Treatment-Related Interstitial Lung Disease - Episode 10
Take-home messages regarding the optimal identification and management of ILD in breast cancer through the lens of multidisciplinary care.
Joyce A. O’Shaughnessy, MD: The greater the number of opportunities that subspecialists and members of the multidisciplinary care team have to be together, the better. Tumor conferences generally are weekly in our cancer centers or in our hospitals with community practices. Those are probably the most valuable ways of communication. That’s the issue, how to get efficient communication going. That’s certainly true when the patients are earlier in the course of their breast cancer journey. I think other opportunities are, for example, CME [continuing medical education] conferences where there’s discussion of a breast cancer topic for example, including as many of the people who work together on behalf of patients with breast cancer. It’s another opportunity. There is also heavy use of the communication tools within EMRs [electronic medical records] and our encrypted ways to communicate with each other. That’s really helpful because it allows quick back and forth. But basically, we rely so much on our personnel and our practices that send all the patients’ records and get the appointments and the preauthorization that they need. That’s all critically important for the patients being able to see these other specialists that are part of the multidisciplinary team.
Mark D. Pegram, MD: Breast cancer has become so complex because of the genetic predisposition in a fraction of patients, the varied mutational landscape of human breast cancer, where every tumor is indeed unique, no 2 tumors in 2 different patients have exactly the same repertoire of mutations that give rise to the cancer. Some of these mutations have therapeutic implications. The imaging that’s required to establish a cancer diagnosis, the biopsy that’s necessary to make a cancer diagnosis, the expertise of the pathology to be able to tell among the many different, highly varied histopathologic subtypes of breast cancer, these are critical to make the right treatment decision as well. So the pathologists are absolutely fundamental to this equation. The surgeons are still doing most of the heavy lifting in terms of breast cancer treatment by removing the bulk of the tumor en bloc at the time of initial diagnosis. That’s absolutely an area that requires special expertise. Management of the axilla requires particular surgical expertise in the area of sentinel lymph node biopsy, for example. The radiation therapists do a lot of work after the surgery in terms of postlumpectomy radiation, or in the case of locally advanced disease or patients with positive lymph nodes, they may require radiation. Sometimes even postmastectomy radiation is necessary for high-stage, high-risk patients, for instance. Our radiation therapy colleagues are absolutely integral to the successful outcome of breast cancer treatment. The medical oncologist is coming up with all the systemic approaches based upon the repertoire and mutational profile of the patient’s tumor. In addition, they’ll be looking at the steroid receptor status and perhaps doing multigene assays such as Oncotype DX or MammaPrint, to make difficult treatment decisions, like when to use chemotherapy for example, in an ER-positive, HER2-negative early-stage breast cancer.
The geneticists are critical if there’s a germline mutation. We need help for patients in terms of psychosocial support. It’s necessary to have that area of expertise integrated into clinical practice as well. So, multidisciplinary care has become standard now in breast cancer treatment because of all of its complexity, all the nuances in each interdisciplinary area. With integration of all that information, all that expertise contributed by numerous colleagues, you can come up with a tailored individualized treatment plan for each patient with breast cancer, and it can be different from patient to patient.
Charles A. Powell, MD, MBA: I’d say the most important points to keep in mind are that, first, seamless continuous communication between multiple specialists, with multiple areas of deep expertise, is incredibly beneficial to patients who have cancer or patients who have other complex diseases as well. That can be done very easily using electronic health record systems available within a single health system, but that communication can also be achieved with specialists who may not be in the same setting at the same time. That is a crucial component for successful patient-centered multidisciplinary care.
As we think about a patient who may have drug-related interstitial lung disease [ILD] associated with treatment with a compound such as an antibody-drug conjugate such as in HER2-positive disease, there’s a role for multiple specialists to be involved in multiple different steps in this pathway. For example, there may be an important role for a pulmonologist to play in a patient who at initiation of treatment may have symptoms or signs that can be caused by ILD, or an abnormal chest imaging study. So it would be important for the patient, the oncology treating physician, and for the pulmonologist to work together to better characterize the underlying lung disease if there is one, and to determine what risk if any that may play in the treatment that may result in a pneumonitis for a specific patient. As the patient is moving along with their treatment for their cancer with a drug such as in HER2, it’s important for the pulmonologist and oncologist to work together if the patient develops new respiratory symptoms or has new abnormal findings on chest imaging. Again, because it is important to exclude other conditions that can cause those symptoms or those findings, it’ll be important then for the oncologist and the patient to know that they require specific treatment for their ILD, and to know whether the drug should be held to prevent progression of ILD that may be drug-related.
Transcript Edited for Clarity