Insights From: Victor Villalobos, MD, PhD, University of Colorado School of Medicine; Saketh Guntupalli, MD, University of Colorado School of Medicine; Shreyaskumar R. Patel, MD, University of Texas MD Anderson Cancer Center; Anthony P. Conley, MD, University of Texas MD Anderson Cancer Center
Shreyaskumar R. Patel, MD: From a management standpoint, there are multiple disciplines that may play a role: surgical oncology, medical oncology, and radiation oncology. Because these different disciplines are involved, multidisciplinary discussions and the formulation of a treatment plan, a priori, becomes very critical, although it is also important in managing other epithelial tumors, too.
This is a lesson that we learned from osteosarcoma, a bone tumor, decades ago. In the older days, we played football. Whoever got the patient first did their thing, and then passed on the patient to the next discipline. We’ve learned the lesson that the diagnostic arm of the multidisciplinary team, meaning the radiologists who interpret the X-rays and scans, the ones who do the biopsy, and the pathologists who help interpret the tissue to come up with the histopathologic diagnosis, have to be in the same room. They need to be talking to the therapeutic team that, then, chimes in on how to best formulate the care. Once we have all the information available, it’s a simple question that has been posed—what’s the prognosis for this patient?
And, it gets back to, what are the prognostic factors for the sarcoma? The grade of the tumor, size of the tumor, location in relation to fascia, and the presence or absence of metastases are all factors. The AJCC (American Joint Committee on Cancer) staging system is basically designed based on these 4 criteria. What it tells us in simplistic terms is, tumors that are small, tumors that are superficial, and tumors that are low grade, that don’t look very angry under the microscope, clearly are more likely to have a local biology. That’s where the surgeons and radiotherapists are going to take the lead, in terms of management. As long as you can completely extricate the tumor from the local area, that patient has a decent chance of doing well, long term.
Then, you run into the stage 3 patients, who are high-risk primaries. The size is large, the grade is high, and these are deep-seated tumors. Fifty-plus percent of these patients will develop metastatic disease in 3 to 5 years. Therefore, the debate is, should there be multidisciplinary, multimodality care incorporated, early on, in the management of these patients?
For the advanced disease patients, clearly, the systemic therapy component will take the lead. But, again, this is a disease where we have always incorporated surgical removal of solitary or limited sites of disease, pre- or post-exposure to systemic therapy, to render them free of disease. So, the take-home message, here, is that there is integration of different disciplines at various stages of the management of the patient. This can only be efficiently, effectively, and most appropriately adjudicated if the components are talking to each other. This is where local referrals and regional care centers (where there is multidisciplinary care and expertise available) can be very helpful, in, at least, designing the plan. Then, which component of it gets done at the center versus pushed out to the community can be worked out on an individual basis.
At academic centers, we’re all well aware of the fact that there are limitations in the community, in terms of expertise available. With the best of intentions, if we change the diagnosis or we change the treatment recommendations, we would tell the patient and explain to them why, what and how. Patients, then, will participate in the decision-making process, based on insurance and their own personal scenarios, to figure out where they would get treatment.
There are instances where they will stay at the academic center for their treatment, if feasible and possible. There are instances where it’s clearly impractical, in which case we would absolutely partner with the local team, in terms of implementing whatever component of the treatment that can be farmed back out to the community. The classic scenario is, in a patient with advanced sarcoma, if it’s a standard chemotherapy recommendation where they’re not eligible for any upfront clinical trials or something more specific directed at their particular diagnosis, then we would make the recommendation. Not infrequently, we create sample orders and let them carry it back to the local oncologist. We will communicate with the local oncologist and ascertain and make sure that there’s comfort level on both sides. If so, there can be shared care over a period of time. They take 2 cycles of chemotherapy. Then they may come back, for their scans, to the academic center so we can help with the response assessment and decide whether to continue treatment or not, and so on, and so forth.
There are times when even that’s not practical. In which case, we would have the local team keep us posted on every decision-making time point, as to whether or not to continue. Or, is there time to switch gears and change? More often than not, if surgery is involved and there are complex surgical resections, they will end up coming back to the local academic center for the surgical decision-making process.