DMG activity (Service) – yearly aims and objectives, special arrangements to achieve these, any audit report, OPD timings, surgery days etc. other information relevant to patients and referring doctors.

The thoracic oncology DMG is amongst the few specialized multidisciplinary thoracic oncology groups in the country treating a wide variety of lung, esophageal, chest wall and mediastinal tumors.

A team of experts from different specialties customize the management of patients by designing the most effective combination of Surgery, Radiation therapy, Chemotherapy and Radiology & Pulmonary Medicine to suit the individual’s needs in a multi disciplinary Joint Clinic (JC) which is held on every Monday and Wednesday . All newly diagnosed patients as well as patients who have undergone a complete staging evaluation are usually evaluated during this clinic. These management decisions are based on evidence but tailored to the individual patient.  

OPD Timings (General & Private)

Surgical Oncology: Monday and Wednesday 9.30 to 5.30 PM
Radiation Oncology: Monday to Friday 9.30 to 5.30 PM
Medical Oncology: Monday to Friday 9.30 to 5.30 PM
OT Days- Tuesday, Thursday & Friday

Pulmonary Medicine: Monday to Friday ( Except Wednesday ) 8 am to 1 pm

Thoracic JC: Monday & Wednesday 12:30 to 3:00 pm.

High Risk JC  The initiation of the “high-risk” multidisciplinary meeting with thoracic surgeons, anesthesiologists, critical care specialists and pulmonary physicians, a unique feature of the DMG has led to increasing numbers of high-risk patients being considered for surgery with the aim of improving outcomes, optimizing the care of patients with multiple comorbidities prior to surgery. Active participation from the physiotherapy department on postoperative rounds ensures individualized attention to specific patient needs over and above the routine.

Achievements

• Lung & Esophagus Cancer Support group meeting: Esophageal and lung cancer support group meeting is held on 4th Tuesday of every month. It has invited talks, discussions focusing on patient-centric problems. The involvement from patients has been encouraging and this provides them a forum for exchange of experiences, discussing their fears, concerns and closer interaction with other patients and their treating physicians. In addition, the availability of dedicated counselors for patients with thoracic cancers and the institution of early palliative care into the treatment continuum are some more initiatives to improve the overall experience for patients.

• Management of complex airway problems including tracheobronchial stenting and laser therapy

• Evidence based management of advanced lung and esophageal cancers with molecular-based personalized targeted therapy and chemotherapy

• State of the art radiotherapy services include tomotherapy, image-guid ed and stereotactic body radiotherapy

• Immediate postoperative, post chemotherapy and radiation therapy outcomes comparable with similar high volume centers in the world.

• In addition to the above the DMG also has a very effective program for palliation of both advanced esophageal and lung cancers, with early involvement of the palliative care team

• The Pulmonary Medicine Unit has proposed a 2 year academic programme towards Fellowship in Onco-Pulmonology for Chest Physicians through Homi Bhabha National Institute (HBNI) that is currently awaiting approval by the Board of Studies for academic year 2018-2019.

The DMG conducts dedicated teaching sessions and on-the job training for the MCh (Surgical Oncology), DM (Medical Oncology) and MD (Radiation Oncology) courses. In addition, a two-year fellowship in thoracic surgical oncology is offered under the Homi Bhabha National Institute and is the only one of its kind in the country. The teaching programme is highly structured and includes didactic lectures, seminars and case-presentations. Regular orientation lectures are taken for all new registrars and fellows working in thoracic surgery nine times a year. Two comprehensive CMEs were conducted covering the entire spectrum of lung cancer which was attended by postgraduates, residents and fellows from across the country. A lung practicum was conducted in the department of radiation oncology, a limited hands-on course focusing especially on stereotactic radiotherapy in lung cancers.

The DMG has several trainees - ten thoracic surgical fellows (two 2-year fellowships, two one-year fellowships and six 6-month fellowships); twelve senior MCh (Surg Onco) registrars, fifteen junior MCh (Surg Onco) registrars, six medical and twelve radiation oncology registrars rotate through the DMG every year. In addition, training is provided in diagnostic bronchoscopy to 24 physicians from across the country annually.

We also conduct:
Case capsules: Every Monday and Wednesday in surgical oncology department.
Difficult Case Discussion : Tuesday & Thursday in Medical oncology department.

Newer initiatives in the DMG

• Enodbronchial Ultrasound (EBUS) and EBUS guided trans-bronchial needle aspiration (TBNA)
• Robotic surgery for thoracic cancers
• Stereotactic radiotherapy for lung cancers
• Lung and esophagus cancer patient support group.
• Pharmacovigilance program for chemotherapy drugs.
• Introduced early palliative care for lung cancer patients.
• Dedicated counsellor for lung cancer patients.
• Availability of 68Galium DOTA Peptide for neuro-endocrine tumors
• Alk-1 IHC test for lung was introduced as routine diagnostic test in TMH since Jan 2015 In June 2015, ALK testing by Ventana D5F3 IHC clone (used in TMH) got US FDA approval as companion diagnostics.
• Started a preceptorship program with hands-on training for EGFR and alk mutation testing.

Key indicators of DMG activity: Information that emphases activity.

• The DMG is amongst the highest volume thoracic cancer referral centers in the world. A total of 3802 new patients, comprising over 10% of the hospital registrations were registered in the DMG in 2014, of which 2,263 (59.6%) were general and 1537 (40.4%) were private patients. Lung cancers were the majority, 2374 (62.4%) followed by esophageal cancer 1070 (28.1%).

• The thoracic surgical unit is the highest volume thoracic oncology centre in India and operated 197 patients with esophageal cancer, 104 patients with lung cancer, 145 patients with pulmonary metastases, 35 patients with mediastinal tumors and 32 patients with chest wall tumors. In addition, several minor procedures including diagnostic and therapeutic bronchoscopy, port insertions, intercostal drainage, pleurodesis etc were performed. Early post-operative outcomes are comparable with most high volume centres in the world. A large number of patients are operated by minimally invasive surgery including thoracoscopy, laparoscopy and robotic surgery.

• The thoracic medical oncology unit has amongst the highest volumes in the country and treated 1414 patients with lung cancer and 503 patients with esophageal cancer. These include neoadjuvant, adjuvant and palliative chemotherapy including targeted therapy. Overall response rates, toxicity and survival figures were similar to high quality thoracic oncology centres worldwide.

• Thoracic radiation oncology treated 503 patients with lung cancer with compliance of 98% and 77 patients with esophageal cancer with a compliance rate of 91 percent. Short and medium term outcomes have been meticulously documented and periodic audits conducted to monitor performance critically. All modern techniques of radiation including IGRT, IMRT, 3DCRT and SBRT are available and used regularly to provide superior treatment outcomes.

• Development of guidelines, scientific report, educational modules, etc: The guidelines for the treatment were last updated in the Evidence Based Management Guideline Meeting on Thoracic cancers held in February-March 2013. In addition any updates in literature that warrant a change in the management guidelines are also taken into account. An annual report including the annual activities of the DMG and DMG members is compiled every year.

The DMG maintains ongoing quality improvement measures with continuous audits of peri-operative, post chemotherapy and post radiotherapy morbidity and mortality estimation with emphasis on post operative infections and treatment compliance

Research

The thoracic DMG conducts several investigator-initiated and sponsored research studies. Practice changing studies in the Thoracic DMG

• Three field radical esophagectomy versus two field esophagectomy – a prospective randomized controlled trial
• Effect of screening with visual examination and double-contrast barium swallow on oral and upper aerodigestive tract cancer mortality – a cluster-randomized trial
• A prospective study of telephonic contact and subsequent physical follow up of radically treated lung cancer patients
• Prospective study of variations in breath holding times in various phases of respiration & effect of respiratory training in Lung cancer patients. A step towards image guided radiotherapy
• Phase II randomized trial comparing NACT and NACTRT for locoregionally advanced esophageal cancer
• Molecular Profiling of lung cancer for actionable mutations
• Comparative study for efficacy and safety of Paclitaxel with Cisplatin/Carboplatin versus 5-Fluorouracil with Cisplatin/Carboplatin in resectable carcinoma esophagus or gastroesophageal junction carcinoma
• A randomized trial comparing metronomic chemotherapy vs observation in patients receiving chemoradiation in esophageal cancer.
• A randomized study comparing IV chemotherapy vs TKI in third line and beyond in advanced non-small cell lung cancer
• Phase III Study Evaluating Efficacy and Safety of low dose Gemcitabine compared to standard dose Gemcitabine with platinum in advanced non-small cell lung cancer -
• Comparative study of QOL of patients on Pemetrexed versus Erlotinib in Maintenance therapy for Advanced NSCLC (Other than Squamous Cell Carcinoma)
• A randomized study comparing Erlotinib vs Gefitinib in second line in advanced non-small cell lung cancer
• A Study to evaluate the variability in delineation of the target volumes in lung cancer by comparing two techniques using Four- dimensional computed tomography
• Distress screening and Quality of Life in treatment naive Lung cancer patients attending radiotherapy outpatient department
• Randomized clinical trial of best supportive care compared with best supportive care with chemotherapy in advanced unresectable or metastatic esophageal cancer
• Prospective observational study of thromboembolic events in patients of advanced stage non-small cell lung cancer (NSCLC) treated with platinum based chemotherapy

The thoracic DMG is involved in the conduct of several investigator-initiated and sponsored research studies. Some of the studies initiated earlier were published and presented in high impact journals and international conferences respectively. The randomized trial evaluating the role of perioperative erythromycin to prevent delayed gastric emptying in patients undergoing esophagectomy was presented in the biennial conference of the International Society for Diseases of the Esophagus in Vancouver. Ongoing randomized trials include the trials comparing radical three-field vs two field esophagectomy for operable esophageal cancer, and neoadjuvant chemotherapy with neoadjuvant chemoradiation for locoregionally advanced esophageal cancer. In addition, several new studies were initiated this year and planned for the next year.

The CHEST (Cancers of the Hypopharynx and Esophagus Trial) screening trial is underway in Ratnagiri district with over 33000 individuals having been screened and given health awareness for upper aerodigestive tract cancers. Extensive health education and awareness of health hazards of tobacco use is an integral part of the programme. Several other randomized trials are underway in advanced lung and esophageal cancers. Several articles have been published by DMG members in various peer reviewed journals.

Lung & Esophagus Cancer Support group meeting: Esophageal and lung cancer support group meeting is held on 4th Tuesday of every month. It has invited talks, discussions focusing on patient-centric problems. The involvement from patients has been encouraging and this provides them a forum for exchange of experiences, discussing their fears, concerns and closer interaction with other patients and their treating physicians. In addition, the availability of dedicated counselors for patients with thoracic cancers and the institution of early palliative care into the treatment continuum are some more initiatives to improve the overall experience for patients.

About Us

Realizing the increasing need to address the respiratory co-morbidities in cancer, the seed for the Pulmonary Medicine Services was sown in 2006 by Dr. Sandeep Tandon, Pulmonologist and Staff Physician at Tata Memorial Hospital.

What began with a few referrals has exponentially increased to over 6000 consultations annually.

The Department now is constituted by Dr. Tandon, two-part time Pulmonology Consultants and a Post MD (Respiratory Medicine) Senior Registrar.

The Pulmonary Medicine Unit aims at creating a teaching programme that will train future young minds to develop the skills to cater to this ever increasing need for Pulmonologists specializing in management of respiratory diseases that are prevalent and often unique to Cancer patients.

We also aspire to developing research aimed at creating new information that will bolster management of respiratory disorders and strive towards achieving a better quality of life in this group.

The 2 year HBNI fellowship in Onco-Pulmonology has been proposed with this goal in mind.

The Unit has been set up with an aim to increase the scope of diagnostic services offered including EBUS with rapid on-site cytology, medical thoracoscopy and bronchoscopy for pulmonary infections in paediatric age group apart from adults and in intensive care unit, in conjunction with the Department of Thoracic Surgery, Anesthesiology, Interventional Radiology, Microbiology and Pathology thus promoting a multidisciplinary approach.

In the pipe-line is also the plan for setting up a state of the art Airway Management Lab in conjunction with the Department of Thoracic surgical services that will ensure catering to the ever increasing need for palliative relief of airway obstruction in cancer patients.