Multidisciplinary Collaboration Needed to Provide Cohesive Care in Advanced NSCLC

David R. Spigel, MD

A multidisciplinary approach is needed to improve the delivery and quality of care for patients with stage III/IV non–small cell lung cancer (NSCLC), according to David R. Spigel, MD, and results from a comprehensive, double-blind survey have helped to inform criteria for ideal care.

The objective of the Fostering Excellence in Care and Outcomes in Patients with Stage III and IV NSCLC initiative was to examine the benefits of lung cancer care with a multidisciplinary team, assess and quantify practitioners’ understanding of evolving standards in diagnosis and treatment of the disease, determine and overcome obstacles to care, and to explore process improvement models.¹

In order to provide cohesive care, multidisciplinary collaboration is needed, according to Spigel. Through Association of Community Cancer Centers (ACCC) leadership, a steering committee was created; this committee ultimately decided the different elements that would be incorporated into the comprehensive, double-blind survey. Responses were received from 639 participants affiliated with 160 cancer programs across the United States.

Preliminary data from the survey were reported during the 2020 ASCO Virtual Scientific Program. Results revealed that 41% of participants (n = 261) indicated that their cancer program did not have a thoracic multidisciplinary clinic.² He also explained that nurse navigators (P = .03) and radiation oncologists (P = .04) were at higher likelihood to engage in shared decision-making practices compared with other disciplines. The most prominent barriers to care included a lack of community awareness, patient interest, and transportation.

The steering committee also worked together to compile evidence-based recommendations on how to provide ideal care for this population. Recommendations included a multidisciplinary evaluation of suspicious findings, multidisciplinary coordination for effective biopsy collection, and the use of expansive molecular profiling to identify rare mutations.³

“You can see that the power of committing to providing some information and then collecting that at a broad level could provide really valuable information to effect care not only in the United States but potentially globally,” said Spigel, chief scientific officer, director of the Lung Cancer Research Program, and principal investigator at Sarah Cannon Research Institute.

In an interview with OncLive, Spigel discussed the Fostering Excellence in Care and Outcomes in Patients with Stage III and IV NSCLC initiative, analyzed the survey data, and next steps for the research.

OncLive: Could you provide some background on the initiative?

Spigel: This effort was designed to look at how we manage [patients with] stage III and stage IV lung cancer in the community, specifically with a focus on multidisciplinary conferences. The management of lung cancer, especially for stage III disease, really involves different disciplines of care beyond just medical oncology [to work together]; radiation oncologists, surgeons, pathologists, or pulmonologists, [should be included]. Bearing this in mind, [it’s important to] have tumor boards or multidisciplinary tumor conferences.

Are these meetings happening routinely in centers in the community? Are they happening at academic centers? How does they happen? What happens at those meetings? Do we believe care is impacted by whether they happen or not? Are these meetings being done well or could they be improved? The whole idea here was to look into this further. The ACCC objective was to collect information from those who take care of patients with lung cancer, measure what is actually happening, and then use that knowledge to affect change.

Prior to conducting the survey, what were the primary barriers to cohesive care in those community and academic settings?

To be honest, a lot of this hinges on the time it takes to get busy clinicians together to meet. In fact, it's amazing this all happened before [the] COVID-19 [pandemic] because, although our meetings are now all virtual, it's a little bit different when you're in a room together and you can have conversations more easily. Honestly, time is the perceived biggest barrier, but usually there are solutions to those challenges.

There's great motivation and interest to meet and improve on patient care. There's a desire to have the comfort of other clinicians and colleagues to validate your care choices. It's not that ego is preventing [us from] getting together. [There is no], ‘I know how to do things better than anyone else and so I don't need any help.’ It's more, ‘How do we do this? How do we practically get together in a regular cadence that works for everyone?’

How was the survey conducted?

Through ACCC’s leadership, a steering committee was created to discuss the kinds of elements that we want to include in a survey; I was part of that committee. Then, with the help of many individuals, nearly 1200 surveys were sent out across the country. What ended up getting just under 640 responses affiliated with 160 unique cancer programs across 44 US states that were suitable for analysis.

We had different disciplines that responded—again, it wasn't just medical oncologists; it was really anyone [involved in] lung cancer care at 1 of these centers who could respond. Then, we collected information and were able to parse out the different disciplines, their responses, and see how those vary.

Two abstracts were presented at the 2020 ASCO Virtual Scientific Program based on these findings. How did they inform the recommendations?

There's still a lot of analysis [to be done]. Just under half of respondents, so about 41%, indicated that their center did not have a thoracic multidisciplinary clinic. We were all surprised to see that the number was so high. That's not to say things don't happen that involve different colleagues in the care of a patient at those centers, but in terms of a formal, multidisciplinary clinic, that was a pretty high number. When you think about disciplines involved in care and who is most involved in terms of that shared decision-making, a couple of [insights] have emerged.

One is that not every program has a nurse navigator; this is an individual who helps shepherd that patient's care through these different points of contact. Not surprisingly, in those centers that had nurse navigators, these individuals were found to be among the most engaged disciplines involved in that shared decision-making process. The lesson there is that every center should have a nurse navigator because they will be the most engaged.

The other, [which is] a little bit of surprise, were radiation oncologists. Radiation oncologists seemed to be among the most likely groups to be involved in shared decision-making. Often, patients with stage III lung cancer present to other disciplines, such as thoracic surgeons or medical oncologists. Having those patients present and then getting them referred to a radiation oncologist involves a lot of communication. It's gratifying to see that our radiation oncology colleagues are among the most engaged and involved in that shared decision-making process. Understanding what your medical oncologist wants to do, how they are doing it, and how they’ll start [is essential]. Coordinating that care in terms of when you're starting radiation therapy, either around chemotherapy or even around surgery, is critical and that was reflected in the data.

Could you expand on the significance of nurse navigators in this setting?

I wish we had a nurse navigator for every patient who had cancer just because our system can be quite complex. If you think about stage III cancer and all of those involved in a patient's journey through that care, it can be overwhelming. Not to mention, if a patient needs to go to different centers or places in the community to meet a radiation oncologist and medical oncologist, get a biopsy done, and have an interview with a surgeon—that can be overwhelming. That's probably more so in a community setting than in an academic center, where everything tends to be centralized. Having a navigator to help [a patient] get from A to B to C is invaluable.

What next steps can or should be taken?

The most exciting part of this whole project is first collecting information and, as I said, tthere is a lot to learn with the potential to dive [deeper] into [certain] areas. However, the next major objective—and we're in the middle of this now—is trying to affect change, so to take learnings about what centers have and don't have in terms of best practices, and then focusing in on a handful of those centers and working in-depth on specific issues. For example, we can tackle something like molecular testing, [work on] understanding how it is done at your center, as well as the barriers to getting that done, and what we see as a group [in terms of] potential solutions. How do we take a problem, come to some agreement on what the barriers are to fix that problem, and then attack and solve that problem.

At a broader level, how can we learn what works well from the survey, what doesn't work well, and then convert that into a standard best practice, and put that into action? We haven't really leapt that far ahead yet but I could imagine measuring those results. Could you affect change that leads to better outcomes for patients? Could you package that all up and kind of widely distribute that? That's what's exciting: learning from ourselves, learning from each other, and then applying best practices to improve the lives of all our patients with cancer, or in this specific case, lung cancer.

Is there anything else that you wanted to highlight?

Lung cancer care is moving so fast, with new therapies approved and new approaches in early-stage disease, but we anticipate even [more developments]. Coming together and educating each other about these rapid changes can be the best way to translate what's being discovered in the laboratory to the clinic.

References

1. Association of Community Cancer Centers releases preliminary findings from survey on advanced non-small cell lung cancer care. News release. Association of Community Cancer Centers. June 18, 2020. Accessed July 13, 2020. https://bit.ly/33rfQw2.
2. Salgia R, Boehmer L, Celestin C. Improving care for patients with stage III/IV NSCLC: Learnings for multidisciplinary teams from the ACCC national quality survey. J Clin Oncol. 2020;38(suppl 15):e19195. doi:10.1200/JCO.2020.38.15_suppl.e19195
3. Socinski MA, Boehmer L. What constitutes high-quality NSCLC care? Overarching quality considerations for improving NSCLC care at US cancer centers. J Clin Oncol. 2020;38(suppl 15):e19181. doi:10.1200/JCO.2020.38.15_suppl.e19181