A behind-the-scenes look at cancer care: Medical providers pool their expertise as they tackle tough cases

Jason Wallen, MD (right) is medical director of Upstate's Thoracic Oncology Program. Members of the team meet each week to review cases. (PHOTO BY SUSAN KAHN)

Jason Wallen, MD (right) is medical director of Upstate’s Thoracic Oncology Program. Members of the team meet each week to review cases. (PHOTO BY SUSAN KAHN)

BY AMBER SMITH

Just before 2 p.m. every Wednesday, 18 men and women, most wearing white coats, take seats around a conference table in the Upstate Cancer Center.

Some carry water bottles, others tote laptop computers. There’s no chitchat or daydreaming. This is a meeting with an important purpose.

This is where Upstate’s medical experts gather to discuss patients with the most confounding cancers of the lungs, chest or esophagus.

Santiago Miro, MD, discusses a case with the team. (PHOTO BY SUSAN KAHN)

Santiago Miro, MD, discusses a case with the team. (PHOTO BY SUSAN KAHN)

It’s called the TOP Multidisciplinary Care meeting. TOP stands for Thoracic Oncology Program, and multidisciplinary means that doctors, nurses and other medical professionals are involved from a variety of specialties, including medical imaging, medical oncology, pathology, pulmonology, radiation oncology and surgery.

“The group focuses together on one case at a time, tapping our collective experience to benefit each patient,” explains Jason Wallen, MD, an assistant professor of surgery and medical director of the program.

A large screen on one wall is a showcase for imaging scans. A smaller screen shows other pertinent patient records. Each week’s discussion includes a half dozen new patients who are suspected of having cancer, along with a half dozen established patients who have new test results or a significant change requiring group input.

At the center of the table sits Wallen. At a nearby podium stands Santiago Miro, MD, an assistant professor of radiology. As Wallen introduces each case, Miro projects the corresponding images.

Here’s the computerized tomography scan of a 66-year-old woman who underwent lung cancer screening. She has a tumor measuring almost 8 centimeters, which is huge. Next for her, everyone agrees, is a positron emission tomography (PET) scan, which will help determine if the tumor is cancerous. They also talk about what to do if it is.

The next patient is a 57-year-old woman with a tumor in the lower lobe of one lung. Her doctor tells the group, “She’s very interested in surgery” and that she quit smoking three days ago. Miro shows scans of her lungs on the big screen: Cysts are visible throughout both lungs. The group discusses what stage of cancer the woman may have, if it’s cancer, and what other problems may account for the cysts, if it’s not.

The meeting is filled with instruction, questions asked and answered, and cordial discussion. For each patient’s case, his or her doctor provides a synopsis of the situation. Miro displays the most recent imaging scans, sometimes with previous scans for comparison.

“This thing is obviously growing like crazy,” Miro says, pointing to a tumor affecting a 77-year-old woman. It has not invaded her lungs, but it’s close to her spinal column. He explains how her imaging scans make him wonder if she has an infection or an immune disorder, rather than cancer. The group decides the best course of action is to examine a sample of her lung tissue and a sample of the fluid from her chest cavity.

For another patient, they discuss the merits of radiation or chemotherapy. And for another, they concede that he could have two unrelated cancers at the same time, or, perhaps, cancer plus a fungal infection in his lungs.

More than an hour later the meeting is over. In that time, each patient’s case receives undivided attention — and the patient will receive a personal plan for his or her next course of action.

LungCancer Group19b (1)

The Upstate Cancer Center was designed to accommodate a model of multidisciplinary care. Thoracic Oncology was the first multidisciplinary program at Upstate, beginning in 1999. Specialists in other types of cancer at Upstate also offer this team approach. Pictured, front row from left: nurse Patricia Bravo; Linda Veit, MPH; Manju Paul, MD; Ernest Scalzetti, MD. Second row: Jeffrey Bogart, MD; Ajeet Gajra, MD; Leslie Kohman, MD; Jason Wallen, MD; Robert F. Dunton, MD. Third row: Brenda Sah, MD; Santiago Miro, MD. Fourth row: Christopher Curtiss, MD; Stephen Graziano, MD; Rolf Grage, MD. (PHOTO BY SUSAN KAHN)

A look at lung cancers

Lung cancer is the second most common cancer in men and women, but it is the deadliest of cancers. Each year more people die of lung cancer than of colon, breast and prostate cancers combined, reports the American Cancer Society. Tobacco smoking is by far the leading cause of lung cancer, responsible for at least 80 percent of lung cancer deaths. Most lung cancers are either small cell or non-small cell.

Non-small cell lung cancer

Percent of cases: 85.

Types: Squamous cell carcinoma, adenocarcinoma and large cell carcinoma are all non-small cell lung cancers.

Signs and symptoms: Persistent cough, chest pain, hoarseness, shortness of breath and recurrent chest infections are among the common signs of non-small cell lung cancer.

Treatments: Surgery, radiation including stereotactic body radiation therapy, radiosurgery, chemotherapy, targeted therapies and/or immunotherapy may be recommended.

Survival: Almost half of patients survive at least five years if the cancer is found before it spreads.

Small cell lung cancer

Percent of cases: 10 to 15

Types: Small cell lung cancer is rare in someone who has never smoked.

Signs and symptoms: Because this type spreads quickly, it is usually discovered after it has spread and before the emergence of signs or symptoms, which would be the same as those for non-small cell lung cancer.

Treatments: Chemotherapy, radiation therapy and/or surgery may be recommended.

Survival: Almost a third of patients survive at least five years if the cancer is found before it spreads.

Source: American Cancer Society

spring16cancerhloa-art2This article appears in the spring 2016 issue of Cancer Care magazine. Hear a radio interview/podcast with thoracic surgeon Jason Wallen, MD, discuss lung cancer, including screening, surgery and chemotherapy. 

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