Multidisciplinary Approaches in Lung Cancer

Transcript:Luis E. Raez, MD: Lung cancer is a disease that needs a multidisciplinary approach because at several times during the natural history of the disease, we need the help of the other experts. The best example is stage III lung cancer when you have a locally advanced tumor in the chest, and you have to decide whether the best treatment is surgery followed by chemotherapy or instead of surgery, starting with chemoradiation or maybe transferring to chemoradiation later—or there may be no surgery at all. You have to involve the surgeons, the radiation oncologist, the medical oncologist, and we often also need the help of the pulmonologist because we need to do, for example, testing for all of these genetic aberrations. The pulmonologists have been mastering the science of biopsy for years, giving us a smaller and smaller amount of tissue for the benefit of the patient.

But, in the last 3 or 4 years, with the discovery of these aberrations, we’re now moving in the other direction. We need all of these pulmonologists to give us bigger and bigger samples of tissue, because we need to do genetic testing on all of these patients. It’s important that pathologists are involved, so they can focus and give us this information about the genetic aberrations and not use all the tissue for other types of staining, focusing only on the minimal amount necessary to diagnose lung cancer, so we can use the rest of the tissue for the genetic aberrations. Another example is if we need to have the radiologist to read out PET scans. So, that’s why lung cancer is very multidisciplinary. A lot of centers, like ours, have a dedicated tumor board for lung cancer every week with all of these specialists.

Benjamin P. Levy, MD: Multidisciplinary care is so critical now that lung cancer has gotten so complex with therapeutic advances, not only from systemic approaches, but also from radiation and surgical approaches. I think what’s critical within that multidisciplinary team in terms of molecular testing is that there needs to be a physician champion.

There needs to be someone within that group who can take the role of educating the others on the importance of molecular testing. And the question is where that can happen. That generally happens in a tumor board at a multidisciplinary conference. We published these recommendations a few years back to say, “Now that lung cancer has gotten so complex, and now that there’s a growing list of mutations—not just EGFR/ALK—that are so important to test for, how do we get the word out?” Getting the word out means identifying someone within health systems—because hospitals are no longer hospitals, they’re health systems.

We need to have a physician champion—someone who works there, who knows the data, who can lead and educate on the science to make sure that they are educating the other members of the team. I think it’s the most important way to get the word out about molecular testing.

Philip C. Mack, PhD: I am a strong advocate for a multidisciplinary approach to oncology. I think this has been a wonderful advent to the field. As a molecular biologist, I bring some unique perspectives on the actual genetics of tumors and what sort of approaches we can take, but I fully recognize that most institutions, particularly community institutions, aren’t going to have a molecular biologist sitting in on their team. In many cases, it then falls on the pathologist and the physician to understand the advances and the advantages of molecular testing, particularly as it applies to nonsquamous histology.

In the front line, it’s important to determine whether or not a patient has an actionable mutation—it could be EGFR, it could be ALK, or it could be others. If they do, when those patients have a good response to that therapy, and the process of recurring or relapsing, then additional analysis at that point can help guide the best options for subsequent therapy. That’s where things get a little complex. There are a lot of nuances and details in those data. So, a multidisciplinary team brings a lot of different eyes and perspectives along with some information about how to proceed for these patients to the table.

Transcript Edited for Clarity