Lung Cancer Paradigm Pushes Toward Accessible Care and Improved Telemedicine

Rogerio C. Lilenbaum, MD

In light of the numerous advances that have led to improved outcomes for patients with lung cancer, the field should work to devote more research to minority populations who have been historically underrepresented in clinical trials, said Rogerio C. Lilenbaum, MD, who added that formal training on telehealth services is also needed to ensure these advances are accessible to every patient.

“We should never be complacent; we should never be skeptical,” said Lilenbaum. “We need to continue to pursue new treatments, and if nothing else, the past 2 decades are a testament to how we can actually make a difference in the natural history of the disease by appropriate interventions.”

In an interview with OncLive® during the 18th Annual Winter Lung Cancer Conference, a program hosted by the Physicians Education Resource®, Lilenbaum, director of the Banner MD Anderson Cancer Center, discussed some of the key clinical issues facing the lung cancer field, the roles of genomic testing and multidisciplinary care, and the challenges that arose with telemedicine during the coronavirus disease 2019 (COVID-19) pandemic.

OncLive®: What critical clinical issues in lung cancer have to be kept in mind to ensure patients receive optimal care?

Lilenbaum: Number 1 is to individualize the approach to treatment. [We have] to ensure we identify patients for whom targeted agents are appropriate and those who would benefit the most from checkpoint inhibitors. The second [point] is to make sure we have a sensible and patient-centered approach to end-of-life [care] in lung cancer.

We have made great strides in the treatment of patients with lung cancer, to the point where the overall mortality from cancer has decreased.

Do you recommend genomic testing in the adjuvant and metastatic settings now that osimertinib (Tagrisso) is approved for patients with resected EGFR-mutant disease? Do you order broad panels or EGFR-specific tests in the adjuvant setting?

Yes, and I don’t know that it is any more costly or cumbersome to do a broader panel. I suspect that we will see data in the near future for other targets in the adjuvant setting.

Do you recommend repeat PD-L1 testing for patients with lung cancer given tumor heterogeneity?

I am personally not in the habit of repeating PD-L1 testing.

How often should multidisciplinary tumor boards meet? Do they always conclude in a consensus on a patient’s treatment plan?

It depends on the size of the program and how many patients are typically presented. In most of the places I have been, tumor boards meet once a week.

I don’t know that it is the goal of tumor boards to necessarily reach a consensus. I believe that the more proper goal is to provide a recommendation to the treating physician.

What are the modalities that reside at the center of these multidisciplinary discussions?

Typically, patients who are candidates for more than 1 modality are the ones who benefit most from a multidisciplinary discussion. Patients with lung cancer at a very early stage, who have a completely surgically resectable [cancer], may not need to be presented [at a multidisciplinary tumor board discussion] at that time. [Similarly,] patients with clear-cut metastatic disease may not need a multidisciplinary conversation, although it would be useful to have the input of other medical oncologists. Everyone who may benefit from a combined modality approach should be discussed ahead of time.

How has telehealth contributed to the continuity of care in the COVID-19 era? Do you believe providers felt prepared to integrate virtual care into their practice?

No one was prepared, despite years of attempts at streamlining [the telehealth] approach. Of course, the COVID-19 pandemic made it a must-have. Everyone rushed and did the best they could with the tools that they had.

I think telehealth is a very important tool and continues to be very useful during the COVID-19 pandemic. I do not get a sense that it was, at least at my institution, realized to its full potential. The question that comes up now is: How do we see telehealth playing a role outside the pandemic?

What should be done moving forward so that future generations of providers are more prepared to utilize telemedicine?

The process still [varies] depending on how each institution decides to utilize a virtual platform. I am not advocating that we use only 1 [platform], but I am saying that there are choices out there, and it is not yet clear to the medical community which is more user friendly or more effective from a patient perspective. I think this is a terrific area to interrogate patients and their families to gauge their experience.

Second, to the best of my knowledge, nobody has received any formal training on this. Yes, we are all living in a digital era, and we understand computers and phones. However, as we try to reach our patients virtually and in a way that is effective and patient centered, a more formal approach [to telehealth] would be helpful.

How do your treatment recommendations differ for minority populations given that they are not often well represented in clinical research?

It is known that such discrepancy happens. Of course, no physician will ever believe that they [treat minority populations differently], so it is an unconscious bias that we tend to harbor and are not aware of. However, the data are unequivocal when it comes to racial minorities especially. It is an issue of great concern that adds to health care disparities in the country. Cancer care is a reflection of other types of inequalities that we see in the delivery of health care in the United States.

Which clinical guidelines affect your practice? Is there a particular reason you find yourself turning to one vs another?

I’m biased in this respect. First, I am an editor on UpToDate, so I do go to UpToDate. Up until my move to Arizona, I was a member of the National Comprehensive Cancer Network Expert Panel and sat on the board for more than 2 years. I like those 2 [sets of guidelines].

I don’t usually consult the American Society of Clinical Oncology [ASCO] for treatment guidelines. I look to ASCO for other issues, such as policy recommendations and practice-related recommendations. I read their guidelines when they are issued, but it is not a go-to place for me to answer clinical questions.