(Chest. 2003;123:332S-337S.)
© 2003
American College of Chest Physicians
Practice Organization
W. Michael Alberts, MD, MBA, FCCP;
Gerold Bepler, MD;
Todd Hazelton, MD;
John C. Ruckdeschel, MD, FCCP and
James H. Williams, Jr, MD, FCCP
* From the H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL.
Correspondence to: W. Michael Alberts, MD, MBA, FCCP, Associate Center Director for Clinical Affairs, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr, Tampa, FL 33612; e-mail: alberts{at}moffitt.usf.edu
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Abstract
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The management of patients with suspected or known lung cancer is becoming increasingly complex. State-of-the-art care often requires input from many sources, including pulmonology, thoracic surgery, medical oncology, radiation oncology, pathology, and radiology. Valuable contributions to care also come from nursing, social work, psychology, psychiatry, pastoral care, and palliative care, among others. As a result, multidisciplinary input into care is vital. Patients with suspected lung cancer should be expeditiously evaluated and referred for management. Clear and understandable information on the diagnosis, treatment options, and possible outcomes should be provided. Treatment recommendations should be based on locally agreed-on adaptations of clinical practice guidelines. Provisions for ongoing care should be apparent to all concerned
Key Words: communication • coordinated care • multidisciplinary care • practice organization
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Introduction
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The management of patients with suspected or known lung cancer is becoming increasingly complex. State-of-the-art care often requires input from many sources, including pulmonology, thoracic surgery, medical oncology, radiation oncology, pathology, and radiology. Valuable contributions to care also come from nursing, social work, psychology, psychiatry, pastoral care, and palliative care, among others. As a result, multidisciplinary input into care is vital.
Patients with lung cancer may follow a variety of routes within the health-care system. Traditionally, consultation and management have been achieved with referrals to specialists occurring in a sequential fashion. This process may be slow, and delays are common. Numerous referrals to a variety of specialists may result in fragmented, poorly coordinated, and even inappropriate care, especially where treatment requires the coordination of multiple specialties. Establishing a seamless coordinated approach to the management of the patient with lung cancer is critical for state-of-the-art diagnosis, treatment, and care.
Recommendations on practice organization are infrequently included in lung cancer guidelines published by other organizations or groups.1
2
3
4
5
In general, these guidelines advocate for multidisciplinary care but cite the paucity of objective data.
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Multidisciplinary Approach
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Many groups have attempted to coordinate care through multidisciplinary management conferences and multidisciplinary clinics. In the latter, physicians from several specialties conduct clinics in the same location at the same time. In addition to streamlining the workup and treatment planning, multidisciplinary conferences and clinics provide a forum for collegial exchange of professional opinions. The team approach and consensus development enables the consulting physician to convey a clear and consistent management opinion to the patient.
The feasibility of multiple specialty evaluations is affected by many factors, including the availability of physicians with appropriate expertise and willingness to interact in this manner, referral patterns of the community of primary care physicians, and many economic factors. Economic factors often have broad impact, affecting motivation of patients, participating physicians, and referring physicians. Success has often depended on the support of third-party payers. Compensation for the time spent by multiple physicians in a single encounter may prove an obstacle in some settings. These issues need to be considered when forming multidisciplinary teams, as the durability of the program will often hinge on how effectively these issues are addressed and managed.
Although widely advocated, there is sparse objective evidence that a multidisciplinary approach to treating lung cancer is more effective than traditional care. There is evidence that patients referred to a respiratory specialist receive more expeditious and more appropriate care6
and that a fast-track system of diagnosis and staging can increase the proportion of patients reaching surgery.7
Studies of multidisciplinary breast cancer clinics have shown an increase in patient satisfaction and a shorter time from diagnosis to treatment.8
Nevertheless, a multidisciplinary team or clinic approach to the management of the patient with suspected or known lung cancer seems appropriate, where feasible.
Regardless of the presence or absence of a multispecialty clinic, all cancer units, treatment facilities, and centers should have a multidisciplinary lung cancer conference where new cases may be discussed in a prospective fashion. This conference should occur on a regular and continuing basis. The composition of the multidisciplinary thoracic oncology team will vary depending on availability and local interest but should, where possible, include representatives from pulmonology, thoracic surgery, medical oncology, radiation oncology, radiology, and pathology. A physician with expertise and an interest in palliative care would be a valuable asset to the team. A lead (or coordinating) clinician should be identified, and sufficient clerical support should be provided. Scheduled meeting times with adequate time allotted for all case presentations should be identified. This forum may serve to assist in the development of the initial treatment plan and in the design of adjuvant, second-line, and palliative care plans.
Medical economic forces vary between and within regions. While ideally these factors should not affect the care of patients with lung cancer, their impact needs to be considered. The perspective of primary care physicians and specialists in managed-care settings may differ and may therefore lead to varying use of resources. While the impact of these forces on the treatment of lung cancer is incompletely documented, there is no reason to assume the forces differ with this disease. Finally, personal and financial issues of the patient may affect their desire to seek intervention, including the costs of medical care, availability of family support, and the potential impact of a prolonged period of diminished capacity of the patient. However, awareness of these factors should not inhibit education of patients and their families regarding the potential options for diagnosis, treatment, and palliation.
Recommendations
- All cancer units, treatment facilities, and centers should have a multidisciplinary lung cancer conference that meets on a regular and continuing basis. Quality of evidence: poor; net benefit: substantial; strength of recommendation: C
- Multidisciplinary lung cancer teams should consider establishing a multispecialty lung cancer clinic. Quality of evidence: poor; net benefit: substantial; strength of recommendation: C
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Referral Pattern
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Patients with suspected lung cancer are often identified by their primary care physician. Patients should be expeditiously referred to a physician with experience in the management of lung cancer, often a pulmonologist or a thoracic surgeon. Either may be responsible for the diagnostic workup and the pretreatment functional assessment. If available, the patient may be referred to a multidisciplinary lung cancer clinic where new referrals are triaged to the most appropriate specialist for their initial evaluation and subsequent diagnostic and staging procedures.
Alternatively, the primary care physician may conduct the initial evaluation and, based on the results, refer the patient to the appropriate specialist. Patients with presumed stage I and stage II lung cancer may be referred directly to a thoracic surgeon. The management of a high-risk surgical candidate, however, may require the input of a pulmonologist, cardiologist, or other subspecialists. For patients considered to have stage III tumors where more than one treatment modality is usually considered, a multidisciplinary evaluation should be performed. This may be coordinated by the primary care physician, a pulmonologist, or by referral to a multidisciplinary lung cancer clinic. Should neoadjuvant chemotherapy and/or radiation therapy prove efficacious in patients with stage I and II, the indication for a multidisciplinary evaluation would significantly broaden. While other treatment modalities may be employed and other specialists consulted, patients with documented stage IV disease may be referred directly to a medical oncologist.
All patients should have equal access to lung cancer services regardless of age, gender, race, or socioeconomic status. While age predicts the presence of other medical conditions that may affect the management recommendation, age alone is not a reliable predictor of the success of interventions.9
However, effective multidisciplinary management must tailor diagnostic, therapeutic, and palliative approaches to accommodate the particular medical, social, moral, ethical, and economic issues of each patient.
Recommendations
- All patients with known or suspected lung cancer should be referred to a multidisciplinary team of physicians or a physician with experience in the management of lung cancer. Quality of evidence: poor; net benefit: substantial; strength of recommendation: C
- For patients in whom tissue diagnosis or staging remains incomplete, referral should be to a specialist with expertise in these areas. When completed, the choice of referral may vary with the interventions(s) proposed. Quality of evidence: poor; net benefit: moderate; strength of recommendation: C
- A multidisciplinary group is particularly valuable for management of patients who may be offered multimodality therapy. Quality of evidence: poor; net benefit: substantial; strength of recommendation: C
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Management Decisions
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Management decisions emanating from the multidisciplinary conference should be guided by locally agreed-on adaptations of clinical practice guidelines or other evidence. There is evidence that use of clinical practice guidelines modified to fit local practice patterns may improve both the process and the outcome of care.10
Documentation of recommendations made by the management team should be periodically reviewed for adherence and resultant patient outcomes. All patients should be evaluated as potential candidates for clinical trials, and enrollment should be encouraged. Ideally, these trials should include opportunities to evaluate the full range of approaches, including interventions with curative and palliative intent, as well as studies of comfort care near the end of life.
Management input from nursing, social work, psychology, and palliative care is advised. A functional and emotional assessment of the patient should guide the planning and implementation of nursing care. Nursing care should be viewed as collaborative within the wider care team and should focus on family-centered care.4
Locally agreed-on standards of nursing care, incorporating current research and best practices, should be implemented. There is good evidence that specialist nurses working as a part of a multidisciplinary team can improve patient outcomes in terms of relief of symptoms and time spent at home.4
Ideally, patients and family should have easy access to an appropriately trained specialist nurse throughout the illness.
A specific physician coordinator of care should be identified to the patient and his or her caregivers. This individual should serve as the point of first contact and the orchestrator of the diagnostic, staging, and treatment plan. In many cases, this may be the primary care physician who wants to remain involved in the whole diagnostic and treatment process. Alternatively, it may be the physician with the most contact with the patient during treatment.
Recommendations
- Management decisions emanating from the multidisciplinary conference should be guided by locally agreed-on adaptations of clinical practice guidelines or other evidence. Quality of evidence: fair; net benefit: substantial; strength of recommendation: B
- All patients should be evaluated as potential candidates for clinical trials, and enrollment should be encouraged. Quality of evidence: poor; net benefit: none/negative; strength of recommendation: I
- A specific coordinator of care should be identified to the patient and caregivers. Quality of evidence: poor; net benefit: substantial; strength of recommendation: C
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Timetable
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Although there is no direct evidence that accelerated diagnostic testing reduces mortality, individuals with known or suspected lung cancer and their families are understandably anxious. As a result, rapid evaluation, diagnosis, staging, and treatment planning is important, even if only for the management of psychological stress. Specialists and primary care physicians should collaborate to organize an intake process that produces minimal delays. Coordinated care, such as provided by multidisciplinary teams, should help to minimize delay in the delivery of care for every stage of the disease.
Guidelines developed by the British Thoracic Society recommend specific time frames for evaluation, diagnosis, and treatment.3
Although local situations vary greatly and timelines may need to be adapted to local standards, these recommendations may serve as a general guide. All patients should be seen for an initial evaluation within 1 week of referral by the primary care physician. Diagnostic tests should be performed within 2 weeks of the decision to undergo the test, and the results should be communicated to the patient as soon as they are available. Chemotherapy should be initiated within 7 working days of the decision to use a particular protocol. Radiation therapy should be initiated within 2 working days for urgent cases, within 4 weeks for radical treatment where complex treatment planning is needed, and within 2 weeks for palliative purposes. Surgery should occur within 4 to 8 weeks of referral to a management team and within 4 weeks of a surgical evaluation, or later if purposefully delayed for initial neoadjuvant therapy.
Recommendation
- For patients with suspected lung cancer, evaluation, diagnosis, and treatment planning should be expedited. Quality of evidence: fair; net benefit: substantial; strength of recommendation: B
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Communication
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Patients with lung cancer have reported a need to have clear information about their diagnosis, treatment, and possible outcomes.11
At every stage of treatment, patients and their families should be offered clear, full, and prompt information in both verbal and written form. Lack of information can increase anxiety, uncertainty, distress, and dissatisfaction.11
Communication should include information about the disease, diagnostic procedures, and the aims and likely effects of treatment (including potential adverse effects). Patients should be given a clear indication of the expected start date and duration of the course of treatment. All health professionals involved in the care of the patient should receive communication as to the clinical staging, what the patient has been told, and the proposed treatment plan. Information about available support groups and organizations should be made available to the patient and family. The patient should have access to written information, appropriate to his or her case, to supplement the verbal communication. Although some patients do not wish to take an active part in decision making, there is strong evidence that patients value accurate information and many feel that they are not provided sufficient information.12
Where additional testing or consultation is deemed necessary, this should be arranged as expeditiously as possible.
Communicating the diagnosis and the treatment should be undertaken with great care. Bad news may be best communicated in person by an individual with experience and training. If possible, the patient should be accompanied by a relative or friend. A quiet room is essential and the presence of a nurse for support both during and after the meeting is advisable. Telephone (followed by written documentation) or written communication with the primary care physician should occur within 2 days. It is essential that there are clear and efficient channels of communication within the lung cancer team and with the primary care physician, nurses, and other health-care professionals.1
Recommendations
- Patients with lung cancer should have clear understandable information about their diagnosis, treatment, and possible outcomes. Patients and their families should be offered clear, full, prompt, and culturally appropriate information, preferably in both verbal and written form. Quality of evidence: fair; net benefit: substantial; strength of recommendation: B
- All health professionals involved in the care of the patient should be aware of the management plan. This communication should include the clinical staging, what the patient has been told, and the proposed treatment plan. Quality of evidence: poor; net benefit: substantial; strength of rcommendation: C
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Ongoing Care
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Patients with lung cancer are rarely cured, and those treated with curative intent are at high risk for relapse or second primary lung cancers. As a result, continued follow-up by a physician or a team of physicians with expertise in lung cancer is vital (the reader is referred to the chapter "Follow-up and Surveillance of the Lung Cancer Patient" earlier in this issue). Explicit guidelines for follow-up and surveillance after the initial treatment should be developed. This plan should be appropriate to local needs and capabilities. Any new findings or developments may be presented for opinion at the multidisciplinary conference. It should be clear to the patient who will be supervising their ongoing care and surveillance. Patients should have clear instructions regarding who to contact for urgent problems.
It is the responsibility of the communicating physician to provide accurate information to the patient so that the patient and his or her family can be meaningfully involved in treatment decisions. The patient’s wishes should be sought and must be honored. It is the physician’s duty, however, to provide adequate and appropriate information on which the patient’s decision may be based. Where major decisions are to be made concerning a change in treatment, the decision should be made after verbal consultation with the primary care physician and the appropriate management team members, including the nurses.
Unfortunately, the majority of patients with lung cancer will ultimately succumb to their disease. As a result, access to ongoing care, including primarily palliative care, is vital. A system should be established to ensure that patients receive optimal symptom control, together with psychological, social, and piritual care throughout their illness.1
Such support should also be available to caregivers, both during the patient’s lifetime and during bereavement.5
Admission to the hospital, where appropriate, for symptom control should be expedited.
When death occurs, the primary care physician and all management team members should be advised within 1 working day. Likewise, the primary care physician should notify the team and all interested parties should the patient die at home. Bereavement information detailing the availability of support should be provided where appropriate.
Recommendations
- For all patients with lung cancer, explicit guidelines for follow-up and surveillance after the initial treatment should be developed. It should be clear to the patient who will be supervising their ongoing care and surveillance. Patients should be aware of who and how to access assistance for urgent problems. Quality of evidence: poor; net benefit: substantial; strength of recommendation: C
- For patients with lung cancer in whom death or a significant change in clinical status occurs, the primary care physician and all management team members should be advised. Likewise, the primary care physician should notify the management team and all interested parties if a change in clinical status of the patient should occur at home. Quality of evidence: poor; net benefit: substantial; strength of recommendation: C
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Conclusion
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State-of-the-art management of lung cancer usually requires input from and participation by a number of specialties and disciplines. Optimal care is therefore dependent on a coordinated series of events from identification of the patient with possible lung cancer, to diagnosis of malignancy, to evaluation for potential treatment options, to actual management, and finally to palliative care. Although objective proof is wanting, this coordination is conceptually best delivered in a multidisciplinary fashion, whether that be via joint conferences, virtual networks, or actual multidisciplinary clinics. The structure of this delivery system is dependent on local circumstances and capabilities but would nevertheless appear to be a laudable goal worth pursuing.
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Summary of Recommendations
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Multidisciplinary Approach
- All cancer units, treatment facilities, and centers should have a multidisciplinary lung cancer conference that meets on a regular and continuing basis. Quality of evidence: poor; net benefit: substantial; strength of recommendation: C
- Multidisciplinary lung cancer teams should consider establishing a multispecialty lung cancer clinic. Quality of evidence: poor; net benefit: substantial; strength of recommendation: C
Referral Pattern
- All patients with known or suspected lung cancer should be referred to a multidisciplinary team of physicians or a physician with experience in the management of lung cancer. Quality of evidence: poor; net benefit: substantial; strength of recommendation: C
- For patients in whom tissue diagnosis or staging remains incomplete, referral should be to a specialist with expertise in these areas. When completed, the choice of referral may vary with the interventions(s) proposed. Quality of evidence: poor; net benefit: moderate; strength of recommendation: C
- A multidisciplinary group is particularly valuable for management of patients who may be offered multimodality therapy. Quality of evidence: poor; net benefit: substantial; strength of recommendation: C
Management Decisions
- Management decisions emanating from the multidisciplinary conference should be guided by locally agreed-on adaptations of clinical practice guidelines or other evidence. Quality of evidence: fair; net benefit: substantial; strength of recommendation: B
- All patients should be evaluated as potential candidates for clinical trials and enrollment should be encouraged. Quality of evidence: poor; net benefit: none/negative; strength of recommendation: I
- A specific coordinator of care should be identified to the patient and caregivers. Quality of evidence: poor; net benefit: substantial; strength of recommendation: C
Timetable
- For patients with suspected lung cancer, evaluation, diagnosis, and treatment planning should be expedited. Quality of evidence: fair; net benefit: substantial; strength of recommendation: B
Communication
- Parients with lung cancer should have clear understandable information about their diagnosis, treatment, and possible outcomes. Patients and their families should be offered clear, full, prompt, and culturally appropriate information, preferably in both verbal and written form. Quality of evidence: fair; net benefit: substantial; strength of recommendation: B
- All health professionals involved in the care of the patient should be aware of the management plan. This communication should include the clinical staging, what the patient has been told, and the proposed treatment plan. Quality of evidence: poor; net benefit: substantial; strength of recommendation: C
Ongoing Care
- For all patients with lung cancer, explicit guidelines for follow-up and surveillance after the initial treatment should be developed. It should be clear to the patient who will be supervising their ongoing care and surveillance. Patients should be aware of who and how to access assistance for urgent problems. Quality of evidence: poor; net benefit: substantial; strength of recommendation: C
- For patients with lung cancer in whom death or a significant change in clinical status occurs, the primary care physician and all management team members should be advised. Likewise, the primary care physician should notify the management team and all interested parties if a change in clinical status of the patient should occur at home. Quality of evidence: poor; net benefit: substantial; strength of recommendation: C
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References
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- . The Royal College of Radiologists’ Clinical Oncology Information Network. (1999) Guidelines on the non-surgical management of lung cancer. Clin Oncol 11,S1-S53[CrossRef]
- Ginsberg, R, Roth, J, Fergusson, M Lung cancer surgical practice guidelines. Oncology 1997;11,889-895[Medline]
- British Thoracic Society.. BTS Recommendations to respiratory physicians for organising the care of patients with lung cancer. Thorax 1998;53(suppl1),S1-S8
- Scottish Cancer Therapy Network (SCTN)/Scottish Cancer Coordinating, and Advisory Committee (SCCAC).. Summary of draft guidelines on best current management for lung cancer 1996 Lung Cancer Focus Group Edinburgh, Scotland.
- National Health Service Guidance on Commissioning Cancer Services. Improving outcomes in lung cancer 1998 Department of Health London, UK. June
- Fergusson, RJ, Gregor, A, Dodds, R, et al Management of lung cancer in South East Scotland. Thorax 1996;51,569-745[Abstract/Free Full Text]
- Billing, JS, Wells, FC Delays in the diagnosis and surgical treatment of lung cancer. Thorax 1996;51,903-906[Abstract/Free Full Text]
- Gabel, M, Hilton, NE, Nathanson, SD Multidisciplinary breast cancer clinics: do they work? Cancer 1997;79,2380-2384[CrossRef][ISI][Medline]
- Massard, G, Muug, R, Wihlm, JM, et al Bronchogenic cancer in the elderly: operative risk and long term prognosis. Thorac Cardiovasc Surg 1996;44,40-45[ISI][Medline]
- Smith, TJ, Hillner, BE Ensuring quality cancer care by the use of clinical practice guidelines and critical pathways. J Clin Oncol 2001;19,2886-2897[Abstract/Free Full Text]
- Sell, L, Devlin, B, Bourke, SJ, et al Communicating the diagnosis of lung cancer. Respir Med 1993;87,61-63[CrossRef][ISI][Medline]
- Meredith, C, Symonds, P, Webster, L, et al Information needs of cancer patients in the West of Scotland: cross sectional survey of patient’s views. BMJ 1996;313,724-726[Abstract/Free Full Text]
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Abstract
Introduction
