|LETTER TO THE EDITOR
|Ahead of print
Initial experience with the development of a lung cancer tumor board in a tertiary cancer center
Leo Sneha1, Rajaram Manju1, Penumadu Prasanth2, Ganesan Prasanth3
1 Department of Pulmonary Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
2 Department of Surgical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
3 Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
|Date of Submission||20-Feb-2021|
|Date of Decision||03-Mar-2021|
|Date of Acceptance||12-Mar-2021|
|Date of Web Publication||29-Jun-2022|
Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry
Source of Support: None, Conflict of Interest: None
Lung cancer is the most common cancer among men and accounts for 11.6% (5.9% in India) of all new cancer cases and 18.4% (8.1% in India) of all cancer-related deaths among both sexes and all ages worldwide. In the past two decades, several new diagnostic and therapeutic options have emerged for lung cancer. In a multispecialty tertiary care hospital, patients with lung cancer may be seen by various departments depending on their presenting symptoms. Timely completion of the complex diagnostic process and appropriate referral of these patients to the “treating” department is crucial. Considering these, we initiated a weekly “Lung Cancer Clinic” (LCC) with a team consisting of pulmonologists, pathologists, radiologists, medical oncologists, surgical oncologists, radiation oncologists, and nuclear medicine specialists in our institute in 2019 [Figure 1]. When required, further investigations such as imaging, tissue diagnosis, driver mutation analysis, and others were planned during the discussion, and patients were reassessed in the clinic. In addition to coordinating the referral of patients, one of the key objectives of the clinic was to reduce the time required for a patient to transition through the system from presentation until the initiation of treatment.
To assess the impact of this multidisciplinary tumor board, we conducted an audit of the patients who attended the LCC (from March 2019 to February 2020) from a prospectively maintained database [Table 1]. The audit focused on assessing two performance parameters: time from presentation to hospital to initiation of treatment and the proportion of dropouts.
|Table 1: Baseline profile of patients who attended the lung cancer clinic|
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Among the 107 patients discussed, 92 were planned for treatment, whereas 15 were advised supportive care. Of the 92 patients, only 65 reported to the treating departments, and therapy was initiated. Of these, 45 patients received palliative chemotherapy (± palliative radiation therapy), and 20 were started on “curative-intent” treatment (concurrent chemoradiation, n = 5; neoadjuvant chemotherapy followed by surgery, n = 2; surgery followed by adjuvant chemotherapy, n = 3; surgery alone, n = 3; and chemotherapy alone, n = 7). The patients who received chemotherapy alone included those who had undergone surgery outside, those who had diagnoses such as lymphoma, or those who defaulted/progressed after starting initial chemotherapy.
The median time taken for a patient from initial presentation to the hospital to establishment of diagnosis was 22 days (range: 3–115 days) and from diagnosis to LCC discussion was 7.5 days (range: 1–64 days) and from discussion to treatment initiation was 12 days (range: 1–59 days). The overall time (median) from patient presentation to treatment initiation was 48 days (range: 10–150 days) among the treated patients. The maximum delay was during the evaluation phase. However, the time from diagnosis to treatment initiation was reasonable for patients attending the LCC. The other issue identified was the high dropout of 29.3%. These were patients who were given a treatment plan in the LCC but did not seek further treatment.
The fact that almost 15% of patients discussed in the LCC are unfit for any form of therapy points out the very poor general condition of these patients, which may be attributed to the delay in seeking medical attention. In India, there is a possibility of delay in the evaluation of respiratory symptoms due to the prevalence of common respiratory infections such as pulmonary tuberculosis. There is a need at the public health level to sensitize physicians to investigate and consider imaging studies for persistent respiratory symptoms.
Going forward, efforts would be directed to reduce the time to diagnosis in these patients by incorporating the following steps. First, the primary departments would be sensitized about the LCC and encouraged to make early references to LCC to facilitate this faster investigations. Even patients with “suspected” lung cancer could have an initial evaluation in the clinic to facilitate coordination between radiologists and pathologists for interventional diagnostic procedures.
The next step would be in reducing the dropouts, which is more challenging. Incorporating a social worker and possibly a psycho-oncologist could help assess the patient factors associated with dropout risk. Specific interventions by these professionals could help reduce the proportion of dropouts.
Setting up the LCC was challenging, requiring coordination and commitment from busy doctors from several departments and identifying an accepted meeting time. However, we believe that the process has helped many patients receive timely access to combined modality treatment models. Further studies will be required to understand its impact on survival rates. We also believe that continued work in this area would significantly improve lung cancer-specific services and foster teaching and research in this area. As a first step, we have proposed a prospective study to understand the impact of the LCC on reducing treatment times, and a structured counseling program is planned for these patients to reduce dropouts.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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