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The Continuum of Care in NSCLC

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: You’ve touched upon a lot of the responsibilities for the APP, not only in terms of helping make a diagnosis and coming up with a treatment plan, assessing the toxicities, setting what the toxicities will be in assessing toxicities, but also really marshalling the plan through and following the patients through the treatment continuum. It’s quite a responsibility to have this role. And given the responsibility, maybe you can touch upon the biggest challenges you think APPs like yourself face when managing patients with lung cancer or any cancer for that matter?

Rasheda Persinger, AGNP-C: In particular to me, the challenges that I have are overwhelming. As exciting as lung cancer is, it’s just as overwhelming. And knowing the knowledge and wanting to know what’s coming out that is new, and how to understand it, and how to articulate it to our patients when they ask questions, that sometimes can be stressful. That’s one of the biggest challenges for me.

Benjamin P. Levy, MD: Yes, keeping up with the data.

Rasheda Persinger, AGNP-C: Keeping up the data, exactly. Communication as well. Although I think I do a great job, I’m always challenged to think I could do more. I put myself in the place of a patient or a caregiver that’s calling about the need to follow up and the need to bring them in and address them. I think I do a great job with it, but I think there’s always room for growth.

Benjamin P. Levy, MD: I think all of us have that challenge.

Rasheda Persinger, AGNP-C: I think, not necessarily for me, but in general, one of the ongoing themes with APPs is the collaboration with the physician. It’s so important for an APP to feel part of the team and to have that respect with the physician that they’re working with and vice versa. The APP should know that he/she can come and ask questions and the physician wants to teach you about what the disease is and what the new study is, but still notice you have to take the onus on yourself to educate yourself. That collaboration is key, and I think that one of the reasons why I enjoy working where I work at is because I think we do that very well.

Benjamin P. Levy, MD: I think you mentioned every challenge that physicians face, which include collaboration, communication, and keeping up with the data. It just tells you, I think we work together as a team. There’s not some sort of hierarchy. We are delivering care, and we each face the same challenges and trying to get the best plan available for the patient. That means keeping up with the data, collaborating, and communicating, which is what the whole purpose of a team is. I think you’ve really touched nicely on the challenges that I think we all face.

Rasheda Persinger, AGNP-C: Yes.

Benjamin P. Levy, MD: Well, Rasheda, thank you for coming on and really layering in your own unique perspective as an APP.

Rasheda Persinger, AGNP-C: I appreciate it. Thank you.

Benjamin P. Levy, MD: We talked in the last segments about the importance of the interventional pulmonologist and the pathologist in making a diagnosis, that first step where we need to procure enough tissue, and then the tissue journey of mutational testing and additional testing, whether it be PD-L1 or, potentially, tumor mutation burden. But it’s important to recognize that both of you, the pulmonologist and the pathologist, do stay relevant along the treatment continuum, even after diagnosis is made. So, Andrew, can you talk about some of the things that you bring to the table or that may still be involved with for a patient who’s already started treatment?

Andrew Lerner, MD: Yes. I think that’s one of the benefits of having a comprehensive cancer center where you have a lot of different facets in one area as an interventional pulmonologist, or even a pulmonologist, after making the diagnosis. I still follow very closely along with the patient after treatment and as they move forward. A lot of times these are playing the role of a pulmonologist and interventional pulmonologist with regard to complications that arise from the tumor or even the treatment of the cancer itself with regard to the lungs. One example would be that oftentimes it’s not uncommon to develop fluid around the outside of the lungs with lung cancer, called pleural effusion. This fluid can compress and collapse the lung, and oftentimes draining the fluid will significantly help with shortness of breath and symptoms. But, unfortunately, with cancer, the fluid often comes back and you need some more advanced things to do to kind of keep the person breathing well and keep them healthy and feeling well throughout the day.

And so, some of the more advanced things we do, one of which is placing a small indwelling catheter. It’s flexible and soft, and it goes under the skin, which allows the patient and their family to drain at home so they don’t have to keep coming in and out for doctors’ appointments. Another thing would be to put some medicine into that space around the outside of the lungs, called pleurodesis, to help close the space so fluid cannot develop in there. Our focus is to keep the person breathing as well as they can so not only do they feel better, but I think they tolerate their treatment better throughout that process as well.

Then another thing that we do as interventional pulmonologists is deal with airway obstructions. A lot of times tumors can invade the airway, cause blockage or cause obstruction. We have techniques to go in with bronchoscopies or even something a little more advanced called rigid bronchoscopies where we go in the airway in a nonsurgical manner and open that tumor with different techniques. Sometimes we even put airway stents in to help with their breathing, so they can continue on their treatment and have as good of a functional status as possible. And then finally while some of the treatments out there, especially some of the newer ones, can cause a lot of inflammation in the lungs and cause...

Benjamin P. Levy, MD: Immunotherapy, in particular.

Andrew Lerner, MD: Right, immunotherapies with pneumonitis and even radiation pneumonitis can cause this. We stay closely involved in terms of diagnosis of that, making sure there’s not an infection and also treating and following along to make sure their lungs are as healthy as possible.

Benjamin P. Levy, MD: Yes. And sometimes we get a diagnosis for lung cancer and maybe we have enough tissue, but for one reason or another, whether it’s an outside procurement that happened or we’re getting a second opinion on for the tissue, there may not be enough to do certain tests. We may need to retest for mutations. It’s up for debate whether we need to retest for PD-L1 or whether PD-L1 will have relevance in the future and even potentially using tumor mutation burden to guide treatment decisions. Talk about how you talk to the patient about that re-biopsy if needed.

Andrew Lerner, MD: So, oftentimes, a re-biopsy for more tissue comes up as a request from the oncologist or the oncology team. And sometimes it’s with regard to their treatment. Other times it’s within the realm of a trial. And I think this is kind of the value of some of these minimally invasive techniques. You always sit down with a patient and go through it with mutual decision making and informed consent. I think as it is a less invasive approach that’s a relatively safe and outpatient procedure, many of them tend to be okay with going through another biopsy.

Benjamin P. Levy, MD: Andrea, Andrew touched upon this, from a pathologist’s perspective. Discuss your role in staying involved in the care during the treatment continuum and how you see that unfolding.

Andrea Richardson, MD, PhD: Well, we continue to be important when a pleural effusion is drained, for instance. Sometimes it’s inflammatory and sometimes it’s a malignant effusion and we’re making that diagnosis. Often with a large pleural effusion, we’ll have plenty of tumor cells and those can be in a cell block. They can be used for research studies or for repeat testing. We try to preserve all of that tumor material from any of the procedures, such as repeat biopsy, in order to have that available for future studies that might be needed. We’re also sometimes involved in biopsies to try to look at the etiology of a pleural disease or a lung disease to see whether it’s an inflammatory cause or the cancer in a new place.

Benjamin P. Levy, MD: We have a lot of research trials that are either at our center or coming down the pike that have put the pathologist back front-and-center because they’re mandating re-biopsies upon progression, which is making your life a little busier. I think that’s important that there’s an understanding that while you guys are front-and-center for the diagnosis, that you stay involved and remain involved throughout the treatment continuum. Thank you, guys, for talking about your continued role not only at the beginning of treatment but throughout the patient’s treatment continuum, as well.

Transcript Edited for Clarity 
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Transcript: 

Benjamin P. Levy, MD: You’ve touched upon a lot of the responsibilities for the APP, not only in terms of helping make a diagnosis and coming up with a treatment plan, assessing the toxicities, setting what the toxicities will be in assessing toxicities, but also really marshalling the plan through and following the patients through the treatment continuum. It’s quite a responsibility to have this role. And given the responsibility, maybe you can touch upon the biggest challenges you think APPs like yourself face when managing patients with lung cancer or any cancer for that matter?

Rasheda Persinger, AGNP-C: In particular to me, the challenges that I have are overwhelming. As exciting as lung cancer is, it’s just as overwhelming. And knowing the knowledge and wanting to know what’s coming out that is new, and how to understand it, and how to articulate it to our patients when they ask questions, that sometimes can be stressful. That’s one of the biggest challenges for me.

Benjamin P. Levy, MD: Yes, keeping up with the data.

Rasheda Persinger, AGNP-C: Keeping up the data, exactly. Communication as well. Although I think I do a great job, I’m always challenged to think I could do more. I put myself in the place of a patient or a caregiver that’s calling about the need to follow up and the need to bring them in and address them. I think I do a great job with it, but I think there’s always room for growth.

Benjamin P. Levy, MD: I think all of us have that challenge.

Rasheda Persinger, AGNP-C: I think, not necessarily for me, but in general, one of the ongoing themes with APPs is the collaboration with the physician. It’s so important for an APP to feel part of the team and to have that respect with the physician that they’re working with and vice versa. The APP should know that he/she can come and ask questions and the physician wants to teach you about what the disease is and what the new study is, but still notice you have to take the onus on yourself to educate yourself. That collaboration is key, and I think that one of the reasons why I enjoy working where I work at is because I think we do that very well.

Benjamin P. Levy, MD: I think you mentioned every challenge that physicians face, which include collaboration, communication, and keeping up with the data. It just tells you, I think we work together as a team. There’s not some sort of hierarchy. We are delivering care, and we each face the same challenges and trying to get the best plan available for the patient. That means keeping up with the data, collaborating, and communicating, which is what the whole purpose of a team is. I think you’ve really touched nicely on the challenges that I think we all face.

Rasheda Persinger, AGNP-C: Yes.

Benjamin P. Levy, MD: Well, Rasheda, thank you for coming on and really layering in your own unique perspective as an APP.

Rasheda Persinger, AGNP-C: I appreciate it. Thank you.

Benjamin P. Levy, MD: We talked in the last segments about the importance of the interventional pulmonologist and the pathologist in making a diagnosis, that first step where we need to procure enough tissue, and then the tissue journey of mutational testing and additional testing, whether it be PD-L1 or, potentially, tumor mutation burden. But it’s important to recognize that both of you, the pulmonologist and the pathologist, do stay relevant along the treatment continuum, even after diagnosis is made. So, Andrew, can you talk about some of the things that you bring to the table or that may still be involved with for a patient who’s already started treatment?

Andrew Lerner, MD: Yes. I think that’s one of the benefits of having a comprehensive cancer center where you have a lot of different facets in one area as an interventional pulmonologist, or even a pulmonologist, after making the diagnosis. I still follow very closely along with the patient after treatment and as they move forward. A lot of times these are playing the role of a pulmonologist and interventional pulmonologist with regard to complications that arise from the tumor or even the treatment of the cancer itself with regard to the lungs. One example would be that oftentimes it’s not uncommon to develop fluid around the outside of the lungs with lung cancer, called pleural effusion. This fluid can compress and collapse the lung, and oftentimes draining the fluid will significantly help with shortness of breath and symptoms. But, unfortunately, with cancer, the fluid often comes back and you need some more advanced things to do to kind of keep the person breathing well and keep them healthy and feeling well throughout the day.

And so, some of the more advanced things we do, one of which is placing a small indwelling catheter. It’s flexible and soft, and it goes under the skin, which allows the patient and their family to drain at home so they don’t have to keep coming in and out for doctors’ appointments. Another thing would be to put some medicine into that space around the outside of the lungs, called pleurodesis, to help close the space so fluid cannot develop in there. Our focus is to keep the person breathing as well as they can so not only do they feel better, but I think they tolerate their treatment better throughout that process as well.

Then another thing that we do as interventional pulmonologists is deal with airway obstructions. A lot of times tumors can invade the airway, cause blockage or cause obstruction. We have techniques to go in with bronchoscopies or even something a little more advanced called rigid bronchoscopies where we go in the airway in a nonsurgical manner and open that tumor with different techniques. Sometimes we even put airway stents in to help with their breathing, so they can continue on their treatment and have as good of a functional status as possible. And then finally while some of the treatments out there, especially some of the newer ones, can cause a lot of inflammation in the lungs and cause...

Benjamin P. Levy, MD: Immunotherapy, in particular.

Andrew Lerner, MD: Right, immunotherapies with pneumonitis and even radiation pneumonitis can cause this. We stay closely involved in terms of diagnosis of that, making sure there’s not an infection and also treating and following along to make sure their lungs are as healthy as possible.

Benjamin P. Levy, MD: Yes. And sometimes we get a diagnosis for lung cancer and maybe we have enough tissue, but for one reason or another, whether it’s an outside procurement that happened or we’re getting a second opinion on for the tissue, there may not be enough to do certain tests. We may need to retest for mutations. It’s up for debate whether we need to retest for PD-L1 or whether PD-L1 will have relevance in the future and even potentially using tumor mutation burden to guide treatment decisions. Talk about how you talk to the patient about that re-biopsy if needed.

Andrew Lerner, MD: So, oftentimes, a re-biopsy for more tissue comes up as a request from the oncologist or the oncology team. And sometimes it’s with regard to their treatment. Other times it’s within the realm of a trial. And I think this is kind of the value of some of these minimally invasive techniques. You always sit down with a patient and go through it with mutual decision making and informed consent. I think as it is a less invasive approach that’s a relatively safe and outpatient procedure, many of them tend to be okay with going through another biopsy.

Benjamin P. Levy, MD: Andrea, Andrew touched upon this, from a pathologist’s perspective. Discuss your role in staying involved in the care during the treatment continuum and how you see that unfolding.

Andrea Richardson, MD, PhD: Well, we continue to be important when a pleural effusion is drained, for instance. Sometimes it’s inflammatory and sometimes it’s a malignant effusion and we’re making that diagnosis. Often with a large pleural effusion, we’ll have plenty of tumor cells and those can be in a cell block. They can be used for research studies or for repeat testing. We try to preserve all of that tumor material from any of the procedures, such as repeat biopsy, in order to have that available for future studies that might be needed. We’re also sometimes involved in biopsies to try to look at the etiology of a pleural disease or a lung disease to see whether it’s an inflammatory cause or the cancer in a new place.

Benjamin P. Levy, MD: We have a lot of research trials that are either at our center or coming down the pike that have put the pathologist back front-and-center because they’re mandating re-biopsies upon progression, which is making your life a little busier. I think that’s important that there’s an understanding that while you guys are front-and-center for the diagnosis, that you stay involved and remain involved throughout the treatment continuum. Thank you, guys, for talking about your continued role not only at the beginning of treatment but throughout the patient’s treatment continuum, as well.

Transcript Edited for Clarity 
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TitleExpiration DateCME Credits
Community Practice Connections™: 18th Annual International Lung Cancer Congress®Oct 31, 20181.5
Clinical Interchange™: Translating Research to Inform Changing Paradigms: Assessment of Emerging Immuno-Oncology Strategies and Combinations across Lung, Head and Neck, and Bladder CancersOct 31, 20182.0
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