Collaborative Care for Liver Disease in a Time of COVID-19

Spurred by the need to overcome industrywide resource restrictions during the early days of the COVID pandemic, the multidisciplinary liver tumor board at Cleveland Clinic Weston Hospital turned a challenge into an opportunity to improve patient care.

The tumor board format

Cleveland Clinic Florida’s Center for Liver Disease, which includes physicians and locations across southeast Florida, conducts weekly multidisciplinary liver tumor boards to review complex cases and discuss treatment options. Several specialties are represented in each session, including hepatology, medical oncology, radiation oncology, surgery, pathology, radiology and interventional radiology.

“Our tumor board format brings together a team skilled in leading-edge modalities and promotes interdisciplinary collaboration with nurses, patient navigators, social workers, and genetics experts,” says Xaralambos Zervos, DO, MBA, Department Chair and Medical Director of Liver Transplant at Cleveland Clinic Florida, who specializes in advanced and decompensated liver disease, hepatitis C, and individuals requiring liver transplantation. “It is also used as an educational platform for our fellows and residents.”

The purpose of the tumor board, also called a multidisciplinary cancer case conference, has not changed since it was first outlined in 1931 by the American College of Surgeons’ (ACS) Board of Regents. It is designed to bring together all members of a care team to discuss a patient’s diagnosis and treatment options.

“What has changed is the level of specialization involved in caring for patients today thanks to all that we’ve learned over the years of medical advancement and treatment innovation,” says Dr. Zervos, who notes another potential difference. “In addition to weighing treatment approaches, we now also collaborate on the best way to implement treatment plans to optimize patient adherence.”

Leaning into collaborative care

Tumor boards have been embraced by cancer programs for decades as a way to improve patient care and is an eligibility requirement for accreditation by the ACS Commission on Cancer (CoC). All three Cleveland Clinic cancer centers in Florida – the Maroone Cancer Center in Weston, the Robert and Carol Weissman Cancer Center in Stuart, and the Scully-Welsh Cancer Center in Vero Beach – are CoC accredited.

An umbrella review looking at the impact of tumor boards on cancer care published in 2020 concluded that “the multidisciplinary approach is the best way to deliver the complex care needed by cancer patients.” This was specifically observed in terms of improved decision making, patient care coordination, and reduced wait times.

According to the review writers, however, evidence of the impact of tumor boards on clinical practices is still lacking in terms of survival rates, quality of life, and patient satisfaction, and merits further research. While the full benefits conferred by multidisciplinary tumor boards remains in question, Cleveland Clinic’s team in Weston, Florida, has leaned into the approach by encouraging the participation of referring physicians.

“We know time to treatment is a critical factor in cancer care that can affect patient outcomes, and during the early days of COVID we wanted to minimize the impact of pandemic-related delays,” recalls Dr. Zervos. “We sought greater collaboration with physicians in the community to overcome some of the barriers patients were experiencing and began to invite them to participate in our tumor board meetings.”

Acceleration of care is a common benefit of a tumor board, in part by cutting out some of the individual specialty consultations that can take time to coordinate. Dr. Zervos notes that “using a video conferencing platform to engage referring physicians during these important discussions also made it possible for our patients to get imaging and other diagnostic testing appointments more quickly and improved overall care coordination.”

Recognizing the benefits to patient care, it is a practice the team continues today.

Promoting multimodal treatments

Multimodal treatment strategies fostered by Cleveland Clinic’s tumor board consists of locoregional and systemic therapies. Beyond resection and chemotherapy, these may include ablative techniques, transarterial therapies, such as transarterial chemoembolization (TACE), and stereotactic body radiation therapy. In some cases, eligible patients also may be referred for clinical drug trials.

Nikhil Kapila, MD, who was recently named Medical Director of the Liver Tumor Board, points to the added benefit of having experts in transplantation as part of the multidisciplinary team in Weston. “For some of our patients with liver cancer, early intervention with locoregional therapy and listing for transplant is the best course,” he shares.

As a transplant hepatologist in the Liver Transplant Program at Cleveland Clinic Florida, Dr. Kapila is also responsible for preparing exception score requests for patients with hepatocellular carcinoma listed for liver transplant.

“These are submitted to the National Liver Review Board and are a very important part of the waitlist process,” Dr. Kapila explains. “Exception scores factor in the complications of liver disease that put patients at increased risk of mortality or waitlist dropout but are not reflected in the standard MELD score.”

Beyond liver cancer

In addition to complex liver cancers, the tumor board also confers on cases of advanced hepatitis, cirrhosis, liver failure, and biliary tract diseases. “As a GI referral center, our team sees a large volume of advanced, rare, and difficult-to-treat liver disease,” says Dr. Zervos.

He recalls one case involving a patient who continued to experience pain after having gallbladder surgery at a community hospital to drain an abscess. The patient was referred to Cleveland Clinic Weston Hospital, where a review of existing CT scans revealed a large gallstone that eroded into the abdominal space had been missed and required removal.

Another case reviewed by the tumor board entailed a patient with a portal vein thrombosis experiencing severe ascites who underwent a failed transjugular intrahepatic portosystemic shunt (TIPS) placement. The case was referred to Weston Hospital, where interventional radiologist Mehul Doshi, MD, successfully performed the image-guided TIPS procedure, connecting the portal vein to the hepatic vein within the liver to maintain portal vein patency and avoid fluid retention complications.

“In both of these cases, our patients benefitted from a team of specialists looking to provide the very best care and outcomes,” Dr. Zervos adds.