documenting-tumor-board-presentations

# Documenting Tumor Board Presentations

Structures multidisciplinary tumor board case presentations with radiology, pathology, and treatment synthesis.

## Why This Skill Exists

Multidisciplinary tumor boards (MTBs) are the standard of care for cancer treatment decision-making, required by CoC accreditation (Standard 5.1) for commission-accredited cancer programs. Evidence consistently shows that MTB review changes management in 20–50% of cases. CoC requires prospective case presentation for a minimum percentage of analytic cases, with documented attendance by representatives from surgery, medical oncology, radiation oncology, pathology, and diagnostic radiology.

Accurate tumor board documentation serves as the medical-legal record of consensus recommendations, supports prior authorization for treatment plans, and provides evidence of multidisciplinary care coordination for quality reporting. Poorly documented tumor boards fail CoC surveys, create liability gaps when treatment deviates from consensus, and lose institutional knowledge that could inform future cases.

---

## Checkpoint A: Pre-Draft Intake (Mandatory)

1. What is the patient's cancer diagnosis, stage, and histology? (Default: [VERIFY])
2. What is the specific clinical question being brought to the tumor board? (Default: treatment recommendation for newly diagnosed cancer)
3. Which specialties will be represented at this tumor board? (Default: medical oncology, surgical oncology, radiation oncology, pathology, radiology)
4. Is pathology review being requested (slides for second opinion or re-review)? (Default: yes)
5. Is radiology image review being presented (not just report)? (Default: yes)
6. Are there genomic/molecular results to discuss? (Default: if available)
7. What is the timeline for treatment decision? (Default: within 2 weeks of presentation)

### Documents to Request

- Complete pathology report with synoptic staging
- Radiology imaging studies (not just reports) loaded in PACS for live review
- Molecular/genomic profiling results (FoundationOne, Tempus, Guardant, etc.)
- Complete staging workup summary
- Patient history and comorbidity summary
- Prior treatment history (if previously treated)
- Relevant clinical trial availability for the disease and stage
- Pertinent social history (performance status, patient goals of care)

---

## Step 1: Structure the Case Presentation Summary

Use the standardized tumor board presentation format:

**A. Patient Demographics and History**
- Age, sex, relevant medical history, performance status (ECOG)
- Smoking history (pack-years), alcohol use, occupational exposures if relevant
- Family cancer history (particularly for hereditary syndromes)
- Relevant surgical history

**B. Presenting Complaint and Diagnostic Workup**
- Presenting symptoms and timeline
- Diagnostic studies performed with key findings
- Biopsy site, date, and results

**C. Pathology Summary**
- Histologic type and grade (WHO classification)
- Receptor/biomarker status (ER/PR/HER2, PD-L1, ALK, EGFR, RAS, BRAF, MSI/MMR, etc.)
- Synoptic pathology data elements: margins, lymphovascular invasion, perineural invasion, lymph node counts

**D. Radiology Summary**
- Imaging modalities reviewed (CT, MRI, PET/CT, bone scan)
- Primary tumor size and extent
- Nodal disease distribution and size
- Distant metastatic sites if present
- Comparison with prior imaging if available

**E. Staging**
- AJCC 8th edition TNM (clinical and/or pathologic)
- Stage group (anatomic and prognostic when applicable)

---

## Step 2: Frame the Clinical Question and Decision Points

Every tumor board case must have an explicitly stated clinical question. Examples:

- "Is this patient a candidate for surgical resection, or should neoadjuvant therapy be recommended?"
- "Given progression on first-line therapy, what is the recommended second-line regimen?"
- "Does the molecular profile support a targeted therapy approach?"
- "Is this patient eligible for any open clinical trials?"
- "Should radiation be added to the adjuvant plan given positive margins?"

List each decision point separately. For each, document what information is needed from each specialty to inform the recommendation.

---

## Step 3: Document Specialty-Specific Input

Record each specialist's contribution:

| Specialty | Expected Input |
|-----------|---------------|
| Pathology | Histologic confirmation, grade, biomarkers, additional staining if needed |
| Radiology | Image review findings, staging assessment, response evaluation |
| Surgical Oncology | Resectability assessment, operative approach, margin considerations |
| Medical Oncology | Systemic therapy recommendations, clinical trial options, molecular targets |
| Radiation Oncology | RT indication, field design, dose considerations, sequencing with systemic therapy |
| Genetics (if present) | Germline testing recommendations, hereditary syndrome assessment |
| Palliative Care (if present) | Symptom management needs, goals of care considerations |

Document verbatim quotes for key recommendations and any areas of disagreement between specialties.

---

## Step 4: Record Consensus Recommendation and Dissent

The consensus recommendation must include:

1. **Recommended treatment plan** with sequencing (e.g., "neoadjuvant FOLFOX × 4 cycles, followed by restaging imaging, then surgical resection if resectable")
2. **Evidence basis** — cite NCCN guideline node or pivotal trial supporting the recommendation
3. **Alternative options discussed** and reasons they were not preferred
4. **Areas of dissent** — if any specialist disagreed, document the dissenting opinion and rationale
5. **Contingency plans** — "If patient declines surgery, recommend..." or "If genomic testing reveals..., consider..."
6. **Required additional workup** before initiating recommended treatment
7. **Clinical trial referral** — document trials discussed and screening plan if applicable
8. **Follow-up** — when the case should return to tumor board for re-review

---

## Checkpoint B: Post-Draft Alignment (Mandatory)

1. Is the clinical question clearly stated at the beginning of the documentation?
2. Are all required specialties (surgery, medical oncology, radiation oncology, pathology, radiology) represented in the discussion?
3. Is the consensus recommendation documented with evidence basis and dissenting opinions?
4. Does the documentation meet CoC Standard 5.1 requirements for prospective tumor board review?
5. Is the treatment recommendation actionable — specific regimen, sequence, and timeline?

---

## Quality Audit

- [ ] Patient demographics and relevant history included
- [ ] Pathology summary includes histology, grade, and biomarker status
- [ ] Radiology imaging reviewed (not just reports referenced)
- [ ] AJCC 8th edition staging documented
- [ ] Clinical question explicitly stated
- [ ] Input from minimum 5 specialties (surgery, medical oncology, radiation oncology, pathology, radiology) documented
- [ ] Consensus treatment recommendation with sequencing recorded
- [ ] NCCN guideline or evidence basis cited for recommendation
- [ ] Dissenting opinions documented when present
- [ ] Alternative options discussed and documented
- [ ] Clinical trial eligibility assessed and documented
- [ ] Follow-up plan specified (return to tumor board, restaging timeline)
- [ ] Attending physicians identified by name and specialty
- [ ] Documentation completed within 7 days of tumor board meeting

---

## Guidelines

- Every tumor board presentation must have a stated clinical question — unfocused "case reviews" are insufficient for CoC compliance
- Document who attended the tumor board by name and specialty — CoC requires attendance records
- Pathology slides should be reviewed live at tumor board, not just summarized from the report
- Radiology images should be displayed and reviewed, not just reports read aloud
- Always document the molecular/genomic discussion, even if results are pending — note what testing has been ordered
- Record disagreements as professionally worded dissent, not as personal conflicts
- Tumor board recommendations should be entered into the patient's medical record within 7 days
- Track cases that return for re-review to ensure continuity of recommendations