Who are the key members of your lung cancer care team?

[NikoleV]

Who are the key members of your lung cancer care team?

May 10th, 2013 - by Dr. Jack West

http://expertblog.lungevity.org/2013/05 ... care-team/

There are many overwhelming aspects to a new diagnosis of lung cancer. One of those is the sheer number of people who may need to become involved in your care. Many people may have little or no idea what the various specialists do, or why it’s often necessary to see many different people. But lung cancer management is becoming more and more “multi-disciplinary”, which means that it’s valuable to have input from many different people with complementary skill sets. Though the team may vary based on the health care system you’re in, here’s a primer on the key components of the care team for many people with lung cancer:

Primary care physician (PCP): Of course, you know what a primary care physician does in general, but in the context of lung cancer, they are often the first person learning of a suspicious finding on an imaging study like a chest x-ray or CT scan. These studies are often done in the workup by the PCP of symptoms like shortness of breath, non-exertional chest pain, a persistent cough, or maybe just weight loss and weakness. Once a concerning finding is detected, the PCP may refer a person to interventional radiology for a CT-guided biopsy, or alternatively to a specialist like a pulmonologist or thoracic surgeon to obtain a definitive diagnosis. What is their role after the diagnosis? It depends on the situation. Sometimes, they remain involved because of a strong relationship built over years, and they may continue to manage other medical issues beyond the cancer, but it’s also common for their role to become less prominent if the lung cancer becomes the medical issue that dominates the picture.

Radiologist: Radiologists read imaging studies, ranging from chest x-rays to CT scans to PET scans, MRIs, etc. They are involved from the time of identifying the initial disease before diagnosis to the ongoing follow-up of patients to monitor response to treatments given over time. There are often different subspecialists in various aspects of radiology, so the person who does a lot of the reading of body imaging studies may be different from the person who reads head imaging. People who read PET scans and bone scans may have a particular expertise in these modalities. And then there is interventional radiology, with specialists who have specific training to serve a role that can be closely akin to a surgeon (at least within the realm of minor surgeries), doing biopsies of nodules directed by CT or other imaging studies, implanting catheters, and various other procedures that may be needed.

Pulmonologist: A specialist in lung disease (cancer or benign), a pulmonologist is often the specialist who evaluates a new, concerning lung nodule or mass to obtain a diagnosis. They assess the probability that a lung finding represents infection, inflammation, cancer, or some other issue, and they may recommend nothing more than repeat imaging after a time interval if a nodule is relatively small and not too suspicious, or they may favor obtaining a tissue diagnosis. They will often do a bronchoscopy, which is a procedure in which they navigate a small camera down the airway and potentially take biopsies of different areas to obtain a tissue diagnosis. Some pulmonologists are more “interventional” and may do “endoscopic bronchial ultrasound” or EBUS, a procedure in which they can find lymph nodes around the bronchial trial and do biopsies to obtain more accurate staging than scans alone can provide. Interventional pulmonologists may remain involved in the care of people with lung cancer by placing stents in compressed airways or draining pleural fluid from outside of the lung. Pulmonologists may also remain longitudinally involved in the care of lung cancer patients by managing challenging cough, shortness of breath, trying to optimize lung function before or after surgery, radiation, etc.

Thoracic surgeon (or other surgeon): A thoracic surgeon is a surgeon with a specific training and expertise in lung surgery, which is its own board-certified sub-specialty of general surgery. The surgeon may be involved in the process of making a diagnosis of a lung nodule/mass. They often direct at least the initial part of the staging process and are the pivotal person who provides insight about the feasibility of surgery in someone who appears to have an earlier stage lung cancer. They may do a video-assisted thoracoscopic surgery (VATS), i.e., laparoscopic surgery in the chest, to make a diagnosis or assess whether the pleural space outside of the lung is involved with cancer. They will often do an invasive procedure called a mediastinoscopy to view (again, through a laparoscopic camera) and remove lymph nodes in the mid-chest, behind the sternum, as part of a thorough staging process. Even if curative surgery isn’t feasible, they may do a procedure called a pleurodesis that is its own subject of discussion but is essentially a procedure to treat a recurring pleural effusion. Though the surgeon is often involved primarily in a time-limited fashion at the early part of the management of lung cancer and only “as needed” thereafter, they will often do the long-term follow-up of patients who undergo surgery for an early lung cancer, especially if these people don’t go on to receive post-operative treatment from a medical oncologist.

The final key point about the surgeon on your team is that there is often a very big difference in outcomes between treatments done by a dedicated, well-trained thoracic surgeon who does high volumes of lung surgeries and a more general cardio-thoracic surgeon or especially general surgeon who typically does fewer lung cancer surgeries. Thoroughness and accuracy of staging, as well as survival from lung cancer, are often far superior for board-certified thoracic surgeons, so it’s often worth finding the best surgeon around, not just the closest one or the one whose schedule is open a few days earlier.

Pathologist: A pathologist interprets the tissue collected on a biopsy under a microscope. Because a diagnosis of lung cancer can’t really be made with certainty without a biopsy, the pathologist is critical in establishing the diagnosis. In the last decade, their role has become more and more important, as we’ve learned that different subtypes of lung cancer that are established by their appearance under the microscope and a variety of special molecular tests can be important in predicting the behavior of the cancer with or without treatment. The pathologist is typically the specialist coordinating the molecular marker testing for targets such as EGFR mutations and ALK rearrangements that have transformed the management of lung cancer in recent years.

Medical oncologist: The medical oncologist is a specialist who directs the systemic (whole body) therapies like intravenous chemo or oral targeted therapies, whether given before or after surgery, with radiation, or alone as the primary treatment for advanced lung cancer. In addition, they are typically the specialist who is likened to the “quarterback” of the team of cancer specialists. They will often oversee the symptom management and referral to other specialists as needed, and with the exception of the earlier stage patients noted above and followed primarily by the surgeon over time, the medical oncologist is generally the doctor providing longitudinal care for lung cancer patients.

Radiation oncologist: The radiation oncologist provides radiation therapy to a specific area as needed by the specific situation. For patients with early stage NSCLC who refuse or are not fit enough to pursue surgery, they often do radiation as a potentially curative alternative. For patients with locally advanced NSCLC or limited stage SCLC, they will typically give radiation to the chest disease concurrent with or sometimes sequentially with a systemic treatment like chemotherapy. Because radiation is typically the recommended approach for brain metastases, they direct this process, whether given as stereotactic radiosurgery for one or a few lesions, or whole brain radiation therapy to broadly treat more extensive metastatic disease throughout the brain. They will often do radiation to painful bone lesions or other metastases that need to be controlled because they are causing local symptoms such as pain, compression of an airway, hemoptysis (coughing up blood), or risk of a fracture of a weight-bearing bone that is structurally compromised by metastatic disease. The radiation oncologist tends to be involved as needed over discrete periods of time, rather than being longitudinally involved in the care of a patient with lung cancer.

Beyond this list, there are other members of the care team who can be critically important, including patient navigators, nurses with specialized skills, caregivers like a spouse, children, and close friends, and even the online community. But because this list and this post is already quite long, and the availability and role of these other components of the care team are quite variable, I’ll end here and hope that this quick tour is helpful for those people just coming to terms with a bewildering collection of new health care providers to see.