Leora Horn, MD, MSc, and Evan C. Osmundson, MD, PhD, discuss how patients are seen by various members of a multidisciplinary team and remark on Vanderbilt’s role in partnering with community oncologists to provide better care to all patients facing a lung cancer diagnosis.
PUBLISHED November 10, 2017
Philippa Cheetham, MD: We’re talking about the multidisciplinary team, clinical experts, pathologists, social workers, and nurse practitioners who are involved in decision making on behalf of the patient, so the patient gets the right treatment at the right time. Where does the patient come into this? Certain centers are running multidisciplinary teams where they actually meet with the patient. The surgeon, the medical oncologist, the radiation oncologist, often even pathologists and radiologists sit in 1 ring at 1 time with the patient and their caregiver. Is that what you do at Vanderbilt, or is this all behind the scenes?
Leora Horn, MD, MSc: Most of it is behind the scenes, but our patient may meet with multiple providers in a day. If I see a patient and I think they need to see a surgeon or a radiation oncologist the same day, even if they’re not scheduled, we might call and say, “Hey, this patient needs your expertise, can you fit them in?” We don’t necessarily all go in together to see the patient, because we’ve each got a slightly different conversation to have, but we are all available to see the patient in a single day to make that visit as productive for the patient and their family as possible.
Philippa Cheetham, MD: More and more, we’re telling patients, “You need to own your disease. You need to get educated. You can direct the course of your journey.” Do you think there is a role for having the patients sitting in to hear the discussions between medical oncologists, radiation oncologists, surgeons, the nurse practitioners, and the affiliate staff, being able to weigh in and discuss not just the physical issues that the patients are dealing with, but the logistics, the finance, the travel, and the emotional issues? Do you think that we’ll move towards that? Certainly, some centers are doing that, where the patient is actually in the room. Do you think there’s a role for that or no?
Evan C. Osmundson, MD, PhD: I think it’s a double-edged sword. I think that it’s very easy for patients to get lost when the information is highly medicalized and discussed in a very specialized manner. I think that can be done in another setting, and then usually we can sit down with the patient. Oftentimes, I’ll sit down, even with medical oncologists, side by side, just talking to the patient. That may suffice. But I think it is challenging to have a multidisciplinary tumor board and have the patient present. In some circumstances, it may be good.
Philippa Cheetham, MD: Just to wrap this segment up, we’ve talked about how we involve other institutions that may come under the Vanderbilt empire. Do you wait for individuals to contact you for a second opinion, whether it be a patient or a community oncologist, who may say, “I’d like you to review this case?” Or do you actually go proactively into the community and say, “Well, look, we’re a center of excellence, we specialize in lung cancer, and we actively encourage you to send patients to us rather than manage them in the community?” How proactive are you are in going out to bring people in?
Leora Horn, MD, MSc: We go out to the community, we give talks in the community, and a lot of the community doctors have our cell phone numbers. So, they don’t always have to send the patient. We’ll often get calls: “Can I just run a case by you? I’m not sure if this patient should come there, or can you help me over the phone?”
Philippa Cheetham, MD: Is it usually this collaboration where the patient may still be managed in the community but you’re weighing in? Or is it more common for the patient to be actually referred to you so you can take over care?
Leora Horn, MD, MSc: We’ll take over care if the patient requests we take over care. What we do a lot is try and encourage patients to participate in clinical trials. I see trials as the first option, not the last. You can always go back to FDA-approved therapies. So, if they’re on a clinical trial, we take over the care, but we always involve their community doctors, because they may get treatment 1 day every 2 weeks. If something happens at home, we want their community doctors involved. If there’s nothing that Vanderbilt can offer that’s different from what they get at home, we encourage them to go back to their community doctors. We’re happy to review scans, happy to see them on an ad hoc basis.
Philippa Cheetham, MD: Just a final comment. We’re all encouraged to practice evidence-based medicine and follow national guidelines, but experience is a huge part of the value of managing patients. Is most of what you do evidence-based? How much does your professional experience of managing patients on an individual basis weigh in to how you treat patients?
Evan C. Osmundson, MD, PhD: I would say that just about everything we do is evidence-based. There has to be a rationale for me offering a potentially toxic therapy to a patient. In terms of clinical experience and expertise, I say that’s very, very important. In particular, when you’re talking about technical expertise. For example, some of the radiation types that we deliver—high-dose per fraction, SBRT [stereotactic body radiation therapy] to the lung or to the brain—need to be done at places that are high-frequency centers. There are data suggesting that outcomes are improved when they’re done at high-frequency centers. So, if I see a patient who’s a candidate for that, I will encourage them to go to a high-frequency center, whether that be at Vanderbilt or closer to their home. But it’s very, very important for certain procedures.
Philippa Cheetham, MD: Thank you so much to the 3 of you for a very insightful education about how to manage lung cancer together. I’m sure behind the scenes, you don’t always agree on patient management, but it’s healthy to have different opinions as well. Thank you so much to all of you.