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Emily Stone
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ES13 - Global Political, Legal, and Financial Strategies For Tobacco Control (ID 16)
- Event: WCLC 2019
- Type: Educational Session
- Track: Prevention and Tobacco Control
- Presentations: 1
- Now Available
- Moderators:Desmond Carney, Esteve Fernandez
- Coordinates: 9/08/2019, 15:15 - 16:45, Vienna (2016)
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ES13.03 - Foundation for a Smoke Free Future: Funding Opportunities or Smoke Screen for the Tobacco Industry? (Now Available) (ID 3226)
15:15 - 16:45 | Presenting Author(s): Emily Stone
- Abstract
- Presentation
Abstract
The tobacco industry has long sought interactions with the health and medical communities that will enhance its legitimacy and augment profits. In the early 20thcentury, advertising involved the medical community emphasizing doctors who recommended cigarette smoking. From the mid 20thcentury, as scientific evidence developed, the tobacco industry contested restrictions vigorously as tobacco regulation intensified. The advent of ENDS products opened a new phase in marketing which stretched the limits of conventional tobacco control. The PMI Foundation, launched in 2017, targets the health and medical communities, promising research funding, the “Smoke-Free” aim and its interactions with high profile researchers. In the first few decades of the 20thcentury, tobacco companies involved physicians in advertising campaigns to promote health benefits and minimisation strategies for particular brands. Analysis of 1930s and 40s tobacco advertising in medical journals identified a number of strategies employed to involve doctors in promoting cigarettes including flattery, tobacco ‘science’, the advisory role to patients, less “irritating” brands and promotion of specific brands1. Analysis of tobacco advertising from the 1920s to the 1950s identified a focus on throat irritation, strategies to protect from harmful symptoms and portrayal of otorhinolaryngologists as promoters of cigarette-related benefits2. The “More Doctors smoke Camels” campaign3launched in the late 1940s by RJ Reynolds made a number of zealous health benefit claims, although landmark publications linking tobacco cigarettes to lung cancer led to scepticism from the health community and eventual banning of cigarette advertising and promotion in medical journals and at medical conventions3.
From the mid-1960s, the paradigm for tobacco regulation shifted as evidence accumulated for the harmful effects. Additional key papers include a 1912 monograph, one of the first publications to link lung cancer with tobacco, early writings on lung cancer surgery and the 1964 US Surgeon General Report on Smoking and Health. Legislative efforts to control tobacco accelerated with, in the United States, the pivotal 1998 Master Settlement Agreement by which tobacco companies were obliged to pay compensation to 46 states to offset costs of smoking-induced illnesses4. In the early 21stcentury the WHO FCTC came in to force in 2005 with the launch of the MPOWER measures in 2008, setting up the tobacco framework that has characterised the last decade and a half and to which 181 countries are signatories. The emergence of e-cigarettes and other ENDS products has shifted tobacco control outside the current purview of the FCTC and opened up new areas of controversy as these products evade conventional regulation. E-cigarettes first appeared in the 20thcentury including designs from the 1960s from BAT and from the 1990s from PMI with the contemporary model attributed to an individual inventor5. The early designs were abandoned at least in part due to concerns about commercial viability6,7and it was not until the last decade or so that e-cigarettes have reached prominence. The emergence of highly appealing and commercially successful ENDS products such as the Juul device has stimulated concern at the level of the FDA and review of e-cigarette regulation. Companies such as Juul Labs (now owned by a tobacco corporation) and PMI advocate harm-minimization through their ENDS products while parent companies continue to sell conventional tobacco cigarettes in less tightly regulated markets.
The Phillip Morris Foundation for a Smoke-Free World8was launched in 2017 and immediately prompted controversy. The stated aims of the Foundation include the funding of research, a focus on smoking cessation and harm reduction and the search for solutions to “unique challenges”8. Its launch prompted immediate debate and discussion, including a Lancet Viewpoint by the Foundation’s director, advocating the benefits of reduced-harm products and expressing concern that full implementation of the FCTC would take many years. An editorial in the same Lancet issue raised strong concerns about involving the tobacco industry in tobacco control while acknowledging that (at the time of writing) the Foundation had yet to begin work9. An accompanying commentary piece questions the credibility of the Foundation and points out that the funding of research is used by the tobacco industry as a deliberate strategy that in fact acts as a “public relations” exercise while PMI, in this instance, continues to sell cigarettes as its core product10. More recently, a review of the published tax returns from the Foundation suggest that it is having trouble both raising and spending funds, perhaps indicating some trouble engaging with the research community and multiple publications raise questions about its ethical robustness, the risks of long-term nicotine dependence and its commercial integrity. While the stated aims of the Foundation may appeal, concerns remain about engaging with the tobacco industry, about persistent global cigarette sales, about the use of the Foundation to divert attention from PMI’s efforts to build its market for ENDs products and about the prioritisation of harm-minimisation (with accompanying profits) over genuine efforts to make the world free from tobacco.
References
1. Jackler RK, Ayoub NF. “Addressed to you not as a smoker… but as a doctor”: doctor-targeted cigarette advertisements in JAMA. Addict Abingdon Engl. 2018 Jul;113(7):1345–63.
2. Samji HA, Jackler RK. “Not one single case of throat irritation”: misuse of the image of the otolaryngologist in cigarette advertising. The Laryngoscope. 2008 Mar;118(3):415–27.
3. Gardner MN, Brandt AM. “The doctors’’ choice is America’s choice": the physician in US cigarette advertisements, 1930-1953.” Am J Public Health. 2006 Feb;96(2):222–32.
4. Schroeder SA. Tobacco control in the wake of the 1998 master settlement agreement. N Engl J Med. 2004 Jan 15;350(3):293–301.
5. Grana R, Benowitz N, Glantz SA. E-cigarettes: a scientific review. Circulation. 2014 May 13;129(19):1972–86.
6. Risi S. On the Origins of the Electronic Cigarette: British American Tobacco’s Project Ariel (1962-1967). Am J Public Health. 2017;107(7):1060–7.
7. Dutra LM, Grana R, Glantz SA. Philip Morris research on precursors to the modern e-cigarette since 1990. Tob Control. 2017;26(e2):e97–105.
8. Foundation for a Smoke-Free World [Internet]. [cited 2019 Mar 2]. Available from: https://www.smokefreeworld.org/
9. Lancet T. Tobacco control: a Foundation too far? The Lancet. 2017 Oct 14;390(10104):1715.
10. Daube M, Moodie R, McKee M. Towards a smoke-free world? Philip Morris International’s new Foundation is not credible. The Lancet. 2017 Oct 14;390(10104):1722–4.
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IBS29 - How to Successfully Run a Multidisciplinary Tumor Board (Ticketed Session) (ID 51)
- Event: WCLC 2019
- Type: Interactive Breakfast Session
- Track: Interventional Diagnostics/Pulmonology
- Presentations: 1
- Now Available
- Moderators:
- Coordinates: 9/10/2019, 07:00 - 08:00, San Francisco (2009)
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IBS29.01 - Can a Multidisciplinary Team Meetings Improve Lung Cancer Survival? (Now Available) (ID 3375)
07:00 - 08:00 | Author(s): Emily Stone
- Abstract
- Presentation
Abstract
Multidisciplinary team (MDT) management for lung cancer has been increasingly introduced globally with the aim of improving outcomes for patients. This is reflected by the recognition that lung cancer MDT management is the standard of care in some countries
The proponents of MDT care note the perceived benefits of MDT care to all stakeholders, including the patient, their clinicians and the general population. On the other hand, there are potential disadvantages associated with MDT lung cancer care, particularly the costs of setting up the service, the time commitment from the clinicians involved and possible delay to treatment.
Observed obstacles to implementing effective MDT management include inadequate infrastructure and organisational/administrative support, lack of enabling technologies, incomplete specialist representation and low attendance by some MDT disciplines, inadequate case preparation and sub-optimal quality information for decision making.
The organisation and performance of MDT lung cancer varies round the world and even within countries. This heterogeneity may affect the effectiveness and quality of MDTs such that quality assurance for MDT is essential.
This talk will identify the eidence for the effects of lung cancer MDT care on patient centred outcomes including survival in the context of unparalleled improvements in the range of therapeutic options currently available for lung cancer.
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OA09 - Lung Cancer: A Preventable Disease? (ID 134)
- Event: WCLC 2019
- Type: Oral Session
- Track: Prevention and Tobacco Control
- Presentations: 1
- Moderators:Bienvenido Barreiro, Carolyn Dresler
- Coordinates: 9/09/2019, 11:00 - 12:30, Melbourne (1991)
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OA09.09 - IASLC Lectureship Award for Smoking Cessation (ID 3903)
11:00 - 12:30 | Presenting Author(s): Emily Stone
- Abstract
Abstract not provided
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P1.14 - Targeted Therapy (ID 182)
- Event: WCLC 2019
- Type: Poster Viewing in the Exhibit Hall
- Track: Targeted Therapy
- Presentations: 1
- Moderators:
- Coordinates: 9/08/2019, 09:45 - 18:00, Exhibit Hall
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P1.14-02 - Survey of EGFR Molecular Testing of NSCLC in the Asia-Pacific Region (ID 1521)
09:45 - 18:00 | Author(s): Emily Stone
- Abstract
Background
Around 1 million new lung cancer cases occur annually in the Southeast Asian and Western Pacific regions combined, comprising more than half the global new cases each year. In recent years several key oncogenic driver alterations have been identified in non-small cell lung cancer (NSCLC), including epidermal growth factor receptor (EGFR) gene mutations, which are detected in up to 60% of adenocarcinoma in Asian patients. EGFR mutation testing to optimise therapy and outcomes has become the standard of care in advanced NSCLC. This study aimed to survey the practice of EGFR mutation testing in NSCLC across countries in the Asia-Pacific region.
Method
The survey was circulated as a web-based electronic online survey questionnaire (www.surveymonkey.com) from 18 August to 3 October 2018 to members of the Asian Pacific Society of Respirology. Survey questions sought information on the following aspects of EGFR molecular testing: prevalence, methods of testing, funding and cost, type of tissue or sample, time frame for test results, retesting after progression, prevalence of T790M testing and use of liquid biopsy.
Result
Of 121 respondents from 16 countries who treated lung cancer patients, 71 (58.7%) treated <10 lung cancer patients per week, 38 (31.4%) treated 10-30 lung cancer patients per week, and 7 (5.8%) treated >30 lung cancer patients per week. A significantly higher percentage of NSCLC patients was tested for EGFR mutation in academic/tertiary centres and public hospitals than in private hospitals [96 of 99 (97.0%)] vs [18 of 22 (81.8%)] (OR, 7.11; 95% CI, 1.47–34.50; p=0.02). The percentage of EGFR mutation testing for >50% of cases was significantly higher when the number of lung cancer patients treated in the practice was >10 per week [40 of 45 (88.9%)] vs [49 of 71 (69.0%)] (OR, 3.56; 95% CI, 1.13–11.17; p=0.023). Testing for molecular aberrations in the initial biopsy was more commonly physician initiated [89 of 121 respondents (73.5%)] than reflex (i.e., ordered by the reporting pathologist based on histopatholgy) [32 respondents (26.4%)]. The percentage of EGFR mutation testing for >50% of cases was significantly higher when the test was fully reimbursed [46 of 51 (90.2%) compared to otherwise [47 of 70 (67.1%)] (OR, 1.63; 95% CI, 1.25–2.12; p=0.003). The turnaround time (days) was <7 (35.5% of the practices), 7-14 (47.9%) and >14 (12.4%). A significantly higher percentage of respondents would perform tissue rebiopsy in >50% of the cases with disease progression while on treatment with 1st- or 2nd-generation EGFR-TKIs if osimertinib was accessible for use, 34 of 72 (47.2%) compared to 7 of 49 (14.3%) if otherwise (OR, 5.37; 95% CI, 2.13-13.53; p<0.0001). Liquid biopsy for T790M mutation detection was performed more frequently in practices where there was access to osimertinib (91.6% vs 28.6%; OR, 27.50, 95% CI, 9.72-77.84; p<0.0001).
Conclusion
It was more likely for >50% of NSCLC patients to be tested for EGFR mutation by respondents who treated >10 lung cancer patients per week and if the test was fully reimbursed. Tissue rebiopsy and liquid biopsy for T790M mutation detection was more frequently performed in practices with access to osimertinib.
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PL02 - Presidential Symposium including Top 7 Rated Abstracts (ID 89)
- Event: WCLC 2019
- Type: Plenary Session
- Track:
- Presentations: 1
- Now Available
- Moderators:Giorgio Vittorio Scagliotti, Ramon Rami-Porta
- Coordinates: 9/09/2019, 08:00 - 10:15, Barcelona (2005)
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PL02.02 - Lung Cancer Screenee Selection by USPSTF Versus PLCOm2012 Criteria – Interim ILST Findings (Now Available) (ID 2804)
08:00 - 10:15 | Author(s): Emily Stone
- Abstract
- Presentation
Background
The National Lung Screening Trial showed that lung cancer screening of high-risk individuals with low dose computed tomography can reduce lung cancer mortality by 20%. Critically important is enrolling high-risk individuals. Most current guidelines including the United States Preventive Services Task Force (USPSTF) and Center for Medicare and Medicaid Services (CMS) recommend screening using variants of the NLST eligibility criteria: smoking ≥30 pack-years, smoking within 15 years, and age 55-80 and 55-77 years. Many studies indicate that using accurate risk prediction models is superior for selecting individuals for screening, but these findings are based on retrospective analyses. The International Lung Screen Trial (ILST) was implemented to prospectively identify which approach is superior.
Method
ILST is a multi-centred trial enrolling 4000 participants. Individuals will be offered screening if they are USPSTF criteria positive or have PLCOm2012 model 6-year risk ≥1.5%. Participants will receive two annual screens and will be followed for six years for lung cancer outcomes. Individuals not qualifying by either criteria will not be offered screening, but samples of them will be followed for lung cancer outcomes. Outcomes in discordant groups, USPSTF+ve/PLCOm2012-ve and PLCOm2012+ve/USPSTF-ve, are informative. Numbers of lung cancers and individuals enrolled, sensitivity, specificity and positive predictive values (PPV) of the two criteria will be compared.
Result
As of March 2019, ILST centers in Canada (British Columbia), Australia, Hong Kong, and the United Kingdom had enrolled and scanned 3673 individuals. Study results are summarized in Figure 1.
Conclusion
Interim analysis of ILST data, indicates that classification accuracy of lung cancer screening outcomes support the PLCOm2012 criteria over the USPSTF criteria. The PLCOm2012 criteria detected significantly more lung cancers. Individuals who are USPSTF+ve and PLCOm2012-ve appear to be at such low baseline risk (0.2%) that they may be unlikely to benefit from screening.
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