MDT critical to best outcomes in stage lll NSCLC

Lung cancer

By Mardi Chapman

21 Mar 2019

Dr Emily Stone

The lung cancer multidisciplinary team (MDT) is critical to best practice and better outcomes in patients with stage lll non-small cell lung cancer (NSCLC).

However, according to a review article in the Asia-Pacific Journal of Clinical Oncology, only about half of patients are receiving this level of care in Australia.

“Patients with stage III NSCLC are clinically heterogeneous and it can be difficult to fit them into a standard algorithm, thereby highlighting the value of the MDT to individualise treatment and improve survival,” the review authors wrote.

“MDTs play a significant role in improving the efficiency of the diagnostic process and as a result lead to better clinical outcomes. The specialised lung cancer nurses and care coordinators further support the patient in their care pathway.”

Co-author Dr Emily Stone, from St Vincent’s Hospital in Sydney and the Kinghorn Cancer Centre, told the limbic that while it was probably not practical to put every NSCLC case through the MDT, it was generally warranted in stage lll.

“Certainly the MDT process shouldn’t be rigid but stage lll cases often have some complexities about them and in general everybody would be recommending they have multidisciplinary discussion as part of their care.”

“It’s probably where the multidisciplinary discussion is really needed because there are lots of different sub-types in stage lll – lllA, lllB – and you can come up with a stage lll score because of the size of the primary, or the pattern of distribution in the lymph nodes, and various other ways.”

“And patients could be a stage lll who could be treated just with chemotherapy or radiation, there are stages lll who are likely to benefit form surgery perhaps combined with another modality… and there is a bit of a gap in the literature in terms of high level evidence.”

The review noted that rapid access clinics for lung cancer have been established in some Australian centres.

“The aims of the rapid access service are to triage and provide expedited appointments within the clinic. Rapid access clinics are designed to fit around the MDT meetings to ensure timely review and management of the patient,” it said.

“Best practice for rapid access clinics and MDTs involves collecting outcome data for patients seen in the clinic and the use of key performance indicators (KPIs) to measure efficiency of the process.”

The review also highlighted the importance of early presentation to GPs and speedy referral to specialist care as part of an optimal care pathway.

Dr Stone said most GPs would only rarely see a lung cancer patient.

“So they don’t necessarily have their systems in place for a rapid work up or rapid referral. Some do, but many GPs don’t. So certainly in my institution, the concept of rapid access is designed to get GPs who don’t have ready pathway set up for themselves, a mechanism where they can arrange very prompt review.”

“What we don’t want is patients, without intent, taking three months to work-up because it takes four weeks in a regional centre to get a PET scan and then you have to wait for the biopsy.”

The review said clinical judgment, as part of the MDT review, was required to determine the sequence as well as choice of diagnostic and staging investigations including imaging such as PET-CT and biopsy.

In terms of therapeutic advances, the review said that immunotherapy such as durvalumab in Australia can improve progression-free survival and time to distant metastases.

There are currently no Australian guidelines for follow-up of patients following curative treatment.

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