Transcription:
Northwestern Medicine GU Oncology Program and Tumor Board

Melanie Cole, MS: This is Better Edge, a Northwestern Medicine podcast for physicians. I'm your host, Melanie Cole. Today, we are discussing the Northwestern Medicine Genitourinary Oncology Program in the Polsky Urologic Cancer Institute of the Robert H. Lurie Comprehensive Cancer Center, which takes a comprehensive approach to care, collaborating across medical disciplines to develop an integrated and personalized treatment plan for patients with genitourinary cancers. We have three expert guests from Northwestern Medicine with us today. Dr. Ashley Ross, Associate Professor of Urology; Dr. David VanderWeele, Associate Professor of Medicine in the Division of Hematology and Oncology; and Dr. Sean Sachdev, Associate Professor of Radiation Oncology.

Welcome, Drs. Ross, VanderWeele, and Sachdev. I'm so glad that you could join us today to talk about the GU Oncology Tumor Board. Dr. VanderWeele, I'd like to start with you. Can you set the table for us a little bit and tell us about the Northwestern Medicine GU Oncology Program, the specialties that are represented? You represent three specialties all focused on treating patients with genitourinary cancers. Tell us about this combined clinic. What are you finding are the largest benefits?

David VanderWeele, MD, PhD: Sure. Thank you for having us on. I'm the representative from medical oncology. We have made a concerted effort to be very multidisciplinary. And actually, in that effort a couple years ago, the medical oncologists on the team all moved from the floor where generally most of the medical oncologists have clinic to move in with the urology clinic and the urologic oncologists to facilitate those interactions and make sure that we are talking to each other and can pop in and ask each other questions. Or if a patient needs some urologic care while they're in seeing medical oncology, that that can happen well. All this is to try to give a more comprehensive multidisciplinary team management for our patients, particularly patients with prostate cancer, with urothelial or bladder cancer and with kidney cancer.

And also along with that, we have a very active multidisciplinary tumor board that happens weekly. And, you know, actually one of the results of the pandemic is that people move things to more virtual meetings instead of all in-person meetings. And so, that's actually helped our sort of attendance and discussions, facilitate discussions, and then also facilitate the ability to join with other physicians in our network, not just in our more central campus, so that we have the chance to discuss more difficult or challenging or more unusual cases and get everybody's input, that being medical oncology, radiation oncology, urologic oncology, as well as reviewing with radiology and pathology and get everyone on board to discuss and hopefully come up with a unified recommendation for how to proceed with a patient's care.

Melanie Cole, MS: Thank you so much, Dr. VanderWeele, for explaining that to us. And Dr. Sachdev, walk us through how your team develops an optimal treatment plan for each patient. Can you tell us a little bit more? Expand on what Dr. VanderWeele said about this collaborative approach from screening to recovery and the impact that this model has had on patient outcomes.

Sean Sachdev, MD: For sure. Adding to what Dr. VanderWeele very nicely described, we are fortunate to be in a health system where we have a lot of distributed expertise and several very interested and invested clinicians. And we have the fortunate opportunity to have a very thorough discussion at least once a week when we go through cases that have a certain degree of complexity or therapeutic uncertainty. We get to have the opportunity to hold a very thorough discussion with every specialty bringing their expertise to the table. And also during this time, we can check for potential patient enrollment into our extensive clinical trial portfolio for patient benefit.

From my vantage point as a radiation oncologist, I'm fortunate to work with both Dr. Ross and Dr. VanderWeele and other gifted future thought leaders in the GU oncology space. And we can really have a very collaborative approach in being able to figure out what is needed from each of our own individual expertise for patients for the benefit of our patients.

More recently, we've also been fortunate to now be able to leverage the extensive and well regarded expertise of the Lurie Cancer Center and our clinical trials office by organizing a very sophisticated system that has been set up across our health system, which allows us to enroll patients onto new clinical trials that may offer significant benefit in difficult disease scenarios.

Melanie Cole, MS: Such a comprehensive approach. And Dr. Ross, I'd like you to speak a little bit more about the Oncology Tumor Board. And providers often submit their difficult cases for review. I'd like you to share one of your recent difficult or complex cases. Speak about how you managed it and the value of this multidisciplinary case-based discussion, how this model really improves patient care and outcomes.

Ashley Ross, MD, Ph.D: Thank you very much for having me. And it's great to be here with Drs. VanderWeele and Sachdev. We work together frequently and seamlessly. And I think that's been a wonderful part of being at Northwestern.

I'll talk about a couple cases that often will require a multi-disciplinary approach. We had one gentleman recently. He had had a prostatectomy at an outside facility. He had then had radiation in the salvage setting when his PSA did not go to undetectable. And then, his PSA continued to rise and he had come to see me after treatment asking what to do. We got a PET PSMA scan, which is a type of imaging that is more specific and sensitive for prostate cancer, and it showed only one hotspot near the hilum of the lung, so a lymph node kind of near the central portion of the chest and lung.

A couple quick approaches before he even got to multidisciplinary oncology clinic, I reached out to some of my colleagues, one of Dr. VanderWeele's colleagues, Dr. Fenton, and asked her like, which way did she go about doing these biopsies of these things to figure out what they are. And she recommended an interventional pulmonologist who could do an endobronchial biopsy and get a little bit of a cellular sample of this through an FNA. That came back showing that it indeed was prostate cancer. So, this is a guy with oligometastatic or low-volume metastatic prostate cancer, who has had complete treatment to his prostate and pelvis. And the question is what to do.

And so, that's the kind of case that I often will bring to the multidisciplinary oncology tumor board to ask opinions about should he have radiation alone, radiation and hormonal therapy, radiation and a combination of hormonal therapy with androgen deprivation and an androgen receptor signaling inhibitor; what should the duration be and what are the different clinical trials that are open for this patient.

And this is a patient that's going on to be managed by Dr. VanderWeele and Dr. Sachdev with both hormonal therapy and radiation. This patient, although somewhat straightforward, it really galvanizes and sort of puts us all on the same page about their care. And they're allowed to then go through like an accelerated approach to those findings. And there's lots of times where, again, the literature is unclear and having the opinions of not just David and Sean, but often dozens of us on the conference is very helpful.

The other minor point I'll make, and it was already sort of suggested, is how do we deal with these multidisciplinary tumor boards? You know, how do we actually make this into a practical solution for folks? And there's lots of different models of tumor boards that have been made. Some of them have all the providers seeing the same patient the same day, including ancillary providers, et cetera. The problem is that we have an increasing population, all of which needs expert care. There's uncertainty about decisions and we want to make sure that everyone has access to different clinical trials.

I think that our approach, and I think Dr. VanderWeele mentioned this, that maybe it was helped by COVID, our approach by saying, "Let's have the patients come in wherever they come in," whether it's through urology, medical oncology or radiation oncology. And if their case is complicated or maybe requires multiple sets of eyes, then elevate them to our tumor board discussion where we can have all of us together on a conference, go through these cases quickly, maybe present as many as 10 difficult cases, have review by radiology and pathology if needed at that conference and then, move forward from there. And I think that this approach, which maybe was not born out of COVID, but became much more kind of operationalized during this time, I really think it is the winner to like serve a growing population of aging Americans that are unfortunately going to have not only prostate cancer, but other cancers, as they're controlling their heart disease and other things more effectively. Maybe a long-winded answer, but I wanted to give my 2 cents on how happy I've been with this system for other hospital systems that are thinking about how they want to operationalize their tumor board.

David VanderWeele, MD, PhD: Yeah. And I'll chime in that we seem to be having a growing number of these cases where we're operating a little bit in a gray area of what to do. I think often it's patients with kind of recurrent prostate cancer, there have been some major disruptions in the field. We've been blessed by having these PSMA PET scans become more widely available, which is great because they're much more sensitive than the older scans. But all of our ways of establishing what to do in response to the imaging comes from the older scans. And then even though the new scans are very sensitive, we're not exactly sure what the best way to respond to them with different therapies. And at the same time, we've had a lot of data suggesting that if you're more aggressive earlier on treating cancers that have better outcomes. But we're not really sure, we haven't had that data and the new PET scans around long enough to know for a lot of these patients who are kind of newly diagnosed, a little bit of metastatic disease, but a relatively low burden or patients who are kind of newly recurrent after surgery. It's kind of a gray area right now and really sort of the intersection of all of our specialties, what's the best approach to take.

So often, we have clinical trials available and we have a couple clinical trials in these spaces, kind of depending on what the exact clinical scenario is. So often, it's a discussion about those trials. Or the patient might not be interested in the trial or maybe they don't really quite fit the criteria for the trial. And then, it's a discussion of, "Okay, we're moving ahead with standard of care. What do we do?" And it really is helpful to have everybody's input often before we see the patient, again after the patient, and then again at our tumor board meeting, reaching a consensus about how we move forward.

Sean Sachdev, MD: I'll also add a few comments here to what was well said by both Dr. Ross and Dr. VanderWeele. When we look from a high level view of prostate cancer, we see that we are dealing with a malignancy where we're finding better and better ways to treat different stages of prostate cancer. And not only are we doing that, we're actually realizing that patients are doing better and better. We're seeing improved clinical outcomes. And I believe a lot of that arises from teamwork.

If we go back historically, as I often explain to patients, modern cancer care is a three-headed beast of different cancer doctors that bring individual expertise, their own individual expertise to the table. A surgical oncologist like Dr. Ross has a lot of expertise, a lot of extensive training in being able to remove some cancer from a certain location in the body. Myself as a radiation oncologist, I can harness the power of radiation and ionizing energy to, again, go after one or a few spots in the body. And if it's anything more extensive than that, then historically we would always think of a skilled medical oncologist like Dr. VanderWeele, who is in charge and oversees any treatment that goes in through the mouth or through an IV. If we go back historically, we perhaps operated in a very siloed manner. If a patient needs surgery, they're going to Dr. Ross after he does a biopsy. If they have a biochemical recurrence, by which I simply mean that the PSA's rising after surgery, well, maybe they got some localized radiation to a certain region of the body. And if it becomes more extensive than that, then we have the patient see Dr. VanderWeele for expertise on how to manage a systemic burden of disease.

But a lot of the newer data, and in fact we just had a national meeting this past week, and all three of us were in attendance, a lot of the newer data continue to show that with more improvement in research, more improvement in our understanding of how we can harness our individual expertise and specialties, the best outcomes emerge from when we all worked together.

So, going back to the case that Dr. Ross presented just a few minutes ago, a patient who initially had surgery that had recurrence after surgery, got radiation, but not radiation by itself, radiation with modern systemic agents, and now has a different area of disease, which was picked up with very modern molecular imaging. And here again, while I can be of use in this kind of a scenario where I can focally go after one area of new disease, but not just by myself, also, utilizing the expertise and opinion of Dr. VanderWeele to add something on like hormonal therapy or androgen deprivation therapy, add a newer modern agent, which would be an androgen receptor signaling inhibitor. So, we find to the benefit of our patients, that as we continue to work together, as we continue to bring all of our modalities onto the table, oftentimes increasingly in close coordination and at once, we find that patients are doing better and better.

Melanie Cole, MS: That was very well said, Dr. Sachdev. I'd like to give you each a chance for a final thought here. This is such a comprehensive approach and such advanced medicine, Dr. Sachdev. I'd like you to start this by just anything you would like other providers to know about some of these advances. Now, Dr. VanderWeele just briefly mentioned PSMA. But in your specific field, as we talk about the multidisciplinary approach and how important it is that you all work together, in your specialty of radiation oncology is there anything exciting, anything on the horizon that you would like to let other providers know?

Sean Sachdev, MD: Well, as we get the better tools that allow us to more carefully define where the tumor is in the body. We can also leverage the more advanced technologies that we have in being able to target those lesions. So from a high level view, I'd say the advancements in technology that we've realized over the past 10, 15 plus years have really transformed how we can very carefully and very lethally go after cancer in different parts of the body while still preserving important structures that, of course, it's in the patient's best interest for us to stay away from.

Even in how things have changed from the radiation oncology perspective, I'd say, if you were to think of how we've gone from using flip phones to very modern touchscreen-based smartphones, previously we could only be able to generally direct semi-ionizing radiation to a region of the body, usually in the pelvis. But now with the capability to more carefully define other areas of localized disease, we now have the technological capability to essentially go after lesions very carefully, very individually. And from a high-level view again, what that simply means is whereas previously we're just confined to treating the prostate or the pelvis, now we have the capability to go after metastatic lesions, which allows us to be very able and effective in a whole different pattern of disease spread and be able to work alongside my other colleagues in order to have a concerted effort for better patient outcomes.

Melanie Cole, MS: What an exciting time to be in your field. So many advancements. Dr. VanderWeele, I'd like you to look to the future for us. If you were to look to the next 10 years, what do you feel will be some of the most important areas of research and what does that indicate for future developments in treatment? Take us from bench to bedside.

David VanderWeele, MD, PhD: Yeah. Thank you. So, a lot of sort of what we're on the cusp of right now is kind of redefining who is curable. And I think we keep pushing that boundary. You know, being able to detect disease earlier, realizing that if we treat aggressively upfront with our pills and with our medications, and also that there's still value to radiation even when the cancer is metastatic, those are all relatively new advances for our field, and so we're still figuring out the best way to combine all those things. And could we at least keep the cancer controlled for a very long period of time for someone who normally we would think would progress relatively quickly? Or could we actually cure people who before we thought were incurable? That's yet to be determined.

As we advance the field, I think we are going to continue to bring therapies that currently we're using just for late stage prostate cancer. We're going to be trying them out earlier and earlier to seeing if there's value to being more aggressive early on with those kinds of therapies. There's a new sort of liquid radiation or radioligand therapy that's approved that's being tested in earlier and earlier disease states.

PARP inhibitors, we've had around for quite a while. But we have a lot of new data coming out that trying them in different combinations or at different times in terms of the disease states that that can be effective. We have other biomarker-driven therapies, but a relatively small group of patients for whom immune therapy works. In some other diseases, we've found that highly selected patients using immune therapy very early on can be really helpful. We haven't made that leap yet in prostate cancer.

But beyond those, there's a relatively small minority of patients that we're using biomarker therapy, I think we're still pushing to try to figure out for all the other patients for whom their genomics isn't having a huge impact on how we're treating their cancer. Are there other vulnerabilities that we can take advantage of other ways that we can attack those pathways that we know are important for the cancer cells, but haven't yet figured out a way how to take advantage of them?

Melanie Cole, MS: And Dr. Ross, last question to you, because this is really a fascinating program for other providers. And is there anything you'd like them to know when you feel it's important they refer patients or to submit their difficult cases to the tumor board? I'd like you to speak to that now and anything else you'd like to make sure as a key takeaway from this interesting podcast today.

Ashley Ross, MD, Ph.D: You know, I think that one thing I would say is whenever you believe that a multidisciplinary approach would help the patient, or when you're thinking that there's ambiguity in the case or wonder if there's a clinical trial open for that patient, so that's a good time to submit to your tumor board.

One thought looking forward, I know we talked a little bit about the technology and the science in terms of therapeutics and diagnostics, but where's the future going? I think that on our tumor board, besides having a great collaboration among the treating providers, we're also benefited from having expert radiologists and pathologists on the tumor board that are reviewing these cases, often clearing up a lot of things that were not as clear.

The future's going to go more into management of big data and, also, I hope into more algorithmic care, and that helps providers with things that are maybe less ambiguous, but that they might not have as much depth of knowledge in. And what do I mean by that? I think that we're going to look at artificial intelligence-assisted pathology and radiology that might help us be more definitive about our reads in those regards. I think we're going to be able to look at leveraging the big data in healthcare and the EMR to help prompt us about guideline decisions. And in this way, we can make our normal workflow both more concrete in terms of what we're thinking of and limit the burden on these tumor boards. But also at the tumor boards, be able to run through multiple difficult cases in a much faster manner. And with the ability of these virtual meetings, I think that your threshold in your activation energy to bring a case to everyone's attention, it should be much lessened.

Hopefully, for people that are out there and have their own tumor boards, I think that's great. Use them just as much as I use mine. I typically will put up several cases every week. For those of you who are thinking about getting involved in a tumor board and are part of our Northwestern system, our tumor board is open for all comers. For people who are not involved in a tumor board or outside of our system and want to start a tumor board, I really think leveraging the digital models of virtual tumor boards that can be done efficiently and effectively. That is the way to go, much more than the kind of an older times where we used to do chart carrying or the patients seeing multiple providers in a day. I think this is going to allow us to treat the most amount of men and women with malignancies.

Additionally, we thought it's important that because the pace of new knowledge is so fast that we should develop a CME program that is available not just within Northwestern, but for any providers who are interested in updates and advances in genitourinary conditions. We have this CME for GU oncology happen right after our tumor boards. It's virtual, it's free. It provides class 1 PRA credit per attendance for providers that are within our system or outside of our system mainly so that everybody can keep up with this rapidly evolving fields and knowledge in GU oncology.

Melanie Cole, MS: Well, I thank you all so much and it really is innovation as a philosophical shift from providers working in silos to working together, as you've all just described, and really being able to take advantage of clinical research to disseminate that data and research quickly for the best patient outcomes. I thank you all for joining us today and telling us about the tumor board.

And to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/urology to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole.