Going Above and Beyond Standard of Care for Thoracic Cancers
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When patients have thoracic cancer, access to multidisciplinary care and the most advanced surgical and non-surgical treatments can mean the difference between life and death. The University of Maryland Cancer Network, led by NCI-designated University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center (UM GCCC), provides access to nationally renowned experts and some of the most cutting- edge treatments, technologies and clinical trials available for thoracic cancer.
Multidisciplinary Tumor Boards for Comprehensive Care
UM Cancer Network oncologists take a multidisciplinary approach to determining diagnosis and course of treatment for thoracic conditions. "We need to be careful to allocate patients into the right therapy. To do this, we need multidisciplinary experts that are able to interpret all of the information available to us,"says Christian Rolfo, MD, PhD, MBA, the director of the Thoracic Medical Oncology and the Early Clinical Trials at UM GCCC and professor in the Division of Hematology-Oncology at University of Maryland School of Medicine (UMSOM).
To determine the best care plan possible, patients are evaluated by a tumor board of thoracic experts -- including pulmonologists, surgical oncologists, medical oncologists, radiation oncologists, molecular biologists, geneticists, pathologists and radiologists. These tumor boards analyze all of the clinical and radiological findings available to determine the best course of treatment. This multidisciplinary approach produced oncological outcomes that have been published in high-impact medical journals.
If the patient's tumor qualifies for molecular analysis, the case may be brought before a molecular tumor board for an additional layer of evaluation.
"The molecular tumor board performs an analysis of the liquid or tissue biopsy results and allocates patients to the best treatment options," Rolfo explains.
The thoracic experts across the UM Cancer Network offer referring physicians a multidisciplinary perspective, while ensuring that the patient receives care locally when possible. In fact, referring physicians seeking a second opinion can participate on these tumor boards and present their own case for a particular course of treatment. "We wish to serve as an academic partner and supporting party. We are in the position to collaborate," says Rolfo.
Lung-Sparing Surgery for Pleural Cancers
Seeking a second opinion becomes even more important when encountering a patient who has a rare or aggressive cancer -- like mesothelioma.
"We are a true center of excellence for this orphan disease, of which there are only very few in the country," says Joseph Friedberg, MD, the Charles Reid Edwards Professor of Surgery and Chief of the Division of Thoracic Surgery at UM SOM, and thoracic surgeon-in-chief for the University of Maryland Medical System.
Friedberg pioneered a lung-sparing surgery technique that was shown to prolong survival for mesothelioma patients in a 2016 study. Surgery is not currently considered standard of care for mesothelioma, but when incorporated into a treatment plan, the surgeon typically removes entire lung and pleura from the chest cavity.
The standard of care for mesothelioma, developed in 2003, combines the chemotherapy drugs pemetrexed with cisplatin or carboplatin.
"The response rate to standard-care chemotherapy is only 44 percent. This is arguably one of the worst, most virulent cancers known to man," says Friedberg. The numbers confirm Friedberg's assertion. Only 19 percent of patients live an additional two years after chemotherapy treatment, and only 4 percent lived an additional five years.
However, the combination of treatments applied in the 2016 study – including Friedberg's lung-sparing surgery technique – produced impressive results. The median survival rate for study participants was almost three years, with a small subset of participants living more than seven years.
The lung isn't sacrificed during the procedure, improving quality of life.
"We try to save as much of the normal structure as possible to preserve the patient's physiological function, breathing capacity and comfort," says Friedberg.
Friedberg's technique can be utilized in care plans for other cancers as well. If a cancer has spread to the pleura but has not yet penetrated the lung tissue, the thoracic team may recommend the patient as a candidate for lung-sparing surgery. In certain instances, the surgery is also recommended for thymic cancers.
Robotic Surgery for Faster Recovery
For certain stages of many thoracic cancers, a traditional thoracotomy is part of the standard treatment plan. During a thoracotomy, surgeons spread the ribs and make a large incision to access the thoracic cavity. Robotic surgery offers a minimally invasive alternative to this method.
The robotic method begins with only a few small centimeter-size incisions. The surgeon, operating from a console, can see tissues and blood vessels at a magnified size. Due to the increased visibility and precision, robotic surgery results in less blood loss overall.
Some studies have also suggested that robotic surgery results in a greater number of dissected lymph nodes, potentially yielding more accurate staging diagnoses.
"I had a surgery patient where I got about 45 lymph nodes. Only one of those 45 was positive for metastases. That changed how we treated her. She got chemotherapy after her surgery. If I had only gotten 10 lymph nodes, I might not have found that one," says Shelby J. Stewart, MD, assistant professor of surgery at UMSOM and board-certified thoracic surgeon at UMMC and UM St. Joseph Medical Center (UM SJMC).
Robotic surgery lessens tissue trauma and doesn't require rib spreading, which often decreases the pain patients experience during post-operative care.
"You don't splint when you try to breathe. You can take nice big breaths, you can cough and ambulate. It may decrease your likelihood of getting pneumonia," says Stewart.
Postoperative ambulation becomes possible sooner, which is particularly beneficial for older patients.
"Much of our elderly population is already deconditioned. To have surgery on top of that only drains their reserves further," says Stewart.
Overall, this minimally invasive method decreases the length of time patients spend at the hospital.
"If you've had your lung resected robotically, you could potentially go home on post-operative day two or three. For a thoracotomy, patients usually spend about four to five days in the hospital," says Stewart. This makes the surgery especially appealing for patients who are eager to return to daily activities.
Robotic surgery has many uses, but the thoracic team may consider robotic surgery for a number of patients, including those with early-stage lung cancers, early-stage esophageal cancers, and surgeries for elderly patients.
Robotic surgery can be especially helpful when considering trimodality therapy, either in the form of induction chemotherapy followed by surgery/radiation or induction chemoradiotherapy followed by surgery. In the latter option, patients undergo high-dose radiation therapy and chemotherapy, followed by surgical evaluation. In these treatments, surgical and post-operative care teams work closely with radiation and medical oncologists to ensure the best results. This is especially important for patients with stage III disease, who typically experience only local failure, which surgical resection can help salvage before recurrence develops.
Proton Therapy for Precise Treatment
The UM Cancer Network offers many cutting edge treatments for thoracic cancer, but proton therapy is unique in the region.
Proton therapy is available at fewer than 25 centers nationwide, with the Maryland Proton Treatment Center (MPTC) offering the East Coast's only fully integrated system of image-guided proton therapy (IGPT) and intensity-modulated proton therapy (IMPT).
"This ensures increased precision and helps reduce the risk of side effects to surrounding tissues by limiting the radiation to the target area," says Pranshu Mohindra, MD, MBBS, DABR, assistant professor of radiation oncology at UMSOM and radiation oncologist at UMMC.
According to a 2017 report, proton therapy was found to produce a 38 percent improvement in overall survival at five years compared to traditional X-ray therapy. This is only one of many reports supporting the effectiveness of proton therapy for thoracic cancers.
When patients are approved for proton therapy, many continue to receive chemotherapy and other treatments at their local institutions.
"We maintain extensive one-on-one contact with the treating physician at the patient's local center -- either through email or phone, to ensure continuity of care," says Mohindra.
Though the treatment is utilized for a variety of cancers, it can be particularly attractive for those with non-small cell and small cell lung cancer, thymoma/thymic carcinoma, mesothelioma, thoracic sarcomas and cardiac tumors. Proton therapy can also help thoracic patients with recurrent disease, especially for those who have already had radiation therapy in the chest. In-house and multi-institutional clinical trials utilizing proton therapy for thoracic cancers are also offered.
Going Above and Beyond
The ultimate goal of evaluating patients from a multidisciplinary, academic perspective is to provide the best possible care methods available. Rather than settling on standard-of-care, the UM Cancer Network is dedicated to partnering with referring physicians to find innovative treatments and approaches that best suit the individual patient.
Refer a patient for one of these innovative treatments.