Evidence-based Cancer Care: Assessing Multidisciplinary Tumor Board Recommendations and Guideline Adherence in a Non- Academic Medical Center

doi:10.21203/rs.3.rs-5145193/v1

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Evidence-based Cancer Care: Assessing Multidisciplinary Tumor Board Recommendations and Guideline Adherence in a Non- Academic Medical Center

https://doi.org/10.21203/rs.3.rs-5145193/v1

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Purpose

Multidisciplinary tumor boards (MTB) are associated with improved outcomes. Yet, most patients in Western countries receive cancer care at non-academic medical centers. Guideline adherence of MTB recommendations in non-academic medical centers as well as factors contributing to non-adherence have so far not been systematically investigated.

Methods

All cases discussed at the MTB of the Landesklinikum Baden-Moedling, Austria were eligible for inclusion. Guideline non-adherence was assessed by two reviewers independently using the AWMF S3 guidelines. Factors associated with guideline non-adherence were investigated.

Results

In total, 579 patients were included in the final analysis: 486 were female (83.9%) and 93 were male (16.1%), with a median age of 70 years (IQR 60–80). Most had breast cancer (n = 451; 77.9%), while 128 had colorectal cancer (22.1%). Complete adherence to guidelines was observed in 453 patients (78.2%), major deviations in 60 (10.4%), and minor deviations in 66 (11.4%) patients. Non-adherence was primarily due to patient preferences (n = 24; 40.0%), lack of surgical treatment recommendation (n = 24; 40.0%), and comorbidities (n = 9; 15.0%). After adjusting for relevant variables, predictors of non-adherence included older age at diagnosis (OR 1.02, 95% CI 1.00-1.04), colorectal cancer (OR 3.84, 95% CI 1.99–7.42), higher ECOG status (OR 1.59, 95% CI 1.18–2.16), and a more recent MTB conference (OR 1.20, 95% CI 1.03–1.41).

Conclusion

Overall, guideline adherence was high for colorectal and breast cancer and comparable to results from academic medical centers. This study provides support for high-quality cancer treatment in the setting of a non-academic medical center. However, results need to be confirmed in other tumor entities.

Multidisciplinary tumor board

Guidelines adherence

Non-academic medical center

Multidisciplinary tumor boards (MTB) are flexibly composed panels comprising oncological, surgical, pathological, and radiological specialists as well as others tasked with the comprehensive review of individual cases and subsequent provision of a consented state-of-the-art treatment recommendation ^1–3. While prospective evidence is lacking, MTBs have been associated with superior overall survival, diagnostic accuracy, quality of life, and patient satisfaction ^4–6. Furthermore, both national and international guidelines, as well as certification requirements for cancer centers mandate the discussion of patients at MTBs ^7–9.

Guideline adherence has been linked to improved outcomes in various tumor entities, and some studies have investigated guideline adherence of MTB recommendations ^10–13. However, most of these studies were conducted at academic medical centers, leaving guideline adherence at non-academic medical centers, including community hospitals, largely unexplored ^14,15. Meanwhile, analysis of registry data indicates that patients treated in community cancer programs have a significantly lower likelihood of receiving guideline-compliant care ¹¹. This is particularly notable as most cancer patients in Western countries receive care at a non-academic medical center ^16,17. For instance, data from the United States indicate that approximately 80% of cancer patients are treated within a community hospital setting ¹⁸.

Despite the large number of cancer patients treated and the association of guideline adherence with improved outcomes, there is a relevant gap in knowledge regarding the adherence of MTB recommendations in non-academic medical centers to established guidelines. Furthermore, potential factors contributing to guideline deviations and the extent to which MTB recommendations are implemented into clinical practice remain insufficiently understood. Notably, academic medical centers typically have a variety of highly specialized MTBs for individual organ system, strongly contrasting the non-specialized MTBs commonly present at non-academic medical centers ¹⁹.

This exploratory study aims to assess the guideline adherence of MTB recommendations in a representative non-academic medical center in Austria. Additionally, it aims to identify predictors of guideline deviation and to evaluate the implementation of guideline-adherent recommendations into clinical practice, thus addressing a critical gap in cancer care research.

Study Design and Study Setting

This study adhered to the STROBE recommendations for observational studies ²⁰. The study was approved by the local ethics committee (Vote GS3-EK-4/902–2024) and was conducted in accordance with the Declaration of Helsinki. All patients discussed at the MDT at the Landesklinikum Baden-Moedling, a non-academic medical center in Austria, were identified from a prospectively maintained electronic tumor board database (OIS, St. Poelten, Austria) and assessed for eligibility. The MTB at the Landesklinikum Baden-Moedling meets weekly and discusses a wide range of cases with malignancies involving different organ systems and specialties, including general surgery, oncology, urology, and others. Additionally, physicians-in-training routinely attend the MTB.

Study population

All patients with malignant tumors of the breast, colon, and rectum discussed at the MDT between 01/2019 and 03/2024 were eligible for inclusion. Only the first MDT discussion of each patient was considered. Patients with benign tumors, precancerous lesions, pregnant patients, as well as minors were excluded. Additionally, in line with the study's objectives, patient records that lacked documentation of UICC/AJCC stage and/or TNM stage were excluded.

The following information was extracted from the electronic health record and the tumor board information system: date of birth, sex, ICD-10 diagnosis, date of first diagnosis, date of death, family history of cancer, TNM stage, UICC/AJCC stage, date of MDT conference, ECOG status, training level of the presenting physician (specialist vs resident), presenting department (surgery vs internal medicine), and MDT recommendation. Furthermore, data on the date of first therapy after MDT discussion, neoadjuvant treatment, hormone therapy, chemotherapy, immunotherapy, targeted therapy, number of treatment cycles, radiation therapy, and chemoradiation were also extracted.

Primary and Secondary Outcomes

The primary outcome was guideline adherence of MTB recommendations. Secondary outcomes included the identification of predictors of guideline adherence, with odds ratios as estimands. Additionally, the study evaluated the implementation of MDT recommendations. Specifically, patients with guideline-adherent recommendations were analyzed to determine if the care they received was consistent with the MDT recommendation. These results are presented descriptively.

Assessment of Guideline Adherence and Deviations

Guideline adherence was classified as reported previously by Krause et al. ¹⁵. Briefly, major criteria for guideline adherence were defined based on different treatment modalities with deviations in one or more criteria classified as major deviation. Minor criteria included specific therapeutic strategies within the respective treatment modalities. Deviation from one or more minor criterion was classified as minor deviation of guideline adherence ¹⁵. MTB recommendations lacking essential information were classified as non-assessable.

Guideline adherence was assessed using the German AWMF guidelines (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften - Associations of the Scientific Medical Societies in Germany) in their current version at the time of case presentation ^21,22. Two reviewers independently evaluated adherence to guidelines as well as reasons for any deviation, based on MTB protocols. In cases of disagreement, a discussion with the senior author was initiated until a consensus was reached.

Statistical analysis

Demographic parameters and quantitative variables are described using means and standard deviations, while qualitative variables are reported as absolute and relative frequencies. Statistical inference was performed using two-tailed Student's t-test, chi-square test, Fisher's exact test, and Kolmogorov-Smirnov test. The normality assumption was investigated using the Shapiro-Wilk test.

Ordinal logistic regression was used to assess associations of selected variables with guideline adherence, minor deviation, and major deviation. Patients classified as non-assessable were excluded from the analysis. Given the low frequencies, ECOG 3 and 4 categories were combined. Additionally, due to the small number of patients presented by various specialties at the MDT, these specialties were grouped into surgical versus non-surgical categories. To account for the time of the MTB conference and potential changes over time, the earliest date of MTB conference in the dataset was set as zero, and all subsequent MTB conference dates were recalculated in years relative to this baseline. All variables were chosen based on domain knowledge and previous literature ^15,23,24.

Missing data for covariates were imputed for model building using imputation of multiples, under the assumption that data were missing at random ²⁵. No imputation was performed for the outcome variable. Continuous variables were entered in the model and sensitivity analysis using non-linear forms did not lead to a relevant change in results. The proportional odds assumption for ordinal logistic regression was assessed using the Brant test ²⁶. Subgroup analysis was conducted only focusing on breast cancer and female sex, while keeping all the other variables in the model constant. Only female participants were included, as a very small number of male breast cancer cases were expected. A two-sided p-value < 0.05 was considered significant. The Bonferroni correction was applied to control the family-wise error rate when comparing characteristics of assessable versus non-assessable patients. All analyses were conducted using R (R project for Statistical Computing).

Patient population

After applying the exclusion criteria, a total of 639 patients remained. Of the these, no guideline adherence could be assessed in 60 patients due to a lack of essential information in the MTB recommendation (n = 51) or no MTB recommendation (n = 9) (Fig. 1). Comparisons of demographic and clinical variables between non-assessable versus assessable patients are shown in Suppl. Table 1.

The final cohort is depicted in Table 1. Most were females (n = 486, 83.9%) and the median age was 70 years (interquartile range 60–80). In total, 451 (77.9%) had breast cancer while 128 (22.1%) patients had colorectal cancer. Most MTB recommendations were adherent to guidelines (n = 453, 78.2%), while 60 (10.4%) exhibited major deviations and 66 (11.4%) minor deviations. Major deviations were primarily lack of conservative treatment recommendation (n = 24; 40.0%), patient refusal of suggested treatment (n = 24; 40.0%), and patient-intrinsic factors including inoperability (n = 9; 15.0%) (Suppl. Table 2).

Table 1

Characteristics of the study cohort.
Patient characteristics	n	%
Total	579	100
Tumor entity
Breast cancer	451	77.9
Colorectal cancer	128	22.1
Sex
Male	93	16.1
Female	486	83.9
Age
Median (IQR)	70.0 (60.0–80.0)	-
Positive family history
Yes	106	18.3
No	227	39.2
Not available	246	42.5
ECOG status
ECOG 0	412	71.2
ECOG 1	113	19.5
ECOG 2	35	6.0
ECOG 3	9	1.6
ECOG 4	4	0.7
Missing values	6	1.0
UICC stage
UICC I	288	49.7
UICC II	145	25.0
UICC III	83	14.3
UICC IV	63	10.9
Treatment characteristics	n	%
Training level
Resident	50	8.6
Specialist	457	78.9
Missing values	72	12.4
Department
Surgery	537	92.7
Internal medicine	34	5.9
Missing values	8	1.4
Time MTB conference in years (mean, IQR)	2.76 (1.89–3.94)	-

Predictors of guideline non-adherence

Univariable ordinal regression analysis revealed a significant association between age at diagnosis (OR 1.03, 95% CI 1.02–1.05), AJCC/UICC stage (OR 1.46, 95% CI 1.22–1.74), colorectal tumors (OR 3.12, 95% CI 2.05–4.75), and higher ECOG status (OR 1.89, 95% CI 1.50–2.39) and a higher probability of guideline deviation of the MDT recommendation. In contrast, female sex (OR 0.53, 95% CI 0.33–0.85) and presenting department surgery (OR 0.43, 95% CI 0.21–0.87) were associated with a lower probability (Table 2). After adjusting for prespecified variables, older age at diagnosis (OR 1.02, 95% CI 1.00-1.04), more recent MTB conference (OR 1.20, 95% CI 1.03–1.41), colorectal versus breast cancer (OR 3.84, 95% CI 1.99–7.42), and higher ECOG status (OR 1.59, 95% CI 1.18–2.16) were independently associated with a higher probability of guideline deviation (Fig. 2).

Table 2

Univariable ordinal logistic regression analysis.
Variable	Odds ratio	95% Confidence interval	P value
Training level (specialist vs resident)	0.58	0.32–1.07	0.08
Age (continuous)	1.03	1.02–1.05	< 0.001
UICC (continuous)	1.46	1.22–1.74	< 0.001
Tumor type (colorectal vs breast cancer)	3.12	2.05–4.75	< 0.001
Department (Surgery vs internal medicine)	0.43	0.21–0.87	0.02
Sex (Female vs male)	0.53	0.33–0.85	0.01
ECOG	1.89	1.50–2.39	< 0.001
Family history (No vs yes)	0.88	0.50–1.55	0.65
Time MTB conference (continuous)	1.11	0.96–1.28	0.15

Subgroup analysis for breast cancer

As most patients were diagnosed with breast cancer, a subgroup analysis was conducted focusing on breast cancer only. Higher ECOG status (OR 1.66, 95% CI 1.10–2.49), and older age at diagnosis (OR 1.03, 95% CI 1.00 -1.05) were significantly associated with a higher probability of guideline deviation of MTB recommendation (Fig. 3).

Adherence to tumor board recommendation

Next, the implementation of guideline-adherent MTB recommendations into clinical practice was analyzed. While the implementation of the MTB recommendation could not be assessed in 22 (4.9%) patients, 395 (87.2%) were adherent to MTB recommendations. In contrast, 36 (7.9%) patients did not receive the recommended treatments.

Academic medical centers are integral to cancer care and research. However, most cancer patients receive treatment at non-academic medical centers within their local community. The present study revealed a high-level of guideline adherence of MTB recommendations at a representative non-academic medical center in Austria. Predictors of guideline non-adherence included older age at diagnosis, a higher ECOG status, colorectal cancer versus breast cancer, and a more recent MTB conference.

Adherence to guidelines has been associated with improved outcomes, and guideline adherence of MTB recommendations is considered a quality criterion for cancer care ². However, time pressure, a high number of cases, lack of MTB leadership, as well as lack of information including imaging, and pathologic workup, have been associated with low-quality decision making ²⁷. On average, 3.2 minutes are spent on each case in MTBs ²⁸. Interestingly, most literature on the quality of MTB recommendations originates from academic medical centers, while most patients receive treatment in non-academic medical centers ¹⁷. Furthermore, data indicate that increased travel time is associated with a worse quality of life, which potentially presents a barrier to the implementation of highly centralized care ^29,30. Therefore, results from studies conducted in academic settings may not accurately reflect real-world experiences.

In the present study, guideline adherence was 78.2%, which is comparable to previous studies from academic medical centers, reported adherence rates between 37–100% ^12,14,15,31. Additionally, several predictors of guideline deviations were identified. Each additional year of age was associated with an approximately 2% higher probability of guideline deviation, while a one-point increase of ECOG status corresponded to a more than 60% higher probability of guideline deviation. Thus, both results indicate a clinically relevant difference. While performance status is frequently used as an indicator of a patient’s fitness for undergoing treatment, evidence suggests that it might be a suboptimal indicator ³². Additionally, randomized controlled trials, which form the foundation for guidelines typically include a highly selected population with low ECOG status, which might not reflect real-world patient cohorts ³³. Our findings thus emphasize the lack of high-quality evidence for cancer treatment in the elderly ³².

The strongest effect estimate was observed in patients suffering from colorectal cancer in contrast to breast cancer, resulting in a fivefold increase in the probability that the MTB recommendation would deviate from established guidelines. Several factors could be responsible for this finding. The Landesklinikum Baden-Moedling is certified as a breast cancer center by national authorities, potentially contributing to a higher guideline adherence in breast cancer cases. Interestingly, new study results, such as those from the RAPIDO trial in colorectal cancer, also led to guideline deviations, highlighting that deviations may be justified based on emerging evidence ³⁴.

Previous research from academic medical centers suggests that a higher tumor stage is associated with a higher probability of guideline non-adherence ^35,36. In our study, a higher UICC stage was associated with a 6% increased probability of guideline deviation. However, 95% confidence intervals were fairly evenly distributed around the null value. Future studies with a larger population are necessary to evaluate tumor stage as a predictor of guideline deviation.

Notably, a more recent case discussion at the MTB was associated with a higher probability of guideline deviation. The reasons for this are difficult to evaluate in a retrospective study; however, it is important to consider that the AWMF guidelines are not updated annually, while new evidence from clinical trials is continuously emerging. To address this, we opted for a relatively short eligibility time span when evaluating adherence, thereby reducing potential sources of heterogeneity. Interestingly, in the subgroup analysis focusing on breast cancer, only a higher ECOG status and older age at diagnosis remained independent predictors while a more recent MDT conference was not identified as a predictor.

Furthermore, previous reports have suggested that female sex is associated with guideline non-adherence of MTB recommendations ¹⁴. However, while significant in univariable analysis, after adjusting for potential confounding factors, no such association could be confirmed in our study. This might be due to different tumor entities.

Several strengths are worth mentioning. To the best of our knowledge, this is the first study systematically assessing guideline adherence of MTB recommendations in a non-academic medical center, thereby addressing a critical knowledge gap. Furthermore, a previously reported classification system was used to assess guideline adherence, enhancing validity and comparability of our results. Additionally, clinically relevant predictors of guideline non-adherence of MTB recommendations were identified using rigorous statistical methodology ³⁷.

However, several caveats need to be acknowledged. Guideline adherence in this study was based on the AWMF guidelines, which are specific to German-speaking countries. Additionally, some guidelines, such as the NCCN guidelines, are updated more frequently and may better incorporate recent developments in the field. For instance, the S3 guideline for colorectal cancer was published in 2019, while the S3 guideline for breast cancer was last updated in 2021. This difference in the dates of the last updates might partially explain the higher probability of guideline non-adherence observed in colorectal cancer cases. Also, this study was performed in a Western European country with a universal healthcare coverage. Thus, the applicability of the results to other healthcare settings requires external validation.

Additionally, the present study only included colorectal and breast cancer cases. Thus, the present results do not generalize to other malignancies, in particular cases of high-complexity oncological care such as esophageal and pancreatic cancer, for which a well-known volume-outcome relationship exists ^38,39.

Furthermore, no data on comorbidities, such as the Charlson Comorbidity Index (CCI), were available. This is noteworthy as previous studies have identified comorbidities as a relevant factor for guideline deviation ¹⁵. However, we tried to account for this limitation and incorporated performance status into our model, which has been shown to correlate with comorbidities ⁴⁰. Also, as this was a retrospective study, selection bias cannot be ruled out. Only patients presented at the MTB were considered in the present study, no data were available on patients with breast or colorectal cancer who were not presented at the MTB. Additionally, no conclusions can be drawn on the effect of guideline adherent MTB recommendations on survival.

Finally, while this study took place at a non-academic medical center, it is part of an integrated care network. Thus, specialists at the MTB often join virtually from other centers. New possibilities in telemedicine might thus provide an opportunity for high-quality local cancer care. This is in line with data from the United States indicating higher guideline adherence at integrated network cancer programs compared to community cancer programs ¹¹. Some evidence points to improved outcomes after joining care networks with an academic-community hospital collaboration model ⁴¹.

In summary, the majority of MTB recommendations in a non-academic medical center are compliant with guidelines, comparable to academic medical centers and therefore indicating a high-quality of care for colorectal and breast cancer patients. Furthermore, the identified predictors might aid in MTB decision-making. However, external validation is necessary, ideally in a prospective fashion. Additionally, investigation in other tumor entities besides colorectal and breast cancer should be conducted. Notably, complete adherence cannot and should not be ever reached as new evidence emerges and individualized patient care might not be adequately reflected in guidelines.

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Funding:

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Competing Interests:

The authors have no relevant financial or non-financial interests to disclose.

Author Contributions:

All authors contributed to the study conception and design. Study design, data collection and data analysis, methodology and writing of the primary draft were performed by Carl-Stephan Leonhardt and Martin Bodingbauer. Leopold Lanzenberger and Raphael Puehringer performed data collection and data analysis. Gerold Prager, Irene Hauser, Oliver Strobel and Ulla Klaiber assisted in methodology, data analysis as well as data interpretation. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Data Availability:

Data is available from the corresponding author upon request.

Ethics approval:

The study was conducted in line with the principles of the Declaration of Helsinki. Approval was granted by the ethics committee of Lower Austria (Vote GS3-EK-4/902-2024).

Consent to participate:

Due to the retrospective nature of the study, informed consent was waived by the ethics committee of Lower Austria.

No competing interests reported.

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Evidence-based Cancer Care: Assessing Multidisciplinary Tumor Board Recommendations and Guideline Adherence in a Non- Academic Medical Center

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INTRODUCTION

MATERIAL AND METHODS

Study Design and Study Setting

Study population

Primary and Secondary Outcomes

Assessment of Guideline Adherence and Deviations

Statistical analysis

RESULTS

Patient population

Predictors of guideline non-adherence

Subgroup analysis for breast cancer

Adherence to tumor board recommendation

DISCUSSION

Conclusions

References

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