1 Introduction

Tumor boards were initially developed to meet the demands of general practitioners and internists who were historically the primary treating physician. As specialists were increasingly consulted and played a growing role in oncologic care, tumor boards were created to guide the primary physicians. At first, tumor boards were gathered once during the clinical course of patients, mainly when there was a necessity for interdisciplinary discussion for consultation purposes. Over time, they evolved to become more comprehensive so that they could be actively involved in all steps of the management, from initial diagnosis to treatment and follow-up.

The purpose of this review is to summarize the impact of the multidisciplinary tumor board as a tool or mechanism for orthopedic oncology care, to highlight its evolution and changing role over time, to assess its strengths and weaknesses, and to report our institutional experience as an NCI-Designated Comprehensive Cancer Center.

1.1 Purpose of tumor boards

The National Cancer Institute defines a tumor board as “A treatment planning process in which a group of cancer doctors and other health care specialists meet regularly to review and discuss new and complex cancer cases.” [1]. The goal of a tumor board is to leverage the collective wisdom of the group in order to determine a patient’s best treatment plan, which cumulatively, provides a higher quality of institutional care. These meetings are recurrent and depending on the need, relative rarity of the tumor topic, or other logistical considerations, the meeting can be held weekly, biweekly, or monthly. In most cases, the boards are moderated by one of the physicians from either the surgical team or the medical oncology team, however, programs are at liberty to select the moderator according to their needs, preferences, or institutional culture. Classically, the group contains a surgical oncologist or other surgical specialists involved in the care of the relevant tumor type, a medical and/or pediatric oncologist, a radiologist, a nuclear medicine specialist, a radiation oncologist, and a pathologist. Additional participants are often invited or included on a case-specific basis when needed and larger institutions often have multiple representatives from each sub-specialty attend. Patients are generally presented to the board with a brief summary of their clinical history and physical examination findings, followed by a review of their imaging and pathology, whenever available. The cases are either discussed for diagnostic purposes or clinical decision-making purposes, in both cases, all relevant stakeholders are present to review or discuss imaging, histology, or other related considerations. A patient might be presented at multiple time points, depending upon their needs along the care journey. The discussions are meant to either challenge the opinion or plan being presented, or conversely, to demonstrate larger consensus and agreement. In either case, the wisdom of the crowd is beneficial and oftentimes reveals diagnostic considerations that might have been overlooked, management options that should be considered, or guidelines or recent literature that might be germane. Reviewing and discussing as a group ensures thoroughness, safety, and feasibility. It also provides some degree of reassurance to the patient and their family, knowing that the plan was arrived at by many, rather than by a single, provider.

Given the rarity of sarcoma in general, as well as the complexity of sarcoma patients’ collective care, repeatedly discussing them adds further value by kee** the physicians well-informed about their current condition or most recent clinical dilemma. The conference has the added value of providing an excellent educational forum for less experienced providers or trainees. Lastly, the conference can and should include allied providers, including social services, rehabilitation and/or palliative care experts, and others that may play unique and important parts in complicated care requiring a multi-disciplinary approach.

1.2 History and evolution of tumor boards

Tumor boards have been one of the mainstays of cancer care dating back many decades. Gustave Roussy, a revered pathologist who founded the first cancer center in Europe in 1926, was a staunch advocate of interdisciplinary communication in the management of tumors for better standards of care and quality improvement. He believed dedicated meetings between the various providers were necessary for optimal outcomes and he has been credited with creating the first multi-disciplinary tumor board. Over the ensuing years, a few large institutions around the world adopted this practice. However, most centers continued treating patients without formal means of coordination and communication, resulting in degrees of disconnect between care providers. Over time, modest improvements took hold, albeit slowly. In the 1940’s, for example, the Veteran Administration Center General Medical and Surgical Hospital in Los Angeles held tumor board meetings routinely, but they segregated medical and surgical tumor boards [2]. In the 1960’s and 1970’s, as tumor boards were organized across an increasing number of institutions, they played a growing and central role in patient planning as well as in the education of oncology fellows in the United States [3]. Histology-specific tumor boards were also emerging in the same period. For example, the MD Anderson Cancer Center began to institute weekly breast tumor conferences. It was within this context that tumor boards began to provide the medical community with a platform for reporting rare tumors with a multi-disciplinary consensus, instilling more confidence in the results and making significant and impactful contributions to the oncology literature [4]. In the 1990’s, as quality improvement in medicine gained traction and as the number of cancer specialists around the world continued to increase, the idea of organizing multidisciplinary discussions became even more popular [5]. Finally, with the incorporation of tumor boards into accreditation requirements, tumor boards became a true standard of care within the practice of oncology.

1.3 The current role and value of tumor boards

Today, multidisciplinary tumor boards exist in many comprehensive programs and cancer centers around the world. The field of oncology has evolved substantially, both as a science and as a medical practice. The evolution of cancer care with an ever-increasing focus on quality and optimized outcomes has led to the need to discuss increasingly specific tumor types, and this has propelled the creation of specialized tumor boards [6]. Bone and soft tissue sarcoma tumor boards were eventually developed in this way and have since become widely adopted. Currently, evidence indicates that tumor boards can improve diagnostic accuracy, ensure appropriate treatment, increase patient satisfaction, and even provide a survival benefit [7,8,9].

The success demonstrated by the tumor boards both in the literature and inside institutions has led to a trend of increased adherence to tumor board recommendations over the years. A study by Hollunder et al. showed that 80.1 percent of all recommendations in tumor boards were implemented, and moreover, that deviances from the board decisions decreased significantly over time [10]. As many physicians feel encouraged and more confident in their interactions and decision-making as a result of multidisciplinary collaboration and cooperation, the culture of following board recommendations has become more engrained. Nevertheless, there are still notable shortcomings in the adoption of tumor boards around the world. Data from the Department of Veterans Affairs Central Cancer Registry (VACCR) showed that 75 percent of the 138 veteran affairs (VA) medical centers had tumor boards in 2005, and only 30 percent had more than one [11]. A study from Germany that investigated sarcoma centers showed that between 2017 and 2020, only 56.1% and 78% percent of patients were discussed pre- and post-treatment respectively. Although the study demonstrated a progressive increase in utilization, with high compliance demonstrated in both high-volume and in certified cancer centers, the data also revealed that overall only 50% of patients were being discussed before intervention [12]. As it becomes increasingly clear that tumor boards improve outcomes in cancer care, measures should be taken to increase utilization and compliance by addressing organizational and cultural changes, incentivizing teamwork, and requiring tumor boards as accreditation requirements [13].

In addition to institutional tumor boards, national and international tumor boards have also become popular. These conferences have the added value of enlisting differing perspectives, influenced and nurtured across varying healthcare systems and institutional cultures. The diversity of ideas can be particularly valuable in the context of complicated, unusual, or rare clinical dilemmas. A national multi-institutional, multidisciplinary, virtual monthly Ewing sarcoma tumor board designed to discuss complicated and challenging Ewing sarcoma cases leveraged their expertise to establish guidelines for diagnostic algorithms, defining the indications and regimens for interval compressed chemotherapy, and the roles of other treatment modalities such as autologous stem cell transplantation and whole lung irradiation [14]. A national tumor board can leverage far-reaching experience and insight, while simultaneously providing access to a platform which may not otherwise be available for the providers in need. The Transatlantic Australasian Retroperitoneal Sarcoma Working Group (TARPSWG), a clinical network of physicians established in 2013, organizes a monthly tumor board to overcome the challenges associated with the management of retroperitoneal sarcoma [15]. Their group includes 52 physicians from 18 countries, who collaborate on cases prospectively for real-time advice. Similarly, the Global Cancer Institute hosts global tumor board meetings twice a month [16]. This provides the opportunity to seek expert opinions and multidisciplinary discussions in low and middle-income countries which have fragmented health systems and busy hospitals, and may not have access to institutional or regional conferences. As of writing, 25 countries across four continents participate in these meetings, demonstrating the need, feasibility, and value of cross-border collaborations.

The development of new technologies such as virtual meetings has facilitated organizing tumor boards and provided the benefit of easier access to the sessions over time. By eliminating the travel time required to physically reach a conference room for an in-person gathering, providers and participants can attend more often, more easily, and without having to sacrifice or eliminate other obligations. The technology greatly improves or preserves daily workflow, thereby increasing the allocation of more time for patient care, management, and/or other obligations. Virtual tumor boards can also be leveraged for collaboration between multiple institutions. Online multi-institutional conferences can potentially help physicians in underserved or remote geographical areas with few sarcoma specialists to seek consultations from experienced colleagues in distant centers. One other possible benefit of these virtual gatherings is the ability to maintain social distancing, which was crucial during the COVID-19 pandemic and would be a necessary and perhaps mandated strategy in the event of a similar outbreak.

1.4 Tumor boards in orthopedic oncology

Orthopedic oncology is among one of the most specialized and unique areas in medicine. Not only does it involve rare tumors that present diagnostics difficulties, but the entire management of these conditions also differs significantly from the norm of oncology as physicians face the challenges of reconstruction after tumor resection, accounting for the functional demands of patients especially when considering their palliative options, and balancing the surgical and medical treatments for the best outcomes in line with the patient’s wishes and expectations. Surgeons are confronted with the questions of when and how to biopsy, and which surgical approach to take because of the anatomical variety of bone and soft tissue tumors. On the other hand, pathologists often have to apply special stains and diagnostic techniques to lead to the correct diagnosis because of the wide spectrum of diseases. In many cases, pathologists need to see the case in advance to have a better and more complete understanding of the clinical and radiographic presentation to avoid mistakes and arrive at an accurate diagnosis. Pre-treatment presentations in tumor boards can facilitate diagnosis and provide an initial plan for the most effective and optimal management with an agreement between all parties that will eventually be involved.

Unlike many carcinomas, sarcomas often afflict younger age groups, in addition to adults. Involving age-relevant social services, child-life services, and allied professionals in the conferences can help with their understanding and participation in what is often very complex long-term care. The inclusion of these professionals in interdisciplinary discussions can assist in improving the quality of life outcomes of sarcoma patients as well as provide another perspective for a better patient-centric decision-making process [13].

1.5 The additional utilities: education and institutional accreditation

Orthopedic oncology tumor boards play an important role in the education of medical students, residents, and most importantly, fellows and young specialists who wish to develop a career in this field. A study published by a French sarcoma center noted that multidisciplinary tumor boards were well received by trainees, who found them to be engaging, intellectually challenging, and of real value [17]. The majority of surveyed participants reported that the knowledge gained was immediately applicable to their daily practice. Our experience parallels this report, as we have anecdotally received positive feedback from our orthopedic surgery residents and orthopedic oncology fellows over the years. Our trainees have reported that the orthopedic oncology tumor board taught them how to better communicate with other providers, educated them on algorithmic approaches to clinical decision-making, and helped keep them abreast of treatment proposals, which in turn allowed them to interact with patients with more confidence.

Education of personnel and promotion of engagement should be encouraged to maximize the efficiency of interdisciplinary interactions. The American Society of Clinical Oncology (ASCO) has been advocating for multidisciplinary care through its global courses known as Multidisciplinary Care Management Courses [18]. These courses involve participation in mock tumor board discussions to improve the communication and collaboration between physicians in such circumstances. Organizing initiatives that instruct and educate care providers may encourage team-based approaches, which can help with the adoption of tumor boards in newly emerging practices. Moreover, tumor boards can act as a forum to discuss the value of emerging evidence in orthopedic oncology practice. Over the years, numerous landmark studies have been published in orthopedic oncology, focusing on various topics such as the management of surgical margins [19, 20], the duration of antibiotic treatment [21], and the administration of medical therapies [22,23,24,25]. From retrospective cohort studies to clinical trials, attendees can share their experiences with novel therapies and encourage or discourage other physicians to incorporate them into clinical practice. A secondary benefit of debating scientific developments in tumor boards is the indirect promotion of further research by prompting academics to brainstorm ideas within a conference.

Establishing interdisciplinary tumor boards is required for accreditation by the American College of Surgeons for the Commission on Cancer (CoC) certification of a program [26]. Institutions are obliged to present at least 15 percent of their newly diagnosed cancer patients in these forums, and at least 80 percent of these need to undertake prospective cases (newly diagnosed or previously diagnosed cases discussed for adjuvant treatment, recurrence, or palliative care). Programs must have a policy that addresses the multidisciplinary participation, frequency and format, elements of discussion for each case, number of cases, percentage of prospective cases, and methods to address the areas that fall below the levels in the policy. Finally, a designated cancer conference coordinator must summarize the objectives with an annual report. Although it can be time and resource consuming to maintain these accreditation standards, there are some benefits. Adherence to a standard set of policies can increase efficiency and promote engagement, ultimately improving the quality of care. Accreditation and teaching have also been shown to increase participation in tumor boards among physicians [27]. These in turn yield better healthcare outcomes for the institutions and more coordination among care providers, thereby outweighing the potential disadvantages of accreditation.

1.6 Challenges and limitations of organizing tumor boards

There are some challenges in establishing orthopedic oncology tumor boards that are worth noting. Garnering buy-in and finding all the relevant and needed specialists is not always easy or possible. Careful coordination before the boards each week is necessary to communicate which cases will be presented, as it allows time for the preparation of materials and slides. One of the incentives for attendance is to receive credit for continuing medical education (CME) which can require added paperwork and funding. Smaller institutions can be in a disadvantaged position compared to well-established or large centers due to logistical shortcomings and restrictions in available personnel [28]. Firstly, given the rarity of the disease portfolio in musculoskeletal sarcomas and the need for significantly experienced physicians, having all the necessary departments under a single institution may not always be possible. Attendance to tumor boards has historically been time-consuming, especially for providers who must travel long distances to join these meetings, although this can now be overcome with online/hybrid meetings. Additionally, waiting for a board meeting for patient care decisions can cause delays in treatment, but is minimized particularly in routine weekly meetings. Organizing the meetings can be difficult in busy clinics, and crowded meetings can become difficult to moderate. Complicated cases can take a long time to discuss, leaving less time to focus on the following cases. To overcome this, some institutions ensure adequate time for discussion by segregating the pre-diagnosis and post-diagnosis cases into different meetings. In busy meetings when numerous cases can cause overloading, physicians may find it difficult to concentrate and may experience increased burnout, and attendance of tumor boards can become burdensome, especially for parents and women [29]. Another potential drawback is the risk of creating institutional biases when the same group of physicians attend a single board for a prolonged time, and educational efforts should be taken to mitigate this pitfall.

1.7 Our experience as an orthopedic oncology clinic

Our institution is an urban academic medical center in the United States with a long-standing National Cancer Institute (NCI)-designated cancer center designation and recent NCI Comprehensive Cancer Care recognition (As of writing, there are 72 NCI-designated cancer centers and 56 NCI-designated comprehensive cancer centers). We hold a weekly Orthopedic Oncology tumor board that is moderated by one of the orthopedic oncology surgeons and attended by representatives from pediatric oncology, medical oncology, radiation oncology, musculoskeletal radiology, bone and soft tissue pathology, surgical oncology, nuclear medicine, palliative care, as well as social services. Periodically, vascular surgery, thoracic surgery, spine, or plastic surgery will join as well on an as needed basis. Although initially held as an in-person meeting, the COVID-19 pandemic prompted rapid evolution to and adoption of a virtual meeting, which has persisted because of logistical convenience and team member preference. Patients who have a suspected or proven bone or soft tissue lesion are presented for multidisciplinary discussions about their findings, differential diagnosis, definitive diagnosis and/or their management. On occasion, lesions that are benign or atypical, are presented to capitalize on the audience and its experience, leveraging the wisdom of the crowd. In addition to the faculty members, the tumor board is attended by residents, fellows, and physician assistants from the various involved subspecialties, providing them with tremendous educational opportunity and cross-disciplinary exposure.

We store every case that is discussed on our tumor board in a password-protected shared server that is compliant with the Health Insurance Portability and Accountability Act (HIPAA). We are able to query cases based on their medical record numbers to show their slideshow. This facilitates revisiting each case after discussions as well as creating a comprehensive database that possesses a wide variety of musculoskeletal tumors. This database can be utilized for research purposes as well when an institutional review board approval is obtained for a specific study purpose. Over the five-year span from August 2018 through August 2023, we were able to discuss a total of 1093 individual patients, spanning many diagnoses both benign and malignant. There was an almost even distribution of patients by sex, with 549 female (50.2%) patients and 544 male (49.8%). Patient ages at diagnosis spanned from 3 months old to 93 years old, with diagnoses peaking in the second and sixth decades of life (190 and 189 patients, respectively) (Fig. 1).

Fig. 1
figure 1

The distribution of patients that were presented in the sarcoma tumor board based on age group

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The most common neoplastic diagnosis that was presented in these meetings was giant cell tumor of bone (n = 51). Osteosarcoma (n = 41) was the most common diagnosis among the primary malignant bone tumors, and liposarcomas (n = 41) were the most frequently discussed soft tissue sarcoma histology. Other frequently diagnosed tumors include extra-abdominal desmoid tumors (fibromatosis), leiomyosarcoma, and lipomas. There were also 187 patients who were eventually found to have non-neoplastic diagnoses based on radiology and pathology workups, including bone cysts, osteomyelitis, fat necrosis, and unusual radiographic findings secondary to either arthritis or chronic inflammation. Table 1 summarizes the most common twenty histologies presented and discussed. There were numerous infrequently diagnosed tumors that are not listed in the table, including adamantinoma, clear cell sarcoma, spiradenoma, and nodular fasciitis, amongst others.

Table 1 The most common twenty histologies presented in the sarcoma tumor board
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The majority of patients were discussed once (55%) or twice (21%) (Fig. 2). Three or more discussions took place for the remainder of the patients (24%), and one tremendously complex patient was presented seventeen times. Our approach has been to leverage the group and the protected time to revisit inherently complicated cases, recognizing the value in consensus, coordination of care, and careful consideration in circumstances which often have no realistic optimal approach.

Fig. 2
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The pie chart illustrates the distribution of the number of discussions per patient in the sarcoma tumor board

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1.8 Future directions

Although tumor boards have remained somewhat similar over the past decades, there have been innovations stemming from technological advancements. As we previously discussed, the increased usage of virtual conference rooms in recent years has been one of the “game-changers” in the culture of convening for oncological patient care. Even though nobody can predict the future, the rise of artificial intelligence (AI) is believed to be the next major leap in technology. This will undoubtedly have significant societal impacts, which will increasingly be reflected in healthcare. The emergence of machine learning tools to aid and improve accuracy in the radiographic and histologic diagnosis may play a central role in future sarcoma boards [30, 31]. These tools can assist with diagnosing lesions that can be overlooked by clinicians, allowing for an earlier diagnosis [32]. In the setting of a tumor board, diagnostic AI tools can also help with the demonstration and annotation of the lesions, focusing the attention of the board attendees in the disease area. Large language models (LLM) can be implemented to recommend simulated board decisions [33]. Other applications for LLM might include real-time dictation of board discussions, providing summaries of the board decisions, and sharing details about individual cases for the attendees unfamiliar with the patients.

As the world continues to advance and develop, virtual meetings and AI can increase access to multidisciplinary care in resource-scarce underserved areas. The increase in internet access and telecommunication is expected to grow further, and the develo** countries of today may have better means to provide quality care in the next decades. The emerging technologies of virtual reality (VR) and augmented reality (AR) might also play a role in tumor boards. These technologies can facilitate access to the meetings as well as increase the level of immersion, which can lead to a more comprehensive and better understanding of the cases. Regardless, innovations in orthopedic oncology board meetings are likely to occur over the next decades, and it is not unrealistic to expect a better quality of care in the future.

2 Conclusion

In summary, tumor boards have played a central role in cancer care for almost a century. They have evolved from singular meetings conducted by oncologists who sought specialists’ opinions, to interdisciplinary boards that can now traverse both institutional and national boundaries. Currently, there are many specialized tumor boards, and organizing a sarcoma tumor board allows providers to provide a very well-considered and informed opinion, increasing the accuracy of their diagnosis and their confidence in their decision-making. Our experience at an NCI-designated comprehensive cancer center has yielded a review of over a thousand individual cases in only a 5-year span of time, with some complex cases requiring repeated presentation over the course of their care. Innovations with the advent of new technology can break new grounds in the future of tumor boards and raise the bar for high-quality care and optimal outcomes for cancer patients.