American Brain Tumor Association Webinar

What Happens at a Tumor Board?

>> Welcome to the American brain tumor Association webinar series. Thank you for participating during this month of May which is brain tumor awareness month. Today is about what happens on a tumor board and how you can benefit. This will be presented by Dr. Christopher McPherson. All lines are muted today. If you have any questions you would like to ask, type and submit it using the question box in the control panel on the right-hand side of your screen. Doctor McPherson will answer questions at the end of his presentation. Tomorrow you will receive an email asking you to event would be webinar. It is a brief survey. Take a few minutes please do share your comments and/or feedback -- your feedback which is important to us. Today's webinar is being recorded. The recording will be posted to the website shortly. Registered participants will receive a link any follow-up email message once the webinar is available.

>> The American brain tumor Association is pleased to welcome you back to our webinar series our webinar today, we will discuss what happened that a brain tumor board and how you can benefit from this process.

>> My name is Sue Ward, I am the Director, National Volunteer Programs, here at the American Brain Tumor Association. I am delighted to introduce our speaker today Christopher McPherson, MD. Dr. Christopher McPherson is a neurosurgeon at the University of Cincinnati Brain Tumor Center, and a member of the Mayfield Clinic in Cincinnati. He is also currently the director of the Division of Surgical Neuro-Oncology for the Department of Neurosurgery at the University of Cincinnati College of Medicine, and Associate Professor in the Department of Neurosurgery at the University of Cincinnati College of Medicine. He is a member of the national executive committee for the Tumor Section of the AANS/CNS.

>> Thank you for joining us Dr. McPherson. You may now begin your presentation.

>> Thank you. As you said, we are going to talk about tumor board and this is a topic that a lot of people have probably heard about but I think a lot of patients don't necessarily understand or get a good idea of what really goes on in a tumor board. Today what I will go through is some of the basics of what is a tumor board and how do we do that. Then I will show you some presentations of tumor board cases that we have set up so that you can actually see how a tumor board works.

>> What is a tumor board? I think everyone has their own mental picture of what a tumor board is like. I found on a website, KevinMD.com, this patient Kathryn O'Brien felt like it was like being in a courtroom. She said, "A tumor board is like the justice league of oncology, only instead of Superman…you get a bunch of medical, surgical, radial oncologists. It is a closed meeting. Cancer patients are generally not invited to give testimony. The cells that are accused of breaking and entering. Yes I do. There they are on that side. Last year my oncologist presented my case on-site by Dr. Gregory Peck and to kill a Mockingbird. Passionately arguing for some treatment plan."

I wanted to show that quote because I think it is a good quote from Kathryn. She is a very imaginative patient. I think everyone has a different mental picture of what a tumor board is.

>>What is tumor board? The bottom line is it is a meeting of specialists. There are many kinds of tumor boards. A center has their own tumor board, for brain or breast cancer, and head and neck cancer. It is a meeting of specialist regarding a specific topic. For what we are talking about it will be the brain tumor board. It is a meaning of those physicians that are involved in specialty management a brain tumor care. The purpose is to go over and discuss cases using a multidisciplinary approach, that means that we are all discussing it from each point of view and then with the goal coming to bring a consensus on the diagnosis and treatment plan.

>> You have heard that putting two heads together is better than one. That is what a tumor board is. It is multiple doctors coming together and providing their opinions. Who comes to a tumor board? At our tumor board we can have anywhere from 10 to 20 physicians and attendees. We have specialists from every area of brain tumor care, so we have neurosurgeons, the radiologists, oncologists, radiation oncologists, pathologists clinical trial specialists are extremely important as well to go over each case and discuss the possible clinical trials. We work with our ENT colleagues such as pituitary tumors and acoustic tumors, they are there. The technologists also come. Tumor board is not just about patient care – it’s an educational experience. There are students and trainees that are also there. It is a pretty big meeting.

>> Most institutions have their own tumor board. At the University of Cincinnati we meet weekly. I think most boards meet weekly for about 90 minutes. We review anywhere from 10 to 20 cases per week. If you do the math that's about five minutes per case. Some cases take longer than others. We provide the right amount of time for each case. We make sure for a tumor board that there is at least one physician from each specialty. We want to make sure there is at least one neurosurgeon, oncologist, radiation oncologist, etc. We really want to make sure to have their feedback because what discussions and we want to multiple opinions to come to that decision.

>> Our tumor board, we use a moderator who is there to direct the tumor board and direct the discussion to make sure that we stay on track. Sometimes we do run off-track discussing ideas and literature. Also to summarize the case at the end, for the record and for the message that will be delivered to the patients and physicians. We also try to review based on clinical guidelines. We use the NCCN, which has published guidelines for many types of patient care in tumor care. We really try to use published guidelines.

>>What is the goal for tumor board review? The goal is different for each case. We definitely want to review the radiology. Sometimes that is what we are doing. What is this lesion? What should we do about it? We start by reviewing the neuro-radiologist and determine the diagnosis. For recurrent tumors we want to determine if it is recurrence or treatment effect. The treatment plan is extremely important. We want to be surgeons and radiation doctors and oncologist to weigh in and get their opinion, what are the options for treatment. What is the observation we will do? Pathology is important to review. We review pathology slides. We can all see and share the information from the surgery, share the tumor markers, and use that information to make our decision. We want to evaluate for clinical trials. Each case, whether there is a clinical trial available, do they qualify? Are there multiple clinical trials? We discussed that as well. And we also present follow-up cases, cases after treatment, cases that we initially are following or observing and what is happening overtime. This is good, not only for patient care but also for our own education and experience.

>> What happens after a tumor board? Obviously first and foremost is we get the information back to you - the patient. Some tumor board reviews are done immediately before an appointment. Then we will be with the patient immediately after and go over the findings of the tumor board and let them know. Sometimes we call later that day with that information. We also want to let the referring doctors and other doctors know. With our tumor board we provide a summary, written statements through a database that then goes into the patient’s chart, so other doctors can see. We also commonly call or directly talk to specific referring doctors, like a oncologist referred the patient, I will contact the oncologist and let the doctor know what the tumor board decided.

>> How as tumor board changed? The bottom line is that the visual advances, electronic advances, the things that make all of our life easier now with computers and digital era, help tumor board. I can remember not too long ago, 10 years ago or so, gather all of the x-ray, try to get everything together. Nowadays we can do everything online so that we can get the films online and share them online. This helps a lot especially for outside referrals, if someone somewhere else wants us to review a case. All they have to do is send the files to our website

and we can do that. That increases efficiency. It also makes it easier for radiologists to look at. Five minutes per case doesn't sound like a lot but we don't have to spend a lot of time putting up x-rays and film so we can spend more time with the discussion. That has helped a lot.

>>We also use the information to put into a database. We are storing that information for the next time we do a review. We have the information for the first review and use that for going forward. All of these advances have helped out a lot. I mentioned the database and our tumor board does feed directly from a database. We can discuss the information ahead of time. This is the kind of information that we would see on tumor board. Here is the patient: How old are they? What is their clinical history? Headaches for five months, when was the MRI done? Where is the lesion? What is the purpose of the tumor board discussion? For this person it is to look at treatment options and suggest treatment. For someone else it may be a diagnosis. This is the area where we would then put in the information at the end for the tumor board review. That is pretty much how our tumor board works in the database side.

>> Now I want to go through some specific cases for you. We have three cases to talk about. I will tell you about them ahead of time. The first case is the kind of case that we review every single week which would be patients with newly diagnosed GBM. Several things that you will see is radiology is important. Most of our cases start with radiology reviews. Certainly with GBM we get information from that. Surgical options are important and we talk about different options from there. Obviously, it’s very important to talk about the clinical trials for GBM. And the last thing is that, at the end of the day, we want to develop a consensus of agreement, we don't always agree. That is okay. You see instances where there are different treatment options are and sometimes they are split, but at the end of the day we will share that with you. [Video playing]

>> This is a 57-year-old female who has had a history of five months of headaches.

>> We have a clear contrast of images. On the clear image you can see a large area. With extension across midline.

>> Can you please review the MRI scans?

>> Yes, we have a flare with post-contrast. On the flare image you can see that a large regular mass with extension across midline; on the post-contrast, we can see a large irregular enhancing mass that corresponds with a signal abnormality. If you look at the central irregular areas of non-enhancement that is indicative of necrosis of the tumor due to the overall appearance of legions, signal characters of…most consistent with a high grade…such as glioblastoma . Other etiology is including metastatic disease. Most likely a GBM.

>> There are two surgical options. One is a large operation to remove the tumor…One hand the tumor is very large and has swelling …associated with it. This would be a large operation. On the other hand it is a very invasive tumor. It crosses over to the opposite hemisphere. As I look at this set of MRIs I would say…[low volume ]. Establish a diagnosis for the patient and then moving on to the appropriate therapy. Other surgical opinions of our

>> I would probably go on the other end…we can achieve an extensive resection.

>> I would probably…[low volume]. Have a hard time with radiation giving me massive swelling. I do agree that this is a big tumor and there is a lot of risk with surgery. She already has a field of depth that is the primary depth that I would expect. So I do think we can ask to -- achieve an extensive resection without too much risk to her. I would recommend a craniotomy… [low volume.]

>> What do you think about this patient?

>> I don't think there is any wrong answer. The patient always has a chance. What the experts say and what their own opinion is, obviously we are dealing with a very aggressive tumor in a 57-year-old individual. There is some longevity. You want to get the best you can for the patient. I would come out on the side of offering the patient a radical operation to take out as much of the tumor as possible, which I think based on my experience and in the literature, gives the patient the best long-run probability of quality of life. Obviously, you have to add to that other adjuncts if -- other therapies, such as radiation and chemotherapy…[low volume], ultimately, the patient will make the decision.

>> What is your opinion regarding radiation for this patient?

>> On this glioblastoma the recommended radiation therapy would be 30 treatments of radiation to…we would use IMRT or…as well as image guidance to try to decrease the amount of normal tissue that is exposed to radiation. You would also get a fusion MRI after biopsy of the resection to better determine the area to be treated with radiation. Using those techniques, specific to the resection question, I don't think there is a significant difference in the tissue that would be exposed or in the planned schedule to radiation based on the biopsy vs resection.

>> When would you typically start radiation after those scenarios?

>> It would depend on how the patient has healed from the surgery. If there are any complications, we would certainly take the nurses opinion into account. Additionally there can be trials and protocols that would determine, when the radiation should be started.

>> Dr. Ricks so what clinical trial be considered for this patient?

>> With the combination of radiation and chemotherapy…given the same time given for seven weeks followed by … [low volume]… for one year. This is the recommendation that we can make. Radiation versus chemotherapy/radiation…[low volume]. We can discuss these two options with the patient. We can discuss this on Wednesday when she is at the clinic. I think the patient is eligible for the clinical trial ….

>> Any other opinions?

>> What biomarker do you normally perform…?

>> We have a molecular marker…for prognosis and we have markers for research studies. The markers for prognosis [low volume]. And then we also have … Molecular studies … [Low volume]

>>Any other opinions? The official recommendation of tumor Board of surgery. This seems to be the opinion that the large operation is favored because of the size of the tumor and followed by standard treatment with radiation … [low volume]. Or consideration for clinical trial. The case has been reviewed.

>> The next case is a benign tumor. We spend a lot of time talking about glioblastoma but we spend as much time talking about the benign tumors, pituitary tumors – meningioma, etc. And we spent a lot of time talking about things that we don't necessarily know if they are tumors are not. Sometimes regions or spots that we are not sure of, we will review and our report as well. This is a case of a pituitary tumor. You will see the importance of the radiology review and this one especially for the lesions where we are not sure what they are. And then a focus on treatment option of surgery and radiation as well.

[Video playing]

>> This is a 21-year female…She failed a vision test with her ophthalmologists. She saw her neurologist who recommended observation. She an MRI last year it showed some growth and further observation was recommended. This year she has had another MRI with similar change. [ Indiscernible ] visual fields recently checked are intact. [ Indiscernible - low volume ]

>> We have three MRI scans on this woman. This is her most recent one which shows a lesion in the left sell it -- be post contrast images -- on this study it currently measures 1.3 cm. If we compare that to the scan done in 2005, it measured 0.7 cm and on the scan from 2010 it measured 1.1 cm. And on the current study is 1.35 cm. It's a gradual increase over the three scans and it is consistent…

>> How close are the optic nerves?

>> Very mild super cellular extension. The point where it is close to be left…optic nerve is about 3 mm. There is no sign is involved.

>> In terms of treatment options, what do you think about this patient?

>> I think this patient actually is best suited for surgical treatment. You could consider radiation but she is young. You have followed her for a period of five years and it has doubled in size. Be tumor is still confined to the pituitary area. It is not causing compression of the optic apparatus. It is an elected procedure but given the increase given the ability of the surgery to cure this tumor I think that would be the best approach. The technique would also offer a lot of mobility and that is a technique where you go through the nose and there is no incision on the skin. It has a very low morbidity and a low probability of causing pituitary decline or pituitary insufficiency because the patient still has, as I understand, a normal functioning to the pituitary gland although it is compressed because of the tumor. I would recommend that approach. They may want to consider radiation as well.

>> What are the radiation options?

>> I agree that this indicates with the progression of the scans that there are a couple of radiation options. There would be the choice of using fractionated radial therapy, that would be daily treatment five days a week for 5 1/2 weeks. But because this tumor is far enough away from the optic pathway, I think surgery would also be an option as well. That has the advantages of being done in a much more compressed fashion, much less difficulty for the patient to go back and forth for treatment. Both of those options give pretty good treatment control. In a young patient where there is a lifespan ahead of them of maybe decades, there is not as much data about radiotherapy being effective 30 or 40 years after treatment as we have with surgery. For that reason I would favor surgery as well. I would agree with Dr. Too.

>> If choosing radiation, which of those would you choose for them and what would be the risks in terms of hormonal dysfunction?

>> Surgery would be a good option because it is that single treatment. The hormonal dysfunction after radiosurgery is probably like to be a higher risk than it is with surgical incision over the period of 5 or 10 years, about five it -- about 30%.

>> Dr. Paidor, what is your opinion regarding radiation for this patient?

>> I think given the relevant lack of long-term data going out 30 to 40 years for radiation, I think surgery would be preferable. If the patient did want radiation and wanted to avoid surgery for whatever reason, the stereotypical treatment would be the preferred method…

>> The potential need for radiation after surgery.

>> If this is a complete resection there would be no indication for radiation. If there was some concern that there was residual tumor afterwards I think depending on the degree of concern, you would need to observe for a period of time or consider radiosurgery.

>>After hearing all these are recommendations, what is your final recommendation?

>> I agree with Dr. Too, given the age of the patient, and progression overtime, that surgery would be the best approach. That would be my recommendation. Radiation would be an option to discuss with her as well.

>> Our official tumor board as consensus says surgery is the primary option and radiosurgery is another option which is available to the patient. There are no NCCN Guidelines pertaining to pituitary tumors.

>> Our last case is certainly something that takes up a lot of time in tumor board and that is the discussion of recurrent tumors. As you will see in this case, radiology is important in determining recurrence especially in treatment effect is a difficult thing and something that radiologists help out a lot with. Options, with recurrent tumors a big part is clinical trials. We will present this case.

[Video playing]

>> Our next patient is a 50 –year-old white male initially diagnosed with a glioblastoma after having two seizures and surgeries. Over the last few months he has had to increase in headaches and difficulty with speech, getting his worth out and incoordination of his right hand.

>> Would you review the MRIs?

>> We have two MRIs 4 to 5 months apart. On the first scan, you will notice that there is no abnormal enhancements in the brain cranium -- reducing postoperative changes. On the scan that was 4 to 5 months later, we see a large irregular area of enhancement in the left particle realm. This appearance is very concerning for recurrent -- recurring tumors. We have done methodology ….and profusion. Both of those showed that this area of abnormal enhancement is most consistent with recurrent high-grade tumor.

>> Is there a role for additional surgery?

>> I do think so. It's in the left frontal lobe, dominant hemisphere, surgery should be safe. I would recommend surgery but do a functional MRI for planning….I do think surgery would be my first recommendation since this is a recurrent tumor. I would like the replacement of … chemotherapy waivers… would be a good option for him.

>> Is there a role for one of the other of those treatments alone? What would you consider?

>> We have good evidence that combining the two has a somewhat synergistic effect. There is more benefit doing a two together and then there is with one of. There are individual situations where one might work better than the other. I think for him, this would be the best potential affect.

>> What do you think about this patient?

>> There are two ways to look at this. The patient having aggressive surgery, doing it again may add some time to the life but does it add quality to life? We have to present this in a very clear way so they can understand. We want to let the patient make a choice.

>> What are the radiation options for this patient?

>> I think after surgery or together with the surgery using an implant with a radioactive isotope would offer the potential of giving radiation to the area where the tumor has occurred and being able to confine it to that area without unnecessarily damaging some of the surrounding tissues that have previously had radiation. That is why to help and minimize the risk of further injury from treatment due to radiation…The addition of the chemotherapy waiver is a good idea.

>> Is there a role for repeat radiation after the surgery?

>> If this was a case where surgery resection was not impossible, we could use a radio surgical technique to also use a dose of radiation to that area. We could ask Dr. Ricks about the effects of that external radiation and protect against any adverse effects.

>> Where the chemotherapy options for this patient?

>> Avastin is a good choice at this point. It is a targeted agent. It targets the blood vessels in tumor. It works differently than other chemotherapy agents that we have. After that, we have some potential open trials that should be coming in. I think Doctor Ricks could speak to that.

>> What clinical trials are available?

>> When we get the reading from the … Phase 1 study with in -- an anti…[low voice] We have a specific picture right now. The other caution -- option is a dual indication. [indiscernible language ] All of these options could be discussed and considered by the patient in clinic based on the biomarker studies of tissue. Wait for in favor in surgery and radiation and then clinical trial.

>> Speaking of biomarkers, Dr., how long would it take the get the biomarkers.

>> Usually we have results within a week or so….

>> Around the time of the postoperative appointment, we could have that….The official tumor board recommendation is a option of surgery with implant of [low volume]. The other option would the repeat radiation repeated with radiosurgery. Whether this is a clinical trial based on the biomarkers, we reviewed this patient according to NCCN guidelines and we’re in compliance.

>> Hopefully with those three cases you can now see how tumor board works. The bottom line is -- tumor board is multiple specialists coming together to provide an opinion, hopefully one that we agree on. Sometimes we don't. Hopefully we do. Provide that opinion to direct diagnosis and treatment. The ultimate goal is to make a plan, a plan for the whole team and help deliver to you, the patient. Clinical trials are extremely important. We review every case for clinical trials. You also understand now the importance of tumor board from the team standpoint. This is one of the few times that all of us get together in one place and talk about our cases. Get us together in one place to help each other and hopefully help you. That concludes my presentation. I will turn it back over now for questions.

>> Thank you Dr. McPherson. Dr. McPherson will now take questions. If you have a question you would like to ask, please type and submit it using the question box in the webinar control panel on the right hand side of your screen.

>> I have some questions that have already been asked. How do you get your case in front of a tumor board?

>> Sometimes it is physicians who direct that. I may personally choose to present specific cases. We have patients who request, and both inside and outside patients. You can always ask your physician as a patient, I would like this to be taken to the tumor board. We could do that. We also nowadays through online, we get a lot of outside referrals as I know most centers to. People from other places will sometimes submit their cases. Maybe they are looking for confirmation of treatment that is going on somewhere else. That saves them from having to travel far just to get that opinion. We are happy to do that just as I know many other centers do that too. Online is a good way to do this because they can submit their films and information online to us or to another center and we can present that and get back to that patient and let them know if there is anything that we can offer them in clinical trial or something that would be worth traveling for, rather than just travel to find out it is the same treatment plan.

>> Another question that we had is, to the neurosurgeons ever opt away from surgery?

>> Definitely. As you saw in the first case, there was a disagreement there as to whether it was a biopsy or major surgery. There are times when we as surgeon say, absolutely not. The first thing I will say on this cases, no surgery. Maybe it is unsafe. Maybe it might cause neurological deficit. Maybe someone has already had surgery or maybe it is something that we think is better treated with radiation. Definitely, it seems like the surgeon is always saying surgery in the radiation -- radiologist is always saying praise -- radiation but we do look at it from a balanced standpoint and provide recommendations based on that.

>> We have follow-up to go along with that question. If the tumor board cannot come to a consensus agreement, how do you tell the patient that and do you give them options?

>> That is important. I always communicate that to the patient. I will tell them that there was not agreement from the tumor board. Maybe three neurosurgeons and one said he would not operate and two said that they would. Then it falls back onto the patient to decide. This is the thought process of those different neurosurgeons. Ultimately the patient has to make the decision. We try to come to a consensus when we can. Obviously medicine is an art and not a science and not always 100% -- knowing exactly the right answer.

>> Thank you. To patients or caregivers ever participate in the tumor board?

>> We don't typically have patients or caregivers at the tumor board specifically. I think it is good to have a bit of a neutral viewpoint. Everyone can talk about the case without having the patient presents. In addition, we discussed multiple cases and certainly nowadays with HIPAA rules we can't have patients there because of other patients being discussed. We haven't done that. I don't know of other centers that have done that. We always do it as a closed meeting and then we bring that information back to the patient.

>> Thank you. Does every hospital have a tumor board?

>> Pretty much every hospital has some form of a tumor board. Some of the more community-based hospitals may have one tumor board for all tumors. The larger centers specialty centers -- and specialty centers may have more specialty tumor board such as a lung tumor board or a brain tumor board. Most of the major cities will have a brain tumor board.

>> Thank you. Besides the doctors, are there other types of healthcare professionals to participate and get their opinions?

>> There are. As you saw, the doctors dominate. We have a tendency to do that. The nurse professionals, nurse clinicians are definitely there. They serve more to provide information. We might ask for an acoustic Norrell [ sic ] they may be able to get that information to us. With a clinical trial specialist, we sometimes ask them if a patient would qualify for clinical trial based on the information. There is a lot of other support personnel, administrative personnel that are there. They don't always directly involve themselves in the tumor board. We are certainly open to input from everyone. Residents are often there, if they have input from seeing the patient. They speak up as well. We tried to get as much input as we can.

>> What happens when the patient does not agree with the tumor board's suggestions?

>> That is an important question. Sometimes it is just like any medical opinion. It is an opinion of 10-20 physicians, but maybe it is not exactly what the patient agrees on or what they want to do. There are two different avenues. It is always open to discussion with the patient. It may have been that the recommended surgery is not what the patient wants radiosurgery. They want radiosurgery. If we think that is an -- a reasonable alternative, we may go with that. If it is something that doesn't fit with our recommendation, there are always other opinions and institutions. The tumor board is an opinion, a group opinion for multiple people. It is not always the final words.

>> Thank you. That concludes the questions that we have had at the crowd.

>>That is all the time we have for today; thank you all for joining us and thanks once again to Dr. McPherson for your time.

>>For more information on the topics discussed here today or for more information on brain tumors and their treatment options, our licensed health care professionals can provide you with support or help you navigate information available on our website. Call the ABTA CareLine at 800-886-2282.

>> Let's pause to conclude the webinar recording.