The role of thoracic surgeons in guiding a multidisciplinary team (MDT) of healthcare providers is more critical than ever as they lead the way in the incorporation of breakthrough treatments and helping shape the future of patient care.
In this pivotal role, thoracic surgeons join patient care teams, which include medical oncologists, radiologists, pathologists, and pulmonologists, whose expertise is needed to discuss and manage complex cases. By collaborating closely with each other to determine the best treatment—such as surgery alone or combined with chemotherapy, immunotherapy, or targeted therapy as part of a neoadjuvant or adjuvant strategy— thoracic surgeons are considered leaders of MDTs because they ensure precise diagnosis, staging, and treatment decisions and are experts who move the needle forward with the latest research and therapies, resulting in the best options for patients.
We spoke with one of the leading experts in the field, Jessica Donington, MD, a thoracic surgeon at the University of Chicago, about the value of an integrated team approach to thoracic oncology care, the latest lung cancer therapies, rapid changes in non-small cell lung cancer (NSCLC), and the future of lung cancer care.
A Multidisciplinary Team Approach ─ The Gold Standard of Cancer Care
According to Dr. Donington, MDTs are essential to modern cancer care because they allow for more personalized treatment plans based on a patient's cancer type, stage, and genetics. With each physician focused on a different aspect of the patient’s health, MDTs are more likely to identify novel treatment needs and effectively manage those needs. This holistic approach to cancer care reassures patients that anything that can be done medically will be available to them.
“Multidisciplinary care is essential in thoracic oncology and will only become more critical as systemic therapies get more effective and less toxic, allowing for greater integration with surgery,” said Dr. Donington. “The overall age and comorbid conditions within the thoracic oncology population also make multidisciplinary care critical, since not all patients are ideal for aggressive treatment regimens or resection. Finding ways to safely combine multiple types of therapy will only get more common in the coming years.”
Advances in Early Detection and Treatment
Lung cancer cure rates have trailed behind other solid tumors for many decades due to several factors. Most patients are diagnosed with lung cancer in its final stages, when survival rates are low. Also, advances in treatment alternatives have lagged primarily due to poor funding for lung cancer research. “Lung cancer is a smoking-related malignancy, and this carries significant stigma that limits research funding,” Dr. Donington explained.
“While thoracic oncology had been quiet and without significant treatment evolution between the 1970s and early 2000s, we now are seeing rapid and exciting advances in lung cancer treatment,” noted Dr. Donington. “Antibody-drug conjugates are the newest agents being investigated by thoracic medical oncologists. For surgeons, the focus is on integrating targeted agents and immunotherapies into surgical populations.”
Cancer immunotherapies harness the body’s immune system to fight cancer by stripping away the shields that cancer cells use to evade the immune system. Targeted therapies focus on specific molecular alterations that exist within certain cancer cells. These two classes of medications are central to recent improvements in perioperative thoracic oncology care.
“These potent and highly selective therapies ushered personalized care into early-stage NSCLC care and have also improved outcomes in mesothelioma and esophageal cancer,” said Dr. Donington. “However, in all these disease states, the efficacy of the agents often depends on selecting the appropriate therapy for each patient.” "Care is no longer ‘one plan fits all,’" Dr. Donington added, underscoring the importance of a multidisciplinary team approach.
Researchers have also made significant strides in early detection CT screening for lung cancer. Screening was approved by the US Preventative Service Task Force in 2015, and work continues to increase both the reach and adherence of low-dose computed tomography screening.
There is also a lot of excitement in the field around the integration of circulating tumor markers in lung cancer, including the use of cell-free tumor DNA (cfDNA) — small fragments of DNA that circulate freely in the bloodstream and carry genetic information specific to the tumor — as a detection tool in early-stage disease. These circulating tumor DNA fragments can be detected and analyzed, providing valuable insights into tumors' presence, characteristics, and behavior.
Applications of cfDNA in early-stage lung cancer include using it to help detect minimal residual disease after treatment, monitoring recurrence, and identifying targetable mutations. "The technology needs to be more sensitive for it to be effective in everyday use in patients with early-stage lung cancer, but it is not far away," explained Dr. Donington.
Addressing Uncertainties
- Screening and the steady stage shift in NSCLC, where more patients will eventually be diagnosed with early rather than late-stage disease.
- The integration of novel agents is better controlling and eliminating micro-metastatic disease, which allows patients to live longer and increases the importance of definitive control of their local disease through resection.
As new therapies and innovative treatments increase in surgical care for lung cancer, so do risks and uncertainty. When working as part of an MDT, the different disciplines can share their knowledge and insights to better address a patient's multifaceted symptoms, evaluate new treatment options, and reduce risk and medical errors.
“As the head of the multidisciplinary team, thoracic surgeons should address uncertainties about a patient’s treatment or the potential of a negative outcome with the realization that uncertain outcomes are always part of making advances in the field,” noted Dr. Donington. “As team leaders, we must embrace that discomfort to help move the science forward.”
There is uncertainty the first time one tries a new treatment regime or surgical technique, but this is an essential part of evolution. “It’s impossible to advance the field without taking some challenging steps,” acknowledged Dr. Donington. “I do my best to acknowledge the discomfort and keep moving, remembering that this is how we advance.”
Looking Ahead
Artificial intelligence and natural language processing soon will help thoracic surgeons better detect and diagnose lung cancers from screening CT scans and scans performed for other reasons. As targeted therapies and cancer immunotherapies improve, they will be integrated into the care of earlier-stage patients. Eventually, the hope is that treatment will resemble that associated with other solid tumors, where most patients with invasive cancers receive some systemic therapy to help prevent recurrence after resection.
The outlook for patients is better than ever, and MDTs continue to push science forward and work to integrate recent advances into everyday care. "Patients must understand recent lung cancer care advancements, and it's our job as thoracic surgeons to educate them," said Dr. Donington. Within a landscape of new therapies and technologies that can potentially improve lung cancer patient outcomes, Dr. Donington noted that "It is a great time to be in thoracic surgical oncology. There are so many advances happening at once."