Management of non–small cell lung cancer (NSCLC), particularly early-stage disease, is becoming more complex given the availability of multiple treatment options and modalities such as neoadjuvant/perioperative/adjuvant targeted therapies and immunotherapy, surgery, and radiation therapy. A multidisciplinary team (MDT) approach is therefore essential to guide treatment decisions and optimize patient outcomes. The MDT is typically involved in diagnosis and staging, tumor biopsy and pathologic assessment, evaluation of resectability, selection of multimodality therapy, assessment of response, and follow-up (surveillance) after curative-intent treatment (Figure 1).¹ Pathologic assessment in particular has taken on growing importance in light of the many actionable alterations identified and growing number of available targeted therapies and immunotherapies. NSCLC evidence-based treatment guidelines and expert recommendations now support biomarker testing for the majority of patients with NSCLC to better inform prognosis and treatment decisions.^2-6 MDT-based care can help ensure a more informed and integrated approach to biomarker testing and interpretation of results and optimize selection of biomarker-informed therapy for NSCLC.^7-10

Biomarker-informed therapy encompasses both targeted therapies directed at specific oncogenic drivers and immunotherapy-containing regimens for patients without actionable driver mutations. While the use of biomarker testing and biomarker-informed therapy have increased substantially in the United States over the past decade, shortcomings still exist. A retrospective cohort study of patients with metastatic disease bearing targetable molecular alterations found that while 86% received biomarker-informed therapy (which was associated with improved overall survival [OS] in the first-line setting), a substantial proportion did not receive guideline-directed targeted therapy.¹¹ While biomarker testing rates in early-stage NSCLC have been increasing, use of biomarker-informed treatments in this setting is suboptimal as well.¹² Such shortcomings in testing and use of biomarker-informed therapy may particularly impact racial minorities and patient subpopulations such as those on Medicare and Medicaid.¹³ Common barriers to NSCLC biomarker testing include inadequate provider knowledge, gaps in communication, and the increasing complexity of genomic data and biomarker test reports.¹⁴ These barriers and treatment gaps can be addressed by an MDT.   

The main advantage of having regular multidisciplinary team meetings is that people will know what they need to do and their role in the oncologic care, which will minimize the time needed to get biomarker tests performed. Sinchita Roy-Chowdhuri, MD, PhD

The growing number of NSCLC alterations characterized, expanding treatment armamentarium, and evolving treatment guidelines require oncologists to maintain a high level of expertise in order to guide biomarker-informed treatment decisions. MDT-based care can significantly improve patient outcomes by supporting appropriate biomarker testing, expert interpretation of results, and use of guideline-concordant biomarker-informed therapy in both early-stage and advanced/metastatic NSCLC.^7,8 According to Sinchita Roy-Chowdhuri, MD, PhD, Professor in the Department of Pathology at The University of Texas MD Anderson Cancer Center, “The main advantage of having regular multidisciplinary team meetings is that people will know what they need to do and their role in the oncologic care, which will minimize the time needed to get biomarker tests performed.” For example, the MDT can ensure that adequate tumor tissue is collected from the start so the patient does not have to come back for another biopsy. Prompt ordering of testing also avoids wasting time waiting for results. “This way, by the time the patient sees our thoracic medical/surgical oncology team, we have the results needed to match the patient with the right treatment,” she said.

MDT Roles and Functions in NSCLC Care

The MDT typically comprises medical oncologists, thoracic surgeons, pulmonologists, surgical pathologists, molecular pathologists, cytopathologists, interventional radiologists, radiation oncologists, pharmacists, and other ancillary staff (nurses, advanced practitioners, geneticists, etc).^9,15 Generally, the pulmonologist/interventionalist collects the initial tumor biopsy; the pathologist provides the diagnosis; the molecular pathologist performs and interprets the genomic profiling and recommendations for systemic therapy; the surgeon decides when and if resection is appropriate; and the oncologist has available the armamentarium of approved drugs and investigational therapeutic options (through clinical trials). All MDT members need to be aligned so everyone has a voice in treatment decisions and treatment options can then be presented to the patient, Dr. Roy-Chowdhuri emphasized. “Having multidisciplinary team conversations is key so all the people at the table—those making the diagnosis, collecting the tissue, performing the molecular testing, as well as clinicians treating the patient—function as one team to ensure that everybody's on the same page in terms of the diagnosis, biomarker testing results, potential therapies, and the treatment selected,” she said. In the absence of a well-balanced, effective MDT, one specialty is likely to predominate, without due consideration given to other potential treatment approaches. According to Jessica Donington, MD, Chief of Thoracic Surgery at University of Chicago Medicine, “Who’s on the multidisciplinary team really does direct what happens to patients, and that's why I believe getting that team as robust as possible is so important.”

Having multidisciplinary team conversations is key so all the people at the table … function as one team to ensure that everybody's on the same page in terms of the diagnosis, biomarker testing results, potential therapies, and the treatment selected. Sinchita Roy-Chowdhuri, MD, PhD

The MDT can help determine the feasibility and method of tumor biopsy for biomarker assessment, assess pulmonary function, determine the possibility and optimal type of surgery for biopsy or resection (where appropriate), review pathology reports and biomarker testing results, and decide on clinical staging.¹⁵ Its members work collaboratively to develop an individualized treatment plan for each patient, including choice and optimal sequencing of systemic therapy based on tumor stage, biomarker results, patient functional status, and goals of therapy. MDT expertise can be invaluable when reviewing difficult NSCLC cases or analyzing highly complex biomarker results. The MDT also evaluates response to treatment and can suggest any subsequent-line therapy based on current treatment guidelines. The need for MDT-based care is growing and encompasses all stages of disease. “Management of all of stage II and III NSCLC has become 100% multidisciplinary, so everybody needs to be on board for those conversations,” noted Dr. Donington.

Management of all of stage II and III NSCLC has become 100% multidisciplinary, so everybody needs to be on board for those conversations. Jessica Donington, MD

MDT Consensus Statements

Expert recommendations and consensus statements support the need for MDT-based care across all stages of NSCLC and emphasize how this approach can optimize tissue biopsy, biomarker testing, treatment, and other aspects of patient care.^14,16-18 Regular MDT meetings are recommended to avoid delays in testing, evaluation, and identification of treatment options in order to facilitate prompt initiation of therapy. All MDT members should receive periodic training on biomarker testing, NSCLC biomarker-informed therapy, and current treatment guidelines to maintain competency and address any knowledge gaps resulting from emerging clinical trial results and recent guideline updates.

Molecular Tumor Boards

Given the complexity of NSCLC molecular alterations and biomarker reports, and the increasing number of therapies now available, molecular tumor boards (MTBs) can provide support to the MDT by evaluating and applying biomarker test results to clinical practice. The MTB often consists of a tumor-specific medical oncologist and a pathologist with expertise in molecular diagnostics, who can guide the MDT on molecular or immunohistochemical testing and recommend the most appropriate personalized therapy based on the biomarker profile. MTBs work to ensure equitable, timely, and comprehensive biomarker testing by optimizing tissue acquisition, processing, and analysis to improve workflow; minimizing turnaround time; and tracking, interpreting, and communicating results to the MDT.¹⁹ The MTB can also advise on the best site for biopsy, assess specimen quality, recommend testing methods, and report and interpret particularly complex test results.²⁰ Biomarker testing results should be clearly presented using standardized reports that include clinicopathology (tumor characteristics, treatment history), biomarker findings (testing results, biopsy details, interpretation of alterations), and recommendations (treatment, retesting, genetic counseling).⁹

MTB review of NSCLC cases is associated with significantly improved OS compared with no MTB review, demonstrating its value in MDT treatment decisions.^21,22 In patients with newly diagnosed NSCLC, poorer survival was significantly associated with lack of MTB review (hazard ratio = 8.61; 95% CI = 3.83–19.31; P < .0001).²¹ The survival benefit associated with MTB review may be due in part to overcoming some physicians’ lack of experience with comprehensive genomic profiling and interpretation as well as ensuring adherence to biomarker-concordant treatment guidelines.

Benefits of MDT Care in NSCLC

Multiple studies have documented the benefits of MDT-based care for patients with NSCLC. A systematic review and meta-analysis, based on over 61,000 patients with lung cancer (mostly NSCLC), indicated that MDT care was associated with significantly longer OS, shorter treatment time, and a higher proportion of complete staging compared with non-MDT care.¹⁰ Such an approach may also shorten time from diagnosis to first treatment, allowing earlier initiation of first-line therapy. Another study reported that MDT care was associated with improved patient outcomes, including longer survival for all stages of lung cancer.²³ Furthermore, it resulted in more patients receiving active treatment, increased the use of surgery, radiotherapy, and chemotherapy, and improved adherence to treatment guidelines. According to Dr. Donington, “MDTs push all of us toward better evidence-based care through the continual sharing of ideas, presenting evidence, trials, and guideline changes in other specialties that we may not be aware of.”

MDTs push all of us toward better evidence-based care through the continual sharing of ideas, presenting evidence, trials, and guideline changes in other specialties that we may not be aware of. Jessica Donington, MD

A real-world study of patients with metastatic NSCLC found that those who received MDT care had a significantly longer OS compared with those who underwent non-MDT care (14% lower mortality risk), with survival benefit noted across most patient subgroups.⁸ Similar benefits were also seen in a retrospective study of earlier-stage disease, where MDT care of patients with resectable NSCLC was associated with significantly longer OS compared with non-MDT care, as well as shorter waiting times for bronchoscopy, pathology reports, and surgery scheduling (Figure 2).⁷ MDT-based care might also result in lower health-care costs due to fewer diagnostic tests, fewer provider visits, and reduced need to manage toxicity due to use of inappropriate therapy.²⁴  

In spite of its proven benefits, practice gaps remain in the use of MDT-directed care for NSCLC, indicating room for improvement. A global survey of physicians, for example, reported that only 37% used MDT care for all patients with early-stage NSCLC. When it was employed, the top three drivers of MDT success were multispecialty representation, availability of complete diagnostic information, and effective communication.²⁵ Conversely, another study indicated that the top three barriers to effective multidisciplinary management of NSCLC among community oncology providers were infrequent communication, misalignment on communication methods, and lack of strong interpersonal relationships among the team.²⁶ Addressing these practice gaps led to increased biomarker testing, improved workflows, and better communication among the MDT.