Increasing knowledge of the diverse pathologic and molecular phenotypes in non-small cell lung cancer (NSCLC) has driven a more complex treatment algorithm in recent years.
Increasing knowledge of the diverse pathologic and molecular phenotypes in non-small cell lung cancer (NSCLC) has driven a more complex treatment algorithm in recent years. This complexity emphasizes the need for a multidisciplinary approach to better manage comprehensive, personalized patient care.
It is estimated that over 224,000 new cases of lung cancer will be diagnosed in the United States alone in 2014.1Considered the leading cause of all cancer-related mortality, the 5-year relative survival rate for this disease is less than 20%.
Benjamin P. Levy, MD, on the Role of Chemotherapy in the Treatment of Lung Cancer
Levy is the director of Thoracic Medical Oncology at Mount Sinai.
Smoking is the predominant risk factor for lung cancer; however, lifelong nonsmokers can also suffer from this disease, in the majority of cases due to adenocarcinomas.
Together with adenocarcinoma, large cell carcinoma and squamous cell carcinoma are the most common histologic subtypes of NSCLC, a classification that comprises any epithelial lung cancer other than small cell lung cancer (SCLC).
As NSCLCs are relatively insensitive to conventional chemotherapy and/or radiation therapy, surgery is often recommended when patients are diagnosed at an early stage. Radiation and/or chemotherapy may be used as neoadjuvant or adjuvant therapy before or after surgery, respectively.
“Unfortunately, at this time, up to 60% of patients diagnosed with NSCLC have more advanced disease (beyond stage 1),” said Bernard J. Park, MD, deputy chief of thoracic surgery at Memorial Sloan-Kettering Cancer Center.
In advanced/metastatic cases, particularly nonsquamous disease, many patients may benefit from molecularly targeted therapies shown to improve survival in subsets of patients with specific genetic mutations.
“It is an exciting time for patients with nonsquamous NSCLC because of recent advances in molecular characterization of tumors,” Park added. “Up to 40% of patients will have a mutation in their tumor that can be treated with targeted therapy.”
Mutations in the epidermal growth factor receptor (EGFR) gene and translocations in the anaplastic lymphoma kinase (ALK)-tyrosine kinase receptor are 2 of the most common genetic abnormalities for which targeted treatments are available.
Patrick C. Ma, MD, MS, from the Cleveland Clinic Taussig Cancer Institute, added that “a timely, multiplexed genomic profiling determination…is already becoming a new standard.”
Overall, “the vast majority of these patients require multimodality care with combinations of systemic therapy (chemotherapy, targeted therapy) and local therapy (radiation, surgery),” Park stated. As a result of this growing complexity, “thoughtful multidisciplinary evaluation is a must.”
“Our multidisciplinary cancer team,” commented Ticiana Leal, MD, assistant professor at the University of Wisconsin Madison Carbone Cancer Center, “involves a dedicated group of medical oncologists, radiation oncologists, thoracic surgeons, nurses, thoracic radiologists, pulmonologists, pathologists, social workers, and a palliative care team.”
This collaborative group combines a diverse team of experts “who work together to assist in providing clinical care that encompasses the initial diagnosis, management, and treatment of patients with lung cancer and also to support the patient and their families,” she added.
Initially, for instance, pulmonologists, interventional radiologists, and thoracic surgeons are often the first to perform biopsies of the tumor. At this stage of care, providing adequate tissue samples to the pathologist is crucial to accommodate the growing number of tests that may be required.
As pathologists undergo histologic subtyping and molecular characterization of the tumor, the efficiency of proper testing is paramount in allowing treatment decisions to be made and implemented more quickly.
“In the case of advanced NSCLC, it is important to be able to start treatment as soon as possible,” noted Rex Yung, MD, of Johns Hopkins University.2“The patients can be debilitated and the window of opportunity before they slip further into a worse-functioning status could be short.”
Once obtained, test results are utilized by the medical oncologist to make informed treatment decisions for the next phase of patient care. According to Howard (Jack) West, MD, medical director of the thoracic oncology program at the Swedish Cancer Institute in Seattle, Washington, histologic and molecular test results are often “an integral part of the decision-making process.”
West explained that, “in the setting of advanced-stage disease, there is an early branch point for whether a patient has squamous or nonsquamous [histology]…Particularly for nonsquamous disease, especially adenocarcinomas, the presence or absence of an activating mutation…is going to lead to an immediate diversion of the treatment plan.”
“In terms of targeted therapies,” West added, “it is becoming more and more granular all the time. We have gone from finding a [single] common activating mutation to now having to look at specificEGFRmutations.” According to West, one might individualize the choice of targeted therapy depending upon the subtype of the patient’s mutation.
Even conventional chemotherapy can be “profoundly affected by the histology itself,” noted West. For instance, while the drug bevacizumab (Genentech/Roche) shows a survival benefit in nonsquamous cases, due to the increased risk of hemoptysis, it may be life-threatening in patients with squamous NSCLC.
Irrespective of therapy choice, however, inclusion of other allied health care professionals in the multidisciplinary team is a critical component of ensuring optimal patient care. Individuals such as nurses, nurse practitioners, and social workers work closely with each patient throughout the process to ensure his or her needs are being met.
Margie Cook, RN, OCN, a care support nurse at The West Clinic, commented that “helping patients navigate through the system,”3in terms of scheduling appointments, understanding their diagnosis and treatment plan, side-effect management, and meeting any transportation, childcare, nutritional, or psychological needs, is another crucial role for allied health care professionals.
“The need for social worker and palliative medicine team input in NSCLC patients cannot be underestimated,” stated Ma. “Our patients often have significant unmet needs in social and psychological stress after the diagnosis and during treatment.”
“When patients come to us,” Cook added,3 “cancer is not usually the only issue they are dealing with. They still have families to take care of, they still have bills to pay, they still have all of these other things on their plate, so we are there to help them deal with everything we can.”
A final member of the multidisciplinary team who should not be overlooked is the patient. “In my view and practice, the most critical part of forming a ‘personalized treatment plan’ for my patients involves incorporating the patient's values, culture, social setting, and personal preference into the treatment planning,” commented Ma. “I call this the ‘patient factor.’”
“As the field becomes more complex,” West added, “it becomes more important for patients to learn what they can about their treatment options and become active participants in their care.”
Overall, the course of patient care in NSCLC has changed significantly over the last decade, since the time of a single, standard treatment algorithm for all metastatic NSCLC.
With today’s awareness of the impact of histologic and molecular profiles on the course and proper treatment of this disease, combining the expertise and efficiency of a multidisciplinary team is becoming the only approach to ensuring optimal patient care.
“One of the most important advances in the care of cancer, and especially in the care of non-small cell lung cancer…is the fact that we have forged much better working relationships,” said Yung,2 “recognizing that for the patient’s well being…we should be practicing in a multidisciplinary approach.”