Active Engagement of Pulmonology Is a Must in the Multidisciplinary Management of Lung Cancer

David J. Feller-Kopman, MD

Pulmonologists play a critical role in the diagnosis and staging of lung cancer, the latter of which should always include thorough lymph node evaluation with endobronchial ultrasound before a patient is presented to a multidisciplinary tumor board, explained David J. Feller-Kopman, MD.

“One of the biggest things that I’ve been trying to teach people across the country is the importance of lung cancer stage. One of my old mentors used to say, ‘If you don’t look at the lymph nodes, everyone has stage I disease.’ It’s crucial to do the staging because that’s going to affect treatment,” said Feller-Kopman.

In an interview with OncLive®, Feller-Kopman, section chief of Pulmonary and Critical Care Medicine and a professor of medicine at the Geisel School of Medicine at Dartmouth, discussed the imperative role of the pulmonologist in the screening and management of lung cancer.

OncLive®:How would you define the scope of a pulmonologist’s role in the care of patients with lung cancer?

Feller-Kopman: Pulmonologists play a central role in the care of patients with lung cancer. I am an interventional pulmonologist, which typically involves some extra training in more therapeutic procedures, but there are a lot of advanced diagnostic procedures that non–interventional pulmonologists do, as well as general pulmonologists.

The pulmonologist’s role in the evaluation and management of lung cancer has been nicely defined by a document from the American Thoracic Society [released] several years ago. [The document] outlines the importance of the pulmonologist in caring for patients with lung cancer, and it’s basically soup to nuts. It [addresses] everything from smoking cessation to screening to staging to diagnosis to helping get tissue to guide oncological therapy or planning non-surgical and surgical therapies to palliation in terms of central airway obstruction and pleural effusion as well as managing things like tobacco cessation and underlying chronic obstructive pulmonary disease [COPD], and all that.

What are your thoughts on pulmonologists as a contact point for lung cancer screening?

Unlike colonoscopy, pap smear, and mammography, where about 80% of eligible patients are getting those screening tests, unfortunately, despite excellent data showing 20% to 35% reduction in lung cancer mortality with CT screening, only about 5% of eligible patients are getting screened. We have a lot of work to do in that regard.

Pulmonologists play a very active role in the screening process, and a lot of that relates to the time and effort it takes for shared decision making. Primary care physicians tend to be very overwhelmed with managing hypertension, diabetes, back pain, and all that. They may identify patients who meet criteria for screening and then send them to a general pulmonologist or a dedicated screening program.

At Dartmouth, we’re very fortunate to have a multidisciplinary screening program that is staffed by pulmonary [and] thoracic surgery [staff] as well as our advanced practice providers. The screening process considers patient risk factors, but also the specific benefits of screening that individual patient. Younger patients, for example, may have greater benefit vs a 90-year-old who may not have as much benefit, or zero benefit if they don’t qualify. For a patient who does qualify, let’s say they’re 68 years old and have a 3-pack-a-day smoking history, if they have multiple other comorbidities, such as bad emphysema or heart disease, they may not benefit [from screening] either. You really need the time to pursue shared decision making and take that opportunity for tobacco cessation, which is one of the most important discussions we could have with our patients.

How does transthoracic needle biopsy compare with endobronchial ultrasound in the workup of patients with lung cancer?

Several studies have shown that transthoracic needle biopsy, for example, although could [be done to] obtain diagnosis and molecular tests, doesn’t do staging. Pulmonologists are key here, because you need to look at the lymph nodes and do a very systematic evaluation of the lymph nodes, making sure there’s no local regional disease before you decide on a treatment plan. Endobronchial ultrasound has really changed the way that lung cancer is evaluated and staged. Great data suggest that endobronchial ultrasound gives plenty of tissue for diagnosis, but more importantly, these molecular markers that are going to guide therapy. Pulmonologists are essential in this process.

What follows the diagnosis and staging of patients with lung cancer?

Once the patient has been adequately diagnosed and staged, they’re often presented to the multidisciplinary tumor board. The stage and the diagnosis [of the disease] will guide therapy. Therapy can be combined chemotherapy and radiation, surgery alone, or a combination of approaches with neoadjuvant or adjuvant therapy and or radiotherapy. For patients who are too sick to undergo primary resection, stereotactic ablative body radiation can be given, but it’s a disservice to the patient to say they are not a surgical candidate, unless a surgeon is in the room. A surgeon really needs to say that the patient is not a good surgical candidate, again bringing in the multidisciplinary care that’s essential to the care of these patients.

Do you believe there is a lack of knowledge when it comes to the role of general pulmonologists?

I do, and it’s not a default criticism. It’s just that everybody is busy, and it’s impossible to be an expert in everything. We often go into pulmonary and critical care because we love all internal medicine. We love [managing] asthma, COPD, lung cancer, pleural disease, interstitial lung disease, and pulmonary hypertension and all that, but it is hard to be an expert in everything. Like many other cancers, there’s a distinct knowledge set that you gain as you do more sub-subspecialty work.

It’s been shown that patients who receive good staging do better than patients who don’t receive good staging. It’s important to look at small lymph nodes when you do endobronchial ultrasound, and it’s not just the pulmonologist’s role there, which gets into a broader discussion of making sure that your pathologists or cytopathologists are used to looking at small biopsy specimens; these aren’t big, nice surgical specimens. There’s a distinct skill set locally that needs to happen. Things like rapid onsite evaluation, having a cytopathologist or cytotechnologist in the room to guide the staging is important as well.

How would you define the success of a multidisciplinary team?

Everybody plays an important role, including pulmonologists, thoracic surgeons, medical oncologists, radiation oncologists, the chest radiologists who are reviewing images, as well as the pathologists reviewing the pathology. Ideally, good multidisciplinary care includes all those disciplines. One of the key factors in the successful multidisciplinary tumor board is the communication that occurs throughout all those disciplines. If the thoracic surgeon is evaluating a patient and identifies nodes on imaging, they may send them to us, and we’ll do the staging first, but we’ll also be communicating with the oncologist and making sure that we’re sending all the tests that they need and communicating with the pathology laboratory to make sure those [tests] are ordered and sent. Oncologists [also] must communicate with the pathology laboratory to make sure all the testing is ideally reflexively done for lung cancer.

Are high functioning multidisciplinary teams feasible for all treatment centers?

The ideal is that every multidisciplinary team is high functioning, and what makes it high functioning is engagement of all these disciplines and communication. You must make it happen, and unfortunately, it’s not something that people get reimbursed for. It’s done because it’s the right thing to do. If mom needed lung cancer care, you want her getting care by the providers who are engaged in a multidisciplinary discussion of best practice.

What do you hope medical oncologists take away from this conversation?

One, make sure you’re providing multidisciplinary care. Two, make sure you’re communicating and have a pulmonologist that you can actively engage, [be it] advanced diagnostic bronchoscopists or interventional pulmonologists to ensure that adequate staging has been done.