We hear from key personnel making an impact in the world of lung cancer

We start with Dr Lynette Sholl, Associate Professor, Pathology, Harvard Medical School, Associate Pathologist, Brigham And Women’s Hospital.
 

Dr Sholl is a graduate of Johns Hopkins University and Stanford University School of Medicine.
 
Her research focuses on identifying markers that will improve the classification of lung cancer, providing predictive information regarding therapy, and more precise prognostic information. She has a special interest in understanding the genomic modifiers of tumour behaviour, morphology, and response to treatment. 
  
What first motivated you to work in lung cancer treatment? 
 
It was really the timing of my training that led me into lung cancer studies. I finished medical school in 2003, right about the time that TKIs (targeted kinase inhibitors) were coming to the fore and there was a lot of excitement around EGFR and the potential to target different tumour types.
 
Personally, seeing one lung cancer patient in particular in the ICU – a woman of Asian descent who had never smoked – responding to TKIs, brought to life the way those new types of medicine could improve outcomes for people with lung cancer.  
 
I then had the privilege to train with some of the leading lights in pathology during my second-year residency in Boston. Pathology struck me as a unique way to think about disease mechanisms and visualise in situ disease at the cellular level. I find it thrilling to look down the scope and see complex biological processes at work in high detail. 
 
What is different about your role today from when you started your career?
 
The principle difference is that we now know more about the molecular underpinnings of cancer. In terms of our molecular understanding, we were at the tip of the iceberg in 2004. Now, we have cast new light on the variations between cancers and made more sense of the diversity of tumours. Improved molecular understanding has improved the accuracy of tumour classification, added nuance to diagnostics and increased the specificity of diagnoses.
 
What have been the biggest advances in pathology? 
 
Essentially, it’s about sequencing. We are now able to do massive amounts of sequencing with very small amounts of tissue. This allows us to engage in discovery during routine diagnostics and to support the use of targeted therapies on the basis of mutations like EGFR, B-RAF and ALK. 
 
This information enhances traditional staging and grade information to better inform treatment decisions and to make more judgments about how we expect patients to respond to treatment. 
 
What do you see as the most significant challenges in your field?
 
The main challenge is educating both the profession and the population about genomics. For instance, the IASLC/CAP/AMP biomarker guidelines identify only a few genes that require routine testing. We are still really only scratching the surface in terms of using genomics in treatment decisions. Efficacy of treatment is still only registered in a subset of patients. 
 
The medical school education scheme will need to shift to incorporate genomic analysis. For example, today there’s still limited understanding amongst clinicians about the difference between germline and somatic mutations and the implication this has in terms of treatment decisions. As genomic medicine is used more and more in routine care we need to be thinking now about how we can fit genomics into the curriculum. 
 
What are you most excited about in your field?  
 
One of the most exciting prospects is the opportunity to combine a number of new technologies and testing techniques. By synthesizing a large number of biomarkers and using emerging technologies like liquid biopsies, we have the potential to develop even more sophisticated approaches to staging and diagnosis. 
 
Liquid and genetic profiling could bring together all the most powerful diagnostic technologies to deliver the most accurate diagnoses yet. 
 
More powerful visual technology, married to advances in computational technology, also have the potential to transform pathology by allowing us to use a host of new algorithmic tools and analytics to better understand disease. 
 
In sum, we’re seeing the emergence of powerful prognostic models embracing genetics and new biomarkers that will provide better diagnostic tools so that we can further stratify patient populations. 
 
What role do you see international collaboration playing in advances in lung cancer treatment?
 
International collaboration helps the field to advance faster, as opposed to working in an insular fashion. I believe it is critical that we speak about launching biomarker testing and what this means at an international level. It is crucial that we think carefully about how we prepare health systems across the globe to deliver these new approaches to diagnosis, staging and stratification. 
__________________________________________________________
 
Professor George Eapen, Deputy Department Chair and Professor of the Department of Pulmonary Medicine, Division of Internal Medicine at the University of Texas MD Anderson Cancer Centre. 
 
 
Professor Eapen completed his training at the University of Benin before undertaking his residency at the Southern Illinois School of Medicine and a clinical fellowship at Baylor College of Medicine, Houston, Texas.
 
In addition to his position at the Department of Pulmonary Medicine, Professor Eapen is Section Chief of Interventional Pulmonology, University of Texas. He is also a member of American College of Chest Physicians and the President-Elect of the American Association for Bronchology and Interventional Pulmonology.  
 
What first motivated you to work in pulmonary medicine and lung cancer? 
 
When I started working 20 years ago, attitudes to lung cancer were negative and nihilistic. A diagnosis was tantamount to a death sentence and there was an undercurrent of victim blaming – a sense that lung cancer was self-inflicted because it is often caused by smoking. I always felt this was unfair and that this neglected patient population deserved more attention and care. This attracted me to practice in lung cancer. 
 
I was then drawn to interventional pulmonology because it was an optimistic speciality, looking for solutions. Interventional pulmonologists were exploring new possibilities in treating lung cancer, experimenting with new technologies and techniques like stents or rigid bronchoscopy. It was an energetic field and I found this very appealing. 
 
What is different about your role today from when you started your career?
 
The role of the interventional pulmonologist has morphed and expanded as new technologies have come through. When surgery was the only curative treatment available, we used to be confined to the pre-operation assessment, working out whether a patient could cope with surgery.
 
Today, we have a major footprint in diagnosis and staging, with the use of less-invasive procedures like endobronchial ultrasound (EBUS). Our options for curative treatment have expanded beyond surgery to less invasive procedures. We also have better techniques and tools for symptom management, so that gives us a bigger role in patient care.
 
Secondly, we have seen a decisive shift toward multidisciplinary care. 20 years ago, patients were treated in silos. Now, with MDTs we have a one-stop shop to discuss individual patients’ needs and bring together different perspectives and expertise to enhance their care. This is a very positive development. 
 
What have been the biggest advances in your specialty, in terms of how we have improved outcomes for people with lung cancer? 
 
Change is often incremental, and small steps add up to a big impact. One of the biggest advances is that we now know that lung cancer screening can provide a mortality benefit. If we can shift from two thirds of people being diagnosed with a late-stage cancer to two thirds being diagnosed with an early-stage cancer, we can increase survival rates. 
 
In staging, EBUS has been a major step forward: a minimally invasive way of getting the right information, with a better safety profile than surgery, increasing the numbers of patients who have staging information. In terms of treatment, stereotactic ablative radiotherapy (SABR), is becoming more mainstream. We’re seeing more patients with controlled disease at three years – almost equivalent to lobectomy. 
 
What do you see as the most significant challenges to continuing to improve outcomes for people with lung cancer in the coming years?
 
The key issues are cost and accessibility. The cost of developing and then rolling-out new treatments is high. Equally, geographic access to high-quality and appropriate care is another challenge. It is no use building a better mouse trap if you don’t put it where the mice are.
 
Some patients live far away from expert centres. Since we can’t put a centre in every town, we need to find ways for professionals to disseminate their expertise to expand access. We must aim to deliver the greatest amount of care to the greatest number of people. 
 
What are you most excited about in your field?  
 
Immunotherapies have changed how we approach lung cancer treatment. Consider the past: we dealt only in crude terms of small cell or non-small cell lung cancer. Now we have identified over 23 actionable mutations and treating the right target with the right drug has resulted in big improvements in progression-free survival. 
 
SABR is also very promising. If we can move towards more non-surgical approaches to lung cancer treatment, that would be very exciting. From my perspective as an interventional pulmonologist I find transbronchial biopsy and ablation the most exciting development. It’s early days but the fact that resources are being moved in this direction fills me with optimism. 
 
What role do you see international collaboration playing in advances in lung cancer treatment?
 
I believe science is a team sport. As Isaac Newton said, if we see further, it is because we stand on the shoulders of giants. Collaboration means we can advance science and get better outcomes for patients. We can always improve on what we knew or had before.
_____________________________________________________________
 
Professor Young Tae Kim, Professor and Chair of the Department of Thoracic and Cardiovascular Surgery, Seoul National University, South Korea. 
 
 
Professor Young Tae Kim graduated from Seoul National University College of Medicine and trained at Seoul National University Hospital Cardiovascular Surgical Residency Program, before taking an Advanced General Thoracic Surgical Fellowship at the Mayo Clinic, Rochester, MN, USA.
 
He is an active member of the American Association for Thoracic Surgery (AATS), the Society of Thoracic Surgeons (STS) and the International Association for the Study of Lung Cancer (IASLC). Professor Kim’s clinical practice and research interests are focused on the surgical technique of lung cancer and genomic studies of thoracic malignancies.
 
What first motivated you to work in thoracic surgery and lung cancer? 
 
I suppose the decision to work in thoracic surgery, and lung cancer specifically, was a matter of personal preference. I was initially interested in cardiac surgery as it is a reconstructive surgery but on the other hand, I did not want to give up my interest in oncology, so I chose thoracic surgery focused on lung cancer. 
 
What is different about your role today from when you started your career?
 
A lot has changed with the availability of new treatments and technologies. In the past, there were only a few chemotherapy treatments available and radiation treatment was not well established. The only available curative treatment for early-stage lung cancer was surgery, while a late-stage diagnosis was effectively a death sentence for many patients. 
 
Today things have improved. We have better diagnostics for tracking cancer in the early stages. For advanced stage patients, we have targeted therapies as well as immunotherapies, which have transformed lung cancer survivorship a great deal. These advances have changed the role of the surgeon quite significantly. 
 
What have been the biggest advances in thoracic surgery? 
 
The most significant advance in thoracic surgery has been in the technology. Minimally invasive surgery has been a real step forward. We are now seeing video-assisted and robot-assisted surgical procedures as a standard surgical practice for lung cancer.
 
Also, the lung cancer screening program has resulted in an increased number of early diagnosed cases, and recently, we are seeing more candidates for surgical resections. All together, these advances provide the best chance of a cure to lung cancer patients.    
 
Multidisciplinary team practice is another adance. As surgeons, we are also working more closely with both radiation oncologists and medical oncologists. For example, we might work with our colleagues to shrink a tumour to make it easier to remove with surgery or to provide treatment after surgery to eliminate any last cancer cells and reduce the risk of cancer recurring. 
 
What do these advances mean for people with lung cancer?
 
For the first time, there is now a real chance of patients being cured of lung cancer with early diagnosis and advanced treatment. However, treatment pathways have become much more complicated than in the past.
 
Patients are faced with many different routes to treatment, from traditional therapy to various clinical trials including new drugs. While treatment is more complicated than before, it is also more effective and there is more hope of survival than ever. But the patients may need increased support throughout their cancer journey. 
 
What do you see as the most significant challenges in your field?
 
In my opinion, there are three major challenges facing lung cancer treatment. Firstly, treatment is expensive and paying for advanced approaches to diagnosis and treatment can be challenging: screening, targeted therapies, immunotherapy, personalized medicine – these are all very expensive and the financial burden can be significant.
 
Secondly, there is still more that we need to do concerning smoking cessation so that we continue to drive down the number of cases of lung cancer associated with smoking. We have to also bear in mind that e-cigarettes may yet create new lung-related issues in the future. 
 
And thirdly, the incidence of non-smoking patients continues to rise. This has the potential to pose a significant challenge in the future as the genetic profile of the tumours from patients who have never smoked is significantly different from those of smokers. 
 
What are you most excited about in your field?  
 
Genomics offers exciting possibilities for lung cancer treatment. I have been participating in the development of sophisticated gene panel tests for lung cancer, through which we can choose appropriate target agents by detecting mutations in the ALK, EGFR and ROS1 genes, for example. 
 
As a surgeon, a priority for me is educating the next generation of surgeons. Teaching young surgeons is both fun and deeply rewarding. I believe that the development of an effective education program in lung cancer treatment is the key point to develop in the future. 
 
What role do you see international collaboration playing in advances in lung cancer treatment?
 
International collaboration has been very productive in lung cancer. For instance, the IASLC staging committee, on which I have served for some time, has been vital for improving cancer staging systems. 
 
I believe that international collaboration represents an important opportunity for education too. As clinicians from different nations and disciplines, we all have a lot to learn from each other and I believe we can achieve our goal through IASLC. 
 ____________________________________________________________
 
Dr Emily Stone, Consultant Respiratory Physician and Acting Head of Thoracic Medicine, Department of Lung Transplantation and Thoracic Medicine, St Vincent’s Hospital, Sydney.
 
 
Dr Stone is a Senior Lecturer at the University of New South Wales and the Chair of the St Vincent’s Hospital Lung Cancer Multidisciplinary Team (MDT). She has developed clinical practice and research interests in the fields of lung cancer, multidisciplinary team care and tobacco control since 2006.
 
Dr Stone has been a member of the IASLC Tobacco Control and Smoking Cessation Committee since 2013 and is currently Chair of the Committee.
  
What first motivated you to work in thoracic medicine and lung cancer? 
 
What first drew me to thoracic medicine was its intellectual offering. I focused on lung cancer in my early years of clinical practice: I worked with the lung cancer multidisciplinary team (MDT) and loved the collegiate atmosphere. 
 
I find lung cancer a very rewarding field to work in. There is a crying need for patients with lung cancer to be cared for by people who believe they need respect and the best care, including support with smoking cessation. I used to feel despairing about smokers with lung cancer.
 
Being on the IASLC Tobacco Control Committee – where I have the opportunity to work with exceptional people (I know everybody says their teams are exceptional, but these people really are) – has educated me and made me a better clinician. 
 
What is different about your role today from when you started your career?
 
There is much more to offer patients now, due to advances across the spectrum of treatment and care. Advances in imaging, the wider use of PET scans and the introduction of EBUS (endobronchial ultrasound-guided biopsy) mean that our ‘diagnostic toolkit’ is much more sophisticated than it once was, so we can better diagnose lung cancer and identify staging. Use of low-dose CT raises the potential of larger scale screening programmes for lung cancer. I’m presently involved in a trial looking at this. 
 
The development of MDT teams and lung cancer pathways has also been very important. Developing well-validated lung cancer pathways can make a huge difference to advancing care and improving outcomes.
 
Now a whole team of people, from the GP through to the respiratory physicians, oncologists, surgeons, palliative care physicians, lung cancer  nurses and allied health care workers can collaborate to provide the best care for each patient. MDT teams also include imaging specialists and pathologists.  There is a lot of expertise that comes together. 
 
With some of the newer therapies including targeted therapies and immunotherapies we are seeing more patients living good quality lives after diagnosis. It is not uncommon now to see people with lung cancer who are active and busy, even after their diagnosis. I often hear about how patients are able to travel or enjoy playing golf, which once seemed unthinkable. 
 
This is not true for everyone, but it seems to be happening more often. Maybe we can turn lung cancer into a more chronic condition. 
 
What do you see as the most significant challenges for advocates?
 
Lung cancer in non-smokers is very tricky to diagnose early and given that around 15% of lung cancer cases occur in non-smokers we still need to improve early detection. 
 
We will also need to keep driving down smoking levels. There have been big steps on tobacco control. During my medical career smoking rates have halved. We are looking at about 12% in Australia at the moment, but we want to see that pushed down to around 5% in the future, which will be difficult. The use of e-cigarettes also poses a new challenge to our existing models of tobacco control. 
 
In many ways, survivorship is an unexplored field in lung cancer. But there are more and more patients diagnosed at stage IV who are living well. Pathways for survivorship care are well established in other fields, like breast cancer. More work needs to be done on helping patients with lung cancer cope with diagnosis and supporting them to live well on active treatment. 
 
What are you most excited about in your field?  
 
I think developments in the use of biomarkers and genomics have a lot to offer.  We have seen the impact on treatment options from markers such as EGFR receptor mutation and EML4-ALK gene rearrangement.  I look forward to future markers that may help refine treatments even more, with better outcomes for patients.
 
What role do you see international collaboration playing in advances in lung cancer treatment?
 
International collaboration is essential. Different nations and groups have different expertise and working together has been critical in improving lung cancer treatment. For example, some of the high-impact early phase III EGFR TKI trials were carried out across several countries in Asia because the rates of gene mutation are particularly high there.
 
Tobacco control has to be an international effort because the tobacco industry itself is globalized. 
 
International guidelines, such as those developed by IASLC, are also very important as they often reflect more recent information and clinical trial data and help us optimize the choices for patients.
 ______________________________________________________________
 
Professor Umberto Ricardi, Professor of Radiation Oncology at the University of Turin and Chairman of Oncology Department at the San Giovanni Battista University Hospital in Turin, Italy. 
 
 
Professor Ricardi is a radiation oncologist whose main areas of clinical and scientific interest include lung cancer, lymphoma, childhood tumours, and central nervous system tumours. He is an expert in the development of cutting-edge technologies in radiation oncology, including radiosurgery, stereotactic ablative radiation therapy, image-guidance, and volumetric IMRT.
 
Prof Ricardi is also a member of the Italian Association of Radiation Oncology, the European Society for Radiation and Oncology (currently serving as ESTRO President) and the EORTC Radiotherapy Group. In 2007, he was appointed to the Italian Ministry of Health’s National Oncological Commission.
 
What first motivated you to work in thoracic medicine and lung cancer? 
 
There were really two factors that led me to thoracic medicine and later lung cancer: the clinical challenge and the technical challenge. When I was in training the prognosis of lung cancer patients was dismal. I believed that it was very important for me as a clinician to try and make the biggest effort possible to improve the prognosis of lung cancer patients. From the perspective of radiation oncology, lung cancer can be a very challenging disease to treat. 
 
What is different about your role today from when you started your career? 
 
A lot has changed over the last 30 years. There have been huge technical advances in the field which have changed my practice in the last two decades. New developments such as stereotactic ablative radiotherapy (SABR) and intensity modulated radiotherapy (IMRT), for instance, have increased the precision and effectiveness of radiation therapy, both in early stage and locally advanced lung cancer.
 
We can precisely target the tumour with a high dose of radiation, while the surrounding healthy tissue receives only a low dose. This has really changed the way we treat patients with lung tumors. 
 
What have been the biggest advances in your specialty, in terms of how we have improved outcomes for people with lung cancer? 
 
Two technical advances have really transformed the way that we work as radiation oncologists. SABR has made it possible to treat small tumours diagnosed at an early stage much more effectively, to the point that you could say we are curing patients without the need for surgery. 
 
For those patients diagnosed with later stage cancers, combination of systemic treatments (platinum-based chemotherapy) and modern radiotherapy (4D-CT scan at simulation, planning with IMRT, image guided radiotherapy) has had a significant impact on outcomes.
 
In the 1990s, standard treatment for locally-advanced (stage III) NSCLC was radiotherapy alone, with a median survival rate of between 9-10 months; thanks to advances  in medical oncology, radiation oncology, and imaging techniques,  median survival has improved to around 30 months. This is better, but there is still plenty of room to improve. 
 
What do you see as the most significant challenges to continuing to improve outcomes for people with lung cancer in the coming years? 
 
In my view the biggest challenges are around ensuring access to high quality multi-disciplinary care, education and resourcing. Multi-disciplinary team working offers the optimum standard of care but this varies at a national and an international level. I believe we should be working to guarantee access to high quality multi-disciplinary care for everyone with lung cancer, as well as with other cancers sites. 
 
We also need to educate the next generation of clinicians, ensuring that all the different healthcare professionals caring for people with cancer are well trained and supported to work in a multi-disciplinary way. This will mean finding new ways of working and pathways of care. For example, roles will need to change to support people who are on active treatment for much longer. 
 
Globally, the availability of resources is also an issue. Patients in some countries simply do not have access to effective and up-to-date treatment. Widening access to new and better treatments and the workforce to deliver them will continue to be a challenge for many countries. 
 
What are you most excited about in your field?  
 
We are finding new ways to better target and treat lung cancer. For example, combining PDL1 inhibitors and radiations is an incredibly exciting new area of clinical research. I feel optimistic about the prospect of finding new ways to combine these medicines with radiation oncology to improve outcomes in different disease settings. 
 
I also feel that the wider use of Patient Reported Outcome Measures (PROMs) is important. By directly capturing outcomes from the perspective of the patient, PROMs have the potential to narrow the gap between the clinician’s and patient’s view of what is needed and help tailor treatment plans to meet the patient’s preferences and needs. 
 
What role do you see international collaboration playing in advances in lung cancer treatment? 
 
International collaboration is fundamental to improving the treatment of lung cancer. In my role, as current President of ESTRO, I see on an almost daily basis how improving collaboration between international societies such as ESTRO and IASLC, is vital to sharing best practice and optimising education and care. I am certain that international collaboration will allow us to continue to improve multidisciplinarity and patient care across all cancer types. 

 _________________________________________________________________________________

Professor Gilberto de Lima Lopes Jr, Associate Director for Global Oncology, Sylvester Comprehensive Cancer Centre and Associate Professor of Clinical Medicine, University of Miami in Florida   
 
 
Prof Gilberto Lopes is a medical oncologist and has dedicated his career to thoracic cancers and the issues of cancer control and access to medications in low and middle-income countries.
 
He is the editor in chief of the American Society of Clinical Oncology’s (ASCO) Journal of Global Oncology, associate editor for the ASCO University Editorial Board, 2016-2017 chair of the International Clinical Trials Workshop Working Group, and global health track leader for the Cancer Education Committee. 

 

What first motivated you to work in lung cancer treatment? 
 
Cancer made my mother an orphan at 17 years of age. Her mother died of breast cancer and her father had died of a heart attack shortly before. It changed my mother’s life. Once I was at medical school, going into cancer medicine was a natural choice. 
 
My interest in lung cancer developed while I was training. I was fortunate to be a young oncologist at a time of exciting new developments in cancer treatment. We were learning about cancer cells and how they respond to the immune system, and it seemed like an area with real promise for new treatments. I began volunteering in oncology clinics, did laboratory research and it became my career. 
 
What have been the biggest advances in medical oncology, in terms of how we have improved outcomes for people with lung cancer? 
 
There have been two major advances that have revolutionised how we treat patients today: tyrosine kinase inhibitors (TKI) which work by blocking cancer growth, and immunotherapies which use our body’s immune system to fight cancer. 
 
Working with new TKI treatments we noticed that some patients, notably women, non-smokers and people of Asian descent, had a much better response to their treatment, with their lives being considerably extended.
 
What we learnt, thanks to the work of two teams in Boston, was that these different responses reflected the role that different genetic mutations in cancer cells (in this case EGFR) play in determining how these cells respond to treatment. This ushered in a new way of ‘targeting’ cancer treatment to particular mutations in cancer cells such as EGFR, ALK, ROS1 and B-RAF, which control the way the cells grow and thus how cancer cells can be treated.
 
Third generation TKIs, osimertinib and crizotinib, for example, target EGFRs and ROS1 proteins and based on this targeted approach, we’re seeing patients living longer – up to three years, rather than three months, after diagnosis. This really is an amazing development. 
 
We’ve also seen new immunotherapies such as nivolumab and pembrolizumab being used in lung cancer and we’ve again seen patients doing much better than with chemotherapy alone. These treatments target particular cancer cells that have high levels of proteins called PD-1 and PD-L1.
 
Today we’re learning more about how to use immunotherapy and chemo therapy in combination, which is improving survival even further. We are finding that single treatments are no longer the most effective options for all patients. 
 
What do you see as the most significant challenges in continuing to improve lung cancer treatment? 
 
Cancer resistance is a major challenge. We need better understanding of why cancers become resistant to treatments, and then we can work out how to keep resistance away. 
 
Funding for lung cancer research is also a problem. We know that lung cancer gets less than its fair share, relative to other common cancers. We need more investment in research so we can improve the treatment and care we provide to patients. 
 
What are you most excited about in your field?   
 
Molecular therapies are a game-changer. With further advances in treatment, I believe we can make metastatic lung cancer a chronic disease. We are still a long way off, but one day we will get there. 
 
What role do you see international collaboration playing in advances in lung cancer treatment? 
 
I’ve been lucky to study and work in different countries, so I have seen the way different health systems are confronting lung cancer. International collaboration is paramount. Without international trials and studies, we will not advance as quickly as we could. We have to work together if we’re to make real progress for patients.