How and Why a Dedicated Spine Tumor Board Can Enhance Care of Complex Patients

A stand-alone spine tumor board (STB) is invaluable for promoting collaborative strategizing and management of these varied and often hard-to-treat cancers, offering multiple benefits to patients, clinicians and trainees. So concludes a group of Cleveland Clinic physicians with specialties related to spine tumor care, who reviewed the workings of the Cleveland Clinic STB and characterized it in terms of case diversity, treatment recommendations and process. The comprehensive review, one of the first and deepest explorations of this topic to date, was published in World Neurosurgery (2023 Apr 1;S1878-8750(23)00434-5).

“Our spine tumor board is popular and optimizes patient care,” says the study’s senior and corresponding author, Lilyana Angelov, MD, a neurosurgeon who serves as Director of Cleveland Clinic’s Gamma Knife Center and Head of the Section of Spinal Tumors. “This review provides insight into processes that work well when implementing such a board.”

Spine tumors post special challenges

Tumor boards are regularly used in hospitals and academic centers to facilitate multidisciplinary collaboration for making diagnoses, developing treatment strategies and coordinating care. However, stand-alone STBs are less common, and little has been published describing and evaluating them. Many types of spine tumors are rare, and treatment options are frequently complex and controversial and require multiple steps. These qualities make diagnosis and management particularly challenging and increase the imperative for timely multidisciplinary collaboration.

STB processes

The Cleveland Clinic STB uses the following format and practices:

• Meetings are held weekly and last for 1.5 hours; all have been fully virtual for the past three years.
• Participants include physicians and advanced practice providers from neurosurgery, radiation oncology, neuro-oncology, medical oncology, neurology, orthopaedic surgery, interventional radiology and pathology, with consistent imaging reviews by two dedicated spine neuroradiologists
• Cases tend to be unusual or challenging, but there are no formal criteria, and any spine tumor care provider can present a case.
• Providers present cases in conjunction with the neuroradiologist, who displays relevant images.
• The presenter poses questions and concerns to the group for discussion.
• Recommendations are collectively decided upon and formally recorded.
• The provider conveys the treatment strategy to the patient, thus providing integrated multispecialty care in a personalized way.

Review results: cases and decisions

All cases discussed at the STB on Cleveland Clinic’s main campus from its inception in May 2006 through May 2021 were included in the review. Highlights of the findings are listed below.

Caseload. In total, there were 4,549 cases (2,618 patients). Caseload grew throughout the study period, ranging from an average of four cases per week early on to an average of 15 cases per week in 2021; some weeks see more than 20 cases discussed. The transition from fully in-person attendance to a fully virtual format spurred by the pandemic increased attendance and number of cases presented.

Presenters. Nearly three-quarters of cases were presented by surgical providers (the vast majority were neurosurgeons), which is unusual for other tumor boards, according to Dr. Angelov.

Pathology. The most frequently presented pathology was metastasis to the spine (40%). There were also intradural extramedullary tumors (18%), primary glial tumors (12%), nonneoplastic tumors (7%), vascular/neuroendocrine tumors (6%), lymphoma/multiple myeloma (5%) and primary bone tumors (5%).

Management recommendations. Management recommendations, which are made in all cases, included the following (numbers exceed 100% because of overlap in some cases):

• Direct treatment of the tumor in 38% of cases, specifically surgery (16%), stereotactic radiosurgery (13%), additional radiation (12%) and systemic chemotherapy (2%)
• Follow-up/expectant management with no other treatment specified in 35% of cases
• Supplementation of the existing management plan, including additional imaging (12%), biopsy (9%), referral to another specialty (7%) and more testing (4%)

Benefits of the STB

In their paper, Dr. Angelov and her co-authors outline important benefits conferred by the STB, including the following:

• Greater assurance in decisions. The STB expands and streamlines the consultation process, allowing for focused input from a variety of experts on problematic diagnosis and management issues.
• Quicker orchestration of care. With multidisciplinary practitioners in attendance at the STB, care coordination can be more promptly planned and care often ends up being delivered by providers who are familiar with the case through the STB.
• Education and training. The STB is regularly attended by a variety of caregivers with different levels and areas of expertise, including nurse practitioners, physician assistants, medical and surgical neuro-oncology fellows as well as experienced physicians from different specialties.
• Increased patient confidence in treatment plans. Patients are reassured to know that their care plan has backing from a team of experts after careful deliberation of their case.
• Enhanced longitudinal care. Because many spine tumors must be managed over years, a substantial percentage (36%) of patients included in the study had their cases presented more than once, with 9% being presented four or more times.

“Management of spinal tumors is particularly well suited to the multidisciplinary collaboration inherent in a spine tumor board,” says Dr. Angelov. “The large increase in annual case presentations from the early years to the present clearly demonstrates that providers and patients find the process valuable. This highly experienced spine tumor board makes Cleveland Clinic one of the best centers in the nation for patients with complex spine tumors to come for care.”