Opinion
Video
Optimal Multidisciplinary (MDT) Approach for the Management of NSCLC
A panel of experts review what an effective multidisciplinary approach for NSCLC management looks like and subspecialties included in multidisciplinary teams.
David Carbone, MD, PhD: Hello, and welcome to this AJMC® Peer Exchange program titled Tailoring Treatment Selection for Various Stages of Non-small Cell Lung Cancer: Optimizing Patient Outcomes. I am David Carbone, medical oncologist at the Ohio State University Comprehensive Cancer Center and professor in the department of medicine at the Ohio State University School of Medicine. Joining me today in this discussion are my colleagues, Dr Dietrich, medical oncologist and assistant professor of internal medicine, University of Central Florida Cancer Center. Dr Forde, division of upward aerodigestive malignancies, associate professor of oncology, Johns Hopkins University. And Dr Gillaspie, assistant professor of thoracic surgery, department of thoracic surgery at Vanderbilt University. And Dr Jabbour, professor, vice chair of clinical research and faculty development, department of radiation oncology at Robert Wood Johnson Medical School, Rutgers University and associate director for faculty affairs and development at Rutgers Cancer Institute of New Jersey.
Welcome to our series, where we'll explore key topics in non-small cell lung cancer management. We'll discuss the role of multidisciplinary teams in holistic care, dissect the current treatment landscape for early-stage non-small cell lung cancer, and delve into the tailored strategies for metastatic lung cancer. We'll also address unmet needs and barriers faced by health care professionals. Thank you, and let's get started. Dr Dietrich, what does an effective multidisciplinary approach for non-small cell lung cancer management look like?
Martin Dietrich, MD, PhD: I think that's a very good question. I think there's been a lot of development and I think it starts with the recognition that lung cancer, even in the earliest stages, is a systemic disorder that requires multiple treatment approaches, that addresses both local and systemic therapy options for even the most early disease. In my opinion, lung cancer has now entered a stage where effective therapies have been introduced, both targeted and immunotherapeutic approaches to complement the traditional approaches of radiation surgery and chemotherapy, and should be utilized in a very prudent, sequential fashion. Therefore, I think the approach going forward should be to include medical oncology, radiation oncology, and surgical or thoracic oncology under 1 umbrella upfront, in addition to the services that are needed for diagnostics, radiology, pathology, and obviously the support services of palliative care. They should be done synchronously.
It's really a discussion about what the optimal sequence for each patient is reasonable. Cases that may have been resectable in the past shouldn't be resected upfront, in many cases, now that we have such effective therapies upfront that are more of a systemic nature. I believe this goes from all the way from stage 1 into stage 4, where we've seen the introduction of radio ablative approaches upfront to a 4-sided reduction. I think this is going to get more and more complicated and the classical sequence of treatment of resection or definitive local treatment, followed by systemic therapy, has really been turned upside down to really favor the inclusion of systemic therapies in many cases, especially rescectable cases, now in the upfront setting. I think this is going to be a very important part and we really need to form these teams at each institution to really facilitate the process of multidisciplinary in many cases. This is really a sequential handoff. The data would really suggest that moving the sequences around and including systemic therapy first will lead to the best outcomes, both with prognostic information as well as the optimization of surgical outcomes.
David Carbone, MD, PhD:It was really clear many years ago there wasn't much multidisciplinary input into especially early-stage lung cancer. They showed up at the medical oncologist by virtue of the surgical decision or not. But now the upfront discussion of the optimal management, I think, is really crucial. What subspecialties are included in multidisciplinary teams and what are their roles? Anybody want to answer that?
Erin A. Gillaspie, MD, MPH, FACS: Sure, I can. I can start off. I think all of us participated and we can highlight in some of the ways that we do, as a surgeon. I love participating in tumor board because I love to be able to talk about all of my patients now to determine if they are candidates for upfront therapy, special clinical trials. For me, very selfishly, wanting to have great outcomes for my patient, I love the opportunity to participate in tumor board. Where I play a role is helping to determine rescectability and helping to work through a patient's comorbidities to determine if they're going to be a good surgical candidate. Often partnering specifically with pathology, both in the preoperative and postoperative setting, because we're bringing patients in both of those time periods to our tumor boards.
David Carbone, MD, PhD: Not just determining respectability, but sometimes in the workup of patients. I just had a patient that had a malignant pleural effusion and there wasn't enough cells in the effusion for molecular. I've asked my surgeon to do a thorough cystoscopy and a biopsy of pleural nodules so we could get the right molecular testing done. What other specialties?
Salma Jabbour, MD, FASTRO: Yes. Radiation oncologists. I'm a radiation oncologist, and I feel that what we can bring to the tumor board is an understanding of how to manage microscopic disease potentially in the postoperative setting and the definitive setting for early-stage tumors that can be resected obviously, in the definitive setting when patients are not candidates for neoadjuvant therapy and stage 3 or 2 disease. We also work closely with our pulmonologists who give us insight as to whether biopsies can be performed, what their capabilities are to reach difficult tumors. Our radiologists give us valuable insights about the scans that we are faced with and the details of whether this may land a patient to have a surgery or not. Finally, I think we can't forget about our pathologists who give us really detailed information about the pathology specimen and what we're looking at in terms of factors that may not come out just in the pathology report, some special insights that can help us really tailor the management for the patient.
David Carbone, MD, PhD: So, ideally it includes, not just the inner vent of the medical oncology, radiation and surgical, but pathology, radiology, pulmonary medicine in a variety of specialties in that situation. For radiation, it's not just curative intent. More and more we're seeing in metastatic disease using locally ablative therapies for oligo persistent or oligo progressive disease with hints of improved survival in that setting and the other additions to that team, Dr Ford?
Patrick Forde, MBBCh: I think it's become much more complicated in the last 15 years, I would say. But that's welcome, I think, to everyone. It's good that we're having these discussions and I think it's really bleeding through to benefits for our patients because we have a lot of new therapies. But we if we don't use them in the optimal way, then they're not giving us their full worth.
Transcript is AI-generated and edited for clarity and readability.
