The painting of a patient: Provider representations of patient fitness and preferences in multi-disciplinary tumor board meetings.

Abstract

246 Background: Pancreatic cancer treatment can involve multiple treatment modalities (e.g. chemotherapy, surgery, radiation) that vary greatly in intensity and timing. The most intense treatments are associated with substantial toxicity and only recommended for medically ‘fit’ patients regardless of age. Despite evidence-based guidelines demonstrating the benefit of including the geriatric assessment (GA) and patient preferences, these may not be formally included in multidisciplinary tumor boards (MDTBs) where treatment decisions are often made. Methods: This qualitative study evaluated MDTB meetings at a single institution between November 2021 and February 2022 for inclusion of fitness and patient preferences. Discussions of patients with stage I-IV pancreatic cancer were identified for inclusion. These recordings were transcribed and analyzed using NVivo for recurring themes and exemplary quotes regarding how providers characterize patients’ fitness and present their preferences to the board. Results: Thirteen MDTB meetings including 50 individuals with stage I-IV pancreatic cancer were included. Descriptions of patient fitness largely consisted of the presentation of common demographic traits such as age and gender. Additional context, primarily focused on occupation, comorbidities, and patient attitudes, was provided when demographic information did not align with perceived fitness level; for example “He’s 60 years old. He’s actually very strong. He used to, or he does, work in landscaping”. There was no formal inclusion of GA data. Explicit references to patient preferences or agentive decision-making only occurred in 19 cases; 11 referring to the patient’s (non-)interest in clinical trials, 3 denying additional testing (tone suggesting non-compliance), and 7 specifically referring to treatment type preference (e.g. surgery vs. chemotherapy). Conclusions: At present, MDTB treatment discussions primarily rely on shared understandings of the cultural significance and meaning of various demographic traits and rarely reference patient-reported preferences or fitness when determining the best pathway for patient care. Further work is needed to understand how to better formally incorporate fitness and preferences into decision-making.