Developing an Effective Lung Cancer Program in a Community Hospital Setting

original contribution Developing an Effective Lung Cancer Program in a Community Hospital Setting Richard J. Fischel, Robert O. Dillman Abstract Lung cancer remains the number one cause of cancer-based mortality in men and women. The importance of proper lung cancer care outside of major academic centers cannot be overemphasized because the vast majority of lung cancer care occurs in community hospital settings. We have had the opportunity to develop a highly successful community hospital–based lung cancer program. Utilizing a multidisciplinary approach, we have achieved steadily improving survival rates that are much higher than those observed nationally for patients diagnosed with lung cancer. Key components of this successful program include: (1) a weekly multidisciplinary lung cancer case conference with medical doctor representatives from medical oncology, thoracic surgery, pulmonary medicine, radiology, radiation oncology, and nuclear medicine who discuss patient presentation, test results, treatment history, and plans for therapy; (2) thoracic surgeons skilled in minimally invasive video-assisted thoracoscopic surgery; (3) nurse navigator/coordinators to help patients through the process from detection to recovery and provide a personal bond that greatly improves patient satisfaction; (4) utilization of treatment guidelines for patient-specific treatment strategies; (5) formal continuing medical education; (6) an emphasis on early detection that includes consideration of computed tomography screening of former smokers; (6) a cancer center that allows for many services to be offered at a single location for patient convenience and to promote interdisciplinary care; and (7) access to research protocols. These components have helped us provide a quality lung cancer program in a community hospital setting that is associated with excellent clinical outcomes. Clinical Lung Cancer, Vol. 10, No. 4, 239-243, 2009; DOI: 10.3816/CLC.2009.n.032 Keywords: Computed tomography, Lobectomy, Multidisciplinary, Thoracotomy, Video-assisted thoracoscopic surgery

Introduction Approximately 85% of all lung cancer care in the United States is provided in the community hospital setting.1 In light of the potential high morbidity and mortality associated with lung cancer care, it is imperative that these community-based programs practice in the most effective and efficient manner possible. Even a small increase in cancer-specific survival translates into the potential saving of thousands of lives. For many years we have been involved in community hospital lung cancer care and have endeavored to build and modify the program based on best care practices. This has been associated with striking improvements in lung cancer survival. This Presented in part at the Ninth International Lung Cancer Congress, June 18-21, 2008; Koloa, HI Hoag Cancer Center and Hoag Memorial Hospital, Newport Beach, California Submitted: Sep 12, 2008; Revised: Dec 11, 2008; Accepted: Dec 16, 2008 Address for correspondence: Richard J. Fischel, MD, PhD, Medical Director Thoracic Oncology Hoag Hospital, Hoag Memorial Hospital Presbyterian, Thoracic Surgery, 500 Superior Ave, Ste 305, Newport Beach, CA 92663 Fax: 974-764-8165; e-mail: [email protected]

article summarizes several of the key components for a quality multidisciplinary program in a community hospital setting.

Multidisciplinary Lung Cancer Care Although it is often an overused as a “buzzword,” a truly multidisciplinary approach to lung cancer care is critical to the success of a lung cancer program. A weekly meeting to discuss clinical cases of known or potential lung cancer is attended by a multitude of professionals in order to share knowledge and information regarding possible approaches to care. Meetings are attended by oncologists, thoracic surgeons, pulmonologists, radiologists, pathologists, radiation oncologists, lung cancer nurse navigators, and research personnel. Intense interaction often results with each specialty helping to educate the other attendees regarding specific information or insight from their unique point of view. This interaction often results in clarification of a treatment plan or allows the treating physician to discuss an array of options with the patient after having obtained other specialty-specific information such as lesion resectability, appropriateness for radiation, and amenability to minimally invasive techniques, etc. Often the discussion leads to the discovery of new

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Developing a Lung Cancer Program observations such as identification of a second or growing lesion, or recognition of a pathologic peculiarity that might affect the treatment plan. An additional unique benefit of the multidisciplinary lung conference is the ability to offer other medical doctors in the community the opportunity to present or have their patients presented at the conference, in essence, providing multiple free second opinions. Most physicians and patients truly appreciate the real and perceived benefit of such a presentation. In our experience, when patients are informed that their case will be presented in this forum, they express appreciation and gratitude knowing that a team will be helping to direct their therapy. The educational aspects of such conferences, and the management considerations for individual patients, may contribute to a higher survival rate. For example, gaining acceptance for adding chemotherapy to radiation therapy for the treatment of regionally advanced non–small-cell lung cancer was associated with improved outcomes because of a multidisciplinary approach.2,3 We previously reported that the opening of the Hoag Cancer Center in 1991 was associated with improved 5-year relative survival for lung cancer from 20% to 24% for the eras immediately preceding and following the opening (1986-1991 vs. 1992-1999).4 In a more recent analysis, we discovered that relative lung cancer survival rates were 15% for patients diagnosed during the 6-year period 1983-1988 (before initiating multidisciplinary case conferences in 1989), improved to 22% for patients diagnosed with lung cancer during 1989-1995 (before initiating weekly lung cancer–specific case conferences in late 1996), and further improved to 28% for patients diagnosed during 1996-2002.

Guidelines and Education One of the first things that becomes evident after bringing together all of the practitioners involved in treating lung cancer is the variety of treatment methods being used for each stage of cancer. While some or most practioners are up to date and rational in their decision making, others are not. In order to present a unified front as a program it is essential to educate all community physicians associated with the program regarding the latest advances in diagnosis and management. Existing guidelines for the treatment of lung cancer are broken down by stage in a fashion that is easy to follow. The National Comprehensive Cancer Network guidelines for lung cancer care are an evidence-based set of guidelines that can easily be used by a lung cancer treatment group.5 Of course it is important to realize that each case must be individualized to fit the patients’ wishes and performance status. The guidelines provide a consistent backbone or starting point for therapy planning. As new data, techniques, and procedures become available, the group is able to integrate these into the already established guidelines based on recent literature and personal knowledge. We have found that establishing a journal club to review papers on subjects related to lung cancer care is a great way to update all involved, bring in outside doctors who may not have time to attend the weekly meetings, and to build camaraderie among the team members. Educating the local physicians and physician extender population is critical to providing good lung cancer care in a community set-

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ting, especially in developing a center of excellence for lung cancer care. Many doctors only see one or two lung cancers or suspicious lesions per year in their practice, but rapid referral is crucial for diagnosis and aggressive management of lung cancer at a time when treatment can be most beneficial. The attitude that lung cancer is a death sentence no matter what is a belief that should be challenged at every opportunity with education. We have found that setting up lunches or office visits with internists and family practice physicians provides an opportunity to make them aware of the components of our lung cancer program, the potential benefits of early detection, the use of guidelines for optimal cancer care, and the availability of the multidisciplinary lung case conferences to which they are invited. Most truly appreciate the opportunity to become involved or at least to have an informed group available to review what may be a puzzling or difficult case. We also have developed a system in which physicians associated with the lung cancer team agree to see newly diagnosed lung cancer patients within 48 hours of referral. This greatly decreases the dissatisfaction and anxiety associated with lengthy intervals between diagnosis and intervention. Referring physicians are kept in the loop at all times and are assured that their patient will continue to be seen by them, both during and following the completion of therapy. Nurse coordinators help assure the continued involvement of primary doctors. We have found that such efforts greatly increase overall satisfaction with the program, and assure continuing referral of such patients. The weekly meetings also provide an excellent opportunity for invited speakers or members of the team to present information and/or data related to lung cancer care. In particular, institutional updates on survival rates, technological innovations, and positive community interaction or feedback keep the team members fresh and optimistic that what they are doing truly matters.

Thoracic Surgery Although not every hospital has a board-certified thoracic surgeon, the data suggest that centers specializing in lung cancer care should have such personnel on their teams. As shown in Figure 1, studies have shown that thoracic surgeons achieve significantly better 5-year survival rates compared with general surgeons performing over 10 lobectomies per year.6 Furthermore, procedural mortality was lower when surgery was performed by a thoracic surgeon especially for cases associated with extreme comorbidity. We feel it is crucial to have thoracic surgeons who are well-trained in minimally invasive techniques such as video-assisted thoracoscopic surgery (VATS) lobectomy. Numerous studies have demonstrated the advantages, or absence of inferiority, of such an approach. Comparative studies have shown that, compared with lobectomy by open thoracotomy, VATS is associated with decreased postoperative pain and shortened length of stay,7,8 which in some studies translated into reduced cost9; reduced release of inflammatory cytokines10; identification of similar numbers of lymph nodes, including mediastinal lymph nodes11; lower rates of postoperative infection and other morbidity, especially in the elderly and frail12,13; and similar survival rates for low-risk stage T1 N0 M0 patients.14 As shown in Figure 2, in one comparative study in elderly patients, patients undergoing a VATS lobectomy had a much better survival than those undergoing open thoracotomy.15 In addition, more patients

Richard J. Fischel, Robert O. Dillman Figure 1 Comparisons of Outcomes for Patients Undergoing Lung Cancer Surgery by Thoracic Surgeons or General Surgeons During 1991-1995 in South Carolina

Figure 2 Survival of Patients with Stage I Lung Cancer: Comparison of Cohorts Undergoing Lobectomy by VATS Compared with Open Thoracotomy

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Study in Brief • Retrospective analysis • 1583 patients who received lung cancer resection: - Between 1991 and 1995 in South Carolina - 773 treated by board-certified thoracic or cardiac surgeons - 810 treated by board-certified general surgeons

Reproduced with permission from Silvestri et al. Chest 1998; 114:675-80.6

are able to function independently following discharge after a VATS procedure than with open thoracotomy. There are now a number of training programs available where surgeons can train in the VATS procedures; therefore, increasing availability of surgeons who are facile with this approach will be critical to a program’s success.

Early Detection of Lung Cancer For many years we have encouraged consideration of radiographic screening for lung cancer in former smokers because of early evidence that cure rates were highest in patients in whom lung cancer was an incidental finding.16 We currently offer a

Abbreviation: VATS = video-assisted thorascopic surgery Reproduced with permission from Kaseda et al. Ann Thorac Surg 2000; 70:1644-6.15

low-radiation-dose high-resolution thin-cut computed tomography scan of the chest to patients who wish to be evaluated for lung cancer, whether they are symptomatic or not. Lung cancer screening for the general population and heavy smokers remains controversial and is the subject of ongoing studies. The major arguments against screening include the low incidence in low-risk patients; the lack of specificity of the procedure, which necessitates more scans and/or invasive biopsies; and the lack of evidence that early diagnosis in active smokers can yield an improvement of survival. In a program where expertise exists in bronchoscopic needle biopsy and minimally invasive surgical techniques, we have not seen an increased death rate or morbidity rate in asymptomatic patients with benign disease. In addition, a significant number of patients with asymptomatic early lung cancers have been detected and treated with a chance for cure utilizing resection of stage I diseases.17 In our program with an emphasis on smoking cessation and on early detection, especially in former smokers, we have seen a dramatic increase in the proportion of patients with local disease at diagnosis, and especially compared with national data (Table 1). During 1996-2003, the proportion of patients with localized disease at diagnosis increased to 25% compared with 21% for 19891995, despite more sensitive tests for distant metastatic disease and more thorough evaluation of lymph nodes in the most recent era. In addition, an early detection program functions as an entry point for patients into the institution, and often leads to further testing or referral to physicians in the program.

Participation in Research and Clinical Trials The best academic programs in the country function at the highest level for a number of reasons. While exceptional facilities and staff are important, most often their reputation is built on research and involvement in clinical scientific trials. Because the majority of patients with lung cancer are never seen at major academic centers, it is imperative that community lung cancer programs become

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Amid the confusion and angst associated with a diagnosis of lung cancer, individuals are expected to make appointments, understand medical jargon, and deal with an uncertain future. Navigating the traditional care process has become increasingly complicated, making it difficult to coordinate care among multiple specialties in different locations. We have found that a clinical nurse navigator is an invaluable asset to our lung cancer program.20 The nurse coordinator helps the patient make the connections needed with diagnostic services, primary care physicians, surgeons, oncologists, radiation oncologists, and social workers. They help deal with patient’s needs, including the need for a rapid work-up, assistance with provider selection, assistance with treatment selection, assistance resolving specialist disagreements, ongoing education, psychosocial services, and symptom management. The nurse coordinators bring the benefits of a multidisciplinary program to patients. While responsibilities vary, all care coordinators provide patient education and serve as an ongoing resource for patients during a period of significant anxiety. Nurse coordinators often function as the glue that holds a multidisciplinary program together, resulting in increased patient and physician satisfaction, decreased time to diagnosis and treatment, and significant overall quality improvement. The nurse coordinator is also responsible for organizing the weekly prospective multidisciplinary treatment and planning conferences that are so critical to the program’s success.

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involved in clinical trials. This not only helps to accrue patients to trials critical to improving lung cancer care but also provides tissue for future study of proteomic- or genomic-based therapies. In addition, it allows a program to offer patients the latest up-todate and often otherwise unavailable opportunities for care. Active participation in trials obviates the need for local patients to travel afar to find investigational studies, enhances the programs visibility and reputation, and allows the institution to become a part of the larger worldwide research community with access to investigational agents and opportunities to publish and present data. To date, we have participated most enthusiastically in nonrandomized trials that provided access to unique agents and take advantage of our institutional cell biology laboratory,18,19 but we are endeavoring to broaden participation in clinical trials.

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Figure 3 Relative 5-Year Survival Rates for Patients Diagnosed with Lung Cancer

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Table 1 Comparison of Patients Diagnosed with Lung Cancer During 1996-2003 and Accessioned to the Hoag Cancer Center Tumor Registry (n = 1627) Compared with National Data from SEER (n = 209,212)

Comparisons of Hoag Cancer Center and SEER data for various time periods for which published SEER data are available. Steady improvement since 1988 is shown. Abbreviation: SEER = Surveillance, Epidemiology and End Results

The Cancer Center The cancer center itself functions as a symbol to the community and patients that the hospital and staff care deeply about providing excellent comprehensive care in a calming, efficient, modern and convenient environment. The cancer center facility includes an outpatient infusion center and radiation therapy. It is a convenient place for patient education and support groups. It is also the home base for clinical research efforts. Many community and physician education events and all tumor board conferences occur at the cancer center. A cancer center is an ideal location for patient-centered, one-stop shopping for cancer patients. This enables true interdisciplinary care rather than fragmented multidisciplinary care. Such an approach, if possible, greatly simplifies the coordination of care for patients with lung cancer, which increases patient satisfaction.

Outcomes Studies show that high volume is often associated with higherquality care from increased experience. Lung cancer is one of the most common cancers treated at Hoag Hospital, with 150-270 cases treated per year since 1990. Hoag physicians have consistently provided care to the largest number of newly diagnosed lung cancer patients compared with other hospitals in Orange County. The population of patients over 80 years of age has consistently increased as has the overall percentage of female lung cancer patients, currently at 54.6% of the total. There has been a consistent migration toward earlier stage at detection, which has been associated with increased rates of surgical resection and steadily improving survival rates. As awareness of the importance of proper staging has increased, thorough lymph node dissection has become a standard component of all lung cancer surgery. There is an increasing emphasis on minimally invasive surgical procedures whenever possible. Radiation therapy continues to improve enabling delivery of higher cGy doses more precisely. The systemic therapy armamentarium has been greatly expanded with a wider choice of chemotherapy and biologic agents. Adjuvant chemotherapy has become standard for surgically resected stage II and III disease. When compared

Richard J. Fischel, Robert O. Dillman with the most recent national Surveillance Epidemiology and End Results (SEER) data, patients at Hoag had better survival for every stage and a greater percentage of patients detected with early-stage disease (Table 1). Our overall lung cancer survival rates have improved steadily in contrast to the relatively flat curve for the SEER data (Figure 3). We feel that our improved patient survival rates and higher rate of early-stage disease are due, at least in part, to the diagnosis and treatment of a large number of lung cancer cases in a coordinated, comprehensive, multidisciplinary program.

Disclosures Dr. Fischel has no relevant conflicts of interest to report. Dr. Dillman has received research support from Biogen Idec, Bristol-Myers Squibb Company, CancerVax, Favrille, NovaRx, and SuperGen; has served as a consultant or been on the advisory board of Amgen, Arius, and Onyx Pharmaceuticals, Inc.; and has served on a speaker's bureau for Biogen Idec, Chiron, Genentech, Inc., sanofi-aventis U.S., and SuperGen.

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