Thoracic Malignancy Care: Secret to Success Resides in the Team

By Alejandro Bribriesco, MD

Cleveland Clinic is the only U.S. institution to have earned three-star (highest) composite quality ratings for both lobectomy for lung cancer and esophagectomy in the Society of Thoracic Surgeons (STS) General Thoracic Surgery Database for the three-year period ending 12/31/2017. I attribute that in large part to our team approach.

Our comprehensive Section of Thoracic Surgery — spanning lung, esophageal and other chest tumors — offers the latest minimally invasive techniques for thoracic cancer care. We work closely with Cleveland Clinic colleagues in medical oncology, radiology, pathology and other ancillary services to ensure that the care we deliver offers patients the best hope for recovery. While the operation is an important piece of the puzzle in complex cancer treatment, it is by no means the only piece. Communication and careful planning among a patient’s care team are essential to achieve the optimal outcome.

Frequent tumor boards bring all specialists together

Our multidisciplinary tumor boards meet weekly or semiweekly. Every Tuesday morning, our thoracic tumor board meets to discuss cases involving cancers of the chest, including lung cancer, mediastinal tumors and pleural cancers such as mesotheliomas. Our esophageal tumor board meets every other Friday, and our chest wall sarcoma group meets on Monday mornings.

Specialists from regional hospitals in the Cleveland Clinic health system, and even from affiliate hospitals working with our Heart & Vascular Institute Advisory and Affiliation Services, are welcome to attend these meetings to seek advice on specific patients. Attendance can be in person, by phone or by Skype. We can review a patient’s images together with the staff radiologist, as well as the patient’s biopsies with the staff pathologist, as both of these specialists are part of the team and present at all meetings. We make it a priority to have every aspect of a cancer patient’s care represented by a specialist seated in these meetings every week.

While we follow national guidelines for management of the various malignancies, many of the patients referred to us are highly challenging and do not fit neatly into standard classifications. That is where we have to turn to expert opinion and consensus about the best way to manage a particular patient.

New treatments and surgical approaches

We are increasingly including immunotherapy as part of our treatment plan for nearly all types of cancers. These medications, which help the patient’s own immune system attack the tumor, have dramatically changed both our pre- and post-surgical approaches, and we are moving toward using them even sooner within our developing algorithms.

We are also examining new surgical approaches. Cleveland Clinic is a participating center in the joint STABLe-mates Trial conducted by the Lung Cancer Trialist’s Coalition. This phase 3 study is randomizing high-risk operable patients with stage I non-small cell lung cancer to either sublobar resection or stereotactic ablative radiotherapy. The hypothesis is that three-year overall survival will be greater in patients who undergo stereotactic ablative radiotherapy compared with standard sublobar resection.

We are also performing minimally invasive/robotic surgeries for thoracic malignancies when possible, as these generally result in less pain, faster recovery and shorter hospital stays. We are highly experienced in using the robot for lung resection, such as lobectomy and segmentectomy, and for selected patients we use a robot-assisted approach as part of minimally invasive esophagectomy. Excellent outcomes with those procedures (detailed here) are one contributing factor to our three-star STS ratings.

Addressing challenges

Of course, we face some practical challenges that go beyond the cancer itself and involve national healthcare issues more broadly. For example, access to healthcare and insurance coverage are unfortunate but real issues that need to be considered. At a recent thoracic tumor board meeting, the increasingly common issue of insurance denial of necessary tests and procedures was discussed. Given our common goals and purpose, we shared our different experiences and arrived at common strategies to best advocate for our patients.

We are also striving to address the new “time to treat” metric, which measures the time from cancer diagnosis to the start of any kind of treatment. One logistical hurdle for a referral center like Cleveland Clinic is that time to treat does not account for unavoidable delays between diagnosis and treatment of lung cancer, such as patient factors that limit patients’ ability to come in for care. Fortunately, our team approach allows patients to see all their specialists on the same day to ensure efficient and effective care.

In most of our cases, the time to treatment is less than two weeks. For patients already being seen at Cleveland Clinic, the time to treatment is minimal. Of course, we have less control when patients are referred from elsewhere. We jump through hoops, but invariably these patients’ time to treatment will be longer. We have ongoing meetings and discussion about how to improve this metric, which remains a work in progress.

As with all aspects of our thoracic malignancy program, continuous refinement and improvement is the rule. This ethos is reflected in what our Section Head of Thoracic Surgery, Sudish Murthy, MD, PhD, tells our collaborating colleagues in other disciplines: “Managing thoracic malignancies is complex, and success lies in the ability to coordinate care among multiple subspecialties, risk-stratifying patients to select the most appropriate treatment for each individual. It also requires ongoing innovation aimed at increasing efficacy and reducing morbidity. These are the cornerstones of care in this complex patient population.”

Photo credit: © Russell Lee