Philippa Cheetham, MD: For patients watching this segment who are hearing about what’s going on at Vanderbilt, where you’re working very closely together with tight collaboration between pathology, imaging, radiation, and medical oncology, how does a patient who may be treated in a community hospital know what to ask for? Is it appropriate, do you think, for a patient to go to their physician who’s taking care of them and say, “Well, has my case been discussed at a multidisciplinary team meeting? Can it be?” Should they be asking for a re-read of slides? What do we tell the patients? How do we get the message back to patients who are watching this segment, looking for guidance for their particular tumor and management?
Evan C. Osmundson, MD, PhD: I think it’s appropriate for a patient to ask their physician about anything. And it’s important for the patient to feel like they have confidence in their physicians. There are some cases that are relatively clear-cut where the pathologist has no question as to what this diagnosis is, but there are those cases that are challenging. Many outside pathologists will often send their slides, whether or not we see the patient, to Vanderbilt for a second opinion, interpretation, because so much does ride on that diagnosis. But I think it’s entirely appropriate for a patient to say, “Has my case been discussed at multidisciplinary clinic?” There’s no harm in that. I think it would be fine.
Philippa Cheetham, MD: For patients who are in the early phases of their cancer journey, where they may have already had imaging but not necessarily have had a biopsy—if you were advising patients who are watching this segment—do you think it’s okay to get the biopsy local to where they may live and say, “Once you’ve got a diagnosis, then maybe go to a center of excellence.” Or would you advise patients even early on, “No, go to a center of excellence even earlier to get that biopsy done”? Maybe they get more tissue, better quality tissue, or more markers. At what point does the patient need to plug in to a center of excellence? Is it before biopsy? Do you think there’s value in that?
Leora Horn, MD, MSc: I think it depends on their level of concern. There are a lot of great doctors out in the community, and sometimes having the biopsy and the tissue diagnosis helps us to figure out which doctor at Vanderbilt they should see. If a colon cancer patient came into my clinic, I would basically say, “Nice to meet you, but I need to get you in to see one of my colleagues, because this is not the tumor type that I treat.” But as long as there are skilled folks at a community hospital who are going to be able to get that tissue—I think that we’re doing a better job of getting the information out there that this is important—it’s perfectly fine to have the biopsy closer to home. That’s often a procedure that will require someone to drive you home, so maybe that patient is OK to come to the cancer center on their own and not have family take off multiple days of work. It really depends for each individual patient on what their family and they are comfortable with and capable of doing.
Philippa Cheetham, MD: Evan, before we talk about mutations and PD-L1, which are coming into the management of many cancers—just to give us a rough summary—when you’re sitting in these meetings and the cases are presented, do you see errors typically? Is it with delayed diagnosis? Is it bad management? Is it a delay in getting patients into clinical trials, and maybe off of standard of care? Where do you see the errors in management or diagnosis in patients who may not have been managed at centers of excellence, so that we can learn how to improve care for patients by getting them into the right centers?
Evan C. Osmundson, MD, PhD: I would say that timeliness is important. Once a patient has a suspicion of lung cancer, from then the clock is ticking. I’ve seen situations where patients have languished not getting the workup as quickly.
Philippa Cheetham, MD: Even after diagnosis—they have a confirmed diagnosis of lung cancer—there are further delays, yes?
Evan C. Osmundson, MD, PhD: All throughout the spectrum, even from imaging to biopsy, from biopsy to referral, I would say that is sometimes the biggest challenge that I see in getting patients to the appropriate care.