Multidisciplinary Practice Management Is “Critical” in Lung Cancer

Joshua K. Sabari, MD

Thoracic Medical Oncologist

NYU Langone Health

Assistant Professor Department of Medicine

NYU Grossman School of Medicine

Director, High Reliability Organization Initiatives

Perlmutter Cancer Center

New York, NY

Q: What comes to mind when discussing practice management at your institution?

SABARI: Cancer care is complex. It involves creating an operation overseeing the day-to-day management in the oncology practice, starting with having an intake coordinator— somebody who talks to the patient up front, explains the practice, gathers their clinical information, the scans and reports, and maybe even starts the process of setting up any imaging that is needed. Having that housed in a formal role, as intake coordinators, is important in expediting care for our patients.

Working with other health care providers such as nurse practitioners and physician assistants is critical to understanding responsibilities and setting up for a new patient visit.

These other health care providers make sure the necessary laboratory tests and next-generation sequencing are ordered, which is especially important for patients with lung cancer. When patients are potential surgical candidates or have earlier-stage disease, the intake coordinator will submit the case for our weekly tumor board discussion.

Q: Please elaborate on your health care team and initial process for new patients.

I work at an academic medical center, so we are blessed to have many resources that may not be available to community oncologists or oncologists practicing in other institutions or situations. Access to care is a critical part of getting a patient in to see the oncologist. Many patients tell us that it takes weeks or months to see a medical oncologist. There’s a lot of fear and anxiety once they get that diagnosis or have a finding on a scan that may be concerning. So when patients call our office, they are put in touch with an intake coordinator who takes down the patient’s history and will acquire the records from the patient, imaging, and pathology if available.

They will give the patient an appointment to see a thoracic medical oncologist within 48 to 72 hours from point of contact. Access to care is crucial, and we take that very seriously at NYU Langone Health. We want patients to be seen in a timely manner and be able to start effective therapy quickly. We know start time on therapy, making the right diagnosis, and using the correct therapy are critical for patient outcome and for patients’ well-being.

We have a large health care team including nurse practitioners, physician assistants, and nurses, as well as learners—medical students, residents, and fellows—working together to care for our patients. Personally, I go through my new patient cases with my nurse practitioner or intake coordinator, so we have a plan and we’re ready to discuss a plan with the patient when we meet them in the office. If the patient has early-stage disease, we make it a point to put that patient and the case onto our roster for the interdepartmental tumor board meeting, where we get a consensus opinion from our thoracic surgeons and radiation oncologist, as well as medical oncologists and radiologists.

If the patient is a candidate for multimodality therapy, we do our best to schedule that patient with those experts the same day they come into the office. For example, I work very closely with a radiation oncologist and a thoracic surgeon. If it’s a patient with stage III lung cancer, it’s critical to get opinions from all 3 of those subspecialists in 1 setting as opposed to patients trying to figure out the complex medical system on their own.

Having all subspecialists on the same page at the time of initial consultation allows for more effective and streamlined care for our patients. Discussing patient cases prior to the visit in a multidisciplinary team allows us to get ahead; we order the correct laboratory tests that are needed and can expedite care.

Molecular testing has become an important issue in thoracic medical oncology and many other solid tumors, because it helps guide therapy in the neoadjuvant and adjuvant settings and clearly in the metastatic setting.

We want to have those orders put in beforehand so we can start that process, even before we meet the patient in clinical practice. Importantly, the day the patient comes in for the visit, meeting the health care team and understanding the process and the plan for that patient are going to be critical. We have patients meeting with nutritionists as well as social workers once they start their systemic therapies to give them a well-rounded approach for their care. We must realize that the medical oncologist is not the only individual in the team taking care of the patient—it is a health care team. It takes a village to take care of patients, and it’s our whole community that puts their heart into the care of the patient.

Q: What are the main components when communicating between inpatient and outpatient care services and for end-of-life care in patients with lung cancer?

In a former role I had as a medical director of an inpatient oncology floor, I worked closely on the integration between outpatient and inpatient medical oncology service. Unfortunately, a lot of our patients do require inpatient care at some point in their journey, so the communication between the outpatient and inpatient setting becomes critical. We have a dedicated oncology hospitalist who takes care of our patients who are admitted to the hospital. Communicating with that hospitalist oncologist is crucial in allowing patients to get optimal care and understanding the plan and the goals of care.

It is also important that patients who are reaching the end of life or whose therapies are not working well have a meaningful goals-of-care discussion. I like to have those discussions with patients up front—initially upon meeting them and throughout their cancer journey, typically around the time we obtain scans to assess whether treatments are effective.

Having that discussion with patients allows us to select the best options for them. Many times, patients do not want to pursue a systemic therapy, and we support that. One of the things we look at in the inpatient integration to the outpatient setting is chemotherapy given in the last 30 days of life; that is a quality metric both for patient outcome and palliative purposes, but also for cost-related purposes. It’s important that these discussions happen and are documented and we are aligned with patient goals, particularly at the end of life. This integration between the inpatient and outpatient oncology units has been very rewarding to me because it allows me to care for the patient in the clinical practice, follow them throughout their journey with their cancer diagnosis, and be the connection between those parts. I think it’s critical that all oncology outpatient offices have some form of connection to their inpatient teams, where they’re able to convey the plan but also the goals for the patient’s care.