A multidisciplinary approach to care
November 23, 2015
It takes a village to provide comprehensive lung cancer care.
For patients at UT Southwestern, that village is populated with lung cancer specialists in pulmonary medicine, medical and radiation oncology, thoracic surgery, radiology, and pathology, as well as oncology nurses and practitioners in a wide range of supportive services. Those specialists are supported by the infrastructure of the university and Simmons Cancer Center, which fosters frequent and in-depth collaboration and promotes seamless delivery of care.
Conferring on complex cases
Lung cancer is a tumor type that often is treated by multiple approaches—surgery, radiation, chemotherapy, targeted therapy. The trick is to get all the doctors in the same room at the same time to determine which patient requires what treatment—and when.
UT Southwestern’s full range of lung cancer expertise is brought to bear weekly on the most complex cases at the Thoracic Oncology Tumor Board. The Friday afternoon conference regularly includes about 40 clinicians, basic and translational scientists, residents and fellows, data and clinical trial managers, and others involved in patient care or clinical research. The goal is to reach an evidence-based consensus on the best avenues for an individual’s care, says radiation oncologist Dr. Puneeth Iyengar, co-leader of the Cancer Center’s lung cancer disease-oriented team (DOT).
“The tumor board may have four or five physicians from each discipline, so we really get a consensus across the DOT on the difficult cases,” he says. Usually, three to five cases, and sometimes more, are discussed each week.
Cases can be submitted for consideration without charge by oncologists in the community as well as by UT Southwestern physicians. “This is a hugely valuable service,” notes thoracic surgeon Dr. Kemp Kernstine. “We look over each other’s shoulders, we criticize, we use the literature, we use guidelines and meta-analyses to make sure each of the treatment pathways is appropriate to that patient. Almost every patient has some wrinkle, a little something that’s different.”
Typically, eight or more pathologists attend each tumor board meeting, he says, which is essential to understanding the outcomes of immunohistochemistry studies and molecular profiling done on each tumor and what they imply for diagnosis and prognosis. “Things were very simple before,” Dr. Kernstine says. “Now lung cancer is broken up into many different cell types and molecular subsets and evaluating the behavior on the pathology slides. So getting the educated opinion of a lung cancer pathologist is a very important aspect of sending patients to UT Southwestern.” (See “One family’s lung cancer legacy”)
At the end of each tumor conference, a document is created for each case that summarizes the discussion and conclusions that are reached. On campus, that information is shared with all of the patient’s providers through the Medical Center’s electronic medical record, which is also used to submit cases for discussion. And the deliberations, minus information about the patient’s identity, can be accessed on the Medical Center’s intranet. Lung cancer program leaders hope to expand tumor conference access to other institutions’ physicians who wish to observe a discussion by allowing them to sign on and watch the de-identified deliberations or request a case review and provide relevant patient records via the Internet—and perhaps even participate from remote sites.
The convenience of one-stop care
Lung cancer patients at UT Southwestern also benefit from the Cancer Center’s Thoracic Multidisciplinary Clinic. With the convenience of just one visit, “patients can be evaluated by pulmonologists, medical oncologists, radiation oncologists, and surgeons,” Dr. Iyengar says. The ability of those physicians to confer immediately onsite, he adds, facilitates the prompt development of a multidisciplinary treatment plan.
Dr. Kernstine cites a recent patient whose PET scan suggested metastatic disease. A radiologist reviewed the scan then and there and concluded with a high degree of certainty that the cancer had metastasized.
“This is all within about an hour of the patient’s arrival,” Dr. Kernstine says. “Then we were able to consult with medical oncology, who was right there—the patient didn’t have to leave the room. And a clinical trials person came down and was able to give the patient a series of appropriate trial opportunities.” Such immediate follow-up allows patients to receive the care they need sooner, without enduring anxiety-filled gaps worrying about what might come next.
Because the patient spoke Spanish, an interpreter was on hand to help, Dr. Kernstine adds, and all needed documents were provided in Spanish.
The Cancer Center’s comprehensive, multidisciplinary approach ensures cutting-edge care is available to all patients in the region, which includes a large, diverse, urban-to-rural population.“That,” says Dr. Kernstine, “is what a cancer center is all about.”
Efficient, compassionate support at all stages of treatment
Collaboration among UT Southwestern’s specialists is supported by the integrated Epic electronic medical record (EMR), which allows providers to access all test results and other information about a patient’s care in any university hospital or clinic without delay. “We can all read what the others are writing about and doing—it’s just a single page away,” says interventional pulmonologist Dr. H. Thomas Chiu.
The EMR improves efficiency, adds medical oncologist Dr. David Gerber. “It decreases the amount of time until results are available, and it prevents unnecessary repeat testing. If all physicians have access to a result, then only one of us needs to draw a blood test.”
That system is further enhanced by a tool called Care Everywhere, which facilitates secure sharing of patient records outside UT Southwestern. And for patients, the MyChart health portal, part of the EMR, allows direct communication with health providers and clinical staff, as well as prescription renewals, appointment scheduling, and access to results of lab tests and radiological studies. Patients’ MyChart use grew fivefold each year over a recent six-year period, with overall logins increasing more than tenfold, Dr. Gerber says.
Patients at the Cancer Center also have access to specialists who assist with many issues that arise during and after cancer treatment. Oncology supportive services help patients and families with disease- or treatment-related side effects, as well as other physical, emotional, social, or spiritual concerns, says Dr. Jeff Kendall, Clinical Leader of Oncology Supportive Services at Simmons Cancer Center.
Dietitians are available to guide patients who are managing eating challenges amid treatment. Psychologists and social workers help patients and families adjust to the changes a cancer diagnosis brings and ensure needed resources are available. Chaplains provide spiritual support. And integrative care such as music therapy is available to improve well-being and aid with stress management. “Many cancer programs don’t have the specialists to deal with these problems,” Dr. Kendall says.