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Importance of Tumor Boards in NSCLC Management

Insights From: Ben Levy, MD, Sibley Memorial Hospital; Andrew Lerner, MD, Sibley Memorial Hospital; Rasheda Persinger, AGNP-C, Sibley Memorial Hospital; Andrea Richardson, MD, PhD, Sibley Memorial Hospital
Published: Friday, May 25, 2018



Transcript: 

Benjamin P. Levy, MD:
Two more questions. One is the importance of tumor boards. We talk about the team approach. I mentioned in the first segment that lung cancer treatment is not a 1-woman or 1-man show, it’s a team. Can you guys layer in some perspective on the importance of tumor boards?

Andrew Lerner, MD: Yes. Well, I think it’s immensely important because it really hones in on that whole multidisciplinary team approach. Not only that, it gives a fresh set of eyes to look at this picture. You have the doctor who knows the patient best, who could provide some insight into their preferences and how they feel and their performance status. But there’s also a lot of other people looking at it. As the pulmonologist, we’re there oftentimes making the diagnosis and then help with the palliation of symptoms afterward. But from my eyes, I can’t think of anything more important than that.

Benjamin P. Levy, MD: Yes. I think it provides a forum for the communication that’s needed, too. Every patient who I have that is considered for a clinical trial or there’s a nuance treatment decision, these multidisciplinary tumor boards really provide an open forum for different perspectives that you normally wouldn’t get. Certainly, having the pathologist there is very important where they can give you some nuances. We’ve had plenty of times in multidisciplinary tumor boards where the pathologist says, “Look, this looks like an adenocarcinoma but it’s favoring now more squamous cell.” So, it gives an opportunity to think in a different direction.

Andrew Lerner, MD: And I think it adds a layer of trust as well from the patient knowing that their case is being presented.

Benjamin P. Levy, MD: Yes. I think that patients like hearing that there’s going to be 20 doctors in the room discussing their case and we’re going to try to render some sort of decision. The last question I think is important to touch upon is just, what do you think the challenges are with making a diagnosis? You mentioned some of these. Maybe we can go back and talk about the ones that you think are most important. But what are the real challenges? I think community oncologists and even academic oncologists are facing challenges getting the tissue that they need to make the diagnosis in a timely fashion to deliver the care quickly. A lot of these patients are sick, and I hear over and over again how challenging this can be. So, maybe some of this may be looking back and summarizing some of the things we’ve talked about, but in your mind, top level challenges of tissue procurement, making a diagnosis, and molecular testing.

Andrew Lerner, MD: Right. Yes, I think from the procedure side of it, I can comment that you’re right. A lot of the newest techniques, or maybe they’re even not so new, aren’t available everywhere. For example, EBUS bronchoscopy or just staging by bronchoscopy has become almost widespread, and it has almost replaced mediastinoscopy completely with a good positive and negative predictive value. But there are certainly places out there that still don’t have that option. They still do mediastinoscopy, and that’s a fine approach. It’s not wrong to do it that way. But as far as the concerns with minimally invasive procedures, the positives are they’re minimally invasive, there’s low risk of bleeding, well-tolerated as an outpatient, and can oftentimes be performed with moderate sedation or less anesthesia than is needed for surgery. But the negatives are you oftentimes don’t get morphology. So, for things like lymphomas, that can play a big role. For lung cancer, it’s to be seen. A lot of the latest studies show that we get adequate sampling for a lot of the molecular panel and mutational testing. But that’s still a concern. Another concern is tumor heterogeneity.

Benjamin P. Levy, MD: A big one.

Andrew Lerner, MD: So, what you sample in a lymph node, or the primary, and what you test and how you send the markers, how do you know that it’s really showing the full picture?

Benjamin P. Levy, MD: Representative, yes.

Andrew Lerner, MD: And then finally, I think being at 2 different places doing interventional pulmonary, how important that communication is with pathology, because really, this couldn’t run without a really good cohesion between the 2 in processing and tissue procurement. How it goes down that pathway, I think, is immensely crucial.

Benjamin P. Levy, MD: Andrea, from your perspective, pathology, big challenges, 30,000-foot overview.

Andrea Richardson, MD, PhD: Cytopathology, in particular, is very difficult. It requires an extra layer of skill on the pathologist. We also utilize cytotechnologists to screen a smear of slides, looking for that rare malignant cell that may be hiding amongst a lot of benign cells. And the whole processing, making of a cell block, is not straightforward. And while the material is there, it doesn’t always show up in the cell block if you don’t have a laboratory person who’s trained to do it correctly.

Andrew Lerner, MD: I think we’ve adapted our practice multiple times, depending on what works and what hasn’t. It’s kind of a little bit of trial-and-error as well.

Benjamin P. Levy, MD: I think that’s what it takes, some trial-and-error to figure out best practices, because while we may have some data to guide, I think these highlight and underscore the importance of the communication to understand what the challenges and the hurdles are and then redirect and get over that. I’ll layer in an additional challenge, which is the advent of liquid biopsies and how to use these. We’ve got some new technology that can isolate circulating tumor DNA in the blood from a lung cancer; not only isolate it, but sequence it. And it has been a nice welcome change that can kind of leverage, or at least overcome, some of the hurdles that we have mentioned here. But I think we’re starting to learn that it’s an imperfect technology and some of the information it may provide may not be relevant. There’s no doubt that liquid biopsies are important and can be used in certain scenarios. But how to use this and how to use it with tissue, I think, is hot on everyone’s mind in terms of how to do both of these or just one of them to make sure that we have the right diagnosis for the patient in a quick amount of time.

Andrea Richardson, MD, PhD: And I think the liquid biopsies are going to be limited in what you can get from them in terms of tumor mutational burden.

Benjamin P. Levy, MD: That’s right.

Andrea Richardson, MD, PhD: PD-L1.

Benjamin P. Levy, MD: PD-L1, that’s exactly right.

Andrea Richardson, MD, PhD: Confirming that it’s actually a lung cancer and not a metastasis from some other site.

Benjamin P. Levy, MD: That’s right.

Andrea Richardson, MD, PhD: But once you have a diagnosis established, it’s very useful for following the patients during treatment and for recurrence, I would think.

Benjamin P. Levy, MD: Yes. I think that the longitudinal sampling of ctDNA, while not ready for prime time, is going to be there soon and then detecting resistance. But there’s a lot of things that can happen in that complex biospecimen that you’re trying to interpret the results from.

Well, this has been a very informative discussion. The perspective you guys have provided, from a pulmonary standpoint and a pathology standpoint has been really unique and I think meaningful, again underscores the importance of how we all must communicate and how this is really a team approach. We all work together at the center and we probably talk to each other quite often, maybe more often than we’d like to, but we enjoy it and certainly it allows for the facilitation of really excellent patient care. So, I want to thank you guys for joining.

Transcript Edited for Clarity 
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Transcript: 

Benjamin P. Levy, MD:
Two more questions. One is the importance of tumor boards. We talk about the team approach. I mentioned in the first segment that lung cancer treatment is not a 1-woman or 1-man show, it’s a team. Can you guys layer in some perspective on the importance of tumor boards?

Andrew Lerner, MD: Yes. Well, I think it’s immensely important because it really hones in on that whole multidisciplinary team approach. Not only that, it gives a fresh set of eyes to look at this picture. You have the doctor who knows the patient best, who could provide some insight into their preferences and how they feel and their performance status. But there’s also a lot of other people looking at it. As the pulmonologist, we’re there oftentimes making the diagnosis and then help with the palliation of symptoms afterward. But from my eyes, I can’t think of anything more important than that.

Benjamin P. Levy, MD: Yes. I think it provides a forum for the communication that’s needed, too. Every patient who I have that is considered for a clinical trial or there’s a nuance treatment decision, these multidisciplinary tumor boards really provide an open forum for different perspectives that you normally wouldn’t get. Certainly, having the pathologist there is very important where they can give you some nuances. We’ve had plenty of times in multidisciplinary tumor boards where the pathologist says, “Look, this looks like an adenocarcinoma but it’s favoring now more squamous cell.” So, it gives an opportunity to think in a different direction.

Andrew Lerner, MD: And I think it adds a layer of trust as well from the patient knowing that their case is being presented.

Benjamin P. Levy, MD: Yes. I think that patients like hearing that there’s going to be 20 doctors in the room discussing their case and we’re going to try to render some sort of decision. The last question I think is important to touch upon is just, what do you think the challenges are with making a diagnosis? You mentioned some of these. Maybe we can go back and talk about the ones that you think are most important. But what are the real challenges? I think community oncologists and even academic oncologists are facing challenges getting the tissue that they need to make the diagnosis in a timely fashion to deliver the care quickly. A lot of these patients are sick, and I hear over and over again how challenging this can be. So, maybe some of this may be looking back and summarizing some of the things we’ve talked about, but in your mind, top level challenges of tissue procurement, making a diagnosis, and molecular testing.

Andrew Lerner, MD: Right. Yes, I think from the procedure side of it, I can comment that you’re right. A lot of the newest techniques, or maybe they’re even not so new, aren’t available everywhere. For example, EBUS bronchoscopy or just staging by bronchoscopy has become almost widespread, and it has almost replaced mediastinoscopy completely with a good positive and negative predictive value. But there are certainly places out there that still don’t have that option. They still do mediastinoscopy, and that’s a fine approach. It’s not wrong to do it that way. But as far as the concerns with minimally invasive procedures, the positives are they’re minimally invasive, there’s low risk of bleeding, well-tolerated as an outpatient, and can oftentimes be performed with moderate sedation or less anesthesia than is needed for surgery. But the negatives are you oftentimes don’t get morphology. So, for things like lymphomas, that can play a big role. For lung cancer, it’s to be seen. A lot of the latest studies show that we get adequate sampling for a lot of the molecular panel and mutational testing. But that’s still a concern. Another concern is tumor heterogeneity.

Benjamin P. Levy, MD: A big one.

Andrew Lerner, MD: So, what you sample in a lymph node, or the primary, and what you test and how you send the markers, how do you know that it’s really showing the full picture?

Benjamin P. Levy, MD: Representative, yes.

Andrew Lerner, MD: And then finally, I think being at 2 different places doing interventional pulmonary, how important that communication is with pathology, because really, this couldn’t run without a really good cohesion between the 2 in processing and tissue procurement. How it goes down that pathway, I think, is immensely crucial.

Benjamin P. Levy, MD: Andrea, from your perspective, pathology, big challenges, 30,000-foot overview.

Andrea Richardson, MD, PhD: Cytopathology, in particular, is very difficult. It requires an extra layer of skill on the pathologist. We also utilize cytotechnologists to screen a smear of slides, looking for that rare malignant cell that may be hiding amongst a lot of benign cells. And the whole processing, making of a cell block, is not straightforward. And while the material is there, it doesn’t always show up in the cell block if you don’t have a laboratory person who’s trained to do it correctly.

Andrew Lerner, MD: I think we’ve adapted our practice multiple times, depending on what works and what hasn’t. It’s kind of a little bit of trial-and-error as well.

Benjamin P. Levy, MD: I think that’s what it takes, some trial-and-error to figure out best practices, because while we may have some data to guide, I think these highlight and underscore the importance of the communication to understand what the challenges and the hurdles are and then redirect and get over that. I’ll layer in an additional challenge, which is the advent of liquid biopsies and how to use these. We’ve got some new technology that can isolate circulating tumor DNA in the blood from a lung cancer; not only isolate it, but sequence it. And it has been a nice welcome change that can kind of leverage, or at least overcome, some of the hurdles that we have mentioned here. But I think we’re starting to learn that it’s an imperfect technology and some of the information it may provide may not be relevant. There’s no doubt that liquid biopsies are important and can be used in certain scenarios. But how to use this and how to use it with tissue, I think, is hot on everyone’s mind in terms of how to do both of these or just one of them to make sure that we have the right diagnosis for the patient in a quick amount of time.

Andrea Richardson, MD, PhD: And I think the liquid biopsies are going to be limited in what you can get from them in terms of tumor mutational burden.

Benjamin P. Levy, MD: That’s right.

Andrea Richardson, MD, PhD: PD-L1.

Benjamin P. Levy, MD: PD-L1, that’s exactly right.

Andrea Richardson, MD, PhD: Confirming that it’s actually a lung cancer and not a metastasis from some other site.

Benjamin P. Levy, MD: That’s right.

Andrea Richardson, MD, PhD: But once you have a diagnosis established, it’s very useful for following the patients during treatment and for recurrence, I would think.

Benjamin P. Levy, MD: Yes. I think that the longitudinal sampling of ctDNA, while not ready for prime time, is going to be there soon and then detecting resistance. But there’s a lot of things that can happen in that complex biospecimen that you’re trying to interpret the results from.

Well, this has been a very informative discussion. The perspective you guys have provided, from a pulmonary standpoint and a pathology standpoint has been really unique and I think meaningful, again underscores the importance of how we all must communicate and how this is really a team approach. We all work together at the center and we probably talk to each other quite often, maybe more often than we’d like to, but we enjoy it and certainly it allows for the facilitation of really excellent patient care. So, I want to thank you guys for joining.

Transcript Edited for Clarity 
View Conference Coverage
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TitleExpiration DateCME Credits
Community Practice Connections™: 18th Annual International Lung Cancer Congress®Oct 31, 20181.5
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