Standards › Standard 51 › Policies
Policy · ONC-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 51.5
At a glance
- Complex or newly diagnosed cancer cases are reviewed by a multidisciplinary tumour board before the treatment plan is finalised.
- The board includes the relevant specialties, and records its input (ONC-REG-003).
- The board’s input is recorded in the treatment plan.
- The board meets at a set interval, and urgent cases can be reviewed sooner.
- Stop and get help straight away if: a newly diagnosed or complex cancer case starts treatment without a board review.
1. Purpose
To make sure complex and newly diagnosed cancer cases are planned with the input of several specialties (51.5).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Complex cancer cases are best decided by a team of specialists together. A tumour board that reviews the case before treatment starts improves the decision.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Board chair | Runs the board and records its decisions | Clinical lead |
| Treating clinician | Presents the case and records the board’s input in the plan | Board chair |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Refer.
- Refer each newly diagnosed or complex case to the board before the plan is finalised.
Key point: Referred.
Step 2. Review.
- The board reviews the case with the relevant specialties and records its input (ONC-REG-003).
Key point: Reviewed.
Step 3. Plan.
- Record the board’s input in the treatment plan before treatment starts.
Key point: Planned.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Eligible cases reviewed by the board before treatment | 100% | Monthly | Board chair | Hold treatment planning until reviewed |
| Board input recorded in the plan | 100% | Monthly | Board chair | Escalate to the clinical lead |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| ONC-REG-003 | Tumour board decision register | Register |
| ADV-POL-001 | Advance care planning conversations (existing, reused) | Policy |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)