President of the International Association for the Study of Lung Cancer, Tetsuya Mitsudomi, highlights the importance of overcoming thoracic cancers.
Lung cancer is a term used to describe a growth of abnormal cells inside the lung. These cells divide and grow at a much quicker rate than normal cells. The cancerous cells stick together to form a cluster and this abnormal cluster of cells is called a tumour. If the cancer cells first started growing in the lungs, the tumour is called a primary lung tumour. However, if the lung cancer cells break off and travel through the blood vessels they may latch on to and start to grow in other parts of the body, such as the bones. This new cancer growth is called a metastasis or secondary tumour.
In addition to this, there are two different types of lung cancer: non-small cell lung cancer (NSCLC), which accounts for 85% of the cases, and small cell lung cancer. Non-small cell lung cancer can further be classified by histology, or how the cells and tissue look under a microscope. The major subtypes of NSCLC are adenocarcinoma, squamous cell carcinoma and large cell carcinoma. Adenocarcinoma is the most common, representing about 40%, whereas squamous cell carcinoma represents about 30%.
We speak to Tetsuya Mitsudomi, the president of the International Association for the Study of Lung Cancer (IASLC). IASLC the only global organisation dedicated solely to the study of lung cancer and other thoracic malignancies. Founded in 1974, the association’s membership includes more than 7,500 lung cancer specialists across all disciplines in over 100 countries, forming a global network working together to conquer lung and thoracic cancers worldwide.
To begin, can you give us an introduction into lung cancer across the globe?
Lung cancer is a growing global epidemic with 1.6 million deaths annually that will require an international effort to reduce the morbidity and mortality of this tragically lethal disease. More than 60% of lung cancers are diagnosed after the cancer has spread, leading to worse outcomes for patients, whereas early detection and diagnosis can lead to lowered mortality. Implementing tools and strategies to reliably find early stage, curable lung cancer is a priority of the International Association of the Study of Lung Cancer (IASLC) in its mission to conquer thoracic cancers worldwide.
From a public health perspective, cancer rates have fallen in some countries where cigarette smoking has declined but increased in other countries where smoking cessation has not been a priority of those governments. Increasingly, researchers are focusing on the 15-20% of lung cancer patients who have never smoked, to examine what environmental or genetic factors may be influencing their disease status.
Some of them may be associated with second-hand smoking but we do not know the aetiology for the vast majority. While screening and other public health measures have reduced the mortality of lung cancer among many populations, researchers have also created breakthroughs in immunotherapy, check point inhibitors and targeted therapies. These developments have given lung cancer patients more viable therapeutic options to extend their life, or in some cases although rare, cure their disease.
What is the importance of education/awareness surrounding lung cancer? What would you say is the most common misconception, and what more can be done?
Despite lung cancer killing more people than breast, prostate and colon cancers combined, there is no global consensus or standard for lung cancer screening. Different treatments are approved and funded very differently in different countries around the world leading to disparities in treatment. This may be our biggest challenge for the next generation.
Fortunately, there is hope on the way as research presented demonstrates low-dose CT screening can reduce mortality rates among patients with lung cancer. The National Lung Screening Trial showed that lung cancer screening by three annual rounds of low-dose computed tomography reduced lung cancer mortality. The Multicentric Italian Lung Detection (MILD) provided additional evidence that extended intervention beyond five years, with annual or biennial rounds, enhanced the benefit of low-dose CT screening.
In 2018, results from the Dutch-Belgian NELSON lung cancer screening trial presented at the IASLC 19th World Conference on Lung Cancer in Toronto, Canada, support the use of low dose computed tomography screening in high risk individuals as one way to reduce lung cancer mortality. Still, CT scans have barriers to widespread implementation as a screening tool. Not all patients live close to a center that has the technology and cost can be a factor. Therefore, development of methods to pre-screen the people who are at higher risk by other methods such as a blood-based test is highly encouraged.
In patients with more advance stage diseases, there is much excitement for utilising blood based tests, too. The possibility of analysing DNA or tumor cells themselves in blood (liquid biopsy) that were shed from the cancer (circulating tumour DNA; ctDNA, or circulating tumour cells; CTC) to understand and identify molecular targets and mechanisms of resistance for current drugs, both targeted agents and immunotherapies, will be extremely beneficial for patients, as will harnessing these strategies to identify new biomarkers.
The future of liquid biopsies is undeniably exciting, but there is a need to more clearly understand the latest developments. The effective use of any screening tool for lung cancer hinges on clinicians’ ability to diagnose and predict, with near certainty, what therapies might be most effective. Properly staging tumors helps clinicians better treat lung cancer and it allows for more clear clinical trials to move forward.
Lung cancer staging is a long-term effort that requires commitment and contributions from researchers and clinicians around the world. In 2009, IASLC announced the new data/classifications to the international staging system. This was published as the seventh edition. The IASLC added data and other characteristics for the eighth edition in 2017. The ninth edition is collecting data now and will publish in 2024. The focus on better, more accurate staging along with a renewed and strengthened screening effort, will make all
lung cancer specialists around the world better equipped to diagnose and treat lung cancer patients.
What is the work and role of IASLC?
The International Association for the Study of Lung Cancer (IASLC) is the only global network dedicated solely to the study and eradication of lung cancer and other thoracic malignancies (including thymomas and mesotheliomas). Since its founding in 1974, the association’s membership has grown to 7,500 lung and thoracic cancer specialists from all disciplines and over 100 countries. Our mission is to embrace the study of thoracic malignancies and to provide education and information on those diseases to the medical community and public, to ultimately eliminate them.
By hosting global and national conferences, funding cutting-edge research and educating the health care community and the public about thoracic cancers, the IASLC works to alleviate the burden lung cancer places on patients, families and communities. Each year, the IASLC hosts the World Conference on Lung Cancer (WCLC), the world’s largest meeting dedicated solely to thoracic cancers. The WCLC attracts 7,500 lung cancer specialists from across the world and offers attendees the chance to collaborate and network while learning about the latest advances in the field.
In keeping with our commitment to education, the IASLC publishes the Journal of Thoracic Oncology (JTO), a primary source for thoracic malignancy prevention, detection, diagnosis and treatment information. The JTO serves as an authoritative resource in the field, with its impact factor increasing from 10.336 in 2017 to 12.460 in 2018. In January, we will launch a new, open access journal, JTO Clinical and Research Reports.
Can you tell us about the Lung Ambition Alliance? What is the importance of this?
The International Association for the Study of Lung Cancer (IASLC), Guardant Health, the Global Lung Cancer Coalition (GLCC) and AstraZeneca announced the Lung Ambition Alliance, a new partnership with a bold ambition to eliminate lung cancer as a cause of death.
The first goal of the Alliance is to double five-year survival for patients with lung cancer by 2025. The Alliance represents a broad range of complementary expertise, including research and education (IASLC), diagnostics (Guardant Health), patient advocacy (GLCC), and medicines research and development (AstraZeneca).
The founding partners have identified three priorities: increasing screening and early diagnosis, delivering innovative medicine, and improving the quality of care for people with lung cancer. Initial projects being accelerated through the Alliance include:
The Early Lung Imaging Confederation (ELIC)
The ELIC is a new, cloud-based worldwide screening database designed to accelerate improvements in the multidisciplinary detection and management of early-stage lung cancer. The project capitalises on growing evidence that CT screening can lead to reduced mortality. This collection of images and data can be used to build better risk models, as well as analysis and detection tools, while serving as a global standard for data quality. In a future phase, Artificial Intelligence (AI) may be applied to further improve the reliability of clinical decision-support with CT screening. The Alliance will contribute to building out the image bank for this IASLC-owned project, first piloted in late 2018, and will assist in measuring patient outcomes to be assessed at various points in the patient journey (including initial scan, initial treatment, and follow up).
Since patients with earlier lung cancer who undergo pulmonary resections are considered to be closet to cure of the disease, yet surgical outcome are not always satisfactory, preoperative immunotherapy followed by surgery is an attractive approach. However, as you can imagine, this type of clinical trial takes a long time if patient survival is used as endpoint. To decide to go or not go earlier, we definitely need a surrogate endpoint.
The Major Pathologic Response (MPR) which is defined as proportion of patients whose tumor contains less than 10% of viable cancer cells, is such a surrogate endpoint. Our MPR Project is a collection of clinical trial data and research that can be used to validate surrogate endpoints and identify predictive biomarkers, which may enable better targeting of tumor characteristics.
Its aims to accelerate development of the next generation of targeted treatments and drive the shift to earlier intervention when there is greater potential for a cure. The Alliance is assisting in the pooling of data from cooperative groups and across pharmaceutical industry trials, which can be used with health authorities around the world when discussing pivotal trial data.
Initiatives in Lung Cancer Care (ILC2)
The ILC2 is an open call launched in November 2019, inviting local patient organisations around the world to develop and submit pilot projects that can potentially transform patient care and improve survival at the local level. It aims to help the local lung cancer community benefit from multidisciplinary best practices, educate patients about their options and provide quality-of-life support to patients throughout and following treatment.
A Lung Ambition Alliance committee will evaluate and select submissions that have met the selection criteria for funding. The Alliance is sponsoring an international survey, led by Ipsos MORI, to identify local barriers that need priority focus. Results, expected in the fall of 2019, will be used to further refine and shape the priorities of the Lung Ambition Alliance. Information about the survey, and how the community can share their perspectives, can be found at LungAmbitionAlliance.org.
Where would you like to see the position of lung cancer in five years’ time? What role do you hope to see IASLC play in this?
We hope that, as stated in the goals for the Lung Ambition Alliance, the lung cancer community can double the five-year survival for patients with lung cancer by 2025. In five years, we hope that screening tools are established worldwide to allows clinicians around the world to screen, diagnose and treat lung cancer patients and those at risk for lung cancer.
We’d like to see an increase research funding of lung cancer as a percentage of research dollars provided to all cancers. We will work to continue to erase the stigma that lung cancer patients face. This stigma acts as a barrier to prevention, screening and treatment compliance. As the global leader in thoracic cancers, our membership including the world’s greatest thought leaders and those working every day to make a difference in the field, we will continue to convene, to educate, to collaborate and to use all available means to accomplish our mission to conquer thoracic cancer worldwide.