|Year : 2022 | Volume
| Issue : 5 | Page : 46-55
Relevance of multi-disciplinary team approach in diagnosis and management of Stage III NSCLC
Ullas Batra1, Anusheel Munshi2, Vedant Kabra3, Gagandeep Momi4
1 Department of Medical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
2 Department of Radiation Oncology, Manipal Hospital, Delhi, India
3 Department of Surgical Oncology, Manipal Hospital, Delhi, India
4 Department of Medical Affairs, AstraZeneca Pharma India Ltd, India
|Date of Submission||12-Jan-2021|
|Date of Decision||18-Jul-2021|
|Date of Acceptance||14-Oct-2021|
|Date of Web Publication||24-Mar-2022|
Department of Medical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Delhi
Source of Support: None, Conflict of Interest: None
Lung cancer is reported as the leading cause of cancer-related mortality worldwide. Non-small cell lung cancer (NSCLC) constitutes 80%–85% of all lung cancers. Diagnosis of NSCLC is a complex multistep process. The prognosis of NSCLC is poor as most of the patients are presented at the metastatic stage. The management of these patients needs the expertise of different specialists. A multidisciplinary team (MDT) comprising specialists from different disciplines has a substantial role in improving outcomes in these patients. This is feasible through extensive discussions, accurate evaluation of patients, reviewing medical records, implementing ideal treatment strategies, and merging local treatments with systemic treatment concepts. Therefore, the MDT approach for stage III NSCLC management can enable early treatment initiation, optimal treatment modalities, and reduce healthcare expenditure. Studies have shown that MDT can provide multimodality care facilitating the diagnosis and treatment of stage III NSCLC, resulting in survival benefit of these patients. Thus, it is imperative to collate scientific evidence to get an insight into the MDT approach in advanced NSCLC treatment. This review aims to summarize the impact of MDT on treatment rates, survival outcome, treatment guideline adherence, and quality of life (QoL) of stage III NSCLC patients.
Keywords: Multidisciplinary team, non-small cell lung cancer, quality of life, stage III non-small cell lung cancer, survival rate
|How to cite this article:|
Batra U, Munshi A, Kabra V, Momi G. Relevance of multi-disciplinary team approach in diagnosis and management of Stage III NSCLC. Indian J Cancer 2022;59, Suppl S1:46-55
|How to cite this URL:|
Batra U, Munshi A, Kabra V, Momi G. Relevance of multi-disciplinary team approach in diagnosis and management of Stage III NSCLC. Indian J Cancer [serial online] 2022 [cited 2022 May 22];59, Suppl S1:46-55. Available from: https://www.indianjcancer.com/text.asp?2022/59/5/46/340527
| » Introduction|| |
Lung cancer has the highest incidence rate (11.6%) and is the most common cause of cancer-related mortality (18.4%) globally as per the GLOBCAN 2018 report. Majority of the patients are diagnosed at advanced stage of lung cancer due to lack of clinical symptoms. It is important to know the accurate stage of cancer to provide optimal treatment strategies.
Non-small cell lung cancer (NSCLC) constitutes approximately 80%–85% of all lung cancers. The stage III NSCLC is the locally advanced stage of the tumor and is highly heterogenous with variability in tumor/nodal status, treatment options, and prognosis. Based on the tumor, node, and metastasis (TNM) staging system, the stage III is subclassified into stage IIIA, IIIB, and IIIC. As per the 8th edition of TNM (TNM 8) classification, the 5-year survival rate for clinical/pathological stage IIIA is 36%/41%, stage IIIB is 26%/24%, and stage IIIC is 13%/12%. According to a report from the American Cancer Society (2019), the 5-year survival rate of NSCLC is 23%. Approximately 70% of NSCLC patients are present at metastatic stage of the disease with poor prognosis; this is responsible for reduced survival outcomes.,
The treatment options available for stage III NSCLC are surgery, radiotherapy, and chemotherapy. To improve outcomes in these patients, it is very important to perfectly combine local treatments with systemic treatment concepts in right sequence and time. Furthermore, it depends on the institution's experience and the patient preference. To understand the whole situation and plan the treatment for these patients with varied tumor extent and location, molecular characteristics, histology, and the immunologic situation, a multidisciplinary team (MDT) is essential. Wakeam et al. defined MDT as “a model of healthcare delivery which is comprised of coordinated care delivered by groups of appropriate specialists.” MDT for tumor includes physicians (oncologists, surgeons, radiologists, pulmonologists, anesthetists, pathologists, and palliative care specialists), nurses, social workers, physiotherapists, dieticians, and occupational therapists., This group of healthcare specialists could be from more than one hospital. Several studies are being conducted worldwide to assess how MDT affects outcomes in cancer patients, including lung cancer, and have shown positive results.,,
This review aims at collating the evidence and understanding how MDT aids in the diagnosis and treatment of NSCLC with a focus on its impact in the management of the heterogenous stage III NSCLC.
| » Methods|| |
An electronic search was conducted on databases, including PubMed and Google Scholar, in August 2019. The search terms included “Lung cancer,” “NSCLC,” “Stage III,” “multidisciplinary team,” multidisciplinary meetings,” “diagnosis,” “treatment,” “survival,” and “quality of life.” No search filters were applied for language or search duration. Furthermore, relevant cross-references in the retrieved articles were also referred.
| » Diagnosis of NSCLC: What are the Challenges and How MDT can Minimize them?|| |
Challenges in the diagnosis of NSCLC
Accurate diagnosis and staging are important to preplan the multimodality treatment for the individual lung cancer patient. To confirm cancer in suspected cases, tissue diagnosis is required that guides for further investigation, management, and prognosis. However, obtaining tissue samples may be a complex process and involve multiple specialties. Several factors have been reported to result in delay of diagnosis and treatment of lung cancer, including delay due to investigation and diagnostic procedure to establish the cancer diagnosis, lack of symptoms, multiple procedures, and specialist visits. Diagnosing lung cancer is now being recognized as a multidisciplinary problem with the advancements in the molecular biology and oncology, including discovery of EGFR mutation and the emergence of radiologic-pathologic correlations, which can predict histologic type, patient prognosis, and type of surgery.,
Role of MDT in diagnosis
As several diagnostic tests are required to establish a diagnosis and accurately define the stage of the lung cancer and deliver appropriate treatment, access to specialist diagnostic investigations, including endobronchial ultrasound fine-needle aspiration, is required. It is now required that all specialists come together to ensure correct diagnosis and to obtain appropriate and adequate tissue for molecular testing. [Figure 1] presents all the specialists required at various stages of lung cancer management. Furthermore, the role of MDT during various phases of diagnosis of NSCLC is shown in [Figure 2].
|Figure 1: The role of MDT during diagnosis of NSCLC. Abbreviations: CT: Computed tomography, NSCLC: Non-small cell lung cancer|
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|Figure 2: The role of MDT during diagnosis of NSCLC. Abbreviations: CT: Computed tomography, NSCLC: Non-small cell lung cancer|
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MDT involvement in lung cancer management improves accurate staging and timely diagnosis
Studies have reported that MDT plays a role in staging and timely diagnosis., Boxer et al. (2011) reported that TNM staging was more frequently assessed in lung cancer patients managed with MDT approach as compared to non-MDT (100% vs. 75%; P < 0.05). Furthermore, the study also reported that pathologic diagnosis was missing less frequently for patients managed via MDT approach as compared to those with the non-MDT approach (4% vs. 13%; P < 0.01). Harbegue et al. (2019) specifically showed the role of MDT in staging in NSCLC stage III patients. Involvement of MDT has been reported to accurately define the stage (esophageal cancer). Further, a study by Salomaa et al. (2005) also concluded that having MDT is helpful in shortening the diagnostic and treatment delay times. Conron and colleagues in their study concluded that lung cancer patients managed by MDT receive timely diagnosis and staging. MDT is also involved in coordinating and managing the diagnostic process and can thus reduce the patient's risk of undergoing recurrent procedures. [Table 1] presents complete details of these studies. Travis et al. (2013) emphasized the need of MDT strategy to be developed by the multidisciplinary committee in all institutions for small sample obtaining, processing, preserving, and expediting the transport of the sample for laboratory testing and reporting results. These small specimens aid not only in diagnosis but also in molecular testing and evaluation of markers of resistance to therapy.
|Table 1: Studies assessing the impact of multidisciplinary team on outcomes in NSCLC patients|
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| » Reduction in healthcare expenditure|| |
A recent study by Voong et al. (2019) investigated the healthcare expenditure incurred by patients who were managed by a single-day thoracic oncology multidisciplinary clinic (MDC) in the diagnostic period prior to NSCLC treatment compared with those managed by non-MDC settings. The study results found that patients seen at MDC had on average a decrease of 23% in overall charges per patient incurred (savings: $5839; range: $5213–$6464) compared to patients seen through non-MDC settings. The average number of provider visits per patient prior to treatment start were reduced by evaluation through MDC (non-MDC, 6.8 vs. MDC, 4.8; P < .01), which led to a decrease of 50% (average: $3092; range: $2451–$3732) in provider charges per patient (P < .01).
The guidelines from the American College of Chest Physicians (ACCP) also recommend involving MTD at the early stage of evaluation of the lung cancer patient, that is, from diagnosis and clinical staging and developing a treatment plan, proceed in an overlapping, not sequential manner. Doing so will make the evaluation proceed more quickly with fewer unnecessary tests.
Thus, the involvement of MDT right from the diagnosis of lung cancer is helpful not only in expediting the diagnosis process but also in improving the accuracy of both diagnosis and staging. Thus, MDT plays an important role in the diagnosis of all lung cancer across all stages (stage I–IV).
The guidelines from the European Respiratory Society/European Society of Thoracic Surgeons (ERS/ESTS) for fitness for radical therapy of lung cancer recommend that lung cancer should be managed in specialized settings by MDTs (pulmonologists, thoracic surgeons specialized in lung cancer, medical oncologists, and radiation oncologists).
| » Treatment of NSCLC Stage III: Role of Multidisciplinary Team|| |
Surgery remains the standard of care (SOC) for NSCLC patients at resectable stage I and II until and unless there are contradictions to it. As discussed above, stage III NSCLC is highly heterogenous, presenting either with extensive mediastinal infiltration or discrete mediastinal node involvement, or a small focus of nodal involvement after resection despite negative preoperative invasive mediastinal staging. Thus, a surgical oncologist, medical oncologist, or radiation oncologist cannot individually decide if the tumor is resectable. Any patient of any stage of lung cancer should go through a multidisciplinary tumor board for decision regarding management.
The guidelines by the ACCP have given recommendations for the treatment of stage III NSCLC, including infiltrative stage III (N2,3), discrete mediastinal node involvement, and occult N2 involvement discovered at resection despite thorough preoperative staging (Stage IIIA). Furthermore, the ACCP guidelines also recommend that patients requiring multimodality therapy should be managed using a MDT approach, which should include a representative from “pulmonary medicine, thoracic surgery, medical oncology, radiation oncology, palliative care, radiology, and pathology.”
Another recent consensus statement has also been published jointly by various scientific societies and provides recommendations on stage III NSCLC management. It also supports the need for MDT in the management of stage III NSCLC.
Evaluation of the impact of MDT in treatment of stage III NSCLC patients
Several studies have investigated the impact of MDT in making treatment decisions and its effect on various other outcomes, including treatment rates, patient survival, treatment as per guidelines, and quality of life (QoL)., We will discuss the impact of MDT on these factors below:
Treatment rates and approach
Studies have reported improvement in treatment rates after a review of the patients by MDTs. A systematic review (2010) reported that MDTs implementation was associated with a change in practice patterns, that is, resulted in the increased receipt of surgery or radiotherapy or chemotherapy. In a study by Boxer et al. (2011), MDT resulted in the increased receipt of radiotherapy by NSCLC patients (with good performance status) through stage I to stage IV. Overall, MDT was an independent predictor of receiving chemotherapy, radiotherapy, and referral to palliative care, which can impact the QoL of lung cancer patients.
In a study by Keating et al. (2013), among the centers with more than one tumor board (n = 41), lung cancer specific-tumor board was in place at all centers. NSCLC patients at stage IIIA (who did not undergo resection) treated at centers with MDT received more chemotherapy and radiotherapy treatment as compared to those treated at centers with no MDT. However, the study also concluded that it is not sufficient to only measure the presence of tumor boards; understanding the structure and format of tumor boards that lead to the highest quality care is required.
Dickhoff et al. (2014) analyzed the outcomes for stage IIIA NSCLC patients in whom decision for treatment with trimodality (TT) and concurrent chemoradiotherapy (con-CRT) was taken by MDT in all patients. The study concluded that selected stage IIIA patients treated with TT have long-term survival, thus supporting the decision-making of MDTs. Ray et al. assessed the use of MDT and multimodality treatment in NSCLC in four hospitals and patients were stage stratified as I, II, III, and IV. It was found that patients managed by MDT received more active and multimodality care. Heterogeneity was noted in the pattern of care in different hospitals despite being under the same healthcare system. Further, it suggests that MDT Programs can improve access to care.
Another study from Japan reported the review of 202 patients by MDT comprising specialists from eight general hospitals connected via high-security communication lines. The discussion by MDT resulted in different diagnostic and treatment recommendations for 49 (four for diagnostic and 45 for treatment) out of 202 patients. Further, the study presented a case of one patient who benefited from this MDT approach rather than a single-institution tumor board. Such approaches provide a platform for extensive discussions, varied perspectives, and implementation of best treatment strategies for the patients.
MDT can facilitate a patient with locally advanced NSCLC with optimal therapy by timely evaluating/assessing the patient's treatment tolerance and encouraging them to report adverse events so that they can be provided supportive treatment. Details of the studies are presented in [Table 1].
Early treatment initiation
A study by Friedman et al. (2016) reported that patients managed via MDCs had a shorter time to initiate treatment (mean: 19.85 ± 13.8 days) as compared to patients managed via non-MDCs (mean: 29.09 ± 27.3 days; P = 0.043). In another study, time from diagnosis to first oncology assessment decreased from an average of 12.4 days to 3.9 days, and from diagnosis to first cancer treatment decreased from 39.5 to 15.0 days in lung cancer patients.
Several studies have evaluated the impact of MDT on survival outcomes in stage III NSCLC patients as shown in [Table 1].,,, A systematic review of 16 studies by Coory et al. (2008) found that MDTs affect changing patient management more than affecting patient survival. It concluded that although less evidence was found for association between survival and MDT in this systematic review, it does not mean that that MDT does not affect survival. It can be because the evidence currently available is limited. It further suggests conducting prospective studies to examine the effect of MDTs on lung cancer outcomes. Many more studies have been conducted since this review was published and have shown MDT involvement to be associated with higher survival rates. Significantly improved median survival rates after the introduction of MDT were also noted in another study that had NSCLC patients at stage III and IV (3.2 months vs. 6.6 months; P < 0.001). In a recent study by Stone et al. (2018) in Australia, MDT managed less than 25% of the patients (both NSCLC and SCLC). Stage-wise survival analyses showed that patient review by MDT was associated with higher survival at 1, 2, and 5 years except for patients with stage IIIB NSCLC at 1 year. Further details of the studies assessing outcomes are presented in [Table 1].
Treatment guidelines adherence
Several international guidelines have been developed that provide recommendations on the management of NSCLC patients at various stages., As the management of lung cancer patients by MDT is becoming a standard of care in many countries, studies have been conducted to assess if MDT adheres to treatment guidelines while making treatment decisions for the patients.
A study by Vinod et al. assessed if MTD followed treatment guidelines in lung cancer patients (NSCLC: 82%, SCLC: 14%, no pathologic diagnosis: 4%). Most of the NSCLC patients were at advanced stages (stage III: 36%, stage IV: 34%). The overall concordance of MDT to guidelines was reported to be high (surgery: 58%, chemotherapy: 77%, and radiotherapy: 88%). Non-adherence by the MDT to treatment guidelines was higher for stage III patients (n = 17; 47%) and the reason for the same was the physician's decision. The physician's decision for not adhering to the guideline was mainly due to older age and poor Eastern Cooperative Oncology Group (ECOG) performance status. Another study reported a significant increase in adherence to the National Comprehensive Cancer Network (NCCN) treatment guidelines in patients managed prior to and after multidisciplinary thoracic malignancy care conference (TMC; 81/97%; P < 0.0001). A recent study (2019) assessing the review of NSCLC patients at stage III by MDT reported that adherence to European Society for Medical Oncology (ESMO) guidelines was 90%. A recent study (2018) reported MTD to have high concordance with treatment recommendations, that is, 90% (which was above the target of 85%). Conron et al. in their study concluded that lung cancer patients managed by MDT receive timely diagnosis, staging, and treatment according to guideline recommendations. Swalduz et al. (2019) conducted an audit to assess the compliance to regional recommendations for molecular analyses and management of advanced lung cancer patients. The study found compliance to be approximately 75%, and the reasons for the non-compliance were no multidisciplinary meeting and type of institutions.
Table 1 presents the details of the studies assessing adherence of MDT to recommendations by international/national guidelines.
| » Quality of Care|| |
Literature focusing on the impact of MDT on QoL specifically in NSCLC cancer is not available. However, several RCTs have assessed the impact of using the MDT approach in advanced stages of cancers, including breast cancer, lung cancer, colorectal cancer, and neck and head cancer., A RCT showed a significant improvement in overall QoL (FACT-G scale) at week 4 among patients with advanced cancers (receiving radiotherapy) randomized to multidisciplinary intervention group compared to standard treatment group (74.2 vs. 68.7; P = 0.02). However, another RCT (2013) reported MDT intervention to improve QoL more in older patients as compared to younger patients with advanced-stage cancers during radiotherapy. The study results reported that older patients compared to younger adults had better overall QoL (Linear Analogue Self-Assessment; LASA: 74.4 vs. 62.9; P = 0.040), higher social well-being (Functional Assessment of Cancer Therapy – General; FACT-G: 91.1 vs. 83.3; P = 0.045), and fewer problems with anger (Profile of Mood States; POMS Anger-Hostility: 95.0 vs. 86.4, P = 0.028). Significant benefits for older patients occurred in the Anger-Hostility scale at week 27 (92.2 vs. 84.2, P = 0.027) and week 52 (96.3 vs. 85.9, P = 0.005). A previous study by Lapid et al. (2007) had also shown MDT intervention to benefit geriatric patients with advanced stages of cancer receiving radiotherapy. At week 4, overall QoL scores were higher in these patients compared to those on standard care (79.3 vs. 62.9, P = 0.0461).
An RCT by Rummans et al. (2006) reported QoL (assessed by Spitzer QoL Uniscale) to be 9 points higher in the intervention group compared to the control group (72.8 vs. 64.1, respectively; P-=-.047). Thus, the MDT approach appears to improve the QoL in cancer patients. Further studies with a large population size focusing on the impact of MDT specifically in NSCLC patients' needs to be conducted.
Challenges in implementation of MDT approach
Several clinical studies have shown the impact of MDT intervention on speeding up the diagnosis, improving treatment rates and approach, survival rates, and QoL; still, effective implementation of the MDT approach has been challenging.
A study by Jalil et al. (2013) reported that clinical decision-making by MDT is hindered due to lack of investigation results, inadequate clinical information, non-attendance of key members of MDT, and technological failures. Other barriers reported in the literature include the lack of administrative support, lack of funds, unavailability of enough and appropriate venue space, communication gap, record keeping, and lack of enough time to review due to high caseloads. A systematic review from Canada focusing on barriers to effective MDT care reported the lack of specialists in community hospitals to be one of the important barriers. Most of the above-discussed studies assessing barriers to MDT care implementation are more than a decade old. A recent study by Kedia et al. (2019) identified financial disincentives, co-location, and time constraints as major barriers to physicians' full participation in MDC. Other challenges were the maintenance of referral streams, integration of a multidisciplinary care model into the existing healthcare system, and designation of the physician primarily responsible for a patient's care.
| » Conclusion|| |
The diagnosis of NSCLC is a complex multistep process including investigations and diagnostic procedures required to establish the cancer diagnosis, lack of symptoms, multiple procedures, and specialist visits. This further delays the initiation of treatment in highly heterogeneous stage III NSCLC patients. The MDT approach provides timely evaluation, better treatment strategies, prolonged survival, and improved QoL in these patients. The selection of specialists for MDT is of utmost importance as this determines the quality of care received by the patients. Extensive research assessing the impact of MDT on QoL in stage III NSCLC patients needs to be conducted. Implementing MDT care in stage III NSCLC management might be demanding. However, the benefits of the MDT approach can outweigh the challenges and improve clinical outcomes in stage III NSCLC patients.
The authors would like to thank AstraZeneca Pharma India Ltd. for the development of this manuscript in collaboration with Turacoz Healthcare Solutions in accordance with the GPP3 guidelines (http://www. ismpp.org/gpp3).
Financial support and sponsorship
AstraZeneca Pharma India Ltd.
Conflicts of interest
Gagandeep Momi is an employee of AstraZeneca Pharma India Ltd.
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[Figure 1], [Figure 2]