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Multidisciplinary Care in Glioblastoma

Insights From: Maciej Mrugala, MD, PhD, MPH, University of Washington Medical Center; Suriya Jeyapalan, MD, MPH, Tufts Medical Center; Daniela Bota, MD, UC Irvine Medical Center
Published: Thursday, Dec 29, 2016



Transcript:

Maciej Mrugala, MD, PhD, MPH:
In terms of the approach to therapy, we like to implement, at our institution, a multidisciplinary approach. Treatment of a brain tumor requires a whole team of specialists. It’s not just a neurosurgeon, but also a radiation oncologist, a neuropathologist, neuroradiologists, and neuro-oncologists. We try to see our patients in a multidisciplinary clinic where a patient comes in and sees all the subspecialists in sequence, starting usually with neurosurgeon and then either a radiation oncologist or neuro-oncologist. So, we try to create a visit during which the patient has the ability to meet with the whole team and ask the questions, and also understand what is going to be the trajectory of treatment, what will be done first, what will be done second, and what are the side effects associated with each treatment approach.

Even though these visits might be a little long—sometimes they go on for several hours—we believe that it gives the patient the ability to really meet with everybody all at once and then understand who the care team is. I think, over time, it actually helps with the anxiety and an unknown—what is going to happen to me, who is going to be my provider? So, that’s how we do it.

Daniela Bota, MD: When our patients present to our care, irrespective of which one of the team members they access—either the neurooncologist, the neurosurgeon, sometime even the radiation oncologist—they get discussed in the tumor board. A tumor board is a collection of a large number of physicians that are all interested in the care of patients with brain tumors, in our case. And this tumor board includes the neurosurgeons, neuro-oncologists, neuroradiologists, neuropsychologists and psychiatrists, the neuropathologists, and the radiation oncologists. So, we all together discuss what’s the best treatment for the patients. Why is it important to be multidisciplinary? Because the treatment of glioblastoma patients is not where one doctor does a procedure or a treatment and the other doctor comes along and you are passing the patients from one part to the other of the team. Right now, the treatment involves one or more physicians. By example, during the surgery, many times we want tumor tissue collected in order to see if the patient qualifies for immunotherapies. Many of the immunotherapies are based on cell count and cell collection from the tumor. And in absence of fresh tissue, the patients are not going to be eligible for that type of treatment.

After the surgery is completed, the patients will receive radiation in combination with temozolomide. The radiation is administered by the radiation oncologist, and the temozolomide, it’s administered in our case by the neuro-oncologist. The patients have multiple symptoms and those have to be addressed sometimes by colleagues in neuropsychology and neuropsychiatry. So, our approach at my university is that the neuro-oncologists function as the half of the team, with the other physicians connecting to us as the spokes. I think that it’s also important to mention that the care of patients with brain tumors start even before the surgery and before the diagnosis is made. And the reason for which I’m saying that is that a lot of thought has to go on their presurgical planning for those patients talking about the advanced modalities that we use.

In our case at our university, the majority of the patients that have brain surgery for the resection of their brain tumors go, first, to an extensive imaging evaluation using modalities like functional imaging, infusion tests, or MRIs to identify the centers of the speech, of the memory, and of the motor and sensory areas, and then to identify the fibers that connect those centers. All this information is then built in the neuronavigation system that our neurosurgeons use. It’s used in order to make the surgery not only the most complete possible, but also the safest possible for the patient. So, at the end of this first stage of treatment, the patient has a great surgical resection, but at the same time the treatment is maintaining or even improving their neurological function and their quality of life.

Suriya Jeyapalan, MD, MPH: So, in our institution, in a lot of tertiary medical care centers in the United States, we have what are called tumor boards that evaluate patients and present their entire history, their laboratory results, their radiological results, and their pathology results. In a room, what you usually have is a surgeon, who has taken the tumor. You have oncologists, who’ll be giving the chemotherapy for the tumor. You have the radiation doctor, who will be giving the radiation for the tumor. You have the pathologist, who will show you want the tumor looks like under the microscope. And you’ll have the radiologist, who will show you what the tumor looks like under imaging. So, there are usually about 10 to 15 people in the room.

In our own tumor board, we have a cancer registry, so there’s a representative from the cancer registry. We have our clinical trials department in there to talk to us about available clinical trials options. We have medical students because we’re a teaching center. We’ll have residents in the room, Fellows in the room. It’s quite a big crowd in the room. And there’s a very thorough discussion that’s given on every patient; a lot of back and forth that’s given. I do recommend it very highly for patients. If you have a disease that is somewhat complicated or that you’d like a second opinion for, go to a tertiary medical care center. Because it’s not just one person making the decision, it’s multiple people making a usually very informed decision, and we try and come up with the best treatment option for the family.

Daniela Bota, MD: I think the best way for the community oncologists to work with academic centers is to collaborate with one of the brain tumors teams that is close to their location. And what I’m trying to say is that a lot of our patients love to have care close to their home with their doctors in the community, and the other part of this is that many patients live far from university centers. And when you have somebody that is maybe functionally disabled, it’s not fair even for the patient to have to travel such a long distance. However, there are important points in the patient’s care when it is for the benefit of the patient to try to refer to the academic center. One of them, again, is for the resection of complicated tumors in order to make sure that we achieve the best possible surgery. The other one is after doing the standard of care treatment, glioblastoma tends to recur, and many times that’s the point in which patients, if they’re interested, should be offered the possibility to participate in clinical trials.

It is important to note that in many clinical trials we also incorporate the standard of care regimen, and we add the experimental agent in addition to the standard of care treatment. And again, the standard of care treatment on those studies can be done in the local community. So, instead of the patient having to come every 2 weeks to receive both the standard of care treatment and the experimental treatment, maybe the patient can come only at the time when there is an experimental treatment, which might be, by example, for some studies every 8 weeks.

Transcript Edited for Clarity
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Transcript:

Maciej Mrugala, MD, PhD, MPH:
In terms of the approach to therapy, we like to implement, at our institution, a multidisciplinary approach. Treatment of a brain tumor requires a whole team of specialists. It’s not just a neurosurgeon, but also a radiation oncologist, a neuropathologist, neuroradiologists, and neuro-oncologists. We try to see our patients in a multidisciplinary clinic where a patient comes in and sees all the subspecialists in sequence, starting usually with neurosurgeon and then either a radiation oncologist or neuro-oncologist. So, we try to create a visit during which the patient has the ability to meet with the whole team and ask the questions, and also understand what is going to be the trajectory of treatment, what will be done first, what will be done second, and what are the side effects associated with each treatment approach.

Even though these visits might be a little long—sometimes they go on for several hours—we believe that it gives the patient the ability to really meet with everybody all at once and then understand who the care team is. I think, over time, it actually helps with the anxiety and an unknown—what is going to happen to me, who is going to be my provider? So, that’s how we do it.

Daniela Bota, MD: When our patients present to our care, irrespective of which one of the team members they access—either the neurooncologist, the neurosurgeon, sometime even the radiation oncologist—they get discussed in the tumor board. A tumor board is a collection of a large number of physicians that are all interested in the care of patients with brain tumors, in our case. And this tumor board includes the neurosurgeons, neuro-oncologists, neuroradiologists, neuropsychologists and psychiatrists, the neuropathologists, and the radiation oncologists. So, we all together discuss what’s the best treatment for the patients. Why is it important to be multidisciplinary? Because the treatment of glioblastoma patients is not where one doctor does a procedure or a treatment and the other doctor comes along and you are passing the patients from one part to the other of the team. Right now, the treatment involves one or more physicians. By example, during the surgery, many times we want tumor tissue collected in order to see if the patient qualifies for immunotherapies. Many of the immunotherapies are based on cell count and cell collection from the tumor. And in absence of fresh tissue, the patients are not going to be eligible for that type of treatment.

After the surgery is completed, the patients will receive radiation in combination with temozolomide. The radiation is administered by the radiation oncologist, and the temozolomide, it’s administered in our case by the neuro-oncologist. The patients have multiple symptoms and those have to be addressed sometimes by colleagues in neuropsychology and neuropsychiatry. So, our approach at my university is that the neuro-oncologists function as the half of the team, with the other physicians connecting to us as the spokes. I think that it’s also important to mention that the care of patients with brain tumors start even before the surgery and before the diagnosis is made. And the reason for which I’m saying that is that a lot of thought has to go on their presurgical planning for those patients talking about the advanced modalities that we use.

In our case at our university, the majority of the patients that have brain surgery for the resection of their brain tumors go, first, to an extensive imaging evaluation using modalities like functional imaging, infusion tests, or MRIs to identify the centers of the speech, of the memory, and of the motor and sensory areas, and then to identify the fibers that connect those centers. All this information is then built in the neuronavigation system that our neurosurgeons use. It’s used in order to make the surgery not only the most complete possible, but also the safest possible for the patient. So, at the end of this first stage of treatment, the patient has a great surgical resection, but at the same time the treatment is maintaining or even improving their neurological function and their quality of life.

Suriya Jeyapalan, MD, MPH: So, in our institution, in a lot of tertiary medical care centers in the United States, we have what are called tumor boards that evaluate patients and present their entire history, their laboratory results, their radiological results, and their pathology results. In a room, what you usually have is a surgeon, who has taken the tumor. You have oncologists, who’ll be giving the chemotherapy for the tumor. You have the radiation doctor, who will be giving the radiation for the tumor. You have the pathologist, who will show you want the tumor looks like under the microscope. And you’ll have the radiologist, who will show you what the tumor looks like under imaging. So, there are usually about 10 to 15 people in the room.

In our own tumor board, we have a cancer registry, so there’s a representative from the cancer registry. We have our clinical trials department in there to talk to us about available clinical trials options. We have medical students because we’re a teaching center. We’ll have residents in the room, Fellows in the room. It’s quite a big crowd in the room. And there’s a very thorough discussion that’s given on every patient; a lot of back and forth that’s given. I do recommend it very highly for patients. If you have a disease that is somewhat complicated or that you’d like a second opinion for, go to a tertiary medical care center. Because it’s not just one person making the decision, it’s multiple people making a usually very informed decision, and we try and come up with the best treatment option for the family.

Daniela Bota, MD: I think the best way for the community oncologists to work with academic centers is to collaborate with one of the brain tumors teams that is close to their location. And what I’m trying to say is that a lot of our patients love to have care close to their home with their doctors in the community, and the other part of this is that many patients live far from university centers. And when you have somebody that is maybe functionally disabled, it’s not fair even for the patient to have to travel such a long distance. However, there are important points in the patient’s care when it is for the benefit of the patient to try to refer to the academic center. One of them, again, is for the resection of complicated tumors in order to make sure that we achieve the best possible surgery. The other one is after doing the standard of care treatment, glioblastoma tends to recur, and many times that’s the point in which patients, if they’re interested, should be offered the possibility to participate in clinical trials.

It is important to note that in many clinical trials we also incorporate the standard of care regimen, and we add the experimental agent in addition to the standard of care treatment. And again, the standard of care treatment on those studies can be done in the local community. So, instead of the patient having to come every 2 weeks to receive both the standard of care treatment and the experimental treatment, maybe the patient can come only at the time when there is an experimental treatment, which might be, by example, for some studies every 8 weeks.

Transcript Edited for Clarity
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