Abstract: Delay in management of thoracic malignancies and lung nodules can result in poor clinical outcomes. Multidisciplinary tumor boards (MTBs) represent a standard of care that must evolve in the setting of social distancing. We present a single center’s experience transitioning from in-person to virtual MTB. Institutional stakeholders were interviewed, and meeting level data was collected between 2019 and 2020 for thoracic tumor and nodule board cases. Descriptive and comparative statistics were employed. Over the course of 141 meetings between January 2, 2019 and August 5, 2020, 1335 thoracic tumor and nodule board cases were reviewed. The transition to virtual MTB occurred over one month. Obstacles regarding data presentation, videoconferencing etiquette, and workflow modification were addressed. The transition from in-person to virtual tumor board is feasible and in the context of social distancing will likely solidify its place as an efficient model for expert, multidisciplinary patient management.
Key Words: SARS-Coronavirus-2, social distance, tumor board, virtual
An estimated 228,150 lung and bronchus cancers were anticipated in 2019 with 142,670 deaths.1 Recommendations for patients with thoracic cancers are constantly changing based on evolving data. The collaborative, nuanced management these cancers demand is achieved via multidisciplinary tumor board (MTB) review, which has become a standard of care for this population.2-4
Thoracic MTBs at our Seattle-based institution serve patients in the Pacific Northwest region. There are two separate MTBs: one discussing patients with suspicious or significant lung nodules as part of lung cancer screening or incidental discovery and the other serving thoracic oncology patients. s such, each conference requires a different flow of information, expertise, and sharing of diagnostic imaging and histopathology to appropriately discuss clinical management.
Patients reviewed at nodule board are selected via provider request or screened positive for suspicious nodules (Lung RADS 4).5 Members include a coordinating nurse who presents the clinical case and generates electronic reports of the meetings, a radiologist who reviews imaging in real time, as well as thoracic surgeons and pulmonologists who apply guidelines and experience. The weekly meeting is allocated 30 minutes and provides review for up to nine patients. The thoracic MTB guides care of patients with more complex, biopsy-proven lung, esophageal, and other thoracic malignancies. The team includes representatives from pathology, radiation, and medical oncology in addition to those above. Between nine and 17 patients are usually reviewed over a 90-minute period weekly.
The standard format in 2019 and early 2020 was an in-person MTB. On January 31, 2020 the United States Department of Health and Human Services Secretary Alex Azar declared a public health emergency responding to the Coronavirus disease-2019 (COVID-19) pandemic.6 On February 29, Washington state issued a state of emergency. By March 19, elective surgical procedures were halted, and on March 23 social distancing was recommended, necessitating a change in our practice of MTB and nodule board.7-9 Over this time, many health care functions ceased or transitioned to social-distancing-compliant methods, in turn posing potential delays in care for these patient populations. Virtual meetings represent one method to comply with social distancing and prevent delay of patient care.
Few have reported their experiences transitioning to virtual MTB during the COVID-19 pandemic. A pathology laboratory found that transitioning to an online, video-based methodology allows for collaboration between faculty and residents, continued patient care, and continued learning while respecting social distancing.10 At the University of Pittsburgh, the ear, nose, throat oncologic MTB also reports success.11 We present our institutional experience with rapid transition from in-person to virtual nodule board and MTB during the COVID-19 pandemic.
Materials and Methods
A review of our institutional transition from in-person to virtual nodule and MTB boards was performed. Informal interviews were solicited from select tumor board members. Mechanisms of transition and obstacles encountered were identified. Patient data and volumes from both boards beginning in January 2019 through August 2020 were collected. Descriptive analysis was performed with emphasis on year-to-date 2020 data against our control, the corresponding 2019 data. Comparative statistics were applied to describe data within context of the Washington state response to COVID-19. Student’s t tests were utilized for continuous variables. Alpha was set to 0.05. Statistics were calculated with Microsoft Excel, Version 15.0.5249.1001 (Redmond, WA).
Results
Between January 2, 2019 and August 5, 2020, 1335 cases were reviewed over 141 meetings. The nodule and thoracic MTB reviewed 307 (23%) and 1028 (77%) cases, respectively. Standard deviation for 2019 case numbers were 2.1 patients per meeting for nodule board and 3.8 for thoracic MTB. Standard deviation in 2020 for nodule board and MTB were 1.9 and 5.2, respectively.
Transition to virtual MTB review took place on March 18, 2020. Over the subsequent month, workflow changes and improved time management resulted in return to baseline MTB volume on April 22, 2020 (Figure 1a-1b). During the study period, there were no significant month-by-month MTB volume differences as a result of this transition (Table 1). Nodule board weekly volume was also similar between these two periods, except February 2020, which revealed an increased number of reviewed cases.
Workflow Changes
Skype for Business (Microsoft, Redmond, WA) software was adopted to facilitate rapid transition to virtual nodule and MTB conferences over a one-week period. Thoracic nurse coordinators were responsible in maintaining patient lists, coordinating schedules, and setting up logistics of nodule and MTB. Their responsibilities evolved from in-person room set-up to coordination of virtual review and documentation. Radiology and pathology screen-sharing, new flow of case presentation, and recoding of documentation were adopted by all team members. Specifically, pathology slide presentation was transitioned from electronic projection of specimen slides to PowerPoint (Microsoft, Redmond, WA) photo image presentations.
Obstacles included speaker etiquette, mitigating audio feedback, screen-sharing technical difficulties, and optimization of surrounding environment to maintain HIPAA compliance. In-conference team discussion was transitioned from verbal in-person to audio and Skype-based messaging. The transition was considered complete when workflows among staff and physician MTB members stabilized after the April 22, 2020 conference.
Discussion
The transition from in-person to virtual thoracic MTB meetings was successfully accomplished with the involvement of key stakeholders, expansion of the scope of existing technology, extra training, and workflow changes for providers, with reinforcement of video conference etiquette. Analysis of patients reviewed per meeting found no differences between 2019 and 2020 with the exception of an increase of nodule board patients reviewed February 2020. In the wake of this transition, providers have found that the virtual format allows for more convenient participation, efficient flow between patients, and ultimately a more effective MTB, consistent with previous research.12
At our institution, patients are included for discussion via multiple pathways. Nodule board patients are directly included when suspicious lung nodules are identified on routine lung cancer screening or at provider discretion. Selection of patients for MTB occur at the direction of individual providers. Providers are encouraged to make their submissions by 5pm on the Monday prior to the Wednesday meeting to allow pathology and radiology time to review and develop their presentations. Internet connections and computers were found to be sufficiently powered to support live review of computerized tomography scan and other radiographic imaging modalities. However, pathology has turned to slide-sharing software, PowerPoint (Microsoft, Redmond, WA) as it is less resource intensive.
Meetings are called to order by the coordinating nurse with a previously established agenda. They present the first patient, their demographics, relevant history, and then segue to radiology. Radiology reviews relevant imaging who hands off to pathology. After pathology, the patient’s referring provider reframes the question to consultants who then weigh-in. Notably, clarification and questions are asked throughout the presentation but are encouraged to wait until the end. Recommendations are summarized at the conclusion of the discussion. With the absence of pathology, patients are allocated 3 to 4 minutes for nodule board vs 8 to 10 minutes for more complex presentations at MTB.
Feedback is solicited at each meeting by the thoracic surgeon board lead. Recommendations are often submitted, discussed in real time, and implemented in the next meeting according to the Plan-Do-Study-Act management cycle.13 This accelerated model greatly helped to facilitate the transition and ongoing adaptation of our nodule and MTB to their present virtual formats.
Based on our experience, we propose some considerations for those planning to transition to virtual tumor board. First, identify all stakeholders who will require workflow changes and be affected by outcomes. MTB is made up of individual experts all bringing varied information and experience to the group; for a successful transition, all interested parties should therefore be involved. Second, identify the conferencing software to be used. We suggest disseminating a brief tutorial on its use, specifically where the mute/unmute button is accessed, and a description of audio feedback with techniques on avoidance. Third, many parts of the patient presentation may require modification based on internet bandwidth and computer power. Be sure to consider both the modality and preparation time that specialties such as radiology and pathology will require for their contributions. Finally, we encourage the use of a predetermined feedback and implementation mechanism, as these transitions are often evolving projects and further change should be anticipated.
An added benefit of virtual meeting is that it allows for participation of clinical colleagues from our sister hospital in Yakima, WA (144 miles from Seattle) via the same methodology. Such advantage has been reported previously for cancer care in England in a 2002 article describing oncologic collaboration despite being 120 km apart.14 Indeed, MTBs have been shown to change treatment plans in 40% of patients and staging and assessment plans in 60% of patients via the MTB review process, affecting patients throughout WA state.2
Thoracic oncologic diseases are indifferent to public health issues related to the current pandemic. Providers and professional societies are struggling to direct cancer treatments in the context of overall risk-benefit assessment.15 Shared decision-making is a key component to patient-centered care. A transition to virtual multidisciplinary review allowed us to maintain our standards of care and continues to shape clinical pathways for those with cancer given our new health environment.
Limitations of our project include the informal nature of provider opinion assessment as well as a potentially underpowered weekly patient per meeting comparison, risking a type one error.
Conclusion
In summary, a transition from in-person to virtual nodule and thoracic MTB is possible with adjustments to workflow, team collaboration, and commitment. While virtual MTB is not a novel concept, its broad expansion within the context of social distancing will likely solidify its place as an efficient model for expert, multidisciplinary patient management. Our goal is to liberate barriers to access MTB review for a broader audience, especially those in remote locations.16 Future research should be directed toward such expansion efforts, leveraging technology to provide equitable care, irrespective of geographic constraints.
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