A Seat at the Table

My hospital has tumor boards for liver cancer, GI tract cancers, pancreas cancer, lung cancer, and urologic cancers. This year we started one for neuroendocrine cancers. There are too many for IO to staff them all, yet they are an incredible source of referrals and enduring relationships with other specialists.

The weekly liver tumor board focuses on HCC and includes the transplant hepatologists and surgeons as well as med onc, rad onc, IO and diagnostic radiologists. Most patients  with HCC awaiting transplant get neoadjuvant therapy, and their imaging is reviewed at the tumor board every three months during the typical one-year wait for transplantation. Once a month we have pathology review, and get to see the explants on patients we have treated -- a humbling experience for the interventional oncologists in the room! This tumor board became so successful that it spawned a multidisciplinary liver tumor clinic, where patients get one-stop shopping for consultation with all of the specialists. The IO faculty staff this clinic in rotation; patients seen your assigned week become yours to treat and follow.

The neuroendocrine tumor board took a couple years to get up and running. Few people appreciate that NETs are the second most prevalent GI malignancy after colon cancer, accounting for more patients than all other upper digestive tract cancers and hepatobiliary cancers combined. NETs are a highly diverse group of tumors. There are specialists from 25 different areas involved in caring for these patients, from genetics to neurosurgery. Some of these specialists I already knew well; the gastroenterologists, GI oncologists and surgeons with whom I regularly interfaced. Through the NET tumor board I met a new set of med oncs, rad oncs, nuclear therapists, surgeons, and internists who deal with thoracic and adrenal axis NETs. Not only did I learn a lot from them about some unfamiliar diseases, but by exposing them to IO, I now have a brand new referral source for image-guided therapies for tumor types and locations I rarely saw before. Nothing quite gets your blood pressure up (and the patient’s) like ablating a norepinephrine-secreting tumor!

Contrast these success stories with the tumor boards we fail to staff. The GI tract tumor board meets in the middle of the day, when we do not have anyone available. Colon cancer is woefully underrepresented in our practice. Often I meet patients in the advanced stage of their disease. Review of old images reveals the missed opportunity to ablate their tumor burden instead of waiting for systemic chemo to fail. It is not that the GI oncologists aren’t aware of what IO has to offer, but if you don’t have a seat at the table when a new patient is being discussed, it is hard to get inserted into the treatment algorithm. Same problem with lung cancer. With no IO at the lung tumor board, the thoracic specialists don’t know what we have to offer. A senior pulmonologist recently told one of my partners that lung ablation isn’t done at our hospital!

I mentioned in a prior posting the market research done by one of our corporate partners regarding the awareness gap between IO and medical oncologists (see “If a Cancer Grows in the Forest...”, August 6th). They recently updated their market survey, and were kind enough to share a synopsis. About two-thirds of medical oncologists surveyed routinely participate in a tumor board. Of these, one-third said an IO was always present, and another half said IO participated some of the time. 90% said the IO was an important contributor to the tumor board. Medical oncologists who had an IO at their tumor board were twice as likely to refer patients for image-guided therapy. Half of medical oncologists still do not know anyone who offers yttrium radioembolization, yet the majority of medical oncologists believe that the IO is the major decision maker regarding use of Y-90. 

Ultimately, if IO is to become the fourth pillar of cancer care, image-guided therapies will have to be supported by sufficient evidence to be incorporated into national and international treatment guidelines. In the meantime, the most efficient way to disseminate these therapies lies with multidisciplinary management teams. From colon cancer to carcinoid, from California to Croatia, if IO’s want to be players in this arena, they need to take a seat at the table.

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