Practical Perspectives on Treatment of Advanced Gastric/GEJ Cancers - Episode 3

Multidisciplinary Management of Gastric/GEJ Cancers


David Ilson, MD, PhD: Having multidisciplinary teams is key, and major cancer centers do this. We have disease management teams for all subspecialty cancers, including esophagogastric cancers and hepatobiliary cancers. Typically, these groups meet once or twice a month, and particular cases are presented. Radiology films are reviewed, pathology is reviewed, endoscopic staging is reviewed, and we come to a consensus about what the optimal management is.

Minaxi Jhawer, MD: Multidisciplinary care works in 2 ways. There’s a multidisciplinary clinic, where we actually see patients with the surgical oncologist, medical oncologist, and radiation oncologist all in 1 center under 1 roof together. And then there is the tumor board setting, where patients are presented prospectively. The way we structure it at our center is that the pathologist generates a list of patients who have undergone biopsies or surgery over the last few weeks. That list is then given to the tumor board heads, which include me and some of my colleagues from gastroenterology. We review that list. As long as we have the patient data to prospectively make decisions, those patients are then presented at the tumor board.

The tumor board essentially includes medical oncologists, surgical oncologists, radiation doctors, radiologists, and pathologists, as well as support staff, which includes genetic counselors, nutritionists, social workers, and child life support team. All these team members work together to discuss the cases as they’re presented at the tumor board and come up with a comprehensive plan. We tend to have a lot of debate when it comes to neoadjuvant therapy, so it’s a pretty lively discussion. Eventually, that plan is then taken back by the treating physician, whether the surgical or the medical oncologist, up front to then discuss it with the patient. We have these meetings almost 3 times a week, so essentially all our patients are prospectively managed. But the strength in our institution also includes having multidisciplinary clinic or office hours, when these patients are seen every week in a timely fashion so that there’s really no delay or waiting for the tumor board to present these cases.

David Ilson, MD, PhD: Esophageal and gastric cancers are relatively uncommon in the United States because treatment of these diseases involves participation with the radiation, medical, and surgical oncologists, as well as with the gastroenterologist. You really need a skilled multidisciplinary team that interacts, reviews cases, and comes to a consensus about management. We also know, certainly for esophagus and GE [gastroesophageal] junction cancers, that the quality of surgery, even in gastric cancer, is very important. High-volume centers tend to do better surgery. They have better outcomes. They have better supportive measures. Although there are good community-based surgeons, sometimes they don’t see these patients that often. We really consider in these rarer cancers referral to a tertiary cancer center, where there’s access to a multidisciplinary team. The cases are discussed, consensus is developed, and patients receive the appropriate chemotherapy, potentially radiation, and appropriate standard-of-care surgery.

Minaxi Jhawer, MD: In our institution, what we strive to do is get the experts involved up front at the tumor board or the multidisciplinary clinic. The way it works is that our upper GI [gastrointestinal] surgeons, who are designated specialists doing mostly upper GI surgery, and medical oncologists who have a subspecialty—such as me, who does GI medical oncology—team up and discuss patients in both the form of the tumor board on a day-to-day basis and dedicated multidisciplinary clinical hours. That essentially leads to a very comprehensive concrete plan for the patients and a high level of expertise. We do have clinical trials open at our institution, but if there are trials available that the patients would benefit from and would be good candidates for, I essentially refer them out to those institutions. In summary, patients who have a specific and rare diagnosis—if they’re not seen in a community center or a hospital center that doesn’t have that expertise—should be referred. But at centers such as ours, where I believe we do have the expertise, I think those patients can be taken care of as they would in any other institution.

Transcript Edited for Clarity