Streamlining NSCLC Treatment Through Collaboration and Pathway-Guided Decisions

In this interview, Sonam Puri, MD, Moffitt Cancer Center, discusses the critical role of multidisciplinary teams, pathway-guided decision-making, and patient-centered strategies in optimizing care for non-small cell lung cancer while addressing challenges in research accessibility and treatment misconceptions.

Please introduce yourself by stating your name, title, organization, and any relevant professional experience.

Sonam Puri, MD: My name is Sonam Puri. I'm a thoracic medical oncologist at Moffitt Cancer Center. I'm also the clinical research medical director for the Department of Thoracic Oncology, where I oversee the development of and conduct clinical trials within the department.

In your experience, how have multidisciplinary teams influenced the creation and adherence to treatment pathways in non-small cell lung cancer (NSCLC), and what improvements could be made to enhance collaboration?

Dr Puri: Multidisciplinary team approaches are not a luxury in lung cancer—they’re essential. Lung cancer is diagnosed in different stages, and every stage requires partnerships between medical oncology teams and other specialties to provide comprehensive care to the patient. For example, if a patient is potentially surgically resectable, collaboration between the surgeon and the medical oncologist is required. If a patient needs radiation, collaboration between the radiation oncologist and the medical oncologist is necessary. Even when treating stage IV patients, multidisciplinary discussions, collaborations, and support from the palliative care team are critical and have been shown to benefit lung cancer patients overall.

At Moffitt, we have a specialist in every subspecialty. Within medical oncology, our physicians specialize in thoracic oncology, and we have dedicated thoracic radiation oncologists. All specialists are very approachable, making communication easy. We also have a weekly multidisciplinary tumor board to discuss complex cases and all new patients. We have several systems in place at Moffitt to facilitate effective collaboration.

In non-cancer centers or community settings, similar multidisciplinary times could be established. Physicians from different specialties should form a multidisciplinary team in which they have an open way of communicating with each other about the patient and ensure there are no delays in care. If such a structure is not part of an organization, collaborations should be sought outside the institution.

How do you approach patient education and shared decision-making when discussing complex treatment options like immunotherapy or targeted therapy in NSCLC?

Dr Puri: Patient education is instrumental. I try to simplify explanations as much as possible. I carry a sheet with me to every patient visit that describes the type of cancer they have, how it looks under the microscope, what biomarkers or genetic testing are needed, and the treatments they are eligible for.

For example, when discussing treatments, I explain that immunotherapy helps the immune system fight cancer, chemotherapy kills cancer DNA directly (but can also kill DNA of other important cells in your body), and targeted therapy blocks abnormal pathways that make lung cells grow into lung cancer. Visual aids and simple explanations help patients understand their options.

I avoid overwhelming patients with too much information at once. I tell the patient, "This is what we're going to discuss today, and this is our immediate next step. There are many steps that are going to come after that, but it is important that we take it one day at a time and don’t overwhelm ourselves with information."

Emotional context is equally important. If I'm not getting feedback from the patient that they're understanding or if I feel that they’re overwhelmed, I have to stop to ensure they understand. I always encourage patients to bring a family member to appointments because, again, it's extremely difficult when you're having tough conversations to isolate your emotions from what's going on and hear the whole thing. Having a family member or a friend there really helps.

What are some of the most common misconceptions patients have about NSCLC treatments, and how do you address them?

Dr Puri: A common misconception is that treatment is worse than the disease. Another is that all cancer treatments are similar. When I meet a patient, I tell them to forget the movie representation of a cancer patient. When the goal of treatment is not cure, it is to improve quality of life and survival. It is very important to explain that side effects depend on the treatment. If a particular treatment has side effects that are not agreeable, we can change the treatment or modify the doses so that it does get to that balance of being acceptable.

I always ask the patient what is acceptable to them. Some people might say, "I absolutely don't want any fatigue." For them, that is their level of acceptability. Other patients might say, "As long as I can do the things that I do, I'm okay." That is the most common response I hear, and I assure them that we will aim to achieve that. Some patients say things like, "My daughter is having a baby next month. I just want to make it until then."

The misconception is that treatment is one size fits all. It is not—it is very much tailored to the patient’s expectations for their life. Not all treatments are the same. Breast cancer treatment differs from leukemia treatment, which differs from lung cancer treatment. Certain cancer treatments, especially some breast cancer and leukemia regimens, are extremely strong. They can wipe out the bone marrow, and patients may lose all their hair, but this does not happen with all lung cancer treatments. That is the biggest misconception I encounter.

Another misconception is that lung cancer does not occur in non-smokers. Not everyone who smokes gets lung cancer, and many cases occur in patients who have never smoked. Other factors, such as radon and air pollution, are becoming almost as significant as tobacco use.

What role do you see for pathway-guided treatment decision-making in patients who experience resistance to first-line immunotherapy or targeted therapy?

Dr Puri: The world of oncology is becoming extremely complex, especially when a medical oncologist is treating multiple cancers simultaneously. It is crucial to have all the resources necessary to make clinical trial data-guided, evidence-based decisions for patients in a timely manner. That is where pathways are valuable, as they streamline decision-making by addressing the most common scenarios.

Pathways take the guessing game out of the process. When pathways are developed, they anticipate specific patient scenarios and recommend treatments. For example, if a patient progresses on one therapy, the pathway provides guidance on what to assess and what treatments might be most appropriate. It helps us get the best treatment to the patient in a timely manner.

Pathways are especially important for medical oncologists treating multiple type of cancer. It's often very challenging to keep ourselves up to date on advancements in oncology. I find it challenging just to keep up to date about lung cancer, so I can imagine how difficult it must be for oncologists managing several cancer types.

What do you see as the biggest unmet need in NSCLC research, and where should future studies focus to address these gaps?

Dr Puri: The biggest gap in lung cancer research is improving trial eligibility and access. Research should focus not only on bringing the best treatments to the patients as soon as possible, but also ensuring they reach the highest number of patients. Studies should address ways to improve accessibility to trials and broaden eligibility criteria.

Additionally, studies should focus on making the existing approved treatments more accessible. Even with FDA-approved treatments, patients often need to travel long distances for therapy. It's not only important to focus on the research behind new drugs, but also improving the accessibility and feasibility of treatments—from clinical trials to FDA approval and beyond.

Another critical area is recognizing that lung cancer, in all areas, is not one size fits all. Many genetic factors influence treatment decisions, but these can only be taken into consideration if they're tested and if the right test is ordered. It is important for all clinicians to be aware of the proper tests to order and ensure that tests are sent in a timely manner. I cannot tell you how many patients I have lost because they came to me too late or because tissue samples collected at other hospitals were not sent for testing. Accountability at every step of care is vital. Research should focus on how to improve that as well.