“What does the PET scan show?
Is she a non-smoker?
If it were me I would recommend observation.
This is not a classic small cell carcinoma.Certainly not textbook.
Did she have surgery in the past?
How old is she? The pre-op risk seems high.
What’s the patient’s social status? Does he have a family?
There is something there that looks a little suspicious.
Was it biopsied?
Does he have metastatic disease?
She’s a healthy woman. I think it should come out.
So goes the observations by a multidisciplinary group of physicians in a conference room in the Center for Comprehensive Care, located on the 4th floor of St. Barnabas Hospital. Two oncologists sit across the table from a thoracic surgeon who sits next to two pathologists and the divisional director of pulmonology. Seated across the table is the chair of radiology and a radiation oncologist. Also in the room are medicine and surgical residents, a PA and patient navigators who will help these patients, once next steps are established, negotiate the system. The Lung Tumor Board, held monthly, is a new initiative at SBH, brought to the institution by Dr. Rocco Lafaro, who arrived here a year ago after a long career as a cardiothoracic surgeon at a nearby medical center. Dr. Lafaro chairs these monthly meetings with Dr. Raghu Loganathan, SBH’s director, Division of ICU/Pulmonary Medicine.
“Patients are discussed in an orderly, multidisciplinary way, with cooperation and input from all services,” says Dr.” “Lafaro. “At the table, we have individuals from pulmonary, thoracic surgery, radiation oncology, oncology, pathology and radiology. A treatment plan is established and then we go forward, and there is always follow-up.”
Patients, admitted to the hospital primarily through pulmonology and oncology, present with undetermined or cancerous nodules of the lung or mediastinum. In most cases, surgery has been performed, with radiation and/or chemotherapy recommended as follow-ups. In some cases, a wait-and-see attitude is suggested.
“The program, according to Dr. Loganathan, has worked extremely well. “This is a high performing group,” he says. “The discussions have been excellent. It’s not only a good teaching experience for the residents, but also for us to learn as a group, such as about the latest targeted therapies.”
A lung tumor board, he adds, could only have been introduced once a thoracic surgeon was in place and a diagnostic tool like a lung cancer screening program – which is now nearly two years old – well established.
A recent study in the American Journal of Respiratory and Critical Care Medicine concluded that a multidisciplinary tumor board (MDTB) “aids in decision- making for difficult cases by providing dispassionate an alternative perspectives from multiple specialties. In addition, studies have associated MDTB with several benefits including increased operative mortality, survival rates and overall satisfaction for cancer patients.” At the conference table, Dr. B. Bobby Chiong, chair, Department of Radiology, artfully manipulates the various images, apprising the group of tumor size and location. A slide with the patient’s tissue sample is reviewed by Dr. Ali Chaudri, a pathologist.
“We discuss the patient’s history and examine the images before we reach any decisions,” says Dr. Lafaro. “The literature suggests clearly that a diagnosis is changed about 25 percent of the time. The way medicine is today the information is overwhelming, so we look to get a consensus from the experts. There is so much information out there that you need input from other people.”
New technologies and medicines, he says, including the advent of tumor boards and other avenues for doctors with different sub-specialties to discuss patient histories, have dramatically changed the rules of the game, giving patients far better odds at survival than in the past.
“They are going to look at us 25 years from now and say ‘You guys were barbarians,’ ” says Dr. Lafaro. “Even bigger than the technology, with catheter-based and minimally invasive robotics, is the molecular biology.
The drugs today are phenomenal. It is astonishing what can now be done with what we call targeted therapy or checkpoint antibody treatment of tumors. Cancer isn’t what it was as little as five years ago. These drugs are turning on our immune systems to target these cancers and drive them out.” Patients, adds Dr. Lafaro, should feel good knowing that a large group
of experts – some of whom they will never come into contact with – are working collaboratively to benefit their care.”