A conversation between Thoracic Oncologist Bindu R Potugari, MD and Thoracic Surgeon Andrew M Popoff, MD, FACS
This conversation has been edited for brevity.
How have MDTs evolved/shifted in the last few years within Lung Cancer?
Dr. Potugari: I think multidisciplinary teams likely started with the medical oncologist, radiation oncologist, and thoracic surgeon. And now there is a growing body of evidence suggesting that involving the radiologist and involving the intervention pulmonologist is definitely going to help in the patient’s care.
Dr. Popoff: I think that the emphasis on multidisciplinary care has dramatically increased, because even early stage disease can now be treated in a multi modality fashion. And so we see patients that may not have been discussed in that format previously. And so engaging the oncologist, the radiation oncologist, and the surgeon in those discussions has never been more important than it is now.
In your role, how do you actively support or participate in the MDT approach to ensure patients receive guideline-driven care?
Dr. Potugari: Dr. Popoff, as a thoracic surgeon, how would you make sure that you actually maintain the guideline driven care to your patients?
Dr. Popoff: So I think we all have an obligation to know and understand the NCCN guidelines for care and seek to implement those guidelines when it’s appropriate for the patient. As a thoracic surgeon on the multidisciplinary team, I think as we make a decision about neoadjuvant or perioperative strategies versus definitive treatment strategies, the decision about resectability requires the involvement of a surgeon. And so the role of the surgeon in the tumor board, particularly in the area of multi modality treatment for even early stage disease, is increasingly important.
Are there situations where MDT meetings are used to compare roles and responsibilities when it comes to treatment options? If so – Can you, please elaborate on the shift from the standpoint of various specialties involved?
Dr. Popoff: Every participant has his or her own responsibility to contribute their expertise based on their clinical practice and experience. But the purpose of the MDT is not to compare and contrast or reassign responsibilities based on sort of preexisting roles or anything like that.
Are there situations in which you might find it necessary to pursue a treatment approach that differs from what another provider or specialist recommends, or where you prefer an alternative course of action? If so, what steps did you take to address or resolve it?
Dr. Potugari: If there’s a concern about a particular type of a treatment, we actually raise that particular question to the other provider. Then the other providers usually try to explain their concerns about proceeding with that treatment. Then we agree with the total recommendation. So typically we get their opinion about the other modalities of the treatment, and how we should pursue that particular patient’s care.
Dr. Popoff: That’s a big part of the value of the multidisciplinary team is that dialog and the open communication to try to resolve if there is a difference of opinion about the best way forward for the patient to try to resolve some of those discrepancies. As a physician and especially as a surgeon, you have to be comfortable with the treatment plan. So if the consensus opinion is surgery, but for another reason that maybe isn’t readily apparent (say medical comorbidities, the patient’s performance status or something), and it’s not until I see the patient that I understand that that’s probably not going to be the best option for the patient. Then, I need to either bring that back to the multidisciplinary team or reengage the members as part of that discussion, saying, ‘Hey, I think maybe there’s another option here that we should consider.’
Dr. Potugari, do you think that being part of the multidisciplinary team has helped you stay on top of evolving treatment paradigms?
Dr. Potugari: I totally agree with that one. Because of the evolving evidence coming up, sharing each other’s specialty of data really helped me stay up-to-date on the patient’s care.
Dr. Popoff: As things unfold, I think you have an obligation to your patients and also colleagues to remain abreast of the latest developments. Being in a teaching institution, obviously we have other motivations, but that’s certainly one of the benefits from participating in a multidisciplinary team.
Dr. Potugari: It definitely makes me stronger by actually participating in the multidisciplinary team. I try to do my best to come up with the patient’s care.
Are there any challenges with dealing with complex patient cases within these MDT meetings, any way to better address these cases?
Dr. Popoff: There are always challenges with complex patients and those complexities can arise from a number of different angles. Medical complexity, case complexity, and social socioeconomic factors that are considerations in a patient’s care. The multidisciplinary approach to care helps resolve some of that, ideally. But those factors are real and they certainly influence the way in which we deliver care to patients.
Dr. Potugari: I think every lung cancer patient is a complex patient right now with this growing evidence. As previously mentioned, I typically collaborate with our thoracic surgeon or radiation oncologist in the early stage lung cancer. But when it comes to Stage Four lung cancer, it’s much more complex. I definitely need support from the palliative care teams like oncology and social needs. I also need the assistance from our financial team. Not many of our patients can even afford transportation.
Do you feel like there’s a better way than the MDT approach to address complex care situations for lung cancer patients?
Dr. Potugari: I don’t think so. This is the best way. And apart from that, now there are actually evolving bodies with the metastatic tumor board or multidisciplinary teams where they actually address brain metastases. More multidisciplinary team involvement is definitely going to help the patient.
Dr. Popoff: I think we will continue to refine the multidisciplinary team approach to care. There’s always an opportunity to do better than we’re doing, right? And I think we’re all focused on that. But certainly MDT is a core component of care currently and will likely continue to be for the foreseeable future.
How are patients and their families involved in the decision-making process and care planning within your MDT team?
Dr. Potugari: Typically, during the multidisciplinary team, the provider who is responsible for that patient also engages with the patient and their family. Sometimes I end up calling the patient’s family on the phone, trying to explain about the tumor board’s recommendations when the family member is not available – so both the patient and also the patient’s families are involved in the patient’s decision making.
Dr. Popoff: The families don’t actively participate in the multidisciplinary discussion, but I think family support, family input, and collective decision making by the patient and the family are certainly a large part of the ultimate decision regarding the patient’s care, and the pathway forward.
How does your team collaboratively develop treatment plans?
Dr. Popoff: So the treatment plan results from the discussion by the multidisciplinary team. So the case is presented, the data is reviewed, and then there’s a discussion that not only summarizes the patient’s situation, but also attempts to elucidate from the participants what the collective opinion is regarding the best treatment pathway forward for the patient.
How are these MDT discussions personalized to the patient’s choice in creating their treatment plans, and who has the discussions with the patient and or family member?
Dr. Potugari: Each patient is a different individual. So we have to tailor the treatment plan to the patient. We provide some of the options whether the patient is a candidate for surgery versus not a candidate for surgery. That actually gives the patient their options. We present those options to the patient. And then we respect the patient’s wishes how they actually would like to proceed with the treatment.
Dr. Popoff: So true. The patient preference matters hugely. So a patient who might be a candidate for surgery but doesn’t want surgery – what’s an alternative?
Dr. Potugari: Thanks for talking with me today, Dr. Popoff.
Dr. Popoff: That was really fantastic. Thanks, Dr. Potugari.