Integrating Community Oncologists Into the Multidisciplinary Team

Transcript:Brian A. Van Tine, MD, PhD: Let’s not forget that the standard of care is still the clinical trial, and so let’s not forget everybody’s large clinical trial research team. This goes on and gets bigger and bigger and bigger. But you know one of the unsung heroes that really is peripheral to our multidisciplinary team, but actually quite integrated, is the community oncologist, because there aren’t that many of us. There’s 40. And if the 40 of us tried to treat every sarcoma patient, it wouldn’t be possible. So, by incorporating community oncologists into how we practice, just how are you doing that in Miami, Jonathan?

Jonathan C. Trent, MD: We do it all the time, and very actively. We’re very actively engaged in the community. In Miami, which is a metropolitan area of nearly 7 million individuals, there’s a very large number of sarcoma patients. As I mentioned, we see patients from the Caribbean and Latin America, as well as other sites around the US. And so engaging with the community oncologist is critical. The community oncologists often are involved in making the diagnosis. So, that’s the first step.

The community oncologists are often involved with making sure the slides or pathology blocks are sent to an expert sarcoma pathologist for review. And then we work with the community oncologist to figure out how best to administer the optimal therapy for the patient; whether that’s chemotherapy, targeted therapy, surgery, radiation therapy. We work with the community oncologist so that the patient may be treated optimally and in a way that works logistically for the patient. So, we’re very engaged with the community oncologists.

I have probably 30 community oncologists on my phone on speed dial, essentially. We’re very actively engaged in follow-up with patients. So, we may see the patient every 3 months after completion of therapy or we may alternate 3 months with the community oncologist, 3 months back in Miami, or at other time points that might meet their vacation schedule or their other logistics with their family.

Brian A. Van Tine, MD, PhD: As you move to the middle of the country I think one of the things that’s interesting is, I love my community oncologists because, as the middle of the country has decided, we’ll do all the trials at Washington University and we’ll do all standard of care in the community. It’s really just been this really nice system where we all work together so that everybody does well, so people are only traveling when they’re doing something special. Then, if we move towards and jump across the pond over to London I’m sure it’s a little.…

Robin L. Jones, MD, MRCP: It’s a reciprocal relationship in that respect that we help each other. So, in the UK, we work very closely with local oncologists who can help deliver standard therapy and help with follow-up. That close communication is essential, and patients and their families really appreciate that we talk to each other and that there’s a very clear plan. I think it’s essential wherever you are, so United States, Europe, anywhere else in the world, it’s very, very important that there’s that strong link between the referral center and the community doctors.

Brian A. Van Tine, MD, PhD: And at the larger trial …

Shreyaskumar R. Patel, MD: I think a good way of describing it would be a partnership, right? It has to be a good partnership. It works both ways. I think they end up being the gatekeepers for us in identifying the right patients who need to come see us for input.

And then in this day and age, it’s impossible for patients to stay away from home for an extended period of time, so we help patients by working with the community oncologists to deliver whatever can be safely delivered back home, whether it’s monitoring or actual delivery of therapy. So, it’s a two-way partnership, and I think they are a very critical component of that partnership.

Brian A. Van Tine, MD, PhD: So, Robin, briefly, what do you think the role is of clinical trial in 2015 in sarcoma?

Robin L. Jones, MD, MRCP: I think because these tumors are so rare, because the outcome for patients with metastatic disease is generally poor, and because the drugs that are available to treat metastatic disease are limited, that participation in clinical trials should basically be offered to every single patient and that it should be an essential component of the management of patients at specialist centers, both in the United States and in Europe.

R. Lor Randall, MD, FACS: I’d just challenge you for a moment. You even think for the more low-grade, well-contained lesions?

Robin L. Jones, MD, MRCP: For patients with metastatic disease.

R. Lor Randall, MD, FACS: Oh, I’m sorry. Then, yeah, sure. Okay.

Robin L. Jones, MD, MRCP: Yeah, but I take your point. And for patients that have low-grade, indolent subtypes, then of course if they can be treated with local therapy, then…

Jonathan C. Trent, MD: But this could also be a clinical trial. There are plenty of clinical trials for a desmoid tumor that is nonmalignant, nonmetastatic, and incorporating a clinical trial into a patient’s care is always ideal.

The best patient care is probably delivered on a clinical trial because a large number of very smart people have reviewed the clinical trial. IRBs have reviewed the clinical trial. Our sarcoma team is managing the patient, but also there’s a research team who’s managing the patient. So there’s additional caregivers. So clinical trial for, for every single sarcoma patient in my practice is, is considered.

Robin L. Jones, MD, MRCP: It’s interesting, the comment regarding the research coordinator. A lot of my patients that have been on clinical trials have found the research coordinator is invaluable in terms of their care, in terms of managing their schedule. And again, another member in many ways, of the multidisciplinary team.

R. Lor Randall, MD, FACS: No, I agree with the sentiment. I just try to bring some balance to it in that, in terms of risk stratification, we know there are some very low-risk sarcomas. And in the Children’s Oncology Group, for example, for the low-risk rhabdomyosarcomas, it has been declared: we’re no longer going to study this disease.

The standard of care has pushed the curve far enough to the right that there’s no reason to do it. And there’s overhead with clinical trials. So, while in concept I definitely agree with what we’re all saying, just for the community oncologists who wanted to make sure that they understood …

Robin L. Jones, MD, MRCP: But in terms of the medical oncologist treating metastatic soft tissue sarcoma, I think …

R. Lor Randall, MD, FACS: No, right, and that’s a high-risk patient. But I just…we’ve sort of been mixing in our tumors.

Brian A. Van Tine, MD, PhD: But to play devil’s advocate, as the immunotherapies and the metabolic therapies come in, we may revisit these because what if we could make things just incredibly smaller—I mean we may be able to alter this field which has had so many amazing people work in it. It’s still a very small field. So, still pushing, I think we can do better.

Transcript Edited for Clarity