Electronic Medical Records Outpatient Practice

We Need National Telemedicine Tumor Boards

Tumor boards have been shown to improve cancer outcomes by incorporating the expertise of many specialists in order to formulate a personalized treatment plan for each patient. These interdisciplinary management plans can give patients the best chance of cancer control or cure. Tumor boards typically consist of a surgeon, a medical oncologist, and a radiation oncologist but may also include a pathologist and a radiologist. Organ-specific tumor boards may consist of other specialists. For example, a thoracic tumor board may include a pulmonologist or a GI tumor board may include a gastroenterologist. Tumor boards allow specialists to bring their own expertise to an individual patient’s cancer treatment plan in order to determine the timing of surgery, the use of adjuvant or neoadjuvant chemotherapy, and the use of radiation therapy.

Summary Points:

  • Recent advances in cancer care have led to the evolution of different cancer-specific tumor boards
  • There is an unmet need to bring these cancer-specific tumor boards to rural and underserved areas of the country
  • Telemedicine tumor boards offer an opportunity to improve cancer treatment to all Americans
  • There are a number of obstacles that need to be addressed before national telemedicine tumor board implementation


Tumor boards have become even more important as advances in cancer genetics have resulted in many new treatments based on the molecular make-up of individual cancers. The advisability and timing of these newer treatments such as immunotherapy and driver-directed therapy can also be incorporated into the patient’s cancer treatment plan during tumor board discussions. Also, patients eligible for clinical trials of promising experimental treatments can be identified during tumor board discussions and enrolled in research studies.

In large medical centers, tumor boards typically meet once every week or two weeks. In smaller hospitals, tumor boards meet less frequently, often monthly. Each patient’s history, physical exam, radiologic staging study results, and tumor pathology results are reviewed. Specialists then develop a personalized cancer treatment plan tailored for that patient. A tumor board is far more efficient than having the patient see multiple physician specialists in their office for separate consultations and then having the physicians forward their individual recommendations to the primary care physician for coordination of care.

Survival of most cancers has improved significantly over the past several decades, largely due to development of new medications to treat cancers and to advances in cancer screening. But cancer is not one disease and cancer treatment has also become highly specialized. Oncologists used to be cancer generalists who were expert in the treatment of all forms of malignancy but now, medical and surgical oncologists specialize. The result is that there are different medical oncologists who treat lung cancer, gastrointestinal cancers, skin cancers, breast cancer, etc. As a consequence, tumor boards have also become specialized with different tumor boards for lung cancers, gynecologic cancers, and breast cancers. Large academic medical centers will often have 8-10 different tumor boards, each for a different type of cancer.

This specialization of oncologists and of tumor boards has posed a challenge for smaller hospitals and rural hospitals that do not have the luxury of multiple medical oncology specialists, surgical oncologists, or gynecologic oncologists. These hospitals either have to rely on general surgeons, general medical oncologists and general tumor boards or have to refer their newly diagnosed cancer patients to large medical centers for subspecialty evaluation that can sometimes be hundreds of miles away.

In the past, tumor boards were held in hospital conference rooms with physicians attending in-person. The COVID-19 pandemic showed us that multidisciplinary conferences could be just as effective when performed remotely. For more than 15 years, I led our medical center’s multidisciplinary interstitial lung disease conference which is the equivalent of a tumor board for non-cancer diseases such as pulmonary fibrosis. We found that our interdisciplinary discussions were just as easily done by a Zoom or Teams meeting as they were by in-person conferences. In fact, we had better attendance when the conferences went remote because physicians who practiced at off-site clinics could more easily attend.

A 2014 proof of concept study involving two Veterans Administration hospitals showed that virtual telemedicine tumor boards were both feasible and well-accepted by participants. The COVID-19 pandemic forced most hospital tumor boards to convert to virtual meetings. A study from the University of Pittsburgh demonstrated that virtual tumor boards during the COVID pandemic were very effective. But can we develop virtual tumor boards utilizing telemedicine technology to bring multidisciplinary expertise to smaller hospitals in order to improve cancer outcomes in rural and underserved areas of the country?

Lessons from institutional review boards

Institutional review boards (IRBs) are sometimes referred to as “human subjects committees” and are multidisciplinary groups that review clinical trials in medicine to ensure that medical experimentation involving humans is performed ethically and with appropriate study design. In the past, each hospital had its own IRB composed of volunteer reviewers. The volume of study proposals and the burden of IRB meetings by physicians, university faculty, and lay public members often resulted in long delays in getting clinical trial proposals approved.

In 1968, the Western Institutional Review Board was founded as an independent ethical review organization that allowed hospitals to outsource their clinical trial reviews for a fee. Hospitals no longer needed to rely on internal human subjects committees and Western was able to turn proposals over more quickly than the hospital IRBs. Our university outsources most of our clinical trial reviews to Western and this has greatly expedited research. Over time, more independent IRBs arose and consolidated. Now, most clinical trials undergo their ethics review by independent IRBs such as Western (now known as WCG IRB). These independent IRBs can match ethics and research specialists with specific clinical trials in order to provide superior reviews in a shorter period of time.

Our nation’s tumor boards can learn a lot from the independent IRBs. By assembling a large group of specialists in the treatment of each type of cancer, state-of-the-art recommendations individualized to each patient’s cancer can be made anywhere in the country, or for that matter, anywhere in the world. And those recommendations can be made faster, thus allowing patients to get started on optimal treatment as quickly as possible. A criticism of American cancer research is that racial and ethnic minorities are often underrepresented as subjects in clinical trials. By better reaching these minorities through telemedicine tumor boards and identifying clinical trial candidates, such disparities could be reduced.

Barriers that need to be overcome

There are several obstacles that need to be addressed before national telemedicine tumor boards can be implemented:

  1. Medical licensure. In telemedicine, the medical encounter is legally considered to occur at the patient’s physical location and not the doctor’s location. As a consequence, physicians providing telemedicine must be licensed to practice medicine in the state that the patient is in at the time of the telemedicine encounter. A physician in Ohio cannot legally provide telemedicine care to a patient located in Florida unless that physician has a Florida medical license. For this reason, state-specific telemedicine tumor boards would be easy to implement from a medical licensure standpoint but a national telemedicine tumor board would require physician participants to have dozens of individual state medical licenses. The development of the Interstate Medical Licensure Compact may simplify the process of obtaining medical licenses in many states but not all states participate in the Compact. A national telemedicine tumor board could perhaps most easily be implemented in the Veterans Administration system since VA-employed physicians can practice in any state as long as they are licensed to practice in any one state.
  2. Cost. Physicians participating in hospital tumor boards are generally not compensated for their time – they participate pro bono as part of their professional duties to the hospital. A 2021 study from a single academic medical center found that the total cost in physician time to participate in the hospital’s 9 separate tumor boards was $648,183 per year. Currently, there is not a mechanism to pay for national telemedicine tumor boards and this would need to be addressed by Medicare and commercial insurance policy changes. Alternatively, this could be financed by subscription fees charged to participating hospitals.
  3. Radiographic and pathologic review. Like medical oncology and surgical oncology, radiologists have become subspecialized. Chest CT scans of patients with lung cancer are reviewed by a thoracic radiologist whereas brain MRIs of patients with brain tumors are reviewed by a neuroradiologist. Pathologists have become similarly subspecialized. Tumor boards at large academic medical centers are usually attended by the subspecialty radiologists and subspecialty pathologists who originally reviewed the patient’s materials. Smaller hospitals will typically only have general radiologists and general pathologists. A mechanism would need to be in place so that subspecialty radiologists could review original radiographic images and subspecialty pathologists could review full slides of tumor biopsy specimens. There are existing telemedicine solutions to both of these challenges but this could require smaller hospitals to purchase equipment and software to transmit radiographic and histologic images.
  4. Malpractice insurance. When a physician’s name appears on a treatment recommendation, that physician can be named in event of a medical malpractice lawsuit. Several years ago, I was a defense expert witness in a malpractice case involving a patient with a rare eosinophilic lung disease. The pathologist reviewing the lung biopsy slides called a pathologist in a different city who was a national expert in pulmonary pathology and asked that pathologist over the phone about the diagnostic significance of all of the eosinophils that were present on the biopsy slides. The second pathologist was named in the suit, even though he had only spoken by phone with the initial pathologist and had not, himself, seen the actual biopsy slides or provided a formal pathology report. Malpractice insurance coverage would need to be worked out before implementing a national telemedicine tumor board. Board participants would either need to have immunity against civil litigation or would have to be provided telemedicine malpractice insurance.
  5. Medical record access. Tumor board participants must have access to patients’ medical records. Many factors need to be considered when formulating a cancer treatment plan including laboratory test results, radiologic images, medication lists, drug allergies, past medical history, family history, social history, and the physical exam. All of these data must be available to tumor board specialists for them to provide the best recommendations for any given patient. Electronic medical records have improved physicians’ ability to access medical information at other hospitals, such as the ‘CareEverywhere’ app on Epic’s electronic medical record. Nevertheless, not all electronic medical record software are equally good at permitting cross-hospital patient information transfer. The success of a national telemedicine tumor board would be contingent on development of robust integrated electronic medical record networks.
  6. Patient selection. Not every cancer patient needs to be presented at a tumor board. For example, the management of a patient with stage 1A non-small cell lung cancer is pretty straight-forward – they get a lung lobectomy. But cancer treatment guidelines change rapidly and it can be difficult for the general oncologist or the general surgeon in a small, rural hospital to keep up with these guidelines. Not too many years ago, the standard of care for stage 1B lung cancer was surgery alone but several years ago, adjuvant chemotherapy was added, followed more recently by neoadjuvant chemotherapy. Last month, a study showed that neoadjuvant chemotherapy plus immunotherapy was better still. There would need to be some process in place to identify those patients who would benefit most from a national telemedicine tumor board. One option could be to refer only those patients that general tumor boards identify as needing discussion at a subspecialty telemedicine tumor board.

Somebody is going to make a fortune

Successful entrepreneurs identify unmet consumer needs and then figure out a way to meet those needs. Those who are successful in a large consumer market become wealthy. Providing specialized cancer treatment recommendations is currently an unmet healthcare need in much of the United States and throughout most of the world. A national telemedicine tumor board has the potential to be an enormous commercial success and has the promise of making whoever can pull it off rich.

However, most physicians did not go into medicine just to be wealthy, we go into medicine so that we can improve people’s lives. I can think of few better ways of improving large numbers of people’s lives than by ensuring that every cancer patient in the U.S. has access to prompt treatment recommendations from specialists up to date on the latest in evidence-based oncology. It is time for national telemedicine tumor boards.

June 22, 2022

By James Allen, MD

I am a Professor Emeritus of Internal Medicine at the Ohio State University and former Medical Director of Ohio State University East Hospital