Endocrine Tumor Board: Ten Years’ Experience of a Multidisciplinary Clinical Working Conference



 

Alison Savitz, MD1; Bryan Fong, MD2; Aaron Hochberg, MD3; Gregory Rumore, MD4;
Cui Chen, MD4; Juanita Yun, MD5; Craig Sadur, MD6

Perm J 2020;24:19.140

https://doi.org/10.7812/TPP/19.140
E-pub: 06/17/2020

ABSTRACT

Introduction: Advances in specialized medical areas and updated clinical guidelines show a need for a focused approach for patients with specific disorders.

Objective: To describe a multidisciplinary tumor board for patients with endocrine tumors.

Methods:  We established an endocrine tumor board at a large health maintenance organization and studied cases presented between September 2007 and August 2017. To resolve diagnostic and/or therapeutic questions, a multidisciplinary team of specialists discussed patients’ clinical presentations. Cases were broken down into diagnostic categories, demographic characteristics (age, sex), and need for repeated presentations to the board.

Results: We included 608 patients: 401 female (66%) and 207 male (34%). Ages ranged from teens to more than 90 years, with the peak decade 50 to 59 years (26%). Although most patients needed only 1 presentation to the board, 151 (25%) required representation, for a total of 853 presentations. The diagnoses reflected the workup status with tumor identification and localization at the initial case presentation. Diagnoses included thyroid cancer (234 patients, 38.4%), adrenal mass (165 patients, 27.1%), primary hyperparathyroidism (120 patients, 19.7%), thyroid nodule (95 patients, 15.6%), and extrathyroidal mass (23 patients, 3.8%). Other diagnoses composed the remaining 14.6%. Tumor board attendees overwhelmingly supported the meetings’ benefits, with all clinicians reporting frequently changing patient management because of the meetings.

Conclusion: Patients with endocrine tumors may benefit from a specialized approach to care. A multidisciplinary tumor board can focus discussions efficiently, provide a forum to advance care, apply endocrine-related clinical guidelines, and lead to recommendations that clinicians often employed.

Keywords: endocrine tumor, tumor board, endocrine tumor board, thyroid cancer, adrenal mass, primary hyperparathyroidism, thyroid nodule, extra-thyroidal mass.

INTRODUCTION

General oncology tumor boards have been a mainstay of medicine for several years. The meetings typically call for a team of specialists to provide diverse expertise in medical fields related to the evaluation and treatment of patients with cancer. Review of patient cases with discussion by the various experts can lead to action plans to direct patient care and limit unnecessary tests and procedures.1-3

However, one format does not fit the needs of all patients with assorted medical issues. Specific physician talents are needed with the ongoing medical research and updated field-specific guidelines. For that reason, separate specialty-specific tumor boards developed.1,2 To our knowledge, there has not been a report of a tumor board dedicated to all endocrine tumors. If such a tumor board existed, it would be helpful to determine whether it reflected expected endocrine patients’ diversity and whether the case discussions led to changes in evaluation and treatment plans. We present a 10-year experience of a multispecialty endocrine-specific tumor board serving a large patient population.

METHODS

The Kaiser Permanente Diablo Service Area (KPDSA) located in the San Francisco Bay Area provides health care to more than 400,000 members. The affiliated facilities include 2 hospitals and 8 medical office buildings. Thyroid, parathyroid, adrenal, and pancreatic surgeries were directed to few surgeons, ones who performed those procedures frequently and demonstrated expertise in the fields. The KPDSA Endocrine Tumor Board (ETB) is a multispecialty board composed of endocrinologists, pathologists, radiologists, and nuclear medicine specialists in addition to surgeons. When specific cases arose, neurosurgeons, gynecologists, and urologists participated.

The period studied was the 10-year span from August 2007 through September 2017. Before each scheduled meeting of the ETB, presenting physicians posted the cases onto a secure electronic site, which was viewable by meeting attendees. The pattern of the conference was to select patients who presented diagnostic and/or therapeutic questions for which clinical discussion could result in an agreement leading to a subsequent plan. The clinical cases for some patients evolved and required repeated presentations for further diagnostic and/or therapeutic questions that arose. The radiologists, pathologists, and nuclear medicine physicians planning to discuss cases at the meeting reviewed the data in advance.

Board members convened monthly at a central meeting location, where there was large-screen visualization of the electronic medical record (EMR) of each patient presented. The EMR afforded access to necessary clinical details, such as clinic appointment notes, medical problem lists, and available data from other medical centers as well as results of imaging, cytology, surgical pathology, and laboratory reports. Projections of medical images provided the same details that were available to the reading radiologists or nuclear medicine physicians. The attending pathologists provided electronic images of cytologic and surgical pathology specimens. Other doctors connected to the meeting via remote access with audio linkage and simultaneous visualization of the same EMR elements viewed by attendees. Endocrinologists presented almost all the cases, with the patients’ surgeons almost always attending the meeting. Cases included both initial presentations and follow-up reports, with a variable number of patients discussed during the 90-minute meeting. All members were encouraged to ask questions and voice their assessments, leading to a consensus for further actions. Cultural diversity sensitivities4 were emphasized as part of the pertinent discussions to consider patient-centered concerns, with the goal to provide high-quality medical care in the most optimal ways. Attendees filled out continuing medical education questionnaires for educational credits.

A 10-question questionnaire was presented via email to the regularly participating ETB attendee clinicians to tabulate if and how they found the ETB useful for the clinical needs of their patients with endocrine disorders.

RESULTS

A total of 608 cases were presented at least once. Of those 608 patients, 151 (25%) were subsequently discussed at least 1 more time. Ninety-six (64%) of those 151 patients were discussed in follow-up 1 time; 32 patients (21%), 2 more times; 15 patients (10%), 3 more times; 4 patients (3%), 4 more times; 1 patient (< 1%), 5 more times; 2 patients (1%), 6 more times; and 1 patient (< 1%), 7 more times. Thus, there was a total of 245 times a patient was reviewed in follow-up. Coupled with the initial presentations of 608, there was a total of 853 times a case was discussed either initially or in follow-up.

The distribution by sex was 401 female patients (66% of the total) and 207 male patients (34%). Age distribution at the time of the initial case presentation followed somewhat of a normal distribution curve, which peaked in the sixth decade (23%) and was skewed toward the older age ranges. The age brackets by decade are shown in Figure 1.

The diagnoses listed reflected how far along the workup was in terms of tumor identification and localization at the time of the initial case presentation (Table 1). The most common diagnosis was thyroid cancer, which affected 234 patients (38.4% of the total patient population). Included among them were papillary, follicular, Hürthle cell, insular cell, medullary, anaplastic, and metastatic carcinoma to the thyroid as well those who had a history of thyroid carcinomas but for which the original pathologic diagnoses were unobtainable. The second most frequent diagnosis, which accounted for 165 patients (27.1%), was adrenal mass. Diagnoses that each made up to less than 3% of the total were pituitary mass, goiter (both neck and mediastinal), pancreatic mass, and pheochromocytoma/paraganglioma. A total of 51 patients (8.4%) cumulatively included the most sporadic diagnoses that led to inclusion in the meeting agenda or were adjunctive to the primary disorder. Those conditions included adnexal masses, sphenoid mass, calcifying fibrous pseudotumor, gastric diverticulum mimicking an adrenal tumor, tertiary hyperparathyroidism, normocalcemic hyperparathyroidism, carcinoid, gastrinoma, Cushing syndrome, insulinoma, pancreatic mass, parathyroid carcinoma, and Rathke cleft cyst.

The 10-question questionnaire was sent to clinicians with their responses listed in Table 2. All 12 doctors polled completed the survey. Results showed that 11 (92%) came into the ETB meetings to establish a treatment plan, and 12 (100%) came with goals to establish a diagnostic plan as well as learn updates in fields related to the care of endocrine patients. Similarly, 100% of the respondents reported cultural diversity was addressed, no commercial bias occurred, coordinating care with different specialties was facilitated, interacting with those different specialties was educational, clinical practice guidelines were addressed when appropriate, continuing medical education hours were worthwhile, and the ETB overall was considered of value. The clinicians were asked what estimated percentage of cases they presented led to changes in management. Six (50%) of the doctors responded that the ETB led to management changes in 20% to 39% of their presented cases; 2 (17%), 40% to 59% of cases; and 4 (33%), 60% to 79% of cases. Regarding whether the meeting outcomes led to improvement in patients’ quality of care, all respondents either strongly agreed or agreed (Table 2).

19 140 figure 1

DISCUSSION

Whereas a standard oncology tumor board works with patients with known malignancies, an ETB could include patients with benign, malignant, or at times coexisting benign and malignant lesions. A tissue diagnosis was not needed for inclusion of a case in the ETB’s meeting agenda because a clinical working conference of endocrine patients can help greatly with diagnostic evaluations that are in progress as well as treatment recommendations. Consensus opinions for diagnostic issues ranged from not pursuing any further testing to performing invasive procedures for more precise tumor characterization, including when to operate and how extensive a surgery should be performed. Treatment-centered discussions included whether postoperative aggressive treatment was indicated and specific postoperative steps.

The ETB illustrated different trends of patient populations presented. Three-fourths of the patients required only 1 case conference discussion. Follow-up presentations often reflected challenging aspects of the conditions and/or ongoing endocrine issues that lent themselves to reopening the case discussion. Of those cases discussed in follow-up presentations, 64% needed only 1 other time for seeking consensus opinions. The other 36% that lead to repeated follow-up presentations typically reflected an increased complexity in those cases. Most patients whose cases were on the agenda were female, likely reflecting the female predominance among patients with thyroid and hyperparathyroid disease. Another contributing factor could be that women are more likely than men to seek medical evaluation in a timely manner.5 Although pediatric endocrinologists were not part of the roster of physicians attending the ETB, 7 patients 19 years of age or younger were included in the case population. Most were teenagers with thyroid cancers, patients not typically followed up by general pediatric endocrinologists. The peak decades for patients discussed in conference were the ages of 40 through 59 years, likely reflecting times of increased thyroid and parathyroid disease detection.

A mainstay of clinical medicine in general and tumor boards more specifically is to apply updated evidence-based developments for patient care. In 2017, new changes in classification of thyroid cytopathology were published.6 Guidelines published from leading medical organizations provide frameworks for evaluation and treatment of various medical conditions. During the 2007 through 2017 years of this study, updated guidelines on thyroid nodules and differentiated thyroid cancer emanated from the American Thyroid Association.7 Also, during that period the Endocrine Society announced new guidelines on Cushing syndrome treatment,8 pheochromocytoma and paraganglioma,9 acromegaly,10 and pituitary incidentaloma.11 In 2014, the Fourth International Workshop updated the recommendations on asymptomatic primary hyperparathyroidism.12 Experts published an update for primary aldosteronism in 2016.13 The ETB reviewed the new recommendations in management as they were released by the governing bodies and quickly adapted these changes, using them to guide patient discussions and care plans.

 Polling the clinicians who brought their patients’ clinical cases to the ETB showed overwhelmingly positive results. When entering the ETB, nearly all surveyed clinicians sought to establish diagnostic and treatment plans. After completing the meetings, each of the doctors reported subsequent changes in patient management for a substantial percentage of the cases they presented. The meetings facilitated coordination of care with different specialties in a simultaneously educational setting, making the time spent considered of value, particularly with a unanimous sense of improved patient quality of care.

CONCLUSION

As medical research advances in the various specialty fields, recommendations require updating. Multidisciplinary teamwork can help promote clinical excellence.14 Clinicians caring for patients with various endocrine disorders can benefit from tapping into the expertise of specialists in a tumor board setting, which often can lead to modifications of diagnostic and treatment plans. Because of the complexities of evolution in the areas of endocrinology, endocrine surgery, neurosurgery, gynecology, urology, radiology, neuroradiology, nuclear medicine, and pathology, an endocrine-specific tumor board provides a forum for quick and practical discussions in busy clinical settings.

Table 1. Diagnosis distribution of patients at initial case presentation (N = 608)
Diagnosis Number (%) of patients
Thyroid cancer 234 (38.4)
Adrenal mass 165 (27.1)
Primary hyperparathyroidism 120 (19.7)
Thyroid nodule 95 (15.6)
Extrathyroidal mass 23 (3.8)
Pituitary mass 16 (2.6)
Goiter 14 (2.3)
Pancreatic mass 5 (0.8)
Pheochromocytoma/paraganglioma 3 (0.5)
Other endocrine tumorsa 51 (8.4)

a 608 patients had 726 diagnoses because some patients had more than one endocrine diagnosis; See the Results section for a breakdown of types.

 

Table 2. Clinician survey responses regarding
tumor board meetings
Survey question Number (%) of respondents
Coming into the meeting, have your possible goals included
the options below? (You can select ≥ 1 answer)
Establishing a diagnostic plan 12 (100)
Establishing a treatment plan 11 (92)
Learn updates in fields related to the care of endocrine patients 12 (100)
In the meetings, was cultural diversity addressed?
Yes 12 (100)
No 0 (0)
Was there commercial bias in the meetings?
Yes 0 (0)
No 12 (100)
Were the meetings helpful in coordinating care with
the different specialties?
Yes 12 (100)
No 0 (0)
Were clinical practice guidelines discussed when appropriate?
Yes 12 (100)
No 0 (0)
Was interacting with the different specialties in the
meeting educational?
Yes 12 (100)
No 0 (0)
Were the meetings worthy of continuing medical education hours?
Yes 12 (100)
No 0 (0)
What estimated percentage of cases that you presented
led to changes in management?
< 20 0 (0)
20-39 6 (50)
40-59 2 (17)
60-79 4 (33)
> 80 0 (0)
As a result of the meeting, the quality of care improved for my patients.
Strongly agree 11 (92)
Agree 1 (8)
Neither agree nor disagree 0 (0)
Disagree 0 (0)
Strongly disagree 0 (0)
Did you see value in the meetings?
Yes 12 (100)
No 0 (0)
 
Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Acknowledgments

We sincerely thank Quincy McCrary, MA, MLIS, for assistance with manuscript preparation.

Kathleen Louden, ELS, of Louden Health Communications performed a primary copy edit.

Author Affiliations

1 Department of General Surgery, Kaiser Permanente, Walnut Creek, CA
2 Department of Head and Neck Surgery, Kaiser Permanente, Walnut Creek,  CA
3 Department of Radiology, Kaiser Permanente, Walnut Creek, CA
4 Department of Pathology, Kaiser Permanente, Walnut Creek, CA
5 Department of Nuclear Medicine, Kaiser Permanente, Walnut Creek, CA
6 Department of Endocrinology, Kaiser Permanente, Pleasanton, CA (retired)

Corresponding Author

Alison Savitz, MD ()

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Keywords: : endocrine tumor board, tumor board, endocrine tumor, thyroid cancer, adrenal mass, primary hyperparathyroidism, thyroid nodule

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