Communication critical in management of patients with ocular cancer

Medical professionals have differing roles in the diagnosis and treatment of ocular cancers and cancers that affect the eye.

As cancer patient care becomes more coordinated and highly specialized, ophthalmologists, ophthalmic oncologists and oncologists are forging new relationships for managing patients with ocular and other types of cancers.

David Abramson, MD, chief of the ophthalmic oncology service at Memorial Sloan-Kettering Cancer Center, and Dan S. Gombos, MD, FACS, an ocular oncologist at the University of Texas MD Anderson Cancer Center, spoke about cooperation among the specialties in interviews.

Abramson said the cooperation works both ways. In some cases an ophthalmologist finds a possible ocular cancer and seeks the help of oncologists; in other cases an oncologist may seek the assistance of an ophthalmologist.

“Ophthalmologists and optometrists are usually the first people to see patients who either have symptomatic or asymptomatic ophthalmic problems related to benign or malignant tumors,” Abramson said. “Most adults complain when they notice things related to their vision, but young children often don’t complain about anything, and their cancers are picked up by their parents.”

Abramson said for primary cancers of the eye and the orbit, ophthalmologists must take the primary role, with oncologists and other health care professionals in secondary roles. With cancers that are secondary metastatic diseases to the eye, the roles are usually reversed.

He said the roles of ophthalmologists continue to change as the field advances. More often today, cancer care is handled in a tertiary setting.

“Nowadays in the United States, most patients are referred to someone who is doing ophthalmic oncology,” Abramson said. “We’ve really gone beyond the realm of what a good practicing, comprehensive ophthalmologist can handle with a cancer patient. I think if anything has changed in our field, it’s the recognition that ophthalmic oncology patients need coordinated care that is beyond what ophthalmologists themselves can offer.”

Role of communication

Communication plays an important role in a coordinated effort to battle cancer, Abramson said. He said that physicians practicing in this subspecialty must strengthen their communication skills. As they do so, this will help patients by allowing them access to the full expertise of the medical profession.

“The management of cancer of the eye is now shifting away from just ophthalmologists to well-coordinated, well-organized, highly communicative situations, where ophthalmologists, radiation oncologists, nurses, pediatric oncologists, pathologists, radiologists, geneticists and social workers are all playing a role in helping patients who have ophthalmic neoplasias,” he said. “That’s what patients need, and that’s what they deserve. As each of these fields gets better in the way it helps patients with cancer, the need for coordination of all these specialists will become greater.”

Gombos said communication is critical. He said there are often situations at his cancer clinic where oncologist colleagues rely significantly on him and his fellow ophthalmologists.

“Communication has huge implications,” he said. “When a patient develops choroidal metastasis from, for instance, breast cancer, it might be the first sign of a new metastatic lesion. It’s up to the ophthalmologist to communicate with the medical oncologist their diagnosis.”

Gombos’ hospital uses the voice-activated system Vocera (Vocera Communications), which allows doctors to speak instantly to each other through a device worn around the neck. He said as the treatment of cancer patients becomes more multidisciplinary, a system like Vocera for dissemination of patient information and treatment protocols takes on new importance.

“We’re seeing that health care is very subspecialty oriented,” he said. “Ocular oncology is emerging as a distinct field within ophthalmology, like cornea or pediatrics. Increasingly we are going to find that subspecialty institutions, often university-based, can provide broad-spectrum multidisciplinary care. That’s really where the success in cancer management lies.”

Melanoma detection

Abramson said that for each type of cancer, the interactions between specialties and subspecialties are different, suited to the needs of patients and their specific disease.

A general ophthalmologist, for example, is usually the first person to see a patient with ocular melanoma, Abramson said.

About 60% of patients who have ocular melanomas have no symptoms, rendering the routine dilated exam by the general ophthalmologist important in diagnosis, he said.

“The ophthalmologist on a routine dilated exam suddenly sees melanoma in the eye,” Abramson said. “The other 40% of ocular melanomas are patients who present visual symptoms – usually it’s an abnormality in the visual field or visual acuity. In evaluating the patient, the ophthalmologist finds out the patient has an ocular melanoma.”

Gombos said that at the MD Anderson Cancer Center the ophthalmic oncology service is within the head and neck department.

All new patients are presented at both ophthalmic tumor boards and head and neck tumor boards, so there is multidisciplinary discussion to review the implications from the start of care.

At his institution, uveal melanoma is often treated with radiation therapy with other therapies, he said. The radiation oncologists work with ophthalmologists, attending operations and playing a role in dosimetric planning.

Retinoblastoma care

Gombos said the management of retinoblastoma is a perfect example of the multidisciplinary approach now being taken in ophthalmic oncology. The ophthalmologist evaluates the patient and makes the initial diagnosis.

Then careful ancillary testing must be done, sometimes through the ophthalmology department, sometimes through neuroradiology. He said the coordination of the two departments helps physicians and patients to achieve the most accurate, timely care.

Additionally, pediatricians play a key role in administering chemotherapy and dealing with neutropenia, hair loss or other toxicity from the treatment, he said.

Abramson said parents are commonly the first to detect retinoblastoma, often through the appearance of leukocoria. He said they often take the child to the pediatrician rather than an ophthalmologist. The pediatrician sends the child to a general or pediatric ophthalmologist, who refers the child on to the ophthalmic oncologist.

Retinoblastoma management has left the domain of ophthalmologist-only care, he said.

“These children need complex, coordinated care,” Abramson said. “The decision-making process must involve a number of physicians, and the children need a lot more than ophthalmologists can offer. The eye can be very well handled by ophthalmologists, but what the kids and the families need is way beyond that.”

He said the family of a child with retinoblastoma could need genetic counseling, radiology, radiation oncology, social work and psychological help, all of which can be addressed with a multidisciplinary approach to medical treatment.

Metastatic tumor care

Metastatic tumors can affect the eye in two scenarios, both of which now involve multidisciplinary approaches, Abramson said.

The first scenario is in a patient who has a known cancer, such as breast cancer, who develops a metastasis to the eye. For that patient, diagnosis is usually not an issue because an oncologist is already in control of the care, he said. An ophthalmologist will work together with the oncologist in that patient’s treatment.

“This is a case where managing the eye has no impact on long-term survival, but it has a huge impact on quality of life and how somebody sees,” Abramson said.

The second scenario is in a patient who does not realize he or she has cancer, he said.

The first manifestation not only of the ocular disease, but also of the system cancer, is an eye tumor and blurred vision. Often the ophthalmologist will see the tumor, suspect it is metastatic disease, and send that patient on to the oncologist, Abramson said.

Managing side effects

Abramson said many cancer treatments – radiation, chemotherapy, surgery – can be toxic to the lid, the cornea, the orbit, the optic nerve, the retina and other parts of the eye.

Patients can sometimes develop significant ocular complications from the successful treatment of a cancer elsewhere in the body, he said.

In those cases, the ophthalmologist may be called upon to help manage ocular problems that are a manifestation not of the cancer, but of the treatment.

Gombos said helping patients recover from treatment complications through a multidisciplinary approach is key to assisting them through the healing process.

“Some of these patients are profoundly immunocompromised,” Gombos said. “Addressing all of their ocular complications even after their cancer is cured is a significant component of the care we provide.” – by Erin L. Boyle

This article also appeared in Ocular Surgery News, a SLACK Incorporated publication.