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Collaboration and alliance: Those are two key concepts behind the multidisciplinary team (MDT) to fully manage patients with lung cancer. But what happens when collaboration gets curtailed and alliances get annulled? Researchers in Italy sought to answer that question with an interdisciplinary analysis with risk management activities in MDT for lung cancer.

"Barriers to MDTs include poor attendance, inadequate patient data, lack of technical support, unskilled leadership, and underprovision of administrative support," stated Alessandro Morabito, MD, of the Istituto Nazionale Tumori, IRCCS "Fondazione G. Pascale," in Napoli, Italy, and colleagues, in . "This study aims to highlight sources of harm that could negatively affect decision making or affect the planning process of the lung MDT at the National Cancer Institute in Naples."

The team pinpointed three main process-related risk factors -- outpatient specialist visit, MDT discussion, and MDT program implementation, with case discussion (MDT-D) being a standout. The researchers described MDT-D as "[e]xcessive number of cases discussed in one meeting and complex cases discussed at the end of the MDT meeting (decision fatigue)."

What control measure was used to mitigate that risk? "A checkbox has been placed in the patient information form to allow the case manager to distinguish clinical cases in routine [versus] complex, to prepare two different [patient lists], and to start the discussion with the complex cases," the researchers explained.

Ultimately, Morabito and colleagues found that the case discussion-control measure, and others, offered some reduction in MDT risk, mostly because they could be handled by "the MDT members themselves in a short time." However, other control measures were "beyond the control of the MDT and require a structured systemic approach with a prolonged implementation period ... in the multidisciplinary pathway of patients with lung cancer, vulnerability factors can compromise the outcome efficacy, influencing the MDT-D process or delaying implementation of the program."

In a presentation at the 2022 American Society for Radiation Oncology (ASTRO) annual meeting, Mara Antonoff, MD, of the University of Texas MD Anderson Cancer Center in Houston, discussed the importance of the MDT for patients with locally advanced lung cancer who are candidates for surgery.

How has the landscape for surgery in locally advanced lung cancer changed in recent years?

Antonoff: What I hope you get out of this [ASTRO] session ... [is an appreciation for] the importance of an [MDT] approach to the treatment planning for these patients with locally advanced disease.

I think ultimately that the end theme here really should be exemplified by the panel we've put together -- medical oncologists, radiation oncologists, and surgeons -- we really can emphasize the true importance of having all of our specialties at the table as we discuss managing patients with stage III disease.

For those of us who are surgeons, the landscape is certainly changing. Lobectomy was felt to be a standard of care for lung cancer, and we know effective options are expanding. And for those of you who work with surgeons, I think it's important for you to tell them this is not a threat; they still will be employed, and that, while some patients may no longer need operations, other patients may ultimately become surgical candidates, and the surgical cohort definitely has changed and it will keep changing.

How would you describe that changing surgical cohort?

Antonoff: This new surgical cohort does tend to consist of more advanced disease -- more patients that may have been thought, either in prior eras or other places, to be inoperable, and definitely include more frequent salvage procedures.

So the role for surgery -- let's think about those , recognizing that certainly a lot has changed in the last year. The important part that I want to point out ... is this idea that at the very beginning, when a patient has confirmed stage III NSCLC, there needs to be a multidisciplinary discussion or consult with the surgeon regarding whether the disease is resectable or unresectable. I'm going to argue that the way that [these ASCO guidelines are] written -- even though I was part of making these guidelines -- is that consult with a surgeon is probably not the best way to describe it.

Multidisciplinary discussion is really the key here. Everyone needs to be talking about it and having a seat at the table, and realizing what the advantages and disadvantages are going to be for every patient, and we all need to be familiar with the data.

How should a multidisciplinary team approach the idea of resectability?

Antonoff: So [which NSCLC patient] is resectable? That can be highly subjective with more frequent receipt of surgery at places of more experience. One thing that I would argue is that if you're in doubt, rather than assuming surgery is not a reasonable option, consider systemic therapy based on tumor markers and then reassess.

Most importantly, we have to communicate as a team at every stage of treatment planning, restaging, and reassessment, which ultimately gets me to my endpoint, that collaboration is crucial. All team members need to be involved, they need to know their patient, they need to know the data, they need to have a seat at the table in terms of every patient's care, but as well as in creating clinical trials and guidelines.

And the era where a surgeon can wait for surgical patients to be sent to them, operate on them, and send them back to someone else to take care of them is long since gone. I hope that all of my surgeon colleagues with whom you all interact on a regular basis really understand the importance of us all being familiar with the latest trials, and all of us understanding the outcomes of all these different novel therapeutic options, but also fully recognizing that going forward, all of our specialties are going to have a key component in operating on all patients regardless of the stage of disease.

This notion that stage I cancer was operated on by the surgeon, stage II and III required some multidisciplinary approach, stage IV was the medical oncologist's problem -- I think that's long gone. Every single one of us, regardless of our specialty, needs to have a strong role in patients stage I through IV, and I think that is something really incredibly evident as I look at where we're going with stage III disease.

What is the take-home message in terms of the MDT for this patient population?

Antonoff: Surgery for stage III lung cancer can be helpful in disease eradication as well as by providing highly valuable pathologic data. In the era of novel therapeutic agents, which patients are selected for surgery is highly subjective. The old dogmas are changing; there's enormous subjectivity, and operability needs to be determined by the surgeon in consideration of the skills and resources in that given system, with the option for external referrals if need be.

And most importantly, a multidisciplinary approach to treatment planning at all steps in the pathway is critical for locally advanced disease.

Read the study here.