Multidisciplinary team care in advanced lung cancer

Improving the quality of patient care in lung cancer: key factors for successful multidisciplinary team working

International Guidelines as well as Cancer Associations recommend a multidisciplinary approach to lung cancer care. A multidisciplinary team (MDT) can significantly improve treatment decision-making and patient coordination by putting different physicians and other health professionals "in the same room", who collectively decide upon the best possible treatment. However, this is not a panacea for cancer treatment. The impact of multidisciplinary care (MDC) on patient outcomes is not univocal, while the effective functioning of the MDT depends on many factors. This review presents the available MDT literature with an emphasis on the key factors that characterize high-quality patient care in lung cancer. The study was conducted with a bibliographic search using different electronic databases (PubMed Central, Scopus, Google Scholar, and Google) referring to multidisciplinary cancer care settings. Many key elements appear consolidated, while others emerge as prevalent and actual, especially those related to visible barriers which work across geographic, organizational, and disciplinary boundaries. MDTs must be sustained by strategic management, structured within the entity, and cannot be managed as a separate care process. Furthermore, they need to coordinate with other teams (within and outside the organization) and join with the broad range of services delivered by multiple providers at various points of the cancer journey or within the system, with the vision of integrated care.

Disparities in Access to Multidisciplinary Cancer Consultations and Treatment for Patients With Early-Stage Non-Small Cell Lung Cancer: A SEER-Medicare Analysis

PURPOSE

Disparities in access to a multidisciplinary cancer consultation (MDCc) persist, and the role of physician relationships remains understudied. This study examined the extent to which multilevel factors, including patient characteristics and patient-sharing network measures reflecting the structure of physician relationships, are associated with an MDCc and receipt of stereotactic body radiation therapy versus surgery among patients with early-stage non-small cell lung cancer (NSCLC).

METHODS AND MATERIALS

In this cross-sectional study, we analyzed Surveillance, Epidemiology, and End Results (SEER)-Medicare data for patients diagnosed with stage I-IIA NSCLC from 2016 to 2017. We assembled patient-sharing networks and identified cancer specialists who were locally unique for their specialty, herein referred to as linchpins. The proportion of linchpin cancer specialists for each hospital referral region (HRR) was calculated as a network-based measure of specialist scarcity. We used multilevel multinomial logistic regression to estimate associations between study variables and receipt of an MDCc and multilevel logistic regression to examine the relationship between patient receipt of an MDCc and initial treatment.

RESULTS

Our study included 6120 patients with stage I-IIA NSCLC, of whom 751 (12.3%) received an MDCc, 1729 (28.3%) consulted only a radiation oncologist, 2010 (32.8%) consulted only a surgeon, and 1630 (26.6%) consulted neither specialist within 2 months of diagnosis. Compared with patients residing in an HRR with a low proportion of linchpin surgeons, those residing in an HRR with a high proportion of linchpin surgeons had a 2.99 (95% CI, 1.87-4.78) greater relative risk of consulting only a radiation oncologist versus receiving an MDCc and a 2.70 (95% CI, 1.68-4.35) greater relative risk of consulting neither specialist versus receiving an MDCc. Patients who received an MDCc were 5.32 times (95% CI, 4.27-6.63) more likely to receive stereotactic body radiation therapy versus surgery.

CONCLUSIONS

Physician networks are associated with receipt of an MDCc and treatment, underscoring the potential for leveraging patient-sharing network analysis to improve access to lung cancer care.

Does Multidisciplinary Team Management Improve Clinical Outcomes in NSCLC? A Systematic Review With Meta-Analysis

Introduction

The implementation of multidisciplinary teams (MDTs) has been found to be effective for improving outcomes in oncology. Nevertheless, there is still a dearth of robust literature on patients with NSCLC. The aim of this study was to conduct a systematic review regarding the impact of MDTs on patient with NSCLC outcomes.

Methods

Databases were systematically searched up to February 2023. Two reviewers independently performed study selection and data extraction. Risk of bias was evaluated using the Newcastle-Ottawa and certainty of evidence by the Grading of Recommendations Assessment, Development and Evaluation approach. Overall survival was the primary outcome. Secondary outcomes included mortality, length of survival, progression-free survival, time from diagnosis to treatment, complete staging, treatment received, and adherence to guidelines. A meta-analysis with a random-effect model was performed. Statistical analysis was performed with the R 3.6.2 package.

Results

A total of 22 studies were included in the systematic review. Ten outcomes were identified, favoring the MDT group over the non-MDT group. Pooled analysis revealed that patients managed by MDTs had better overall survival (three studies; 38,037 participants; hazard ratio 0.60, 95% confidence interval [CI]: 0.49-0.75, I2 = 78%), shorter treatment time compared with patients in the non-MDT group (six studies; 15,235 participants; mean difference = 12.20 d, 95% CI: 10.76-13.63, I2 = 63%), and higher proportion of complete staging (four studies; 14,925 participants; risk ratio = 1.36, 95% CI: 1.17-1.57, I2 = 89%).

Conclusions

This meta-analysis revealed that MDT-based patient care was associated with longer overall survival and better quality-of-care-related outcomes.

Clinical and financial outcomes of pulmonary resection for lung cancer in safety-net hospitals

OBJECTIVE

Safety-net hospitals (SNHs) have previously been associated with inferior outcomes and greater resource use. However, this relationship has not been explored in the contemporary setting of pulmonary lobectomy. In the present national study we characterized the association between SNHs and mortality, complications, and resource use.

METHODS

All adults (18 years of age or older) who underwent elective lobectomy for lung cancer were identified within the 2010 to 2019 Nationwide Readmissions Database. Hospitals in the highest quartile of safety-net burden were categorized as SNHs, and others non-SNHs. Multivariable regressions were developed to assess the independent association between safety-net status and outcomes of interest.

RESULTS

Of an estimated 282,011 patients who met inclusion criteria, 41,015 (14.5%) were treated at SNHs. Patients at SNHs were younger but as commonly female, compared with non-SNHs. After multivariable adjustment, there was no association between SNHs and mortality. However, treatment at SNHs was linked to higher odds of pneumonia (adjusted odds ratio [AOR], 1.11; 95% CI, 1.02-1.21) and prolonged ventilation (AOR, 1.36; 95% CI, 1.11-1.66), as well as infectious (AOR, 1.24; 95% CI, 1.08-1.43), intraoperative (AOR, 1.22; 95% CI, 1.07-1.39), and overall complications (AOR, 1.07; 95% CI, 1.01-1.14). Patients at SNHs also showed a greater need for a blood transfusion (AOR, 1.37; 95% CI, 1.23-1.53). In addition, SNHs were associated with increased length of stay (+0.33 days; 95% CI, 0.17-0.48) and greater costs (+$4130; 95% CI, 3.34-4.92), relative to non-SNHs.

CONCLUSIONS

Hospital safety-net status was associated with greater odds of perioperative complications and greater health care expenditure. Further investigation is necessary uncover the mechanisms contributing to these complications and eradicate persistent disparities in lobectomy.

Morphologic Severity of Atypia Is Predictive of Lung Cancer Diagnosis

In cytologic analysis of lung nodules, specimens classified as atypia cannot be definitively diagnosed as benign or malignant. Atypia patients are typically subject to additional procedures to obtain repeat samples, thus delaying diagnosis. We evaluate morphologic categories predictive of lung cancer in atypia patients. This retrospective study stratified patients evaluated for primary lung nodules based on cytologic diagnoses. Atypia patients were further stratified based on the most severe verbiage used to describe the atypical cytology. Logistic regressions and receiver operator characteristic curves were performed. Of 129 patients with cytologic atypia, 62.8% later had cytologically or histologically confirmed lung cancer and 37.2% had benign respiratory processes. Atypia severity significantly predicted final diagnosis even while controlling for pack years and modified Herder score (p = 0.012). Pack years, atypia severity, and modified Herder score predicted final diagnosis independently and while adjusting for covariates (all p < 0.001). This model generated a significantly improved area under the curve compared to pack years, atypia severity, and modified Herder score (all p < 0.001) alone. Patients with severe atypia may benefit from repeat sampling for cytologic confirmation within one month due to high likelihood of malignancy, while those with milder atypia may be followed clinically.

The Multidisciplinary Heart Team in Cardiovascular Medicine: Current Role and Future Challenges

Cardiovascular multidisciplinary heart teams (MDHTs) have evolved significantly over the past decade. These teams play a central role in the treatment of a wide array of cardiovascular diseases affecting interventional cardiology, cardiac surgery, interventional imaging, advanced heart failure, adult congenital heart disease, cardio-oncology, and cardio-obstetrics. To meet the specific needs of both patients and heart programs, the composition and function of cardiovascular MDHTs have had to adapt and evolve. Although lessons have been learned from multidisciplinary cancer care, best practices for the operation of cardiovascular MDHTs have yet to be defined, and the evidence base supporting their effectiveness is limited. This expert panel review discusses the history and evolution of cardiovascular MDHTs, their composition and role in treating patients across a broad spectrum of disciplines, basic tenets for successful operation, and the future challenges facing them.

Developing a visual model for predicting depression in patients with lung cancer

AIMS AND OBJECTIVES

To investigate and analyse the prevalence of depression among patients with lung cancer, identify risk factors of depression, and develop a visual, non-invasive, and straightforward clinical prediction model that can be used to predict the risk probability of depression in patients with lung cancer quantitatively.

BACKGROUND

Depression is one of the common concomitant symptoms of patients with lung cancer, which can increase the risk of suicide. However, the current assessment tools cannot combine multiple risk factors to predict the risk probability of depression in patients.

DESIGN

A cross-sectional study.

METHODS

The clinical data from 297 patients with lung cancer in China were collected and analysed in this cross-sectional study. The clinical prediction model was constructed according to the results of the Chi-square test and the logistic regression analysis, evaluated by discrimination, calibration, and decision curve analysis, and visualised by a nomogram. This study was reported using the TRIPOD checklist.

RESULTS

130 patients with lung cancer had depressive symptoms with a prevalence of 43.77%. A visual prediction model was constructed based on age, disease duration, exercise, stigma, and resilience. This model showed good discrimination at an AUC of 0.842. Calibration curve analysis indicated a good agreement between experimental and predicted values, and the decision curve analysis showed a high clinical utility.

CONCLUSIONS

The visual prediction model developed in this study has excellent performance, which can accurately predict the occurrence of depression in patients with lung cancer at an early stage and assist the medical staff in taking targeted preventative measures.

RELEVANCE TO CLINICAL PRACTICE

The visual, non-invasive, and simple nomogram can help clinical medical staff to calculate the risk probability of depression among patients with lung cancer, formulate personalised preventive care measures for high-risk groups as soon as possible, and improve the quality of life of patients.

Virtual Multidisciplinary Tumor Boards: A Narrative Review Focused on Lung Cancer

To date, the virtual multidisciplinary tumor boards (vMTBs) are increasingly used to achieve high-quality treatment recommendations across health-care regions, which expands and develops the local MTB team to a regional or national expert network. This review describes the process of lung cancer-specific MTBs and the transition process from face-to-face tumor boards to virtual ones. The review also focuses on the project organization's description, advantages, and disadvantages. Semi-structured interviews identified five major themes for MTBs: current practice, attitudes, enablers, barriers, and benefits for the MTB. MTB teams exhibited positive responses to modeled data feedback. Virtualization reduces time spent for travel, allowing easier and timely patient discussions. This process requires a secure web platform to assure the respect of patients' privacy and presents the same unanswered problems. The implementation of vMTB also permits the implementation of networks especially in areas with geographical barriers facilitating interaction between large referral cancer centers and tertiary or community hospitals as well as easier access to clinical trial opportunities. Studies aimed to improve preparations, structure, and conduct of MTBs, research methods to monitor their performance, teamwork, and outcomes are also outlined in this article. Analysis of literature shows that MTB participants discuss 5-8 cases per meeting and that the use of a vMTB for lung cancer and in particular stage III NSCLC and complex stage IV cases is widely accepted by most health professionals. Despite still-existing gaps, overall vMTB represents a unique opportunity to optimize patient management in a patient-centered approach.

Quality indicators and excellence requirements for a multidisciplinary lung cancer tumor board by the Spanish Lung Cancer Group

Multidisciplinary care is needed to decide the best therapeutic approach and to provide optimal care to patients with lung cancer (LC). Multidisciplinary teams (MDTs) are optimal strategies for the management of patients with LC and have been associated with better outcomes, such as an increase in quality of life and survival. The Spanish Lung Cancer Group has promoted this review about the current situation of the existing national LC-MDTs, which also offers a set of excellence requirements and quality indicators to achieve the best care in any patient with LC. Time and sufficient resources; leadership; administrative and institutional support; and recording of activity are key factors for the success of LC-MDTs. A set of excellence requirements in terms of staff, resources and organization of the LC-MDT have been proposed. At last, a list of quality indicators has been agreed to achieve and measure the performance of current LC-MDTs.

Current Management of Oligometastatic Lung Cancer and Future Perspectives: Results of Thermal Ablation as a Local Ablative Therapy

A growing body of evidence shows improved overall survival and progression-free survival after thermal ablation in non-small cell lung carcinoma (NSCLC) patients with a limited number of metastases, combined with chemotherapy or tyrosine kinase inhibitors or after local recurrence. Radiofrequency ablation and microwave ablation are the most evaluated modalities, and target tumor size <3 cm (and preferably <2 cm) is a key factor of technical success and efficacy. Although thermal ablation offers some advantages over surgery and radiotherapy in terms of repeatability, safety, and quality of life, optimal management of these patients requires a multidisciplinary approach, and further randomized controlled trials are required to help refine patient selection criteria. In this article, we present a comprehensive review of available thermal ablation modalities and recent results supporting their use in oligometastatic and oligoprogressive NSCLC disease along with their potential future implications in the emerging field of immunotherapy.

The prognostic value of USP14 and PSMD14 expression in non-small cell lung cancer

Background

Ubiquitin specific peptidase 14 (USP14) and proteasome 26S subunit, non-ATPase 14 (PSMD14) are two deubiquitinases that are closely related to the human 19S proteasome. These are highly expressed in various types of cancers and are associated with prognosis. However, the expression, clinicopathological features, and prognostic relevance of these two deubiquitinases remain unclear in patients with non-small cell lung cancer (NSCLC). Moreover, the correlation between the expression of these two deubiquitinases in NSCLC has not been reported.

Methods

In this study, the expression of USP14 and PSMD14 in NSCLC tissues and adjacent non-tumor tissues were examined by immunohistochemical staining. The association of these two deubiquitinases with the clinicopathological features and overall survival (OS) of patients with NSCLC was evaluated meanwhile.

Results

The expression of USP14 and PSMD14 was upregulated in NSCLC tissues compared with adjacent non-tumor tissues. High expression of both these deubiquitinases was positively correlated with the TNM stage of NSCLC. In addition, PSMD14 was positively correlated with lymph node metastasis in NSCLC. The survival analysis showed that elevated levels of USP14 or PSMD14 were associated with poorer survival of NSCLC patients compared with low expression of USP14 or PSMD14. Cox regression analysis indicated that TNM stage, USP14, and PSMD14 were independent prognostic factors for OS in NSCLC.

Conclusions

This study demonstrated that USP14 and PSMD14 may play important roles in the progression of NSCLC, especially when they are expressed simultaneously at elevated levels. Thus, USP14 and PSMD14 may be potential novel biomarkers and therapeutic targets for the prognosis and treatment of patients with NSCLC.

A Highly Responsive Pancreatic Ductal Adenocarcinoma with Liver Metastasis: A Rare Case Report

Background

Pancreatic ductal adenocarcinoma (PDAC) is one of the most refractory and lethal cancer. The overall survival is dismal due to the high frequency of recurrence and metastasis after surgery and resistance to chemotherapy. Patients with the locally advanced or metastatic disease usually have the poorest prognosis. Herein, we report a rare highly responsive PDAC with liver metastasis.

Case Presentation

A 49-year-old female presented with dull abdominal and back pain, discomfort after eating, fatigue, and recent weight loss of 5 kg. Clinical examination was normal and no relevant oncological history was observed. A routine blood test showed low red blood cell count and low hemoglobin level. Markedly increased carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 125 levels were detected. Computer tomography (CT) of the abdomen revealed a massive pancreatic tumor with the invasion of almost all important surrounding blood vessels and liver metastasis. After the genetic test and percutaneous biopsy for this tumor, a multidisciplinary team (MDT) discussion was initiated. Subsequently, oral chemotherapy (S-1) and ¹²⁵I radiative seeds implantation were recommended. Surprisingly, the tumor shrank significantly after treatment. On August 14, 2019, pancreatoduodenectomy was performed. The tumor was successfully resected and liver metastasis was not detected. Based on the postoperative histopathological result, there was only fibrous tissue hyperplasia and inflammatory cell infiltration. Besides, no tumor tissue was found. Until now, through outpatient follow-up, no signs of recurrence and metastasis have been observed.

Conclusion

Although the therapeutic efficacy and prognosis of PDAC are dismal, we successfully cured a patient with a metastatic disease through multidisciplinary cooperation. However, the therapeutic experience should be summarized and further research should be performed to confirm whether it is appropriate for other PDAC patients.

Uncovering the Pharmacological Mechanism of 2-Dodecyl-6-Methoxycyclohexa-2,5 -Diene-1,4-Dione Against Lung Cancer Based on Network Pharmacology and Experimental Evaluation

Background: 2-Dodecyl-6-Methoxycyclohexa-2, 5-Diene-1,4-Dione (DMDD) was purified from the roots of Averrhoa carambola L. Previous research demonstrated that DMDD is a small molecular compound with significant therapeutic potential for tumors. However, the potential targets and pharmacological mechanism of DMDD to treat lung cancer has not been reported.

Methods: We employed network pharmacology and experimental evaluation to reveal the pharmacological mechanism of DMDD against lung cancer. Potential therapeutic targets of DMDD were screened by PharmMapper. Differentially expressed genes (DEGs) in The Cancer Genome Atlas (TCGA) lung cancer data sets were extracted and analyzed by GEPIA2. The mechanism of DMDD against lung cancer was determined by PPI, gene ontology (GO) and KEGG pathway enrichment analysis. Survival analysis and molecular docking were employed to obtain the key targets of DMDD. Human lung cancer cell lines H1975 and PC9 were used to detect effects of DMDD treatment in vitro. The expression of key targets after DMDD treated was validated by Western Blot.

Results: A total of 60 Homo sapiens potential therapeutic targets of DMDD and 3,545 DEGs in TCGA lung cancer datasets were identified. Gene ontology and pathway analysis revealed characteristic of the potential targets of DMDD and DEGs in lung cancer respectively. Cell cycle and pathways in cancer were overlapping with DMDD potential targets and lung cancer DEGs. Eight overlapping genes were found between DMDD potential therapeutic targets and lung cancer related DEGs. Survival analysis showed that high expression of DMDD potential targets CCNE1 and E2F1 was significantly related to poor patient survival in lung cancer. Molecular docking found that DMDD exhibited significant binding affinities within the active site of CCNE1 and E2F1. Further tests showed that DMDD inhibited the proliferation, migration and clone formation in lung cancer cell lines (H1975 and PC9) in a dose and time dependent manner. Mechanistically, DMDD treatment decreased the expression of CDK2, CCNE1, E2F1 proteins and induced cell cycle arrest at the G1/S phase in H1975 and PC9 cells.

Conclusion: These results delineated that DMDD holds therapeutic potential that blocks tumorigenesis by cell cycle regulation in lung cancer, and may provide potential therapies for lung cancer.

Barriers and Facilitators for Implementation of a Computerized Clinical Decision Support System in Lung Cancer Multidisciplinary Team Meetings-A Qualitative Assessment

Simple Summary

Oncological computerized clinical decision support systems (CCDSSs) are currently being developed to facilitate workflows of multidisciplinary team meetings (MDTMs). To successfully implement these systems in MDTMs, the aim of this qualitative assessment was to identify barriers and facilitators for implementation and to provide actionable findings for an implementation strategy. The main facilitators for implementation of the CCDSS were considered to be easy access to well-structured data, and reducing time spent by clinicians on MDTM preparation and duration of the MDTMs. Main barriers for adoption were seen in incomplete or non-trustworthy output generated by the system and insufficient adaptability of the system to local and contextual needs. Actionable findings for an implementation strategy were a usability test and validation study involving key users in the organization’s real-life setting. Given the growing interest in CCDSSs in oncology care, insight in barriers and facilitators for successful implementation seems highly relevant.

Abstract

Background: Oncological computerized clinical decision support systems (CCDSSs) to facilitate workflows of multidisciplinary team meetings (MDTMs) are currently being developed. To successfully implement these CCDSSs in MDTMs, this study aims to: (a) identify barriers and facilitators for implementation for the use case of lung cancer; and (b) provide actionable findings for an implementation strategy. Methods: The Consolidated Framework for Implementation Science was used to create an interview protocol and to analyze the results. Semi-structured interviews were conducted among various health care professionals involved in MDTMs. The transcripts were analyzed using a thematic analysis following a deductive approach. Results: Twenty-six professionals participated in the interviews. The main facilitators for implementation of the CCDSS were considered to be easy access to well-structured patient data, and the resulting reduction of MDTM preparation time and of duration of MDTMs. Main barriers for adoption were seen in incomplete or non-trustworthy output generated by the system and insufficient adaptability of the system to local and contextual needs. Conclusion: Using a CCDSS in lung cancer MDTMs was expected to increase efficiency of workflows. Successful implementation was seen as dependent on the reliability and adaptability of the CCDSS and involvement of key users in the implementation process.