDT |
P value | |
|---|---|---|---|
| Yes (n = 166) | No (n = 24) | ||
| Mean age at diagnosis | 62.59 | 68.16 | |
| Gender | 0.67 | ||
| Male | 96 (57.8%) | 15 (62.5%) | |
| Female | 70 (42.2%) | 9 (37.5%) | |
| Race | 0.07 | ||
| White | 131 (78.9%) | 19 (79.2%) | |
| African American | 13 (7.8%) | 5 (20.8%) | |
| Asian | 5 (3.0%) | 0 | |
| Other | 17 (10.2%) | 0 | |
| Ethnicity | 0.16 | ||
| Hispanic | 23 (13.8%) | 6 (25.0%) | |
| Non-Hispanic | 143 (86.1%) | 18 (75.0%) | |
| Pathology | 0.003 | ||
| Malignant | 139 (87.3%) | 24 (100%) | |
| Benign | 27 (16.3%) | 0 | |
| Pathology | 0.74 | ||
| Pancreatic adenocarcinoma | 106 (63.9%) | 21 (87.5%) | |
| Malignant IPMN | 9 (5.4%) | 3 (12.5%) | |
| Benign IPMN | 7 (4.2%) | 0 (0%) | |
| Duodenal adenocarcinoma | 6 (3.6%) | 0 (0%) | |
| Ampullary adenocarcinoma | 6 (3.6%) | 0 (0%) | |
| Cholangiocarcinoma | 5 (3.0%) | 0 (0%) | |
| Pancreatic neuroendocrine tumor | 4 (2.4%) | 0 (0%) | |
| Solid pseudopapillary neoplasm | 4 (2.4%) | 0 (0%) | |
| Mucinous cystic neoplasm | 3 (1.8%) | 0 (0%) | |
| Metastatic lesion to pancreas | 3 (1.8%) | 0 (0%) | |
| No pathology | 3 (1.8%) | 0 (0%) | |
| Acinar cell adenocarcinoma | 2 (1.2%) | 0 (0%) | |
| Other* | 7 (4.2%) | 0 (0%) | |
*Other includes serous cystadenoma and nondiagnostic pathology such as chronic pancreatitis or benign cyst.
IPMN indicates intraductal papillary mucinous neoplasm.
A total of 131 patients underwent surgical resection (Table 2). Of the patients who were presented at MDT with pancreas/periampullary masses, 66.2% (n = 110) underwent surgical resection. The rate of postoperative complications in this group was 30.7%. In comparison, 87.5% (n = 21) of patients not presented at MDT underwent surgical resection; the postoperative complication rate in this group was 58.3%. No difference was seen in the rate of oncologically appropriate resection (including recommended lymphadenectomy) by presentation status (61.8% vs 45.8%, P = 0.65). Patients more commonly received appropriate pretherapy workup if they were presented at MDT (81.9% vs 37.5%, P < 0.001). Further, patients who were presented at MDT were more likely to receive appropriate posttreatment surveillance (52.4% vs 20.8%, P = 0.004). There was no difference between patients presented at MDT and those not presented in the use of adjuvant chemotherapy (54.8% of patients presented at MDT vs 58.3% of patients not presented, P = 0.75). The mean follow up period was 13.5 months.
Table 2.
Outcomes for patients with oncologic pancreatic surgery based on presentation at a multidisciplinary tumor board
| Variable | Presented at MDT |
P value | |
|---|---|---|---|
| Yes (n = 166) | No (n = 24) | ||
| Appropriate pretherapy workup* | 136 (81.9%) | 9 (37.5%) | <0.001 |
| Appropriate posttherapy surveillance* | 87 (52.4%) | 5 (20.8%) | 0.004 |
| Surgical resection | 110 (66.2%) | 21 (87.5%) | 0.04 |
| Appropriate oncological resection* | 68 (61.8%) | 11 (45.8%) | 0.65 |
| Postoperative complications | 51 (30.7%) | 14 (58.3%) | 0.008 |
| Neoadjuvant chemotherapy | 73 (50.7%) | 15 (62.5%) | 0.09 |
| Adjuvant chemotherapy | 91 (54.8%) | 14 (58.3%) | 0.75 |
| Adjuvant radiation | 21 (12.6%) | 3 (12.5%) | 0.93 |
| Recurrence | 58 (34.9%) | 10 (41.6%) | 0.52 |
| Time to recurrence (months) | 5.6 | 9.1 | 0.08 |
| Deaths | 40 (24.1%) | 8 (33.3%) | 0.33 |
| Time to death (months) | 7.3 | 11.5 | 0.72 |
| Overall survival (months) | 9.5 | 7.2 | 0.10 |
*Per National Comprehensive Cancer Network guidelines.
Of the patients who were presented, 34.9% (n = 58) experienced disease recurrence and 24.1% (n = 40) died. Of those not presented, 41.6% (n = 10) experienced disease recurrence and 33.3% (n = 8) died. There was no significant difference between those presented at MDT and those not presented in time to recurrence (5.6 vs 9.1 months, P = 0.08), time to death (7.3 vs 11.5 months, P = 0.72), or overall survival (9.5 vs 7.2 months, P = 0.10).
DISCUSSION
This study compared patients undergoing formal pancreatectomy for pancreas/periampullary mass who were presented at MDT meetings with those patients who were not presented. Patients who were presented at MDT meetings were more likely to receive appropriate pretherapy workup and posttreatment surveillance and had fewer postoperative complications compared to patients who were not presented.
MDT has been a widely adopted by healthcare systems, usually consisting of a dedicated conference where multiple care teams meet to discuss the management of cancer patients. Members of a MDT consist of a core of surgeons, medical oncologists, radiation oncologists, pathologists, and radiologists and may include many other specialists and healthcare teams, such as nurses, dietitians, and patient care navigators. The existence of formal MDT boards in the United States dates back to the 1940s, though it was not until the 1970s that tumor board meetings became popular across major oncology institutions in the United States. For example, MDT meetings were first established at our institution in 1979, modeled primarily after the established weekly breast tumor board meetings at the University of Texas MD Anderson Cancer Center.13 The development of specialized cancer centers further popularized the idea of merging communication and treatment plans among all cancer specialists at these institutions. MDT meetings are now an integral part of patient care, both at large institutional cancer centers and at smaller, community-based hospitals.
The effect of MDT meetings on patient outcomes has been well studied in the literature. Studies have shown that patients presented at MDT meetings are more likely to undergo proper staging workup with more diagnostic accuracy than those not presented. A systematic review of 27 studies found that MDT meetings resulted in changes to diagnostic reports (i.e., stage, primary site of tumor, histology, pathological grade) in 4% to 35% of patients.6 Other studies comparing patients discussed at MDT meetings with those who were not discussed have similarly demonstrated a more complete and accurate staging workup among those patients presented at MDT meetings.3,4,14,15 A systematic review of 36 studies reporting on pancreatic cancer–specific multidisciplinary team meetings found that MDT presentation led to changes in the initial diagnosis in 3.4% to 21.7% of cases and led to changes in the treatment plan in 18.2% to 72.2% of patients.16 Similarly, our study found that patients who were presented were more likely to have appropriate staging and diagnostic workup (81.9% vs 37.5%, P < 0.0001).
Patients discussed at MDT meetings may experience alterations in their treatment plan. The study by Pillay et al demonstrated that 19% to 34.5% of patients presented at MDT meetings underwent changes to their treatment plan.6 Furthermore, in a review of MDT meetings on patients with gastrointestinal malignancies, the treatment plan of the referring physician was changed or altered in 23% to 42% of patients after discussion at MDT meetings; treatment plans were most often changed after an alteration in the initial diagnosis or stage, which occurred in 18.4% to 26.9% of the presented patients.17 Changes in treatment plans may either favor neoadjuvant treatment or upfront surgery; the study by Pillay et al found that patients who were presented at MDT meetings were more likely to receive neoadjuvant treatment (systemic therapy or radiotherapy) compared to patients who were not presented. Additionally, previous studies have shown that presenting patients at MDT meetings may increase clinical trial enrollment by 50%.18 These findings argue for the widespread use of MDT meetings across all types and stages of malignancies. In the present study, however, we did not evaluate whether treatment recommendations changed as a direct result of MDT discussion because treatment plans before MDT discussion were not consistently documented in the available medical record; some outpatient consultation notes were not accessible for review. Future studies assessing changes in management recommendations following MDT discussion would help clarify the mechanisms by which multidisciplinary care improves patient outcomes, as this was not specifically examined in our study.
Though changes to patient diagnosis and treatment strategies with MDT presentation are well documented, fewer studies have proven a survival benefit. A meta-analysis by Kočo et al examining the effects of MDT meetings on colorectal, lung, prostate, and breast cancer found that six out of eight studies on MDT meetings in colorectal cancer demonstrated an increase in survival of patients presented at MDT meetings.19 Similarly, all five studies regarding lung cancer and all three studies regarding breast cancer showed a significant improvement in survival in patients presented at MDT meetings. Despite statistically significant findings of improved survival, they theorized that the improved survival may be partially explained by improvements in techniques, guidelines, and clinical practice during the long measurement time of the studies. Though our study did not demonstrate a statistically significant difference in overall survival, there was a trend toward increased overall survival in the MDT group.
The diagnosis and treatment of pancreatic cancer remains a complex challenge, which often requires the input of a multidisciplinary team. Despite this, few studies regarding the benefit of MDT meetings on patients with pancreatic cancer exist. Furthermore, the majority of these studies focused on changes in diagnosis or resectability criteria of patients presented at MDT meetings. Few studies have compared outcomes data in patients with pancreatic cancer presented at MDT meetings versus those who are not presented. Our study demonstrated improved outcomes in patients who were presented at MDT meetings compared to those who were not presented. We demonstrated a significant difference in both pretherapy workup as well as posttreatment surveillance. These findings highlight the importance of MDT meetings in treatment of complex diseases such as pancreatic cancer, as ensuring appropriate diagnostic workup and treatment is likely to result in improved outcomes and survival.
The current study has several limitations. A key limitation of this single-institution study is the lack of generalizability, as the findings may not be representative of broader populations due to variations in patient demographics, clinical practices, and resources across different institutions. We did not collect data from outside institutions; therefore, patients who may have obtained care from multiple institutions may have incomplete data. Furthermore, the small sample size of only 190 patients, and smaller comparison group of only 24 patients, limits the statistical power of the study, making it difficult to detect significant differences between treatment groups. The study is limited by its short follow-up period of 13.5 months, which may not fully capture the long-term outcomes or potential late recurrences of pancreatic cancer, thereby restricting the assessment of treatment efficacy and survival rates. Additionally, the relatively short follow-up period may have underestimated adherence to guideline-recommended posttreatment surveillance, as surveillance was assessed according to National Comprehensive Cancer Network recommendations over a 2-year period, whereas the mean follow-up in this cohort was only 13.5 months. Furthermore, there is likely significant selection bias inherent to the decision to present or not present patients at MDT meetings. Though presentation at MDT is strongly encouraged at our institution, it is not mandatory. Presentation at MDT meetings varies by patient status (inpatient vs outpatient, upfront resectable vs unresectable disease) or by physician discretion. This selection bias may be further impacted by selecting patients based on retrospective review from MDT meetings. To our knowledge, larger, randomized controlled trials or cohort studies comparing patients with pancreatic cancer presented at tumor board meetings versus patients not presented do not presently exist.
In conclusion, patients diagnosed with pancreatic cancer who are presented at MDT board experience more appropriate diagnostic workup, treatment, and surveillance and experience significantly improved postoperative outcome as compared to patients who are not presented in a formal MDT fashion. These findings support our strong recommendation that all patients with aggressive malignancies such as pancreatic cancer should be discussed at MDT meetings prior to providing treatment recommendations.
Disclosure statement/Funding
The authors report no funding or conflicts of interest.
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