DR LOVE: So in the fall of 2016, we launched one of the more interesting projects as a CME group we’ve ever done before. We called it the Morbidity & Mortality Conference Concept applied to contemporary oncology. We all remember the classic M&M conference where you take a case — a lot of times maybe with a bad outcome — look what happened, how was the patient managed?

Is there anything that couldn’t have been done differently? Maybe that was for our patients with acute problems. But we thought, what about the same concept looking at clinical oncology? And we thought, in particular it’d be interesting to look at cases of patients with solid tumors, who, like many of those patients, unfortunately die of the disease.

So we recruited a random sample of 102 general medical oncologists in the United States. This is docs who take care of all types of oncology cases, hem onc cases, et cetera, and they contributed a number of cases to a case registry we put together. What we asked them for who was the last patient in their practice who died of either lung cancer — and we specified wild-type lung cancer because, of course, mutations really define a different type of lung cancer — of metastatic colorectal cancer and of ovarian cancer. So we picked these 3 common tumors and asked them to tell us about their last patient.

So we were able to gather 233 cases of patients who died of these 3 cancers, and you can see the median age is in the sixties. Interestingly, the time from the diagnosis of metastatic disease to death, as we know, is very short, particularly for wild-type lung cancer. And you can see these patients in general, though, received at least 2 or 3 lines of systemic therapy, in some cases more.

So a couple of interesting things that we observed as we asked these docs about the treatments that the patients received. The first thing was, we asked them to tell us when they gave the treatments. So we asked for a list of treatments — if it was chemotherapy, whatever type of systemic therapy, a list of the regimens that the patients had — did they get hospice or palliative care, et cetera? How long they were on the treatment? And then we asked them also, did they have to adjust the dose or even stop the therapy because of toxicity?

And if you look at this, these are just the lung cancer regimens that these patients were treated with, and you can see the red, the treatments actually had to be stopped because of toxicity. But yellow, the patients had dose modification because of toxicity. So for many of these regimens, toxicity was a very common problem that needed close monitoring.

You’ll note here a theme that we saw was the more biologic therapies, for example, the checkpoint inhibitors seem to be a little better tolerated, sort of more green.

When we look at colorectal cancer, same thing. A lot of patients with yellow. A lot of patients requiring a dose modification because of toxicity, reinforcing this theme that in this setting, with all 3 of these cancers, oncologists are really, and their patients, are functioning at the very edge of the therapeutic toxic ratio.

So we can see that management in this situation requires a lot of careful monitoring for toxicity.

You also see this same pattern in ovarian cancer. And again, in terms of biologic therapy, bevacizumab without chemotherapy as monotherapy, a lot of green there. Not very much dose adjustment.

It did appear that the way systemic therapy was being utilized by these general medical oncologists seems to follow, in general, the same patterns that we see in clinical investigators specializing in lung cancer, in colorectal cancer, in ovarian cancer.

Pretty evidence-based therapy. And this is the clinical oncology end of what we saw with this informal case survey.

The other thing that we asked them about that I found particularly fascinating about this endeavor was we said to the physician who took care of the patient who died, to what extent was it personally and professionally satisfying to take care of this specific patient? So it’s not how they find taking care of patients in general, it was, how was it to take care of this particular patient?

We also asked them, were you able to identify any short-term goals that the patient had that they wanted to achieve that you were trying to help them achieve? You hear this a lot from people in oncology — patients looking at a limited life span often focus on a wedding, a birth, a marriage, and it’s really the bonding with the physician to try to be able to enjoy these special moments. And most of these cases, the physicians were able to identify specific short-term goals.

And maybe that ties into the fact that, to me, very interestingly, for the majority of these cases, the treating oncologist found it satisfying to take care of this patient who actually died of the disease.

And, in fact, in more than 40% of the cases, the physician found it very satisfying to take care of the patient. Maybe something that someone outside of the field would find very interesting and maybe even surprising, but also maybe something that people within the field know exist every day in clinical practice.

When you really take a step back and think what we did here, it was kind of simple, just asking people about what happened specifically to patients who they took care of, of course in a very difficult situation. There were so many things that we learned in these cases — end-of-life care, end-of-life hospitalization, hospice, a lot of psychosocial issues. And, ultimately, what this really is about was looking at quality, a different way, a personalized way, to look at your own practice, try to assess quality. Not just in terms of oncologic decisions being made, oncologic management, but maybe at a more human, personal level.

Metastatic wild-type nonsquamous non-small cell lung cancer (NSCLC)

Metastatic colorectal cancer (mCRC)

Metastatic epithelial ovarian cancer (OC)