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Multidisciplinary Care in Glioblastoma

Insights From:Susan C. Pannullo, MD, Weill Cornell Brain and Spine Center; Steven A. Toms, MD, Geisinger Health System
Published: Monday, Feb 22, 2016


Transcript:

Susan C. Pannullo, MD:
The multidisciplinary team is very important in the management of a complicated situation such as a glioblastoma. These patients require the expertise of a variety of specialists. Often, the first member of the team that’s called in is a neurologist who evaluates the patient’s neurologic symptoms and therefore orders the appropriate imaging. The diagnosis is made by a neurosurgeon who is doing the operation. That is often the first person who is being called in to discuss the patient’s disease—and, therefore, is the one that will be putting together the multidisciplinary team if there isn’t already a neurologist onboard.

The neurosurgeon will then amass a team that consists of a neurologist or a neuro-oncologist in a center where one is available. A radiation oncologist will be called in to perform radiation therapy on the patient. If the neuro-oncologist is not available, depending on the way a center is set up, a medical oncologist will often be a part of this team, as well, to manage chemotherapy approaches.

Social workers, nurse practitioners, physician assistants, and rehabilitation medicine doctors are all a part of this team to get the patient through their initial weeks of treatment. The additional people that may be added to the team, depending on the patient’s particular needs, may include additional subspecialists such as a neuro-ophthalmologist. If the patient has presented with visual challenges, they may require services of an interventionist—who may need to perform procedures on the patient, such as putting in filters.

If the patient has complications such as a blood clot, there may be infectious disease doctors who are pulled in. So, the net cast by this tumor, in terms of the people that may be called in to see a patient with this disease, is very wide. But in general, the core members of the team include a neuro-oncologist, a neurologist, a neurosurgeon, and a radiation oncologist.

In a patient with a complicated disease such as a glioblastoma, a multidisciplinary team is usually amassed weekly in the context of a bulky disciplinary tumor board meeting. In those meetings, the relevant history is presented. The neuroradiologist will present the appropriate imaging for the team. The neuropathologist will review the pathologic findings, and then a multidisciplinary discussion will ensue to create, for a particular patient, the appropriate therapeutic approach going forward.

In an academic center, the patients will often come from far away, and it’s very important for these patients to coordinate care—not only in the institution where the patient has their initial surgery, but where the patient may be having ongoing care. So, in an academic institution, which is often a magnet for a rare and complex tumor such as a glioblastoma, we will reach out to the community physicians to help coordinate care for a patient with this disease.

Steven A. Toms, MD: When I encounter a patient who comes into my office with glioblastoma, there are a lot of things to get out on the table right as we’re starting. Obviously, it’s hard to break the news to the family that we’ve got something that looks very serious that may be this horrible diagnosis called glioblastoma. But we need to know that up front for a number of reasons.

First and foremost, for myself as a surgeon, is we need access to that tissue to make the diagnosis. We also use some of that tissue in our labs, and then collaborators help study the disease to figure out what we can do to make treatment better. But we also need to know beforehand whether the surgeon and the family think this might be a glioblastoma, because many of our therapies now require tissue. For example, some of the therapies involve cell-based vaccines like the dendritic cell vaccine. So we need to have this discussion before surgery—before the pathologist makes their final diagnosis—that they may have this horrible disease.

When you’re looking at glioblastoma, one of the most important prognostic factors is the age of the patient—as elderly patients don’t do nearly as well as younger patients—what’s called their Karnofsky performance level. Someone who comes in absolutely normal is 100, someone who has moderate disabilities is about 70, and someone who’s hospital-bound might be around 30. Patients who are in better shape when they start tend to do better. The other important prognostic factor, aside from getting the standardized therapy these days with radiation and temozolomide, includes extended resection.
                                                                                                                                                                                                                                                                                                                
Transcript Edited for Clarity
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Transcript:

Susan C. Pannullo, MD:
The multidisciplinary team is very important in the management of a complicated situation such as a glioblastoma. These patients require the expertise of a variety of specialists. Often, the first member of the team that’s called in is a neurologist who evaluates the patient’s neurologic symptoms and therefore orders the appropriate imaging. The diagnosis is made by a neurosurgeon who is doing the operation. That is often the first person who is being called in to discuss the patient’s disease—and, therefore, is the one that will be putting together the multidisciplinary team if there isn’t already a neurologist onboard.

The neurosurgeon will then amass a team that consists of a neurologist or a neuro-oncologist in a center where one is available. A radiation oncologist will be called in to perform radiation therapy on the patient. If the neuro-oncologist is not available, depending on the way a center is set up, a medical oncologist will often be a part of this team, as well, to manage chemotherapy approaches.

Social workers, nurse practitioners, physician assistants, and rehabilitation medicine doctors are all a part of this team to get the patient through their initial weeks of treatment. The additional people that may be added to the team, depending on the patient’s particular needs, may include additional subspecialists such as a neuro-ophthalmologist. If the patient has presented with visual challenges, they may require services of an interventionist—who may need to perform procedures on the patient, such as putting in filters.

If the patient has complications such as a blood clot, there may be infectious disease doctors who are pulled in. So, the net cast by this tumor, in terms of the people that may be called in to see a patient with this disease, is very wide. But in general, the core members of the team include a neuro-oncologist, a neurologist, a neurosurgeon, and a radiation oncologist.

In a patient with a complicated disease such as a glioblastoma, a multidisciplinary team is usually amassed weekly in the context of a bulky disciplinary tumor board meeting. In those meetings, the relevant history is presented. The neuroradiologist will present the appropriate imaging for the team. The neuropathologist will review the pathologic findings, and then a multidisciplinary discussion will ensue to create, for a particular patient, the appropriate therapeutic approach going forward.

In an academic center, the patients will often come from far away, and it’s very important for these patients to coordinate care—not only in the institution where the patient has their initial surgery, but where the patient may be having ongoing care. So, in an academic institution, which is often a magnet for a rare and complex tumor such as a glioblastoma, we will reach out to the community physicians to help coordinate care for a patient with this disease.

Steven A. Toms, MD: When I encounter a patient who comes into my office with glioblastoma, there are a lot of things to get out on the table right as we’re starting. Obviously, it’s hard to break the news to the family that we’ve got something that looks very serious that may be this horrible diagnosis called glioblastoma. But we need to know that up front for a number of reasons.

First and foremost, for myself as a surgeon, is we need access to that tissue to make the diagnosis. We also use some of that tissue in our labs, and then collaborators help study the disease to figure out what we can do to make treatment better. But we also need to know beforehand whether the surgeon and the family think this might be a glioblastoma, because many of our therapies now require tissue. For example, some of the therapies involve cell-based vaccines like the dendritic cell vaccine. So we need to have this discussion before surgery—before the pathologist makes their final diagnosis—that they may have this horrible disease.

When you’re looking at glioblastoma, one of the most important prognostic factors is the age of the patient—as elderly patients don’t do nearly as well as younger patients—what’s called their Karnofsky performance level. Someone who comes in absolutely normal is 100, someone who has moderate disabilities is about 70, and someone who’s hospital-bound might be around 30. Patients who are in better shape when they start tend to do better. The other important prognostic factor, aside from getting the standardized therapy these days with radiation and temozolomide, includes extended resection.
                                                                                                                                                                                                                                                                                                                
Transcript Edited for Clarity
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