Lung cancer is a common cause of morbidity and mortality. The investigation and management of patients with lung cancer have become more complex and therefore requires a multidisciplinary teamwork approach. The lung cancer multidisciplinary team usually includes the respiratory specialists, radiologists, histopathologists, thoracic surgeons, clinical and medical oncologists, pulmonary physiologists, clinical psychologists, palliative care specialists and the cancer nurse specialists. The work of the lung cancer multidisciplinary teams can be subdivided into three aspects: the initial investigational pathway, treatment pathway and finally palliative care support. The multidisciplinary approach allows for the rapid diagnostic pathways for staging and histological diagnosis. The management of lung cancer has significantly improved in the recent years therefore a multidisciplinary team collaboration between thoracic surgeons and oncologists has become more important. As many patients with lung cancer present in advanced stages of the disease, palliative care team approach would frequently be required to be adapted. The development of new investigational and therapeutic options makes the multidisciplinary team approach the most appropriate model to meet the challenges of the complexity of the current management of patients with lung cancer.

Keywords: Lung Cancer; Radiotherapy; Bronchoscopy

Lung cancer is a common cause of morbidity and mortality with over 2 million new cases and 1.8 million deaths reported yearly worldwide [1]. A large proportion of patients with lung cancer are diagnosed at a stage where the disease is incurable and only around 15% of cases are in the early stages of the disease [1]. Patients presenting with the more advanced disease usually have symptoms such as breathlessness, cough, hemoptysis, weight loss, or pain. In contrast, patients with early-stage lung cancer may remain asymptomatic. To improve the detection of early stages of lung cancer there have been initiatives introduced to increase the public awareness of lung cancer, early detection of high-risk individuals within the primary care setting, or initiation of lung cancer screening programs. The investigation and management of patients with lung cancer have become more complex and therefore require close multidisciplinary teamwork. The lung cancer multidisciplinary team usually includes respiratory specialists, radiologists, histopathologists, thoracic surgeons, clinical and medical oncologists, pulmonary physiologists, clinical psychologists, palliative care specialists, and cancer nurse specialists [Table 1]. The work of the lung cancer multidisciplinary teams can be subdivided into three aspects: the initial investigational pathway, treatment pathway, and finally palliative care support.

Table 1: The roles of the members of the multidisciplinary lung cancer team.

The current expectation is to deliver rapid diagnostic pathways for lung cancer, which relies on close multidisciplinary teamwork [2]. Many centers assess patients with suspected lung cancer through designated fast-track lung cancer clinics [3]. This approach allows the initiation of investigations such as imaging in the form of computed tomography (CT) scan, which gives initial staging and diagnostic information, to be performed in advance of the clinic visit. The patients are seen in a designated lung cancer clinic by a lung cancer respiratory specialist in the presence of a specialist lung cancer nurse who would provide continuous support through the patients’ investigational and treatment pathways [1]. The lung cancer investigational pathways require efficiency and at the same time need to be flexible in order to provide the diagnosis in a timely manner using the most appropriate tests for defining precise staging and histological confirmation of lung cancer. In fact, the use of rapid diagnostic pathways for lung cancer has been shown to result in some benefits in lung cancer survival outcomes [2]. One of the most important aspects of the multidisciplinary team approach for the investigation of lung cancer lies in the initial coordination of the investigations. This can take the form of a designated investigational multidisciplinary team meeting supported by an administrative pathway coordinator and managed by the team composed of the respiratory physicians, radiologists, thoracic surgeons, and specialist lung cancer nurses, who review the investigations for the individual patients and decide on the order of the subsequent tests. The team makes sure that the patient is regularly informed about the findings of the investigations and explains the need for the most appropriate subsequent tests. For example, Positron Emission Tomography (PET) scan results may be able to guide the appropriate tests required for tissue histological confirmation of lung cancer. A PET scan is of particular importance in mediastinal lymph node staging [1]. Combined bronchoscopy and endobronchial ultrasound (EBUS) and in some centers Endoscopic Ultrasound (EUS) has become the most appropriate approach to mediastinal lymph node sampling, which forms a pivotal aspect of lung cancer staging and ultimately determines the therapeutic management as well as providing histological confirmation [4].

Many patients considered for radical therapy would require physiological assessment in the form of detailed lung function tests to enable post-operative predicted Forced Expiratory Volume in one second (FEV1) and transfer factor (DLCO) to be calculated and to make a decision as to whether further physiological tests such as a shuttle walk or cardiopulmonary exercise testing (CPET) may be required. These tests assist in the assessment of physiological parameters including maximal oxygen uptake (VO2 max), which is frequently used in stratification with regards to fitness for lung cancer surgery thus highlighting the role of the pulmonary physiology laboratories and the respiratory physiologists within the lung cancer pathways [5]. The physiological assessment with regards to fitness for surgery or radical therapies is of particular importance for patients with early-stage lung cancer. In these patients obtaining histological confirmation may be associated with some degree of difficulty as many may present with a solitary, not infrequently, peripheral lung lesion. The investigation of peripheral lung lesions requires multidisciplinary teamwork between the respiratory physicians, thoracic surgeons, and radiologists as the choice of tests to sample these lesions vary from a CT-guided biopsy to the newer modalities such as radial EBUS or navigational bronchoscopy [6,7]. Similarly, patients with more advanced disease would require access to a wider range of investigations such as an ultrasound guided liver or neck lymph node biopsy, which again requires careful interaction between the respiratory specialists and the interventional radiologists.

Once histological and staging confirmation of lung cancer is complete the next step would be a multidisciplinary team decision on the most appropriate therapeutic options. For patients with early-stage lung cancer, the options would include surgical resection or, if the patients are considered unfit for surgery, radical radiotherapy could be offered. The multidisciplinary team approach here allows an in-depth review of the imaging, histological findings, pulmonary physiological tests, and patients’ co-morbidities. The results of lung function tests such as FEV1 and DLCO help to assess the patients’ fitness for surgery and determine whether to proceed with a pneumonectomy, lobectomy, or lung-sparing surgery such as segmentectomy or wedge resection [5]. Guidelines recommend sub-lobar resections (wedge resection, segmentectomy) for peripheral lung cancer and this is considered a useful option for patients with impaired pulmonary reserve [8]. In patients with adequate pulmonary function, a lobectomy with systematic lymph node dissection remains the gold standard operative approach. Evolution in thoracic surgery has yielded minimally invasive procedures via robotic-assisted and video-assisted thoracic surgery performed through several small incisions. These approaches have allowed more operative dexterity and precision, reduced hospital stay and pain while maintaining excellent oncological outcomes [9]. The involvement of the thoracic surgeons as part of the multidisciplinary team is essential to identify patients that would benefit most from the various surgical approaches available.

In patients considered to be borderline with regards to fitness for surgery an assessment of maximal oxygen consumption using CPET may be required with a VO₂ max of more than 20 ml/kg/min suggesting a low risk for surgery. However, if VO₂ max is reduced then alternative radical therapies need to be considered and this would require close work between the thoracic surgeons and clinical and medical oncologists. Radiotherapy is one of the main therapeutic options for treating lung cancer [1]. The role of the multidisciplinary team is to decide which patients would benefit from radiotherapy and what type of radiotherapy to use especially when deciding on intensity-modulated radiotherapy (IMRT) and stereotactic ablative body radiotherapy (SABRT) [10]. SABRT has become the standard of care for patients with early-stage small peripheral lung cancer deemed inoperable [11]. In a proportion of patients with lung cancer, a combination of radiotherapy and systemic anticancer therapy such as chemotherapy and more recently immunotherapy may be an option requiring close work between clinical and medical oncologists (1). This is of particular importance since the publication of the PACIFIC trial, which showed that the combination of concurrent chemo-radiotherapy with adjuvant immunotherapy Durvalumab showed improved overall survival rates at 24 months [12]. In cases of advanced lung cancer, several new immunotherapeutic agents including Atezolizumab and Bevacizumab have been shown in addition to chemotherapy to improve progression-free and overall survival [13]. Another example of a multidisciplinary team approach is in managing patients who have positive surgical margins, where it is acceptable to consider postoperative radiotherapy with the aim of preventing local recurrence [14]. In advanced cases of lung cancer, curative intent radiotherapy is not possible and palliative radiotherapy for symptom control can be offered.

Another area where multidisciplinary teamwork is required is in the management of stage 3 lung cancer and N₂ disease where there remains uncertainty as to the best therapeutic approach [15]. In patients with large mediastinal lymph nodes, concurrent chemo-radiotherapy may be an option [16]. Although some guidelines recommend that an early and locally advanced lung cancer of non-small cell type may be considered for surgery and multimodality treatment, which may take the form of induction chemotherapy followed by surgery, chemoradiotherapy followed by surgery or surgery followed by adjuvant chemotherapy [17]. However, this is with the understanding that there is not enough evidence to support these approaches, therefore the decision-making would rely upon the multidisciplinary teams [17,18]. The histopathological assessment is of great importance when deciding on the systemic anticancer treatment options. The management of small cell cancer differs from that of non-small cell cancer where therapeutic options would depend on the presence of genetic mutations including epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), or ROS-1 [19]. Moreover, the development of immunotherapy including agents targeting immune-check points in non-small cell lung cancer has been shown to have beneficial outcomes in lung cancer with an expression of programmed death receptor ligand-1(PDL-1), which has resulted in additional therapeutic options for systemic lung cancer therapy [20]. Tyrosine kinase inhibitors such as crizotinib in patients with ALK mutations positive lung cancer have demonstrated longer progression-free survival compared to chemotherapy alone [21]. The National Institute for Health and Care Excellence (NICE) guidelines have approved the use of Erlotinib, Afatinib and Gefitinib for EGFR mutation-positive non-small-cell lung cancer [22]. Therefore, multidisciplinary work between histopathologists and oncologists has become more complex.

A large proportion, around three-quarters, of patients are diagnosed with advanced-stage III and IV of lung cancer [1]. Moreover, around 20% of patients with newly diagnosed lung cancer were reported to die within 30 days from diagnosis [23]. Therefore, a multidisciplinary approach inclusive of palliative care team members forms an essential aspect of managing lung cancer. The main aim of palliative care is to reduce patient's suffering and to offer symptom control, which requires addressing physical, spiritual, and psychological domains related to lung cancer [1]. The symptoms such as dyspnoea, hemoptysis, or bronchial stenosis may be related to primary lung cancer. In addition, patients may have symptoms related to a metastatic disease such as cord compression, pain from bone metastases, or superior vena cava obstruction. In these cases, a multidisciplinary team approach between oncologists, thoracic surgeons, and palliative care teams would be required to decide on the need for palliative radiotherapy, endobronchial stenting, and the more holistic approach to symptom control. For example, management of hemoptysis may require palliative radiotherapy, endobronchial intervention, systemic anticancer treatment, or involvement of the interventional radiologists in cases requiring bronchial artery embolization. In addition, there is also evidence to support the beneficial effect of interdisciplinary teamwork within the palliative care models, which have been shown to have positive outcomes on quality of life in patients with lung cancer [24].

In conclusion, lung cancer management requires close work within the multidisciplinary team settings. The care of patients with lung cancer not infrequently requires interdisciplinary collaborations. The core members of the lung cancer multidisciplinary teams are respiratory physicians, oncologists, lung cancer specialist nurses, and thoracic surgeons. However, the support from radiologists, histopathologists, and palliative care teams also form a valuable component of the multidisciplinary team approach. There are a number of new developments within the diagnostic and therapeutic aspects of lung cancer. The development of new surgical approaches such as robotic-assisted surgery, novel radiotherapy techniques, and treatment options of systemic anticancer therapies will require continuous adaptation of investigational and therapeutic pathways. Therefore, the development of new therapies makes the multidisciplinary team approach the most appropriate model to meet the challenges of the complexity of the current management of patients with lung cancer.