Coordinated Care in Breast Oncology: Tumor Board & Treatment Alignment

In this episode of OncChats: Coordinated Care in Breast Oncology, Jason Ye, MD, and Daphne B. Stewart, MD, of Keck Medicine of USC, discuss how coordinated tumor board reviews enhance continuity of care, treatment personalization, and patient confidence following breast cancer surgery.

Ye: Another topic that maybe we can discuss is, after patients go through the multidisciplinary discussion and treatment planning, [there is] the tumor board. [Maybe we can discuss] what happens there.

Stewart: Sure, happy to introduce that. Earlier, [we alluded to how we] meet together as a team, a five-member [or so] team, before [the patient] undergoes any sort of treatment. Based on that multidisciplinary clinic, we plan for treatment. Then, when a patient undergoes surgery, this five-member team comes back together again immediately after the surgery with a multidisciplinary tumor board to review the response to up-front therapy, the response to the surgery, [determine] what the extent of disease [is], and what the risks of disease [are.] Again, we are discussing how we move forward for the future, to optimize the outcomes and all of our resources. That would be continuing with adjuvant treatment, whether [in the form of] chemotherapy, antiestrogen therapy, radiation therapy, and as Jason mentioned, [we would reflect on] additional breast reconstruction options, occupational therapy and physical therapy, [and] survivorship therapy, so that [the patient] can take advantage of everything to make [them] feel better and more confident [about their care]. [We also ensure] that the team is coordinating so that there is no overlapping confusion where, for example, a surgeon is giving one bit of advice, and the radiation oncologist is giving a different bit of advice. This way, [everything is] connected, and that will give the patients more confidence, because we have one big plan moving forward.

Ye: Absolutely, and our surgical fellows and our radiologists and pathologists do a great job of summarizing [each] case. I really like reviewing the whole treatment journey from diagnosis, to before surgery, to looking at the actual pathology, and then to have a discussion of the treatment. To go back to the multidisciplinary breast clinic concept, and I know we talked about this a lot, but to me, I feel like it’s nice for the patients to then be sent back to a provider that they’ve already met before as opposed to [having to go to] a brand-new doctor for radiation. [This prevents them from having to go see a provider they have] never met before, [after they] just had surgery [and are focused on] recovering. There’s a lot going on in [their] mind [at that point.] I think that coordination is really valuable.

Stewart: For medical oncology, probably about 30% of our patients do get systemic therapy up front because they either have large tumors or they have higher-risk subtypes that benefit from doing neoadjuvant chemotherapy. The idea is that you’re giving chemotherapy or potentially endocrine therapy to shrink the primary tumor, and that impacts long-term survival. We’re very, very eager to assess the response to treatment. So, you give the treatment up front, and the treatment often lasts for 6 months before you actually go to the surgical intervention. [What happens] is, the medical oncologist does the primary management for many, many months. Then, the patient goes back to the surgeon, and then, as Jason pointed out, they go back to radiation oncology. So again, to be able to have this interconnected team that is coordinated on the same path [is important]. It’s very, very useful to already have those initial connections.

I do want to point out that the tumor board becomes so useful with our outstanding radiologists and pathologists, because after you do systemic therapy prior to surgery, it’s crucial that we assess the amount of residual cancer after that up-front treatment. We know that in certain breast cancer subtypes—specifically triple-negative breast cancer or HER2-positive breast cancer—if [a patient has] significant response to treatment, [ie] the tumor shrinks or completely enters remission after systemic therapy [in] that when you do the surgical resection you cannot find any residual cancer, that is associated with a very good long-term prognosis.

I think what we’re going to get into next is discussion about these really provocative clinical trials that are upcoming, which may allow de-escalation of certain therapies after surgical resection, when [a patient has] received up-front systemic therapy, and gives us a lot of opportunities to modify our initial treatment options to improve outcomes, patients’ quality of life, and maybe reduce [adverse] effects.