Lung Cancer Update, 2014

Ray U. OsarogiagbonDirector

Multidisciplinary Thoracic Oncology ProgramBaptist Cancer Center

12th Annual Mid-South Cancer Symposium. Intersection of Primary Care and Oncology.November 14, 2014.

Objectives

• The burden of lung cancer in the mid-South.• Improving outcomes

– early stage: the quest for cure– advanced stage: prolongation of good-quality life

• Update on PCORI-funded project.• Overcome nihilism about lung cancer.

US Lung Cancer Death Map

Flow of Care for Lung Cancer

Hyper-variation in Care

• Access to care.• Processes of care

– Diagnosis– Staging– Treatment selection– Treatment implementation

• Outcomes

Hazard Ratio for Death in pN0in relation to number of lymph nodes examined

Osarogiagbon, Ogbata, Yu. Ann Thorac Surg, Feb 2014.

‘All animals are equal, but some animals are more equal than others’’-George Orwell, ‘Animal Farm’.

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0 2 4 6 8 10 12 14 16 18 20 22 24 26Number of LN examined

95%CI Hazard ratioSmoothed line

Lung Cancer Specific Mortality

Who’s going to give you twenty nodes? Number of Lymph Nodes Examined in ‘Node Negative’ Lung Cancer Resections: SEER 1998-2009

Osarogiagbon and Yu. Ann Thorac Surg, Oct 2013

Detection of Discarded Intrapulmonary (N1) Lymph Nodes

Ramirez et al. J Clin Oncol 2012;30:2823-28

Driver Mutations in Lung Adenocarcinoma

Cheng L, et al. Modern Pathology, 2012;25:347

Oral Targeted Therapy v Chemotherapy Stage IV EGFR Mutation +

Rosell, Lancet Onc. 13:3; 2012

Response to Oral Targeted TherapyALK mutation +

Kwak, NEJM 363:1693; 2010

Flow of Care for Lung Cancer

Building a multidisciplinary bridge across the quality chasm in thoracic oncology

• Aim 1: Multi-stakeholder feedback.• Aim 2: Establish a benchmarked program• Aim 3: Comparative effectiveness study

Patient-Centered Outcomes Research Institute: Improving Healthcare SystemsGrant IH-1304-6147. Osarogiagbon: PI.

Q: Does the multid concept work in the ‘real-world’?

Patient and Caregiver Perceptions Multid Care

• Physician collaboration– ‘No one has all the answers. A team is a lot better than an

individual mind.’ – ‘After they explained everything, I didn't need a second

opinion and went right on with the treatment.’• Efficiency

– ‘…if I’m gonna take a day and take her to the doctor, I think she would feel better to see two or three doctors in one day than to have an appointment this week, and then next week somebody gotta take some time out of their schedule—‘

• Patient-physician communication– ‘I mean Dr…(multidisciplinary clinic) was very clear

about what to expect so that I didn’t have any scary, unpleasant surprises going forward.’

– ‘I never heard anybody that so carefully gave the odds in a way that was somehow reassuring

• Central point of contact – ‘With this, being able to walk into one place and

all your doctors are there. You don’t have to make appointments; you don’t have to chase ‘em down.’

Patients and Caregiver Perceptions Serial Care

• Patient-physician communication‘– Anyway, last year, I did my routine CAT scan, and he

called me on the phone and told me, "The cancer's back into both lungs. You have stage 4 lung cancer. You're gonna die in ten months."’

• Physician-physician communication– ‘Now, had my pulmonologist seen my result, he told me

later, he would've known that. However, my old oncologist also told me there was no reason for me to see my pulmonologist anymore. So he was out of the loop.’

• Inefficient use of time– ‘ “I need to see doctor so and so”, and they say, “Well, you

know, it’ll be a month,” ‘– ‘That was what, I think, bothered me the most because it

seemed like it took forever to get through all the testing before they did the actual surgery.’

– ‘We kept goin’ back for tests’ • Misdiagnosis and mistreatment

– See, I was told, when I was given that false diagnosis, and I said, “I don’t want chemo,”…It’s a good thing because I didn’t have cancer, and it could have done harm, really.’

– ‘The other (doctor) said that, “it was too small to do a biopsy.” A needle biopsy. He didn’t ever mention any other type of thing.’

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Physician Perceptions Benefits of Multid Care

• Patient-appreciation of physician collaboration on their cases• ‘It puts the patient at ease immediately to think that all

these eyes are gonna be looking at them.’• Second opinion, increased confidence in care• Help with complicated and late stage cases• Learning opportunity, professional development

Physician PerceptionsChallenges of Multid Care

• Time away from their own practices– ‘It’d be interesting, but I don’t have time for that.’

• Scheduling conflict– ‘I wanna be there, I plan to be there, and then you can’t.

It’s sort of the logistics of it.’

• Financial dis-incentives– ‘I mean we don’t get reimbursed. The reimbursement we

get is for operating. It’s hard to take another afternoon to go it in another clinic.’

• Disagreement with recommendations– ‘They may make a recommendation and you’re

thinking, “there is no way Mrs. Jones can handle this…that’s something that they have to figure out how to overcome.” ‘

• Overt and covert deep rooted beliefs about lung cancer – “Once you get lung cancer, does not matter what you do -

you are going to die anyway. It’s just a matter of time.”

• Skepticism about impact of multid care on long-term patient outcomes

Aim 2: Establish a rigorously benchmarked

multidisciplinary thoracic oncology program

• Quick, efficient, accurate triage into the treatment pathway most likely to provide the best possible outcome within the bounds of patient preference.

Aim 3: Prospective Matched Cohort Study of Multidisciplinary and Serial Care

• End-points– Timeliness of care– Stage-confirmation rates– Stage-appropriate treatment rates– Survey results

• Patients, caregivers, providers

– Survival

Patient Selection• Eligibility criteria:

– Untreated biopsy-proven lung cancer; AND– Diagnosed within 8 weeks

• Controls:– Matched* patients receiving care outside MDC– 2:1 match

* CT-stage; PS; insurance status; race; age range

Summary

• Early detection: screening is (almost) here; more tomorrow.

• Multidisciplinary decision-making– Timely diagnosis– Thorough staging– Optimal treatment selection

• Clinical trials: we are entering an age of light.• Overcome your innate nihilism.