Abstract
Background/Aim: Tumor boards (TUBs) are interdisciplinary meetings designed to determine the most effective cancer therapies and improve patient outcomes. This study aimed to assess which TUB therapy recommendations were easily implemented and to identify factors that hindered their implementation in clinical practice.
Patients and Methods: In this retrospective study, data from ten TUBs held at the University Hospital Bonn between 2014 and 2016 were analyzed. The dataset included 7,152 patients and 13,050 therapy recommendations. The degree of adherence to the recommended therapies was classified into four categories. Additionally, reasons for deviations from the recommendations were categorized based on medical record reviews.
Results: On average, 84.2% of recommendations were implemented: 68.1% were fully and 16.1% partially implemented. Deviations occurred in 8.6% of cases. The most common reasons for partial implementation were therapy changes based on new clinical findings or physician decisions (16.7%) and patient preferences (10.4%). The leading reason for complete deviation from the recommendation was lack of documentation (51.3%).
Conclusion: Most TUB recommendations across ten medical disciplines were fully or partially implemented. However, there remains potential for improvement, particularly in ensuring consistent documentation and integrating patient preferences into clinical decision-making.
Introduction
To address the different symptoms and manage the complexity of modern cancer care, tumor boards (TUBs) have been set up with the idea that multidisciplinary teams (MDTs) may be able to manage and treat the different cancer symptoms more efficiently. A TUB is a regular meeting of a group of healthcare professionals where patient cases are discussed. The aim of these meetings is to provide optimal treatment recommendations. Typical topics of a TUB meeting include management of the next steps, including further diagnostics/investigations or treatment changes, current outcomes, clinical health status, patient’s wishes, and the possibility of participating in clinical trials (1). Studies suggest that patients do benefit from these TUBs. However, there are also studies that do not show a higher survival rate (2, 3). Finally, there is the question of how patients and TUB participants evaluate the TUBs. Patient satisfaction with MDTs remains very high (4), as patients see the advantages of MDTs. A higher quality of care, educational benefits and cost-effectiveness have also been suggested (5). The aim of our study was to determine how many of the treatment options proposed by the TUBs were actually implemented in practice and to identify the reasons why some options remained unimplemented.
Patients and Methods
For this study, 10 TUBs at the Center for Integrated Oncology (CIO) of the University Hospital Bonn from different disciplines were evaluated, such as the departments of dermatology, hereditary tumors, gastroenterology, breast tumors and gynecological tumors, neuroendocrine tumors and thyroid tumors, thoracic tumors, head and neck tumors, sarcomas, musculoskeletal tumors, and neurooncological tumors and urology. These TUBs meet on a weekly basis.
To determine therapy adherence to the recommendations, four categories were established: “total implementation”, “partial implementation”, “deviance” and “implementation not assessable”. The two categories “partial implementation” and “deviance” were divided into subgroups (Table I). These subgroups were to identify why implementation was not entirely complete. The subgroups were “patient’s wish”, “doctor’s decision/change in results”, “patient death”, “missing follow-up” (only for “partial implementation”), “missing documentation” and “other” (Table I, Table II). The category “implementation not assessable” was divided into two subcategories: “patient death”, as in some cases, due to the patient’s death, medical treatment was never administered; and “missing follow-up”, for cases in which, after the initial TUB recommendations, all documentation of the patient’s history stopped (6).
Categorization of therapy recommendation implementation, exemplified by the urologic tumor board. This structure was used to classify the implementation of recommendations from the tumor boards (TUBs).
Definition of reasons for deviance from therapy recommendations. The standardized categories used in the study to classify the reasons for deviating from the tumor board’s original recommendations are listed.
We analyzed cases from June 2014 to December 2016; the data were accessed for research purposes on the 22nd of August 2017. The TUB’s proposed therapy regimens are detailed in each patient’s report. We identified whether the TUB’s recommendations were implemented and, if so, how much the actual treatment adhered to the TUB’s guidance. For our study, a period of one year to fulfill the therapy recommendations was accepted.
The patient data are collected through the hospital information system “Orbis NICE” and the documentation system “HYDMedia” (both from Agfa Health Care GmbH, Bonn, Germany). All available documents from these two systems were used. Furthermore, information was taken from the imaging system “PACS” (Picture Archiving and Communication System) and the tumor documentation systems “ODSeasyNET” and “ODSeasy” (both Asthenis GmbH, Aschheim, Germany).
For the data analysis, the implementation of therapy recommendations was treated as a binomial outcome (e.g., ‘total implementation’ vs. ‘not total implementation’). The proportions (p) for each category were determined. To quantify the precision of these estimates and allow for inference to a broader population, standard errors (SE) and 95% confidence intervals (CI) were calculated.
The standard error for each proportion was calculated using the formula for binomial distributions:
where p is the observed proportion and n is the total number of recommendations in that group. The 95% confidence interval was then determined as: CI=p ±1.96∙SE. All figures and tables were created using Microsoft Office Excel 2007.
The Ethics Committee, which reviews clinical research on humans and epidemic research including personal data at the Medical Faculty of the Rheinische-Friedrichs-Wilhelms-Universität Bonn, confirmed that a retrospective evaluation of routine clinical data was not required according to the rules of the medical association reviewed by the Ethics Committee. Informed consent was not required; nevertheless, the patient data was pseudonymized. The authors had access to information that could identify individual participants during or after data collection.
Results
From June 2014 to December 2016, a total of 13,050 tumor board recommendations for 7,152 patients were reported across the ten evaluated Tumor Boards (TUBs). All these recommendations were considered and evaluated in this study. The specific TUBs and the volume of recommendations and patients were as follows:
TUB for neurooncological tumors: 2,176 recommendations for 1,406 patients.
TUB for head and neck tumors: 1,319 recommendations for 812 patients.
TUB for sarcomas and musculoskeletal tumors: 320 recommendations for 232 patients.
TUB for breast and gynecological tumors: 3,462 recommendations for 816 patients.
TUB for thoracic tumors: 851 recommendations for 745 patients.
TUB for hereditary tumor syndromes: 108 recommendations for 92 patients.
TUB for dermatological tumors: 673 recommendations for 401 patients.
TUB for gastrointestinal tumors: 1,928 recommendations for 1,155 patients.
TUB for neuroendocrine and thyroid tumors: 731 recommendations for 479 patients.
TUB for urologic tumors: 1,482 recommendations for 1,014 patients.
Overall findings across all the investigated TUBs. In total, across the 13,050 recommended therapy approaches reviewed, the overall implementation rate was 84.2% (Figure 1). Therapy options were “completely implemented” in 68.1% of cases and “partially implemented” in 16.1% of cases. It was “not assessable” whether recommendations were put into practice in 7.3% of cases, and a “deviance” from the treatment received occurred in 8.6% of cases. The reasons for deviance were primarily a “lack of documentation”, which accounted for 51.3% of these cases. Other reasons included the “patient’s wish” (25.3%) and a “doctor’s decision or modified results” (20.8%). Reasons classified as “other” made up the remaining 2.6%. The frequencies of each reason for deviance across the ten investigated tumor boards are presented in Table III. The reasons for “partial implementation” were similar to those for “deviance” and were led by “lack of documentation” (58.5%), followed by “change of therapy due to doctor’s decision or modified results” (16.7%) and “patient’s wish” (10.4%) (Figure 2). “Missing follow-up” was the fourth most frequent reason for partial implementation (9.3%), followed by “patient death” (3.4%) and “other” reasons (1.6%). Below, the findings are presented by specific tumor board.
Adherence to tumor board recommendations. This pie chart displays the overall implementation rates of 13,050 therapy recommendations from ten different tumor boards. The data is categorized into “total implementation” (68.1%), “partial implementation” (16.1%), “deviance” (8.6%), and “implementation not assessable” (7.3%), with corresponding patient numbers for each category.
Percentage distribution of reasons for deviance across the ten investigated tumor boards.
Reasons for partial implementation of tumor board recommendations. This pie chart illustrates the distribution of reasons for the 2,100 cases of partial implementation. The primary reason shown is “missing documentation” (58.50%), followed by “doctor decision/change in results” (16.70%), “patient wish” (10.40%), “missing follow-up” (9.30%), “patient death” (3.40%), and “other” (1.60%), with the absolute number of cases for each reason.
TUB for breast and gynecological tumors. For the TUB for Breast and Gynecological Tumors, 3,462 recommendations concerning 816 patients were investigated. The overall implementation rate was 89.1% (3,086 recommendations). Of all recommendations, 67.0% (2,320 recommendations) were for “total implementation” (SE=0.008, CI=0.6543-0.6857) and 22.1% (766 recommendations) for “partial implementation” (SE=0.0071, CI=0.2071-0.2349). Deviance was recorded in 7.1% of cases (247 recommendations) (SE=0.0044, CI=0.0238-0.07962), and implementation was not assessable for 3.7% (129 recommendations) (SE=0.0032, CI=0.03073-0.04327). Among the 766 cases of partial implementation, the reasons were “missing documentation” (503 cases, 65.7%), “doctor’s decision/modified results” (133 cases, 17.4%), “patient’s wish” (96 cases, 12.5%), “patient death” (16 cases, 2.1%), “other” (15 cases, 2%), and “missing follow-up” (3 cases, 0.4%). For the 247 deviance cases, causes included “missing documentation” (143 cases, 57.9%), “patient’s wish” (68 cases, 27.5%), “doctor’s decision/modified results” (32 cases, 13%), and “other” (4 cases, 1.6%). The 129 cases where implementation was not assessable were due to “missing follow-up” (108 cases, 83.7%) and “patient death” (21 cases, 16.3%).
TUB for thoracic tumors. This TUB provided 851 recommendations for 745 patients. The implementation rate was 80.7% (687 recommendations). This was composed of 59.2% (504 recommendations) for “total implementation” (SE=0.0168, CI=0.5591-0.6249) and 21.5% (183 recommendations) for “partial implementation” (SE=0.0141, CI=0.1874-0.2426). Deviance occurred in 16% of cases (136 recommendations) (SE=0.0126, CI=0.1353-0.1847), and implementation was not assessable in 3.3% of cases (28 recommendations) (SE=0.0061, CI=0.02104-0.04496). The 183 cases of partial implementation were attributed to “missing documentation” (115 cases, 62.8%), “doctor’s decision/modified results” (36 cases, 19.7%), “patient’s wish” (25 cases, 13.7%), “patient death” (5 cases, 2.7%), and “other” (2 cases, 1.1%). For the 136 deviance cases, reasons were “missing documentation” (87 cases, 64%), “doctor’s decision/modified results” (25 cases, 18.4%), “patient’s wish” (22 cases, 16.2%), and “other” (2 cases, 1.5%). The 28 non-assessable cases were due to “missing follow-up” (17 cases, 60.7%) and “patient death” (11 cases, 39.3%).
TUB for head and neck tumors. A total of 1,319 recommendations for 812 patients were analyzed. An implementation rate of 82% (1,081 recommendations) was observed. This included 70.3% (927 recommendations) of “total implementation” (SE=0.0126, CI=0.6783-0.7277) and 11.7% (154 recommendations) of “partial implementation” (SE=0.0089, CI=0.09956-0.1344). Deviance was found in 10.5% of cases (138 recommendations) (SE=0.0084, CI=0.08854-0.1215), and 7.6% of cases (100 recommendations) were not assessable (SE=0.0073, CI=0.06169-0.09031). The 154 cases of partial implementation were due to “missing documentation” (73 cases, 47.7%), “doctor’s decision/modified results” (40 cases, 26%), “patient’s wish” (19 cases, 12.3%), “missing follow-up” (14 cases, 9.1%), and “patient death” (8 cases, 5.2%). The 138 deviance cases were caused by “patient’s wish” (56 cases, 40.6%), “missing documentation” (49 cases, 35.5%), and “doctor’s decision/modified results” (33 cases, 23.9%). The 100 non-assessable cases resulted from “missing follow-up” (79 cases, 79%) and “patient death” (21 cases, 21%).
TUB for neurooncological tumors. This TUB comprised 2,176 recommendations for 1,406 patients. The implementation rate was 79.9% (1,738 recommendations). Within these implemented recommendations, “total implementation” accounted for 63.7% (1,387 recommendations) (SE=0.0103, CI=0.6168-0.6572), and “partial implementation” accounted for 16.1% (351 recommendations) (SE=0.0079, CI=0.1455-0.1765). Deviance was noted in 10% of cases (218 recommendations) (SE=0.0064, CI=0.08746-0.1125), and 10.1% (220 recommendations) were not assessable (SE=0.0065, CI=0.08826-0.1137). For the 351 cases of partial implementation, reasons were “missing documentation” (198 cases, 56.4%), “doctor’s decision/modified results” (59 cases, 16.8%), “patient’s wish” (43 cases, 12.3%), “patient death” (27 cases, 7.7%), and “missing follow-up” (24 cases, 6.8%). The 218 deviance cases were attributed to “missing documentation” (126 cases, 57.8%), “patient’s wish” (55 cases, 25.2%), “doctor’s decision/modified results” (36 cases, 16.5%), and “other” (1 case, 0.5%). The 220 non-assessable cases were due to “missing follow-up” (164 cases, 74.5%) and “patient death” (56 cases, 25.5%).
TUB for sarcomas and musculoskeletal tumors. This TUB accounted for 320 recommendations concerning 232 patients. An overall implementation rate of 73.4% (235 recommendations) was recorded. This included 59.1% (189 recommendations) of “total implementation” (SE=0.0275, CI=0.5371-0.6449) and 14.4% (46 recommendations) of “partial implementation” (SE=0.0196, CI=0.1056-0.1824). Deviance was observed in 16.3% of cases (52 recommendations) (SE=0.0206, CI=0.1226-0.2034), and 10.3% (33 recommendations) were not assessable (SE=0.017, CI=0.06968-0.1363). The 46 cases of partial implementation were caused by “missing documentation” (34 cases, 73.9%), “doctor’s decision/modified results” (6 cases, 13%), “patient’s wish” (3 cases, 6.5%), “missing follow-up” (2 cases, 4.3%), and “patient death” (1 case, 2.2%). For the 52 deviance cases, reasons were “missing documentation” (41 cases, 78.8%), “doctor’s decision/modified results” (7 cases, 13.5%), and “patient’s wish” (4 cases, 7.7%). The 33 non-assessable cases resulted from “missing follow-up” (28 cases, 84.8%) and “patient death” (5 cases, 15.2%).
TUB for hereditary tumor syndromes. This TUB provided 108 recommendations for 92 patients. The implementation rate was 79.6% (86 recommendations). “Total implementation” was 66.7% (72 recommendations) (SE=0.0453, CI=0.5782-0.7558), and “partial implementation” was 13% (14 recommendations) (SE=0.0324, CI=0.0665-0.1935). Deviance occurred in 10.1% of cases (11 recommendations) (SE=0.0291, CI=0.04496-0.159), and an equal percentage and number were not assessable. The 14 cases of partial implementation were due to “missing documentation” (11 cases, 78.6%), “patient’s wish” (2 cases, 14.3%), and “other” (1 case, 7.1%). The 11 deviance cases were attributed to “other” (6 cases, 54.5%), “missing documentation” (3 cases, 27.3%), and “doctor’s decision/modified results” (2 cases, 18.2%). The 11 non-assessable cases were caused by “missing follow-up” (10 cases, 90.6%) and “patient death” (1 case, 9.1%).
TUB for dermatological tumors. This TUB comprised 673 recommendations concerning 401 patients. The implementation rate was 90.5% (609 recommendations). “Total implementation” was achieved in 77.1% of cases (519 recommendations) (SE=0.0162, CI=0.7392-0.8028), while “partial implementation” occurred in 13.4% (90 recommendations) (SE=0.0131, CI=0.1083-0.1597). Deviance was recorded in 7.3% of cases (49 recommendations) (SE=0.01, CI=0.0534-0.0926), and 2.2% (15 recommendations) were not assessable (SE=0.0057, CI=0.01083-0.03317). The 90 cases of partial implementation were due to “missing documentation” (42 cases, 46.7%), “patient’s wish” (24 cases, 26.7%), “doctor’s decision/modified results” (10 cases, 11.1%), “patient death” (6 cases, 6.7%), “other” (6 cases, 6.7%), and “missing follow-up” (2 cases, 2.2%). For the 49 deviance cases, reasons included “missing documentation” (19 cases, 38.8%), “doctor’s decision/modified results” (19 cases, 38.8%), “patient’s wish” (7 cases, 14.3%), and “other” (4 cases, 8.2%). The 15 non-assessable cases were the result of “missing follow-up” (12 cases, 80%) and “patient death” (3 cases, 20%).
TUB for gastrointestinal tumors. This TUB included 1,928 recommendations for 1,155 patients. The implementation rate was 84.4% (1,627 recommendations). “Total implementation” occurred in 72.7% of cases (1,401 recommendations) (SE=0.0101, CI=0.7072-0.7468), and “partial implementation” in 11.7% (226 recommendations) (SE=0.0073, CI=0.1027-0.1313). Deviance was found in 6.4% of cases (123 recommendations) (SE=0.0056, CI=0.05302-0.07498), and 9.2% (178 recommendations) were not assessable (SE=0.0066, CI=0.07906-0.1049). The 226 cases of partial implementation were attributed to “missing documentation” (110 cases, 48.7%), “doctor’s decision/modified results” (64 cases, 28.3%), “patient death” (23 cases, 10.2%), “patient’s wish” (22 cases, 9.7%), “missing follow-up” (5 cases, 2.2%), and “other” (2 cases, 0.9%). The 123 deviance cases were due to “patient’s wish” (47 cases, 38.2%), “doctor’s decision/modified results” (44 cases, 35.8%), and “missing documentation” (32 cases, 26%). The 178 non-assessable cases were caused by “missing follow-up” (108 cases, 60.7%) and “patient death” (70 cases, 39.3%).
TUB for neuroendocrine and thyroid tumors. In this TUB, 731 recommendations concerning 479 patients were investigated. An implementation rate of 86.7% (634 recommendations) was recorded. Of all recommendations, 72.4% (529 recommendations) were for “total implementation” (SE=0.0165, CI=0.6917-0.7563) and 14.4% (105 recommendations) for “partial implementation” (SE=0.013, CI=0.1185-0.1695). Deviance was 4.8% (35 recommendations) (SE=0.0079, CI=0.03252-0.06348), and 8.5% (62 recommendations) were not assessable (SE=0.0103, CI=0.06481-0.1052). The 105 cases of partial implementation were due to “missing documentation” (74 cases, 70.5%), “doctor’s decision/modified results” (16 cases, 15.2%), “patient’s wish” (9 cases, 8.6%), “patient death” (3 cases, 2.9%), and “other” (3 cases, 2.9%). The 35 deviance cases were caused by “missing documentation” (14 cases, 40%), “doctor’s decision/modified results” (10 cases, 28.6%), “patient’s wish” (7 cases, 20%), and “other” (4 cases, 11.4%). The 62 non-assessable cases were attributed to “missing follow-up” (59 cases, 95.5%) and “patient death” (3 cases, 4.8%).
TUB for urologic tumors. This TUB comprised 1,482 recommendations for 1,014 patients. The implementation rate was 81% (1,201 recommendations). “Total implementation” accounted for 69.9% of cases (1,036 recommendations) (SE=0.0119, CI=0.6757-0.7223), and “partial implementation” for 11.1% (165 recommendations) (SE=0.0082, CI=0.09493-0.1271). Deviance was recorded in 7.3% of cases (108 recommendations) (SE=0.0068, CI=0.005967-0.08633), while 11.7% (173 recommendations) were not assessable (SE=0.0083, CI=0.1007-0.1333). The 165 cases of partial implementation were due to “missing documentation” (111 cases, 67.3%), “doctor’s decision/modified results” (33 cases, 20%), “patient’s wish” (11 cases, 6.7%), “patient death” (7 cases, 4.2%), and “other” (3 cases, 1.8%). For the 108 deviance cases, reasons included “missing documentation” (59 cases, 54.6%), “doctor’s decision/modified results” (24 cases, 22.2%), “patient’s wish” (17 cases, 15.7%), and “other” (8 cases, 7.4%). The 173 non-assessable cases were caused by “missing follow-up” (154 cases, 89%) and “patient death” (19 cases, 11%).
Discussion
In our retrospective study, we found that the majority of TUB recommendations have been implemented. However, there were a certain number of cases in which implementation was partially or completely inadequate. Among the categories that give reasons for a partial or complete deviation, the three categories “patient request”, “lack of documentation” and “lack of follow-up care” appear to be suitable for future closer examination, as this is where improvements can most easily be implemented.
Patient requests. Our results revealed that, in 537 patients, the patients rejected the recommendations proposed by the TUBs. Each cancer patient’s circumstances differ, as do their respective wishes for therapy and the expected (and aspired) goals. Thus, therapeutic recommendations should be based on both clinical information and the patient’s personal wishes and circumstances.
As a basis for medical recommendations, most TUB members use clinical information (7). Often, only a small number of TUB members knew their patients in person and were unfamiliar with their preferences regarding therapy. Even if the members of the TUB have familiarity with the patient’s wishes, often these are not considered (8), despite the fact that patients achieve a better outcome when their preferences are taken into account (7).
In general, patients’ wishes should be advocated more strongly among the group of TUB participants. One approach is to document different therapy options for the patient, which can then be explained to the patient after the TUB meeting so that he/she can consider the options and come to a decision (8).
Another idea is inviting the patient to join in while his/her case is discussed by the TUB. In 2014, 12% of newly diagnosed breast cancer patients were asked to join their meeting; more than 50% of those asked ultimately took part in their TUB (9), which reveals a definite interest in participation among patients. Patients are interested not only in participating but also in being involved in discussions about therapy recommendations. A study among women with ovarian cancer revealed that 60% of the women requested shared decision-making with their doctor. Another study with breast cancer patients reported an even higher rate of approval for shared decision-making (10). Additionally, the majority of patients who had participated in their TUB would even recommend participation to other patients (11).
Medical personnel perceive patients’ participation in TUB meetings differently. Nurses tend to approve of including patients in TUB meetings more than do doctors (5). The latter stated frightened and overwhelmed patients as a reason for their reserve, as patients might not understand the language used by the medical staff or might not be able to emotionally cope with heated discussions about their case. Additionally, physicians argue that the debate about the patient’s case might not be as open as it is without the patient’s presence (12).
Studies have shown that some doctors’ fears might be refuted, as a study with a small number of breast cancer patients revealed that patients’ participation in TUB meetings did not, on average, increase the level of anxiety among patients (13). In addition, a study revealed that patient participation generated a more effective decision-making process. However, the greater amount of time and the rearrangement of organization that is required if patients participate might be challenging (14).
In conclusion, implementing TUB recommendations might improve if more patients are included in the TUB’s decision-making process. Currently, implementation is hindered by the fact that many patients are unsatisfied and cannot identify with the proposed therapy.
Missing documentation. To ensure good quality care and treatment, sound documentation of the patient’s medical and personal history is of utmost importance for medical personnel, as it organizes their thoughts and decisions. Furthermore, documentation has to be seen as communication between changing medical staff: It enables the staff to stay updated about the patient’s current medical status. In addition, medical documentation serves as a legal document, e.g., in the case of a lawsuit or for the calculation of hospital bills (15). The category of “missing documentation” includes all cases in which documentation of the TUB’s recommendation was either incomprehensible or nonexistent.
Research on the topic of missing documentation in medicine, especially regarding TUBs, revealed a lack of studies and significant information about this topic. Nevertheless, there was a recurrence of specific keywords, which led to the following assumptions: One of these assumptions is that a shortage of medical staff and the resulting lack of time lead to a disregard for documentation. A study investigating the problems deriving from staff shortages in intensive care units showed, among other findings, that staff shortages caused problems in documentation (16). Another possible reason for missing documentation could derive from systemic problems such as missing availability of paper-based files (e.g., as used for the ward round) or missing hardware for electronic health system records (17). Nevertheless, these assumptions could neither be verified nor falsified by studies yet; accordingly, further investigation would be helpful.
The establishment of a “rapid quality reporting system (RQRS)” could decrease the number of cases with missing documentation. This reporting system is able to track and monitor specialized cancer programs with respect to their adherence to, e.g., national guidelines (18, 19). Additionally, the “Rapid Cancer Reporting System”, which is a fusion of the RQRS and the NCDB annual call for data submission, exists (20). These reporting systems might provide an idea of possible future prospects of how these programs might aid in reminding medical staff about the necessity of documentation and thereby provide an opportunity for staff to carry out their work more effectively.
With the same objective, studies have focused on the use of electronic medical record reminders. As reported by one of these studies investigating the documentation of certain information in pediatrics, documentation increased after the use of a digital reminder was implemented (21). Another study examined the probability of screening patients for HIV before and after the implementation of a digital reminder, demonstrating that more patients received a screening when digital reminders were used (22). Although the aforementioned studies are not related to oncology, they show that the implementation of medical documentation and examination can be positively influenced by digital support, such as reporting systems.
Electronic medical report systems could also help during and before the actual TUB meeting. When provided with patient information, digital programs specialized on tumor boards can help keep TUB members updated on their patient’s medical status and prepare them for the meeting. With the use of such digital programs, meetings could also be held online, which is advantageous for discussions among professionals from different hospitals, as in the case of rare forms of cancer. In subsequent tumor board meetings, the progress of the patient’s treatment can then be assessed (23).
Summarizing the aspect of “missing documentation”, it is important to consider the use of digital options to facilitate the documentation of patients’ information and to optimize tumor board adherence.
Missing follow-up. After initial treatment, cancer patients should be offered regular follow-up consultations. These sessions serve to examine both the side effects and the long-term effects of the initial cancer treatment. Furthermore, they help to detect the recurrence of cancer at an early stage. In addition, follow-up meetings support patients with any medical issues related to their cancer diagnosis (24, 25).
Owing to the neglect of follow-up meetings with the patient, our analysis cannot determine whether the recommendations of the TUBs were met. A study with similar findings was conducted in the US in 2018. Out of the investigated group of cancer patients, 50% no longer had follow-up meetings within five years. Among those in the lost-to-follow-up group, 50% no longer had follow-up meetings one year after their diagnosis (26).
One possibility to reduce these numbers could be the use of different ways of collecting information. In this context, a study in Switzerland investigated the use of telephone calls, aiming to determine how telephone follow-up affects general patient satisfaction and the quality of care while also emphasizing controlling the side effects of oral chemotherapy. Telephone calls were carried out by nurses trained specifically for follow-up calls, who used a standardized questionnaire. Patients were asked about the side effects of their oral chemotherapy and about other medical issues. The study revealed that patient satisfaction was high; a majority of patients found the calls helpful (27).
In another study, the overall survival of cancer patients who worked with an electronic patient-reported outcome measures (ePROM) application in comparison to patients who reported their symptoms in the usual way was considered. The group of patients who reported their medical conditions with metastatic cancer with ePROM application had increased survival compared with patients who followed usual care (28).
In Germany, there are two ongoing studies concerning the outcome of the use of ePROM monitoring: the PRO-B (patient-reported outcome for patients with metastatic breast cancer, Charité Berlin) and the PRO-P (influence of patient-reported outcome concerning the postoperative course of patients with prostate cancer, Peter Albers, University Hospital Düsseldorf) (29, 30). In a press release, three German cancer associations noted the merits of utilizing follow-up apps. In addition to tips for leading a healthier life, these apps can also help patients organize their follow-up appointments (31). The implementation of follow-up apps might increase the number of carried out follow-up meetings. Additionally, digital reminders, as mentioned above, might provide help in organizing and standardizing follow-up appointments.
Study limitations. As a retrospective analysis, it relied on the accuracy of existing medical records, which requires careful interpretation of certain results. A key challenge is highlighted by the finding that “lack of documentation” was a primary reason for both partial implementation and deviation. These deviations may reflect missing data rather than true non-adherence, as the available data cannot fully distinguish between a recommendation that was not enacted and one that was simply not documented. This suggests the true rate of clinical adherence may be higher than what was reported.
Furthermore, the study was conducted at a single hospital, which limits how well the findings apply to other settings with different systems, resources, or patient populations. The reasons for non-implementation were based only on what was written in medical records and may have missed other factors like time pressure, communication issues, or patient preferences that were not documented. Additionally, the data covered the years 2014 to 2016, so more recent changes in clinical practice or documentation were not included. The results, therefore, offer a valuable reference point from which to evaluate the impact of subsequent modernizations. Finally, the study did not involve interviews with medical staff or patients, which could have provided more insight into why some recommendations were not followed.
Conclusion
This study demonstrates that while the vast majority of therapy recommendations from multidisciplinary tumor boards are implemented, significant and remediable gaps persist in translating these expert decisions into clinical practice.
The primary barriers to full adherence are not clinical disagreements but rather procedural deficiencies, namely inconsistent documentation, the inadequate integration of patient preferences, and a loss of patient follow-up. The findings strongly imply that the effectiveness of tumor boards is critically dependent on the logistical and communicative processes that support their decisions. Consequently, the most impactful improvements may come from optimizing these workflows.
A key future perspective is the systematic implementation of digital health solutions to overcome these challenges. The use of electronic medical record reminders and rapid quality reporting systems could substantially improve the consistency of documentation, which was the leading cause for both partial implementation and complete deviation.
Furthermore, to enhance patient-centered care and adherence, future efforts should focus on formally integrating patient preferences into the tumor board process, potentially through direct patient participation or structured presentation of their wishes. By addressing these procedural shortcomings through digital tools and a renewed focus on patient-centered communication, the full potential of multidisciplinary cancer care can be more consistently realized, ultimately improving patient outcomes.
Acknowledgements
We kindly acknowledge the support of Christiane Döge and Dr. Leonie Weinhold.
Footnotes
Authors’ Contributions
Johanna Ernst and Katharina Alfter have contributed equally to this work and share first authorship. The manuscript, as well as all figures and tables, were jointly written and created by both first authors. All other Authors mentioned contributed by providing data from each department.
Conflicts of Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Artificial Intelligence (AI) Disclosure
During the preparation of this manuscript, a large language model (ChatGPT, OpenAI) was used solely for language editing and stylistic improvements in select paragraphs. No sections involving the generation, analysis, or interpretation of research data were produced by generative AI. All scientific content was created and verified by the authors. Furthermore, no figures or visual data were generated or modified using generative AI or machine learning–based image enhancement tools.
- Received June 10, 2025.
- Revision received July 14, 2025.
- Accepted August 1, 2025.
- Copyright © 2025 The Author(s). Published by the International Institute of Anticancer Research.
This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).
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