Optimizing Care in Metastatic Colorectal Cancer

Transcript:John L. Marshall, MD: I know everyone at this table loves taking care of patients and loves being a coordinator within their own community—not only on a national level, but we each are our regional resource. How do we interact? Tara, I’ll pick on you first. What’s a good way that we can take care of patients with metastatic colon cancer using all of the resources? I think of it as a team sport. How’s your teamwork?

Tara E. Seery, MD: I completely agree. Every patient is brought to our GI tumor board, which is exclusively colon cancer. The medical oncologist, the radiologist, the pathologist, and the surgeon are at the tumor board.

John L. Marshall, MD: IR (interventional radiologists), do they show up?

Tara E. Seery, MD: They show up. I think that really helps the best interests of the patient. Instead of them having six different appointments, we can have everybody together and decide on what’s the easiest thing. If patients are being seen in the community, then what we do is we call the oncologist. We let them know what we feel is the most appropriate, and we send them back. We work with a teach approach. I love it when I get e-mails from oncologists because it’s a great way to correspond. You can answer it quickly, and we’re helping the patient.

John L. Marshall, MD: Can you all talk a little bit about partnering with the community? We’re good at what we do; patients come and see us. You’re going to do it better than the community. The community therefore gets mad at us because they stay with us. How do we give it our perspective from the ivory tower of that interface and how we really interface with the community? How does it work for you guys?

Cathy Eng, MD: At least at MD Anderson, the majority of patients are from out of town to begin with.

John L. Marshall, MD: They’ve flown in.

Cathy Eng, MD: They’ve flown in. A lot of patients are willing to stay with me and fly back and forth, but actually I discourage that because I would prefer that they get their treatment closer to home. I feel the patients fare better overall in regards to their mentality and how they tolerate treatment; they’re continuing to work. I try to send them back home, and then I coordinate it with their outside physician.

John L. Marshall, MD: You’ve got a mainline patient who gets sent downtown; you’re charming. How does that work?

Daniel G. Haller, MD: Of course. I’ve been at Penn for 36 years, so I have a reputation in town. The truth is that we’re not seen as a roach hotel where you check in and you don’t check out; that’s not a good way to be. For some patients, we do encourage them to stay. If they have a rectal cancer and they’re coming from a place where they don’t have a good board-certified colorectal surgeon, etc, that’s a patient that we push a little bit toward making that commitment. For somebody with metastatic colon cancer or fairly routine care, like with Cathy, we encourage them to be closer to where they get their care. If it’s a simple episodic surgical procedure, or an IR procedure, or something else, yes, we’ll push a little bit to stay. But as with you, we like to use e-mails, and I like being curbsided. We all like that.

John L. Marshall, MD: It’s flattering when we get that e-mail about how you would take care of this or that. But we do partner more and more with our community folks. You guys in Columbus, and I’m sure you guys in Phoenix do that, too—these formal partnerships where we’re even doing clinical trials with our community partners and things like that. We do have unique resources around IR and around surgery that sometimes are worth coming in. So, is that it?

Tanios Bekaii-Saab, MD: I think there are specific cases where the patients, and even the referring physicians, feel more comfortable with us assuming care. There’s the example of rectal cancer, specifically, the surgical component—sometimes the irrigation component. One thing I tell my fellows when they graduate—especially if they stick to academic medicine—I say, “You’re going to go from one day being a fellow to the next day being the GI cancer expert. The doctor in the community has 20 years of expertise seeing more colon cancer patients than probably all the GI colleagues combined. The fact that you just are a specialist on day one doesn’t make you any smarter or better.” It’s very important for us to make our community oncologists feel that we’re just their partners. We have a different level of expertise, and we can help with things, partner with research, and bring more awareness to them. As everyone says, optimally, for patients, they’re better treated in their own community surrounded by their loved ones, closer to home, and others—except in very few instances.

Cathy Eng, MD: It really is a team approach with the outside oncologist. You get to know them. You actually become quite friendly with them, you have this real partnership.

John L. Marshall, MD: And the patient sees that, too. I think that relationship is about…

Tanios Bekaii-Saab, MD: It’s better for the patients.

Tara E. Seery, MD: It makes the patient comfortable so then they have no worry. The issue is, what if they get sick? You don’t want them flying or traveling to see you.

Cathy Eng, MD: Exactly.

Tara E. Seery, MD: You want them to see their local doctor.

Daniel G. Haller, MD: John, although the cooperative groups are certainly having troubles financially and otherwise, they still represent an enormous clinical resource. More than 50% of the patients who enter clinical trials in the cooperative groups don’t come from the academic centers that write the studies; they come from the doctors in the community who actually take care of them.

Transcript Edited for Clarity