COMMENTARY

New Era of Multimodal Cancer Care Demands 'Change in Mindset'

Mark G. Kris, MD

Disclosures

April 25, 2019

This transcript has been edited for clarity.

Hello. It's Mark Kris from Memorial Sloan Kettering. I'd like to say a few words about the use of the multidisciplinary team in caring for people with cancer, particularly those with locally advanced cancers.

A few weeks ago, I participated in a program with cancer specialists of all kinds, from all over the world, talking about multidisciplinary teams. The issue that we were particularly discussing was the management of patients with stage IIIB lung adenocarcinoma who received chemotherapy. These patients are evaluated by surgeons, they receive radiation, and they receive immunotherapeutics. Complex decision-making [is involved to determine] the correct regimen for patients, and then again for the management of patients and the delivery of treatments once the therapy has been chosen.

I think there is universal acceptance that these multidisciplinary panels are essential. We can only do the best for patients by tapping into the expertise, abilities, and interventions that different medical specialists have, but it's very complicated.

These were the practical issues that came up in the discussions that I heard. Where do you hold these meetings? When do you hold these meetings? Who has to be at these meetings? At the meeting, who does what? Who presents the case, and more important, who records it? Who brings the synthesis of that discussion to the patient?

I must say, it's not an easy job to hear all of the different opinions, which are sometimes quite divergent. Ultimately, as the doctor treating the patient, you have to explain the options available, the discussion that occurred, and hone in on that one treatment you are recommending for the patient.

Some thought needs to be exercised as to how we can best do this. The last thing we want to do is leave the patient in the middle of all of this to hear divergent opinions and then ask them to make a decision. We owe it to our patients to come to a decision among the medical specialists to make sure that the decision reflects the diversity of opinions, to tell the patient of the different options that are available, and to explain exactly why we made the decision.

A number of sites that run these meetings mentioned the need for a navigator. I'm sure that has different meanings in different treatment settings, but I think [it's beneficial to have] somebody who can mechanically run the session, make sure it's recorded, and make sure that various multidisciplinary appointments are made.

A navigator can ensure that the decisions and deliberations of that multidisciplinary team are presented to the patient in a way that is understandable, reflects the difference of opinion, and informs patients of the different specialties that were brought to bear in coming to that one opinion.

Another issue is that we are no longer independent practitioners. Again, in the case of stage IIIB lung cancer, each medical specialist has a very distinct role. Only a surgeon, for example, can ultimately determine operability and respectability. The medical oncologist has to be in charge of delivering the chemotherapy and the immunotherapy. The radiation oncologist is in charge of delivering the radiation. Then, however, things get blurry.

Now that there is more of a push to start immunotherapy as quickly as possible after chemoradiation, very often the medical oncologist is seeing patients before the adverse effects of the radiotherapy have worn off. Frankly, there is very little literature available on the optimal management of some of these common side effects.

As a medical oncologist, I'm seeing people more often who have radiation esophagitis, for example, and the fatigue brought on by radiation. I'm being asked to manage these problems, and I have less experience with those patients than the radiation oncologists do. There needs to be a good hand-off when you're both seeing a patient during a time when side effects are happening or we are making decisions for new therapies.

We all have to think about how, when that multidisciplinary team comes to a decision, each and every member of the team has to be clear what that decision is and support that decision in its entirety. For example, the medical oncologist can't say that the surgeon will deal with those issues of operability, the radiation oncologist will deal with this, and I'm going to deal with the chemotherapy or the immunotherapy.

Each and every member of the team must be able to say what the roles of the other team members are and to describe the entire plan of care. The surgeon determines operability and resectability . The radiation oncologist, in concert with the medical oncologist, comes up with the plan for concurrent chemotherapy and radiation, and then immunotherapy begins after that. Everybody has to know the plan.

We have to know the role of each person and support that role. I think that's a change in mindset because each of us kind of focuses on our own role and does not describe the overall plan to the patient. It's absolutely critical in this multimodality world that we reach a decision and that every member of the team understands the decision that was reached in the multimodality discussion.

Every member of the team must endorse the decision and explain not only their individual aspect of that care plan, but also the total care plan to the patient—obviously, focusing on their expertise, but endorsing every aspect of that plan.

This is a wonderful time because we have so many modalities and opportunities available to us. We can personalize care more than ever before, but we need to work together to make sure that the patient receives the recommendation that is right for them. We all have to work together to create it, to support it, and to deliver it.

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