Original ReportAnalysis of decision making at a multidisciplinary head and neck tumor board incorporating evidence-based National Cancer Comprehensive Network (NCCN) guidelines
Introduction
Head and neck cancers (HNC) in the United States account for roughly 3% of all cancers, with an estimated 55,000 new cases and 12,000 deaths occurring annually.1 The treatment of HNC involves a collaborative multidisciplinary approach using surgery, radiation, or chemotherapy to accomplish tumor cure while minimizing acute and long-term morbidity. Determining optimal therapy requires a multidisciplinary team–based discussion between an HNC surgeon, radiation oncologist, medical oncologist, palliative care specialist, nurse specialist, speech and swallow therapist, diagnostic radiologist, and pathologist. Patient characteristics, preferences, functional outcome, and quality of life are also reviewed.2 Multidisciplinary care teams have emerged to guide the management of cancer patients and have been shown to impact care decisions, although many studies have yet to show an improvement in the care of patients.3 As cancer care becomes increasingly specialized and therapeutic decisions become complex, the multidisciplinary team–based approach is postulated to have enormous potential in improving cancer care.4
In addition to team-based care, evidence-based care has also emerged to the forefront of cancer management. The National Comprehensive Cancer Network (NCCN) is composed of 25 leading centers and provides treatment guidelines to standardize and incorporate evidence-based decision making.[5], [6], [7] The NCCN guidelines arise from a commitment to perform outcomes research and refine recommendations based on analyses of patterns of care and outcomes data.8 The guidelines aim to ensure patients receive evidence-based and consensus-driven preventive, diagnostic, treatment, and supportive services that are most likely to yield optimal outcomes. The development of measures to ensure treatment according to guidelines is a national priority because of substantial economic and noneconomic costs related to noncompliant prereferral care, including lost wages, cost of repeat therapy, and potentially diminished survival.9
The purpose of this study was to evaluate the incorporation of evidence-based NCCN guidelines in clinical decision making at a weekly HNC multidisciplinary tumor board (MDT) meeting at our institution and to determine the extent to which NCCN guidelines subsequently translate into patient care.
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Patient selection
Two hundred eleven patients evaluated for HNC between March 3, 2010, and October 17, 2012, were identified from the institutional tumor registry. Of this population, 176 (83.4%) patients were evaluated at the MDT and form the basis of analysis for this retrospective study. Thirty-one (14.7%) patients were not evaluated at the MDT, and 4 (1.9%) patients evaluated at the MDT with nonprimary HNC, pediatric sarcoma, or distant metastases disease were excluded. The final population consisted of 176
Patient and cancer characteristics
Distribution of HNC by primary cancer site and staging for the patient cohort is described in Table 1. The distribution for AJCC stage was 1% for stage 0, 19% for stage I, 10% for stage II, 14% for stage III, 48% for stage IVa, and 8% for stage IVb.
Treatment recommendation
Table 2 describes the distribution of treatment recommendations and actual treatment received in terms of NCCN level of evidence. Appendix E1 (available as supplementary material online at www.practicalradonc.org) further stratifies this distribution
Discussion
This study assessed the incorporation of evidence-based medicine and compliance with NCCN guidelines at a HNC MDT at a tertiary-referral urban academic medical center. Multidisciplinary tumor board recommendations and actual treatment received were evaluated and demonstrated that overall, MDT recommendations follow NCCN guidelines with a compliance rate of 98.3%. This represents an excellent incorporation of evidence-based guidelines in multidisciplinary cancer management and decision making
Conclusion
Incorporation of national guidelines into an HNC MDT and subsequent patient care requires active participation of a multidisciplinary team. Quality improvement research with regard to national treatment guidelines helps highlight current strengths in cancer management as well as its flaws. Once identified, these drawbacks can guide actionable initiatives to narrow noncompliance and provide better oncologic outcomes.
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Cited by (0)
This paper was presented at the 56th Annual Meeting of American Society for Radiation Oncology, September 14-17, 2014, San Francisco, California.
Supplementary material for this article (http://dx.doi.org/10.1016/j.prro.2015.11.006) can be found at www.practicalradonc.org.
Conflicts of interest: None.