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R E S E A R C H A R T I C L E Open Access
The impact of tumor board on cancer care:
evidence from an umbrella review
Maria Lucia Specchia
1,2*
, Emanuela Maria Frisicale
2,3
, Elettra Carini
2
, Andrea Di Pilla
2
, Danila Cappa
2
,
Andrea Barbara
2
, Walter Ricciardi
1,2
and Gianfranco Damiani
1,2
Abstract
Background: Tumor Boards (TBs) are Multidisciplinary Team (MDT) meetings in which different specialists work
together closely sharing clinical decisions in cancer care. The composition is variable, depending on the type of
tumor discussed. As an organizational tool, MDTs are thought to optimize patient outcomes and to improve care
performance. The aim of the study was to perform an umbrella review summarizing the available evidence on the
impact of TBs on healthcare outcomes and processes.
Methods: Pubmed and Web of Science databases were investigated along with a search through citations. The
only study design included was systematic review. Only reviews published after 1997 concerning TBs and performed in
hospital settings were considered. Two researchers synthetized the studies and assessed their quality through the
AMSTAR2 tool.
Results: Five systematic reviews published between 2008 and 2017 were retrieved. One review was focused on
gastrointestinal cancers and included 16 studies; another one was centered on lung cancer and included 16
studies; the remaining three studies considered a wide range of tumors and included 27, 37 and 51 studies each.
The main characteristics about format and members and the definition of TBs were collected. The decisions taken
during TBs led to changes in diagnosis (probability to receive a more accurate assessment and staging), treatment
(usually more appropriate) and survival (not unanimous improvement shown). Other outcomes less highlighted were
quality of life, satisfaction and waiting times.
Conclusions: The study showed that the multidisciplinary approach is the best way to deliver the complex care
needed by cancer patients; however, it is a challenge that requires organizational and cultural changes and must
be led by competent health managers who can improve teamwork within their organizations. Further studies are
needed to reinforce existing literature concerning health outcomes. Evidence on the impact of TBs on clinical
practicesisstilllackingformanyaspectsofcancercare. Further studies should aim to evaluate the impact on
survival rates, quality of life and patient satisfaction. Regular studies should be carried out and new process
indicators should be defined to assess the impact and the performance of TBs more consistently.
Keywords: Healthcare, Tumor board, Multidisciplinary team, Diagnostic accuracy, Personalized treatment, Personalized
medical care, Teleconsultation
© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
* Correspondence: marialucia.specchia@unicatt.it
1
Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8,
00168 Rome, Italy
2
Università Cattolica del Sacro Cuore, Rome, Italy
Full list of author information is available at the end of the article
Specchia et al. BMC Health Services Research (2020) 20:73
https://doi.org/10.1186/s12913-020-4930-3
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Background
Cancer care is a complex path that requires collabor-
ation among professionals with complementary skills
who work together to share the latest evidence and to
pool their expertise, exchanging information through a
regular flow of communication. Technological advances
and the possibility to customize patient treatment plans
(target, molecular and radiation therapy) have further in-
creased the need for regular interactions between health-
care professionals from various areas of expertise.
Consequently, over the last decades, scientific evidence
demonstrates that cancer care has been increasingly de-
livered through multidisciplinary team (MDT) interven-
tions [1].
A MDT is a team composed of professionals from dif-
ferent clinical specialties who work together to make de-
cisions about the recommended clinical pathway of an
individual patient [2,3]. MDT meetings are a fundamen-
tal part of a complex care path, during which MDTs
gather to discuss on a series of patients in order to
achieve a definite staging and formulate a shared treat-
ment plan, in the light of the best available evidence for
customized treatment options and appropriate follow-
up. In most cases, the multidisciplinary approach could
be a great challenge and a useful platform for the coord-
ination of care, and a tool to optimize decision-making
and communication processes. It consequently improves
the healthcare system and its experience for both pa-
tients and professionals, particularly concerning onco-
logical diseases [1,4,5].
When MDT meetings are focused on oncological pa-
tient’s care, they are called Tumor Boards (TBs) [3].
They could also be addressed as Multidisciplinary Can-
cer Conferences (MCC), which have been defined by
Wright et al., 2007 as forum for healthcare providers
aiming to discuss diagnostic and treatment of cancer pa-
tients [6]. This term has been used as a synonym of TB
[6,7]; therefore, this review will comprehensively ad-
dress this concepts as TBs.
While in the literature the multidisciplinary approach
in cancer care is described from 1975, it was not regu-
larly implemented in clinical practice until the late
1990’s (more specifically, starting from 1997) [8,9].
From that moment on, the use of the multidisciplinary
approach has continually increased, eventually becoming
routine with the constitution and improvement of TBs
being pursued as key objectives in many cancer plans
and clinical practice guidelines [10–17].
In the past, internists or general practitioners managed
oncological patients individually, only seeking counsel-
ling from cancer specialists when they deemed it neces-
sary. The formal establishment of multidisciplinary
engagement for oncological patients care began with the
creation of TBs. In the beginning, TBs aimed to advise
and assist the physicians who held the responsibility on
clinical management and on care decision. A TB was
only called at one point in patient management time,
not during the entire staging and treatment pathway,
and the patient was rarely present [7].
Over time, TBs have evolved acquiring a more collab-
orative structure with teams that pay attention to all the
aspects of cancer care, including rehabilitation, psycho-
social needs and long-term care. The patient could also
be present at the meetings and his/her consensus is
sought throughout the duration of the treatment
process. In addition, treatment decisions and clinical re-
sponsibility are shared by the members of the TB. More
recently, technological advances have made collaboration
among TB members easier by introducing the possibility
of “virtual team”meetings when team members are not
available in person [7].
The members of TBs and their attendance at meetings
depend on several factors which include hospital size
and cancer type. In general, professionals eligible to par-
ticipate as members of the TB are medical and radiation
oncologists, surgeons, radiologists, pathologists, nurse
specialists, nuclear medicine specialists, palliative medi-
cine physicians, pharmaceutical experts and psycho on-
cologists. Various professionals with a background in
allied health disciplines such as genetics counsellors,
nutritionists, plastic surgeons may also be called upon
and finally experts specialized in areas related to the
tumor site may also be present. Within the TBs,
leaders are usually identified for the effective coordination
and organization of services and clinical management
[7,18,19].
Cancer patients can be discussed either in a prospect-
ive or retrospective manner. A TB with a prospective ap-
proach gathers the collaborating specialists formally at
scheduled times in order to review individual cancer pa-
tients in a pragmatic way using an evidence-based ap-
proach, to discuss diagnosis and formulate future
treatment and management plans [3].
The retrospective approach, which will not be ad-
dressed by this review, consists of a multidisciplinary
discussion of cases with an educational aim, to assess in
a multi-professional environment whether the decisions
taken for the patient’s management were optimal in an
effort to inform and educate the treating physicians in
hopes of improving care for future cases [20].
Many studies and integrated reviews have been per-
formed in an effort to evaluate the actual impact that
the introduction of TBs have had on the medical prac-
tice. The evidence describes aspects of clinical practice
such as patient assessment, diagnosis and staging [21],
treatment (e.g. adherence to treatment plan or to the
guidelines [22–24]) and clinical outcomes (survival, re-
currence of cancer, etc.) [12,25–27]. Although there is
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awareness that other factors evolved along with the TBs
such as innovative technologies in diagnostics and ther-
apy, the scientific research investigated whether the sig-
nificant investment in time and financial resources for
TBs were matched with an effective improvement of the
outcomes [4,5].
This umbrella review aims to provide stronger evi-
dence for healthcare decision-makers by comparing find-
ings from different reviews that address the same topic
[28]. The researchers aim to present a comprehensive
analysis of the impact of TBs on healthcare outcomes
and processes.
Methods
The study was performed with an umbrella review de-
sign which refers to an analysis that compiles evidence
from multiple reviews into one document. To evaluate if
consistent literature was available, a scoping review was
carried out first. Clear objectives/questions were defined
accordingly, and detailed inclusion and exclusion criteria
were identified. Thereafter, structured search process,
quality assessment of the included reviews, and effective
data extraction were performed to synthesize the results
of the literature review [28].
Search strategy
A systematic research of reviews was conducted through
PubMed and Web of Science databases using the following
string: ((cancer OR neoplasm* OR tumour* OR tumor* OR
malignanc*) AND (“cancer management”OR “tumor
board*”OR “tumour board*”OR “cancer board*”OR “multi-
disciplinary team*”OR “multidisciplinary meeting*”OR
“cancer MDT”OR “cancer care”OR “multidisciplinary con-
ference*”OR “multidisciplinary clinic*”OR “patient care
team*”OR “patient care planning”)AND(“clinical decision-
making”OR “outcome and process assessment”OR “diagno-
sis change*”OR survival OR “guidelines adherence”OR
morbidity OR mortality OR management)). The investigation
of the databases was conducted during January 2019 (until
23rd January). An additional search of citations referenced in
the included studies was performed to complete the research.
The articles retrieved were screened independently by two
researchers by title, then by abstract and eventually by read-
ing the full text according to the inclusion and exclusion
criteria outlined in the next paragraph.
Inclusion / exclusion criteria
PICOS elements (Population, Intervention, Comparator,
Outcome, Study type) were used as parameters to define
inclusion and exclusion criteria.
(P) The studies selected assessed oncological popula-
tions with cancer in different organs. (I) The interven-
tion was defined as “scheduled TBs”in a process of
taking in charge patients in a hospital setting. (C) The
comparison used was no TBs implementation. (O) Out-
comes considered were both clinical and related to care
processes. (S) In this study, only systematic reviews were
considered. Moreover, other inclusion criteria were: Eng-
lish, French, Spanish, and Italian as language of publica-
tion; year of publication later than 1997; and availability
of full-texts. We also excluded articles focused only on
elderly and pediatric population.
Selection process and data extraction
The selection of articles followed the criteria defined in
the PRISMA Statement and was independently performed
by two authors. The same researchers extracted data from
the selected reviews. For each review retrieved the main
information were categorized in a table and classified as
data related to: authors, year and country, databases inves-
tigated and date range, number of studies included, quality
assessment, study population, aim of the review, out-
comes/outputs reported, and main findings.
Quality assessment
The quality of the reviews retrieved was assessed using the
AMSTAR2 tool. This is one of the most widely used in-
struments to enable a reproducible assessment of the
quality of both randomized as well as non-randomized
systematic reviews. AMSTAR2 consists of sixteen do-
mains presented in the form of questions. The possible
answers are ‘Yes’if it denotes a positive result; ‘No’when
both the answer is negative or it can’t be provided; ‘Partial
Yes’in case of partial adherence to the standard [29].
The final quality judgment (high, moderate, low, critic-
ally low) was performed by two researchers and disagree-
ments were overcome by consensus. The judgement was
based on the assessment of specific critical domains,
which were identified as the: presence of a protocol regis-
tered before the commencement of the review; adequacy
of the literature search; justification for excluding individ-
ual studies; evaluation of the risk of bias of the studies in-
cluded; appropriateness of meta-analytic methods when
applicable; consideration of risk of bias when interpreting
the results of the review; assessment of presence and likely
impact of publication bias.
Results
A total number of 4020 records were found. After re-
moving duplicates and reading titles and abstracts, five
systematic reviews met the inclusion and exclusion cri-
teria. Details about the process of exclusion of records
are provided in the PRISMA chart (Fig. 1).
The objectives of four reviews fully aligned with the
aim of this umbrella review; all five were focused on
assessing the impact and effectiveness of case discussion
among TB members on various healthcare outcomes/
outputs and processes with reference to both patients
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and professionals. The review of Lamb et al. (2011) ad-
dressed factors which enhanced or impeded effective
decision-making in TBs. It also provided an analysis of
the impact of TBs that aligned with the objectives of this
study. The five reviews ranged from 2008 to 2017. Three
of the reviews (Lamb et al., 2011 [30], Prades et al., 2015
[31], Pillay et al., 2016 [32]) considered a wide range of
tumors discussed by TBs, while the other two studies
were focused on lung (Coory et al., 2008) [33] and
gastrointestinal (Basta et al., 2017) [34] cancer discus-
sion. The main characteristics of the studies are summa-
rized in Table 1.
The number of studies included in each review varied,
ranging from 16 to 51 studies. Sixteen studies were in-
cluded in the systematic review focused on lung cancer
[33]; 16 in the review concerning gastrointestinal cancers
[34]; and 51 [31], 27 [32] and 37 [30] studies were
included in the other 3 reviews. Some of the articles in-
cluded were found in two or more of the reviews consid-
ered. More precisely, one study was cited in four out of
five reviews [30–32,34] and three studies were shared
by three reviews (one study in common by Prades [31],
Pillay [32] and Basta [34]; one by Prades [31], Pillay [32]
and Lamb [30] and one by Pillay [32], Basta [34] and
Lamb [30]). Other primary studies were common to two
reviews. In particular two reviews not focusing on a spe-
cific kind of tumor (Prades et al., 2015 [31] and Pillay
et al., 2016 [32]) shared a higher number of articles,
seven overall. Coory et al. [33] review was the only one
that had articles in common only with Lamb et al. re-
view [30]. However, 120 studies were considered
globally.
The databases searched for the different reviews were
PubMed, Ovid Medline, PsycINFO, Embase, and Cochrane.
Two studies [31,33] limited the research to one database
and one of them also widened the research with a snowball
search [33]. Two studies [32,34]searchedthreedatabases
each, while one [30] searched a total of four databases. Inclu-
sion and exclusion criteria for each review were clearly stated
and limitations were identified.
Although in general the descriptions of TBs were simi-
lar, the definitions reported by the five reviews showed a
variability concerning the characteristics and compos-
ition of TBs both in terms of format and members
(Table 2). On the contrary, all the reviews reported the
same clinical objectives for the TBs, which was to
Fig. 1 PRISMA Flow chart
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Table 1 Characteristics of the reviews included
Authors,
year, country
Databases and
date range
Number
of studies (studies quality)
Cancer types and
population
Objective Outcomes /
outputs
Main results
Coory et al.,
2008 [38]
(Australia)
Ovid Medline,
and snowball
search. 1984 -
July 2007.
16 (studies quality: not
assessed)
Lung cancer (both SCLC and
NSCLC)
To evaluate and critically
appraise the effectiveness
of multidisciplinary teams
to treat lung cancer and
particularly to assess if the
TBs, compared to
traditional models of care,
improves survival, and
other outcomes such as
practice patterns and
waiting times.
Survival.
Practice
patterns.
Waiting times.
Satisfaction with
care.
Visits to GPs.
Quality of life.
Weak evidence of a causal
association in survival
improvement.
Stronger evidence of the
effect of TBs on changing
patient management:
increase in the percentage
of patients undergoing
surgical resection and in the
percentage of patients
undergoing chemotherapy
or radiotherapy with
curative intent.
Reduced waiting times.
Improved patient
satisfaction.
Reduced number of visits to
GPs.
No-statistically significant
differences in patients’
quality of life.
Lamb et al.,
2011 [30]
(UK)
Embase,
Medline,
PsycINFO
(using OvidSP),
Cochrane
database. 1999
- 15th May
2009
37 (studies quality: low to
medium)
Breast, lung, gynaecology,
urology, upper GI, colorectal,
sarcoma, brain, head and neck
cancer
To examine the literature
on care management
decisions in cancer TBs and
assess the factors that
enhance or impede
effective decision-making
Diagnosis.
Care
management
decisions.
Adherence to
guidelines.
Treatment.
Implementation
of TB decisions.
Survival.
Improvement in diagnostic
accuracy.
Changes in care
management decisions (2–
52% of cases).
Improved adherence to
clinical guidelines.
More likelihood of patients
being offered
chemotherapy (7–23%).
TB decisions not
implemented in 1–16% of
cases.
Significant increase in
survival for patients being
offered chemotherapy (3.2–
6.6 months).
Prades et al.,
2015 [31]
(Spain and
Belgium)
Medline
database.
November
2005–June
2012
51
(studies quality: not
assessed)
Urological, pancreatic, rectal,
head and neck, melanoma,
oesophageal, prostate and
genitourinary, colon, lung,
breast, oesophageal,
osteological, skin,
gynaecological, and
neurological cancer and bone
metastases
To assess the impact of TBs
on patient outcomes in
cancer care and identify
their objectives,
organisation and ability to
engage patients in the care
process.
Diagnosis and/
or treatment
planning.
Survival.
Patient quality
of life.
Patient and
clinician
satisfaction.
Waiting times.
Care
coordination for
professionals
and patients.
Improvement in diagnosis
and staging accuracy; more
appropriate treatment
through preoperative
review of imaging and
pathology results; more up-
to-date treatment; struc-
tured follow-up care plan.
Improved survival.
Patient quality of life
improvement.
Improved patient and
clinician satisfaction.
Reduced waiting times.
Coordination and continuity
of care improvement by
reducing time from
diagnosis to treatment;
achieving early and
appropriate referral patterns.
Furthermore: teaching
environment for healthcare
professionals and junior
doctors; increased
enrolment in tumour
registry; maintaining a
commitment to research
and clinical trials
Pillay et al.,
2016 [32]
(Australia)
OVID Medline,
PsycINFO, and
EMBASE
databases.
1995 - April
2015
27 (studies quality: not
assessed)
Colon or rectal, lung,
oesophageal or gastric,
urological, gynaecological,
breast, hematologic and head
and neck tumours.
Mean or median age range:
54–71 years.
Sample size range: 47–6760.
To summarise, integrate,
and critically evaluate the
literature regarding the
impact of TBs on patient
assessment, diagnosis,
management and
outcomes in oncology
settings.
Patient
assessment/
diagnosis.
Patient
management/
clinical practice.
Waiting times.
Survival,
Changes in diagnostic
reports after TB discussion
(between 4 and 35% of
patients discussed at TBs);
more likelihood to receive
more accurate and
complete pre-operative sta-
ging for patients discussed
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discuss the diagnosis, treatment and management of
oncological patients in a board composed of multiple
healthcare professionals. The working format of TBs was
described in a number of ways, but all the reviews
agreed on the practice of holding scheduled meetings
which could be either daily or weekly, in person, by
video or teleconferencing. Only Prades et al., 2015 [31]
cited TBs Clinic format in which patients were not only
discussed but also simultaneously examined by all board
members. Team members were determined based on
factors such as type of cancer studied and hospital size.
Therefore, each TB included different specialties of
healthcare professional (surgeons, oncologists, patholo-
gists, radiologists, nurses, etc.). In particular, Prades
et al., 2015 [31] described the team according to three
levels of involvement: core and allied members which
are all medical specialists and support members that in-
clude both medical and non-medical professionals.
A structured quality assessment of the included papers
was performed only in two systematic reviews (Basta
et al., 2017 [34]; Lamb et al., 2011 [30]), using different
tools. In Basta et al., 2017 [34] the ‘Quality Assessment
Tool for Before–After (Pre–Post) Studies With No Con-
trol Group’was used to assess the quality of before–after
studies and the ‘Quality Assessment Tool for Observa-
tional Cohort and Cross-Sectional Studies’was used to
evaluate cohort studies. The papers were finally classified
as fair. Also risk of bias was evaluated, using a single tool
(‘To Assess the Risk of Bias in Cohort Studies’) for both
study design. All studies scored as ‘moderate’relating to
risk of bias. In Lamb et al., 2011 [30] Authors chose an
assessment tool to be used in systematic reviews with
heterogeneous articles and the quality of papers was
classified as low to medium [35]..
Quality assessment for the other reviews was per-
formed in a non-structured manner (Coory et al. [33])
or not at all (Prades [31] et al. and Pillay [32] et al.).
Outcomes and outputs
The outcomes and outputs reported by the reviews are
presented in the following paragraphs. More details are
shown in Table 3.
Diagnosis
Four out of five reviews focused on different aspects of
the diagnostic process. Eight studies examined by Prades
et al., 2015 [31] suggested an improvement in diagnosis
and staging accuracy promoted by the establishment of a
Table 1 Characteristics of the reviews included (Continued)
Authors,
year, country
Databases and
date range
Number
of studies (studies quality)
Cancer types and
population
Objective Outcomes /
outputs
Main results
recurrence
rates/remaining
tumour after
resection and
rate of
metastasis.
at TBs.
Changes in patient
management/clinical
practice after discussion
reported in 4.5–52% of
cases.
More likelihood to receive
neoadjuvant/adjuvant
treatment and greater
adherence to guidelines for
patients discussed at TBs.
Limited evidence for
improved waiting times.
Limited evidence for
improved survival of
patients discussed at TBs;
little positive impact on
local recurrence rates/
remaining tumour after
resection and incidence of
metastases.
Basta et al.,
2017 [34]
(The
Netherlands)
PubMed,
MEDLINE and
EMBASE
electronic
databases.
Until 30
November
2016.
16 (studies quality: fair) Gastrointestinal malignancies:
oesophageal or gastric,
colorectal, pancreatic or
biliary, liver malignancy or
neuroendocrine, other
malignancies.
To assess whether the
discussion in a
multidisciplinary
gastrointestinal cancer
team meeting influences
the diagnosis and
treatment plan for patients
with GI malignancies.
Diagnosis and
staging.
Treatment plan
and adherence
to guidelines.
Implementation
of the treatment
plan.
Changes in the diagnoses
formulated by individual
physicians after TB
discussion (18.4–26.9% of
evaluated cases); accurate
diagnosis in 89–93.5% of
cases evaluated by TBs;
more frequent complete
staging evaluation for
patients discussed.
Treatment plan altered in
23.0–41.7% of evaluated
cases; increased adherence
to guidelines.
TB decisions implemented
in 90–100% of evaluated
cases.
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Table 2 TBs characteristics
Coory et al., 2008 [33] Lamb et al., 2011 [30] Prades et al., 2015 [31] Pillay et al., 2016 [32] Basta et al., 2017 [34]
Definition Team working among
specialists with diagnostic
and therapeutic intent,
who meet to discuss the
diagnosis and
management of patients.
Group of different
healthcare professionals,
who meets together to
discuss a patient. Each one
is able to contribute
independently to the
diagnostic and treatment
decisions about the
patients.
Alliance of health care
professionals related to a
specific tumour disease.
Approach to cancer care is
guided by willingness to
agree on evidence-based
clinical decisions and to
coordinate the delivery of
care at all stages of the
process, encouraging pa-
tients to take an active role
in their care.
A regularly scheduled
discussion of patients,
comprising professionals
from different specialties.
The TB serves as a platform
for the coordinated
delivery of care through
consultation amongst
different professionals in a
single setting.
Healthcare
professionals from
different medical
specialties working
together for specific
diseases.
Intent To discuss diagnosis,
treatment and
management of patients.
To discuss patients and
contribute to the
diagnostic and treatment
decisions.
To improve
communication,
coordination and decision-
making between health-
care professionals.
Appropriate and up-to-
date treatment, structured
follow up plan.
To improve coordination
and continuity of care, to
achieve early referral
patterns.
Coordination of care within
the team to ensure
accurate staging,
consideration of different
treatment options,
continuity of treatment,
and follow-up.
To discuss and
diagnose patients
with complex
diseases and
formulate a
treatment plan
according to the
guidelines.
Format Meetings of specialists at
specified time either in
person, by video or
teleconferencing.
Meetings of professionals
at a given time, physically,
by video or
teleconferencing.
(1) Meetings of 30 min - 2
h including either all or a
selection of diagnosed
and/or referred patients.
Patients selection by the
specialist in charge on the
basis of the case’s level of
complexity or the wide
range of therapeutic
possibilities, prearranged
team criteria, or triage by
the clinical coordinator.
(2) Clinics in which
patients were seen and
also simultaneously
examined or remotely
coordinated by all board
members.
(3) Online conferences
within a given hospital or
nationwide. Meeting
presentations involving
prospective reviews of
new and recurrent cases,
previously reviewed cases
requiring additional follow-
up, and second opinions.
TBs conducted either
weekly or fortnightly (daily
meetings reported in one
study).
Team meetings at
periodic intervals (i.e.,
daily or weekly).
Members Thoracic physicians,
thoracic surgeons,
radiation oncologists,
specialist radiologist,
medical oncologists,
pathologists, nursing and
allied health staff and
palliative-care specialists
(there are different local
configurations).
Several healthcare
specialists.
Team members and
attendance vary according
to hospital size and
medical specialty. Three
levels of members
involvement. (1) Core and
(2) Allied: radiologists,
pathologists, surgeons,
radiation and medical
oncologists, oncology
nurses, palliative care
physicians, head and neck
specialists, nuclear
medicine specialists,
respiratory disease
physicians, gastrointestinal
disease physicians and
anaesthesiologists; (3)
Support: psychologists,
Surgeons, medical and
radiation oncologists,
radiologists, pathologists
and nurse specialists. In
addition, professionals from
pharmacy, palliative
medicine, mental health
and other allied health
disciplines may also be
present.
Different medical
specialists.
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multidisciplinary setting. Three studies in Lamb et al.,
2011 [30] reported that TBs improve diagnostic accur-
acy. Fifteen studies by Pillay et al., 2016 [32] described
changes in diagnostic reports after TB discussion and six
studies comparing a TB group with a control group of
patients saw a significant impact of TBs on patient as-
sessment and diagnosis with higher accuracy in staging.
Even Basta et al., 2017 [34] found that four studies
showed a significant impact of TBs in changing the diag-
nosis formulated by the referring physicians, while one
study described no changes in diagnosis or stage after
validation by pathology or follow up. Two studies also
evaluated the accuracy of the diagnosis itself, which was
found to be accurate in 89.0 and 93.5% of cases. Finally,
two studies found that there were influences in tumor
staging related to TBs discussion.
Quality of life
Results concerning quality of life were described in two
of the systematic reviews examined and they reported
two different outputs. One study included in Coory
et al., 2008 [33] found, by submitting a questionnaire to
the patients, no-statistically significant differences be-
tween the patients examined in the TB and the control
group, while six studies of Prades et al., 2015 [31] de-
scribed an improvement on quality of life.
Recurrence and metastasis after resection
Only one review (Pillay et al., 2016) [32] reported the
impact of TBs on recurrence of tumor and metastasis
rates after surgical resection with two studies describing
only a minimal positive impact on local recurrence rates
of rectal cancer and incidence of metastases and
remaining pelvic tumor after resection.
Survival
Results in terms of survival were also reported and
showed non-homogeneous findings. Two studies from
Coory et al., 2008 [33] reported statistically significant
results while three studies did not show a statistically
significant improvement. Ten studies from Prades et al.,
2015 [31] described survival improvement for colorectal,
head and neck, breast, esophageal, and lung cancer.
Lastly, Pillay et al., 2016 [32] described both a significant
association in two studies and no association in four
studies, although one of these studies reported an im-
provement in post-operative mortality in rectal cancer
patients discussed by TBs.
Treatment
All of the reviews retrieved highlighted an impact on treat-
ment strategies and processes. Six studies described by Coory
et al., 2008 [33] measured changes in treatment strategies.
Prades et al., 2015 [31] focused on three aspects of treatment
improvement which was enabled by the preoperative review
of imaging and pathology results, the positive impact of the
multidisciplinary approach regarding offering up-to-date
therapies, and the ability to set up a structured follow-up
plan. The review by Pillay et al., 2016 [32] also reported vari-
ous degrees of changes in treatment management both in
prospective and retrospective studies. Only three case-
control studies found a non-significant difference in treat-
ment. Basta et al., 2017 [34] described an alteration and en-
hancement of treatment plans with an increased adherence
to guidelines. Finally, six studies included by Lamb et al.,
2011 [30] reported changes in care management decisions,
while other six studies described a lack of implementation of
TB decisions. Moreover, in Lamb et al., 2011 [30]fourstud-
ies reported that decisions were based on biomedical infor-
mation while patient choice was considered infrequently. In
fact, only a study in Lamb et al., 2011 [30] reported patient
involvement in regard to the decision-making process reveal-
ing that the involvement was described only in 4% of the
cases. Another result procured through this review was that
four studies reported that telemedicine improves the attend-
ance of meeting and allows to visualize pathological and
radiological reports from different locations.
Table 2 TBs characteristics (Continued)
Coory et al., 2008 [33] Lamb et al., 2011 [30] Prades et al., 2015 [31] Pillay et al., 2016 [32] Basta et al., 2017 [34]
nutritionists, dieticians,
plastic surgeons, speech
therapists, patients’GPs,
physiotherapists,
practitioners of
complementary medicine,
orthopaedic specialists,
medical physicists,
odontologists, faith
counsellors, biologists, data
managers, genetic
counsellors, hospital
pharmacists, social workers
and occupational
therapists.
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Table 3 Outcomes and outputs in the reviews retrieved. Main findings
Outcome / Output Author /
Year
N. of
studies
Results / Findings
Care coordination Prades et al.,
2015 [31]
22 Format, data management and professional roles of TBs impacted positively on care
coordination for professionals and patients.
Diagnosis (Patient assessment,
diagnosis, staging)
Lamb et al.,
2011 [30]
3 Improvement in diagnostic accuracy was reported.
Prades et al.,
2015 [31]
8 Multidisciplinary setting improved diagnosis and staging accuracy.
Pillay et al.,
2016 [32]
15 Diagnostic reports changed after the meeting in 4–35% of patients discussed.
6 The impact of the TB on assessment and diagnosis was significant (higher accuracy
in staging).
Basta et al.,
2017 [34]
1 No changes in diagnosis or stage were reported after validation by pathology or
after follow-up.
4 TBs changed the diagnoses formulated by referring physicians in 18.4–26.9% of
cases.
2 TBs formulated an accurate diagnosis in 89 and 93.5% of evaluated cases.
2 Discussion during the TB influenced staging. After introduction of the TB, more
patients underwent computed tomography (CT) before operation and patients
discussed more often received a complete staging evaluation.
Treatment (Practice patterns,
clinical practice, patient management, I
mplementation of treatment changes)
Coory et al.,
2008 [33]
1 A not statistically significant larger percentage of patients discussed in TB (43%)
received radical treatment than the control group (33%).
1 A statistically significant increase in the percentage of patients older than 70 years
receiving radical radiotherapy (from 3% in 1995 to 12% in 2000; p= 0.004) was
reported. The percentage receiving palliative radiotherapy decreased (from 65 to
55%).
1 A statistically significant increase in the percentage of patients receiving
chemotherapy (from 7% in 1997 to 23% in 2001; p< 0.001) was reported. The
percentage of patients receiving palliative care decreased (from 58 to 44%; p=
0.0045) and the percentage of patients being formally staged increased (from 70 to
81%; p= 0.035).
3 Surgical resection rate was higher in MD groups.
Lamb et al.,
2011 [30]
6 Changes in care management decisions were reported in 2–52% of cases.
1 TBs improved adherence to clinical guidelines.
1 Likelihood of patients being offered chemotherapy increased (from 7 to 23%)
6 Care management decisions by TBs were not implemented in 1–16% of cases due to
contradictory patient choice or because of comorbidities.
Prades et al.,
2015 [31]
21 TBs ensured more appropriate treatment through preoperative review of imaging
and pathology results; multidisciplinary approach guaranteed the most up-to-date
treatment, and set up a structured follow-up care plan.
Pillay et al.,
2016 [32]
25 Changes in patient management/clinical practice were measured. Three studies
reported minimal change in clinical management (less than 9% of cases), four studies
indicated that the percentage of patients who underwent changes in treatment
plans ranged from 19 to 34.5%. Other studies reported that changes in patient
management plan following a TB occurred in 4.5–52% of cases.
13 Patients who were discussed were more likely to receive neoadjuvant or adjuvant
treatment. Greater adherence to National Comprehensive Cancer Network (NCCN)
guidelines was found in two studies.
Basta et al.,
2017 [34]
9 Treatment plan formulated by the referring physician was altered in 23.0–41.7% of
evaluated cases.
5 TB decisions on treatment plan were implemented in 90–100% of evaluated cases.
The reasons for not following TB advice were comorbidity (45%) and patient
preferences (35%), followed by new clinical information (10%), different opinion of
the treating physician (5%), and unknown (5%).
3 TBs increased adherence to guidelines. Treatment plan more often adhered to
national guidelines: 98% versus 83%.
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Care coordination
Only one review (Prades et al., 2015) [31] examined the
impact of TBs format, data management and role of the
professionals on care coordination for professionals and
patients. The resulting impact was seen to be positive.
Satisfaction
Both patients’and professionals’satisfaction was de-
scribed in some of the studies retrieved and improve-
ment was noted for both cases. Patients’satisfaction
related to a better organization of investigations and to
personal experience of care was described in one study
included in the review by Coory et al., 2008 [33]; it was
acquired through the submission of a questionnaire.
Prades et al., 2015 [31] also found improved clinician
satisfaction as a result of teamwork communication and
cooperation.
Visits to general practitioners
Only one study, analysed by Coory et al., 2008 [33],
highlighted the aspect pertaining to visits to General
Practitioners (GPs). In this case, significantly fewer visits
to GPs were reported for the TB group.
Table 3 Outcomes and outputs in the reviews retrieved. Main findings (Continued)
Outcome / Output Author /
Year
N. of
studies
Results / Findings
Quality of life Coory et al.,
2008 [33]
1 No statistically significant difference between groups was found
Prades et al.,
2015 [31]
6 Improvement of patients’quality of life
Recurrence and metastasis
after resection
Pillay et al.,
2016 [32]
2 TB discussion had little positive impact on local recurrence rates of rectal cancer and
incidence of metastases and remaining pelvic tumour after resection.
Satisfaction
(patient or clinician)
Coory et al.,
2008 [33]
1 TBs resulted in better satisfaction for organisation of investigations and personal
experience of care.
Prades et al.,
2015 [31]
5 TBs improved patient and clinician satisfaction as a consequence of team work
communication and cooperation.
Survival Coory et al.,
2008 [33]
2 Two studies reported statistically significant survival improvement. 1 study reported
an improvement of 3.2 months in median survival of patients with inoperable NSCLC,
the other an increase from 18.3 to 23.5% in 1-year survival of lung cancer patients
older than 70.
3 Three studies did not show a statistically significant improvement.
Lamb et al.,
2011 [30]
1 Patients being offered chemotherapy showed a significant increase in survival (from
3.2 to 6.6 months).
Prades et al.,
2015 [31]
10 Improvements in survival were reported for colorectal, head and neck, breast,
oesophageal, and lung cancer.
Pillay et al.,
2016 [32]
4 TB discussion was not associated with overall survival. However, in one of these
studies, rectal cancer patients discussed had improved post-operative mortality.
2 Significant association was shown between TB discussion and survival of patients.
Visits to general
practitioners
Coory et al.,
2008 [33]
1 Significantly fewer visits were reported for the MD group than the control group.
Waiting times Coory et al.,
2008 [33]
3 In one study the median time from presentation to first treatment was 3 weeks in
the MD arm (7 weeks in the control arm) but there was no difference in the time
from diagnosis to radical treatment. Another study reported a reduction in mean
time from presentation to surgery of 15 days. In the last study, a reduction of days
from diagnosis to treatment from 29.3 to 18.8 was reported.
Prades et al.,
2015 [31]
10 TBs resulted in reduction of time from diagnosis to treatment, and achievement of
early and appropriate referral patterns.
Pillay et al.,
2016 [32]
2 In two studies patients discussed in TBs had fewer mean days from diagnosis to
treatment.
1 One study found an opposite trend.
Other Prades et al.,
2015 [31]
7 TBs promoted the establishment of a teaching environment for healthcare
professionals and junior doctors.
9 A commitment to research and clinical trials was maintained.
1 The enrolment in the tumour registry increased.
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Waiting times
Prades et al., 2015 [31] reported an impact of TB inter-
ventions on the reduction of time from diagnosis to
treatment and also on the achievement of early and ap-
propriate referral patterns. Three studies included in
Coory et al., 2008 [33] review also assessed this topic
reporting a reduction of median time from presentation
to first treatment, mean time from presentation to sur-
gery and average number of days from diagnosis to
treatment. Two studies included in Pillay et al., 2016
[32] described fewer mean days from diagnosis to treat-
ment and one study demonstrated an opposite trend.
Other
The systematic review from Prades et al., 2015 [31] also
described other areas of improvement promoted by TBs
such as the establishment of a teaching environment for
healthcare professionals and junior doctors, the increase
in enrollment to tumor registries and stronger commit-
ments to research and clinical trials.
Quality assessment
According to the qualitative assessment tool AMSTAR2
scale, the five systematic reviews have been evaluated as
“critically low”[29] because they presented more than
one weakness among the critical domains previously de-
scribed. Of the 16 domains assessed by the AMSTAR2
scale, all the reviews reported a negative answer in the
domain concerning the source of funding reporting
(10th domain). None of the reviews performed a meta-
analysis (11th and 12th domains), nor an adequate inves-
tigation of publication bias with a discussion of its im-
pact on the results (15th domain). Other weaknesses,
although Basta et al., 2017 [34] got some partial positive
responses, concerned the following domains: absence of
a protocol provided before the conduct of the review
(2nd domain) and absence of a defined technique to as-
sess the risk of bias (9th domain).
Discussion
TBs are recognized as an effective approach in cancer
care to improve quality of healthcare processes and
patient’s outcomes (Lamb et al., 2011) [30]. To our
knowledge, this umbrella review is the first attempt to
synthetize the vast amount of literature available con-
cerning the impact of TBs on health outcomes and clin-
ical processes. This study was performed to provide
stronger evidence on this topic. In fact, the five reviews
included in this paper collected information from 120
studies, although only qualitative and not quantitative
syntheses of the results were provided.
Different aspects emerge from this paper to be consid-
ered for further discussion. Firstly, regarding the descrip-
tion of TBs, the findings of this umbrella review clearly
confirm a progressive evolutionary trend - from 2008 to
date - of TBs, whose characteristics have been changing
and evolving over time. Initially created to provide a
consultation by all physicians in charge at a specific
point of the cancer treatment pathway [7], TBs have
gradually acquired a more collaborative approach in
which the decisions and clinical responsibility are shared
by all the members of the TB, who also address all the
aspects of treatment during all stages of the delivery of
care. Patients could also be involved in the decision-
making processes [7,30–34].
Indeed, all five reviews consistently describe TB as the
place where - although with format and members that
can partly vary - health professionals discuss diagnosis,
treatment and management of their patients in order to
reach shared decisions, improve the diagnostic accuracy,
get an accurate staging and provide the best evidence-
based treatment and patients’health outcomes [30–34].
Moreover, Lamb et al., 2011 [30], Prades et al., 2015 [31]
and Pillay et al., 2016 [32] underline the fundamental
role of TBs in improving communication, coordination
and continuity of care among the different professionals
involved in care process. Furthermore, the definition of
TB by Prades et al., 2015 [31], includes encouraging pa-
tients to take an active role in their care.
Concerning the impact of TBs, the effects on diagno-
sis, treatment and survival were addressed by most of
the reviews. Diagnosis was addressed by four reviews
(Lamb et al., 2011 [30], Prades et al., 2015 [31], Pillay
et al., 2016 [32], Basta et al., 2017 [34]), while treatment
was discussed in all the reviews (Coory et al., 2008 [33],
Lamb et al., 2011 [30], Prades et al., 2015 [31], Pillay
et al., 2016 [32], Basta et al., 2017 [34]), and survival by
four of them (Coory at al., 2008 [33], Lamb et al., 2011
[30], Prades et al., 2015 [31], Pillay et al., 2016 [32]).
In regard to diagnosis, improvements in the diagnostic
and staging processes accuracy were reported (Lamb et al.,
2011 [30], Prades et al., 2015 [31], Pillay et al., 2016 [32],
Basta et al., 2017 [34]). In reference to treatments, the five
reviews (Coory et al., 2008 [33], Lamb et al., 2011 [30],
Prades et al., 2015 [31], Pillay et al., 2016 [32], Basta et al.,
2017 [34]) showed that TB discussion led to changes in
patient management/clinical practices. Pillay et al., 2016
[32] and Basta et al., 2017 [34] also reported an increased
adherence to guidelines. Such impacts are attributable to
the discussion during meetings which lead to modifica-
tions in both diagnostic paths and treatment plans in an
effort to find the best alternatives for the patients while
simultaneously adhering to clinical guidelines. Indeed,
many guidelines specifically included the multidisciplinary
approach as a tool for cancer patients management [15–
17]. By offering different healthcare professionals the pos-
sibility to discuss cases while analyzing imaging and histo-
logical referrals, the TB facilitates multidisciplinary
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approach, that encourages and allows the exchange of
knowledge. This collaboration among professionals with a
variety of experiences allows for a more accurate diagnosis
and assist practitioners to offer the best and most appro-
priate treatment (Basta et al., 2017 [34]; Lamb et al., 2011
[30]). Results on survival were not homogeneous. In some
cases, as described by Prades et al., 2015, [31]survivalim-
proved, in others, as reported by Coory et al., 2008 [33],
Lamb et al., 2011 [30] and Pillay et al., 2016 [32], evidence
was limited. The lack of sufficient evidence on survival -
as noted by Coory et al., 2008 [33]–may be attributed to
a difficulty in conducting randomized clinical trials in
order to demonstrate the potential impact of TB on its
improvement, free from confounding factors. This last as-
pect is also addressed by Houssami & Sainsbury, 2006
[36], in which the survival benefit was shown to be related
to the specialist who operated.
The other TB impacts resulting from this umbrella re-
view were discussed by a fewer number of reviews or
even by single studies, highlighting thence an important
level of heterogeneity and a weaker evidence.
The reviews of Coory et al., 2008 [33] and Prades
et al., 2015 [31] are the only two which investigated
quality of life and patients’satisfaction; two important
goals to be pursued to provide a more holistic and per-
sonalized care approach. Related evidence is weak but
promising, insinuating that these two aspects deserve
further investigation (Prades et al., 2015) [31].
Other aspects (such as recurrence and metastasis after
resection, care coordination, visits to GP and waiting
times) were marginally reported in the retrieved reviews.
Despite this, the results indicated a trend towards im-
provements in care, hence representing additional topics
which deserve attention in future research and studies.
Although they may stray from the focus of this um-
brella review, some points highlighted by the study are
worth mentioning because they are relevant to the
healthcare process. These topics are related to the lack
of patient involvement in the decision-making process
and a lower importance of the inputs provided by nurses
during the meetings (Lamb et al., 2011) [30]. According
to Pillay et al., 2016 [32], patient involvement in the
decision-making processes could have an impact on the
satisfaction level for care received as well as a more care-
ful informed decision about treatment (Pillay et al. 2016)
[32]. Moreover, as suggested by Lamb et al., 2011 [30],
the position of nurses and other healthcare professionals
should be reviewed and encouraged in the context of
TBs. Given the nurses’key role in the care process and
coordination and their close relationship with the pa-
tient, reconsidering and strengthening the position and
role of nurses in the TBs could enhance the implemen-
tation of treatment decisions improving patient’s out-
comes (Lamb et al., 2011) [30].
Finally, sustainability factors for TBs should be
assessed. As stated by Lamb et al., 2011 [30], telemedi-
cine can represent a cost-effective way to increase the at-
tendance to TBs in a cost-effective manner. According
to Coory et al., 2008 [33], as a healthcare intervention,
TBs should be evaluated by cost-effectiveness analysis, in
order to estimate their clinical effectiveness in relation
to their sustainability in the hospital setting (Coory
et al., 2008) [33].
Weakness and strengths
Despite the great number of studies considered (120) in
the five reviews, a meta-analysis was not performed due
to the high heterogeneity among all the studies. Relevant
heterogeneity was also found among studies regarding
the same cancer types, as reported by Basta et al. [34]. In
fact, studies were referred to patients with different sub-
types or at different stages of the same tumor. These
two aspects can influence the assessment and manage-
ment of patients (Pillay et al., 2016) [32]. Therefore, it
would be better to investigate the impact of TBs on sub-
groups of patients. In the present study, results observed
are thence related to cancer patients as a general group,
as stated by Pillay and colleagues (2016) [32]. Moreover,
heterogeneity among the studies is related to the differ-
ent outcomes evaluated (Coory et al., 2008) [33].
Another weakness results from the variety of studies in-
cluded in all the reviews. Most of them are observational
studies, and therefore susceptible to bias because of the
study design. This has probably influenced the methodo-
logical assessment, leading to a low-quality judgement.
Moreover, surveys or qualitative studies are included in
the reviews of Coory et al. (2008) [33], Lamb et al. (2011)
[30], Prades et al. (2015) [31]. Although these reviews con-
tain some experimental studies too, a final strong evidence
was not observed; this is likely due to the heterogeneity
among the studies within the same review.
Finally, another bias to consider is the potential publica-
tion bias. Since the Authors of the reviews only considered
studies published in peer reviewed journals, it is possible
that positive effects of TB may have been overestimated
(Pillay et al., 2016 [32], Coory et al., 2008) [33].
Despite these limitations, the present work represents
the first attempt to synthetize the research available on
the topic of TBs and their impact on health outcomes
and healthcare processes in a comprehensive manner
and using a strict methodology. The only selection and
inclusion of systematic reviews in our umbrella review
was aimed at providing stronger evidence.
Conclusion
Recommendations for health professionals and academics
Definitively, TBs represent the best approach to a complex
care pathway as cancer treatment because it improves
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decision making, patient care coordination, and it reduces
waiting times. At the same time, its multidisciplinary fea-
ture is still challenging since it requires care coordination,
effective decision-making, good communication, and the
active participation of stakeholders including patients and
all professionals. In order to improve the impact of TBs
on healthcare delivery and health outcomes, the afore-
mentioned factors should be addressed by healthcare
managers to improve teamwork within their organizations
[37]. Moreover, the difficulty professionals face in attend-
ing meetings, due to the lack of time, is a relevant barrier
for the implementation of TBs (Coory et al. 2008) [33]. To
make TBs effective, professionals should consider them a
critical part of their working agenda and save time to pre-
pare and attend TBs. Moreover, congruent time should be
dedicated to the meetings in order to avoid discussing
many cases in a short amount of time. Additionally, the
time for acting on decisions made during the TBs should
be taken into account (Lamb et al. 2011) [30]. To be
addressed, all these points require a cultural change con-
cerning the way clinicians and other health professionals
understand their practice. Some changes have been made
towards this and several of the latest guidelines recom-
mend the MDT approach in order to provide better can-
cer care [15–17].
In order to assess the best way to functionally organize
and deliver TBs and their cost-effectiveness, prospective
studies should be carried out. Moreover, they could lead
to better understand and control potential confounders
while measuring impact in a more consistent way (Coory
et. Al. 2008) [33].
For instance, although performing randomized studies
can be time consuming and results have to be contextu-
alized (Coory et al. 2008) [33], such studies could pro-
vide a solution to reduce bias and to gain more
information. Moreover, health outcomes/outputs are not
sufficient to evaluate the performance of TBs due to the
complexity of these healthcare interventions. Thereafter,
[new] process indicators, such as the ability to reach a
decision on a first case or to implement decisions taken
during TBs - as suggested by Lamb and colleagues [30]
in their review - should be defined and measured in
order to assess TBs in a more comprehensive and ex-
haustive way.
Abbreviations
EPAAC: European Partnership for Action Against Cancer; GPs: General
Practitioners; MDT: multidisciplinary team; NHS: National Health Service;
TBs: Tumor Boards
Acknowledgements
We thank Doctor Elizabeth Tyrie for the English language proofreading of
this paper.
Authors’contributions
MLS and GD designed the study under supervision of WR. MLS, EMF, EC
carried out databases search and ADP, DC, AB conducted data extraction.
MLS, EMF, EC, AB and ADP prepared the manuscript that was reviewed by
GD and WR. All authors approved the final version of the paper.
Funding
Università Cattolica del Sacro Cuore contributed to the funding of this
research project and its publication.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8,
00168 Rome, Italy.
2
Università Cattolica del Sacro Cuore, Rome, Italy.
3
Local
Health Authority, ASL ROMA 1, Rome, Italy.
Received: 31 May 2019 Accepted: 24 January 2020
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