Lung cancer remains, by far, the leading cause of cancer death globally, but we believe we are at a turning point. To mark the start of the IASLC 19th World Conference on Lung Cancer (WCLC), we’re speaking with Lanni Boyd, Associate Director of Stakeholder Relations at Lung Cancer Alliance, and Margie Li, Oncology Strategy Director at AstraZeneca to take a look at the catalysts that are setting in motion a real transformation in the detection and management of lung cancer. The time is now for the lung cancer community to take better control of the disease.
The majority of lung cancer patients are diagnosed at a late stage. Have you seen any new tools that show potential for identifying lung cancer in patients at an earlier stage?
Margie: Approximately 60% of non-small cell lung cancer patients are diagnosed with Stage IV, or metastatic, disease.1,2 For these patients, the 5-year overall survival rate is only 6%, compared with the almost 80% 5-year overall survival rate for Stage I patients.3 This means that to significantly shift the survival curve, we must diagnose and treat patients at earlier stages of disease. Because early-stage disease is typically asymptomatic, the solution will need to be in screening programs. In the US, lung cancer screening has been recommended since 2014 based on very exciting data from the National Lung Screening Trial (NLST). This trial enrolled over 50,000 patients, aged 55-80 who were current smokers or who had quit smoking in the past 15 years, and showed a 15-20% decrease in risk of lung cancer related death for patients screened by CT scan.4 While the NLST was pivotal for the lung cancer community, there is still a lot of work to implement these guidelines both in the US and internationally.
Lung cancer has typically been associated with poor prognosis. What can you tell us about the latest in treatment advances and what these mean for patients?
Lanni: Lung cancer remains the leading cause of cancer death in the United States and worldwide.5 Every year we lose more people to lung cancer than breast, prostate, colon and pancreatic cancers combined.5 Recently, we have seen the promise of research with many new advances in treatment and early detection that will help increase survival for patients. Some studies have shown that new therapies, such as Immuno-Oncology (IO) therapies, can result in long-term (>5 year) survival for some patients.6 We are excited that new options can provide the potential for more time and an improved quality of life for patients and their loved ones.
While therapies targeted to specific driver mutations have been in practice since 2002, we’re starting to see “next-generation” agents receiving approval. How do these therapies differ from their predecessors?
Margie: Over the last decade, targeted therapies and IO therapies have provided significant improvement in the outcomes for lung cancer. The growing scientific understanding of cancer driver mutations has allowed for development of targeted tyrosine kinase inhibitors (TKIs). In recent years, we are seeing “next-generation” TKIs showing greater efficacy, lower toxicity, and benefit in new patient populations, compared with the earlier generation TKIs (e.g., ROS1, EGFRm with brain metastasis).7,8 These developments provide terrific new options for patients and highlight the need for genetic testing at diagnosis to appropriately identify all patients. IO therapies are also relatively new entrants to the lung cancer treatment paradigm, but they have already changed the standard of care for some metastatic patients. Various IO therapies have demonstrated significant gains in efficacy. What’s truly exciting is that the story of IO is just beginning. There is growing evidence that IO therapies may be efficacious in earlier stages of disease.9,10 With these early-stage trials, the bar is raised to “curative intent” and that’s where we hope IO will really transform the long-term outcomes for patients.
IO therapies have been used in lung cancer for several years, but we’re now seeing their use in different treatment settings, such as adjuvant therapy or in earlier lines of treatment. How has uptake been?
Lanni: The IO landscape has been rapidly evolving and we have been excited to see these new therapies move into different stages of cancer and earlier lines of therapy. There is a lot of interest in IO from our patient community as well as interest in participating in IO clinical trials. We are also excited about the various combination studies underway including IO + IO, IO + chemotherapy, and IO + targeted therapy. We know IO is not the right option for every patient, and cannot stress enough the importance of considering molecular testing as well as clinical trials to determine the best treatment options, no matter where a patient is in their lung cancer journey, and to discuss those options with their treatment teams.
There has historically been considerable stigma attached to lung cancer. Have we seen any shift in societal attitudes to lung cancer recently?
Margie: Unfortunately, the stigma in lung cancer is still very strong. The stigma is around smoking and there is the perception that lung cancer patients “caused” their own disease. However, we must keep in mind that 10-20% of lung cancer patients have never smoked.11,12 In addition, many patients were former smokers who quit over 15 years before their diagnosis. While stigma around smoking has been important and useful for cessation campaigns, it has been a real challenge for patients with lung cancer. Due to the stigma, patients do not feel empowered to speak about their disease or to advocate for their own care. All patients deserve access to lung cancer treatments. As a society, we need to move beyond the stigma to truly change the landscape of lung cancer.
For several decades, patients with lung cancer were typically less engaged with their treatment programs than patients with other forms of cancer. Have you noticed any shift in behaviors recently? How is Lung Cancer Alliance equipped to help patients who are uncertain about their treatment plans?
Lanni: At Lung Cancer Alliance, we see many different types of lung cancer patients. In recent years, we have seen more hope from our community which can be largely attributed to more treatment options for patients and in many cases, treatments with fewer side effects. There are certainly patients in the lung cancer community who are very engaged with their treatment programs and know exactly what options and clinical trials are currently available to them and even what options are possible in future lines of therapy. However, there are still many patients who are less engaged in their treatment programs which is why LCA has various support and education programs available to meet patients where they are and help arm them with knowledge and questions to discuss with their physician at their next appointment.
1. Ridge C, et al. Epidemiology of Lung Cancer. Semin Intervent Radiol. 2013;30:93-98
2. National Institute of Health. Cancer Stat Facts: Lung and Bronchus Cancer. Available at https://seer.cancer.gov/statfacts/html/lungb.html. Accessed September 2018.
3. Goldstraw P, et al. The IASLC Lung Cancer Staging Project: Proposals for Revision of the TNM Stage Groupings in the Forthcoming (Eighth) Edition of the TNM Classification for Lung Cancer. Journal of Thoracic Oncology. 2015; 11(1):39-51
4. National Institute of Health. National Lung Screening Trial. Available at https://www.cancer.gov/types/lung/research/nlst. Accessed September 2018
5. Peters S, et al. Alectinib versus Crizotinib in Untreated ALK-Positive Non–Small-Cell Lung Cancer. N Engl J Med. 2017; 377:829-838
6. WHO. International Agency for Research on Cancer. Globocan 2012: Estimated Cancer Incidence Mortality and Prevalence Worldwide in 2012: World. Available at http://globocan.iarc.fr/Pages/fact_sheets_population.aspx. Accessed September 2018.
7. Gettinger S, et al. Five-Year Follow-Up of Nivolumab in Previously Treated Advanced Non–Small-Cell Lung Cancer: Results From the CA209-003 Study. JCO. https://doi.org/10.1200/JCO.2017.77.0412
8. Soria J-C, et al. Osimertinib in Untreated EGFR-Mutated Advanced Non–Small-Cell Lung Cancer. N Engl J Med. 2018;378:113-125
9. Antonia S, et al. Durvalumab after Chemoradiotherapy in Stage III Non–Small-Cell Lung Cancer. N Engl J Med. 2017;377:1919-1929
10. Eggermont A, et al. Adjuvant Pembrolizumab versus Placebo in Resected Stage III Melanoma. N Engl J Med. 2018;378:1789-1801
11. Samet J, et al. Lung Cancer in Never Smokers: Clinical Epidemiology and Environmental Risk Factors. Clin Cancer Res. 2009;15(18):5626-5645
12. Planchard D, et al. Lung cancer in never-smokers. European Respiratory Journal. 2015;45:1214-1217
Veeva ID: Z4-12535
Date of next review: September 2020