In 2014 the IASLC, in collaboration with the American Thoracic Society and the European Respiratory Society, published a new classification of lung adenocarcinoma.1 The publication addressed new terminology and diagnostic criteria for lung adenocarcinoma, but it also highlighted “the importance of a close collaboration between oncologist, pathologist, molecular biologist, radiologist and surgeons … to offer the best treatment opportunities” to patients with lung cancer.
This multidisciplinary approach—a phrase that has become much more commonplace in recent years—is a system of care delivery in which the key clinicians involved in a patient’s care evaluate the medical situation before commitment to a pathway of care, certainly before treatment begins, explained Raymond Osarogiagbon, MD, FACP, of Baptist Cancer Center. In the case of lung cancer, the key involved clinicians are radiologists, pulmonologists, pathologists, thoracic surgeons, medical oncologists, and radiation oncologist.
“Unfortunately, there is a huge gap between the almost-universal recommendation for multidisciplinary care and the actual evidence of its implementation in real life,” Dr. Osarogiagbon said. “There are some academic centers that have brought this type of care together, but the vast majority of lung cancer in the United States is treated predominantly at the community level, and multidisciplinary care delivery is scarce in that environment.” Even within academic centers, the implementation of the multidisciplinary care model is highly variable.
Implementation Barriers
One of the biggest challenges to implementing the multidisciplinary care delivery model from the clinician’s perspective is the idea that it is time-consuming or inefficient. “It is easy for clinicians to look at the amount of time spent getting together with the team to go through all the patients’ information and say it is much longer than it would take for them to sit in their own clinic and make a decision on their own,” Dr. Osarogiagbon said.
There is also a chance that patients may be referred out of the hands of one specialist, say, a surgical oncologist, to a different specialist, such as a medical oncologist, based on the decision of the multidisciplinary team. This type of pushback may not be appealing to everyone.
In addition to clinician-based barriers, there are also institutional barriers. Setting up a multidisciplinary team means investing upfront in infrastructure, including a physical or virtual meeting space, audio/visual tools, manpower, data collection resources, and more.
In the face of these barriers, the actual evidence to support the benefits of multidisciplinary care is poor, Dr. Osarogiagbon said. “You are asking people to spend money without any clear return on investment,” he said. “You are asking people to spend all this time without good, quality evidence that the time spent leads to better outcomes for patients. Why would they do this?”
Getting the Data
In an attempt to get this evidence, Dr. Osarogiagbon and colleagues conducted a prospective study comparing patients who were treated in the multidisciplinary setting to those treated with the usual “serial” care. The study included patients from throughout the Baptist Memorial Care System, a system spanning parts of Kentucky, Alabama, and Missouri, states with some of the highest lung cancer incidence and mortality rates.
In this initial study, Dr. Osarogiagbon noted that they had trouble recruiting patients into the serial-care arm because clinicians did not want these patient outcomes compared with that of patients who received multidisciplinary care. The data were skewed, he noted. Analysis revealed that both patients and their caregivers preferred the multidisciplinary care concept and that the quality of staging and use of guideline-recommended treatment were much improved with multidisciplinary care, but there was no difference in survival outcomes.
Next, as described in an oral abstract presented at the Care Delivery and Regulatory Policy session at the 2020 ASCO Virtual Scientific Program,2 they used data from the tumor board registry to separate patients who had received multidisciplinary care from everyone else. The patients who received multidisciplinary care were compared with patients who received usual care in the metropolitan areas of the system and those who received usual care in regional settings. The multidisciplinary program was located in metropolitan Memphis. Cohorts were separated into multidisciplinary care in Memphis, non-multidisciplinary care in Memphis, and non-multidisciplinary care outside of Memphis (regional care). Patients were propensity matched on age, race, sex, insurance, rurality, and clinical stage.
“The multidisciplinary cohort was prospectively defined and identified, and we were able to put them in context with everybody else receiving care within our health system,” Dr. Osarogiagbon said. “We found that the guideline-concordant care rate was highest in the multidisciplinary program, next highest for the patients treated in the metropolitan area, and lowest in the regional cohort.”
What was very striking, he said, was that although only 7% of patients in the multidisciplinary cohort received no treatment, 22% and 30% of the metropolitan and regional non-multidisciplinary care cohorts, respectively, received no treatment. Finally, patients in the multidisciplinary cohort also had the best survival, even when those who received no treatment in all cohorts were eliminated from the analysis.
Proof of Principle
According to Dr. Osarogiagbon, this is the first study to show that a multidisciplinary program can be successfully put into place in a non-academic community setting, with significant survival benefit to patients with lung cancer. Those willing to mimic this successful program, though, will have to put in the work, he noted.
One of the first steps is to have a champion. This person must be willing to take the time and effort to create the environment, attract participants, and help them to become a team. This requires the application of team science principles, such as closed-loop communication, development of shared mental models of team goals, mutual trust, and psychological safety.
“It takes time to develop mutual trust among stakeholders and to help people understand that everyone’s interests are served by participating,” Dr. Osarogiagbon said.
Additionally, the space has to provide everyone with a sense of psychological safety. Dr. Osarogiagbon recalled early multidisciplinary conferences in which a treatment paths were decided, only to have team members approach him after the meeting with concerns, instead of voicing them during the conference.
Successful implementation of multidisciplinary care also means having follow-through and ensuring concordance with the treatment plan. In a 2011 study, Dr. Osarogiagbon and colleagues showed that patients whose care was discordant with the treatment plan had worse outcomes than those who received concordant care.3
Finally, one of the most important aspects of a successful multidisciplinary program is often a coordinator. This person is responsible for scheduling the conferences regularly, reminding attendees, and bringing the correct and most up-to-date information on the patients whose care will be discussed.
“Once we know the key components of implementing a multidisciplinary care system, we can then adapt it to the unique care delivery environment and unique resources available in each community system while staying faithful to those core elements,” Dr. Osarogiagbon said.
References:
- Zugazagoitia J, Enguita AB, Nunez JA, Iglesias L, Ponce S. The new IASLC/ATS/ERS lung adenocarcinoma classification from a clinical perspective: current concepts and future prospects. J Thorac Dis. 2014;6(suppl 5):S526-S536.
- Osarogiagbon RU, Faris NR, Smeltzer M, et al. Survival impact of multidisciplinary thoracic oncology care in a regional healthcare system. Abstract presented at: 2020 ASCO Virtual Scientific Program; May 29-31, 2020. J Clin Oncol. 2020;38(suppl). Abstract 2004.
- Osarogiagbon RU, Phelps G, McFarlane J, Bankole O. Causes and consequences of deviation from multidisciplinary care in thoracic oncology. J Thorac Oncol. 2011;6(3):510-516.
