Dirk De Ruysscher, MD, PhD: When we start a treatment, we of course discuss this in a multidisciplinary setting and with all the different specialties, including the nurses and the trial nurses. And sometimes also the GP [general practitioner] is present. We discuss this, but the most important point is that we should really stick to a written protocol. It’s not a good way to work when you don’t have written protocol, which should be revised every year to keep it updated. And that everybody is sure about their places, what to do, when to do it. And at the same time that the patient also knows who is really responsible for the care because the patient is seeing different specialties, radiation oncology but also pulmonology, medical oncology, depending on the country, nurses. So it’s very important that once something happens, who’s actually responsible for the whole treatment chain. That should be discussed in a written protocol and not for every patient alone.

When we embark with stage III non—small cell lung cancer, we have a variety of coordination but also specialties that should work together for a certain patient. Now, there’s different possibilities, depending on the path and the treatment that you have to give to patients. Some patients receive concurrent chemotherapy and radiation, some receive it sequentially, and some receive only radiation or with surgery.

Now, when it’s about concurrent chemoradiation, that’s the most complex one. What should be done is that you give the patient information about radiation, you give the patient information about chemotherapy but also about adverse effects. This is the most important one because concurrent chemoradiation has a mortality rate of about 3% to 4%, toxic deaths, mostly due to infection but sometimes also due to pulmonary embolism. And there’s a reason why it’s so important that you work together. Practically speaking, again, you have to have a protocol. The protocol should be on paper, of course. The protocol should also be spread not only among specialists but also among nurses. It should be clear to the patients and the family of the patient, and that should all be written down.

Then we discuss with the patient the adverse effects that could go on, but also who the patients should go to. So not only who is responsible for the whole chain, but if you have a specific problem, where should you go. Because you should go the least difficult way. For instance, a patient in the Netherlands sometimes is living literally 90, 100 kilometers away; he should first have to go to the GP. But in certain circumstances, for instance when you have high fever, it’s better to go to the emergency ward. And the emergency ward should not let the patient wait for 3 or 4 hours. Those patients should be seen within 20 minutes or so because otherwise, you could die of sepsis. All those things should be discussed but should be clearly written down on paper, and everybody should know the task. And the patient should also know where to go.

The whole team is very broad, and we discuss patients in a multidisciplinary way. We discuss their cases for even more than 1 week because we have so many patients with lung cancer. First of all, we should have a written protocol because without a written protocol, everybody will just shout something that’s not good. You should have a written protocol that is as much as possible evidence-based, so that we know what to do and how to coordinate. However, you have patients who cannot be defined in a protocol.

We have so many different possibilities, including the diseases that may affect each patient, and therefore we need to discuss this openly with everybody. So in our team and I think in a lot of hospitals, you don’t only involve the specialists, so the pulmonologists, like medical oncologists, surgeon, the radiation oncologist, pathologist, but also the nurse. This is certainly important when patients already have some disease like lung emphysema for which you have a nurse, for instance, who follows those patients for a longer period. The GP, not necessarily physically available but maybe by Skype, where they can also give advice. And for elderly patients, we also do an assessment by the geriatrician because of their frailty. Elderly is difficult to define, but something like 75-plus years old, is certainly important to keep those people on board.

Then you review it and you try to go for a certain aim for treatment. And what is more often known is to keep the patients actively involved to know what exactly the patient is expecting and wanting. For most younger patients in generally good condition, it’s clear that cure is most likely. But for older patients or for patients who are frail, it’s not necessarily cure, and so we are developing shared decision tools so the patient has some tools. Most of the time it’s Web-based, of course, to get informed about the pros and the cons of every possibility in his or her case and to try to give this information in a way that the patient understands. So not only percentages but also what does it mean to have shortness of breath in all situations and so on and so forth. That’s the kind of shared decision making. And that is important for everybody but certainly for old and frail patients who sometimes say, “Well, the only thing that I want is for a year in a fairly good condition and then for the rest I don’t care.” And then of course you should not give very aggressive treatment.

Transcript Edited for Clarity