What Will It Take To Shake The Tree And Save More Lives From Lung Cancer: A Report From ASCO 2019

Every year, the annual meeting of the American Society of Clinical Oncology is unmatched in bringing forward the latest advances in cancer care. It is a time to learn about important—and usually– incremental advances in cancer research and cancer care, and every year has some of us, especially those of us with some years under our belts, thinking about big picture themes in cancer: where we’ve been, where we are, and where we’re going.

For me, today’s theme is lung cancer and the sad fact that our care for those at high risk and those  diagnosed with the disease is far from what it should be. But more than I ever, I am convinced the future holds hope.

Lung cancer is  the major cancer killer in the United States. In 2019 the American Cancer Society estimates 228,150 people will be diagnosed with lung cancer and 142,670 will die.

Lung cancer is a disease that is too-often diagnosed at a late stage,  contributing to low survival rates. It also suffers like no other disease with profound stigma. Tell someone you have lung cancer, and the response either verbally or in thought is likely” “Did you smoke?” And treatment has long been suboptimal at best; at worst ineffective. Survival for advanced disease in years past has too frequently been less than one year.

Put all of that together, and you get a disease that wrapped in stigma, not very treatable, and whose fate could not be altered.

But today that appears to be starting to change. While we still have a long way to go, clinicians and people in public health are stating openly that lung cancer should not be held to a different standard. We can no longer let our judgementalism about cause affect our commitment to saving lives. Smoker, non-smoker, whatever. No one should be made to feel ashamed that they have a cancer. It is now widely recognized we need to stop the stigma and focus on the treatment. Let’s move on from our old beliefs; they are wrong, plain and simple.

And as we open our eyes to how profoundly damaging that stigma has been to the care of patients with lung cancer, we are now have ways to find lung cancer early in those at highest risk. And yet  rates of screening for lung cancer remain abysmally low.

Why?

Well, some colleagues here at the American Cancer Society published an abstract at the other big cancer conference, AACR, earlier this year: Lessons learned from Federally Qualified Health Centers. Not shown in the abstract are a couple potentially contributing factors : Long-term smokers referred for screening say they are repeatedly asked about their tobacco history. The investigators tell me these patients are understandably upset, asking “Why do I need to keep hearing this? I just want to do what I can do now. Stop judging me.” The same study suggested health professionals at the front lines also need better direction as to what to when the results of these scans are not clear cut.

Then there is the issue of treating lung cancer: we have seen substantial progress in finding better ways to treat lung cancer over the past couple of years. And the presentations at ASCO 2019 suggest we are continuing to make progress. The number of new drugs either approved for treatment or in the pipeline of clinical trials is mind boggling. And it continues to grow. At one session I attended on Friday, the experts predicted a substantial increase in the number of new drugs available to treat lung cancer over the next several years. Another session that same day described innovative new therapeutic approaches that will hopefully continue to show success.

However, there is a bit of a catch: many of those new drugs are focused on very small segments of the population of patients with lung cancer; those with mutations and tumor factors that respond to what are some pretty tightly-targeted approaches. So, to figure out if a drug will work on any patient, one needs to test the cancer tissue.

It continues to surprise me how many patients diagnosed with lung cancer are not receiving those potentially life-saving tests. It’s extremely frustrating, but in fact the reality is some doctors for whatever reason don’t appear to be on board with the science and the evidence about current treatments for lung cancer. And in fact, old beliefs about stigma and inevitable outcomes likely play a role in this missed opportunity.

And, some of those drugs may only work for very limited numbers—1% to 5%– of the patients with lung cancer. However, for the those whose tumors have those traits that would predict a positive response to a new targeted therapy or immunotherapy, treatment may lead to a long-term improved outcome with much better quality of life and even long-term survival.

Then there is the impact of immunotherapy, which has changed the landscape of treatment for some patients with advanced lung cancer, especially since the initial reports a little over a year ago of success combining immunotherapy  with more traditional chemotherapy.

Taken together, all of this adds up to a new sense of optimism that we can begin to make a difference for lung cancer patients in the face of a dire situation.

So, if we have all these incredible improvements, why then are there still some nagging doubts?

There is a theme that is emerging in presentations and discussions about lung cancer over the past two days: we have so much opportunity, yet too few are benefitting. Lung cancer has moved from a dismal, back-of-the-room illness without hope to the forefront of modern cancer care, where we can really do something to alter the course of the disease and where my prediction is we will shortly see improvements in outcomes that were not anticipated even a few short years ago.

That last point is instructive.

I mentioned previously that lung cancer was usually fatal until recently. Recently I wrote about the improvements in survival for advanced melanoma, where the data was “hiding in plain sight.” Those same lessons may well apply to lung cancer.

A decade ago advanced melanoma was essentially universally fatal. Today, over half the patients with advanced disease have documented survivals approaching five years. I anticipate we will see similar improvements in lung cancer survival in the not too distant future, and some of my colleagues in random conversations here at the ASCO meeting agree.

But—and this is a really important “but”—we are not doing what we need to do to make that a reality. Our care in many instances is not up to date.  We aren’t screening those at the highest risk for lung cancer. We aren’t doing the right tests on lung cancer tissue to find the right treatment.  We aren’t making that treatment accessible to patients. The list goes on and on.

Why? I suspect that old traditions die hard: many of my colleagues, patients and families still think lung cancer is the disease it was as recently as 5 years ago. News bulletin: it is not. It is detectable, it is treatable, and for some survivable in a way we wouldn’t have dreamed of even recently.

What can we do?

I believe we need a nationwide initiative that rattles the cage, that makes us shake our old ways of thinking and moves us into the modern age. We need to ditch the stigma, treat the disease, and make certain everyone with lung cancer has access to the best possible care.

To be certain, there are a number of advocacy organizations–including the American Cancer Society and our many initiatives  such as the National Lung Cancer Roundtable– that are focused on doing just that. But too frequently they don’t get the attention they deserve. They shout it out, however too few listen. It doesn’t have to be this way.

Every person at high risk of lung cancer or who has been diagnosed with the disease should have access to quality care in a timely fashion and receive the best treatment, whether surgery, radiation, chemotherapy, targeted therapy, and/or immunotherapy for their lung cancer—irrespective of their ability to pay. We should help people through this process with focused navigation and compassionate, meaningful care. No one should feel through their journey that they have been ignored or abandoned, and those who care for us should be held accountable for the quality of the care they provide.

I firmly believe, from my heart, that we can do this, and we can do it right now. No need to dally or delay. It is time to shake off the cobwebs and make the commitment. Too many lives hang in the balance.

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