Virtual Tumor Boards Provide Access to Multidisciplinary Cancer Care for Rural Patients

Although initially considered by some to be a disruptive technology in medicine, virtual multidisciplinary tumor boards (MDTs) were not meant to entirely replace conventional practices before the pandemic, but rather complement them. As we emerge from the pandemic, our experience is that the virtual MDT not only has improved coordination and communication among physicians, but it also has allowed increased efficiencies with the potential to improve outcomes for the cancer patient—especially in a rural setting.

Kansas—known for its wide-open spaces, rolling hills, and prairies that are ideal for farming—is the 15th largest state by area with 82,000 square miles, yet it is only the 34th most populous state in the US, with 3 million citizens. Hence, a large portion of the state is rural, creating challenges in healthcare delivery.

As expected, there is a shortage of healthcare providers in rural areas where patients have limited access to healthcare facilities. Additionally, access to certain specialists (e.g., colorectal surgeons) is limited to the state’s two largest cities, Wichita and the Kansas City metropolitan area.

The ACS Commission on Cancer (CoC) is a consortium of professional organizations dedicated to improving survival and quality of life for patients with cancer by setting and continually raising standards. The CoC promotes cancer prevention, research, education, and monitoring of comprehensive quality care through its National Cancer Database.

CoC accreditation recognizes the commitment of cancer care institutions and programs that provide high-quality, comprehensive, multidisciplinary care for their patients. Kansas has eight CoC programs that carry ACS accreditation, but other than Wichita, they are concentrated in the larger urban areas of northeast Kansas: the capital city of Topeka, Lawrence, Kansas City, Shawnee Mission, and Olathe (see Figure 1). Access to an MDT is often limited to these CoC programs, further impairing access and treatment of cancer patients across the remainder of the state. It is not unusual for a patient in rural Kansas to travel hundreds of miles to receive specialty cancer care.

Virtual MDTs Enhance Collaboration

The medical community of Wichita—the largest city in Kansas with a population of 390,000—provides tertiary care for a referral area that includes southeast, south central, and western Kansas with a medical catchment area that serves approximately 1 million Kansans.

Ascension Via Christi hospitals of Wichita (AVCW) have a long-standing MDT that meets two to three times each month. However, the COVID-19 pandemic required changes to how MDTs function across the US, including transforming the usual in-person interface between medical colleagues and their patients. At AVCW, in-person MDTs were discontinued in March 2020 and resumed with the benefit of virtual technology in June 2020, using a cloud-based software system that supports the functionality of MDTs.

The platform provides a vehicle for physicians and other healthcare professionals to collaborate and review patient cases, make treatment recommendations, and track patient outcomes. Although case information and data can be entered or reviewed anytime, individual case presentations are discussed in real time. Having the ability to log on from any location is a major benefit, given the hectic schedules and daily commitments of participating physicians.

In addition, having physicians in neighboring, outside communities and rural hospitals participate virtually in MDTs reduces isolation in decision-making and potentially improves patient care and outcomes. In fact, a standard array of specialists participate in the virtual MDT (see Table 1) from communities outside of Wichita, in central or southeast cities such as Manhattan, Salina, Hutchinson, Fort Scott, and Pittsburg.

While the patient’s definitive treatment (e.g., radiotherapy, chemotherapy, or surgical resection) may occur in their hometown or in Wichita, input from the referring physician(s) who performed the initial evaluation and management is essential. Furthermore, providing feedback to referring physicians is an important component of these communications. 

AVCW’s Experience with Virtual MDTs

In 2022, 292 individual cancer patients were reviewed via the virtual AVCW MDT (see Table 2). AVCW physicians involved in the virtual MDT that year included representatives from each of the appropriate specialty areas. Patients presented for a variety of reasons, but they were typically complex cases that required input from multiple specialists to develop an optimal treatment plan. Also, patients who had multiple viable treatment options or who required a unique approach were considered, as variables such as age or comorbidities also came into play.

The AVCW MDT is open to any patient at the request of the treating physician, to guide optimal decision-making and cancer management. Cancer diagnoses presented in high volume included prostate (39%), rectum (24%), and lung (17%).

An example of a routine MDT process is that all patients with the diagnosis of cancer of the rectum are discussed before and after completion of treatment, which typically includes surgical resection. This is a requirement needed to receive National Accreditation Program for Rectal Cancer (NAPRC) accreditation, one of the quality programs originated and accredited by the ACS. 

For the AVCW MDT, cardiothoracic surgery, colorectal surgery, and urology services have the greatest involvement from the affiliated surgeons, radiologists, and oncologists. As one would expect, these three specialty services also represent the vast majority of cases reviewed by the AVCW MDT.

Beyond the three top cancer categories presented (prostate, rectum, and lung), the next major category of cancer cases presented is breast cancer at 4%. However, this small percentage is not a true reflection of the breast cancer volume treated at AVCW, as breast cancer has its own individual community-wide MDT that meets separately from the AVCW MDT.

Prior to the COVID pandemic, in-person MDTs were poorly supported and attended by healthcare providers. There are many factors that explain the poor attendance at MDTs, including lack of time, activity at several different hospitals, emergency cases or familial/personal issues, and other commitments.

Research on Virtual MDTs

The data on virtual MDTs are relatively limited. However, some studies suggest that virtual meetings can be just as effective as in-person MDTs. One study revealed that physician attendance at virtual MDTs after the pandemic increased by 46% over in-person attendance before the pandemic, and there also was a 20% increase in the volume of cancer case presentations.¹

Another study showed the participating hospitals were able to run three times as many patients through the virtual MDT process, with a higher level of participation across all specialties than the in-person pre-pandemic counterpart.² This same study noted that the pandemic-era virtual MDT gathered key statistics about each case, which allowed administrators to monitor specific metrics, such as improvements in time from diagnosis to treatment initiation and impact on patient outcomes.

Another study from the University of Pittsburgh found that the majority of MDT participant respondents (58%) preferred the virtual MDT format compared to the traditional in-person format.³ A majority of respondents (79%) also preferred to continue the virtual MDT format once in-person meeting restrictions were lifted.

One of the current goals at AVCW is NAPRC accreditation. The NAPRC Optimal Resources for Rectal Cancer Care (2020 Standards), an education program developed by the ACS, is available online. In the interval between typical cancer program development to NAPRC accreditation, use of these standards may have a significant impact.⁴

A recent review of 40,000 patients from the National Cancer Database, treated between 2011 and 2014, revealed that compliance with established standards before NAPRC accreditation was associated with a significant reduction in patient mortality.⁵ This study documented the importance of the NAPRC as it relates to improving patient outcomes of cancer care.

Having a virtual MDT has facilitated this process by improving the volume of patient participation and attendance from various physician specialists. In addition, the virtual platform has facilitated tracking of metrics needed for NAPRC accreditation.

Indeed, the AVCW MDT experience is an example of how this technology can drive an increase in case volume, and how it can facilitate physician collaboration in an effort to enhance the care of the cancer patient. 

Dr. Noel Sanchez is a colorectal surgeon with the Ascension Medical Group and vice-chair of the Department of Surgery at Ascension Via Christi hospitals of Wichita. He also is program director of the rectal cancer multidisciplinary team at the Ascension Via Christi Cancer Center and clinical associate professor at the University of Kansas School of Medicine-Wichita.

References

1. Davis CH, Ho J, Stephenson R, et al. Virtual tumor board increases provider attendance and case presentations. JCO Oncol Pract. 2022;18(10):e1603-e1610.
2. Blasi L, Bordonaro R, Serretta V, et al. Virtual clinical and precision medicine tumor boards—cloud-based platform-mediated implementation of multidisciplinary reviews among oncology center in the COVID-19 era: Protocol for an observational study. JMIR Res Protoc. 2021;10(9):e26220.
3. Dharmarajan H, Anderson JL, Kim S, et al. Transition to a virtual multidisciplinary tumor board during the COVID-19 pandemic: University of Pittsburgh experience. Head Neck. 2020;42(6):1310-1316.
4. Wexner SD. NAPRC Compliance Reduces Rectal Cancer Mortality. ACS Brief. March 21, 2023. Accessed April 28, 2023.
5. Brady JT, Bingmer K, Bliggenstorfer J, et al. Could meeting the standards of the National Accreditation Program for Rectal Cancer in the National Cancer Database improve patient outcomes? Colorectal Dis. 2023;00:1-7.