Recently, I encountered a patient who was also being co-managed by another oncologist at a major hospital institution in the state. The patient had Stage IV Merkel Cell Carcinoma, which is a particularly aggressive form of skin cancer. Prior treatment with a single agent drug called pembro had failed the patient with rapid progressive disease through the treatments, and I quickly switched the patient to chemotherapy, which produced a near complete response. However, over time, the patient developed sporadic new oligo-metastatic tumors (where we only see one tumor show up at any given point in time), which were treated with multiple rounds of radiotherapy over time. Ultimately, the patient developed a tumor in one of the adrenals, and we all agreed to try an off-label regimen using two immune checkpoint drugs in addition to focal radiation to the adrenal tumor.
Unfortunately, the patient developed moderate pneumonitis or inflammation of the lungs due to this new treatment, which required a prolonged high dose taper of steroids until full recovery back to his baseline. We monitored the patient with surveillance scans over 6-8 months, but the disease unfortunately progressed to new lymph nodes in a different part of the body. The patient then visited the other oncologist, who unbeknownst to me, suggested a third round of immunotherapy. I was perplexed by this decision, as the patient had already undergone two rounds of immunotherapy that failed to produce remission, with the second round even causing life-threatening complications. Typically, immunotherapy when it works well can be very effective for Merkel Cell Carcinoma and keep the disease in remission for years, but in this case, it clearly wasn’t working. Both the patient and the other oncologist were calling my clinic to start 3rd immunotherapy right away but what was I missing?
This is where a direct physician-to-physician conference call needed to happen. I got on the phone with my colleague at the other institution. I suggested that we consider a clinical trial instead with a new promising drug or consider radiation/chemotherapy in the interim. However, the other oncologist believed that a third round of immunotherapy was the best option, citing “great response” in the patient’s post-treatment scans of the adrenal tumor. Unbeknownst to the other oncologist, I pointed out that the adrenal tumor that responded was also treated with focused radiation at our institution. He did not have those records and the patient neglected to mention that bit of pertinent information. Ultimately, after a respectful collaborative conversation, we agreed that a new clinical trial would be in the patient’s best interest. The other oncologist was opening the same exact protocol at their site within months and we were only weeks away from site activation.
Sometimes, too many cooks in the kitchen can create confusion with conflicting opinions and ultimately frustrations that go all around to not only the patient but also the providers. I have another patient who had sought opinions at three institutions for a Carcinoma of Unknown Primary. Each provider had a slightly different opinion on the exact tumor type, surveillance imaging studies, and/or the specific treatment regimen to offer the patient. Generally speaking, to all of us providers, there may be several reasonable ways to evaluate, manage, and/or treat the patient but to the patient and family, this may sound like three different opinions!
Cancer is a complex disease that requires a multi-disciplinary approach to treatment. This often involves a team of doctors, including medical oncologists, radiation oncologists, surgeons, and other specialists. In some cases, cancer patients may be co-managed by more than one oncologist at different institutions, which means that two or more doctors are involved in their care. While there are advantages to co-managing cancer patients, there are also some potential drawbacks.
Advantages of Co-Management
- Expertise: Co-managing cancer patients means that the patient benefits from the expertise of multiple doctors. Each doctor brings a unique perspective and skillset to the table, which can lead to better treatment decisions and outcomes.
- Collaboration: Co-managing cancer patients encourages collaboration between doctors. This can lead to more comprehensive treatment plans that take into account all aspects of the patient’s health and well-being.
- Convenience: Co-managing cancer patients can be convenient for patients who live in different geographic areas. This allows patients to receive treatment from multiple doctors without having to travel long distances.
- Access to Clinical Trials: Co-managing cancer patients can also provide them with access to a wider range of clinical trials. Clinical trials are research studies that test new treatments or procedures to see if they are safe and effective.
Disadvantages of Co-Management
- Communication: Co-managing cancer patients requires good communication between doctors. This can be challenging, especially if the doctors work in different institutions or have different communication styles. Some institutions are very aggressive and others can be conservative in the approach of managing the same patient. Attend any oncology conference where a complicated patient case is presented, bring some popcorn, and enjoy the show!
- Conflicting Opinions: Co-managing cancer patients can also lead to conflicting opinions between doctors. This can create confusion and uncertainty for the patient and their family. There is a saying that too many cooks in the kitchen can be challenging in accomplishing what are probably the same goals.
- Duplication of Tests: Co-managing cancer patients can lead to duplication of tests and procedures. This can be costly and time-consuming for the patient. Certain institutions will charge upfront fees just to walk through the doors plus mandate scans and labs be done at their institution even if the same exact scans/labs were just recently done?
- Increased Risk of Medical Errors: Co-managing cancer patients can increase the risk of medical errors. This is because there is a greater chance of miscommunication between doctors or confusion over who is responsible for what aspect of the patient’s care. The above patient scenario is an example of that.
Co-management of cancer patients can have both advantages and disadvantages. It is important for patients and their families to understand these pros and cons and to communicate effectively with all their doctors. This will help to ensure that patients receive the best possible care and that all aspects of their health and well-being are taken into account.
About the author
Dr. Sajeve Thomas is a distinguished medical professional and a compassionate guide in the field of oncology. With over a decade of dedicated experience as a board-certified medical oncologist/internal medicine specialist, Dr. Thomas has become a trusted expert in the treatment of melanoma, sarcoma, and gastrointestinal conditions. Currently practicing at the renowned Orlando Health Cancer Institute, he brings a wealth of expertise to the complex and challenging world of oncology.