Multidisciplinary Tumor Board

A tumor board (multidisciplinary tumor council) is a weekly meeting where multiple specialists together decide the treatment plan for a head & neck cancer patient. Not one surgeon alone — surgeon, medical oncologist, radiation oncologist, pathologist, radiologist, and speech-swallow therapist deliver a joint decision.

NCCN (National Comprehensive Cancer Network) and ESMO (European Society for Medical Oncology) guidelines define every head & neck cancer case being reviewed in a tumor board as "standard of care" — a decision by a lone surgeon is no longer accepted.

Our board meets Tuesday mornings, reviewing 8-12 new cases + 4-6 follow-up cases on average. Each case takes 10-15 minutes; complex cases up to 30 minutes.

Decisions are not one person's opinion; each specialist brings their discipline's literature, the case is discussed, and consensus or majority decision is recorded in writing.

Same process for international patients — imaging and pathology slides are sent from your country, tumor-board decision is provided as a written English report.

Head & neck surgeon (Prof. Dr. Ahmet Özdoğan): primary surgical resection assessment, neck dissection indication, reconstruction plan.

Medical oncologist: is systemic therapy needed? Adjuvant chemotherapy (cisplatin), induction chemo (TPF protocol), targeted therapy (cetuximab), immunotherapy (pembrolizumab, nivolumab) indication.

Radiation oncologist: is adjuvant radiotherapy required? IMRT vs proton therapy, dose fractionation (70 Gy / 35 fractions classic), concurrent chemoradiation?

Pathologist: positive surgical margin? Extranodal extension? HPV status (p16 IHC in oropharyngeal cancers)? Tumor grade, perineural invasion, lymphovascular invasion report.

Radiologist: interprets PET-CT, MRI, and CT together. Distant metastasis? Correct local staging? Suspicious lesion on post-treatment surveillance imaging?

Speech-swallow therapist: prosthesis and rehab plan after total laryngectomy, swallow study after tongue surgery, voice restoration.

Oncology nurse: side-effect management, patient education, treatment compliance.

Social worker: especially for international patients — accommodation, transfers, insurance-reimbursement documentation, companion coordination.

Step 1 — clinical summary (1-2 min): age, sex, chief complaint, symptom duration, smoking/alcohol history, comorbidities, performance score (ECOG).

Step 2 — physical exam findings (1 min): primary tumor location & size, lymph node status, functional impact (swallow, speech, breathing).

Step 3 — imaging review (2-3 min): contrast neck MRI, contrast CT (including chest/liver), PET-CT (if indicated). Radiologist shows on large screen and interprets.

Step 4 — pathology review (2-3 min): biopsy report, histological type (squamous cell carcinoma 90%+, adenoid cystic, mucoepidermoid), grade, molecular markers if available (HPV p16, EGFR, PD-L1).

Step 5 — TNM staging: AJCC 8th edition is used. T (primary tumor), N (lymph node), M (distant metastasis). HPV-positive oropharyngeal cancer has its own staging system.

Step 6 — treatment options and discussion (5-10 min): surgery-first vs chemoradiation vs organ-preservation approach? Each specialist comments from their discipline.

Step 7 — decision & patient-specific plan: majority or consensus decision + alternatives + estimated oncologic outcome + 5-year survival expectation.

Primary reference: NCCN Guidelines for Head and Neck Cancers (2024 version, online version continuously updated). Evidence level (1, 2A, 2B, 3) stated for each treatment option.

Secondary reference: ESMO Clinical Practice Guidelines + American Head and Neck Society (AHNS) consensus documents.

Patient preference counts: a surgery-preferring larynx cancer patient may choose total laryngectomy instead of organ-preserving chemoradiation. The tumor-board decision is written as "X treatment is appropriate, Y is also acceptable as an alternative, patient will choose with informed consent."

Clinical trial eligibility queried: can the patient enroll in an open trial? (Turkey open trials database: turklinikalaraştırma.gov.tr, with NCT number.)

Surgical margin discussion: R0 (negative margin), R1 (microscopic positive), R2 (macroscopic residual) determines treatment intensity. R1 → adjuvant radiotherapy + (often) chemoradiation.

Extranodal extension (ENE): tumor crossing the lymph-node capsule is an indication for adjuvant chemoradiation — significantly changes oncologic prognosis.

Multidisciplinary decision is documented: date, attending specialists, case summary, discussion points, decision, alternatives, responsible physician. Uploaded to patient file + (for international patients) English version prepared.

Step 1 — inquiry: contact via WhatsApp coordinator or tele-consult form. Existing diagnosis + imaging reports shared.

Step 2 — preliminary assessment (24-48h): our surgeon reviews the reports, decides whether additional tests are needed for the tumor board. Missing items requested.

Step 3 — DICOM and pathology transfer: imaging may arrive via CD/USB or cloud link (PHI-compliant). Pathology slides may be requested as original glass slides (for additional consultation).

Step 4 — tumor-board presentation: case presented at Tuesday meeting. Patient attendance is optional; can listen via video conference (English interpreter included) if desired.

Step 5 — written decision report: within 3-5 business days, English (or German/Russian/Arabic if needed) written report. Content: diagnosis, staging, recommended treatment, alternatives, expected outcome, team signatures.

Step 6 — teleconference (optional): 30-minute video meeting with the physician for Q&A on the report. Interpreter included.

Step 7 — treatment start: patient travels to Istanbul, physical exam + face-to-face meeting with team + surgical date confirmed. Visa support and accommodation coordinated.

For second opinion: patient may already be undergoing treatment at another center. Tumor board prepares second-opinion report; coordination with the original center is at the patient's discretion.

0-3 months: first post-op physical exam within 2 weeks, then monthly. Wound healing, functional outcome, early complication screening.

3 months: first restaging imaging — neck MRI + chest CT. Toxicity monitoring if adjuvant treatment ongoing.

6 months: restaging imaging + tumor-board follow-up meeting. Response status, residual disease, second checkpoint decision.

12 months: PET-CT + neck MRI. Critical milestone for loco-regional control and survival. Tumor board follow-up decision.

12-24 months: physical exam every 3 months + imaging every 6 months. More frequent for high-risk cases (R1, ENE, advanced stage).

24-60 months: physical exam every 6 months + imaging annually. Late recurrence (24-60 months) seen in 5-10% of cases.

Beyond 5 years: annual physical exam, symptom-driven imaging. Second primary cancer screening (low-dose CT for lung cancer in smokers).

For international patients: visit Istanbul twice in the first 12 months recommended (month 3 + month 12 tumor board). Interim follow-ups in your home country, reports shared with us.

A tumor-board decision is not binding; the patient may decline under informed consent or choose an alternative treatment. The decision is a guideline-based recommendation, not absolute authority.

Questions to ask: "What alternatives were discussed? Why this option? What is the expected 5-year survival? What are the side effects? Is a clinical trial open?"

Right to a third opinion: you may share the decision with your old center or another international center (MD Anderson, Memorial Sloan Kettering, Royal Marsden). Disagreement is open for discussion.

Patient rights: all your pathology slides and imaging belong to you; you may take them at any time. Turkey Ministry of Health regulations are clear (Patient Rights Regulation Article 13).

Decision change: a tumor-board decision can be revisited with new information (e.g., second opinion on pathology slides, new imaging finding). You may request a new meeting.

Complaint and ethics: if you have a complaint about the decision process, the hospital ethics committee or Turkish Medical Association can be approached.