Second Opinions for lung cancer

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1 Second Opinions for lung cancer Egbert F. Smit, Department Thoracic Oncology NKI-AvL, Pieter E. Postmus, Department Pulmonary Diseases VU university medical center Amsterdam 1

2 Disclosures Consultancy: Eli Lilly Advisory Boards: Astra Zeneca, Boehringer Ingelheim, Bayer, Cellgene, Novartis, Clovis, Roche-Genentech, Pfizer, BMS. Research Funding: Astra Zeneca, Boehringer Ingelheim, Bayer, Clovis, Roche-Genentech. Stock Options: None I will not discuss off label use or promote nonregistered drugs

3 Case 1¹ female, 46 yrs history: 9 months earlier NSCLC adenocarcinoom stage 3B RUL curative chemoradiotherapy and PCI (NVALT-11 trial) Dyspnea, wheezing, very severe non-productive cough Additional investigations in referrring hospital PET-CT: cavitation in irradiated area and multiple FDG-PET negative lesions right lung ¹Schook RM et al. J Thorac Oncol 2012 Aug;7(8):e6-e7. 3

4 Conclusion: recurrent NSCLC stage 4 with infection, beyond cure Therapy: ciprofloxacin fatal prognosis discussed with patient Patient initiates second opinion 4

5 VUmc Revision data and new CT scan Conclusion: most likely explanation is all changes due to infection with spread in lung Therapy: antibiotics 5

6 CT-scan VUmc 6

7 Follow-up Despite antibiotics worsening condition patient: Continued cough, shortness of breath, weight loss, anemia Lab/ CRP 257 mg/l, normal WBC (9.6x10^9/L) Therapy: Open-window thoracostomy Aspergillus fumigatus Post-operative: antimicrobial and antifungal therapy Outcome: dramatic improvement in condition and reduction of cough 7

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9 3 months later Hospitalized for bleeding from thoracotomy cavitation Therapy: Gauze tamponade Transposition of m. serratus anterior into cavity 9

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11 Follow-up Uncomplicated post-op No signs of infection or recurrence 15+ months Back to work (lawyer) 11

12 Analysis of Second Opinions for lung cancer 12

13 Background Results second opinions VUmc Reasons for second opinions conclusions 13

14 Background Lung cancer: Incidence 4 th cancer in NL 1 st cancer related cause of death 14

15 Background-2 N in 2010 Prevalence Incidence Fatal Trends uptil 2020: increase, especially in females 15

16 Second opinions A second opinion is a (medical) opinion on a patient, by another MD or medical expert (of the same area of expertise) than the treating physician. Initiated by patient or doctor Well-known phenomenon Hewitt et al, % of 7.2 miljon survivors: 1 or more second opinions Live threatening diseases 16

17 Second opinions-2 Increase in number of requests: Survival increase of cancer patients recurrences second primaries Shift in doctor-patient relationship and decision making Patients more autonomic and critical Better access to information and use of internet 17

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19 Second opinions for lung cancer? 19

20 Redenen second opinions: patiënten Eigen onderzoeken Wens tot check/bevestiging diagnose en beleid Behandelwens bij gevorderde ziekte Wens tot aanvullend onderzoek/advies/behandeling in expert centrum Wens tot mogelijkheden voor trialinclusie Goed contact met het VUmc Problemen met eigen arts (vertrouwen/misdiagnose/onvrede/onrust/twijfel) 20

21 Redenen second opinions: zorgverleners Verzoek tot nagaan/check diagnose en beleid Verzoek tot (extra) aanvullende onderzoeken Ingewikkelde casussen Onenigheid binnen specialistenteam/mdo Voorstel andere/nieuwe therapeutische opties Behandelovername (ook trials) 21

22 Second opinions results VUmc VUmc: expert center for lung cancer ± 400 new patients yearly Part of these: second opinions 22

23 Methods Retrospective, cross-sectional investigation of files Inclusion criteria: patients with the (likely) diagnosis lung cancer period: between January 2005 and December 2009 Earlier evaluation by a medical specialist, outside the ZIP code area of VUmc Referral to the outpatient lung oncology clinic of VUmc 23

24 Aims Comparing data of initial evaluation and 2nd opinion outcome: Characteristics of patients, disease characteristics, medical information on therapy (prior, current, advised) 2nd opinion in expert center: disease characteristics and advise Classifying differences between evaluations 24

25 Endpoints Differences in: (Pathological) diagnosis Staging (UICC 6th TNM staging) Therapy advise others: Initiator second opinion Revisions and additional investigations Inclusion in Trial Reason second opinion 25

26 Secundary endpoints Classification and frequency of differences for staging, diagnosis, therapy: Minor Major Identical 26

27 Results: Baseline N=490 N (%) Male/female 279 (57%)/211 (43%) Median age at presentation Initiator of 2nd opinion -specialist -patient -both Prior known data: -diagnosis -stage -therapy -therapy advise 59 (20-85) 302 (62%) 164 (33%) 24 (5%) 439 (90%) 384 (78%) 233 (48%) 356 (73%) 27

28 Revisions and additional investigations N=490 N (%) Revision of diagnostic material from referral hospital -Tissue -Imaging 131 (27%) 490 (100%) Additional diagnostics by VUmc -New tissue -Mutation analysis (K-ras and EGFR) -CT-scan -PET-scan -Bronchoscopy -X-thorax -MRI -PET-CT scan 350 (71%) 224 (46%) 140 (29%) 127 (26%) 82 (17%) 73 (15%) 41 (8%) 30 (6%) 18 (4%) 28

29 Results of second opinions Diagnosis -confirmed -changed -new Stage* -confirmed -changed -new N(%) total (n=490) 396 (81%) 43 (9%) 51 (10%) 330 (68%) 52 (11%) 91 (19%) N(%) therapy naïve patients (n=257) 179 (70%) 29 (11%) 49 (19%) Patients with a therapy advise (n=356)** 131 (51%) 31 (12%) 86 (34%) -confirmed 193 (54%) -changed 157 (44%) N(%) prior treated patients (n=233) 217 (93%) 14 (6%) 2 (1%) 199 (85%) 21 (9%) 5 (2%) Therapy advise** -confirmed -changed -new 193 (39%) 157 (32%) 134 (27%) 93 (36%) 82 (32%) 79 (31%) 100 (43%) 75 (32%) 55 (24%) 29

30 Therapy in study Request for participation in study (n=490) Effected (n=490) Inclusion in trial (n=490) -therapy naive (n=257) -pretreated (n=233) Relation to initial advise: -changed (n=157) -unchanged (n=193) -no prior advise(n=134) N 77 (16%) 39 (8%) 106 (22%) 61 (24%) 45 (19%) 42 (27%) 37 (19%) 27 (20%) 30

31 Change in diagnosis (n=43) SCLC NSCLC Trachea tumor NSCLC Carcinoma unknown origin: lung cancer other malignancy* Lung cancer other malignancy** Lung cancer benign abnormality change in NSCLC subtype Change in carcinoïd subtype N

32 Change in stage (n=52) higher lower Other* N Aim of Therapy: -Palliative Curative -Curative Palliative -no change

33 Classificatie of changes after second opinions (n=220) potential major effect on outcome: n=135 potential minor effect on outcome : n=54 Changes with potential identical effect on outcome: n=31 33

34 Changes with potential major effect on outcome (n=135) N Change in diagnosis and/or stage Change in combining surgery with or without other therapy resectability Yes or no chemotherapy mutation analysis Chemotherapy chemoradiotherapy (+ possible resection) Curative radiotherapy curative chemoradiotherapy Curative radiotherapy surgery Surgery endobronchial therapy Adding treatment modality to endobronchial therapy

35 Conclusions Of all second opinions (n=490) in 9% change in diagnosis and in 11% change in stage In 44% of patients with a therapy advise (n=356), this was changed for 60 patients change in diagnosis- and/or stage was a major change For 75 patients change in therapy was a major change 35

36 2 casussen uit de praktijk 36

37 Casus 2² Man, 70 jaar, ex-roker, marathon renner VG/ 11 maanden eerder: NSCLC RBK met (mogelijk) kleine satellietlaesies, nodulus in RMK en nodulaire structuur in LBK op CT-scan en 18-FDG-PET scan C/ primaire longkanker met intrapulmonale metastasen (stadium 4, PA bewezen) B/ 6 cycli chemotherapie met cisplatine/gemcitabine ²Avest ter, MJ; Schook RM et al. J.Thorac.Oncol. Nov Accepted pending minor revisions 37

38 Na chemotherapie Kleine reductie laesie RBK Duidelijke reductie laesie LBK Laesie RMK onveranderd 38

39 RBK 39

40 LBK 40

41 RMK 41

42 11 maanden later Progressie laesie RBK Arts geïnitieerde second opinion 42

43 VUmc Revisie patiëntendata, opnieuw PET- en CT-scans C/ Mogelijk multipele primaire tumoren B/ - VATS Wigexcisie LBK - Transthoracale biopt RBK Gevolgd door: - Wigexcisie RMK - Lobectomie RBK + mediastinale lymfeklierdissectie 43

44 Histopathologie postoperatief LBK: papillaire adenocarcinoom 1.8 cm RBK: gemengd papillaire adenocarcinoom/adenocarcinoom in situ 3.3 cm RMK: adenocarcinoom in situ 1.1 cm Allen radicaal gereseceerd, lymfeklieren tumorvrij 44

45 Array-comparative genomic hybridization (a-cgh) analyse Verschillende patronen van gains en losses Consistent met 3 primaire tumoren 45

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47 Beloop B/ ontslag postoperatief in goede conditie 12 maanden postoperatief: controle CT-scan Recidief in operatiegebied LBK Nieuwe laesie LOK Beide laesies 18-FDG-PET positief 47

48 Beloop (2) B/ diagnostische wigexcisies LBK en LOK met mediastinale lymfeklierdissectie PA/ 2 invasieve papillaire adenocarcinomen 1.5 cm resp. 0.6 cm vrije resectievlakken, lymfeklieren tumorvrij C/ recidief LBK en nieuwe primaire tumor LOK 48

49 Verdere beloop Ongecompliceerd postoperatief beloop en ontslag Geen tekenen van recidief 6 jaar na de initiële diagnose Patiënt nog steeds in goede conditie 49

50 Overwegingen m.b.t. second opinions Gevolgen op diagnose en behandeling + Zekerheid + Behandeling op maat (t.g.v. verfjinen van diagnostiek) + Bescherming van ziekenhuis en specialist Onenigheid over diagnose en beleid (achteraf*) Delay in het geven van therapie Gevolgen op de arts-patiënt relatie Negatieve invloed + Positieve invloed 50

51 Overwegingen-2 Behoefte aan informatie en bevestiging anders informeren? beter uitleg over gang van zaken MDO? verwijzen naar betrouwbare informatiebronnen? ( werken aan communicatieve vaardigheden? mogelijkheid tot second opinion aanbieden? second opinion middels interactieve media? Kosteneffectiviteit? extra kosten door second opinion belasting expert centrum + kostenbesparing onnodige ingrepen 51

52 Conclusies en aanbevelingen Second opinion verzoeken kunnen verschillende redenen en initiatoren hebben Bij een second opinion staat het belang van de patiënt voorop Een second opinion in een expert centrum is waardevol en moet voor elk patiënt mogelijk zijn Indien een second opinion wordt verzocht: vóór de start van de definitieve behandeling 52

53 acknowledgement: Romane Schook Coralien van Setten Marleen ter Avest Dr. M.A. Paul Dr. K.J. Hartemink Dr. K. Grunberg 53

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