Is your Oncologist a team player?

[CindyA]

October 18th, 2013 - by Dr. Jack West

These days, I hope the answer is yes. We’ve previously covered the various potential members of a cancer care team, but I wanted to focus today on why it can be so valuable to have more than just an oncologist or other single specialist that you have confidence in, as important as that is. More than ever before, lung cancer care today requires solid people from several medical disciplines and good communication among them. There are a few ways to have them work together, but it should be a red flag if you sense that they don’t work well together or are providing conflicting messages. We’ve probably all been part of teams that were greater than the sum of the parts, but also of ones in which members step on each others toes or even antagonize each other.

Importantly, this applies whether you have early stage lung cancer, late stage, or something in between. Even for someone with stage I cancer, you need input from the pulmonologist who typically initiates a workup, the surgeon who may resect an early lung cancer, the pathologist providing a detailed interpretation, and sometimes a medical oncologist and/or radiation oncologist to provide thoughts on the merits of additional post-operative treatment. For those with advanced/metastatic disease, you often still have the pulmonologist or surgeon doing the diagnosis, the pathologist providing critical input and often coordinating molecular testing, the medical oncologist overseeing systemic therapy, but often a radiation oncologist providing palliative radiation to a painful bone lesion or stereotactic radiosurgery for brain metastases, then your pulmonologist again helping with management of a recurrent pleural effusion or even placing a bronchial stent to help with breathing.

And there is no place where coordination as a team is more important than for locally advanced lung cancer, whether stage III NSCLC or limited SCLC, which routinely requires at least two and sometimes three different modalities (chemo, surgery, radiation) for optimal care. These treatments may be overlapping or require close timing and sharing of decision-making based on imaging and pathologist input from staging performed by the surgeon, pulmonologist, and sometimes interventional radiologist.

How big a difference can teamwork make? I know of many patients who describe the damaging effect of being advised to undergo surgery by the surgeon and then told by the oncologist that this is a bad idea. How confident can a patient be about a decision in which members of the same team openly advise against each other’s recommendations? Knowing that nearly all patients need support along the way from multiple disciplines, poor communication or animosity among team members can lead to effects as small but challenging as delays between referrals (still disconcerting when you find out you have new brain metastases) or as significant as botched coordination of time-sensitive overlapping treatment modalities.

How do team members work well together. Some of it comes down to chemistry, as hard as that is to define. Some of my closest friends are the leading lung cancer radiation oncologist, thoracic surgeons, pulmonologist, and dedicated lung pathologist at my center. I should take more time to step back and be thankful that our team enjoys each other’s company so much — I certainly think it instills confidence in our patients to have us step out of the exam room to call each other to review scans or other aspects of a case together in real time or have them encourage the patient to come right over to their office for an immediate consultation. In some centers, the different specialists walk across the hall or up or down a flight of stairs to talk together; in others, they may have each other on their cell phone speed dials. But it certainly helps to have a team in which you know the members communicate often and comfortably together.

The other leading mechanism for sharing views is a “tumor board” that is done at many leading cancer centers. In big ones, there may be separate tumor board meetings about each of several major cancer types: our center has ones for lung cancer, breast cancer, GI cancers, gynecologic cancers, genitourinary cancers, brain tumors, sarcomas, and blood-based cancers. Smaller centers may have a single tumor board for multiple different cancer types all in the same meeting. Here, cases are reviewed in the format of a typically very brief sketch of the patient background — symptoms, medical issues, etc. — and then imaging is reviewed together, pathology from biopsies reviewed and discussed, and then potential recommended plans are made together with input from many disciplines all at once. Ideally, here the different specialists can hash out a clear consensus recommendation or perhaps a range of 2-3 options to present to a patient — the important issue is to be able offer these ideas as a group and not conflicting individuals.

I have participated in hundreds of tumor boards at dozens of institutions over my past nearly 20 years focused on cancer care, and I have found them to be a critical litmus test for the program. At their worst, the members disrespect each other and roll their eyes or snipe at each other at a scheduled argument every week. But at their best, it can be the highlight of the week as we weigh the merits of different options and develop a solid plan from what started as open questions. Cases become a bit like puzzles to approach and ideally solve together.

So I think it’s critically important to get a sense of how the whole group of specialists you work with in the cancer clinic function together. Whether they work well or poorly together can have a major impact on your care and especially your experience of cancer treatment.

What has your experience been? Do you have an uplifting experience to share that instilled confidence, or perhaps a horror story that led you to a different center?