Kimberly Advento-Torres1 and Soledad Lim Balete2
1Section of Medical Oncology, Jose R. Reyes Memorial Medical Center, Rizal Avenue, Sta. Cruz, Manila, Philippines; 2Metropolitan Medical Center, Sta Cruz Manila, Philippines
ABSTRACT
Objective: By leveraging insights from the case and subsequent discussions, we aim to improve our understanding of thymic malignancies and promote further research and collaboration.
Methods: A 47-year-old female, J.D., who presented with a history of easy fatigability, bilateral extremity weakness, and shortness of breath diagnosed with advanced thymoma and metastases, received a multidisciplinary evaluation. Doctors considered surgery, radiation, and systemic therapy, tailoring the approach based on tumor stage and patient needs. The team monitored response through examinations and tests, planning follow-ups to track progress.
Results: Diagnosing thymoma involves tissue examination and genetic testing, with treatment varying by cancer stage. In this case, the initial evaluation revealed controlled hypertension and a history of four pregnancies. Imaging scans found a mass in the chest and suspicious nodules in the liver and abdomen. A biopsy confirmed thymoma with no signs of spread beyond the initial tumor sites. Surgery is a key treatment option, with minimally invasive techniques being explored for faster recovery. Early-stage surgery may not require radiation, but advanced tumors benefit to systemic therapy to eliminate microscopic disease and improve survival.
A chemotherapy regimen was well-tolerated with minimal side effects, and surveillance CT scans were requested to monitor the response to treatment. While the initial treatment was successful, ongoing challenges exist due to the limitations of systemic therapy and the potential for residual disease. Treating metastatic thymoma after chemotherapy remains a challenge. Some doctors consider pembrolizumab for patients unable to tolerate other treatments, but more research is needed for this complex cancer. Overall, while the treatment itself showed promise, the limitations of current therapies and the potential for residual disease continue to pose challenges in managing thymoma.
Conclusion: This case of thymoma highlights the complexities of diagnosis and treatment for this rare cancer. While initial treatment showed promise, with well-tolerated chemotherapy and careful monitoring, the management of thymoma continues to present challenges. The potential for residual disease and limitations of current systemic therapies underscore the need for ongoing research and personalized treatment approaches. As medical science advances, particularly in areas such as immunotherapy, there is hope for improved outcomes and quality of life for patients with thymoma.
Keywords: Advanced thymoma, multidisciplinary, metastatic disease, thymic malignancies
INTRODUCTION
Thymomas, rare tumors from the thymic epithelium, pose significant challenges in clinical management due to their variable clinical presentation and complex treatment considerations. We present the clinical course of a 47-year-old female, J.D., who presented with a history of easy
fatigability, weakness of bilateral extremities, and shortness of breath. Initial evaluation revealed a mediastinal mass, prompting further investigation through a comprehensive diagnostic workup. The significance of this case lies in its complexity, as the patient was diagnosed with advanced- stage thymoma accompanied by lung and liver metastasis, along with a concurrent ovarian new growth. This unique presentation underscores the intricacies of managing rare malignancies, necessitating a multidisciplinary approach and personalized treatment strategies.
The rationale for presenting this case stems from highlighting the diagnostic challenges, treatment considerations, and emerging therapeutic modalities in advanced thymomas. By synthesizing insights from the initial case presentation and the opening discussions in the forum, we aim to contribute to the understanding of thymic malignancies and stimulate further research and collaborative efforts in this field.
The case presentation provides a comprehensive understanding of the clinical, pathological, and therapeutic aspects of managing advanced-stage thymomas and insights into emerging biomarkers and genetic syndromes associated with thymic malignancies. The learning objectives that readers should gain from the discussion are the following:
Gain insight into the diagnostic challenges associated with rare malignancies like advanced- stage thymomas.
Understand the importance of a multidisciplinary approach in managing complex cases involving thymic malignancies.
Explore the nuances of treatment selection and personalized therapeutic strategies for advanced thymomas.
Appreciate the significance of integrating diverse perspectives and expertise in optimizing patient outcomes in rare malignancies.
METHODS
This case presentation is of a patient diagnosed with advanced-stage thymoma accompanied by lung and liver metastasis, along with a concurrent ovarian new growth. A multidisciplinary forum discussion framework involving experts from pathology, radiology, medical oncology, and surgery analyzes this case.
Participants
The patient included in this case report is a 47-year-old female, denoted as J.D., who presented with symptoms suggestive of advanced-stage thymoma. The case presentation then involves input from experts across various medical specialties, contributing to a comprehensive understanding of the clinical management of rare malignancies.
Data Collection and Analysis
The presenter collected data for this case presentation from the patient’s medical records, which included diagnostic imaging studies, pathological reports, and treatment records.
Diagnostic Workup
The diagnostic process began with a chest X-ray followed by a subsequent investigation through a chest CT scan and biopsy. Further imaging modalities employed included cranial and whole abdominal CT scans, transvaginal ultrasound, 2D echo with Doppler, bone scintigraphy, and pulmonary function tests. Laboratory investigations encompassed anti-acetylcholine receptor
(IgG), CA 125, CA 19-9, and CEA levels. Subsequent histopathological examination supported by immunohistochemistry confirmed the diagnosis of thymoma. The radiology team performed imaging studies to investigate the spread of cancer to other organs. These studies included a cranial CT scan and a 2D echocardiogram with Doppler ultrasound.
Treatment Approach
A multidisciplinary team managed the patient’s case, involving medical oncology, radiation oncology, and surgical specialists. They discussed treatment options, including surgery, radiation therapy, and systemic therapy. The multidisciplinary team considered surgical resection for cases where the disease could be removed entirely (resectable disease). They indicated radiation therapy as a possible treatment approach for locally advanced or unresectable cancers. Radiation therapy could be used in different settings: adjuvant (following surgery), neoadjuvant (before surgery), or definitive (as the primary treatment).
Response to Treatment
The multidisciplinary team monitored the patient’s response to treatment through clinical evaluations, imaging studies, and laboratory investigations. They conducted objective response assessments to evaluate tumor regression, symptom relief, and treatment-related adverse events. The team members scheduled follow-up appointments to actively assess the treatment’s effectiveness, monitor for disease progression, and evaluate patient outcomes.
RESULTS
Patient Selection and Clinical Presentation
A 47-year-old female, J.D., with a history of easy fatigability, weakness of bilateral extremities, and shortness of breath, presented with symptoms suggestive of advanced-stage thymoma. Initial evaluation included a thorough medical assessment, family history review, and physical examination. The patient’s medical history revealed controlled hypertension, and obstetric- gynecologic history indicated G4P4 status, with the last menstrual period in November 2023. There was no history of smoking or alcohol consumption.
Diagnostic Results
A chest CT scan identified a well-defined, enhancing soft tissue mass measuring 4.5 x 6.4 x 8.4 cm in the right anterior mediastinum. Further imaging detected hepatic nodules and a solid mass in the right adnexal region, suggesting metastasis. A tissue biopsy was performed to confirm the diagnosis.
A tissue biopsy confirmed the diagnosis of thymoma, with immunohistochemistry revealing positive CK and TdT expressions and negative Synaptophysin expression. The histological classification indicated a predominance of spindle and polygonal cells, consistent with thymoma. Additionally, relevant laboratory results included normal levels of the anti-acetylcholine receptor (IgG), CA 125, CA 19-9, and CEA, suggesting no systemic involvement beyond the primary tumor sites.
Treatment Outcomes
A medical oncology fellow administered a chemotherapy regimen for the patient consisting of doxorubicin 50mg/m2, cisplatin 50mg/m2 , and cyclophosphamide 500mg/m2 , administered every 21 days for six cycles. The patient tolerated the treatment well, and the fellow managed any side
effects that arose. The fellow recommended scheduling interval CT scans to monitor the response to chemotherapy.
Complications
The patient tolerated the treatment well, with minimal complications consisting of grade 1 neutropenia and nausea with significant adverse events reported during therapy. This positive outcome suggests that the treatment regimen was well-tolerated. However, systemic therapy’s limited efficacy and residual disease postoperatively pose ongoing challenges in disease management.
DISCUSSION
The discussants: Pathology (Dr. Grig Misiona), Radiation Oncology (Dr. Angela Tagle), TCVS (Dr. Giovanni Villaruz), Medical Oncology (Dr. Guia Elena Imelda Ladrera)
The presented case of advanced-stage thymoma with lung and liver metastasis, along with a concurrent ovarian new growth, underscores the complexity of managing rare malignancies. The multidisciplinary discussions within the forum provided insights into various perspectives on diagnostic workup, treatment modalities, and therapeutic challenges.
Pathological Insights
Pathological evaluation, including histological examination and immunohistochemistry, played a crucial role in confirming the diagnosis of thymoma and guiding treatment decisions. The forum discussions highlighted the significance of identifying pathognomonic histologic findings and immunohistochemical markers for accurate diagnosis and classification.
Histological examination remains the initial step, where pathologists classify the predominant cell type—spindle-shaped or polygonal cells—to guide further investigation. However, due to microscopic similarities, IHC becomes crucial for definitive diagnosis. Markers like CD3 and CD20 are commonly employed based on the predominant cell type (polygonal cells) to differentiate between Thymoma and lymphoma.1
What is the role of NGS in this case?
Due to thymoma’s rarity and classification as an epithelial tumor, Next-Generation Sequencing (NGS) is gaining recognition as a viable diagnostic technique. NGS provides comprehensive genotyping, revealing a wide array of genetic changes in the tumor. This detailed information can help tailor therapy to match the patient’s tumor profile. Meta-analyses of NGS studies identify commonly mutated genes like GTF21, TP53, and HRAS, which play roles in thymoma formation and progression.2
NGS also assesses tumor mutational burden (TMB). Studies from The Cancer Genome Atlas and Foundation Medicine indicate that thymomas generally exhibit low mutation rates.3 This low TMB is crucial for determining appropriate treatment strategies. NGS’s ability to analyze genetic data and TMB enhances its role in diagnosing thymoma and guiding personalized treatment plans for improved patient outcomes.
Radiation oncology experts emphasized the role of radiation therapy in locally advanced or unresectable thymomas. The radiation therapy team engaged in a detailed discussion regarding the ongoing debate about adjuvant versus neoadjuvant radiation therapy. They also explored the optimal radiation dose and techniques for minimizing toxicity.
Is radiation involved in locally advanced diseases?
Although surgery is primary for thymoma, radiation therapy (RT) is crucial, especially for locally advanced disease. RT can optimize outcomes before, during, or after surgery. In the adjuvant setting, RT is generally not recommended after complete surgical removal (R0) of early-stage Thymoma (Masaoka-Koga Stage I with no capsular invasion). However, for tumors invading the capsule (Masaoka-Koga Stage II to IV), adjuvant RT is considered to eliminate microscopic disease post-surgery, aiming to improve local control and long-term survival.4 The radiation therapy team selectively chooses neoadjuvant RT for patients with large or locally advanced tumors that cannot be immediately removed (resected). It helps shrink tumors for easier surgical removal. Definitive RT offers an alternative for patients ineligible for surgery, delivering a high radiation dose for long-term tumor control or potential cure.
What is the role of adjuvant radiation therapy in thymoma management?
Adjuvant radiation therapy (RT) plays a complex role in thymoma treatment post-surgery, depending on the surgical removal extent (R status) and disease stage. For completely resected early-stage thymomas (Masaoka-Koga Stage I with no capsular invasion), adjuvant RT is generally not recommended due to a shallow recurrence risk.4
However, the decision on adjuvant RT is nuanced for tumors with capsule invasion (Masaoka- Koga Stage II to IV). Evidence of its efficacy is mixed.5,6 While some studies suggest it helps control the tumor site post-surgery, others question its impact on overall survival.
Adjuvant RT becomes crucial for patients with incomplete tumor removal (R1 or R2). Studies show that postoperative radiation therapy (RT) significantly reduces the risk of tumor recurrence in the chest cavity of these patients. Overall, the decision to use adjuvant RT after thymoma
surgery hinges on resection level and disease stage. While its benefit in R0 resections for Stage I Thymoma remains debated, adjuvant RT is vital for preventing local recurrence in incomplete resections (R1/R2).
Does neoadjuvant therapy for thymoma optimize surgical outcomes?
Neoadjuvant therapy, administered before surgery, is valuable for managing thymoma in specific situations. It aims to shrink tumors, making surgical removal (R0 resection) easier and improving long-term results. Additionally, it enhances resectability by shrinking large or advanced tumors to a size that allows for safer, more complete removal, especially for borderline resectable or initially unresectable tumors. Furthermore, neoadjuvant therapy helps reduce tumor spread during surgery by shrinking the tumor and reducing the number of viable cancer cells, thereby mitigating the risk of unintentionally spreading cancer cells.
Research shows promising results, particularly for Stage III Thymoma, with R0 resection rates ranging from 53% to 75% after neoadjuvant treatment, highlighting its potential benefits for specific patients.
Is radiation therapy a definitive treatment for unresectable thymoma?
When surgery is not possible due to unresectable illness or patient comorbidities, radiation therapy (RT) becomes a definitive treatment for thymoma. This strategy aims to provide substantial radiation to achieve long-term tumor control or a complete cure.
Studies support the efficacy of definitive RT. Arakawa et al. found that 58% of patients with unresectable thymoma survived 1 to 5 years with initial RT.7 Ciernik et al. reported an 87% 5- year survival rate for Stage III to IV Thymoma treated with RT alone.8 Jackson et al. demonstrated a 44% survival rate over ten years for patients with biopsied thymoma who underwent RT.6
Due to the rarity of thymoma, most studies on definitive RT are retrospective with small participant numbers, necessitating careful data analysis.7,8,9
What are the possible side effects after radiation of the anterior mediastinum?
Radiation therapy is crucial for treating thymoma, especially when surgery is not an option. However, irradiating the anterior mediastinum risks affecting vital organs like the heart, lungs, and esophagus, necessitating careful patient selection and treatment planning.10
While radiation can damage nearby structures, most side effects are typically subclinical, meaning they cause no noticeable symptoms. The RTOG/EORTC grading system classifies these toxicities from grade 1 (mild) to grade 5 (fatal). The overall chance of experiencing severe side effects following radiation therapy is reassuringly low at only 5%.
How are radiation therapy-related complications minimized?
Radiation therapy is essential for treating thymoma, especially when surgery is not possible. However, irradiating the anterior mediastinum risks affecting vital organs like the heart, lungs, and esophagus. Therefore, careful patient selection and meticulous treatment planning are crucial.10
Modern radiation techniques have significantly reduced complications. Radiotherapists aim to deliver radiation precisely, targeting the tumor while protecting nearby healthy tissues. One essential technique is Intensity-Modulated Radiation Therapy (IMRT), which uses multiple
radiation beams with varying intensities to create a precise dose distribution, minimizing exposure to vital organs.10,11
Another advancement is 4D Treatment Planning, which accounts for lung and mediastinum movement during respiration, improving treatment for tumors like thymoma. Respiratory Gating delivers radiation during specific breathing phases, typically using the Deep Inspiration Breath Hold (DIBH) technique. DIBH reduces organ and tumor movement, increases the distance between the heart and the target area, and minimizes radiation exposure to healthy tissues.11
The radiation therapy team adapted deep inspiration breath-hold (DIBH), a technique initially developed for treating left-sided breast cancer for thymoma therapy. This adaptation allows for optimal lung expansion during radiation therapy, which reduces the radiation dose delivered to critical structures near the lungs. In conclusion, while radiation therapy for anterior mediastinal thymoma poses potential side effects, innovative approaches like IMRT with 4D planning and respiratory gating significantly reduce these risks and improve patient outcomes.
What is the role of RT in SVC syndrome secondary to thymoma?
The team carefully weighs the use of radiation therapy for patients with thymoma, especially when considering the potential risk of superior vena cava (SVC) syndrome, a life-threatening condition. A definitive tissue diagnosis is crucial for mild to moderate SVC symptoms (grades 1-3). If the thymoma is operable, surgery is preferred for complete tumor removal and symptom resolution.12
For severe, life-threatening symptoms (grade 4), immediate intervention with a venogram and stenting is critical to restore blood flow and alleviate symptoms. Once stabilized, surgery remains the preferred option if the tumor is safely removable.12
In advanced cases, treatment focuses on managing cancer spread. For Stage IV thymoma with metastases but no SVC symptoms, systemic therapy targets both the primary tumor and metastases to control disease progression. RT’s effectiveness in treating SVC syndrome depends on symptom severity and disease stage. The surgery team prioritizes completely resectable tumors. Emergent stenting takes precedence in emergencies. Systemic therapy is the preferred course of action for advanced, unresectable diseases. The goal is to balance managing SVC symptoms and addressing the thymoma with the most appropriate treatment.
Surgical Interventions
Thoracic and cardiovascular surgeons debated the feasibility and benefits of surgical resection, including debulking surgery and metastasectomy. Minimally invasive surgical approaches were favored for selected patients, considering their potential advantages in recovery and outcomes.
Is the patient a candidate for upfront surgery?
The decision to perform surgery for a thymoma depends on the disease stage. For Stage IV thymoma, indicating distant metastases, upfront surgery to remove the primary tumor is generally not the most appropriate initial treatment. Surgery might be an option for some Stage IV cases, particularly with a limited number of metastases that can be safely removed, ranging from metastasectomy to extrapleural pneumonectomy. However, researchers debate the effectiveness of this approach due to the limited number of retrospective studies on this rare patient population.16 Given these factors, the focus would likely shift to systemic or radiation therapy, depending on specific considerations and the patient’s overall health.
Is there a role of debulking surgery and metastasectomy in thymic malignancy?
Surgery is multifaceted in managing thymic malignancies, extending beyond curative intent. Debulking surgery and metastasectomy can manage symptoms and potentially improve outcomes.16 Debulking surgery involves removing as much tumor tissue as possible, even if complete removal is not achievable. This approach benefits patients with large tumors causing symptoms like difficulty breathing, chest pain, and superior vena cava (SVC) syndrome. However, Fan et al. found no improvement in overall survival or progression-free survival for locally advanced, unresectable Masaoka-Koga Stage III thymomas with debulking surgery.17 Debulking surgery may positively affect myasthenia gravis symptoms by reducing antibody production. Metastasectomy removes isolated metastatic lesions after controlling the primary tumor. Surgery is not very effective for treating locally invasive disease, necessitating a multimodal approach with adjuvant and neoadjuvant radiation and chemoradiation. The decision to use debulking surgery or metastasectomy depends on factors like tumor size, metastases, and patient health. These procedures offer valuable tools for managing thymic malignancies by alleviating symptoms and potentially improving prognosis when combined with radiation or systemic therapy.
Is a minimally invasive procedure for thymoma possible?
Minimally invasive surgery (MIS) has become the preferred approach for treating thymoma when possible, offering advantages over traditional open thoracotomy.18 Two main MIS procedures are used: Video-Assisted Thoracoscopic Surgery (VATS) and robotic-assisted surgery.
MIS offers faster healing, less pain, and shorter hospital stays than open surgery. However, it is only suitable for some patients, with tumor characteristics and surgical expertise being critical determining factors.
Surgeons may choose either a thoracic or subxiphoid approach, providing minimally invasive access to the mediastinum.19 While MIS offers improved patient outcomes, careful evaluation is crucial to determining its suitability in each case.
Systemic Therapy Options
Medical oncologists deliberated on the limited efficacy of chemotherapy and targeted therapy in metastatic thymoma. They explored the potential role of immunotherapy, particularly pembrolizumab, in thymic malignancies, highlighting its associated adverse events and challenges in patient selection.
Is there a role for maintenance therapy after 1st line chemotherapy in metastatic disease? The lack of clear guidelines for maintenance therapy after first-line chemotherapy in metastatic thymoma exposes a critical gap in our understanding of how to treat this disease. Although no definitive proof supports using maintenance therapy after the first treatment, ongoing research actively investigates its potential benefits. It aims to establish appropriate treatment plans for this specific patient group.
Is there a role for immunotherapy in thymic malignancy in 1st line metastatic setting or subsequent therapy, or as maintenance therapy after chemotherapy?
Immunotherapy for thymic malignancies is a developing field with promising potential and significant challenges. Medical oncologists consider pembrolizumab as a possible first-line treatment for metastatic thymic cancer patients with low functional capacity, although data for this specific use is limited. However, a phase 2 trial reported a 70% incidence of immune-related adverse events (irAEs) in thymoma patients,20 necessitating careful patient selection and monitoring.
Conventional treatments for metastatic thymoma show limited efficacy. The optimal cytotoxic combination yields an overall response rate (ORR) of 44%,21 while paclitaxel and carboplatin have a 20% ORR for thymic cancer.22 Second-line targeted therapies show even lower response rates.23
Pembrolizumab is contraindicated in thymomas due to immune-related side effects.24 However, PD-1/PD-L1 expression in thymic epithelial tumors suggests a potential target for immunotherapy, with higher expression in more aggressive subtypes.
As a second-line treatment, pembrolizumab shows some effectiveness, with 28.6% and 19.2% response rates for thymoma and thymic carcinoma, respectively.25 However, the risk of severe irAEs remains significant, occurring in up to 70% of thymoma patients.24
While immunotherapy shows potential, particularly considering PD-L1 expression, significant obstacles remain. Careful patient selection and continued research are necessary to enhance treatment approaches and establish safer, more efficient immunotherapy protocols for thymic malignancies.
Are there emerging biomarkers in the detection and monitoring of treatment response? Identifying reliable biomarkers for thymic epithelial tumors (TETs) remains an ongoing pursuit in oncology. These tumors have the potential for early detection and treatment monitoring. However, challenges include their rarity and heterogeneity.
Circulating cell-free DNA (cfDNA) shows promise as a non-invasive biomarker. An Italian study identified higher cfDNA levels in TET patients compared to controls. The study also found elevated cfDNA levels in patients with advanced stages of the disease. However, the study did not find a significant link between cfDNA levels and disease stage or tumor burden.26 Research in lung cancer suggests cfDNA could potentially serve for early TET detection. However, further research, including more extensive multicenter studies, is needed to validate cfDNA’s role as a TET biomarker.
A multi-biomarker approach might help address the challenges posed by TET heterogeneity. While challenges exist due to the rarity and heterogeneity of these tumors, cfDNA and other emerging biomarkers offer hope for improved detection, monitoring, and patient outcomes in TET management.
Is thymic malignancy related to any genetic syndromes that have a propensity to develop secondary malignancy?
While thymic malignancies are not typically associated with hereditary cancer syndromes, a limited link with Lynch syndrome (LS) has been reported. LS, an autosomal dominant syndrome, affects 1 in 250 to 1000 individuals and arises from mutations in DNA mismatch repair genes: MSH2, MLH1, MSH6, and PMS2.27, 28
LS increases the risk of various cancers, primarily colorectal and endometrial. Case reports suggest a potential association between thymic malignancies and LS, particularly in patients with MLH1 mutations.27
Diagnosing Lynch syndrome (LS) involves two main tests: tumor-based and germline testing [28]. For patients with both thymic malignancies and suspicious adnexal masses, medical oncologists recommend further evaluation. This evaluation should include a biopsy to obtain tissue samples and testing to assess mismatch repair (MMR) function or microsatellite instability (MSI-H) status. Germline testing should then be performed. Identifying LS in a patient with thymic malignancy has significant implications for cancer surveillance strategies for both the patient and family members. While the link between thymic malignancies and Lynch syndrome (LS) is not fully understood, new evidence suggests a connection worth investigating further. Comprehensive genetic evaluation is essential in patients with thymic cancers, especially those with additional risk factors or a family history suggestive of LS. This approach can lead to more tailored care and potentially uncover crucial genetic information that benefits the patient and their family in cancer risk assessment and management.
CONCLUSION
This case report underscores the importance of interdisciplinary collaboration, ongoing research, and individualized treatment approaches in optimizing outcomes for patients with advanced thymomas. It contributes to our understanding of thymic malignancies and paves the way for future advancements in their management.
The insights gained emphasize the need for tailored patient care, considering specific tumor characteristics and patient preferences. Ongoing collaboration and research are crucial for improving knowledge and enhancing therapeutic approaches.
This case is a stepping stone towards more effective, personalized care for thymic malignancies. It reminds us of the complexity of cancer care and the ongoing need for evidence-based approaches to improving patient outcomes and quality of life.
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DATA AVAILABILITY STATEMENTS
The authors can not publicly share the data to protect ethical considerations and participant privacy.
ETHICS STATEMENT
While derived from anonymized proceedings of the monthly ONCOLLABORATE conference, this manuscript did not undergo formal ethics board review. However, the authors ensured the privacy of the case study participants was fully protected.
AUTHORS CONTRIBUTION
KAT, original draft, writing of the manuscript; SLB, review and editing
FUNDING
This research received no external funding.
CONFLICT OF INTEREST
The authors declare no conflicts of interest related to commercial or financial relationships.
PUBLISHER’S NOTE
This article reflects the views and findings of the authors alone and does not necessarily represent the official position of the author’s affiliated organizations, the publisher, editors, or reviewers. We encourage readers to remember that the content presented here does not constitute endorsement or approval by any of the entities above.
Similarly, any products or services mentioned within this article are for informational purposes only. The publisher recommends that readers conduct independent evaluations before making any decisions, as the publisher does not guarantee or endorse any products or services mentioned.
Kimberly Advento-Torres1 and Soledad Lim Balete2
1Section of Medical Oncology, Jose R. Reyes Memorial Medical Center, Rizal Avenue, Sta. Cruz, Manila, Philippines; 2Metropolitan Medical Center, Sta Cruz Manila, Philippines
Introduction
The transformation of conference proceedings into scholarly research articles is an essential process in academia, as it enables the dissemination of knowledge and fosters ongoing dialogue in the scientific community. This article outlines the steps necessary to convert a proceeding, specifically from ONCOLLABORATE, into a full-fledged research paper. This will involve expanding the original material, ensuring rigorous scientific methods, and adapting the content to meet the standards of peer-reviewed journals.
1. Understanding the Starting Material
1.1. Defining the Nature of the Conference Proceeding
Conference proceedings, such as those from ONCOLLABORATE, typically present initial findings, case studies, or preliminary research. These documents are often concise, focusing on key results and discussion points without delving deeply into methodology or comprehensive literature reviews. For example, Advento Kim’s proceeding, Multidisciplinary Management of Advanced Thymoma, presents a case study with discussions on its implications for future research but lacks the depth required for a scholarly article.
1.2. Identifying the Core Content
The core content of a proceeding, like the one provided, includes essential data such as patient details, diagnostic methods, treatment approaches, and the outcome of the case. This content forms the backbone of the research article. The next step involves identifying gaps in this content that need expansion for scholarly publication.
2. Expanding the Introduction
2.1. Deepening the Background
In the proceeding, the introduction provides a brief overview of thymomas, emphasizing their rarity and complexity. To transform this into a research article, it is crucial to expand this section by incorporating a comprehensive literature review. This involves researching current data on thymoma prevalence, challenges in diagnosis, and recent advancements in treatment. The introduction should also highlight the significance of the case study in contributing to existing knowledge.
2.2. Establishing a Clear Hypothesis
A scholarly article requires a hypothesis or research question. While the proceeding hints at the importance of multidisciplinary approaches, a research article should explicitly state the hypothesis or research objectives. For instance, the hypothesis could be: “Multidisciplinary management of advanced thymoma improves patient outcomes by facilitating personalized treatment strategies.”
3. Methodology Enhancement
3.1. Detailing the Research Design
The proceeding provides a basic description of the patient’s diagnostic workup and treatment. However, a research article must offer a detailed methodology section that explains the research design, including the selection criteria for case studies, data collection methods, and analytical techniques. For instance, the research design should specify why this particular case was chosen, what diagnostic criteria were used, and how data on treatment outcomes were gathered.
3.2. Ensuring Reproducibility
One of the hallmarks of a scholarly article is reproducibility. The methodology section should be detailed enough that another researcher could replicate the study. This means including information on all diagnostic tools used (e.g., specific imaging techniques, laboratory tests), the exact chemotherapy regimen, and any follow-up procedures. In the case of the ONCOLLABORATE proceeding, this would involve providing detailed descriptions of the imaging studies, histopathological tests, and the reasoning behind choosing specific treatments.
4. Expanding the Results Section
4.1. Comprehensive Data Presentation
The results section in the proceeding is often a summary of the key findings. In a research article, this section needs to be much more comprehensive. It should include all relevant data, presented in a clear and organized manner, often supported by tables and figures. For instance, the results of the patient’s treatment could be expanded to include detailed imaging results before and after treatment, laboratory findings over time, and a breakdown of the side effects experienced.
4.2. Statistical Analysis
A scholarly article requires the inclusion of statistical analysis to support the findings. The proceeding might simply state that the treatment was “well-tolerated,” but a research article should quantify this tolerance using statistical measures. For example, the incidence of side effects could be reported alongside statistical significance tests to determine whether these outcomes are likely due to the treatment regimen or could have occurred by chance.
5. Discussion and Interpretation
5.1. Integrating Literature
The discussion in the proceeding may touch on the broader implications of the case study but is typically limited. In a scholarly article, this section should be expanded to interpret the results in the context of existing literature. This involves comparing the findings with those of other studies, discussing the potential reasons for any differences, and suggesting how these results could influence future research or clinical practice. The article should critically evaluate the case’s implications for the understanding of thymic malignancies and the effectiveness of different treatment strategies.
5.2. Highlighting Contributions and Limitations
It is essential to clearly articulate the contributions of the study to the field, as well as its limitations. The proceeding might not address limitations, but a research article should. For example, in the case of the ONCOLLABORATE proceeding, limitations could include the small sample size (a single case), potential biases in treatment selection, and the lack of long-term follow-up data. Acknowledging these limitations strengthens the article by demonstrating the author’s critical engagement with the research process.
6. Conclusion and Future Directions
6.1. Summarizing Key Findings
The conclusion of the research article should succinctly summarize the key findings and their significance. Unlike the proceeding, which might conclude with a call for more research, the scholarly article should offer a clear summary of what the case study has revealed about advanced thymoma management and suggest specific areas for future research.
6.2. Proposing Future Research
Based on the findings, the article should propose future research directions. This could involve suggesting larger, multi-center studies to validate the findings, exploring new therapeutic options, or investigating the genetic underpinnings of thymomas to identify potential targets for treatment.
7. Adhering to Journal Guidelines
7.1. Selecting the Appropriate Journal
One of the critical steps in transforming a proceeding into a research article is choosing the right journal for submission. The author should consider journals that focus on oncology, rare diseases, or multidisciplinary approaches to cancer treatment. Each journal will have specific guidelines regarding manuscript structure, word count, and citation style.
7.2. Formatting the Manuscript
The manuscript must be formatted according to the selected journal’s guidelines. This includes organizing the sections in the correct order (typically Introduction, Methods, Results, Discussion, and Conclusion), adhering to word limits, and ensuring that all citations are correctly formatted. Proper formatting not only reflects professionalism but also increases the likelihood of the manuscript being accepted for publication.
8. Peer Review and Revision
8.1. Preparing for Peer Review
Once the manuscript is submitted, it will undergo peer review. This process involves experts in the field evaluating the quality, relevance, and accuracy of the research. The author should be prepared to receive feedback, which may include requests for additional data, clarifications, or methodological adjustments.
8.2. Revising the Manuscript
Revising the manuscript based on peer review feedback is a crucial step in the publication process. Authors should respond to reviewers’ comments thoroughly, addressing each point raised. This may involve conducting additional analyses, expanding the discussion, or clarifying certain aspects of the methodology. The goal is to improve the manuscript and align it with the reviewers’ and journal’s expectations.
9. Ethical Considerations
9.1. Ensuring Patient Confidentiality
When converting a proceeding into a research article, it is essential to ensure that all patient information is anonymized to protect their privacy. This is particularly important in case studies, where details can sometimes inadvertently reveal the patient’s identity. The manuscript should adhere to all ethical guidelines for human subjects research, as stipulated by the journal and relevant institutional review boards.
9.2. Disclosing Conflicts of Interest
The author must disclose any potential conflicts of interest that could influence the research. This includes financial ties to pharmaceutical companies, involvement in competing research, or any other factors that could be perceived as a conflict. Transparency in this area is vital for maintaining the integrity of the research.
10. Finalizing and Submitting the Article
10.1. Proofreading and Editing
Before submission, the manuscript should be thoroughly proofread to correct any grammatical errors, typos, or inconsistencies. This step ensures that the article is polished and professional, which is critical for making a positive impression on the journal editors and reviewers.
10.2. Submission Process
The final step is submitting the manuscript to the chosen journal. This often involves uploading the document through an online submission portal, along with any supplementary materials such as figures, tables, or additional data. Authors should follow the submission guidelines carefully to avoid any delays in the review process.
Conclusion
Transforming a conference proceeding like ONCOLLABORATE into a scholarly research article is a detailed and methodical process. It requires expanding the content to include a comprehensive literature review, detailed methodology, and robust data analysis. The article must also be formatted according to journal guidelines and prepared for peer review. By following these steps, researchers can effectively contribute to the academic community, advancing knowledge in their field and paving the way for future research.
References
eContent Pro. Transitioning a Conference Paper into a Journal Article [Internet]. 2019 [cited 2023 Sep 2]. Available from: https://www.econtentpro.com/blog/transitioning-conference-paper-into-journal-article/107
Politics Blog. Things to remember when transforming your conference paper into a journal article [Internet]. 2016 [cited 2023 Sep 2]. Available from: http://politicsblog.ac.uk/2016/03/16/things-to-remember-when-transforming-your-conference-paper-into-a-journal-article/
Chander NG. Briefing on conference proceedings [Internet]. PMC. [cited 2023 Sep 2]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8045870/
Editage. Submitting the same research to a conference and a journal [Internet]. [cited 2023 Sep 2]. Available from: https://www.editage.com/insights/what-are-the-basic-rules-for-submitting-the-same-research-to-a-conference-and-a-journal/
Taylor and Francis. How to turn a conference paper into a journal article: 5 top tips [Internet]. [cited 2023 Sep 2]. Available from: https://authorservices.taylorandfrancis.com/blog/get-published/conference-paper-into-research-paper/
ETHICS STATEMENT
While derived from anonymized proceedings of the monthly ONCOLLABORATE conference, this manuscript did not undergo formal ethics board review. However, the authors ensured the privacy of the case study participants was fully protected.
AUTHORS CONTRIBUTION
KAT, original draft, writing of the manuscript; SLB, review and editing
FUNDING
This research received no external funding.
CONFLICT OF INTEREST
The authors declare no conflicts of interest related to commercial or financial relationships.
PUBLISHER’S NOTE
This article reflects the views and findings of the authors alone and does not necessarily represent the official position of the author’s affiliated organizations, the publisher, editors, or reviewers. We encourage readers to remember that the content presented here does not constitute endorsement or approval by any of the entities above.
Similarly, any products or services mentioned within this article are for informational purposes only. The publisher recommends that readers conduct independent evaluations before making any decisions, as the publisher does not guarantee or endorse any products or services mentioned.
Melanie Rose Ho Garces-Chua,1 Soledad Lim Balete,2 and Susano B. Tanael Jr.1
1Section of Medical Oncology, Jose R. Reyes Memorial Medical Center, Sta Cruz, Manila
2Metropolitan Medical Center, Sta Cruz Manila, Philippines
Corresponding author: Melanie Rose Ho Garces-Chua; melanierosegarces@gmail.com
ABSTRACT
Objective: This study evaluated the operational effectiveness of the Jose R Reyes Memorial Medical Center (JRRMMC) Multidisciplinary Tumor Board (MDTB) and its association with clinical outcome symptom relief from treatment start.
Methods: This retrospective cohort study examined medical records of cancer patients undergoing MDTB case evaluation from June 2021 to December 2022. It examined case planning/ proceedings, case presentation and discussions, adherence to guidelines, treatment planning, and outcome monitoring. The study also evaluated the clinical outcome of symptom relief from the start of treatment.
Results: The primary motivations for case presentations were therapeutic planning (90%) and educational value (92%). In 92%, the MDTB had an organizational leader. 14% of the members used technology to share patient data. In 60% of cases, dedicated administrative staff supported the MDTB and were trained and knowledgeable.
Information collection and distribution of protocols were followed in 98% of cases to ensure uniformity and clarity. MDTB meeting procedures were followed in 98%, and 94% implemented meeting and discussion actions, demonstrating strong MDTB standards and recommendations. The meeting used a standard procedure to discuss 94% of patient cases.
The MDTB decision followed clinical diagnosis and treatment guidelines in 98% and 96%, respectively. Diagnostic tests were available in 80% of cases. There was consistent alignment between pre-presentation and post-presentation diagnoses. Recommended treatments showed variation in 42% of cases post-presentation while remaining the same in 58%. Neoadjuvant chemoradiotherapy was the most common modality for locally advanced rectal cancer, at 34% of 50 cases.
The mean time from the initial patient complaint to treatment initiation was 222.7 (sd: 149.5) days. Most patients experience symptom relief within a month, but some may take up to 74 days. The mean time from the first complaint to symptom disappearance was 383.15 (sd: 108.6) days. After reporting symptoms, most patients found relief within a year. Some patients endured 623 days.
Conclusion: The JRRMMC MDTB revealed favorable aspects of MDTB operational effectiveness. Therapeutic planning and educational value drive case presentations, highlighting the board’s focus on patient care and professional development. The consistent alignment between pre-presentation and post-presentation diagnoses in all cases and the variation in recommended treatments demonstrate the robustness of the decision-making process while acknowledging the complexity of some cases. Most patients experience symptom relief within a month, proving the treatment works. While the JRRMMC MDTB has relatively solid organizational practices, it could improve the timeline between patient complaints and treatment initiation.
Keywords: Operational effectiveness, Multidisciplinary Tumor Board, symptom relief
INTRODUCTION
Cancer is a complex and challenging disease requiring a multidisciplinary approach to deliver appropriate and effective patient care. Multidisciplinary tumor boards (MDTB) are crucial for effective cancer care.1,2,3 Despite the increasing use of MDTB in cancer care, there is a lack of evidence on the operational effectiveness of MDTB and its association with the clinical outcome symptom relief from the start of cancer treatment.
The primary objective of this research is to evaluate the operational effectiveness of the MDTB of JRRMMC and its association with surrogate patient outcomes. The study will assess MDTB workflow (decision-making, case review, treatment planning), adherence to best practices during discussions, the link between MDTB participation and patient outcomes (survival, treatment response, time to subsequent treatment), and factors affecting MDTB impact (coordinator, collaboration, member participation, communication, infrastructure)
The proposed study is significant because it will help identify MDTB’s strengths and weaknesses and provide insights into how they can be improved to optimize patient outcomes. The study will also contribute to developing evidence-based guidelines for using MDTB in cancer care.
METHODS
This research employed a retrospective cohort approach to assess the operational effectiveness of the MDTB and its association with patient outcomes. The researcher collected data from MDTB document proceedings and medical records, including clinical notes, pathology reports, radiology findings, treatment plans, and follow-up information (See Supplementary Material S1).
The study involved, firstly, the cohort of cancer patients who received care through a multidisciplinary tumor board case review from January 2022 to December 2022. Subsequently, data on the patient’s clinical outcomes were collected retrospectively from the medical records. The data included parameters such as overall survival, treatment response, tumor recurrence, time to initiation of recommended treatment, and time to physical recovery. In addition, the researcher also gathered on the patient’s exposure to the MDTB, encompassing aspects like evidence-based decision-making, timeliness, streamlined case management, adherence to MDTB to evidence- based guidelines and best practices, multidisciplinary collaboration and communications, supportive infrastructure, treatment planning, outcome monitoring.
The study subjects were the cohort of cancer patients who received care through a multidisciplinary tumor board case review from June 2021 to December 2022. Regarding inclusion criteria, the researcher first considered patients’ cases discussed at MDTB from June 2021 to December 2022. Additionally, the inclusion criteria encompassed patients with a confirmed diagnosis of tumors or malignancies, patients with various types of tumors or malignancies (e.g., breast cancer, lung cancer, colorectal cancer) to ensure a diverse sample, patients aged 18 years or older, patients who received treatment recommendations or interventions from the tumor board, and patients treated and managed within the last two years to ensure the availability of relevant data. On the other hand, the exclusion criteria included patients who received their first treatment outside JRRMMC and patients with insufficient medical records that could not provide necessary data for analysis, including follow-up data. The study used the RECIST CRITERIA to evaluate tumor response.4 The researcher took several steps to ensure the accuracy and completeness of the data collected for the retrospective cohort. The researchers utilized standardized data collection forms to ensure consistent and accurate collection of all relevant data. The researcher blinded the data collectors
to the study hypothesis to minimize potential bias during data collection. Additionally, the researchers implemented a thorough training program to ensure that data collectors comprehended the study objectives, methods, and the significance of accurate and complete data collection.
The researchers conducted regular quality checks on the collected data to verify its accuracy and completeness. These checks involved scrutinizing a sample of the data for errors or inconsistencies and promptly correcting any identified issues. To further enhance completeness, multiple data sources, such as medical records, pathology reports, and other pertinent sources, were used to capture all relevant information.
RESULTS
Structure and Processes of JRRMMC MDTB
Table 1 presents the outcomes of document review assessing the organizational structure of the MDTB. In 92%, there was a designated organizational leader for the MDTB, indicating high leadership and accountability in the MDTB process. Collaboration within the team demonstrated consistency and positivity across all cases, with 100% affirmative responses to all sub-questions, suggesting high teamwork, cooperation, and a shared vision for patient care among MDTB members.
TABLE 1 MDTB organizational setup.
Questions
Frequency (%)
Total
Yes
No
Was there a dedicated organizational leader for MDTB?
46 (92)
4 (8)
50
What was the type of collaboration within the team?
co-located
50 (100)
0
non-hierarchical
50 (100)
0
shared consultation
50 (100)
0
via referral-counter-referral
50 (100)
0
Was technology used to facilitate the sharing of patient information?
7 (14)
50
Was technology reliable and secure?
50 (100)
50
Was there a dedicated administrative staff to support MDTB?
30 (60)
20 (40)
50
Was this staff trained and knowledgeable about MDTB?
30 (60)
20 (40)
50
The results revealed a low adoption and utilization rate of technology within the MDTB process, with only 14% of cases leveraging technology to facilitate patient information sharing. This low percentage suggests potential barriers, such as lack of availability, accessibility, affordability, user acceptance, or a mismatch between the technology and the needs of MDTB members or the healthcare system itself. However, when technology was employed, it was reliable and secure in all cases, suggesting a high level of quality and trustworthiness in the technological aspects of the MDTB process.
About 60% had dedicated administrative staff supporting the MDTB, who were trained and knowledgeable in 60% of cases, indicating a moderate level of support and capacity for the MDTB process. Nevertheless, this implies that there were instances where the MDTB process lacked sufficient administrative support or expertise, posing potential sources of inefficiency and error. Table 2 shows the outcomes of document review on preparation before MDTB meetings.
TABLE 2 Preparation prior to MDTB.
Questions
Frequency (%)
Total
Yes
No
Were the steps of MDTB planning enacted?
50 (100)
0 (0)
50
What was the reason for the case presentation?
Seeking additional diagnostic plan
21 (42)
29 (58)
50
Seeking therapeutic plan
45 (90)
5 (10)
50
Finalizing Radiology Results
10 (20)
40 (80)
50
Finalizing Pathology Results
8 (16)
42 (84)
50
Educational Value
46 (92)
4 (8)
50
Was the patient information up-to-date?
1 (2)
49 (98)
50
Outdated patient information was found in 98% of cases, highlighting potential risks to the quality of MDTB decision-making. This finding underscores the critical need for improvements in data collection, management systems, and communication among MDTB members and primary care providers.
Table 3 shows that recommended treatments varied in 42% of cases from pre-presentation while staying the same in 58%.
TABLE 3 Case presentation proceedings.
Questions
Frequency (%)
Total
Yes
No
Were the diagnostic tests available for the patient discussed in MDTB?
40 (80%)
10 (20%)
50
Were there any delays in obtaining diagnostic results?
34 (66%)
16 (32%)
50
Were the diagnostic results complete and accurate?
41 (82%)
9 (18%)
50
Were complete and accurate diagnostic reports available?
43 (86%)
7 (14%)
50
Was the diagnosis of the patient post-presentation the same as pre-presentation?
50 (100%)
0
50
Was the recommended diagnostic test different than pre- presentation?
10 (20%)
40 (80%)
50
Was there a change in the treatment plan?
20 (40%)
30 (60%)
50
Was the recommended treatment different than pre- presentation?
21 (42%)
29 (58%)
50
About 80% of cases had diagnostic tests available during MDTB meetings, demonstrating good planning and collaboration between primary care physicians and MDTB members—however, 68% experienced delays in receiving diagnostic results.
For diagnostic accuracy and completeness, 82% of cases had correct and complete results, and 86% had access to accurate and complete diagnostic reports.
In every case, the post-presentation diagnosis agreed with the pre-presentation diagnosis, suggesting that primary care physicians and MDTB members had a high degree of consensus regarding the patient’s status and prognosis. Additionally, 20% observed a change in the recommended diagnostic test, and 42% saw a change in the recommended treatment, indicating that the MDTB conference had a moderate impact on patient management. The MDTB meeting provided a valuable forum for members to exchange viewpoints and knowledge and to update plans considering the most recent research and best practices.
Table 4 shows a high adherence rate of 98% to the defined information collection and distribution protocols. By implementing the protocol, the MDTB process ensures uniformity and clarity. They act as a standardized structure for submitting case protocols, encompassing patient history, physical examination findings, ancillary test results, working impressions, encountered difficulties, and a critical data summary compiled for each patient. They act as a standardized structure for submitting case protocols, encompassing patient history, physical examination findings, ancillary test results, working impressions, encountered difficulties, and a critical data summary compiled for each patient.
TABLE 4 Case discussion proceedings.
Questions
Frequency (%)
Total
Yes
No
Were protocols standardized for collecting and sharing information?
49 (98)
1 (2)
50
Were the members of the MDTB aware of these protocols?
46 (92)
4 (8)
50
Were these protocols followed in the MDTB meeting?
49 (98)
1 (2)
50
Were the steps of the MDTB meeting and discussion enacted?
47 (94)
3 (6)
50
Was all the information presented by a single presenter?
50 (100)
0
50
Were all relevant members present for each presentation?
43 (86)
7 (14)
50
Did clinicians manually curate the patient information?
49 (98)
1(2)
50
Was the patient information integrated during the presentation?
47 (94)
3 (6)
50
Were all essential information included in the patient information?
44 (88)
6 (12)
50
Was there a standardized procedure to discuss patient cases?
47 (94)
3 (6)
50
Was there a standard presentation format used for this patient?
38 (76)
12 (24)
50
Was the presentation format consistent with the previous meetings?
35 (70)
15 (30)
50
Was the presentation format straightforward to understand?
50 (100)
0
50
Was the MTB discussion captured and documented?
50 (100)
0
50
Was a standard process used to document MDTB decisions?
50 (100
0
50
Were members of the MDTB aware of the standardized process?
40 (80)
10 (20)
50
Following standard operating procedures for case discussions, residents and fellows-in-training submitted cases electronically via email. Prior to the MDTB session, any necessary clarifications were actively sought through email exchanges or personal communication on Viber. During the actual MDTB meeting, presenters employed a standardized format by delivering their cases using PowerPoint presentations.
About 98% of the cases followed these procedures in MDTB meetings, and 94% of the cases implemented the actions from the meeting and discussion, demonstrating strong adherence to MDTB standards and recommendations. Consistency and clarity were ensured throughout presentations by having a single presenter provide all the information for each case. All pertinent members were present in 86% of the cases, which suggests that the MDTB meeting was well- attended and engaged.
In 98% of cases, patient information was manually curated or prepared. In 94%, carefully chosen material was included in the presentation, demonstrating high effort and quality in the data synthesis and preparation process. In 88%, the patient information contained all pertinent information, demonstrating completeness and relevance for the MDTB decision-making process. These results indicate a standardized and well-organized method for case discussions during MDTB meetings.
For 94% of cases, a standardized procedure was in place to discuss patient cases, indicating a high degree of uniformity and structure in the MDTB discussion process. In 76%, a standardized presentation format was utilized, with consistency observed in 70% compared to previous meetings, reflecting moderate variation and flexibility in presentation style. The clarity and comprehensibility of the presentation format were high across all cases, indicating an effective and efficient information transmission and comprehension process.
The process of capturing MDTB discussions followed a set timeline: cases were submitted to medical oncology via email with an off every Friday at 11:59 p.m., the Zoom link and cases received were shared with the MDTB community Viber on Saturday, and the actual discussion occurred on Thursday at 2 p.m. The MDTB implemented a standardized process to capture and document all discussions for every case. This approach demonstrates the team’s commitment to high accountability and transparency in the MDTB documentation and reporting process.
The standard process for documenting MDTB discussions involved assigning a main moderator for the week and co-moderators from the presenting service providing the case. During the MDTB session, case presentations and dilemma discussions were followed by clarifications and expert opinions from different departments, concluding with a consensus on the planned management. For 80% of cases, members of the MDTB were aware of the standardized process, indicating a good level of familiarity and knowledge regarding MDTB documentation and reporting procedures.
Table 5 shows the results of the document evaluation evaluating the guidelines for implementability and feasibility that were adhered to in MDTB meetings.
TABLE 5 Guideline feasibility.
Questions
Frequency (%)
Total
Yes
No
Did the MDTB decision follow the clinical guidelines for diagnosis?
49 (98)
1 (2)
50
Were the recommended diagnostic tests feasible to implement?
39 (78)
11 (22)
50
Did the MDTB decision follow the clinical guidelines for treatment?
48 (96)
2 (4)
50
Was the recommended treatment feasible and practical to implement?
43 (86)
7 (14)
50
In 98% of cases, the MDTB decision adhered to clinical recommendations for diagnosis, and in 96%, it followed guidelines for treatment. This high conformance shows that the MDTB decision- making process adheres to best practices and evidence-based standards.
Regarding practicability and viability, the suggested diagnostic procedures could be carried out in 78% of cases, and the recommended course of therapy could be carried out in 86% of cases. These numbers point to a high degree of practicality and applicability of MDTB recommendations in patient care and clinical settings.
There were situations where the suggested diagnostic procedures or therapies could not be carried out or were impossible, suggesting that obstacles may exist to the MDTB implementation and assessment process. These obstacles could result from accessibility, acceptability, price, availability, or suitability of a treatment or diagnostic choice for a patient or the healthcare system.
Association of JRRMMC MDTB with Clinical Outcomes
Eligible 50 patient cases were discussed in the MDTB meetings, and their characteristics are shown in Table 6.
TABLE 6 Sociodemographic profile (n=50).
Frequency (%)
Gender
Male
23 (46%)
Female
27 (54%)
Age in Years
<20
1 (2%)
20-29
6 (12%)
30-39
5 (10%)
40-49
3 (6%)
50-59
16 (32%)
60-69
16 (32%)
>69
3 (6%)
Civil Status
Single
10 (20%)
Married
36 (72%)
Widow
4 (8%)
Education
Elementary
10 (20%)
High School
26 (52%)
College
13 (25%)
Postgraduate
1 (25)
Occupation
Unemployed
27 (54%)
Employed
23 (46%)
Island
Luzon
45 (90%)
Visayas
5 (10%)
Mindanao
0
Co-morbidity
T2 DM
2
Hypertension
8
T2 DM + Hypertension
5
Pulmonary TB
1
None
34
Table 7 illustrates the distribution of cancer diagnoses based on their intent and treatment modalities. The predominant intent and modality observed were neoadjuvant chemoradiotherapy (ChemoRT; 34%) for locally advanced rectal cancer requiring preoperative intervention to enhance surgical outcomes. The study investigated the application of Neoadjuvant ChemoRT across various cancer stages (II, III, and IV) and subtypes (well-differentiated, poorly differentiated, mucinous).
TABLE 7 Treatment intent and modalities.
Intent and Modalities
Case Diagnosis
Count (%)
Adjuvant ChemoRT
Temporal Glioblastoma Multiforme (GBM)
Right Cerebellar Tumor due to Obstructing Hydrocephalus, s/p Craniotomy
Adjuvant Chemotherapy
Malignant Colon Obstruction due to Sigmoid Colon Cancer Stage IIc
Colon Adenocarcinoma
Ileal GIST s/p Segmental Ileal Resection
Breast Invasive Ductal Carcinoma Stage IIIc
Adjuvant Radiotherapy (RT)
Liposarcoma, Left thigh
Subtotal
7 (14)
Curative and Local Control
Monophasic Synovial Sarcoma Stage Ia
Curative approach; further Diagnostic Plan
Breast Invasive Ductal Carcinoma, Stage IIa
Curative Chemotherapy
Malignant Colon Obstruction due to Splenic Flexure Cancer Stage IIa
Curative Concurrent ChemoRT
Anal Squamous Cell Cancer Stage IIIc
Curative goal, Chemotherapy
Alveolar Rhabdomyosarcoma, L Breast Stage IIIb
Curative RT
Phylloides Tumor of the Breast
Subtotal
6 (12)
Neoadjuvant ChemoRT
Poorly Differentiated Rectal Adenocarcinoma Stage IIIc
Rectal Adenocarcinoma Stage IVa
Rectal Adenocarcinoma Stage IIIc
Rectal Adenocarcinoma Stage IIa
Rectal Adenocarcinoma Stage IIIC
Sigmoid Adenocarcinoma Stage IIIb
Rectal Adenocarcinoma St Stage IIIb
Mucinous Rectal Adenocarcinoma Stage IIIb
Rectal Adenocarcinoma, well differentiated, Stage IIa
Rectosigmoid Adenocarcinoma Stage IIIb
Rectosigmoid Adenocarcinoma Stage IIIa
Rectal Adenocarcinoma Stage IIIa
Rectal Adenocarcinoma Stage IIIC
Sigmoid Adenocarcinoma Stage IIIb
Rectal Adenocarcinoma Stage IIa
Rectal Adenocarcinoma Stage IIIa
Poorly Differentiated Rectal Adenocarcinoma, Stage IIIc
Subtotal
17 (34)
Palliative ChemoRT
Sigmoid Adenocarcinoma Stage IV
Sigmoid Adenocarcinoma Stage IV with lung metastasis
Right Tempo parietal GBM, WHO Grade IV
Palliative Chemotherapy
Obstruction due to Colon Cancer Stage IV with liver and lung metastasis
Complete Intestinal Obstruction due to Rectal
Adenocarcinoma Stage IV
Partial Intestinal Obstruction Stage IV with lung
and liver metastasis
Complete Intestinal Obstruction due to Rectal
Adenocarcinoma Stage IV
Sigmoid Rectal Adenocarcinoma with Perianal Extension
Rectal Adenocarcinoma Stage IV with lung and
liver metastasis
Obstruction due to Colon Cancer Stage IV with
liver and lung metastasis
Complete Intestinal Obstruction due to Rectal
Adenocarcinoma Stage IV
Palliative Surgery
Small Bowel Obstruction due to Ileocecal Mass, Stage IV
Subtotal
12 (24)
Concurrent ChemoRT
Rectal Adenocarcinoma Stage IIIb
Multiple Intracranial Mass, probably CNS Lymphoma
Squamous Cell Cancer, well-differentiated Stage
IV
Establish Diagnosis first and re-biopsy
Rectal Adenocarcinoma, well differentiated, Stage IIIa
Monitoring and Surveillance
Rectal Adenocarcinoma Stage I
Palliative Care
Colon Obstruction due to Sigmoid Colon Cancer Stage IV with lung/liver metastasis
Colon Obstruction due to Sigmoid Colon Ca
Stage IV with lung metastasis
Staged Resection
Obstruction due to Descending Colon Ca Stage IV with liver metastasis
Subtotal
8 (16)
TOTAL
50 (100)
Rectal adenocarcinoma was the most common case (48% of 50 cases).
For the clinical outcome impact of the JRRMMC MBTD, Table 8 shows the duration from the initial recorded patient complaint to the initiation of treatment after MBTD, with a mean of 222.7 (sd: 149.5) days, a median of 172 days, and a mode of 266 days (range 62-682 days) indicating considerable variability. This variance suggests notable delays for certain patients in commencing their treatment.
TABLE 8 Timelines.
Duration (days)
Mean
Median
Mode
SD
Range
Min
Max
Q1
Q3
First Recorded Complaint to Treatment
Initiation
222.7
172.0
266.0
149.5
585.0
62.0
682.0
109.0
266.0
Treatment Initiation to
31.5
27.0
21.0
12.2
73.0
1.0
74.0
21.0
35.0
Symptom Disappearance
First Recorded Complaint to Symptom
Disappearance
383.2
332.5
269.0
108.6
436.0
187.0
623.0
269.0
457.0
The mean duration from treatment initiation to symptom disappearance, or recovery, was moderate at 31.54 (sd: 12.21) days: median 27 days; mode 21 days (range 1-74 days). The mean duration from the first recorded complaint to symptom disappearance was moderate at 383.15 (sd: 108.6) days; median 332.5 days; mode 269 days (range 187-623 days).
DISCUSSION
MDTB Structure and Processes
Document analysis shows commendable MDTB planning and case selection. Tumour board cases match previous treatment, diagnostic, and educational usefulness research.5 However, obsolete patient information threatens MDTB decision-making quality and safety. Addressing this issue and improving decision-making requires strengthening data collecting, administration, and communication systems.
Document assessment identifies strengths and weaknesses in MDTB decision-making. The team must prioritize reducing diagnostic results delays and adapting to therapy adjustments while maintaining diagnostic consistency and accuracy. A delay in the evaluation of test results could delay diagnosis and treatment, resulting in poor clinical outcomes and extended hospital stays.6 MDTB is a crucial forum for collaborative decision-making and patient management innovation. The document assessment shows that MDTB case discussions are well-organized, consistent, and transparent. The results demonstrate MDTB’s dedication to decision-making uniformity, structure, and improvement. MDTB recommendations and clinical adherence are practical. Multidisciplinary tumor boards increase decision-making, clinical adherence, and treatment outcomes.3 However, the feasibility of implementation highlights the need to continuously evaluate and update guidelines to address real-world restrictions and improve patient outcomes. From the MDTB’s organizational perspective, there is strong leadership, excellent collaboration, and precise knowledge of keywords. Despite these characteristics, technology adoption could be faster due to low usage of administrative support and competence variances. Digital tumor board systems help standardize operations, reduce staff workload, and encourage interdisciplinary treatment decision-making, improving patient care.7 By addressing technology use challenges, the team members can improve MDTB efficiency and effectiveness, ultimately guaranteeing excellent patient care and decision-making.
Treatment Time
Interpreting the period between the initial complaint and treatment commencement gives several insights: The extended mean and median durations emphasize the need to improve healthcare system efficiency to treat patients quickly. The vast range of durations implies that the nature and severity of the illness and the patient’s access to healthcare contribute to treatment delays. Limited health literacy, distance to treatment locations, and access to care inequalities can delay treatment.8 Standard deviations above the mean indicate a skewed distribution with longer durations more
common. The significant proportion of patients with 266 days or less (75%) implies that most patients receive therapy quickly.
According to the data, most patients experience symptom relief within a month of therapy initiation, although others take longer. The following interpretations are possible: The treatment’s mean and median durations show significant symptom relief within an acceptable timeframe. The moderate range of recovery times suggests that both a patient’s health and the severity of their illness influence the duration of their recovery.
The lower standard deviation than the mean indicates a well-balanced distribution of recovery lengths across the patient population. The 75% of patients who report symptom improvement in 35 days or fewer indicate that most individuals experience symptom alleviation quickly. Different cancer kinds have different treatment initiation times, determining the duration between therapy and symptom decrease. The time to symptom reduction once treatment begins depends on the therapy modalities and the patient’s response. As a result, the time it takes from treatment to symptom relief can vary greatly.9,10
From the first complaint to symptom absence, most patients see symptom improvement after a month of medication, but others take longer. The following interpretations are possible: The treatment’s mean and median durations show significant symptom relief within an acceptable timeframe. The moderate range of durations suggests that the patient’s health and the illness’s severity affect recovery time. The lower standard deviation than the mean shows a well-balanced recovery length distribution. The 75% of patients who report symptom improvement in 35 days or fewer indicate that most individuals experience symptom alleviation quickly.
Limitations
This investigation has several limitations. Firstly, it relies solely on document review. This approach offers a snapshot of information at a specific point but inherently limits the depth of information available. Crucial real-time interactions that provide insights into the MDTB’s efficiency and operational effectiveness might be missing. Secondly, the data used consists of condensed information and summary figures. While these provide a general overview, they may not always capture the full context of a situation. Additionally, prioritizing specific types of cases or documents during selection can introduce bias. Existing documents might lack essential nuances, and overlooking selection bias is a potential pitfall. Thirdly, document reviews offer a static view, potentially missing changes or improvements in MDTB efficiency that have occurred over time. This can lead to a loss of key insights into the evolution of the MDTB process.
Another limitation is the potential for subjective interpretation. Different reviewers may interpret the material differently, introducing bias into the analysis and impacting the study’s reliability and validity. Additionally, documents may not contain all pertinent information regarding a case or the MDTB process. Incomplete information can hinder researchers’ ability to examine the elements influencing the MDTB’s operational effectiveness adequately. The results of a document review may also be specific to the institution or location where the MDTB operates. Generalizing the findings to different contexts or healthcare systems might be difficult, limiting the study’s external validity. Furthermore, document evaluations often focus on quantitative data, potentially neglecting valuable qualitative insights. Without in-depth interviews or other qualitative data- gathering methodologies, the viewpoints and experiences of key stakeholders participating in the MDTB may be overlooked.
Moreover, the MDTB’s operational effectiveness may change over time since healthcare practices are dynamic. Document reviews may not reflect real-time alterations or adaptations to the MDTB
process in response to challenges or criticism. Similarly, if the document evaluation focuses on MDTB technology utilization, it may not fully reflect the user experience or the reasons for technology adoption or non-adoption. Understanding the human factors associated with technology use is crucial for a thorough examination. Finally, document evaluations may lack the context to grasp the reasons for confident MDT choices or actions properly. Drawing reliable conclusions regarding the factors driving efficiency and operational effectiveness can be difficult without contextual information.
Study design and outcome interpretation should consider these limitations carefully to mitigate them. Combining document reviews with other research methods, such as interviews or observations, and ensuring a large, representative sample can strengthen the study’s findings.
Implications
Understanding the operational effectiveness of Multidisciplinary Tumor Boards (MDTBs) is critical for optimizing patient care. Efficient MDTBs can lead to faster, more effective treatments through improved decision-making processes within the board.11 This study goes beyond just identifying strengths and weaknesses; it illuminates the potential for significant improvements across various aspects of cancer care.
Empowering Healthcare Organizations and Policymakers
This research empowers healthcare organizations to implement quality improvement programs, optimize procedures, and foster collaboration across specialties.12 By identifying factors influencing MDTB efficiency, the study can inform the development of best practices in multidisciplinary cancer care. Sharing these best practices across healthcare institutions can lead to an overall improvement in the quality of cancer treatment.13
Furthermore, the findings can inform resource allocation for healthcare managers and policymakers. Understanding the resource needs and challenges of running an efficient MDTB is crucial for ensuring that the right people, technology, and infrastructure are available to support effective multidisciplinary decision-making.14 This knowledge can guide resource allocation decisions and ensure optimal support for efficient MDTB operations.
Establishing a Foundation for Continuous Improvement
The study also establishes a baseline for ongoing evaluations of MDTB operational effectiveness. Continuous monitoring and improvement are essential in healthcare settings, and this research lays the groundwork for implementing changes and analyzing their impact over time.15 The data can also inform the development of educational programs and training initiatives for healthcare professionals. Understanding MDTB dynamics can improve interdisciplinary communication and collaboration, benefiting patient outcomes.16
Opening Doors for Future Research
Beyond establishing a baseline for MDTB operational effectiveness, this study opens doors for future research endeavors. Here are some promising areas for further exploration:
Longitudinal Studies: Analyzing the long-term impact of efficiency-based modifications on patient outcomes, recurrence rates, and survival rates can assess how advancements in MDTB approaches impact patients over time.17
Qualitative Research: In-depth interviews or focus groups can delve into the human element, providing valuable insights into the experiences and perspectives of key stakeholders (healthcare professionals, patients, administrative personnel) and how human factors influence MDTB effectiveness.16
Technology Exploration: Studies can explore user experience, identify barriers to technological adoption, and understand how human factors influence the effectiveness of technology within MDTBs.18
Comparative Studies: Evaluating MDTB procedures, protocols, and outcomes across institutions can reveal institutional-level factors contributing to efficiency disparities.19
Educational Program Effectiveness: Assessing the success of educational programs in enhancing team communication and decision-making can inform the development of tailored interventions.20
Patient-Centered Research: Understanding patients’ preferences, needs, and experiences can inform strategies to incorporate their perspectives into decision-making, leading to more patient- centered treatment approaches.20
Economic and Resource Implications: Calculating resource needs for maintaining optimal efficiency and measuring the cost-effectiveness of improvement initiatives can provide valuable insights for resource allocation.15
Cross-Disciplinary Collaboration: Examining the applicability of multidisciplinary approaches to decision-making in other medical fields can broaden our understanding of effective collaboration models across healthcare.21
Patient-Reported Outcomes: Integrating patient-reported outcomes into the evaluation process is crucial for understanding how they correlate with clinical assessments and providing a complete picture of treatment success and patient satisfaction within the multidisciplinary care system.22 This research on MDTB operational effectiveness lays a strong foundation for future advancements. By pursuing these diverse research avenues we can leverage the insights gained from this study to improve MDTB effectiveness continuously. Ultimately, this will lead to better patient care and outcomes.
CONCLUSION
The study on the operational effectiveness of MDTB document review provides essential insights into the mechanisms driving collaborative decision-making in cancer care. The findings highlight the MDTB strengths and possible areas for improvement, laying the groundwork for improving patient outcomes and overall healthcare quality.
The study emphasizes the significance of ongoing research and quality improvement programs in addressing the complexity of transdisciplinary decision-making. While the MDTB is an essential platform for collaborative decision-making, some complexities and limitations necessitate ongoing attention and adaptation.
Furthermore, the study underlines the importance of thoroughly understanding the factors that influence treatment delays and recovery duration. These factors are crucial for customizing interventions that maximize MDTB efficiency, guaranteeing timely and effective patient care.
Future research should include longitudinal investigations, qualitative explorations of stakeholder experiences, and comparative assessments across healthcare facilities. An emphasis on technology adoption, patient-centered research, and the economic consequences of MDTB efficiency improvements will also help to a more comprehensive knowledge of multidisciplinary cancer treatment.
In conclusion, this study is a foundation for future research and improvement efforts in the healthcare system. The goal is to improve MDTB processes, foster collaboration, and improve patient-centered, efficient, and effective cancer treatment delivery.
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DATA AVAILABILITY STATEMENTS
Not publicly available.
ETHICS STATEMENT
The Ethics Review Board/Committee of Jose R. Reyes Memorial Medical Center approved the study.
AUTHORS CONTRIBUTION
MRHGC, writing final proposal draft, data curation, writing manuscript
SLB, final conceptualization, approved proposal submission, supervision, review of manuscript SBTJ, initial conceptualization, writing initial proposal draft, methodology, writing manuscript, editing
FUNDING
This research received no external funding.
CONFLICT OF INTEREST
The authors declare no conflicts of interest related to commercial or financial relationships.
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