What Happens if a Multidisciplinary Tumor Board Cannot Agree?

This transcript has been edited for clarity.

Hello. I'm David Kerr, professor of cancer medicine at University of Oxford. I'd like to get your advice, not about a specific patient but about philosophical approaches to how we deliver cancer care.

We, as a community, have talked many times before about the strength, power, and intellectual breadth of delivering multidisciplinary cancer care as a big step forward. It means that the community of patients that we serve get the best treatment, drawing on the wisdom of the crowd and assembling all the necessary specialties in one room to focus on the individual patient.

We had an interesting case that came across our multidisciplinary tumor board recently. It was somebody who presented with a complex colonic mass, who was referred in rapidly to our colorectal cancer team through endoscopy, and who was presented at our multidisciplinary tumor board. CT scan revealed a large, complex mass that was entirely consistent with a colonic tumor. An endoscopy done by one of our senior expert endoscopists reported that it was a mass that was indenting the colon, rather than arising from it or growing out from it. That was interesting.

Several biopsies were taken, none of which showed cancer. There were literally one or two very minor dysplastic cells but nothing to suggest cancer at all. Blood markers were normal — again, nothing fitting in. There's an inflammatory process going on. The erythrocyte sedimentation rate, C-reactive protein, and white cell count are all high. Clearly, there's a problem that we need to deal with.

On surgical presentation, it looked large and complex and was not a straightforward resection. Therefore, an entirely reasonable request was to give neoadjuvant chemotherapy. What about the lack of biopsy evidence? The radiologist said we could do a percutaneous biopsy very reasonably, but there are dangers about perforation, so we’d rather not.

What about the possibility of a laparoscopic biopsy? Our surgical colleagues said that could make it more complicated. It could be peritoneal dissemination of disease or it may make things more difficult subsequently for resection. Again, these are all entirely reasonable thoughts.

Why don't we just go with the flow and give neoadjuvant chemotherapy? Our redoubtable medical oncologist said no. This is a patient who's traveled extensively and lived for long periods in the Far East. We need to think about a wider set of diagnoses.

Could it be mycotic? Could it be fungal? Could it be the great imitator, tuberculosis? We're dealing with somebody who's come back to the United Kingdom, having spent significant periods of time living in a tropical country. Therefore, we need a tissue diagnosis before we move forward.

We go around in circles, discussing the potential difficulties. The way that it was resolved, again, I think rationally, was to invite in the expertise of our infectious disease colleagues who agreed that there is a very reasonable possibility that this could be an infective mass rather than a tumor mass. They're doing all sorts of other tests.

I suspect that we will do various tests that will be equivocal, and I suspect that we will still need a biopsy. I'm sure that within the team we would be able to persuade colleagues to undertake a biopsy of some sort, giving us the tissue that we need to make a more definitive diagnosis before we embark on a definitive treatment, whatever that might be.

Although it was an intellectually stimulating case, it just made me think about what we do when the teams absolutely disagree and they cannot negotiate a way forward. Ultimately, whose responsibility is it? Say the medical oncologist had gone ahead and given chemotherapy, there had been trouble, heaven forbid that the patient had some toxic event or even died as a result of chemotherapy, and at postmortem there's no evidence of cancer; who would be responsible in that setting for having made that decision?

Is it the wisdom of the crowd? Or does it settle with the individual consultant who gave the chemotherapy that, in this hypothetical situation, proved to be fatal? What if the multidisciplinary tumor board remained deadlocked, with the wisdom of the crowd saying, "No, we can't get more tissue, for all the very good reasons that were offered," and the chemotherapy team saying, "Well, we're not going to move without convincing tissue diagnosis and the absence of any other supporting evidence."

We have a patient who is unwell and symptomatic. How do we break a deadlock in that setting? I'm really interested in your own experience. Do we refer the patient to another multidisciplinary tumor board? Do we go to a higher authority? Do we have external referees who come in to break deadlocks?

We've never had to think about or do anything like that before because we solve things together. What do we do if the multidisciplinary tumor board fractures and cannot come together around a clear decision in moving forward? Again, where does responsibility lie for the individual actions that follow from a multidisciplinary tumor board meeting?

I'm interested in your experience. Have you come across anything in which the multidisciplinary tumor board has fractured on a particular decision? How did you resolve it? Is it always dealt with internally? Did you ever need external help and support? I genuinely need the wider wisdom of Medscapers.

Please respond to my cry for help. I'd be terribly interested in any comments that you might care to make. For the time being, from David Kerr, Medscapers, over and out. Thank you.

David J. Kerr, CBE, MD, DSc, is a professor of cancer medicine at the University of Oxford. He is recognized internationally for his work in the research and treatment of colorectal cancer and has founded three university spin-out companies: COBRA Therapeutics, Celleron Therapeutics, and Oxford Cancer Biomarkers. In 2002, he was appointed Commander of the British Empire by Queen Elizabeth II.

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