Caring for cancer by committee
What do you do for a 96-year-old woman who is diagnosed with lung cancer by accident?
Jeffrey J. Spillane, MD, FACS
The patient lives alone, still drives, and is fiercely independent. She did not seek treatment at Cape Cod Hospital for symptoms related to cancer, but rather after falling and hurting her ribs. The cancer was found incidentally on the CT scan of her chest.
What are the consequences for her health and well-being if she undergoes a surgical biopsy, stereotactic radiation, or chemotherapy? What might be the outcome if she does nothing at all?
These are the types of questions that faced the recent monthly gathering of the thoracic tumor board at Cape Cod Hospital- a multi-disciplinary meeting of practitioners who are involved in the diagnosis, treatment and care for patients with cancer. Clinicians from medical oncology, radiation oncology, social services, thoracic surgery, pathology, VNA hospice, and the cancer registry are all represented.
The thoracic conference is one of several tumor boards that meet regularly at Cape Cod Hospital and Falmouth Hospital. They offer a team approach to cancer care, which is more common in academic medical centers.
Cases are presented to the group when there isn’t a clear-cut diagnosis or treatment plan. Typically, further discussion is sought when the cancer is at an advanced stage or other health challenges are present.
“It keeps us in check,” remarked thoracic surgeon Jeffery Spillane, MD. “I can ask my non-surgical colleagues if what I am doing makes sense to them. They ask me the counter, ‘Should we consider other options?’ ”
The goal of the board is to evaluate each situation individually and offer up a plan that fits with the patient’s story.
“We try to tailor the best treatment for these patients by considering all aspects, including their social living, support systems and financial situation,” said Spillane.
On this day, a total of nine cases are being reviewed. The prevalent diagnosis is non-small cell lung cancer (adenocarcinoma), an aggressive type found most often in current or former smokers.
Michael Rabin MD, a medical oncologist from Dana-Farber Cancer Institute and assistant professor of medicine at Harvard Medical School, is a regular member of the thoracic tumor board. He provides an important link to the most recent research and treatment advances in cancer care.
“Dr. Rabin in his position at Dana-Farber has access to and knowledge about the latest research trials and what’s next on the horizon for all cancer patients,” said Dr. Spillane. “He helps us understand where research efforts are being focused.”
During his monthly visit, Dr. Rabin provides counsel to both caregivers and patients.
“The biggest advantage of having specialists like Dr. Rabin is the ability for our patients to see experts in their type of cancer without traveling to Boston,” said cancer registrar Hester Grue.
“We are very fortunate to have relationships with these physicians. Whenever one of our clinicians has a question or a patient they are concerned about, they can call and reach an expert almost immediately,” she added.
The review of the 96-year-old woman’s case is a thoughtful discussion on the merits of performing a biopsy to confirm a near certain lung cancer diagnosis.
“Is this prudent in a woman her age, given the risks of surgery” questioned Dr. Spillane. “Given its appearance and size, the only acceptable answer is that it’s positive.”
The group consensus was to forgo the biopsy and discuss with the patient the benefits of undergoing stereotactic radiation- a minimally invasive procedure using high intensity, precisely focused radiation delivered directly to tumor.
This treatment offers the patient an option with fewer side effects and less down time than chemotherapy, radiation and surgery. It might not change the eventual outcome, but it would preserve her current quality of life for a while.
In another case during that session, the discussion turned to the importance of understanding the patient’s wishes as a guide to a treatment plan.
An 81-year-old woman with stage three colon cancer had been diagnosed with a new metastasis (spread) to her right lung. Unlike the previous patient, she was not in good health.
A robust discussion ensued about the benefits and harms to performing additional diagnostic tests to confirm the cancer cell type. While there was general agreement that palliative care would be the best follow-up plan, the patient’s medical oncologist, Frank Basile, MD, advocated for something more aggressive.
In the end, Dr. Rabin asked one of the most important questions.
“Do we know what her wishes are? We really need to treat the patient, and not the X-ray.”
The other board members agreed.