A few weeks after I wrote “The Patient at The Tumor Board” a strange thing happened.
About 10 minutes before a tumor board was suppose to start as I was checking the microscope, camera and software, the radiologist was logging into the PACS and the surgeons were discussing their difficult management questions amongst themselves, one of the oncologists walked into the room and said “The patient will be here for the first case we are presenting, Mr. S, a 60-year old male with stage 4 colon cancer”. What happened next went something like this:
Surgeon #1: “You are bringing a patient into a tumor board?”
Oncologist #1: “Yes.”
Surgeon #2: “You can’t do that. Does he know what a tumor board is?”
Oncologist #1: “Yes. He asked to be here. He has been to other tumor boards at other institutions and he asked to sit in on ours as well and hear the discussion.”
Surgeon #1: “You can’t bring a patient in here.”
Oncologist #2: “We use to do this all the time where I trained.”
Surgeon #1: “Did you ask legal?”
Surgeon #2: “Did you ask risk management?”
Oncologist #1: “No. He asked to come here. We will present him first and then discuss the other cases when he leaves.”
Surgeon #2: “What are we suppose to do? Talk like we normally do?”
Oncologist #1: “Yes.”
The radiologist at this point is also getting a little anxious at the prospect of showing the films in front of the patient and wondered if we should say “his” films or “your” films. As thrilled as he wasn’t to show the lesions in the liver on CT scan I can’t say I was initially too enthusiastic of showing the patient his partial colectomy and liver biopsy specimen. It wasn’t part of the dry run I had done a few hours earlier preparing for the tumor board. I thought it would just be the “regulars”. No visitors.
The top of the hour struck and Mr. S and his wife were escorted by the oncologist to a couple chairs about 15 feet from the radiologist and I at the front of the room.
The oncologist presented his case, asked the patient if any of his symptoms or findings to date were incorrect and if he had omitted any information. Once the patient replied, the radiologist presented his imaging studies mentioning the pre-operative mass in the right colon, the suspected lymph node involvement and lesions in the liver consistent with metastatic disease. At the end the patient nodded and the oncologist asked to review the pathology.
As usual, I showed the primary tumor, described the degree of differentiation, depth of invasion and a representative example of one of the many positive lymph nodes for review by the group. This was followed by a section of one of the liver biopsies showing a metastatic tumor with similar morphology to the primary colon cancer.
Radiation oncology was asked for their opinion regarding the role of radiation for this patient and addressed the question.
During this dialogue the patient sat quietly while we referred to each other with our professional titles rather than first- and nicknames like we normally may as if the conversation was being transcribed for a clinicopathologic conference to be published in the New England Journal of Medicine.
The radiation oncologist asked the patient directly how he was feeling today and one of the surgeons followed up his question by asking about his appetite and wound healing.
The oncologist then summarized the findings, presented a clinical stage and treatment options based on national guidelines. A short discussion ensued and a few questions were asked of the patient about family history, and he asked about his ability to continue his hobbies, travel to see grandkids and continue to cut down trees on his property.
As the discussion drew near the patient remarked “I have been to three tumor boards and you all have pretty much told me the same thing but I like you guys the best so I am going to come here for my treatment.”
The patient thanked us and we thanked him, a little more honored and humbled.
Footnote: There was over 120 years of clinical experience in the room that day and none of us had the experience we did during that tumor board. The oncologist who mentioned he saw it where he trained admitted later it only occurred once during his fellowship at a large referral academic medical center. While the patient is real, the age, last initial and diagnosis have been changed.