Comprehensive Cancer Care is a vast subject: it encompasses prevention, public awareness, early detection, evidence-based treatment, state-of-the-art advances, surveillance, a tumour registry, epidemiology, multidisciplinary team (MDT) care, audit outcomes, palliative and hospice care, education and research. This series of articles from The Cancer Institute (WIA), Adyar, aims to describe some aspects of comprehensive cancer care practice.
“We would like to highlight that the average outcomes in cancer are much betterthan what is generally perceived by the society,” says E. Hemanth Raj – Vice-Chairman, Cancer Institute (WIA), Adyar. Every cancer patient should be aware of the existence of the service called Tumour Boards or Multidisciplinary Tumour Boards (MTBs) or MDT cancer meetings. This is a service provided to ensure that patients receive evidence-based treatment recommendations by a panel of oncology experts. While the concept of an MTB was first mentioned in medical literature in the 70’s, it has gained widespread acceptance over the past two decades and has become the gold standard in cancer care worldwide.
Three-stage process
To understand MTBs and the need for them, let’s rewind and start from the point of cancer diagnosis. To formulate a cancer treatment plan, three prerequisites need to be fulfilled. Firstly, confirmation of cancer diagnosis forms the foundation of cancer treatment. This entails sampling tissue (the sample may be blood, bone marrow, fluid, tumour tissue etc.) for microscopic examination (biopsy) to confirm if the suspected lesion is benign (not a cancer) or malignant (confirms cancer).
Secondly, tests to stage the disease. Depending on the site of cancer, appropriate investigations in the form of scans (CT/MRI/ PET/nuclear medicine scans), X-rays including mammograms and endoscopies, are performed to map the precise extent of the disease in our body. These investigations help us to stage the disease which is commonly denoted by TNM staging (T= Tumour size and extent, N=lymph Nodal involvement, M= Metastasis- spread to distant organs to bone, brain, lungs, liver etc).
Thirdly, are patient factors: what is the patient’s general (overall health/performance status) condition. Can the patient withstand the treatment and what are the patient’s personal preferences for treatment (if they are unwilling to undergo a particular form of treatment).
Having a round table meeting of oncology experts (physically or virtually) who treat a specific cancer, discussing the cancer patient on an individual basis, is called an MTB meeting. MTBs are critical at all stages of cancer care. Depending on the hospital, MTBs are either general: encompassing all cancers, or site specific for each region (for e.g.: Head & Neck, Gastrointestinal, Breast, Urologic cancer boards etc.). “In the patient’s best interest, all specialists and post-graduate students at our hospital carve out time to mandatorily attend the weekly meeting. This is also a place where knowledge is imparted and imbibed,” says Kalpana Balakrishnan – Chief Executive Officer and Medical Director Cancer Institute (WIA), Adyar.
The methodology to conduct MTBs is stringent. Individual patient reports are flashed on a screen for the entire panel of experts to comment on, and only when the most satisfactory treatment under the circumstances is agreed upon, will the discussion progress to the next patient. Quite often the situation is complex and unique for each patient, such that it is not easy to adopt a management according to guidelines. “Thus, the collective wisdom of the panel of experts, arriving at a treatment recommendation upon discussion of an individual patient makes the entire process patient-centric and patient-safe,” says Arvind Krishnamurthy, Head, Surgical Oncology.
“Some patients are undecided and delay treatment commencement for prolonged periods, and potentially, the cancer mayp rogress in the interim. Hence, when there is time lapse of many months, it is prudent to re-evaluate the disease prior to MTB discussion and a decision should be based on the most recent scans,” says R. Krishnakumar, Head of Nuclear Medicine.
Composition of the MTB assembly
Every MTB meeting comprises of surgeons, medical and radiation oncologists, oncopathologists, radiologists and nuclear medicine specialists, pain and palliative specialist and allied health specialists (including dieticians, physiotherapists, speech language therapists, and psychologists who have an oncology focus).
Surgeons (surgical oncologists, specialist surgeons, reconstructive surgeons) play a key role at MTBs. During the meeting, for patients who may require surgical management, discussions will revolve on the extent of the lesion and if it is safe to perform a surgery and remove the entire cancerous lesion with clear margins. Details of reconstructive surgery will also be discussed for advanced cancers.
Radiation Oncologists are specialists who deliver radiation therapy. This is a form of primary treatment to the radio-sensitive tumours or an alternative to certain types of early cancer to preserve function. “After surgery, the presence of adverse features and aggressive cancer biology may warrant the need for adjuvant therapy in the form of radiation to the surgical site to reduce the chance of recurrence,” says Alexander John, Senior Radiation Oncologist
Medical Oncologists will comment on if chemotherapy is indicated and if it is for curative purpose or for a palliative setting. Primary medical treatment in the form of chemotherapy or targeted therapy or immunotherapy is given for chemo-sensitive tumours like blood cancers or lymphomas. It is also prescribed as a form of adjuvant treatment, based on the histopathology report after surgery. “If there are cutting-edge clinical trials that are ongoing for cancers that are considered rare or incurable, these meetings serve as forums to assess whether the patient could avail of a newer form of treatment,” says Venkatraman Radhakrishnan, Head of Medical Oncology.
Oncopathologists examine the biopsy or resection surgical specimens to confirm the diagnosis of cancer, assess its aggressiveness and confirm if the cancer was completely removed with adequate margins. This is crucial for staging, treatment decisions and future adjuvant treatments. “In instances where the investigations have been done at a different centre, and the patient is seeking treatment at our hospital, the biopsy glass-slides or paraffin blocks are procured and reviewed again to ensurethat the diagnosis and staging are accurate. The final treatment decisions are based only after reconfirmation by our team,” says Shirley Sundersingh, Head of Oncopathology Department.
Radiologists and Nuclear Medicine specialists reassess the scans to demarcate the tumour extent and comment on critical areas of concern and rule out distant spread (metastasis). “In our hospital, we value early treatment commencement. Hence, investigations are completed within the week, so patient records can be presented at MTBs on time,” says Karthigaiselvi, Head of Radiology.
Palliative team: The panel will also collectively decide if the patient needs palliative treatment and focus on pain management, comfort care, and hospice placement. This collective decision-making also avoids unnecessary prolongedtreatment.
Allied Health Specialists: A dietician, physiotherapist, speech language therapist and psychologist with oncology focus are the backbone of a holistic cancer care services and help the patient cope with the disease, optimise them for treatment and rehabilitation. V. Surendran, Head of Psycho-oncology adds, “One of the strengths of our hospital is its tobacco cessation services. This is crucial for treatment success.
Anand Raja, Lead Uro-oncology and Musculo-Skeletal Oncology, says, “Maintaining tumour board synoptic data meticulously reveals cancer trends and facilitates research.” According to V. Venktesh, Senior Surgical Oncologist, “When we are confronted by complex case scenarios, there is a need for unified treatment plan from specialists in the field with decades of experience. This surpasses conventional textbook learning.”
In summary, MTBs are a confluence of diverse oncology experts getting together to deliver precision treatment for each patient’s unique presentation. The treatment objective is to balance cure and quality of life in tandem with scientific treatment advances. The primary objective of multidisciplinary tumour boards are patients, they are at the heart of decision-making!
Multidisciplinary Tumour Board Merits
1. Confirm diagnosis and stage
2. Improve survival outcomes
3. Early treatment commencement
4. Appropriate treatment implementation
5. Balancing quality of life measures with cure
6. Negating over-treatment
7. Educational for post-graduates
8. Monitoring cancer trends
9. Audit outcomes
(Dr. Mahalakshmi R. Shetty is an ENT specialist with the Cancer Institute (WIA), Adyar. [email protected]).
Published – April 03, 2025 11:41 pm IST