Benjamin P. Levy, MD: Welcome to this OncLive® Insights® video series “Inside the Clinic: Interdisciplinary Care for Stage 4 Non—Small Cell Lung Cancer.” I am Dr. Ben Levy, clinical director of medical oncology and medical director of thoracic oncology at the Johns Hopkins Kimmel Cancer Center at Sibley Memorial Hospital in Washington, D.C. Today, I am joined by my colleagues from the center. Let me introduce you to the team: Dr. Andrew Lerner, director of interventional pulmonology here at the Johns Hopkins Kimmel Cancer Center; Dr. Andrea Richardson, associate professor of pathology and director of pathology at Johns Hopkins Sibley Memorial Hospital; and Rasheda Persinger, a board-certified adult nurse practitioner for thoracic oncology.
We are going to talk about multidisciplinary management of stage 4 lung cancer and how we do that at our center. I think for lung cancer, we have witnessed unprecedented advances in the past 1 to 2 years with both treatment and diagnostics. On the treatment side, we now have, of course, targeted therapies that allow our patients to receive pills rather than chemotherapy for the right patient. And we have immunotherapies, a drug that can harness the patient’s own machinery and their immune system and turn it against the cancer.
While these drugs have been quite exciting for patients, they have forced us to have a better understanding of lung cancer biology and the complexity of lung cancer biology. This means that we have to order appropriate tests on the tumor, including genetic testing and PD-L1, but also understanding that when we deliver these therapies to the right patient, there are toxicities that we have to keep in mind. Of course, it doesn’t stop with therapies. We have new ways to diagnose lung cancer by a simple blood test, which would seem like science fiction 5 to 10 years ago but has now become a clinical reality.
With all of these new drugs and all of these new diagnostic algorithms, with the advent of targeted therapies and immunotherapies, it really forces us at the Sidney Kimmel Cancer Center to work as a team. Oncology in this day and age is not a one man or one woman show. It is a team comprised of different disciplines that work together to deliver the best care possible. The purpose of these video series is to talk about how we communicate and how we each function in our own role, but work together synergistically to deliver the best care possible for our patient.
I’m fortunate now to be joined by our interventional pulmonologist, Dr. Andrew Lerner, and our pathologist, Dr. Andrea Richardson. We’ve talked before in prior panels about how important making a diagnosis is for lung cancer, but we’ve never really had the people who are making this happen on. And this is why I think having these discussions is so important. We know lung cancer is a heterogeneous disease and making a histological diagnosis is fine, dandy, and good, but we need extra steps, and we also know it’s important to get the tissue. Let’s just have this conversation as the patient is walking in for the first time and, Andrew, you’re trying to make a decision about what’s the best place to biopsy and how you’re going to procure enough tissue. Walk us through your decision making and what you’re thinking along that line.
Andrew Lerner, MD: I think that’s a great question. I think the first thing I typically do is define what I am as an interventional pulmonologist. Essentially, what that is, is a pulmonologist trained in internal medicine, general pulmonology, and critical care but oftentimes has advanced training in minimally invasive procedures for diagnosis and treatment of lung cancers. And oftentimes, there’s an extra year or two of advanced training on top of the normal training. From this, we have a lot of experience with lung nodules and lung masses and the effects of cancer and its treatment on the lungs. So, we work very closely alongside with the oncologists, the radiation oncologists, the pathologists, and the palliative care team; kind of providing that multidisciplinary care.
When a patient comes in, one of the things we have at our institution is a dedicated lung nodule, lung mass clinic, essentially spots in the lungs. And these things can be found either incidentally due to imaging performed for another reason or the person has a respiratory complaint and they had an X-ray or a CT scan, or they’re in a lung cancer screening trial and this was picked up on that. So, really, the first question is, what’s the cause of this abnormality? Because many times, lung nodules are not cancerous. So, you really look into what else causes these spots, and infection and inflammation really can almost be indistinguishable from cancer. It’s really the role of the initial pulmonologist or initial diagnostician to do a thorough history and physical to where they get at-risk factors for cancer as well as for infections, inflammation, other things like that. And then from there, kind of decide on whether it’s really that role to make sure that cancer is not missed but also to avoid interventions or invasive surgeries for things that are not cancer.
Let’s say you have a case, a lung nodule or mass that you have a high suspicion that this is cancer, and you decide that you do need tissue for biopsy and sampling to confirm the diagnosis. So, really when you decide on what procedure to do, at least in our clinic, it’s looking at 4 main tenets. And the first is trying to do the least, or at least start with the least, invasive method of sampling in the safest possible manner, making sure that you have enough tissue for characterization and molecular profiling and all the new studies that are being sent, and also to do so by limiting the number of procedures that they need. And then, finally, also to make sure that you stage the patient appropriately and you don’t miss cancer that spread somewhere else, to give the appropriate stage. So, it used to be that, historically, surgery was the way to go to get a diagnosis, and still is oftentimes. But now for the past 10 to 20 years, we have these minimally invasive techniques that we use to try to confirm a diagnosis before taking the next step.
Benjamin P. Levy, MD: And talk to us about this briefly, about those minimally invasive techniques.
Andrew Lerner, MD: So, 2 examples are bronchoscopy and CAT scan, or CT-guided biopsies, through the skin. From this, they get smaller biopsy samples, but they do get it at diagnosis and treatment. Oftentimes now as an interventional pulmonologist, one of my expertise in bronchoscopies is that that’s what we do on a daily basis. Even though that’s what I do, I always tell the patient there is oftentimes no one right way to go about it. There are multiple pathways. A lot of it is geared toward the institution and the resources available and also to patient preference and hearing the risk-benefits and alternatives of each modality. If we end up doing bronchoscopy, which I should probably delve in a little bit about that, the bronchoscopy is a camera into the lungs, as most people know, and it’s done in the outpatient procedure suite. It’s an outpatient procedure most often, and what it allows you to do is in one component go on and sample the lymph node glands in the chest for nodal staging. And we oftentimes do this through what’s called EBUS bronchoscopy. And then once you sample the lymph nodes, the next step is actually to try to biopsy the lesion or mass itself if you need it.
Benjamin P. Levy, MD: Now, I’m going to stop you there because there’s a lot of confusion. How much tissue do you try to get when you’re in there? You’re in that spot, you had a node that you’re visualizing, how do you ensure that you’re getting enough tissue? Do you have a protocol that says we’re going to do a 4-pass FNA or we’re going to do several passes? Walk us down how you ensure adequate tissue procurement.
Andrew Lerner, MD: Got it. So, the first thing we do is start with an idea of staging, especially nodal staging. We start with the farthest lymph node, an N3 node for example, and work our way toward the lesion to get at the N1s. If we reach a lymph node that has malignant cells, we just focus on that because that will give diagnosis and stage. But really, to answer your question of when is enough enough, we utilize an insights pathologist or insights cytopathologist who’s in the room at the time of the procedure. And what we do is we take our sample, we put it on a slide, and we hand it to that pathologist who looks at it in real time under the microscope and gives very important feedback.
Transcript Edited for Clarity