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Lung Cancer Roundtable of Experts: The Importance of Taking Ownership of Your Cancer Treatment

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Published on October 8, 2015

Lung cancer is making swift strides in both research and clinical care.  What's next?  Listen as five experts—Dr. David Carbone (U.S.), Dr. Fiona Blackhall (UK), Dr. Paul Paik (U.S.), Dr. Rohit Lal (UK), and U.S. patient advocate Chris Draft—offer a global perspective in a deep and honest roundtable discussion.  Subjects include genetics, immunother.apy, and economic realities.  Chris Draft sums it up like this: "We're not where we want to be but [we] are progressing.  Keep on fighting.  Keep on believing. The next drug might be for you."

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Transcript | Lung Cancer Roundtable of Experts: The Importance of Taking Ownership of Your Cancer Treatment

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That's how you’ll get care that's most appropriate for you.

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you. 

Dr. Carbone:       

I'm David Carbone.  I'm a lung cancer specialist working at the Ohio State University in Columbus, Ohio.  And we’re gathered today with a group of investigators and a patient advocate at the World Conference on Lung Cancer, 2016 in Denver, Colorado.  This is the premier lung cancer research meeting that is organized by the International Association for the Study of Lung Cancer, for which I am the president-elect.

The organization is focused on advancing the research and clinical care of lung cancer for all means: basic science, clinical research, involvementand transmitting that information to—around the world to different investigators, clinicians, researchers but also to patients interested, family members and to political organizations and governments involved in deciding patient care.  So today we’re going to discuss advances in lung cancer management with this panel, and I'd like to have them introduce themselves to start.  So, Fiona, would you introduce yourself?

Dr. Blackhall:     

Hello, I'm Fiona Blackhall.  I'm a lung cancer specialist,medical oncologist at the Christie Hospital in Manchester in the UK.  And I'm really very pleased to be here in Denver at this meeting, which I've been attending, now, for over 10 years.  And it’s always an extremely stimulating meeting.

Dr. Carbone:       

Thank you.  Chris? 

Chris Draft:         

Chris Draft, founder of the Chris Durant Family Foundation and Team Draft Initiative, where our mission is to change the face of lung cancer.  So I am a patient advocate. 

Dr. Carbone:       

Paul? 

Dr. Paik:                

I'm Paul Paik.  I'm a lung cancer oncologist at Memorial Sloan Kettering in New York City.

Dr. Lal:  

Hello.  I'm Rohit Lal.  I'm a lung cancer medical oncologist at Guy’s [and St. Thomas’] Hospital in London. Thank you for asking.

Dr. Carbone:       

Okay. I would like to start with the earliest stages of—how we find this disease, just a brief discussion on what’s new in finding the disease early when it’s most curable.  And, Rohit, would you like to talk about what’s known about lung cancer screening? 

Dr. Lal:  

It’s really exciting to see new data research and the whole area of CT screening for lung cancer continue to develop further, trying to identify better ways of recognizingsmall spots on CT scans, and which of those may be suspicious for tumors and may need further surveillance.  And also, the area of beginning to do blood tests to look at whether or not there are any identifiable markers in somebody's blood.  That’s an early—that’s still early at this point, but it’s great to see progress in those areas.

Dr. Carbone:       

So the technology of CT scanning has advanced to the point where, with minimal radiation exposure and a very rapid scan, you can image spots in lungs, tiny sized.  And in the United States, it recently was approved to do CT screening for patients that have a high smoking history and are above a certain age.  And this has been shown to decrease the mortality from lung cancer by 20 percent.

And this is a huge decrease  where we can cure patients who might not have been diagnosed until they were advanced and incurable.  And so one thing I did want to emphasize was that the technology is now available and increasingly available around the world.  And we are still in the process of learning how to ideally utilize that technology.  Any other comments from the panel?

Chris Draft:         

My wife was diagnosed with lung cancer in December of 2010 and, unfortunately, passed in December of 2011.  But as we advocate in moving forward from that point, 2011 is special.  I say that just from here in the States, the national lung cancer screening trial that was approved that year.  I know we’re going to talk about treatment in terms of crizotinib (Xalkori), but my wife passed, but in moving forward and being an advocate, we have to hold ontothe things that are important in terms of why there’s hope in moving forward.  And so when you say in CT, I know I got—and you say that it’s exciting, we always have to temper it.  But I know it’s exciting because that’s lives.  That’s lives.

And how the difference of early detection versus treating somebody at stage IV, the amount of years that they could have, the amount of moments that they get to have with their wives, with their kids, with their friends, the thingsthat they can do.  So thank you for the work that you guys are doing in that regard.  And I know it’s new, again, because it’s really 2011, but it’s so encouraging that that’s possible.

Dr. Carbone:       

I'm a medical oncologist, and I treat people with lung cancer. But I would much rather put myself out of business by curing people before they get to me.  So the other point that I would like to make on that, is that it’s an imperfect test, still.  Especially becausewe have a large number of patients that are diagnosed who never smoked and don’t fit into the categories.  So there’s a lot of work that needs to be done, and blood-based tests are important in that.

And I'm just going to mention—we don’t have a surgeon on the panel, but the main treatment for most forms of lung cancer when detected early is surgery.  And we’ve made dramatic strides in surgery where years ago, surgeons would have to have a foot-long incision; it was a major ordeal.  And now we’re doing surgeries robotically, and patients go home in three days with Band-Aids on their side.  And so I think we have made advances in surgery.

But I think some of the most exciting advances have come in the development of in the understanding of the molecular biology of lung cancer and the development of drugs that specifically target an individual’s unique molecular profile in their tumor.  And maybe I could get Paul to comment on the genetics of lung cancer, and what does it mean when you say your tumor has a gene mutation?  Does that mean your children are at risk, for example?

Dr. Paik:                

Right.  So by and large for virtually everyone, this is not a risk factor that you pass onto your children. These are changes in the DNA of the tumors themselves that have caused them to become cancer and the things that the tumor cells depend on for survival.  Which is why if you're able to block the function of these changes with newer targeted therapies, we’re able to see great benefits.  And we’ve seen this from a vast amount of work that’s gone on for—now we can say, in a quite good way—decades, dating back into the early 2000s with the initial work with erlotinib (Tarceva) and then  crizotinib, Chris, as you had mentioned.

And a whole host of other targets and drugs that have come about since then.  But it is important to I think reinforce that these are changes that we’re finding, almost exclusively in the tumors themselves that do not carry risk to family members.

Dr. Carbone:       

So let’s be a little more specific, here.  So a patient comes in with a new diagnosis of non-small cell lung cancer adenocarcinoma subtype.  Are these gene mutations relative to that patient’s care in animmediate sense? Or is this something that’s only relevant to people treated at Memorial [Sloan Kettering]?

Dr. Paik:                

Right.  So this is relevant now, I think we’re all happy to say—particularly in the context of a meeting like this where people are coming from all over the world—it’s sort of standard of care at this point.  Where if you have a particular lung adenocarcinoma, right from the get-go the standard of care worldwide is to do some selected mutation testing to take a look at a handful of genes for which we have approved treatments around the world.  This is testingthat happens in a relatively short period of time and something that does dictate the course of treatment just right at the beginning.

We’ve gotten to the point, as well, of course, for those where we don’t find something immediately, that we’re getting better at finding things at a little bit of a later date.  The number of targets is expanding, and some of that work has been presented here at this conference, also.

Dr. Carbone:       

I would say it’s not becoming a standard.  I think my personal opinion is that it is now the expected standard of care for patients with surgically inoperable lung cancer to have a genetic analysis before any treatment is performed.  And that is, unfortunately, not the practice in a large—even a fraction of the United States, and even around the world.  I was recently speaking in India, for example, andmany places in South America don’t have approval for out targeted drugs and those kinds of things.

So, Fiona, do you have any comments on how you view the genetic testing of individuals, and do you want to talk about the major targets that we have for lung cancer now? 

Dr. Blackhall:     

Sure.  It’s been an enormous change that lung cancer—one time in my training, we thought of lung cancer as a single disease—non-small cell lung cancer as a single disease.  And now it’s subdivided into what we describe as these molecularly or genetically defined subsets.  And the first real breakthrough came for the EGFR-mutated subset.

Dr. Carbone:       

The epidermal growth factor receptor.

Dr. Blackhall:     

Exactly.  Epidermal growth factor receptor.  And it took awhile to exactly link the targeted therapies—the inhibitors of epidermal growth factor receptor to the subgroup of patients who carry a genetic change in mutation in that gene in their cancer cells.  But once we appreciated that, we were able to see the significantly better response rates and survivals in those patients with a targeted therapy that’s taken orally, compared to conventional chemotherapy. And that targeted—targeted therapies of those classes have a much better side effect profile.

They hinder everyday life much less than chemotherapy.  And as time has gone on, what we have observed is that unfortunately those drugs don’t keep the brakes on the cancer indefinitely.  The cancer does develop resistance mechanisms. It develops other genetic changes that can overcome the—what we call the first-generation EGFR inhibitors.  And it really is huge progress that now we have learned about those resistance mechanisms and developed a next generation of EGFR inhibitor that can overcome the resistance so patients can then switch to a different oral therapy and continue to benefit.

Those second—or sometimes referred to as third generation; there was another little class in between, but those drugs are at an advanced stage in clinical trial.  They’re not yet licensed and widely available outside a clinical trial.  But that is anticipated to be the next step.  At the moment, I think for patients on EGFR inhibitors, it is really important at such time as their physician suggests they may not be benefitting so much from that therapy that they discuss with the physician possibility of other trials to access these newer drugs.

Dr. Carbone:       

Until they become approved, right?

Dr. Blackhall:     

Exactly.

Dr. Carbone:       

And what other targets do we have in the genetic analysis of our tumors, Rohit? 

Dr. Lal:  

So along with EGFR inhibitors, the ALK and L4 transfer locations have been identified as a small proportion, but a very important one to seek out because of the difference it makes from the patient’s—at the time of diagnosis for patients who, as you said, are surgically inoperable, couldn’t be treated with any kind of localized radiotherapy, either.  Then it’s very important to know that the ALK transfer location status of a patient from the time of the diagnosis not only so that they can access better targeted therapy, less toxic therapy, but also it begins to give us a kind of view of what this patient’s pathway is going to be like.

And it lets us look into planning further on down the line.  One of the things that I often tell my patients is that we’ve moved from that situation where we were giving chemotherapy in blocks with gaps in between, and now often for many of my patients, they’re actually staying on treatment for a much longer period of time and staying well, tolerating that treatment better. 

Dr. Carbone:       

And I would like to emphasize that the pace of progress in targeting these lesions is incredible.  There are multiple—probably dozens of new drugs that are better than the original generation drugs.  We heard that third-generation EGFRinhibitors are out.  And these drugs are often active when the first ones stop working.  And so the impact of these drugs on patients can’t be understated.  As opposed to prolonging life by six weeks at the cost of significant toxicity, we take a disease where the average survival was six months with no therapy to some of these subsets we’re seeing five-year survival, and in some patients 10.

And, Chris, that’s just—like you were saying—an enormous—you can’t understate the value of detecting these mutations right up front.

Chris Draft:         

You just can’t.  I get a chance to see, by going across the country and sitting with survivors and to look at them—if I didn’t know they were a survivor, I mean you might not know it.  And I think that’s the greatness of where targeted therapies are going.  Again, the fact that it’s still treating lung cancer and the lung cancer is serious, that’s something we understand.  But the alternative, I got to experience a great example of what targeted therapy means, especially—even the difference between it being kind of first-line therapy versus second line so after chemo or second line.

We have a survivor who was treated at Stanford, was diagnosed.  And because he had an EGFR mutation and they tested right away to find that out, he didn’t go on standard chemo.  And because it was less toxic, he was able—probably not the best decision, but he’s a doctor.  He was a doctor so he could do what—he was a neurosurgeon and [had a] fellowship at Stanford.  He actually got his wife pregnant and had a baby.  They had a baby, a little girl, Katie.  Her picture is on my phone.

But that’s the possibilities, the possibilities of life that really come after diagnosis.  Which is—again, which you guys are doing with the research right now is that lung cancer happens, and then there’s the possibility of really still living life afterwards.

Dr. Carbone:       

So I've invited a few of my patients to this meeting and asked two of them to speak.  And one of them is a physician from Columbus who had a malco fusion mutation, and as an aside it’s becoming very clear that the best approach to treating these patients is to treat with the best drug and the targeted drug first, and not after chemotherapy, and not after they’ve gone through other treatments.  But this guy had only about a three-month benefit from the standard drug.

But he was put on a clinical trial, which is being reported at this meeting, with a new drug and has had a complete response that’s lasted for a year, including spots in his brain.  And he tells me that he feels completely normal.  He has no side effects.  He’s still at his medical practice.  He’s got five kids, and one of them actually worked in my lab doing research on lung cancer this summer.  So you can’t underestimate how much of an impact this does have on our patients.

And then the—there’s so many things going on.  I don't want to spend too much time on this, but I would like Paul to just comment, because Memorial [Sloan Kettering] is doing a very large gene panel looking for the next wave of targets.  And we have at least half a dozen other genes that are being studied in research protocols as valid targets.  Could you just say a few words on that?

Dr. Paik:                

That’s right.  So I think it’s important to note that we’ve talked about a couple of the leading targets that were identified earliest in lung adenocarcinomas.  But we can identify something that we think is a driver that has a drug that has at least a chance of working in now upwards of 60 to 70 percent of lung adenocarcinoma patients.  As we typically visualize this in terms of a pie and slicing up the pie.  And those other segments of the pie include a host of other different genes, including ret fusions, ROS1 fusions, BRAF mutations, PIC3C mutations, and many, many others.

And I think what David had mentioned as being important is that the technology has gotten to the point now where we can routinely, at our center—and this is going to expand, I think at a fairly rapid pace across other centers in the United States and worldwide, at really taking a much deeper look at these alterations in cancers where the standard used to be, maybe about four years ago, taking a look at maybe a panel of nine different genes.  I think as David had mentioned, we’re now taking a look at a panel of 401 different genes.

And it’s one of those things where you don’t really know what’s going on until you actually know what’s going on and you look.  And so we found quite a number, including most recently an alteration that’s relatively common in about 4 percent of our lung adenocarcinoma patients that actually does respond to an already approved drug, which is crizotinib—so yet another part of that pie for a substantial number of patients.

Dr. Carbone:       

I'd like to amplify on that by saying that this screening ability is not generally available, and many oncologists in the community may not know about these targets.  And the field is evolving so quickly that nobody, including myself, knows everything about all of these targets.  But at a meeting such as this, the world’s leaders in lung cancer meet to become informed regularly about the progress in each of these targeted abnormalities.  So one thing that’s important to emphasize to patients is that they may have a really great oncologist, and he’s in their community, but he’s charged with knowing all kinds of cancers, often, and can’t possibly keep up with all the details.

So I recommend to patients that if they are being treated by a general oncologist that before they embark on treatment they get a second opinion at an academic medical center or advanced lung cancer specialist.  I see only lung cancer, and I suspect many of you do, as well.  And by only seeing that one type of lung cancer, we really become a specialist, and you go to meetings like this to learn the state of the art.  And so I think it behooves patients to assure themselves that they’re getting the state-of-the-art care.  And one of the ways to do that is to get a second opinion.

Now, I'd like to ask Fiona about some of the newer ways of finding out about these mutations.  Do you have to go in and take out the tumor with a scalpel to find mutations, or might you even be able to do it by a blood test?

Dr. Blackhall:     

Well, it’s an important point; thank you for asking.  And just before I go onto newer ways, I also want to comment on the fact that patients sometimes get concerned about that little extra time that getting the molecular test back on the tumor takes.  It can take perhaps another week after an initial biopsy, and that does cause concern and even distress about not getting onto treatment in that week.  But because of the effectiveness of these targeted treatments, that week is worth the wait.

Anoncologist will be able to gauge whether there is any risk of waiting that time.  So I did just want to emphasize the importance of those few extra days to get that genetic test result back on the tumor.  But because of having, at the present, to use a tumor biopsy that involves usually an invasive procedure, a bronchoscopy or an anesthetic and a needle through the skin, a CT-guided biopsy, that is sometimes technically challenging.  And the biopsy can be too small to analyze.  Sometimes a patient is not fit to undergo that procedure.

So there has been a huge effort over recent years in trying to find less invasive ways of analyzing the genetic changes in the tumor.  A lot of progress has been made.  We can pick up DNA that the tumor has shred into the blood.  And there have been at least 10 presentations—I'm sure more—at this meeting using these blood tests to monitor the DNA changes in the tumor.  So I envisage that in another few years’ time, we will be a little less reliant on biopsy tissue, and we will be using blood tests more.

The beauty of the blood test approach, too, is that having established the genetic change from a tumor biopsy, a blood test can be done to confirm that it’s also picked up in the blood.  And that can then be used to monitor.  At the moment, to get onto next-generation targeted therapies, we often need a further biopsy to look at what the genetics of the resistance are and to select the right match of treatment.  And so to be able to avoid having to have multiple biopsies and use a blood test will be a big advance.

The other area is circulating tumor cells.  We have a number of technologies now that can pick up cancer cells circulating in the blood.  And we have managed to evolve the technology such that from a single cell, you can analyze the genetics.  It’s highly technical.  It’s labor intensive, resource intensive and very expensive at this point in time.  But again, something that there is an intense resurge effort in among scientists and translational clinicians.  And it offers real promise for us in the future to be able to just take a blood sample and get a test result returned on that.

Dr. Carbone:       

So as we develop these drugs that target these highly specific genetic abnormalities, tumors eventually become resistant, as Fiona said.  And often they become resistant by acquiring a new mutation that keeps that drug from binding.  And so these kinds of tests from the blood are very useful for following that in real time without doing a new biopsy but doing what we call a liquid biopsy to assess which of those mechanisms tumors have developed to become resistant. And we now have drugs that target those resistance mechanisms and have second dramatic responses.

It’s quite an exciting time.  So why don't we move onto some of the other new advances in lung cancer, and probably the most—the one that’s getting the most buzz at this meeting is immunotherapy.  And maybe Rohit can summarize what we are learning about the lung cancer in the immune system.

Dr. Lal:  

So we’ve begun to understand elements of the molecular biology of the cancer cell itself, which we could use to target and treat cancers.  But this is a whole new area that has suddenly become open to us, as well, which really looks at how to stimulate the patient’s own immune system in recognizing and attacking the cancer that’s present, using that as a therapeutic advantage.

And so what’s been really exciting over the last couple of years is to see, at a very rapid pace, antibody-oriented therapy come forward and really identify a specific group of checkpoint immune receptors: PD-1, PD-L1, CTLA-4, which control how the body’s immune system recognizes cancer.  And perhaps cancers use these systems to escape, hide, evade from the body’s immune system.  And it’s great to have an additional rationale and strategy now that can unmask these foreign invaders and use our own natural immune system to attack those.

So what we’ve seen over the last few months is the availability of these drugs and the benefit that they have over some of the older kinds of chemotherapy that we’ve used.  And what’s really important for me to recognize in that is that the benefit that they’ve shown is that in that group of lung cancer patients who are always much, much harder to treat, they always had fewer options with these toxic therapies we’ve been talking about. And so that’s really, really good to see that they now have—squamous cell carcinoma was a disease that had very limited treatment options—squamous cell carcinoma of the lung.

Dr. Carbone:       

And they were toxic.

Dr. Lal:  

Absolutely.  And now it’s really got something that gives these patients hope.

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.