A few years ago, a patient with chronic obstructive pulmonary disease received a lung scan in preparation for a potential new treatment. The scan revealed a nodule, or small mass, indicating lung cancer. Dr. Kenneth James Fuquay, the medical director of the Jupiter Medical Center Sleep Center and Respiratory Services, ordered additional testing, which indicated that the patient would not qualify for surgery to remove the cancer.
When Fuquay brought the patient’s case to the hospital’s team of lung cancer physicians, a “radiologist mentioned that his lungs didn’t look that bad on the CT scan, and he felt that the numbers from the pulmonary function test did not make sense,” Fuquay recalls. Fuquay repeated the patient’s breathing test and got a better result, clearing the patient for surgery that removed the cancerous nodule entirely.
For Fuquay, the patient’s case is one success story that illustrates the value of JMC’s multidisciplinary approach to lung cancer care. In the United States, lung cancer kills more people than any other cancer—breast, prostate, and colon cancer combined—according to the U.S. Centers for Disease Control and Prevention. Up to 20 percent of cases occur among people who have never or rarely smoked.
Recognizing the need to combat the disease, JMC began developing a multidisciplinary lung cancer team, backed by state-of-the-art technology, in 2011 through its Thoracic Surgery and Lung Center of Excellence, part of the JMC Anderson Family Cancer Institute. Led by medical director and thoracic surgeon Dr. K. Adam Lee, the effort represented the first coordinated care approach for lung cancer in the region, according to Lee, with the goal of identifying cancers early, then personalizing and streamlining care for improved patient outcomes. The method works: U.S. News & World Report named Jupiter a “High Performing Hospital” in Lung Cancer Surgery, its highest rank.
“It's very rewarding for all of us working together as a team,” says Lee. “We deliver the same high-level care that you'll see in academic or high-end cancer programs, but you're still a member of our community, we know your name, and we ensure that you feel that comfort level.”
EARLY DETECTION
JMC’s multidisciplinary care process begins once a scan displays an abnormal nodule within a patient’s lung. The nodule may be discovered from a scan performed during an emergency room visit at JMC, at another hospital, or through JMC’s lung-screening program, which checks high-risk patients to increase the chances of finding lung cancer before it progresses.
Artificial intelligence (AI) technology assists in reviewing lung CT scans performed at JMC, not only detecting lung nodules but rating the likelihood that the nodule is cancerous. “Every morning, [staff] get an email of every new incidental lung nodule that was picked up through the emergency department and radiology” by AI, explains Lee. The nurses then connect with the patients to ensure they follow up with an outside doctor or through JMC’s lung nodule clinic.
With its screening programs, “our early-stage lung cancer detection is one of the best in the country,” says Lee. Reaching patients early in the course of the disease boosts survival rates, he adds.
“Because there's a lot of imaging that goes on in the emergency department, we try to capture all those patients so that no nodule is left undiagnosed and unnoticed,” says Dr. Lee A. Fox, a diagnostic and interventional radiologist. “We want to make sure that anyone who potentially has an early problem is getting right into the slot that they need to be in, so that we don't leave any nodule behind.”
TEAM APPROACH AT TUMOR BOARD
Screening is essential, but it’s only the first step. Next, JMC’s team ensures the best treatment for each patient by coming together to discuss patients in a weekly multidisciplinary meeting known in the oncology field as a tumor board review.
A tumor board includes physicians specializing in surgery, oncology, pulmonology, radiology, and other fields to comprehensively consider each case. “All those people are in the room at the same time, and the patient benefits by having everyone focused on their case, collaboratively trying to design a treatment plan that’s best for them,” explains Fox. “It’s more than a surgery or a biopsy or radiation or chemo; it’s treating the whole patient.”
The board reviews patients at all stages of disease. “It's not uncommon for patients to be brought up more than one time in the tumor board,” says Fox. “A lot of times, it's a process, rather than a one-time thing.”
At tumor board, the group considers the hospital’s wide range of potential tests or treatments to identify the best fit for each specific patient. “The approach is not what can we do, but what should we do?” says Fox. For example, is surgery or radiation the best treatment for a particular patient? “The discussions we have are patient-centered, and that's why we have such great outcomes.”
This approach is especially important because multiple treatments may work for a patient, but only one might be the best option. “The treatment shouldn't be decided by which doctor sees the patient first; it should be decided by what's best for that individual patient,” says radiation oncologist Dr. Nathan Tennyson. “By having a team approach, you can talk about the modalities that would be appropriate for that patient and then come to a decision together.”
In addition to being tailored to the patient, the resulting treatment plan is decided quickly. “All the tumor board doctors are involved in the input of patient care, which ultimately leads to faster and better decision-making, so we're performing better cancer care in a more expedited manner,” Tennyson explains.
Discussing cases at tumor board is an investment of time for participating specialists, but the physicians say it’s worth it for their patients. “It takes a lot of work—it takes commitment from the institution—but it ultimately results in better patient care,” says Tennyson, adding that the resources needed to hold tumor boards usually limits them to large academic centers. “That's really been our mantra: we’re bringing the academic model to the community setting and trying to set the standard of cancer care in Palm Beach County,” he says.
STREAMLINED CARE
After determining a treatment plan, the next step is carrying it out. With standard treatment models, “the patient goes to the pulmonologist, the pulmonologist gives the patient a prescription for the PET scan, the PET scan takes six weeks to do, the results come back six weeks later, and a lot of time has been lost,” Fuquay explains.
By contrast, with JMC’s multidisciplinary tumor board approach, if “there's a need for an oncology referral, the oncologists who are at the meeting will hear the patient’s case and be able to say, ‘Sure, we'll get the patient in quickly,’” says Fuquay. “It's a direct communication between doctors and a direct discussion about patient-related items that is taking place in real time, so it shortens the length of time needed to get the patient to the right place.”
Rather than scheduling appointments weeks apart in different facilities and waiting for referrals, patients with complex cases can also meet with their entire care team in one afternoon to streamline their treatment at JMC’s multidisciplinary clinic. “You're in one location where you get to meet everybody who is helping make a decision on what’s going to be done, and therefore, you leave there with all your appointments for testing or treatments done,” explains Lee. “Your questions are answered, and your treatment plans are made—all within a couple of hours.”
The coordinated, streamlined team care creates rapid results. “For a lesion of suspected cancer, within two weeks, we can have it diagnosed, staged, and treated,” says Lee.
CONTINUOUS TEAM CARE
Lung cancer care at JMC Anderson Family Cancer Institute is an ongoing process incorporating team input every step of the way. Besides reviewing some patient cases multiple times at different stages of treatment at tumor board, physicians consult together continuously as well.
For instance, if a patient is admitted through the emergency room with a large tumor, multiple specialists may be consulted for treatment, says diagnostic and interventional radiologist Dr. Paul Cofnas. "Although it's not a tumor board at that point, multiple members of the tumor board team are being consulted to discuss the case while the patient is in the hospital," Cofnas explains. "We all know each other, and it facilitates working together."
The strong team relationship and continuity of care also appears to increase patients' comfort level. "When we see the patient for a biopsy or a chemotherapy port placement, you can see it in their eyes," says Cofnas. "You feel that they are aware that everybody's working together—that all of these decisions are cohesive—so they're really confident in their treatment, and it makes them feel better about what they're going through."
TECHNOLOGICAL TOOLBOX
JMC’s multidisciplinary approach also works seamlessly because of its integration of technology to support the team. Using AI from the outset to review scans is the first important component. “Not only does this detect the lesion faster and bring it to the attention of the team responsible for acting upon it, AI also analyzes the chance that it’s malignant,” says pulmonologist Dr. Michael Marsh.
In addition to AI, other types of technology provide a range of options to best suit each patient. “We have advanced technology that allows us to perform radiation services that maybe not all institutions can perform, so it gives the patients more options,” says Tennyson.
The center’s cutting-edge technology also lets the team diagnose smaller nodules and treat them more quickly. New, more effective and minimally invasive treatment tools allow lesions to be biopsied sooner “than maybe I would have if it was [the older] CT-guided biopsy,” says Marsh, simply because these tools make it safer. Still, Marsh stresses that excellent care doesn’t rely solely on advanced technology but on having an experienced physician team. “I can do all the fancy robotics and biopsies I want, but none of that matters if I don't have a thoracic surgeon like Dr. Lee, a hematologist/oncologist like Dr. Jon Du Bois, or a radiation oncologist like Dr. Tennyson to bring everything together,” Marsh says.
Each doctor emphasizes their commitment to their patients, and for Marsh, it’s personal. His grandparents both passed away from lung cancer when he was in medical school after their disease was diagnosed late. “The whole point of finding it early is curing it because the majority of patients are still diagnosed in a later stage, where cure is not impossible but it's much, much harder,” says Marsh, who works with the rest of the team to reach patients as early as possible with the most personalized treatment plan to give them the best outcome possible. “The most important thing to me is that I want to bring this care to my community,” Marsh adds. “And I think that's the way we all feel.”
Jupiter Medical Center’s thoracic multidisciplinary team, which continues to be at the forefront of innovative technology, has had a significant impact with many “firsts” in the region and the nation.