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Multidisciplinary Management: Selecting a Therapy

Insights From: Robert L. Ferris, MD, PhD, UPMC Hillman Cancer Center; Anna C. Pavlick, DO, NYU Langone Hospitals; Todd E. Schlesinger, MD, FAAD, FASMS, Dermatology & Laser Center of Charleston
Published: Wednesday, Feb 20, 2019



Transcript:

Robert L. Ferris, MD, PhD:
Multidisciplinary management almost always results in better quality care, in part because it permits multiple modalities, multiple backgrounds, and often different treatment approaches because the different clinicians come to the table with different experience. And then it creates continuity of care because the patient is well known to a team of clinicians. So we advocate for that, and that’s why we developed an advanced cutaneous skin cancer clinic, to bring folks together to present cases on a weekly basis. So the physicians, the oncologists, the dermatologists, and the surgeons bring cases to our weekly multidisciplinary tumor conference.

Obviously, we talk frequently throughout the week on an ad hoc basis about patients and their best management. But we integrate this multidisciplinary care, and an oncologist is always part of that discussion. So sometimes they’re simply in the room in the discussion, and there’s not an immediate need or role, but because they have continuity and they’re aware of the treatment paradigm in the algorithmic approach of the multidisciplinary team, they’re much better suited and equipped. And sometimes they actually know the patient from the longitudinal clinical course that they’ve heard presented. And then we integrate the oncologist when there is a risk of metastasis, or there are concerns for adequacy of surgery, or there are multiple recurrences, and when we really need to have a thoughtful approach. And then, of course, oncologists often lead the clinical trials at many cancer centers. And so for clinical trial eligibility, the oncologist performs screening and has the coordinating team with them.

Todd E. Schlesinger, MD, FAAD, FASMS: Referring to the medical oncologist for systemic therapy versus radiation therapy can be a tough decision. You know, we have more options now for systemic therapy than we did, than we did in the past. The decision to employ radiation therapy again depends on the location of the tumor. So a few examples, as far as when you would choose radiation therapy: You know when a tumor is, say, larger on the scalp, for example. And you have good bone structure behind that tumor, so you know that when you employ radiation therapy, you can be a little bit more rest assured you’ll not damage underlying structures, structures that are near the tumor.

However, radiation oncology has come a long way, so they’re very good at isolating the tumor and protecting the tissues around that tumor. So we have employed radiation therapy for all kinds of tumors. For example, even ones that we could excise. But if the patient prefers to have a nonsurgical option, that’s something that we see in the clinic, you know we would refer to radiation oncology for consideration. And now that there are systemic therapies available for cutaneous squamous cell carcinoma, that is now an option that we would consider medical oncology for. Of course, any tumors that are locally advanced or regionally, or regionally metastatic, or tumors that exhibit distal metastases, those are ones that are invariably seen in a multidisciplinary team, including medical oncology, as well as other specialties and disciplines.

Robert L. Ferris, MD, PhD: In many cancers, the straw man question comes up: When should somebody refer a patient to a radiation oncologist or a medical oncologist? In a true multidisciplinary setting, as we have in our comprehensive cancer center [UPMC Hillman Cancer Center] in Pittsburgh, Pennsylvania, we don’t see those as mutually exclusive. The patient should always be referred to both because then that discussion can ensue. The patient can be offered different approaches because simply giving a systemic therapy if that patient is infirm, some of those systemic therapies actually have adverse effects. So that doesn’t mean that that’s easier. If a patient is not a good surgical candidate, they may not be tolerant of some of the systemic therapies either.

We know that the immunotherapies are quite tolerable, but they do have some autoimmune adverse events that you want to monitor. And, in fact, thinking about radiation versus medical oncology and systemic therapy as opposite or diametrically separate, I think, takes away 1 of the benefits of the multidisciplinary discussion and care. And, in fact, one may find a lower dose of radiation in combination with a systemic therapy, so that’s really how the field moves forward: Patients should really be referred to both for a multimodality discussion, even if the decision is to proceed with only 1 or the other at that point in time, because usually these patients come back, unfortunately. And once you’ve had a dose of radiation at the maximally tolerated sort of tissue level, that therapy has now really been expended. And so having the medical oncologist on board earlier allows for a better implementation of the next line of therapy, which may be systemic.

Anna C. Pavlick, DO: We use radiation therapy very commonly, after a squamous cell carcinoma has been resected by a surgeon, when we see evidence of perineural invasion or that the lesion is very deep and the margins are very close. And also depending on the location of where the squamous cell was resected. It does require time and effort on the patients we have, but we know that it can really reduce local recurrence and does try to essentially sterilize that area when there’s perineural invasion.

Does it replace systemic therapy, or can systemic therapy replace radiation? I think that’s something that we’re exploring. I think…systemic therapy probably is going to be used in conjunction with the already accepted standards of resection and radiation, and can systemic therapy then reduce the risk of recurrence or metastatic disease? I really don’t think one is going to supplant the other unless it’s a squamous cell that happens in a previously radiated area where you can’t go back and radiate. Or if it’s in a location where radiation is going to cause blindness. For example, if a squamous cell happens on the upper lid or the lower lid, if you radiate that area, you’re going to cause visual damage. And so that may be a case in which you’re going to say, we can radiate, but it’s probably not the best option.

Transcript edited for clarity.
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Transcript:

Robert L. Ferris, MD, PhD:
Multidisciplinary management almost always results in better quality care, in part because it permits multiple modalities, multiple backgrounds, and often different treatment approaches because the different clinicians come to the table with different experience. And then it creates continuity of care because the patient is well known to a team of clinicians. So we advocate for that, and that’s why we developed an advanced cutaneous skin cancer clinic, to bring folks together to present cases on a weekly basis. So the physicians, the oncologists, the dermatologists, and the surgeons bring cases to our weekly multidisciplinary tumor conference.

Obviously, we talk frequently throughout the week on an ad hoc basis about patients and their best management. But we integrate this multidisciplinary care, and an oncologist is always part of that discussion. So sometimes they’re simply in the room in the discussion, and there’s not an immediate need or role, but because they have continuity and they’re aware of the treatment paradigm in the algorithmic approach of the multidisciplinary team, they’re much better suited and equipped. And sometimes they actually know the patient from the longitudinal clinical course that they’ve heard presented. And then we integrate the oncologist when there is a risk of metastasis, or there are concerns for adequacy of surgery, or there are multiple recurrences, and when we really need to have a thoughtful approach. And then, of course, oncologists often lead the clinical trials at many cancer centers. And so for clinical trial eligibility, the oncologist performs screening and has the coordinating team with them.

Todd E. Schlesinger, MD, FAAD, FASMS: Referring to the medical oncologist for systemic therapy versus radiation therapy can be a tough decision. You know, we have more options now for systemic therapy than we did, than we did in the past. The decision to employ radiation therapy again depends on the location of the tumor. So a few examples, as far as when you would choose radiation therapy: You know when a tumor is, say, larger on the scalp, for example. And you have good bone structure behind that tumor, so you know that when you employ radiation therapy, you can be a little bit more rest assured you’ll not damage underlying structures, structures that are near the tumor.

However, radiation oncology has come a long way, so they’re very good at isolating the tumor and protecting the tissues around that tumor. So we have employed radiation therapy for all kinds of tumors. For example, even ones that we could excise. But if the patient prefers to have a nonsurgical option, that’s something that we see in the clinic, you know we would refer to radiation oncology for consideration. And now that there are systemic therapies available for cutaneous squamous cell carcinoma, that is now an option that we would consider medical oncology for. Of course, any tumors that are locally advanced or regionally, or regionally metastatic, or tumors that exhibit distal metastases, those are ones that are invariably seen in a multidisciplinary team, including medical oncology, as well as other specialties and disciplines.

Robert L. Ferris, MD, PhD: In many cancers, the straw man question comes up: When should somebody refer a patient to a radiation oncologist or a medical oncologist? In a true multidisciplinary setting, as we have in our comprehensive cancer center [UPMC Hillman Cancer Center] in Pittsburgh, Pennsylvania, we don’t see those as mutually exclusive. The patient should always be referred to both because then that discussion can ensue. The patient can be offered different approaches because simply giving a systemic therapy if that patient is infirm, some of those systemic therapies actually have adverse effects. So that doesn’t mean that that’s easier. If a patient is not a good surgical candidate, they may not be tolerant of some of the systemic therapies either.

We know that the immunotherapies are quite tolerable, but they do have some autoimmune adverse events that you want to monitor. And, in fact, thinking about radiation versus medical oncology and systemic therapy as opposite or diametrically separate, I think, takes away 1 of the benefits of the multidisciplinary discussion and care. And, in fact, one may find a lower dose of radiation in combination with a systemic therapy, so that’s really how the field moves forward: Patients should really be referred to both for a multimodality discussion, even if the decision is to proceed with only 1 or the other at that point in time, because usually these patients come back, unfortunately. And once you’ve had a dose of radiation at the maximally tolerated sort of tissue level, that therapy has now really been expended. And so having the medical oncologist on board earlier allows for a better implementation of the next line of therapy, which may be systemic.

Anna C. Pavlick, DO: We use radiation therapy very commonly, after a squamous cell carcinoma has been resected by a surgeon, when we see evidence of perineural invasion or that the lesion is very deep and the margins are very close. And also depending on the location of where the squamous cell was resected. It does require time and effort on the patients we have, but we know that it can really reduce local recurrence and does try to essentially sterilize that area when there’s perineural invasion.

Does it replace systemic therapy, or can systemic therapy replace radiation? I think that’s something that we’re exploring. I think…systemic therapy probably is going to be used in conjunction with the already accepted standards of resection and radiation, and can systemic therapy then reduce the risk of recurrence or metastatic disease? I really don’t think one is going to supplant the other unless it’s a squamous cell that happens in a previously radiated area where you can’t go back and radiate. Or if it’s in a location where radiation is going to cause blindness. For example, if a squamous cell happens on the upper lid or the lower lid, if you radiate that area, you’re going to cause visual damage. And so that may be a case in which you’re going to say, we can radiate, but it’s probably not the best option.

Transcript edited for clarity.
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