'Put Your Team Together'--Tumor Board Takeaways

Mark G. Kris, MD


April 04, 2019

This transcript has been edited for clarity.

This is Mark Kris from Memorial Sloan Kettering, speaking today about some discussions that came up in a recent tumor board at my institution. These discussions happen over and over again and are happening even more often now. I would like to share a couple of them with you.

The first one is for patients with locoregional disease. We often see individuals who come to the tumor board having had treatment and ask us to make a decision about further care. What is unclear in these cases is, what was the plan from the beginning? Putting the tumor board together months into a person's treatment is just not the way to do it. Put the tumor board together when care is first being decided. Talk about the various options, choose a plan of care, and follow through with it. Obviously, care has to be modified based on response to treatment and adverse effects of treatment, but you really need a plan of care.

A prime example of that is for patients who have "marginally resectable" lung cancers. I'm not even sure what that truly means, though people claim to have it. There is this attitude of, "Let's try something. Let's try some chemotherapy. Let's try some chemotherapy and radiation." [They want to try something] in the hopes that this marginally resectable cancer will suddenly become resectable. I remind you all that there are no data finding that any of our treatment modalities can suddenly make a "marginally resectable" patient resectable.

Therapies are extremely helpful in the perioperative setting but they have various roles. Radiation can improve local control and systemic treatments can control metastases, but they do not facilitate surgery. I have recently seen a patient who, by the numbers, was deemed inoperable at the time of diagnosis but became operable with the use of intensive " pre-hab" treatment—pulmonary rehab preoperatively. Pulmonary and physical therapy prior to a surgery is something to consider for inoperable people. Again, put your team together at the time of diagnosis. Do it physically or mentally or virtually—however you need to do it to put everybody together.

The other area where this comes up more and more commonly is in oligometastasis. I know it has never really made sense to anybody that you could have a lung cancer with spread to the brain or to the adrenal gland, and resection of both could lead to long-term good outcomes and sometimes cure. I think Ralph Weichselbaum has carried this banner for years. He gave the Karnofsky Lecture at the 2018 American Society of Clinical Oncology annual meeting about this phenomenon of oligometastasis, and it's really become more and more common. We have seen it particularly in patients with lung cancers with an oncogenic driver, particularly EGFR and ALK, and also now with the use of checkpoint inhibitors, where we have a few sites of disease persisting after a good systemic result.

In our tumor board last week was a reminder that this strategy of, say, resecting a lung and an adrenal [metastasis] makes sense only for patients who have controlled systemic disease, whether because of the "intrinsic" nature of the patient's own immune system or because of effective systemic therapies. Our surgical colleagues were very clear that you need to demonstrate control of systemic disease and you need to demonstrate it for a certain amount of time. Traditionally, my time has been 1 year, but obviously that can be modified on the basis of the individual patient. Do not jump to [the conclusion] that the best thing is an operation or stereotactic body radiation therapy or radioablation. Put all of the choices on the table when you have such a patient.

I guess the theme of this is, put your team together. Put it together at the time of diagnosis and initial treatment, and again when thinking about adding other modalities. Also [put it together] when treating oligometastases and oligoprogression, but that is a topic for another time.

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