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

Fieke Hoeijmakers; David J. Heineman; Johannes M. Daniels; Naomi Beck; Rob A.E.M. Tollenaar; Michel W.J.M. Wouters; Perla J. Marang-van de Mheen; Wilhelmina H. Schreurs; Nicole P. Barlo; Bart P.C. Hoppe; Wouter Jacobs; Robin Cornelissen; Joost D.J. Janssen; Sietske A. Smulders; Niels J.M. Claessens; Susan C. van ‘t Westeinde; Steven R. Rutgers; Franz M.N.H. Schramel

doi:10.1016/j.chest.2020.07.054

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

Fieke Hoeijmakers^*, David J. Heineman, Johannes M. Daniels, Naomi Beck, Rob A.E.M. Tollenaar, Michel W.J.M. Wouters, Perla J. Marang-van de Mheen, Wilhelmina H. Schreurs, Nicole P. Barlo, Bart P.C. Hoppe, Wouter Jacobs, Robin Cornelissen, Joost D.J. Janssen, Sietske A. Smulders, Niels J.M. Claessens, Susan C. van ‘t Westeinde, Steven R. Rutgers, Franz M.N.H. Schramel

^*Corresponding author for this work

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Abstract

Background: 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. Research Question: What is the level of agreement on clinical staging and treatment recommendations among MDTs in stage IIIA NSCLC patients? Study Design and Methods: 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. Results: 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. Interpretation: 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.

Original language	English
Pages (from-to)	2675-2687
Number of pages	13
Journal	Chest
Volume	158
Issue number	6
DOIs	https://doi.org/10.1016/j.chest.2020.07.054
Publication status	Published - Dec 2020

Bibliographical note

Funding Information:
FUNDING/SUPPORT: This study was funded by the Dutch Cancer Society [Grant HZ 2015-7782].

Funding Information:
Author contributions: F. H. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis, including and especially any adverse effects. F. H. D. J. H. J. M. D. N. B. R. A. E. M. T. M. W. J. M. W. P. J. M. and W. H. S. contributed substantially to the study design, data analysis and interpretation, and writing of the manuscript. Financial/nonfinancial disclosures: None declared. ?MDT Study Group Collaborators: Nicole P. Barlo, Bart P. C. Hoppe, Wouter Jacobs, Robin Cornelissen, Joost D. J. Janssen, Sietske A. Smulders, Niels J. M. Claessens, Susan C. van ?t Westeinde, Steven R. Rutgers, and Franz M. N. H. Schramel. Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript. Other contributions: The authors thank the Dutch Cancer Society, all participants in the lung oncology MDTs of the hospitals participating in this study, and also all surgeons, registrars, physician assistants, and administrative nurses who register patients in the Dutch Lung Cancer Audit for Surgery. Participating hospitals: Treant Care Group, Scheper Hospital, Emmen; M?xima Medical Center, Veldhoven; Rijnstate Hospital, Arnhem; Martini Hospital, Groningen; Jeroen Bosch Hospital, Den Bosch; Erasmus University Medical Center, Rotterdam; Maasstad Hospital, Rotterdam; St. Antonius Hospital, Nieuwegein; VU University Medical Center, Amsterdam UMC, Amsterdam; Northwest Clinics, Alkmaar; and Leiden University Medical Center, Leiden. Additional information: The e-Appendix can be found in the Supplemental Materials section of the online article. FUNDING/SUPPORT: This study was funded by the Dutch Cancer Society [Grant HZ 2015-7782].

Publisher Copyright:
© 2020 The Authors

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Hoeijmakers, F., Heineman, D. J., Daniels, J. M., Beck, N., Tollenaar, R. A. E. M., Wouters, M. W. J. M., Marang-van de Mheen, P. J., Schreurs, W. H., Barlo, N. P., Hoppe, B. P. C., Jacobs, W., Cornelissen, R., Janssen, J. D. J., Smulders, S. A., Claessens, N. J. M., van ‘t Westeinde, S. C., Rutgers, S. R., & Schramel, F. M. N. H. (2020). Variation Between Multidisciplinary Tumor Boards in Clinical Staging and Treatment Recommendations for Patients With Locally Advanced Non-small Cell Lung Cancer. Chest, 158(6), 2675-2687. https://doi.org/10.1016/j.chest.2020.07.054

@article{7bef8a390f7d478eb1ad43fbad9514e8,

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

abstract = "Background: 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. Research Question: What is the level of agreement on clinical staging and treatment recommendations among MDTs in stage IIIA NSCLC patients? Study Design and Methods: 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. Results: 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. Interpretation: 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.",

author = "Fieke Hoeijmakers and Heineman, {David J.} and Daniels, {Johannes M.} and Naomi Beck and Tollenaar, {Rob A.E.M.} and Wouters, {Michel W.J.M.} and {Marang-van de Mheen}, {Perla J.} and Schreurs, {Wilhelmina H.} and Barlo, {Nicole P.} and Hoppe, {Bart P.C.} and Wouter Jacobs and Robin Cornelissen and Janssen, {Joost D.J.} and Smulders, {Sietske A.} and Claessens, {Niels J.M.} and {van {\textquoteleft}t Westeinde}, {Susan C.} and Rutgers, {Steven R.} and Schramel, {Franz M.N.H.}",

note = "Funding Information: FUNDING/SUPPORT: This study was funded by the Dutch Cancer Society [Grant HZ 2015-7782]. Funding Information: Author contributions: F. H. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis, including and especially any adverse effects. F. H. D. J. H. J. M. D. N. B. R. A. E. M. T. M. W. J. M. W. P. J. M. and W. H. S. contributed substantially to the study design, data analysis and interpretation, and writing of the manuscript. Financial/nonfinancial disclosures: None declared. ?MDT Study Group Collaborators: Nicole P. Barlo, Bart P. C. Hoppe, Wouter Jacobs, Robin Cornelissen, Joost D. J. Janssen, Sietske A. Smulders, Niels J. M. Claessens, Susan C. van ?t Westeinde, Steven R. Rutgers, and Franz M. N. H. Schramel. Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript. Other contributions: The authors thank the Dutch Cancer Society, all participants in the lung oncology MDTs of the hospitals participating in this study, and also all surgeons, registrars, physician assistants, and administrative nurses who register patients in the Dutch Lung Cancer Audit for Surgery. Participating hospitals: Treant Care Group, Scheper Hospital, Emmen; M?xima Medical Center, Veldhoven; Rijnstate Hospital, Arnhem; Martini Hospital, Groningen; Jeroen Bosch Hospital, Den Bosch; Erasmus University Medical Center, Rotterdam; Maasstad Hospital, Rotterdam; St. Antonius Hospital, Nieuwegein; VU University Medical Center, Amsterdam UMC, Amsterdam; Northwest Clinics, Alkmaar; and Leiden University Medical Center, Leiden. Additional information: The e-Appendix can be found in the Supplemental Materials section of the online article. FUNDING/SUPPORT: This study was funded by the Dutch Cancer Society [Grant HZ 2015-7782]. Publisher Copyright: {\textcopyright} 2020 The Authors",

year = "2020",

month = dec,

doi = "10.1016/j.chest.2020.07.054",

language = "English",

volume = "158",

pages = "2675--2687",

journal = "Chest",

issn = "0012-3692",

publisher = "Elsevier Inc.",

number = "6",

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Hoeijmakers, F, Heineman, DJ, Daniels, JM, Beck, N, Tollenaar, RAEM, Wouters, MWJM, Marang-van de Mheen, PJ, Schreurs, WH, Barlo, NP, Hoppe, BPC, Jacobs, W, Cornelissen, R , Janssen, JDJ, Smulders, SA, Claessens, NJM, van ‘t Westeinde, SC, Rutgers, SR & Schramel, FMNH 2020, 'Variation Between Multidisciplinary Tumor Boards in Clinical Staging and Treatment Recommendations for Patients With Locally Advanced Non-small Cell Lung Cancer', Chest, vol. 158, no. 6, pp. 2675-2687. https://doi.org/10.1016/j.chest.2020.07.054

TY - JOUR

T1 - Variation Between Multidisciplinary Tumor Boards in Clinical Staging and Treatment Recommendations for Patients With Locally Advanced Non-small Cell Lung Cancer

AU - Hoeijmakers, Fieke

AU - Heineman, David J.

AU - Daniels, Johannes M.

AU - Beck, Naomi

AU - Tollenaar, Rob A.E.M.

AU - Wouters, Michel W.J.M.

AU - Marang-van de Mheen, Perla J.

AU - Schreurs, Wilhelmina H.

AU - Barlo, Nicole P.

AU - Hoppe, Bart P.C.

AU - Jacobs, Wouter

AU - Cornelissen, Robin

AU - Janssen, Joost D.J.

AU - Smulders, Sietske A.

AU - Claessens, Niels J.M.

AU - van ‘t Westeinde, Susan C.

AU - Rutgers, Steven R.

AU - Schramel, Franz M.N.H.

N1 - Funding Information: FUNDING/SUPPORT: This study was funded by the Dutch Cancer Society [Grant HZ 2015-7782]. Funding Information: Author contributions: F. H. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis, including and especially any adverse effects. F. H. D. J. H. J. M. D. N. B. R. A. E. M. T. M. W. J. M. W. P. J. M. and W. H. S. contributed substantially to the study design, data analysis and interpretation, and writing of the manuscript. Financial/nonfinancial disclosures: None declared. ?MDT Study Group Collaborators: Nicole P. Barlo, Bart P. C. Hoppe, Wouter Jacobs, Robin Cornelissen, Joost D. J. Janssen, Sietske A. Smulders, Niels J. M. Claessens, Susan C. van ?t Westeinde, Steven R. Rutgers, and Franz M. N. H. Schramel. Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript. Other contributions: The authors thank the Dutch Cancer Society, all participants in the lung oncology MDTs of the hospitals participating in this study, and also all surgeons, registrars, physician assistants, and administrative nurses who register patients in the Dutch Lung Cancer Audit for Surgery. Participating hospitals: Treant Care Group, Scheper Hospital, Emmen; M?xima Medical Center, Veldhoven; Rijnstate Hospital, Arnhem; Martini Hospital, Groningen; Jeroen Bosch Hospital, Den Bosch; Erasmus University Medical Center, Rotterdam; Maasstad Hospital, Rotterdam; St. Antonius Hospital, Nieuwegein; VU University Medical Center, Amsterdam UMC, Amsterdam; Northwest Clinics, Alkmaar; and Leiden University Medical Center, Leiden. Additional information: The e-Appendix can be found in the Supplemental Materials section of the online article. FUNDING/SUPPORT: This study was funded by the Dutch Cancer Society [Grant HZ 2015-7782]. Publisher Copyright: © 2020 The Authors

PY - 2020/12

Y1 - 2020/12

N2 - Background: 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. Research Question: What is the level of agreement on clinical staging and treatment recommendations among MDTs in stage IIIA NSCLC patients? Study Design and Methods: 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. Results: 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. Interpretation: 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.

AB - Background: 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. Research Question: What is the level of agreement on clinical staging and treatment recommendations among MDTs in stage IIIA NSCLC patients? Study Design and Methods: 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. Results: 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. Interpretation: 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.

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U2 - 10.1016/j.chest.2020.07.054

DO - 10.1016/j.chest.2020.07.054

M3 - Article

C2 - 32738254

AN - SCOPUS:85096681548

SN - 0012-3692

VL - 158

SP - 2675

EP - 2687

JO - Chest

JF - Chest

IS - 6

ER -

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

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