Multidisciplinary Care for Advanced Melanoma at Georgetown University
MICHAEL B. ATKINS, MD AND KELLIE GARDNER, NP
Tuesday, March 07, 2017
Michael B. Atkins, MD: At MedStar Georgetown University Hospital, we have a multidisciplinary team that deals with our melanoma patients. For our early stage patients — those with stage I to III disease that are just presenting with their initial diagnosis — we actually have a multidisciplinary clinic that includes medical oncologists, nurse practitioners, dermatologists, surgeons, and a head and neck surgeon all seeing the patients. And then, we break to go to a conference that includes our dermatopathologist, our research nurses, and even sometimes radiologists where we discuss the patient’s clinical presentation, review their pathology, come up with not just a treatment but a treatment plan, and then we go and execute it. And for our patients with advanced melanoma, we tend to use the same team because we’re used to working together even though we see patients primarily in our hematology-oncology clinic. Kellie, could you just talk a little bit about your role as a nurse practitioner, as well as how some of our colleagues in the other departments and disciplines help us to manage our patients with advanced melanoma?
Kellie Gardner, NP: As a nurse practitioner, I see the patients when they first present in the clinic —when they’re first diagnosed — and develop a treatment plan for them, also seeing them pretty regularly for toxicity management and evaluation. And we get to know our patients quite well. We’re seeing them very often. Our team includes the radiation oncologists. If our patients present with brain metastases, we can refer to that team, if needed, for treatment of the CNS metastases. We also have a good list of surgeons. Even in our advanced melanoma patients, sometimes surgery is indicated, such as if they have a low metastasis that hasn’t regressed with treatment, and we can have our surgeons remove that metastasis and still see long-term benefit with these patients. We also have used radiation oncology, in the past, a lot for brain metastases.
Historically, melanoma was treated with either whole brain radiation or resection followed by radiation to the surgical bed, so radiating a lot of normal brain tissue. As a result, these patients are living longer with immunotherapies, but we’re seeing long-term consequences from radiation, such as radiation necrosis, which can be quite debilitating. These patients can be essentially disease-free from their melanoma, but they’re on long-term steroids for radiation necrosis and they’re physically debilitated. As a result of that, we were trying to figure out ways to use treatments to avoid surgery or avoid radiation by using immunotherapy. We know immunotherapy can be quite effective in the brain, and we’re trying to see if we can avoid gross resections or radiation, long-term consequences, and instead using the immunotherapy to melt their disease away.
Michael B. Atkins, MD: To add to that — you mentioned this with the role of surgery — a lot of times we’re also looking at when to stop treatment. And so, in patients who have responded to therapy but have residual disease on their CT scans, we’ve tended to do PET scans. If the PET scans are silent, we’ve used that to stop therapy. And, if the PET scans still show evidence of uptake in the residual lesions, we’ve often asked our surgeons to go in and biopsy or even remove a PET-positive lesion. When we review that in our multidisciplinary conference with our dermatopathologist, we’ve been surprised that most of those lesions have no viable tumor in it. That has allowed us to feel comfortable in stopping treatment in those patients as well.
We hope to incorporate, as we move forward, the surgeons even more in the management of patients in our research protocols, potentially getting information early on about how quickly responses develop and also use tissue to examine and to understand mechanisms of resistance to immune therapy that might help us determine what the next best treatment might be.
Kellie Gardner, NP: Patients have several concerns when they’re first diagnosed with advanced melanoma, the first of which is, which treatments are available to effectively treat their cancer and to give them the best shot at a long-term, durable response. There used to be very few treatment options available for advanced melanoma, but more recently, we have multiple treatment options that we can use that have good responses.
Patients also want to know that, as an individual, which treatment would be best for them to give them the best shot at a long-term response. They also want to know how this will affect their life. How’s it going to affect their normal routine — if they’re going to work, if they’re going to be able to travel. And they also want to know what limitations they may have with treatments or clinic visits. Patients also want to know about their staging, what needs to be completed in order to get a complete picture of their melanoma. They also want to know about how to get in contact with their melanoma team if they have questions after their clinic visit, if they develop any side effects or any problems with therapy. They want to know that they have a team that’s available for them any time during the week, nights, or holidays, and how to get in contact with us.
We always tell our patients that they should reach out whenever they have any questions. You’d rather know about any side effects that they have early on, that they should reach out. Even if they think it’s mild, we want to know about it because we may not agree with them. We may think it’s more serious than they do.
We also provide our patients with different packets so they have, for their individual therapies, something that shows how to take their medications, what side effects to expect, when they should call their team and report any side effects, and as well as what other non-standard options there might be — like other clinical trials that they can pursue or treatments that they generally wouldn’t think of if they are pursuing standard therapies.