FRCC's multidisciplinary Gastrointestinal Tumor Board was created in 2004. Multidisciplinary tumor boards can have many functions. The role of this Tumor Board was set forth by the recommendations of the Health Care Advisory Board and others.14,15
This tumor board meets twice monthly. Prospective cases are discussed, literature is reviewed, research efforts are overviewed, and outcome measures are studied. The first outcomes study undertaken was assessing the adequacy of lymph node examination in stage II colon cancer. The Tumor Board reviewed the available literature and made a recommendation that a minimum of 12 lymph nodes should be retrieved and examined in all cases of colon cancer. Surgeons and pathologists were targeted as these disciplines have a direct bearing on the outcome.
With focused attention to this quality metric, the multidisciplinary Gastrointestinal Tumor Board at FRCC was able to spearhead adherence such that 12 or more lymph nodes were reviewed and examined in 79% of the stage II colon cancer cases. Through the Tumor Board's effort, we were able to statistically improve the median number of lymph nodes examined as well as the percentage of patients with 12 or more lymph nodes examined. Before the board's recommendation in April 2005, 49% of stage II colon cancer cases had 12 or more lymph nodes retrieved and assessed. After the recommendation, 79% had adequate lymph node sampling.
The Tumor Board investigated which discipline impacted this outcome; surgery or pathology. Ideal bowel resections, margins, and lymphadenectomy have been described by a National Cancer Institute panel of experts.5
The extent of the bowel resection is defined by removing the blood and lymphatic supply at the origin of the feeding arterial vessel. Although debatable, 5 cm of normal bowel on either side of the primary tumor is considered adequate for minimizing local recurrences. The lymph nodes at the origin of the feeding arterial vessel should be removed if possible and tagged. All suspicious lymph nodes outside the field of resection should be removed or have a biopsy. As mentioned previously, a minimum of 12 lymph nodes should be removed. Multiple surgeons perform colon cancer surgery at FRCC. When asked if the Tumor Board's recommendation lead to a change in their surgical approach, the answer was no. In reviewing the data, it did not appear that any one surgeon had a different rate of obtaining 12 or more lymph nodes.
Pathologists, on the other hand, admit to a change in their practice. After the Tumor Board's recommendation, there was a concerted effort to dissect out more lymph nodes and to make every effort to obtain a minimum of 12 lymph nodes. Pathologic detection of lymph nodes in fat-laden specimens can be difficult. As many as 70% of lymph nodes are less than 0.5 cm in diameter, and these may be the only lymph nodes involved.16
Despite this difficulty, several single institution studies have demonstrated higher rates of lymph node retrieval when employing standardized methods of evaluation.17,18
The pathologist's role is determining whether the number of lymph nodes examined was dramatically reported in a recent correspondence in the Journal of Clinical Oncology
. This report was about a single high-volume surgeon operating at two hospitals with two different pathology groups. In 76 cases at one hospital, the median number of lymph nodes was 10, and in 54 cases at another hospital, the median number of lymph nodes was 18. The authors believed the difference to be driven by the pathologic care at the two hospitals.19
Despite good surgical and pathologic care, other factors may impact lymph node recovery. Some studies suggest that age and left-sided location may decrease lymph node recovery. The strength of this association is not known.8,10
We did a separate analysis on our data looking at whether age, sex, or location of disease had any impact on the number of nodes retrieved, and we did not see a statistical significance.
As previously mentioned, this study demonstrates that multidisciplinary tumor boards can impact the quality of care of patients. Although we do not have survival data on this patient population yet, a future study is planned to review that data. Based on the literature referenced in this document, we expect to see an improvement in survival rates for those patients with 12 or more nodes retrieved and assessed that will improve the quality of care of our stage II colon cancer patients.