Improving Outcomes in Small-Cell Lung Cancer - Episode 6
Phillippa J. Cheetham, M.D.: Lots of patients who are watching this segment are tuning in from all over the world. Some patients are located very close to centers of excellence with an internationally renowned reputation. How important is it, if there is a concern about a diagnosis for lung cancer, to get the biopsy done at a center of excellence as opposed to your, for example, local community hospital?
Edward Kim, M.D., FACP: I have a split experience now. I spent the first 10-plus years in a high powered academic center, [The University of Texas] MD Anderson [Cancer Center] in Houston, and now have spent the last seven years in a community-based, front-facing organization community hospital at Levine [Cancer Institute]. And it really is dependent on the local practice. I think [it’s] going to be more reliable going to an academic center because there are other people who are holding them accountable. I’ve seen high quality work in the community as well. We have a group of pulmonologists for instance who are fantastic, and they do a lot. They can biopsy things that I didn’t think were possible, with good pieces of tissue.
But I think you also see that variability. I have seen some patients come in with just a brushing, or not even an attempt. And you need to have that. I understand everybody’s degree of risk and degree of skill set is different. But absolutely you have to have a biopsy that is confirmed. And if you’re uncomfortable with where you’re at, because many times patients feel like they shouldn’t go out of their small community. They’ve known this doctor or that doctor for the [past] 20 years and their parents were friends with their parents.
Phillippa J. Cheetham, M.D.: Sure.
Edward Kim, M.D., FACP: Look, I tell people if there’s any time in your life that you need to be selfish, it is now. You need, we need to get an accurate diagnosis up front. We don’t want to start the wrong treatment or start in a different manner. It’s always best to have your best treatment up front and give it the best shot.
Phillippa J. Cheetham, M.D.: So a patient comes to your office, they’ve had a biopsy performed already locally, and they’re coming to you for a second opinion, and you have the pathology report in front of you. Do you think it’s important to get a re-read on that pathology and have one of your experts look at the slides again and make sure that that diagnosis is correct and that there’s agreement? Or more often than not is that good enough, what’s on the report?
Edward Kim, M.D., FACP: I like to have our own folks do it. Now that doesn’t mean you send everything to Levine. Clearly we all work with different people on our team. We know who we’re comfortable with. I think it never hurts to have another set of eyes looking at something. There were countless times at MD Anderson where we changed the histology diagnosis.
Phillippa J. Cheetham, M.D.: Really?
Edward Kim, M.D., FACP: Enough that you would not trust just an outside report.
Phillippa J. Cheetham, M.D.: I think that’s an important message for people watching this segment. If you’ve been diagnosed elsewhere, a second opinion is paramount not just to discuss different treatment options but also to have a second look at the pathology. Do you ever have the situation where a patient may have had a biopsy of two lesions in the lung, and the pathology is different, so maybe they have a small cell and they’re non-small cell at the same time?
Edward Kim, M.D., FACP: Yes, I’ve had several of those, and I think that is very important to look at how the disease is distributed. That doesn’t mean we want two biopsies on every patient who comes through the door. But when there are potentially different treatment options, if they, the two lesions or others, were different histologies, then I think it’s important to have two biopsies. Where it gets a little complicated is that we are now doing molecular testing.
Phillippa J. Cheetham, M.D.: Right.
Edward Kim, M.D., FACP: And we will see two of the same histology but have different molecular markers. Not so much in small cell, but we’re seeing that more in non-small cell, which then makes it additionally challenging, knowing that we have two genetically different tumors, even though they look the same under a microscope.
Phillippa J. Cheetham, M.D.: We’re going to be talking about the role of immunotherapy, and challenging, yes, when there’s different molecular backgrounds for these tumors, but also very exciting isn’t it for developments of future drugs with immunotherapies to offer patients targeted precision-based treatments?
Edward Kim, M.D., FACP: I will admit I was not one of the early card-carrying immunotherapy champions out there. I had been working quite a bit with different vaccine trials and other aspects that just didn’t show much promise. But these checkpoint inhibitors have really transformed our care.
Phillippa J. Cheetham, M.D.: And not just in lung cancer, in other cancers as well.
Transcript Edited for Clarity