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Collaboration of Experts in Soft Tissue Sarcoma

Insights From: Victor Villalobos, MD, PhD, University of Colorado School of Medicine; Saketh Guntupalli, MD, University of Colorado School of Medicine; Shreyaskumar R. Patel, MD, University of Texas MD Anderson Cancer Center; Anthony P. Conley, MD, University of Texas MD Anderson Cancer Center
Published Online: Friday, Dec 01, 2017



Transcript: 

Victor Villalobos, MD, PhD: Saketh, as you know, we’re very proud of the program we’ve developed in the past several years for sarcomas. We now have a multidisciplinary setting where we have all of our surgeons, including gynecologic oncology, thoracic surgery, orthopedic oncology, surgical oncology, and the radiologists and pathologists all in one room to treat these really rare types of cancers. I think it’s really important to have that team together, to be able to do that. Can you describe what you guys do on the gynecologic oncology side?

Saketh Guntupalli, MD: I think a multidisciplinary approach is incredibly important, particularly in sarcomas. Historically, gynecologic oncologists have really relied on their own training in sarcomas for treatment of this very rare disease process. But the reality is, it’s very rare, and we don’t see the broadness of sarcomas that a sarcoma expert, like yourself, would see, such as orthopedic sarcomas or gastrointestinal sarcomas. In a subspecialty group likes yours, you see a lot more cases. So, I think it is really important to have that collaborative, multidisciplinary approach. It definitely benefits patient care. You and I have taken care of gynecologic sarcomas together, and I feel like I’ve actually learned quite a bit about the latest trends in sarcoma research and sarcoma care.

Victor Villalobos, MD, PhD: As have I. I think it’s really important to have teams like yours and for your team to have, first off, expert surgeries in the gynecologic areas, which can be very tricky. I think the difficulty in sarcomas, in general, is that it’s almost like treating carcinomas as whole, right?

Saketh Guntupalli, MD: Absolutely.

Victor Villalobos, MD, PhD: It’s not like you’re treating one organ. It can be any organ, in any part of the body. So, getting together a group of people can be quite challenging. But I’m happy that we’ve been able to do that. I think that it does help patients dramatically, particularly in a situation like treating patients in the Denver region, where we treat such a wide area of the country.

Saketh Guntupalli, MD: Collaboration has been incredibly important. From a surgical point of view, we’re the only surgical subspecialty that gives chemotherapy, as well. Because of that, it is important for us to collaborate with groups of individuals and teams that specialize, broadly, in sarcomas. It’s important for us to learn what’s applicable for uterine sarcoma, based on what you’ve found out in synovial sarcomas or gastrointestinal sarcomas, for example. That collaboration has been very, very important.

Victor Villalobos, MD, PhD: And importantly, clinical trials.

Saketh Guntupalli, MD: Oh, absolutely.

Victor Villalobos, MD, PhD: That’s huge. That plays a big part in what we do here.

Saketh Guntupalli, MD: Absolutely.

Victor Villalobos, MD, PhD: You get a new sarcoma patient in your clinic. How do you go about integrating their care with other specialties?

Saketh Guntupalli, MD: The first thing that we do is we get the pathology reviewed. I can’t emphasize that enough. Often, we’ve had patients who come in with a diagnosis of a sarcoma who, then, on pathologic review, by our pathologist, or if we do choose to send it out, come back and say they don’t have a sarcoma. Instead, they actually have another disease. So, that’s the first thing that we do. We work with our pathology colleagues to confirm and agree upon the diagnosis.
After that, it’s very collaborative, between our colleagues, and radiation oncology, and other colleagues within the sarcoma group. We talk about these cases to come up with what we can do. That really happens, most often, in a metastatic or recurrent setting. You and I have shared patients. We’ve had a patient that’s come in, that’s maybe gotten frontline treatment, either outside or with us, and had a progression-free survival. And then, the patient has not done well. Or, the cancer has recurred. We all integrate our management with each other. So, I’ll have a conversation with you, and I will say, “Do you have a protocol?” I think that’s incredibly important. You’ve had quite a few protocols that you have opened.

Victor Villalobos, MD, PhD: And, enrolled your patients on.

Saketh Guntupalli, MD: I think that’s very important, because we’ve got to keep the science going forward, particularly in a disease process that’s rare and aggressive. So, that’s the first thing.

The second thing is, we have a discussion about what we can do for the patient. Are we going to give them chemotherapy? Are we going to give them focused radiation? Do we think surgery is an option for this patient? That collaboration is incredibly important for patients’ overall outcomes. When we’re collaborative, and we go through and discuss the benefits of all of these different modalities that we have to treat sarcomas, I think, ultimately, it is beneficial for patients.

Victor Villalobos, MD, PhD: We do things similarly. Although, in our sarcoma group, we have a relatively unique approach to getting patients in to see us. We have something called the “multidisciplinary clinic.” We’ve become a multidisciplinary clinic. It’s actually run by a team of APPs (advanced practice providers), who help get the patient in. We get them in, typically, on a Friday. That’s when our clinics are open. They see the advanced practice provider in the morning, they’re evaluated, and they get presented at our noon conference. We discuss them, at that visit, in that noon conference. We have a radiologist there. We have a pathologist to review the slides. We have our medical oncology team. We have a surgical oncologist. We have, often times, our thoracic surgeons. We have our orthopedic oncologist. Even plastic surgeons and gynecologic oncology will be there, as well, depending on the cases that are available. And so, the benefit of that is, we get everyone in the room at the first visit. We get to make a decision at one time. We say, “We need to do this sequence of therapy, up front.” “We need to do a neoadjuvant approach with radiation, neoadjuvantly, followed by surgery.” Or, we say, “Surgery, first, followed by everything else.” But the patient can see everyone at one time, saving a lot of time from the time of diagnosis to starting therapy. That has been really beneficial, and the patients really like it. I think it’s particularly important for a center like ours, where we are the hub for such a wide geographic spread. We probably see patients from 600 miles away, frequently.

Saketh Guntupalli, MD: Absolutely.

Victor Villalobos, MD, PhD: Often, we’re a primary treatment center for those patients. Obviously, you and I have each other’s cell phone numbers. If there’s a question, I could say, “Dr. Guntupalli, can you come take a look at this patient?” Or, “Can we get them in to see you?” We can usually get them in pretty quickly.

Saketh Guntupalli, MD: Sure. I think that collaborative approach is so incredibly important in a rare tumor type. The reality is, you have to see, as you said, a certain number of these cases to really, I think, be considered an expert. I think the collaborative approach is very, very important.

Victor Villalobos, MD, PhD: Particularly in those who are considered unresectable or metastatic.

Saketh Guntupalli, MD: Exactly.

Victor Villalobos, MD, PhD: We could use different technologies, or different techniques, to make those resectable. And even in the metastatic setting, we often will offer surgeries. And so, it’s just like I said, different approach, different biology.

Transcript Edited for Clarity 
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Transcript: 

Victor Villalobos, MD, PhD: Saketh, as you know, we’re very proud of the program we’ve developed in the past several years for sarcomas. We now have a multidisciplinary setting where we have all of our surgeons, including gynecologic oncology, thoracic surgery, orthopedic oncology, surgical oncology, and the radiologists and pathologists all in one room to treat these really rare types of cancers. I think it’s really important to have that team together, to be able to do that. Can you describe what you guys do on the gynecologic oncology side?

Saketh Guntupalli, MD: I think a multidisciplinary approach is incredibly important, particularly in sarcomas. Historically, gynecologic oncologists have really relied on their own training in sarcomas for treatment of this very rare disease process. But the reality is, it’s very rare, and we don’t see the broadness of sarcomas that a sarcoma expert, like yourself, would see, such as orthopedic sarcomas or gastrointestinal sarcomas. In a subspecialty group likes yours, you see a lot more cases. So, I think it is really important to have that collaborative, multidisciplinary approach. It definitely benefits patient care. You and I have taken care of gynecologic sarcomas together, and I feel like I’ve actually learned quite a bit about the latest trends in sarcoma research and sarcoma care.

Victor Villalobos, MD, PhD: As have I. I think it’s really important to have teams like yours and for your team to have, first off, expert surgeries in the gynecologic areas, which can be very tricky. I think the difficulty in sarcomas, in general, is that it’s almost like treating carcinomas as whole, right?

Saketh Guntupalli, MD: Absolutely.

Victor Villalobos, MD, PhD: It’s not like you’re treating one organ. It can be any organ, in any part of the body. So, getting together a group of people can be quite challenging. But I’m happy that we’ve been able to do that. I think that it does help patients dramatically, particularly in a situation like treating patients in the Denver region, where we treat such a wide area of the country.

Saketh Guntupalli, MD: Collaboration has been incredibly important. From a surgical point of view, we’re the only surgical subspecialty that gives chemotherapy, as well. Because of that, it is important for us to collaborate with groups of individuals and teams that specialize, broadly, in sarcomas. It’s important for us to learn what’s applicable for uterine sarcoma, based on what you’ve found out in synovial sarcomas or gastrointestinal sarcomas, for example. That collaboration has been very, very important.

Victor Villalobos, MD, PhD: And importantly, clinical trials.

Saketh Guntupalli, MD: Oh, absolutely.

Victor Villalobos, MD, PhD: That’s huge. That plays a big part in what we do here.

Saketh Guntupalli, MD: Absolutely.

Victor Villalobos, MD, PhD: You get a new sarcoma patient in your clinic. How do you go about integrating their care with other specialties?

Saketh Guntupalli, MD: The first thing that we do is we get the pathology reviewed. I can’t emphasize that enough. Often, we’ve had patients who come in with a diagnosis of a sarcoma who, then, on pathologic review, by our pathologist, or if we do choose to send it out, come back and say they don’t have a sarcoma. Instead, they actually have another disease. So, that’s the first thing that we do. We work with our pathology colleagues to confirm and agree upon the diagnosis.
After that, it’s very collaborative, between our colleagues, and radiation oncology, and other colleagues within the sarcoma group. We talk about these cases to come up with what we can do. That really happens, most often, in a metastatic or recurrent setting. You and I have shared patients. We’ve had a patient that’s come in, that’s maybe gotten frontline treatment, either outside or with us, and had a progression-free survival. And then, the patient has not done well. Or, the cancer has recurred. We all integrate our management with each other. So, I’ll have a conversation with you, and I will say, “Do you have a protocol?” I think that’s incredibly important. You’ve had quite a few protocols that you have opened.

Victor Villalobos, MD, PhD: And, enrolled your patients on.

Saketh Guntupalli, MD: I think that’s very important, because we’ve got to keep the science going forward, particularly in a disease process that’s rare and aggressive. So, that’s the first thing.

The second thing is, we have a discussion about what we can do for the patient. Are we going to give them chemotherapy? Are we going to give them focused radiation? Do we think surgery is an option for this patient? That collaboration is incredibly important for patients’ overall outcomes. When we’re collaborative, and we go through and discuss the benefits of all of these different modalities that we have to treat sarcomas, I think, ultimately, it is beneficial for patients.

Victor Villalobos, MD, PhD: We do things similarly. Although, in our sarcoma group, we have a relatively unique approach to getting patients in to see us. We have something called the “multidisciplinary clinic.” We’ve become a multidisciplinary clinic. It’s actually run by a team of APPs (advanced practice providers), who help get the patient in. We get them in, typically, on a Friday. That’s when our clinics are open. They see the advanced practice provider in the morning, they’re evaluated, and they get presented at our noon conference. We discuss them, at that visit, in that noon conference. We have a radiologist there. We have a pathologist to review the slides. We have our medical oncology team. We have a surgical oncologist. We have, often times, our thoracic surgeons. We have our orthopedic oncologist. Even plastic surgeons and gynecologic oncology will be there, as well, depending on the cases that are available. And so, the benefit of that is, we get everyone in the room at the first visit. We get to make a decision at one time. We say, “We need to do this sequence of therapy, up front.” “We need to do a neoadjuvant approach with radiation, neoadjuvantly, followed by surgery.” Or, we say, “Surgery, first, followed by everything else.” But the patient can see everyone at one time, saving a lot of time from the time of diagnosis to starting therapy. That has been really beneficial, and the patients really like it. I think it’s particularly important for a center like ours, where we are the hub for such a wide geographic spread. We probably see patients from 600 miles away, frequently.

Saketh Guntupalli, MD: Absolutely.

Victor Villalobos, MD, PhD: Often, we’re a primary treatment center for those patients. Obviously, you and I have each other’s cell phone numbers. If there’s a question, I could say, “Dr. Guntupalli, can you come take a look at this patient?” Or, “Can we get them in to see you?” We can usually get them in pretty quickly.

Saketh Guntupalli, MD: Sure. I think that collaborative approach is so incredibly important in a rare tumor type. The reality is, you have to see, as you said, a certain number of these cases to really, I think, be considered an expert. I think the collaborative approach is very, very important.

Victor Villalobos, MD, PhD: Particularly in those who are considered unresectable or metastatic.

Saketh Guntupalli, MD: Exactly.

Victor Villalobos, MD, PhD: We could use different technologies, or different techniques, to make those resectable. And even in the metastatic setting, we often will offer surgeries. And so, it’s just like I said, different approach, different biology.

Transcript Edited for Clarity 
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