Variation Between Multidisciplinary Tumor Boards in Clinical Staging and Treatment Recommendations for Patients With Locally Advanced Non-small Cell Lung Cancer

Abstract

BackgroundAccurate diagnosis and staging are crucial to ensure uniform allocation to the optimal treatment methods for non-small cell lung cancer (NSCLC) patients, but may differ among multidisciplinary tumor boards (MDTs). Discordance between clinical and pathologic TNM stage is particularly important for patients with locally advanced NSCLC (stage IIIA) because it may influence their chance of allocation to curative-intent treatment. We therefore aimed to study agreement on staging and treatment to gain insight into MDT decision-making.Research QuestionWhat is the level of agreement on clinical staging and treatment recommendations among MDTs in stage IIIA NSCLC patients?Study Design and MethodsEleven MDTs each evaluated the same 10 pathologic stage IIIA NSCLC patients in their weekly meeting (n = 110). Patients were selected purposively for their challenging nature. All MDTs received exactly the same clinical information and images per patient. We tested agreement in cT stage, cN stage, cM stage (TNM 8th edition), and treatment proposal among MDTs using Randolph’s free-marginal multirater kappa.ResultsConsiderable variation among the MDTs was seen in T staging (κ, 0.55 [95% CI, 0.34-0.75]), N staging (κ, 0.59 [95% CI, 0.35-0.83]), overall TNM staging (κ, 0.53 [95% CI, 0.35-0.72]), and treatment recommendations (κ, 0.44 [95% CI, 0.32-0.56]). Most variation in T stage was seen in patients with suspicion of invasion of surrounding structures, which influenced such treatment recommendations as induction therapy and type. For N stage, distinction between N1 and N2 disease was an important source of discordance among MDTs. Variation occurred between 2 patients even regarding M stage. A wide range of additional diagnostics was proposed by the MDTs.InterpretationThis study demonstrated high variation in staging and treatment of patients with stage IIIA NSCLC among MDTs in different hospitals. Although some variation may be unavoidable in these challenging patients, we should strive for more uniformity. Accurate diagnosis and staging are crucial to ensure uniform allocation to the optimal treatment methods for non-small cell lung cancer (NSCLC) patients, but may differ among multidisciplinary tumor boards (MDTs). Discordance between clinical and pathologic TNM stage is particularly important for patients with locally advanced NSCLC (stage IIIA) because it may influence their chance of allocation to curative-intent treatment. We therefore aimed to study agreement on staging and treatment to gain insight into MDT decision-making. What is the level of agreement on clinical staging and treatment recommendations among MDTs in stage IIIA NSCLC patients? Eleven MDTs each evaluated the same 10 pathologic stage IIIA NSCLC patients in their weekly meeting (n = 110). Patients were selected purposively for their challenging nature. All MDTs received exactly the same clinical information and images per patient. We tested agreement in cT stage, cN stage, cM stage (TNM 8th edition), and treatment proposal among MDTs using Randolph’s free-marginal multirater kappa. Considerable variation among the MDTs was seen in T staging (κ, 0.55 [95% CI, 0.34-0.75]), N staging (κ, 0.59 [95% CI, 0.35-0.83]), overall TNM staging (κ, 0.53 [95% CI, 0.35-0.72]), and treatment recommendations (κ, 0.44 [95% CI, 0.32-0.56]). Most variation in T stage was seen in patients with suspicion of invasion of surrounding structures, which influenced such treatment recommendations as induction therapy and type. For N stage, distinction between N1 and N2 disease was an important source of discordance among MDTs. Variation occurred between 2 patients even regarding M stage. A wide range of additional diagnostics was proposed by the MDTs. This study demonstrated high variation in staging and treatment of patients with stage IIIA NSCLC among MDTs in different hospitals. Although some variation may be unavoidable in these challenging patients, we should strive for more uniformity. Lung cancer is the leading cause of cancer-related death worldwide.1World Health OrganizationFact sheet cancer. 2018.https://www.who.int/en/news-room/fact-sheets/detail/cancerGoogle Scholar New and better imaging methods, such as PET-CT and endobronchial ultrasound (EBUS) or endoscopic ultrasound, have been implemented over the last decades. Furthermore, a rapidly expanding array of treatment options has become available. Although lung cancer treatment has been a disappointing endeavor in terms of overall survival in the past decades,2Netherlands Comprehensive Cancer OrganisationCijfers over kanker. 2019.https://www.cijfersoverkanker.nlGoogle Scholar,3American Cancer SocietyNon-small cell lung cancer survival rates. 2019.https://www.cancer.org/cancer/non-small-cell-lung-cancer/detection-diagnosis-staging/survival-rates.htmlGoogle Scholar evidence shows that survival is improving.4Lou Y. Dholaria B. Soyano A. Hodge D. Cochuyt J. Manochakian R. et al.Survival trends among non-small-cell lung cancer patients over a decade: impact of initial therapy at academic centers.Cancer Med. 2018; 7: 4932-4942Crossref PubMed Scopus (12) Google Scholar This development should prompt the medical community relentlessly to try to improve lung cancer care further.Take-home PointsStudy Question: What is the level of agreement on clinical staging and treatment recommendations among MDTs in challenging stage IIIA NSCLC patients?Results: Intermediate agreement was found among the MDTs in TNM staging and treatment recommendations with κ values of 0.53 (0.35-0.72) and 0.44 (0.32-0.56), respectively.Interpretation: A high variation was found among MDTs in staging and treatment recommendations for patients with stage IIIA NSCLC. Although some variation may be unavoidable in these challenging patients, we should strive for more uniformity. Study Question: What is the level of agreement on clinical staging and treatment recommendations among MDTs in challenging stage IIIA NSCLC patients? Results: Intermediate agreement was found among the MDTs in TNM staging and treatment recommendations with κ values of 0.53 (0.35-0.72) and 0.44 (0.32-0.56), respectively. Interpretation: A high variation was found among MDTs in staging and treatment recommendations for patients with stage IIIA NSCLC. Although some variation may be unavoidable in these challenging patients, we should strive for more uniformity. Accurate clinical staging is necessary to determine the best treatment strategy for the individual patient, particularly with expanding treatment options like stereotactic ablative radiotherapy and different types of induction therapy (eg, immunotherapy). Staging often consists of a combination of imaging methods and (minimally) invasive staging procedures. Although these separate methods show high sensitivity and specificity,5Silvestri G.A. Gonzalez A.V. Jantz M.A. Margolis M.L. Gould M.K. Tanoue L.T. et al.Methods for staging non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines.Chest. 2013; 143: e211S-e250SAbstract Full Text Full Text PDF PubMed Scopus (831) Google Scholar concordance between clinical and pathologic stage of NSCLC is surprisingly low, between 50% and 60%.6Heineman D.J. Ten Berge M.G. Daniels J.M. Versteegh M.I. Marang-van de Mheen P.J. Wouters M.W. et al.The quality of staging non-small cell lung cancer in the Netherlands: data from the Dutch Lung Surgery Audit.Ann Thorac Surg. 2016; 102: 1622-1629Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar Low staging concordance combined with expanding treatment options also may result in differences between hospitals, especially in locally advanced disease, when staging accuracy is relatively low and clear evidence for treatment options is lacking.6Heineman D.J. Ten Berge M.G. Daniels J.M. Versteegh M.I. Marang-van de Mheen P.J. Wouters M.W. et al.The quality of staging non-small cell lung cancer in the Netherlands: data from the Dutch Lung Surgery Audit.Ann Thorac Surg. 2016; 102: 1622-1629Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar Accurate diagnosis and staging are particularly important in stage IIIA patients, because it may influence their chance of allocation to curative-intent treatment. The multidisciplinary team or multidisciplinary tumor board (MDT) has a crucial role in clinical staging and proposing the primary treatment. The literature shows that MDT recommendations change the initial treatment plan in 40% of lung cancer patients, and some studies even show clinically relevant overall survival benefits.7Schmidt H.M. Roberts J.M. Bodnar A.M. Kunz S. Kirtland S.H. Koehler R.P. et al.Thoracic multidisciplinary tumor board routinely impacts therapeutic plans in patients with lung and esophageal cancer: a prospective cohort study.Ann Thorac Surg. 2015; 99: 1719-1724Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar,8Dickhoff C. Dahele M. The multidisciplinary lung cancer team meeting: increasing evidence that it should be considered a medical intervention in its own right.J Thorac Dis. 2019; 11: S311-S314Crossref PubMed Scopus (3) Google Scholar Dutch guidelines require that decisions regarding the treatment of lung cancer patients be made by an MDT and strive for uniform treatment nationwide.9Landelijke Werkgroep LongtumorenNiet kleincellig longcarcinoom Landelijke richtlijn, versie: 2.3. 2011.http://www.oncoline.nl/niet-kleincellig-longcarcinoomGoogle Scholar In 2017, the percentage of NSCLC patients discussed in an MDT meeting before curative treatment in The Netherlands was 98.9%.10Dutch Lung Cancer AuditDutch Lung Cancer Audit annual report 2017. 2018. Dutch Lung Cancer Audit website.https://dica.nl/jaarrapportage-2017/dlcaGoogle Scholar The objective of this study was to determine the level of agreement among MDTs regarding clinical staging and treatment recommendations for patients with stage IIIA NSCLC to gain insight into MDT decision-making. Lung oncology MDTs from 26 hospitals were invited to participate in this study among the total of 42 lung surgery-performing hospitals in The Netherlands. Per hospital, one oncology-specialized pulmonologist—preferably the MDT chair—was approached and asked to participate in the study. This pulmonologist informed the MDT and, as a representative for the entire MDT, provided written consent to participate. The selected hospitals were sampled to represent both academic and peripheral hospitals and both low- and high-volume centers, geographically well dispersed over The Netherlands. Using Dutch Lung Cancer Audit for Surgery data, hospital volume was determined by calculating the mean number of annual oncologic parenchymal lung resections from 2013 through 2015.11Ten Berge M. Beck N. Heineman D.J. Damhuis R. Steup W.H. van Huijstee P.J. et al.Dutch Lung Surgery Audit: a national audit comprising lung and thoracic surgery patients.Ann Thorac Surg. 2018; 106: 390-397Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar We defined low-volume hospitals as those performing 20 to 49 anatomic parenchymal resections per year and high-volume hospitals as those performing 50 or more anatomic parenchymal resections per year (fewer than 20 lung resections per year is not allowed according to the Dutch quality standards [www.soncos.org]). Patients were accrued from 5 hospitals (of which 4 also participated in this study) representing Dutch lung cancer care practice in general regarding volume, teaching status, and geographic area. All of the 2014 and 2015 patients who underwent surgery for locally advanced NSCLC (defined as pathologic stage IIIA regarding the TNM classification, 7th edition12Rusch V.W. Asamura H. Watanabe H. Giroux D.J. Rami-Porta R. Goldstraw P. The IASLC lung cancer staging project: a proposal for a new international lymph node map in the forthcoming seventh of the TNM for lung Thorac Full Text Full Text PDF PubMed Scopus Google were using the Dutch Lung Cancer Audit for IIIA patients were because in this staging be challenging regarding the N and invasion in surrounding and treatment are clear evidence on which strategy in the best The primary these hospitals to and to additional and with the lung it was patients were for the study. considered in this were the of multidisciplinary tumor stage, stage, and different treatment information regarding and imaging to be available. All patients considered were discussed by the primary and lung J. H. and H. 10 patients with a in staging and treatment were selected from hospitals. All information and imaging were of data to the to ensure their The of hospitals were asked to the 10 patients, one or each into their weekly MDT meeting a of 4 to in of in of endoscopic or and images to the MDT on a before the of treatment and necessary to on clinical stage and treatment. Patients were as and in a that be as as from MDTs were asked to the clinical TNM stage implemented for lung cancer from and to a treatment The pulmonologist the study patients the proposed clinical stage and the treatment and a the considered the MDT meeting for each were the level of agreement among MDTs regarding clinical TNM stage and treatment were variation in proposal of diagnostics and to the Dutch staging Werkgroep LongtumorenNiet kleincellig longcarcinoom Landelijke richtlijn, versie: 2.3. 2011.http://www.oncoline.nl/niet-kleincellig-longcarcinoomGoogle Scholar Randolph’s free-marginal multirater was to Scholar is a of agreement for number of patients, or that be when are not to a number of patients to each A κ of than is considered one between and is considered to and one of more than is considered of as a high κ we the for each multirater an to in and Scholar of T stage, M stage, overall TNM stage, and treatment were combined (eg, and and in of by the MDT as the proposal of the stage was (eg, stage stage This was because we that treatment and plans are made on the stage. For when regarding the T stage is or induction therapy be the suspicion of the stage. Furthermore, when between stage N2 or the diagnostics be on the suspicion of N2 hospitals that selected patients not these patients because of or the proposed clinical stage and received treatment were for the The of the this study informed consent from patients was because of and For one of the patients in this written informed consent was from the patient. from 26 hospitals were approached to participate. 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