Communication critical in management of patients with cancer

Different 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

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 M.D. Anderson Cancer Center, spoke about cooperation among the specialties in telephone interviews with Ocular Surgery News.

Dr. 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,” Dr. 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.”

Dr. Gombos noted that when the primary disease is ocular, the ophthalmologist becomes the primary physician in patient treatment; when the ocular disease is secondary, the ophthalmologist plays a secondary but still vitally important role.

Dr. Abramson agreed. With 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,” Dr. 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.”

Communication

Communication plays an important role in a coordinated effort to battle cancer, Dr. 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.

Dan S. Gombos

“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.”

Dr. 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.”

Dr. Gombos’ hospital uses the voice-activated system Vocera, 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.

“I think 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

Dr. 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, Dr. 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,” Dr. 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.”

Dr. Gombos said that at the M.D. 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 in combination with other therapies, he said. The radiation oncologists work with ophthalmologists, attending operations and playing a role in dosimetric planning.

Retinoblastoma care

Dr. 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.

Dr. 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,” Dr. 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.

Testing of fine needle aspirates predicts metastatic risk in ocular melanoma Patients with ocular melanoma are at risk for liver metastases, which are often not detected until they have turned into large, lethal tumors. However, researchers have found molecular markers that indicate the presence of small metastases before they grow. The same group of researchers also found that fine needle biopsy can accurately detect these molecular signatures. “The results show that we can pinpoint these molecular markers in the small amount of RNA and DNA obtained from fine needle biopsy,” said principal investigator J. William Harbour, MD, an associate professor of ophthalmology, cell biology and medicine at Washington University School of Medicine in St. Louis. “This means that testing for the markers is clinically feasible and could be used routinely to identify patients with ocular melanoma who are at high risk for metastasis.” The study was presented at the American Association for Cancer Research’s Molecular Diagnostics in Cancer Therapeutic Development meeting in Chicago. Detecting metastasis In previous studies, Dr. Harbour and colleagues found that a particular molecular signature was an accurate predictor of metastasis. On the basis of this gene expression pattern, patients with ocular melanoma can now be divided into two groups: Those with a class-1 molecular signature have little risk of metastasis, but those with a class-2 signature have a high risk. In the current study, researchers tested whether the minute quantities of RNA obtained from fine needle biopsies were adequate to detect the class-1 and class-2 signatures. The researcher found that signatures obtained from fine needle biopsies corresponded to signatures obtained through conventional biopsies and to those found in the earlier studies. They also found that DNA from fine needle biopsies included another biomarker: on chromosome 8, the loss of DNA in the p region correlated with time to metastasis. Among patients with 8p loss, the median time to metastasis was 25.8 months, compared with 37.4 months for those without 8p loss. Clinical application The RNA- and DNA-based testing of fine needle aspirates is clinically feasible and accurately predicts metastatic risk and time to metastasis in ocular melanoma, Dr. Harbour said. The next step is a larger, multicenter study in which cancer centers around the country will obtain fine needle aspirates from ocular melanoma patients and send them to Washington University for analysis. If this study confirms the usefulness of the procedure on a large scale, it could become routine practice, according to a prepared statement. This article also appeared in Hem/Onc Today, a SLACK Incorporated publication. For more information: J. William Harbour, MD, can be reached at the Barnes Retina Institute, 1600 S. Brentwood, Suite 800, St. Louis, MO63110; 314-362-3315; e-mail: harbour@vision.wustl.edu.

Metastatic tumor care

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

Managing side effects

Dr. 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.

According to Dr. Gombos, 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,” Dr. Gombos said. “Addressing all of their ocular complications even after their cancer is cured is a significant component of the care we provide.”

For more information:

• David Abramson, MD, is chief of the ophthalmic oncology service at Memorial Sloan-Kettering Cancer Center and professor of ophthalmology at Weill Cornell Medical Center. He can be reached at 1275 York Ave., New York, NY 10021; 212-744-1700; e-mail: abramsod@mskcc.org.
• Dan S. Gombos, MD, FACS, is an ocular oncologist at the University of Texas M.D. Anderson Cancer Center. He can be reached at University of Texas M.D. Anderson Cancer Center, Section Of Ophthalmology, Department of Head and Neck Surgery, 1515 Holcumbe, Box 441, Houston, TX 77081; e-mail: dgombos@mdanderson.org.

• Erin L. Boyle is an OSN Staff Writer who covers all aspects of ophthalmology.