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    MTE 22 - Management of Elderly Patients with Lung Cancer (Sign Up Required) (ID 571)

    • Type: Meet the Expert
    • Track: Nursing/Palliative Care/Ethics
    • Moderators:
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      MTE 22.01 - Any Differences in the Management of Elderly Patients with Lung Cancer between East and West? (ID 7863)

      07:00 - 07:30  |  Presenting Author(s): Kwun M Fong

      • Abstract

      Abstract:
      Any Differences in the Management of Elderly Patients with Lung Cancer between East and West? Lung cancer is one of the commoner cancers in the world, accounting for 1.6 million cases annually. In many western countries, lung cancer rates have declined in contrast to the predicted increase in the incidence of lung cancer in Asia, especially among males. Many patients with lung cancer are older and this applies to all parts of the world. There are relatively few data for the older age group, since many studies have an age restriction, such that there can be uncertainty in the extrapolation of trial findings to the average older person. On the other hand it is clear that there are differences in lung cancer in the East and the West including genetic and biological differences such as smoking habits between genders, genetic aberrations such as the frequency of EGFR gene mutations, in addition to cultural and local preferences. Moreover clinical trials are often performed either in the East or the West, as are studies of lung cancer in the older population, such that extrapolation may be needed. In the work up of suspected lung cancer, the older patient may be less tolerant of diagnostic tests given the ageing process and potential concurrent co-morbid disease, especially smoking related diseases which can differ between East and West. In addition in terms of treatment apart from well-known somatic mutation differences, ethnic differences in efficacy and toxicity from therapies may differ, in addition to non-patient factors such as affordability, cultural sensitivities and preferences. Thus the challenge in interpreting and applying research and clinical trials data is includes the relative paucity of data on the older population as well as uncertainty whether the data that is available on the older population applies equally to those in the East and the West, even allowing for known biological differences. This presentation will examine knowledge gaps and differences that should be considered for the management of the older person with the lung cancer from the East and West, in the setting of cultural and genetic uniqueness.

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      MTE 22.02 - Treatment Options in Advanced Non-Small Cell Lung Cancer (NSCLC) in the Elderly: An Evolving Landscape (ID 7807)

      07:30 - 08:00  |  Presenting Author(s): Corey J Langer

      • Abstract

      Abstract:
      Chemotherapy Treating the elderly with advanced NSCLC remains a major challenge. ELVIS (Elderly Lung Cancer Vinorelbine Italian Study) was the first elderly-specific phase III randomized trial to be conducted in advanced NSCLC; this study demonstrated improved survival and quality of life in patients 70 years of age and older, receiving weekly vinorelbine compared to best supportive care. The most studied non platinum-based regimen has been the combination of gemcitabine plus vinorelbine, which proved active and well tolerated in several phase II trials. However, in a large phase III randomized Multicenter Italian Lung cancer in the Elderly Study (MILES), which enrolled about 700 patients, combination chemotherapy with gemcitabine and vinorelbine failed to improve outcomes (response rate, time to progression, survival or quality of life) compared to single agent chemotherapy with either vinorelbine or gemcitabine. Based on these trials, single agent chemotherapy, until relatively recently, was considered the standard of care in PS 0-2 elderly advanced NSCLC patients. However, over the past two decades, retrospective analyses of randomized phase III trials and multiple phase II studies have confirmed the activity and tolerability of cisplatin-based and carboplatin-based chemotherapy in fit elderly patients. In aggregate, these trials suggested that the elderly fared as well or nearly as well as their younger counterparts with respect to response rate and survival, albeit with more toxicity. A randomized phase III trial led by Quoix et al in advanced NSCLC patients between the ages of 70 and 90 with PS 0-2 showed superiority in all outcome parameters for carboplatin and weekly paclitaxel versus either single agent gemcitabine or vinorelbine. Response rate was nearly triple at 29% vs 11% (p <0.0001) with progression-free survival of 6.1 mos vs 3.0 mos (p < 0.0001), median survival of 10.3 mos vs 6.2 mos (p=0.00004), and 1-year overall survival rate of 45% vs 26% (p < 0.001). Quality of life was preserved or improved with the combination regimen. Survival benefit was seen in those 80 years of age and older (n = 114; HR 0.56 [95% CI: 0.37 -0.85], p = 0.0067), and in individuals with PS 2 (n = 122; HR 0.65 [95% CI: 0.44 – 0.95] p =0.027). More recently, in a retrospective subset analysis of elderly individuals enrolled on a phase III study of carboplatin plus either conventional solvent based (sb) paclitaxel administered every three weeks or nanoparticle, albumin-bound (nab) paclitaxel given weekly, the latter regimen resulted in a significant improvement in overall survival at 19.9 mos vs 10.4 mos (p = 0.009). To date, there has been no formal, prospective, phase III comparison of weekly sb- vs weekly nab- paclitaxel in combination with carboplatin in advanced NSCLC in the elderly or any other population. At ASCO 2017, ABOUND 70+ showed that therapy with carboplatin and weekly nab-paclitaxel x 3, followed by a one week break (Arm B) was well tolerated with no dilution in efficacy compared to the “uninterrupted” weekly nab-pacliaxel regimen (Arm A) used in the phase III trial: median PFS (Arms A and B) 3.9 vs 7.0 mo (HR 0.49; 95% CI, 0.30 - 0.79; P = 0.003), confirmed ORR 23.9% vs 40.3% (P = 0.037), and median OS 15.2 vs 16.2 mo (HR 0.76; 95% CI, 0.46 - 1.26; P= 0.292). In addition, the feasibility of cisplatin-based chemotherapy was also reported during ASCO 2017. The results from two separate phase III randomized trials (MILES 3 and 4) led by Gridelli et al comparing single agent gemcitabine to cisplatin+gemcitabine in squamous cell histology or single agent pemetrexed to cisplatin+pemetrexed in non-squamous cell NSCLC, showed a significant improvement in ORR (15.5% vs 8.5%, p=0.02) and PFS (4.6 mos vs 3.0 mos, p=0.005, HR 0.76) and suggested a non-significant trend toward improved median OS (9.6 vs 7.5 mos, p= 0.136, HR: 0.86) in patients receiving the platinum-based combinations. In clinical practice, non-platinum monotherapy remains the standard treatment for unfit elderly patients with advanced NSCLC, but a carboplatin-based combination is a reasonable option for those who are fit enough. Bevacizumab and targeted therapies: E4599 showed a survival advantage for combination bevacizumab and paclitaxel/carboplatin (PCB) vs chemotherapy alone, though a subsequent analysis of those over 70 years of age suggested that this benefit was diluted in older patients. More nuanced analyses by Wakelee and Ramalingam suggested that males of any age sustained a survival benefit, while women up to the age of 60 also realized an OS advantage. It was only in women > 60 years of age where this benefit seemed to be lost, in part because the control arm performed better in this group. A more recent joint analysis pooling the data from the experimental arm of E4599 and the “control” arm of POINT BREAK, both featuring combination PCB, and comparing these data to PC alone (E4599), showed that a survival benefit was sustained up to age 75 with median survival (MS) of 13.4 vs 10.2 mos (HR, 0.78; 95% CI, 0.68–0.89). However, above the age of 75 in a limited cohort (n=157), combination PCB offered no advantage: MS of 9.6 mos vs 13.0 mos for those < 75 yo (HR, 1.05; 95% CI, 0.70–1.57). As for tyrosine kinase inhibitors (TKIs), a retrospective analysis of the elderly enrolled on BR 21, which compared erlotinib to placebo in the 2nd and 3rd line setting in advanced NSCLC showed a consistent response (OR%), progression-free survival (PFS) and OS benefit, albeit a bit more toxicity in older subjects. More recently, in patients with actionable mutations or translocations, phase III trials have demonstrated a consistent OR% and PFS advantage for erlotinib, afatinib, and crizotinib compared to standard front-line or second line chemotherapy regardless of age. Sub-analyses using 65 to 75 as cut points consistently show similar benefits, although the individual comparisons for the elderly have been frequently underpowered to demonstrate statistical significance. In the EURTAC trial comparing erlotinib to platinum-based chemotherapy in patients with exon 19 or 21 mutations, the magnitude of PFS benefit for the TKI was very similar in those above and below 65 years of age: amongst 88 individuals > 65, the HR was 0.26 (95% CI: 0.16 – 0.51), while it was 0.49 for 85 subjects < 65 years of age (95% CI: 0.25- 0.75). In Lux Lung 3, which compared afatinib to cisplatin/pemetrexed in advanced, treatment-naïve patients with EGFR mutations, PFS favored afatinib over chemotherapy in 135 patients 65 years of age and older (HR 0.64, 95% CI: 0.39 – 1.03), not too different from the benefit seen in 211 patients under the age of 65 (HR 0.53, 95% CI 0.36- 0.79). More recently, the J-ALEX trial demonstrated a statistically significant and clinically meaningful PFS advantage for alectinib vs standard crizotinib in TKI-naïve ALK (+) NSCLC. Amongst 207 enrollees, 22 subjects were 75 years of age and older; the hazard ratio for alectinib’s PFS benefit in this very small population was impressive at 0.28, but because of small numbers and an under-powered comparison, the 95% confidence intervals overlapped unity (0.06 – 1.19), and so the putative difference was not statistically significant. Immunotherapy Novel immunotherapy with check-point inhibitors nivolumab, pembrolizumab and atezolizumab have yielded an overall survival benefit compared to standard docetaxel in second-line setting of advanced NSCLC with less toxicity. As of 2017, PD1/PDL1 inhibitors have effectively replaced chemotherapy in the second line setting independent of histology. In these trials, the benefits have been confirmed consistently in subgroup analysis of the elderly, particularly in those between 65 and 75 years of age. Representation of those above 75 years of age in these studies, unfortunately, has been relatively sparse. In some series, there is no indication of increased toxicity of nivolumab in older patients. To date, there are no ongoing elderly-specific trials evaluating immunotherapy in advanced NSCLC. Summary: Elderly NSCLC patients who are fit for clinical trials do reasonably well in comparison to their younger counterparts. However, extrapolating clinical trial data to the general population, is problematic. Clearly, more evidence is required, particularly among octogenarians and patients with multiple chronic conditions. Older patients are at risk for tolerating chemotherapy poorly because of comorbidity and organ dysfunction; in this regard, modified comprehensive geriatric assessments may help facilitate appropriate treatment selection.

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    MTE 23 - Mediastinal Tumors including Thymic Tumors, Lymphoma, Germ Cell Tumors: Biopsy, Diagnosis and Treatment (Sign Up Required) (ID 572)

    • Type: Meet the Expert
    • Track: Thymic Malignancies/Esophageal Cancer/Other Thoracic Malignancies
    • Moderators:
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      MTE 23.01 - Thymic Neoplasms (ID 7808)

      07:00 - 07:30  |  Presenting Author(s): Frank Detterbeck

      • Abstract

      Abstract:
      Thymic malignacies are distintive by being relatively rare and by their generally more indolent behavior; nevertheless all thymomas are malignant tumors. Progress in the understanding of these tumors has been limited until recently. The advent of several regional and international collaborative groups (e.g. the Japanese Association for Research on the Thymus [JART] and the International Thymic Malignancy Interest Group [ITMIG] has provided an infrastructure to facilitate progress, and the field has advanced significantly. The level of understanding available now makes the previously common approach of empiric management of thymic malignancies inappropriate. Three major categories of thymic malnignancies with different biologic behavior are distinguished: thymoma, thymic carcinoma (TC) and Neuroendocrine tumors of the thymus (NETT, also known as thymic carcinoid). Thymomas are subdivided into 5 histotypes with slightly different clinical features, but these clinical differences are small and mixed histotypes are frequent. Through international collaboration, the first fromal stage classification system has been developed. Many patients with thymic malignancies have associated autoimmune conditions, most prominently myathenia gravis. Chest CT with intravenous contrast is the primary imaging modality for patient evaluation. A combination of patient demographics, clinical and imaging features allows a reliable clinical diagnosis of a thymic malignancy to be made in most patients; this can be supplemented with a needle biopsy if needed. However, the ability of imaging to accurately define the degree of local invasion or pleural dissemination is limited. In general, surgical exploration is warranted (in a facility prepared to handle resection of all possibly involved structures) unless imaging clearly demonstrates unresectable invasion. A complete resection of all involved structures is the cornerstone of treatment. The role of adjuvant radiotherapy after an R0 resection remains unclear, especially after resection of more invasive tumors or int he case of TC/NETT. It is easier to argue for adjuvant RT after an R1 resection or an R0 resection with close margins. Surgeons should be prepared to resect involved structures; a planned subtotal (debulking) resection is not recommended. When more invasive thymic tumors raise questions about the ability to achieve an R0 resection, preoperative chemo- or chemoradiotherapy is typically given. Recurrences are relatively low after complete resection. Longer-term (5- and 10-year) survival rates with aggressive multimodality treatment are fairly good, evin in tumors that invade major mediastinal structures or demonstrate pleural dissemination. When resection is not possible, management with palliative chemotherapy (± RT) can be useful. Several regimens have been shown to be active, and an optimal chemotherapy regimen has not been identified.

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      MTE 23.02 - Mediastinal Germ Cell Tumor (ID 7809)

      07:30 - 08:00  |  Presenting Author(s): Lawrence Einhorn

      • Abstract

      Abstract:
      Extragonadal germ cell tumors (EGCTs) are among the most perplexing and embryologically intriguing entities in clinical oncology. They represent only 2-5% of adult germ cell malignancies. Their histology is identical to germ cell tumors (GCTs) derived from primary gonadal sites. However, their biology, especially primary mediastinal non-seminomatous GCT (PMNSGCT), is substantially different. PMNSGCT represents a clinically and biologically distinct subset of EGCT. It carries a poor prognosis with 40-50% overall survival after platinum-based chemotherapy and surgery (1-3). The cure rate is even worse if there is metastatic disease of the lung, liver, or supraclavicular lymph nodes with only 25% overall survival. In contrast, mediastinal seminomas have a good prognosis with 88-90% overall survival (4,5). Survival outcome for PMNSGCT is dependent on successful chemotherapy and expert thoracic surgery to remove residual disease when feasible. Patients presenting with anterior mediastinal tumor do not have a testis primary and there is no need to evaluate with testis ultrasound. The significant elevation in tumor markers including human chorionic gonadotrophin (hCG) > 1,000 U/1 and/or any elevation in alphafetoprotein (AFP) confirms the diagnosis of NSGCT and no biopsy is needed. The patient should be treated with 4 courses of platinum-based triple chemotherapy. We recommend using etoposide (VP-16), ifosfamide and cisplatin (VIP x 4) as the standard chemotherapy for PMNSGCT followed by surgical resection (2). Patients with normal tumor markers or mild elevation in hCG require a biopsy to establish the diagnosis of pure seminoma vs. NSGCT vs. other etiology such as thymic malignancy or lymphoma. Between 1980 and 2013, 221 patients with PMNSGCT who underwent postchemotherapy surgery at Indiana University were retrospectively reviewed. Our initial experience was entirely with BEP x 4. Because of our clinical observation of unacceptable pulmonary toxicity, we subsequently substituted ifosfamide for bleomycin. One hundred sixty-six patients received BEP and 55 received VIP. There were 11perioperative deaths when bleomycin was part of the preoperative chemotherapy (6.6%). By contrast, we saw no perioperative deaths on the VIP arm. Furthermore, 30 patients (18.1%) had prolonged ventilator use for greater than 48 hours. Only 2 patients (3.6%) had this complication on the VIP arm (6). A phase III intergroup study of 181 patients with poor-risk germ cell tumors, including patients with PMNSGCT, demonstrated equivalent survival in patients with VIP compared to BEP. Given the high rate of postoperative pulmonary failure and mortality after BEP, we feel these results strongly support our present policy of preferring to use VIP chemotherapy in patients with PMNSGCT before major thoracic surgical procedure. Surgical resection of residual disease after chemotherapy is an integral part of the management of patients with PMNSGCT. Surgical resection after chemotherapy serves to assess response, remove chemotherapy-resistant disease and direct additional chemotherapy. Viable teratoma or germ cell cancer is present in 30-47% of patients who undergo resection post-chemotherapy (7,8). Chest CT scan every 4 months for 2 years, then every 6 months for years 3-5 is recommended if teratoma or malignant transformation of teratoma is present in the surgical specimen. However, if there is persistent germ cell cancer in the surgical specimen, then patients should receive 2 post-operative courses of etoposide and cisplatin (EP). Surgical treatment for relapsed PMNSGCT in the presence of rising tumor markers after chemotherapy is controversial. Our preferred treatment option is surgery, if feasible, especially if carried out by experienced thoracic surgical oncologists. We recently reported our results with surgery alone in 35 patients with relapsed PMNSGCTs with rising serum AFP (32 patients) or hCG (3 patients). Seven (20%) of 35 patients remained continuously disease-free, with median followup of 64 months (range, 25-220 months) (10). If surgery is not feasible, then high dose chemotherapy in an experienced center is a reasonable approach. Mature teratoma is the most common GCT in the mediastinum. Patients present with large circumscribed anterior mediastinal mass with normal serum hCG and AFP. The treatment of mature teratoma is surgical resection and there is no role for chemotherapy unless elevated tumor markers are present. Mediastinal pure seminomas comprise 30-40% of malignant mediastinal GCT. Mediastinal seminoma carries an excellent prognosis and should be treated with good-risk chemotherapy regimen (3 cycles of bleomycin, etoposide, and platinum or 4 cycles of EP) with no surgical resection needed. References: International Germ Cell Consensus classification: a prognostic factor-based staging system for metastatic germ cell cancers. International Germ Cell Cancer Collaborative Group. J Clin Oncol 1997; 15:594-603. Kesler KA, Rieger KM, Hammoud ZT, et al.: A 25-year single institution experience with surgery for primary mediastinal non-seminomatous germ cell tumors. Ann Thorac Surg 2008; 85:371-378. Rivera C, Arame A, Jougon J, et al.: Prognostic factors in patients with primary mediastinal germ cell tumors, a surgical multicenter retrospective study. Interact Cardiovasc Thorac Surg 2010; 11:585-589. Bokemeyer C, Nichols CR, Droz JP, et al.: Extragonadal germ cell tumors of the mediastinum and retroperitoneum: results from an international analysis. J Clin Oncol 2002; 20:1864-1873. Hartmann JT, Nichols CR, Droz JP, et al.: Prognostic variables for response and outcome in patients with extragonadal germ cell tumors. Ann Oncol 2002; 13:1017-1028. Ranganath P, Kesler KA and Einhorn LH: Perioperative morbidity and mortality associated with bleomycin in primary mediastinal non-seminomatous germ cell tumor. J Clin Oncol 2016; 34:4445-4448. 2016. Vuky J, Bains M, Bacik J, et al.: Role of postchemotherapy adjunctive surgery in the management of patients with non-seminoma arising from the mediastinum. J Clin Oncol 2001; 19:682-688. Kesler KA, Rieger KM, Ganjoo KN, et al.: Primary mediastinal non-seminomatous germ cell tumors; the influence of postchemotherapy pathology on long-term survival after surgery. J Thorac Cardiovasc Surg 1999; 118:692-700. Hinton S, Catalano PJ, Einhorn LH, et al.: Cisplatin, etoposide , and either bleomycin or ifosfamide in the treatment of disseminated germ cell tumors. Final analysis of an intergroup trial. Cancer 2003; 97:1869-1875. Radaideh SM, Cook VC, Kesler KA, Einhorn LH: Outcome following resection for patients with primary mediastinal non-seminomatous germ cell tumors and rising serum tumor markers postchemotherapy. Ann Oncol 2010; 21:804-807.

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    MTE 24 - Basic Cytology for Clinicians (Sign Up Required) (ID 573)

    • Type: Meet the Expert
    • Track: Biology/Pathology
    • Moderators:
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      MTE 24.01 - Diagnostic Value and Limitation of Cytology (ID 7810)

      07:00 - 07:30  |  Presenting Author(s): Kim Geisinger

      • Abstract

      Abstract:


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      MTE 24.02 - Novel Techniques of Cytological Diagnosis (ID 7811)

      07:30 - 08:00  |  Presenting Author(s): Spasenija Savic

      • Abstract

      Abstract not provided

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    MTE 25 - Tobacco Control - Practical Issues (Sign Up Required) (ID 574)

    • 07:00 - 08:00
    • 10/18/2017
    • Location: Room 316
    • Type: Meet the Expert
    • Track: Epidemiology/Primary Prevention/Tobacco Control and Cessation
    • Moderators:
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      MTE 25.01 - Smoking after Diagnosis of Cancer (ID 7812)

      07:00 - 07:30  |  Presenting Author(s): Jacek Jassem

      • Abstract

      Abstract:
      Around one-third of all malignancies are attributable to tobacco smoking. Diagnosis of cancer is a turning point in life and an alarming signal, motivating for smoking cessation. This is particularly true for patients with tobacco-related malignancies, such as cancers of the lung, head and neck, esophagus, pancreas, uterine cervix, kidney, bladder or stomach. Indeed, the quit and quit attempts rates shortly after cancer diagnosis are relatively high, nevertheless a significant proportion of patients continue to smoke or relapse after initial quit attempts. In consequence up to one-third to one-half of cancer patients or cancer survivors continue to smoke, and the smoking rates in cancer survival do not significantly differ from those in the general population[1,2]. Most smoking cessation efforts have been aimed at primary prevention, whereas the importance of stopping smoking in people diagnosed with cancer have been given less attention. In consequence, the provision of tobacco cessation treatment for cancer tobacco users is still not widely available. Patients with tobacco-related cancers feel more guilt and shame resulting from previous smoking, and tend to underreport their current tobacco dependence[3-5]. Many believe that there is no point to stop smoking once being diagnosed with cancer. Additionally, some health care professionals, in fear of increasing patients’ guilt and stress, do not encourage them to stop smoking. Patients who continue smoking experience several adverse effects. Apart from disease site and stage, abstinence from smoking is the strongest and independent predictor of survival in cancer patients who have ever smoked. Several studies have consistently shown that continued tobacco use compromises the effectiveness and increases the complication rates of three main cancer treatments: surgery, chemotherapy and radiotherapy[6]. In patients managed with surgery, continued cigarette smoking is associated with increasing risk of necrosis, slower wound healing, higher surgical site infection rates and prolonged hospitalization[7]. Components of tobacco smoke significantly impact clearance and delivery of many cytotoxic agents, resulting in their decreased efficacy and higher toxicity[8]. Current, compared to former smokers and patients who stopped smoking before starting treatment, have lower response rates to radiation therapy and acerbated radiation side effects, such as oral mucositis, xerostomia, weight loss and fatigue[9,10]. Smoking after a cancer diagnosis results in higher risk of developing secondary cancers, poorer general health and increased all cause mortality[11,12]. In consequence, patients who continue to smoke after cancer diagnosis almost double their risk of dying, compared to those who quit. A deleterious impact of continued smoking on survivorship is particularly high for tobacco-related cancers. Cancer survivors who continue to smoke have also poorer emotional and social functioning, vitality and quality of life[13-15]. In conclusion, quitting smoking and prevention of smoking relapse represent an important opportunity to mitigate cancer treatment complications and to improve survival, general health and quality of life. It also allows avoiding much of the excess risk of secondary cancers and other tobacco-related diseases. Enhanced focus on smoking cessation and its active promotion among cancer patients may increase their motivation to quit. All cancer patients, irrespective of treatment setting, should be screened for tobacco use and advised on benefits of tobacco cessation. Patients who continue to smoke should be offered individualized pharmacologic and behavioral therapy to assist in the quitting process. References Bellizzi KM, et al. Health behaviors of cancer survivors: examining opportunities for cancer control intervention. J Clin Oncol. 2005; 23:8884–93. Burke L, et al. Smoking behaviors among cancer survivors: an observational clinical study. J Oncol Pract. 2009;5:6-9. LoConte NK, et al. Assessment of guilt and shame in patients with non-small-cell lung cancer compared with patients with breast and prostate cancer. Clin Lung Cancer. 2008;9:171-8. Warren GW, et al. Accuracy of self-reported tobacco assessments in a head and neck cancer treatment population. Radiother Oncol. 2012; 103:45–8. Morales NA, et al. Accuracy of self-reported tobacco use in newly diagnosed cancer patients. Cancer Causes Control. 2013; 24:1223–30. Toll BA, at al. Assessing tobacco use by cancer patients and facilitating cessation: an American Association for Cancer Research policy statement. Clin Cancer Res. 2013; 19:1941–8. Sorensen LT, et al. Smoking as a risk factor for wound healing and infection in breast cancer surgery. European Journal of Surgical Oncology. 2002; 28:815–20. O'Malley M, et al. Effects of cigarette smoking on metabolism and effectiveness of systemic therapy for lung cancer. J Thorac Oncol. 2014;9:917-26. Browman GP, et al. Influence of cigarette smoking on the efficacy of radiation therapy in head and neck cancer. N Engl J Med. 1993; 328:159–63. Browman GP, et al. Association between smoking during radiotherapy and prognosis in head and neck cancer: a follow-up study. Head Neck. 2002; 24:1031–7. Stewart BW, et al. Cancer and tobacco: Its effects on individuals and populations, in Robotin M, Olver I, Girgis A (eds): When Cancer Crosses Disciplines: A Physician’s Handbook. London, United Kingdom, Imperial College Press, 2010. Parsons A, et al: Influence of smoking cessation after diagnosis of early stage lung cancer on prognosis: Systematic review of observational studies with meta-analysis. BMJ 2010; 340:b5569 Berg CJ, et al. Correlates of continued smoking versus cessation among survivors of smoking-related cancers. Psychooncology. 2013;22:799-806. Garces YI, et al. The relationship between cigarette smoking and quality of life after lung cancer diagnosis. Chest. 2004; 126:1733–41. Duffy SA, et al. Effect of smoking, alcohol, and depression on the quality of life of head and neck cancer patients. General Hospital Psychiatry. 2002; 24:140–7.

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      MTE 25.02 - What Physicians and Scientists Can Do in Tobacco Control Action (ID 7813)

      07:30 - 08:00  |  Presenting Author(s): Yumiko Mochizuki

      • Abstract

      Abstract not provided

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    MTE 26 - Clinical Trial Design for Novel Treatment (Sign Up Required) (ID 575)

    • 07:00 - 08:00
    • 10/18/2017
    • Location: Room 315
    • Type: Meet the Expert
    • Track: Clinical Design, Statistics and Clinical Trials
    • Moderators:
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      MTE 26.01 - Contemporary Trial Design Considerations in the Era of Immuno-oncology (ID 7814)

      07:00 - 08:00  |  Presenting Author(s): Mary Redman

      • Abstract

      Abstract not provided

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    MTE 27 - CT Screening for Lung Cancer (Sign Up Required) (ID 576)

    • 07:00 - 08:00
    • 10/18/2017
    • Location: Room 501
    • Type: Meet the Expert
    • Track: Radiology/Staging/Screening
    • Moderators:
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      MTE 27.01 - Who Should be Screened for Lung Cancer? (ID 8129)

      07:00 - 07:30  |  Presenting Author(s): Jim Jett

      • Abstract

      Abstract:
      The National Lung Screening Trial (NLST) demonstrated that screening for lung cancer could reduce lung cancer (LC) mortality by 20%[1]. Screening with low-dose CT (LDCT) resulted in more early stage lung cancers and fewer late-stage cancers as compared to chest X-ray screening. It has been estimated that 12,000 lung cancer deaths could be averted each year if all eligible Americans were to undergo LDCT screening[2]. An Italian screening study with LDCT reported that stopping smoking reduces overall mortality by 39% compared with current smokers[3]. Tanner and associates also reported a 20% LC mortality reduction in the NLST in the chest X-ray arm (control arm) in the absence of smoking for 7 years[4]. The maximum mortality benefit was seen in the absence of smoking in combination with LDCT that resulted in a LC mortality reduction of 38% (HR=0.62). Accordingly, current-screening programs must include tobacco cessation counseling and treatment to current smokers[5]. The US Preventive Services Task Force has approved LDCT screening in high-risk individuals (asymptomatic persons aged 55 to 80 years who have a 30-pack-year or more smoking history and have quit within the past 15 years)[6]. However, from 2010-2015 less than 5% per year of those eligible are currently undergoing LDCT screening. Of the 6.8 million smokers eligible for LDCT screening, only 262,700 received it[7]. In the last two years a large number of centers have ramped up their screening programs in the US. Another issue is that of all lung cancers patients in the United States only 30-40% of these individuals were actually eligible for LDCT screening based on the NLST criteria for screening[8]. Tammemagi et al developed an LC-risk-prediction model based on the PLCO (Prostate, Lung, Colon, Ovarian) screening trial[9]. At a six-year LC risk of ≥1.5%, this risk prediction model detected 12% more LC and screened 8.8% fewer individuals than those using the NSLC screening criteria[10]. The number needed to screen to detect one LC was 255 with this model as compared with 320 in the NLST. None of the never-smokers in the PLCO trial had a risk of >1.5%. Do not screen never-smokers! In an effort to detect more lung cancers at an earlier stage, additional risk factors need to be included in screening programs and evaluated for their efficacy. Young and colleagues evaluated a subset of the NLST participants who had pulmonary function testing (PFT) and observed a two-fold increase in lung cancer incidence with COPD[11]. There was a linear relationship between increasing severity of airflow limitation and risk of lung cancer[12]. The heritability of lung cancer is not well explained. The OncoArray Consortium has identified 18 genetic susceptibility loci for LC across histological types[13]. Dr. Stephen Lam in Vancouver, BC is testing this 18-gene array as a risk factor in an international screening trial. The European Study of Cohorts of Air Pollution Effects (ESCAPE) identified particle matter (PM 10 and PM 2.5) as having significant association with LC risk (HR 1.22 and 1.18 respectively)[14]. The hazard ratios (HR) associated with adenocarcinoma was 1.51 and 1.55 respectively. Satellites are able to measure air pollution and have good correlation with simultaneous ground measurements ( accessed 8/4/2017). There is extensive research into biomarkers for risk of lung cancer that might be of use in screening for LC or in identifying risk of malignancy in indeterminate pulmonary nodules. Sources of biomarkers to date have included breath, sputum, urine and blood. Categories of blood biomarkers have included micro-RNA, proteins, circulating tumor DNA and autoantibodies. A randomized prospective trial (RCT) in Scotland is evaluating an autoantibody panel against tumor antigens for early detection of LC[15]. The trial randomized 12,000 high-risk participants to the blood test alone or routine care (no screening). Those with a positive blood test undergo a CT chest scan. Results of this RTC should be available in late 2018. If we (IASLC) are going to decrease the mortality of lung cancer then we must promote tobacco use intervention and implement LC screening so that more LCs are detected in an early and more curable stage. The optimal paradigm for screening has yet to be developed and is likely to vary in different countries. The NLST was a starting point and reveals that is can be accomplished. Continued innovations and research are required. References 1) The National Lung Cancer Screening Trial Research Team. NEJM (2011); 365:395-409 2) Ma et al. Cancer (2013); 119:1381-5 3) Pastorino et al. J Thorac Oncol (2016); 11:693-699 4) Tanner et al. Amer J Resp Crit Care Med (2016); 193:534-541 5) Tammemagi et al. JNCI (2014); 106:doi.1043/jnci/dju168 6) Moyer et al. Ann Int Med (2014); 160:330-338 7) Jemal and Fedewa. JAMA Oncol, published online February 2, 2017 8) Wang et al. JAMA (2015); 313:853-855 9) Tammemagi et al. NEJM (2013); 368:728-736 10) Tammemagi et al. PLOS (2014); 11e 1001764 11) Young et al. Amer J Resp Crit Care Med (2015); 192:1060-1067 12) Hopkins et al. Annals Amer Thorac Society, published online January 11, 2017. 13) McKay et al. Nature Genetics (2017); 49:1126-1132 14) Raaschou-Nielsen et al. Lancet Oncol (2013); 14:813-822 15) Sullivan et al. BMC Cancer (2017); 17:187-196

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      MTE 27.02 - Pulmonary Nodule Guidelines: How Do We Decide Between the IELCAP, ACCP, NCCN, Fleischner Society, BTS, and Lung-RADS? (ID 7815)

      07:30 - 08:00  |  Presenting Author(s): Jin Mo Goo

      • Abstract

      Abstract:
      In the era of multidetector CT and lung cancer screening with low-dose CT, there are increasing number of incidentally or screen detected pulmonary nodules. Because a pulmonary nodule is an important finding of lung cancer, how to manage these nodules has become an essential issue in dealing with lung cancer, which explains why many guidelines on this topic are available. In this talk, overview of several well-established guidelines or protocols of International Early Lung Cancer Action Program (IELCAP), the American College of Chest Physicians (ACCP), National Comprehensive Cancer Network (NCCN), Fleischner Society, British Thoracic Society (BTS), and Lung CT screening Reporting and Data System (Lung-RADS) will be introduced. Nodule management protocols are different whether nodules are detected at screening programs or incidentally. Screening programs target high-risk subjects who need consistent monitoring, whereas incidentally detected lung nodules represent a different population that needs a varied clinical management. ACCP, BTS, and Fleischner Society guidelines deal with incidental nodules, while IELCAP and Lung-RADS are protocols for screening programs. NCCN guidelines state both issues with separate algorithms. Most pulmonary nodule guidelines have common components: risk factor assessment, nodule size, and nodule consistency. Baseline and annual repeat protocols are different at screening programs. Risk factors include age, smoking history, family history, previous cancer history, occupation exposure, etc. Nodules smaller than certain thresholds (NCCN, < 4 mm; ACCP and BTS, < 5 mm; Fleischner, IELCAP, and Lung-RADS, < 6 mm) do not require routine follow-up. The management for larger nodules varies with guidelines, but 8 mm and/or 15 mm are frequently recommended thresholds for more workups. Nodules can be classified into solid, part-solid, and pure ground-glass nodule according to their consistency. Because the likelihood of malignancy and growth rates are quite different depending on the nodule consistency, this classification is important in nodule management. Nodule volumetry and risk-prediction models such as the Brock University tool, currently employed in BTS guidelines, may be used more frequently in future guidelines. While the Fleischner Society, IELCAP, and Lung-RADS guidelines are relatively straightforward focused on the initial workup, ACCP, NCCN, and BTS guidelines also deal with the further workup and treatment. Some studies have shown that there is high awareness and adoption of these guidelines, but there are varying degrees of conformance with these recommendations. With the accumulation of large data, these guidelines will be more meticulous and evidence-based. Computerized tools that can assess both clinical and radiologic information will facilitate handling the issue of nodule management. References I-ELCAP protocol documents at http://www.ielcap.org/protocols Gould MK, et al. Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013 May;143(5 Suppl):e93S-e120S. NCCN guidelines at https://www.nccn.org/professionals/physician_gls/f_guidelines.asp Callister ME, et al. British Thoracic Society guidelines for the investigation and management of pulmonary nodules. Thorax. 2015 Aug;70 Suppl 2:ii1-ii54. MacMahon H, et al. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017. Radiology. 2017 Jul;284(1):228-243. Lung-RADS at https://www.acr.org/Quality-Safety/Resources/LungRADS

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    MTE 28 - Immunotherapy for Earlier Stage NSCLC (Sign Up Required) (ID 577)

    • Type: Meet the Expert
    • Track: Immunology and Immunotherapy
    • Moderators:
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      MTE 28.01 - Rationale for IO in Treatment of Early Stage NSCLC (ID 7816)

      07:00 - 07:30  |  Presenting Author(s): Patrick M Forde

      • Abstract

      Abstract not provided

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      MTE 28.02 - Pros and Cons of IO in Early Stage NSCLC (ID 7817)

      07:30 - 08:00  |  Presenting Author(s): Edward Brian Garon

      • Abstract

      Abstract not provided

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    MTE 29 - Stereotactic Body Radiation Therapy for Early Stage Lung Cancer (Sign Up Required) (ID 578)

    • 07:00 - 08:00
    • 10/18/2017
    • Location: Room 502
    • Type: Meet the Expert
    • Track: Radiotherapy
    • Moderators:
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      MTE 29.01 - Update and Overview of SBRT for Early Stage Lung Cancer (ID 7819)

      07:00 - 08:00  |  Presenting Author(s): Yasushi Nagata

      • Abstract

      Abstract:
      Stereotactic body radiotherapy (SBRT) is a technique, introduced in the late 1990s. SBRT is a method of using single 10-20Gy of high dose and hypofractionated radiotherapy. Recently, many papers have been published on its clinical results, especially in early stage lung cancer. In Japan as JCOG 0403 clinical trial, between July 2004 and November 2008, 169 patients from 15 institutions were registered. 100 inoperable and 64 operable in total 164 patients were eligible. Of the inoperable 100 patients, the % 3-year OS was 59•9% (95% CI: 49•6% - 68•8%). Grade 3 and 4 toxicities were observed in 10, and 2, respectively. No grade 5 toxicity was observed. Of the 64 operable patients, the % 3-year OS was 76•5% (95% CI: 64•0% - 85•1%). Grade 3 toxicities were observed in 5. No Grades 4 and 5 toxicities were observed. SBRT for stage I NSCLC is effective with low incidences of severe toxicity. This treatment can be considered a standard treatment for inoperable stage I NSCLC. This treatment is promising as an alternative to surgery for operable stage I NSCLC. The current ongoing protocols for lung cancer as JCOG 1408 comparing two different doses、42Gy in 4 fractions and 55Gy in 4 fractions for T1N0M0 and clinically diagnosed lung cancer will be presented. In the world, RTOG 0618 showed a good result of SBRT in the treatment of patients with operable stage I/II NSCLC. RTOG 0915 showed no difference in survival between 48Gy in 4 fractions and 34Gy in a single fraction. In central hilar lung cancer patients, additional attentions are required to avoid serious complications. RTOG 0813 is a Phase I/II study for finding an optimal dose. 55Gy in 5 fractions are their recommended dose. JROSG 10-1 recommended 60Gy in 8 fractions. Optimal dose and fractions are still unknown for centrally located lung tumor. Most updated status of SBRT will also be reviewed.

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    MTE 30 - Surgery after Concurrent Chemoradiotherapy (Sign Up Required) (ID 579)

    • 07:00 - 08:00
    • 10/18/2017
    • Location: Room 503
    • Type: Meet the Expert
    • Track: Surgery
    • Moderators:
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      MTE 30.01 - Surgery after Concurrent Chemoradiotherapy (ID 7820)

      07:00 - 08:00  |  Presenting Author(s): G. Lyons

      • Abstract

      Abstract not provided

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    MTE 31 - Perspectives of Anti-Angiogenesis (Sign Up Required) (ID 580)

    • 07:00 - 08:00
    • 10/18/2017
    • Location: Room 418
    • Type: Meet the Expert
    • Track: Chemotherapy/Targeted Therapy
    • Moderators:
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      MTE 31.01 - Perspectives of Anti-Angiogenesis (ID 7821)

      07:00 - 08:00  |  Presenting Author(s): John V Heymach

      • Abstract

      Abstract not provided