The Multidisciplinary Approach in the Management of Patients With Lung Cancer
This podcast series highlights clinical advancements in pulmonology, sleep medicine, and critical care medicine. Moderator, Albert Rizzo, MD, interviews prominent health professionals to help our community gain insight into leadership lessons.
In this episode, Dr Rizzo interviews Rachel Sanborn, MD, about the multidisciplinary approach needed in the management of patients with lung cancer, including techniques that a medical oncologist can use to communicate with the patient and the patient care team in the shared decision-making process, the advancement and impact of biomarker testing in management of patients with lung cancer, and more.
Rachel Sanborn, MD, is the Medical Director of the Thoracic Oncology Program and Director of the Phase One Clinical Trials Program at the Earle A. Chiles Research Institute at Providence Cancer Institute (Portland, Oregon).
Albert A. Rizzo, MD, is the Chief Medical Officer of the American Lung Association and Pulmonary Staff Physician for the Center for Virtual Health at ChristianaCare (Newark, Delaware).
Moderator: Hello and welcome to Critical Observations in Pulmonary Medicine led by Chief Medical Officer of the American Lung Association, Dr. Albert Rizzo. The views of the speakers are their own and do not reflect the views of their respective institutions or Consultant360.
Albert Rizzo, MD: Thank you for joining. Today we are speaking with Dr Rachel Sanborn who is the medical director of the Thoracic Oncology Program and director of the Phase 1 Clinical Trials Program at the Earle A. Chiles Research Institute at Providence Cancer Institute in Portland, Oregon. She's also serving on the American Lung Association's Lung Cancer Medical Expert Advisory Panel.
Okay, well thank you very much for joining me today. Just to start out, why don't you please tell our listeners what your current role is in your practice and or your institution regarding the diagnosis and treatment of patients with lung cancer?
Rachel Sanborn, MD: All right, well thank you Dr Rizzo for the invitation to participate. I am Dr Rachel Sanborn and I am a thoracic medical oncologist. I am the Medical Director of the Thoracic Oncology Program and also the Medical Director of the Phase 1 Clinical Trial Program here at the Earle Chiles Research Institute, but that's at the Providence Cancer Institute in Portland, Oregon.
Dr Rizzo: Very good. So you're well qualified to answer my questions. Thank you. So let's start out with the patient diagnosed with lung cancer today often has a much different journey in their care compared to those diagnosed 15, 20, or 25 years ago. It's been the advent of low-dose lung cancer screening, hoping to shift the diagnosis of earlier, more curable, and treatable stages and also a real explosion of new targeted therapies based on mutations and immunotherapy.
With this change, have you seen a change in the role of the medical oncologist when it comes to treating lung cancer? And maybe to be a little more specific, I know with the wide breadth of cancers that hematology and oncology fellows go through, an oncologist has to deal with a lot these days. So are more and more oncologists specializing in lung cancer? Have you got that impression at all?
Dr Sanborn: So that's a lot to cover, but also a great encapsulation of what the changes have been in lung cancer where we started with not a lot over that time period and there has been this explosion in therapeutic approaches and treatment options that have really changed the lives of people who experience lung cancer and for the better.
Lung cancer still remains the most commonly diagnosed cancer in men and women and this requires medical oncologists time and it requires medical oncologist knowledge as well as attention. With the advances in cancer care particularly with personalized therapy and with immunotherapies that have made this profound impact both in survival as well as in quality of life, there is now more interest and there is less nihilism compared to in the past. And that has led really to more oncologists being interested in specializing in lung cancer, which is great to see.
There hasn't been, and there isn't a specific required training in fellowship or beyond for a thoracic cancer focus, but typically what happens when a person is in fellowship when they are selecting an area of specialization is that they then will spend more dedicated time in clinics and working in research and especially important focusing on mentorship to maximize learning in along that field of interest.
Dr Rizzo: Excellent. I'm glad you mentioned nihilism and certainly, stigma is been something associated with lung cancer for a long time because of the smoking associated with most cancers, but that's good. I'm glad you mentioned that. Tumor boards, as we know have been around for quite some time and now with the advent of things like lung cancer screening, there's been the development of multidisciplinary teams to help patients even before their diagnosis or as part of the lung cancer discussion afterwards. Can you talk about the role of the medical oncologist as far as this interdisciplinary team working together?
Dr Sanborn: Certainly, so multi-specialty team management is absolutely crucial for the overall care of a person with lung cancer throughout their journey. And although in the olden days, people talked about, "Well where's the one doctor who coordinates everything for me?" That is not really a feasible thing and in the modern and more complex management era, we need to have that team approach with each person's area of expertise having recognized value and people working together.
And so when I explain this to patients, I explain that each part of the team has a very valuable role in helping to take care of the whole person and their whole journey. This does include multi-specialty tumor boards where each aspect of specialty, whether it's thoracic surgery or medical oncology, radiation oncology, thoracic radiology, thoracic pathology, a thoracic nurse navigator, the clinical trials research team, all have input in order to help make sure that we are looking at the complete picture, balancing that with the data to help improve outcomes.
One part of that as well as the role of medical oncologists is that we see the role of medical oncology evolving to be involved earlier in a person's care than we have in the past. And particularly now as we are looking at an evolving world of neoadjuvant therapies with considering chemo and immunotherapy prior to surgery, even for early-stage lung cancers, having that input from medical oncology earlier is going to be more important in the future.
Dr Rizzo: Very good, thank you. Sometimes a patient will find their way to the medical oncologist in different ways. Sometimes they're a PCP who may be suspecting cancer will send the patient right to a medical oncologist for a definitive workup and follow up or sometimes a confirmatory biopsy or suspicious imaging results lead to the referral. And then I think very often patients end up going for a second opinion to seek from another medical oncologist after they've been down the road. So how do you approach the first encounter with several types of patients that may come to your office?
Dr Sanborn: So the first part that I always do is make sure that I am starting on the same page as the patient, which sounds very... It sounds simple, but there are times in which a person is coming in to, say as a new patient, consultation and I may think that it's a second opinion and then find out that the patient is actually instead wanting to transfer care for a clinical trial or something like that.
And so clarifying, I think one of the first things I do after introducing myself is to say, "So from what I can see, you're here today for," for example, "a second opinion to talk about your cancer treatment." That way we make sure that we have clear communication and after talking to the person and clarifying their story with them, maybe it's helpful to know and see everything that you have in the chart, but sometimes the chart and the records that you have missed things.
So I go through the steps with the patient to make sure that they think that the summary of their storyline sounds right from their experience too. And then the next thing that is always incredibly important is that I ask them after that to tell me what their understanding is of what their doctors have told them is going on with the lung cancer. Hearing their summary of what has been communicated what they understand and where that is helps me then frame what the next steps are that we need to talk about or clarify to help with that visit.
Dr Rizzo: Right. I'm really glad you've mentioned understanding what the patient knows at that time because we often hear that once that cancer word is talked about, the patient kind of tunes out for a while, and doesn't really hear what their diagnosing physician is saying. So I'm glad you mentioned that point about meeting where the patient is, where they are.
You mentioned earlier the clinical trial navigator as part of the interdisciplinary team. Let me talk a little bit or ask you a little bit about that. We know that for several reasons clinical trials are not available to all or may not be warranted for all patients. What is your approach to discussing the role of clinical trials when you meet with a patient and when do you think it's a good option or not?
Dr Sanborn: So it is true that there are a number of challenges in terms of availability for clinical trials for every person and some of that has to do with safety concerns, about potential risks of investigational drugs if a person's health status may not be at a point where that could be a safe thing for them. Clinical trials also unfortunately can be written in a way to exclude many people that we think of as real-world situations and only want to select the most healthy people or can have exclusion criteria that are not always fair. That is something that is being actively worked on.
Clinical trials by nature of the work that is required and the paperwork required aren't always feasible at every single practice across the nation or across the world. And so there are challenges with all of that, but even at a research-focused institution where we have a large number of studies, there are times in which a clinical trial may not be available for a particular patient or situation.
So the first step is, always when I'm seeing a patient in clinic when somebody's coming in either new or in follow-up, is to look at their situation and evaluate whether there's a clinical trial that we have available or whether one might be available at another institution that would fit for that person. And then you look through their story and you look through their records even before seeing the person to see, "Is this something that I can offer the patient? Is this something that they could be eligible for?" You don't want to offer a study that they can't be eligible for, that would not be fair. And so that evaluation of what those person's options are happens first and then when you have potential options for a person to choose from, I will talk to the patient about that in the course of our visit.
If we don't have a study and a person is asking about whether there's a study available, I will explain why in that particular situation it might not be the case. For example, a person is on a current treatment that and their cancer is under control and there's no growth and a person will ask, "Well, can I go onto a clinical trial now?" And you have to explain things like, "Well, studies though are written for when a current treatment is no longer working, but there may not be a study that is at the time that a cancer is under good control on a well-tolerated treatment, but at the time that cancer may be growing in the future, then we would look at what options might be available at that time including clinical trials." That's a pretty common conversation that we have.
It's hard when we have to explain or talk about that maybe because a person has kidney failure we can't offer a clinical trial for safety reasons or some other type of health condition that makes it a challenge.
But in terms of when it would be a good option, the more people that you have clinical trials as options for that, not only... It may or may not help that particular person, but it helps us learn and it helps us advance cancer care for all over time.
Dr Rizzo: Absolutely. Do you find more recently that more patients are interested in hearing about clinical trials and more of them are accepting of being enrolled if they meet the criteria?
Dr Sanborn: Yes, we do see that and that is because the types of treatments have changed so dramatically and we have treatments that are so much better tolerated now than they have been in the past, that there is a lot more interest and excitement in participating for treatments that really can have the potential to be much more impactful than when it used to just be trying different doses of an almost random feeling chemotherapy.
Dr Rizzo: Right. Many of the impacts on survival and quality of life that you mentioned earlier seem to be related to a couple of different things. The screening certainly and the therapeutic advances in treating non-small cell lung cancer. Has there been much new in the realm of small-cell lung cancer?
Dr Sanborn: There have been advances in the treatment of small cell lung cancer, although the progress unfortunately has not been to the same degree that we see for people with non-small cell lung cancer. Some of the more important, I think potential breakthroughs that will be more impactful over time are, for example, a fairly recent recognition of different subtypes of small cell lung cancer that may help to impact research and therapeutic approaches. So not all non-small cell lung cancers are the same. We know, that non-small cell lung cancer is actually hundreds of different cancers that are diagnosed.
Small cell lung cancer is not all the same. And that has been something that's been terribly hard to pick apart in the same way and right now recently with a diagnosis of some of the different subtypes, we're still learning how to sort that and how to maybe potentially use that to optimize treatment. But I think that's providing insight into a future breakthrough.
Immunotherapy, as well, has improved survival for small cell lung cancer and that has been extremely important, although the degree of benefit is far less than we've seen so far for non-small cell lung cancer, but there's active ongoing research with new targets and new treatment approaches and I think we all certainly hope to see changes and more advances in the coming years.
Dr Rizzo: The NCCN guidelines talk about the importance of tumor testing for biomarkers or biomarker testing. When I last checked there were about 11, I think, specific targeted mutations with specific therapy recommendations, both first and second-line options well, as you mentioned, the identification of immunotherapy markers as well. Can you briefly speak about the significance of these particular advances? The importance of biomarker testing to direct therapy?
Dr Sanborn: This is a subject near and dear to my heart as well as to any thoracic oncologist. The biomarker testing and recognition of actionable driver mutations has made a tremendous impact on outcome for patients. And so understanding and recognizing what particular mutational array, including PD-L1 and protein expression exists in a patient's cancer before starting treatment significantly impacts not only a person's prognosis but also their quality of life.
So it is incredibly important to have that information before starting the first therapy and using the correct selected targeted option if there's an actionable driver or using the correct selected immunotherapy or even avoiding immunotherapy for those patients for whom the mutation profile indicates that it won't work and can increase risk is really important.
So the recognition of these actionable drivers has changed prognosis from the historical months for a person with advanced or metastatic disease. There are times now in which we can tell a person that their survival is going to be expected to be on the order of multiple years and with active research going on from there, there's the potential that it could even be longer. That was something that wasn't even imagined two decades ago.
Dr Rizzo: Right. As good as these biomarkers are in helping direct therapy, we know that for multiple reasons it's just not always done as much as it should be. Can you talk about some of the hurdles that you recognize with regard to getting these biomarkers at the right time for these patients?
Dr Sanborn: Absolutely. This is an incredibly important topic, first of all, rather, as you point out with the question, if you don't look, you won't know it's there. And one of the major problems that we have nationally is that it's not being looked for. So currently in the majority of locations and institutions when a person has a lung cancer diagnosed, there are no further steps to test for mutations until the person meets with the medical oncologist.
And then if the medical oncologist is the one entering those orders, and these are complex tests that take time, it can take a number of weeks to get the results back. The person may have had a biopsy and then by the time the biopsy is done, the pathology is turned around, and an appointment with medical oncology is made. That could be two weeks between their initial biopsy and their meeting and then to add another two to three weeks from that meeting to get the report. Time is ticking and time is life for a patient and that kind of delay puts a patient at risk in many situations.
So in most institutions, there is not reflex testing that is being performed at the time of diagnosis and this causes delays in therapy for patients. The point that I try to make in these discussions is that it's not acceptable for a breast cancer diagnosis to not have automatic ER, PR, and HER2 testing. So why is this accepted for lung cancer? And I think that a lot of it quite honestly goes back to a very uncomfortable topic that you already brought up, which is the stigma associated with the type of cancer and how that can be shortened for people.
The tissue limitations of initial biopsy are also challenging and in many places, there are very small fine needle aspirate specimens that are obtained that don't have enough tissue to be able to perform thorough mutation testing. Using a liquid biopsy is a compliment to assess for mutations has helped this, but it's not always sent, so if it's not sent and you are not looking, you will not know what is there.
There are also demonstrated disparities in what is tested first of all, and so when we look at the recent publications about sending quote, "Any biomarker," the vast majority of the time all that is tested is PD-L1 status but not mutation testing and that doesn't qualify as the complete story for the patient.
Also, we know that there are significant disparities in who is tested and there is a vast difference in whether there is testing for people who are Black versus people who are white or Asian. There's a significant difference in selected testing by smoking history by gender, as well as by socioeconomic status of all different types.
I advocate personally in my personal opinion for reflex testing because reflex testing eliminates those disparities and it tests everybody, it's blind to any potential bias that can be on the part of the care providers or even the person and their families who may have an internal bias or internal stigmatization about what they should or should not have. Testing for all allows us to find things that we won't, again, if we don't look.
Dr Rizzo: And you anticipated a couple of my questions, but the testing is not only getting the testing but as you mentioned, is it the right testing? Are there insurance simplifications as to what will be covered or not when you look at tumor testing of the tissue? Is that a concern?
Dr Sanborn: That can be in different locations and this is such a challenge, particularly in the United States where we have such incredibly complex and overlapping and contradictory laws and even in insurance policies. It's nearly impossible to sort out and it's not universal everywhere or even in different regions.
There are particular challenges, especially with things like a 14-day rule that says that mutation testing can't be performed within 14 days of a patient's hospitalization. Well, if a patient was in a hospital for surgery and they had their early-stage lung cancer removed, they need adjuvant therapy and they need that NGS testing to know whether or not we need to use immunotherapy or a targeted therapy during their adjuvant treatment.
Why do we have to delay getting that information to delay potentially that patient's care for an arbitrary rule that doesn't really benefit the patient? That's really a challenge that I would say personally sometimes defies some symbol logic there.
And so we also see that there can be times in which still selected testing may be mandated with the perception that that might be more efficient or less expensive. Although there have now been very good publications demonstrating that using NGS panel-based testing rather than a selected panel actually is more efficient, and saves money in the long run, that still has not always been recognized.
Dr Rizzo: Do you find with some patients living longer and ultimately recurring, it's important to get repeat biomarker testing at that point in time?
That can be because we see that when resistance is developed with different types of mutations or targeted therapies, you can see changes in what the current clones are and you can see outgrowth of different mutations that can potentially provide other actionable targets. And so using that in information to understand what other treatment options might be present for the patient, including different agents that might only be available on a clinical trial is important because it allows for more options in your therapeutic armamentarium to help the patient.
Dr Rizzo: You mentioned a little bit about the timeline earlier. I know... I often hear that some patients want to be treated as quickly as possible. They don't often like to wait one week, or two weeks to get the biomarker testing done or to see another oncologist. I mean, the timeline seems to be important based on what you've said.
Dr Sanborn: Yes, the timeline is definitely important and one of the critical pieces is that you don't want to have a significant delay in the overall care. The timeline from first abnormalities on imaging to obtaining full staging and tissue diagnosis is really critical, but at the same time, it is also critical not to rush to action that may not help a person. And so having the entire package of information is critical before making those decisions. It's that you want to make sure that you're expediting the completeness of all of that evaluation.
So this is something that should not be evolving over months for a person, but it's important say for a person who might have surgically resectable disease to have appropriate risk stratification to make sure that the proposed surgery is something that they will be able to safely recover from as well. that's absolutely critical.
But then understanding the most appropriate treatment is important. For example, if a person has an actionable driver mutation, but they are started just upfront because of a high PD-L1 status, for example, on immune therapy, and then all of a sudden there needs to be the consideration of switching to treatment for their EGFR exon 19 deletion, that patient can now be at significant risk of toxicity because of the earlier treatment that they were on. Whereas if one had gotten the NGS first and treated accordingly the first time, then that patient has significant benefit and that risk isn't there.
This is something that is being increasingly recognized but important to make sure that we act with the right information to be able to personalize that patient's treatment to provide them with the most optimal benefit and the least amount of risk.
Dr Rizzo: I wanted to circle back a little bit to the disparities that you mentioned earlier. The American Lung Association puts out the state of lung cancer report every fall, and part of that does show the disparities occurring as far as different populations who have less than optimal treatment or don't get treatment at all or less than optimal access to testing. At your institution and your community, do you see that playing out as well?
Dr Sanborn: There are challenges here as there are everywhere in trying to make sure that we have outreach to all populations and especially vulnerable populations. Many of those challenges even start with lung cancer screening, which we see nationally is recognized that lung cancer screening has been offered more and available more to people who are white than they are to people who are Black, Hispanic, or Latino. And so part of that has to do with where advertising and awareness campaigns are. Some of that has to do with different regions with trust. Some of that also has to do simply with where access is located and if access is made difficult for people, then it's harder to get everything done. And so there's a lot of work that needs to be done here and elsewhere in making sure that all aspects of care are brought to the most convenient places for people to be able to reach rather than expecting everyone to come to it.
Also, there needs to be a lot of work and there is focus, for example with our institution as well on helping to improve education, outreach, and trust in all types of communities. Also, even along those lines, there are tremendous needs that can be barriers even outside of access to care. In our country right now, there is tremendous and widespread food insecurity, housing insecurity, and other types of issues that take priority in a person's life over their healthcare or their health screening. And that is something that needs to be coupled with trying to help improve outreach. That's a tall order for any one place, but every place needs to work together on trying to help with those aspects of basic personal needs as well.
Dr Rizzo: Excellent points. And I know, again, as an organization, the Lung Association advocates for those and I want to thank you for being one of the advisors for the American Lung Association over these last few years. That's an important input for us. You've covered a lot of great information here. Are there maybe one or two take-home messages for the primary care doctor or the pulmonologist who may be listing who doesn't always deal with lung cancer on a regular basis? Anything important to give them as the takeaway?
Dr Sanborn: I think the most important takeaway or advice that I would offer would be if a patient is found to appear to have lung cancer or is now newly diagnosed with lung cancer is best to not assume the worst. So even in the setting of metastatic disease with the newer therapies, people are living longer and they're living better than ever. And that can include people who are more frail, who are medically more complex as opposed to in the past where the average survival, again, maybe on the order of months with appropriate personalized therapy, survival can potentially be years. And that can be also with a good quality of life. And that part is still not very well recognized. Unfortunately, that's not the case for everybody, but it is really important to have conversations with the medical oncologist, and having the involvement of medical oncologists is important to be able to help personalize that care and discuss what that personal prognosis may ultimately be.
Dr Rizzo: Yeah, excellent message. Bringing it back to getting rid of the nihilism and the stigma that may be sitting in those positions. That's great. So to close, what do you think are some of the future directions that research is going to take us to or on the horizon, new therapies that might be seen?
Dr Sanborn: I think that the horizon is very exciting, and I think that the future in both the year and the longer term is going to demonstrate a change in how we treat lung cancer. That already has occurred in the last number of years but is just the beginning of what we are going to see. There are so many different aspects of the research that are going to help improve outcomes from improvement of our understanding ultimately of how and what types of immunotherapies to use and when to better monitor people who have early-stage disease as the technology for monitoring, say minimally or... Minimal residual disease is becoming more ready for primetime, helping to better select who gets what type of appropriate treatment when some of the newer treatment modalities, not only the newer targeted therapies but some of the new types of treatments like antibody-drug conjugates or bispecific antibodies or other things, there's so much that is active on a very busy landscape that these are all aspects that are going to impact patients at all stages of the disease.
Dr Rizzo: Well, that certainly is an optimistic note to leave us on, and I think with the number one cancer killer of men and women, the approach to lung cancer certainly looks more optimistic with the things you've mentioned. And again, I want to thank you for all the knowledge and insight you've shared with us today.
Dr Sanborn: Thank you very much for your time and for the invitation to join. I appreciate it.
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