Abstract
This qualitative study uses interview data to explore clinician perspectives on the function of multidisciplinary tumor boards beyond clinical decision-making.
Given the complexity of cancer treatment, multidisciplinary tumor boards (MDTBs) have become standard for cancer care. Despite the ubiquity of MDTBs, their effect on patient survival is debated.1,2 Prior research suggests that MDTBs effect change by altering the management of patient care3,4 and that successful MDTBs result in consensus clinical decisions (eg, whether to recommend surgical, radiation, or chemotherapy treatment) regardless of patient outcomes.5 This qualitative study explores clinician perspectives on the function of MDTBs beyond clinical decision-making.
Methods
This qualitative study was reviewed and approved by the Stanford University Institutional Review Board. Participants provided oral consent. The study followed the Standards for Reporting Qualitative Research (SRQR) reporting guideline.6
We conducted 30 semistructured interviews with physicians who attend MDTBs, purposively sampled across different cancer types and practice settings (Table 1). Forty-six cancer clinicians in the California Bay Area were contacted via departmental registry emails and snowball sampling, with a 65% response rate. After oral consent was obtained, interviews were conducted and recorded over Zoom videoconferencing. The semistructured interview guide was developed with input from a surgical oncologist, a medical oncologist, and a radiation oncologist. Three initial pilot interviews were conducted. The interviews were transcribed and analyzed inductively via a grounded-theory approach to identify the functions of MDTBs. All interviews were conducted by a single researcher (B.O.W.) and coded inductively by at least 2 independent coders (B.O.W., A.W., or K.M.K.).
Table 1. Demographic Characteristics of the 30 Clinician Participants.
| Characteristic | Frequency, No. (%)a |
|---|---|
| Sex | |
| Men | 13 (43) |
| Women | 17 (57) |
| Specialty | |
| Medical oncology | 11 (37) |
| Surgical oncology | 11 (37) |
| Radiation oncology | 8 (27) |
| Posttraining experience, y | |
| 0-5 | 8 (27) |
| 6-10 | 7 (23) |
| 11-15 | 7 (23) |
| ≥16 | 8 (27) |
| Institution type | |
| Academic hospital | 17 (57) |
| Public hospital | 5 (17) |
| Private hospital | 5 (16) |
| Government hospital | 3 (10) |
| Tumor board attendeda | |
| Breast | 10 (21) |
| General | 9 (19) |
| Gastrointestinal | 8 (17) |
| Central nervous system | 5 (11) |
| Thoracic | 4 (9) |
| Ear, nose, and throat | 3 (6) |
| Melanoma | 2 (4) |
| Sarcoma | 2 (4) |
| Genitourinary | 2 (4) |
Frequencies sum to more than 100% because some participants attended more than 1 tumor board.
Results
Thirty clinicians participated in this study, including 13 men (43%) and 17 women (57%). There were 11 medical oncologists (37%), 11 surgical oncologists (37%), and 8 radiation oncologists (27%) (Table 1). Although all clinicians indicated that determining optimal clinical management was a key outcome for MDTB discussions, there were many functions of MDTBs beyond clinical decision-making.
Clinicians described 5 categories of additional functions of MDTBs in which the presenting physician sought something other than a clinical decision (Table 2). In mobilizing the authority of a larger, interdisciplinary group, physicians who may already have a clinical decision in mind present cases to convince themselves (eg, to provide insurance or protection, acquire authority, or receive “blessing”), to convince other physicians (eg, to referee a disagreement or pressure another physician), or to convince patients (eg, to present a unified front or to persuade a patient). Beyond clinical decision-making, physicians also found that MDTBs strengthened the multidisciplinary community by providing opportunities for education and research and by building collegiality and promoting collective professional fulfillment.
Table 2. Functions of Multidisciplinary Tumor Boards and Illustrative Examples.
| Function | Category (frequency)a | Illustrative example |
|---|---|---|
| Convince the presenting physician (ie, themselves) | Provide insurance or protection (9) | “If I know that, like, there’s probably gonna be a complication … and I’m gonna present it at M&M [conferences] … I don’t want to be out there alone … at least you’ve talked to somebody about it … so that, like, they don’t think you’re going rogue.” |
| Acquire authority for more junior individuals or individuals from communities historically excluded from medicine (15) | “And I think it … definitely helps the junior faculty, like the brand-new people who, you know, the patients, they’re very skeptical.” | |
| “Particularly if you’re a female, [then] there are plenty of people who might discredit your singular opinion. But when you’re able to bolster it by saying, ‘Hey, listen. I took the time to go talk to a whole bunch of smart people and experts in this area and we all agree.’” | ||
| Receive “blessing” (18) | “Often, it is just to feel like you’re not making a decision in a vacuum.” | |
| “Like a gut check.” | ||
| Convince a nonpresenting physician | Referee a disagreement (10) | “There may be an outside read on an MRI [scan] that a patient comes with them and says, like, you know, this has tumor progression and then you look at it and then you disagree. So then, just to kind of be democratic about that type of disagreement, then you just take it to [the] tumor board … kind of to break ties of disagreement.” |
| Pressure another physician to do something (9) | “Sometimes one of the attendings who may feel a certain way, they bring it because they want to apply peer pressure to that person.” | |
| Convince a patient | Align physician messages for the patient (6) | “One week you’ll see a surgeon, in another week you’ll see a radiation oncologist, in another couple weeks you’ll see a medical oncologist, and then everybody tells the patient something different.… With [the tumor board], all the physicians are in the same platform.” |
| Mobilize group authority to persuade a patient (22) | “It makes it easier for the patients then to kind of accept that there may be very limited options for them.” | |
| Provide group education | Educate other specialties to improve interspecialty communication (17) | “By participating in tumor boards, other specialties start to know what the pertinent things [are] that people are looking at … [what] we all noticed was that those [pertinent things] started to just automatically show up in their reports.” |
| Inform colleagues of changes in management (16) | “We’ll present a case in terms of guidelines that are significant … major treatment updates usually [go] through the tumor boards in terms of sort of disseminating that information.” | |
| Provide opportunities for research ideation (3) | “We learn from each other and we work together in research. We … you know, we have worked together doing research. We published papers together [and] discussed projects [and] how we can collaborate.” | |
| Promote group social cohesion | Build collegiality, cohesion, and morale (15) | “They’re comfortable asking me, you know, even outside of [the] tumor board, and just calling me, so I think that that’s a nice thing about having this. You know, consistent time that we meet and then developing this, you know, relationship, this collegial relationship that makes people comfortable to do that, to ask questions.” |
| Achieve professional fulfillment (6) | “Having [the MDTB] community is incredibly important for fulfillment at work.” |
Abbreviations: M&M, morbidity and mortality; MDTB, multidisciplinary tumor board; MRI, magnetic resonance imaging.
Frequency indicates the number of clinicians who gave this response.
Discussion
Although prior research has focused largely on the role of MDTBs in clinical decision-making by determining optimal patient treatment across multiple disciplines, the results of this study suggest that there are diverse reasons to present a patient’s case to a tumor board, including some functions that have little to do with clinical decision-making. Research that takes these functions into consideration may yield different outcome measures. For example, aligned physician messages may result in improved patient trust or satisfaction in treatment teams. Providing education for other specialties may result in more referrals for a new treatment approach or increased interdisciplinary research collaboration. Other outcomes may include decreased physician burnout or increased job satisfaction, especially among junior faculty who may benefit more from the “protection” or “blessing” of MDTB conversations.
This study has some limitations. As a small qualitative study, it may not be generalizable to all cancer physicians. Furthermore, although the participants were from a variety of disciplines, specialties, and contexts, they all practiced in the California Bay Area. However, most physicians have practiced in multiple geographic regions, so we encouraged the participants to draw on experiences from throughout their career.
In summary, the findings of this qualitative study suggest that a more expansive approach is needed to evaluate additional effects of MDTBs on patient satisfaction, physician well-being, or institutional productivity.
References
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