Challenges in the Multidisciplinary Management of Breast Cancer

Joyce A. O’Shaughnessy, MD: A particular challenge is when patients are hospitalized. They oftentimes are at an outside institution, and you may not even know they’re hospitalized for a day or 2. Of course, you can get the medical records, but it may not be the same. You may not get a phone call for a couple of days, so you’re reliant on the family of the patient to let you know, so you can get a hold of the hospital that’s admitted the patient. That’s 1 challenge. When patients have scans and labs done closer to home because they live far away from the cancer center, comparing those with the previous scans can be a challenge. That’s more of a logistical thing—we have to get the most recent CT of the most recent scan to the other radiologist to have an addendum done. But that’s time consuming.

Another challenge is that a lot of times in the metastatic setting, there’s not enough tissue for the metastatic biopsy to test for standard biomarkers, PD-L1, next-generation sequencing, and so forth. There’s a variety of innovative diagnostic assays you can do to try to see what clinical trial opportunities are best for patients. But it’s also logistically complex because you’ll be sending tissue to multiple places. It’s very labor intensive for the clinic and all the personnel in the clinic to deal with that, as well as the pathology department. A lot of it is the amount of various aspects to things.

I didn’t mention wound care. Many of our patients have wound care issues. There are a lot of referrals and tracking those referrals to make sure patients get to the specialist in a timely fashion. Oftentimes, we have to get on the phone to make sure that appointment happens, and they’re not given the 2-month appointment. It’s complex because patients have a lot of needs, such as pain specialists. There aren’t a lot of people in psychiatry, palliative care, pain management, even pulmonary, particularly during the early COVID-19 days. Trying to get into very busy practices is challenging. Our patients have sleep apnea, and they have to get sleep studies. Their quality of life is suffering. Patients get migraine and headaches because we’re disrupting their normal hormonal patterns. We’ve got to get them to a migraine specialist. There are a lot of challenges getting patients to where they need to go in a timely fashion. It’s a lot of complexity. It’s a lot of work for the various people in our practice.

Mark D. Pegram, MD: The main challenge is getting all the data in a timely fashion so that it’s ready for presentation at a tumor board conference. This information comes from so many sources. Oftentimes, patients have been seen in multiple hospitals—maybe not even in your same state—and they could be traveling to your tumor conference to get an opinion, for example. Data acquisition is still a major challenge, and it’s important to try to get that in a timely fashion because patients want all this information as quickly as possible so they can get on with their therapy and treat the cancer as soon as possible. There’s a lot of anxiety to make sure that everything is done in a timely fashion as well as to get the best possible outcomes. That’s 1 major obstacle.

Another obstacle is an issue I mentioned previously: there are some situations where we don’t have good data to inform a particular patient’s treatment decision. In those cases, we rely on clinical judgment. There can be honest disagreement about what the best approach is even among experts. That’s another challenge in the tumor board multidisciplinary conference format, at my institution and every other institution where I’ve participated in tumor boards as a visiting faculty or at institutions where I practiced previously. There could be honest disagreement and debate. It can be very academic about what’s best for a particular patient, and there can be honest disagreement. In those cases, sometimes you need to present multiple options to patients and help them make an informed decision about what they think is best for them.

Charles A. Powell, MD, MBA: I can’t emphasize enough how important the communication is to maintain among different specialists. That can take different forms—it can be done by telephone, by secure email, through the electronic health record. That’s the most important component. The second is the data accessibility. When those 2 pieces are in place, everything usually falls into place.

The challenges that most often occur in the setting where we see patients is that the patient will present with symptoms suggestive of a new finding within the chest. It could be because of a new diagnosis of a cancer or a new diagnosis of another condition, or it could potentially be because of a complication of a therapy that a patient is receiving. The patient may even present and come with a report of an abnormal imaging study that they had had performed at an outside center. The problem is that unless we have the actual images in front of us, we’re not able to give a complete assessment of the patient’s condition. We need to be able to see the images to integrate the imaging findings with the patient symptoms with the clinical history.

That’s the most common issue that we run into when we’re caring for patients. It will delay the assessment, the diagnosis, and the treatment. It’s mitigated by the patient having the information on hand as they present or having it sent before they come, and it’s remedied by simply providing that information after the visit. That’s the biggest challenge we run into, but it’s 1 we can deal with when it does occur.

Mark D. Pegram, MD: I’m sure there are some jurisdictions geographically where it’s difficult to amass the type of expertise that would be necessary for a multidisciplinary tumor board conference in breast cancer. While it’s routine and in an academic environment, in a busy community practice, it may be more challenging to bring all the experts together at the same time and at the same place. That can be a real challenge, especially in rural areas. But with the technology and the ability to do virtual tumor boards, that barrier is getting attention. Among experts in the area of breast cancer with varied expertise, this tumor board approach is becoming far more common. I’ve seen situations in which virtual access can bring everybody together. Previously, because of geography and rural areas, maybe that wasn’t possible, but now it is. It’s gaining a lot more traction, in areas where that were challenged by geography. So things are looking brighter in the future of breast cancer in this regard.

Transcript Edited for Clarity