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Rakesh Kapoor

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    PL03 - Relevant Aspects of Lung Cancer Management (ID 90)

    • Event: WCLC 2019
    • Type: Plenary Session
    • Track: Advanced NSCLC
    • Presentations: 4
    • Now Available
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      PL03.01 - Establishing a Nurse Led Follow-Up Service for Patients With Resected Early Stage Lung Cancer (ID 3591)

      09:15 - 10:45  |  Presenting Author(s): Jenny Mitchell  |  Author(s): Elizabeth Belcher

      • Abstract
      • Slides


      Specialist nursing roles within thoracic surgical centres in the UK are unique to each centre and develop to meet the needs of the local service. In Oxford we identified that the follow-up of patients after resection of early stage lung cancer could be improved and would be suitable for management by a specialist nurse.

      Prior to the introduction of the specialist nursing role patients were reviewed by the junior doctors working in the clinic, offering limited continuity of care and often presenting challenges in following-up abnormal results.

      Following the successful development of a nurse led early follow-up clinic1 we instituted a nurse led CT follow-up program for patients on long term surgical follow-up after resection of lung cancer.

      Guidelines recommend that patients are followed up after lung cancer resection2, how this is provided is at the discretion of each individual service and varies in the imaging modality and frequency of interventions3.

      Following review of international guidelines3 and in conjunction with the lung cancer multidisciplinary team we devised a CT follow-up program:

      • CT chest, abdomen and pelvis every 6 months for 2 years after surgery followed by an appointment to be given the results.

      • CT chest, abdomen and pelvis at 3, 4 and 5 years after surgery followed by an appointment to be given the results.

      All patients undergoing lung cancer resection, where adjuvant treatment is either not indicated or declined, are entered into the follow-up program (see diagram). The programme is co-ordinated and CT results triaged by the specialist nurse.

      Following successful introduction of nurse led follow-up in the face to face clinics we found that feedback from patients on our CT follow-up programme indicated they find two trips to the hospital burdensome and they frequently requested results of surveillance imaging over the telephone. In addition, limited capacity in the thoracic surgery clinics led to patients waiting a long time for a face to face appointment to be informed of their imaging results. To address these issues, we developed a model of nurse led telephone follow-up after surveillance imaging. The criteria for telephone appointments are:

      • CT results show no abnormality or minor changes requiring a repeat CT chest in 3 months

      • Patients can communicate adequately over the telephone:

      – Reasonable command of English

      – Able to hear telephone conversations

      – No cognitive impairment

      Patients who do not fit these criteria are given an appointment in a face to face clinic.

      The specialist nurse reviews all the CT follow-up results and allocates patients to the most appropriate clinic, ensuring patients are reviewed in the appropriate setting for their needs and those who need to be see urgently are prioritised. Abnormalities and concerns detected during the follow-up programme are presented at the multidisciplinary meetings by the specialist nurse, who takes responsibility for the actions requested by the team.

      In the period January 2013 to December 2017 there were 546 specialist nurse face to face clinic appointments in 189 clinics for 285 patients with primary lung cancer. The telephone clinic commenced in April 2017 and in the first twelve months there were 254 patient appointments in 51 telephone clinics

      The presence of the specialist nurse within the follow-up clinics has increased clinic capacity and efficiency, reduced waiting time for appointments, promotes junior medical training and ensures continuity of care for the patients. The patients appreciate the continuity of care and improved access to specialist nursing support. The role is appreciated and respected by the multidisciplinary team.

      The telephone clinic has been very well received by patients. They appreciate the opportunity to receive their results without having to make a second journey to the hospital (traffic and parking in Oxford is notoriously bad). They continue to receive continuity of care as the nurse who calls them is the same nurse who they saw at their first follow-up appointment in the face to face clinic. The introduction of the telephone clinic has increased overall clinic capacity and reduced the waiting time for appointments within the face to face clinics.

      In order to effectively carry out this role the specialist nurse requires advanced practice skills1. Qualifications in history taking and clinical examination, advanced communication skills and non-medical prescribing are all held by the specialist nurse carrying out this role. In order to request CT imaging IRMER training was undertaken and an appropriate requesting protocol approved by the hospital clinical governance committee.

      In conclusion we have demonstrated that nurse-led follow-up after lung cancer resection is an effective way of ensuring high quality care for this group of patients. The specialist nurse is able to provide continuity of care and ensure that all imaging results are followed up appropriately. The role requires the support of the multidisciplinary lung cancer team to work effectively across all elements of the patient pathway.

      1. Mitchell J. Relevance of a specialised nurse in thoracic surgery. J Thorac Dis 2018:S2583-S2587.

      2. National Institute for Health and Clinical Excellence (NICE). CG121 - Lung cancer. London: NICE; 2011 Available at Accessed 2.3.12.

      3. Belcher E, Mitchell J, Benamore R, et al. Does the manner of follow-up after lung cancer surgery improve survival? In: Modi P, ed. Perspectives in Cardiothoracic Surgery. London: Society for Cardiothoracic Surgery in Great Britian and Ireland; 2018;3:247-258.

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      PL03.02 - Bringing Immunotherapy into the Curative Setting: Emerging Data on Neoadjuvant Strategies (Now Available) (ID 3592)

      09:15 - 10:45  |  Presenting Author(s): Jamie E. Chaft

      • Abstract
      • Presentation
      • Slides


      Immunotherapy with checkpoint inhibitors targeting PD-1 and PD-L1, as monotherapy or in combination with chemotherapy, have become standard of care in all patients with advanced lung cancer who do not have an actionable oncogene or contraindication.1, 2 Similarly patients with unresectable stage III non-small cell lung cancer who do not progress through concurrent chemoradiotherapy have improved progression free and overall survival with anti-PD-L1 consolidation therapy.3

      In early-stage disease, four randomized phase 3 studies are evaluating the role of adjuvant immunotherapy following standard of care chemotherapy. As is the nature of adjuvant investigation, these studies require years of clinical follow-up and will not mature until sufficient recurrence and/or death events occur.

      Neoadjuvant therapy has many advantages to the patient and for the sake of science. As a therapy, preop treatment is better tolerated and can be monitored for efficacy by imaging and pathologic regression. In terms of research, the early pathologic response endpoint may accelerate trial readouts. Investigation into pathologic response as a surrogate for survival in lung cancer is ongoing.4

      The true excitement about neoadjuvant investigation with immunotherapy and/or chemo-immuno combinations, is the theoretical therapeutic superiority of this approach over an adjuvant approach. This is hypothesized to be due to the tumor with its associated mutation specific neoantigens in situ during exposure to the PD-1 treatment, enabling a more robust tumor specific immune response. In pre-clinical mouse models, PD-1 monotherapy is more effective when administered neoadjuvantly versus adjuvantly.5

      The first experience with neoadjuvant PD-1 therapy in NSCLC was a small pilot study performed for safety and feasibility of this approach. No unexpected safety signals were noted and unanticipated pathologic regression observed.6 Two additional series with neoadjuvant immunotherapy have been presented, the Lung Cancer Mutation Consortiums experience with PD-L1 monotherapy and the MD Anderson study of PD-1 +/- CTLA-4 therapy. Both studies confirmed this approach is both safe and induces pathologic regression (at times pathologic complete response) in some patients.7, 8 Correlative studies to try to identify predictors of response and resistance are ongoing. PD-L1 expression is not as clearly predictive in this patient population as in advanced disease.

      Shortly after PD-1 monotherapy was demonstrated to be safe and have some anti-cancer efficacy, many other monotherapy and combination studies launched. Two combination studies rapidly accrued. The combination of carboplatin, a taxane, and a PD-1/L1 agent have been demonstrated by two groups to induce major pathologic regression in the majority of patients.9, 10 In the Spanish Lung Cancer Group study, complete pathologic response was seen in more than 50% of resected patients.10

      These studies have spurred a tremendous interest in the best neoadjuvant therapy. There are 4 international phase 3 studies enrolling patients to receiving neoadjuvant chemotherapy with or without immunotherapy (NCT03800134, NCT03456063, NCT03425643, NCT02998528). Many of these studies have pre-specified pathologic response co-primary endpoints that will be evaluable well before classic clinical endpoints. These studies will help substantiate the role of immunotherapy in the preoperative setting and pathologic response as a possible surrogate endpoint.

      As the international adjuvant immunotherapy efforts wrap up, the research community should commit to enrolling patients on neoadjuvant studies. This is our best chance to improve cure rates in early stage lung cancer – to identify effective therapy for those cancers of a clinical stage to justify induction therapy and adjuvant therapy for those incidentally upstaged at the time of surgery. Within these therapeutic studies are essential biomarker efforts. These efforts are poised to be successful and position the research community to extend investigation into the earliest stages of non-small cell lung cancer, looking to improve cure rates for all stages of disease.

      1. Gandhi L, Rodriguez-Abreu D, Gadgeel S, et al. Pembrolizumab plus Chemotherapy in Metastatic Non-Small-Cell Lung Cancer. N Engl J Med 2018;378:2078-2092.

      2. Paz-Ares L, Luft A, Vicente D, et al. Pembrolizumab plus Chemotherapy for Squamous Non-Small-Cell Lung Cancer. N Engl J Med 2018;379:2040-2051.

      3. Antonia SJ, Villegas A, Daniel D, et al. Overall Survival with Durvalumab after Chemoradiotherapy in Stage III NSCLC. N Engl J Med 2018;379:2342-2350.

      4. Blumenthal GM, Bunn PA, Jr., Chaft JE, et al. Current Status and Future Perspectives on Neoadjuvant Therapy in Lung Cancer. J Thorac Oncol 2018;13:1818-1831.

      5. Liu J, Blake SJ, Yong MC, et al. Improved Efficacy of Neoadjuvant Compared to Adjuvant Immunotherapy to Eradicate Metastatic Disease. Cancer discovery 2016;6:1382-1399.

      6. Forde PM, Chaft JE, Smith KN, et al. Neoadjuvant PD-1 Blockade in Resectable Lung Cancer. N Engl J Med 2018.

      7. Kwiatkowski DJ. Neoadjuvant atezolizumab in resectable non-small cell lung cancer (NSCLC): Interim analysis and biomarker data from a multicenter study (LCMC3). J Clin Oncol 2019;37:abstr 8503.

      8. Cascone T. Neoadjuvant nivolumab (N) or nivolumab plus ipilimumab (NI) for resectable non-small cell lung cancer (NSCLC): Clinical and correlative results from the NEOSTAR study. J Clin Oncol 2019;37:abstr 8504.

      9. Shu CA. Neoadjuvant atezolizumab + chemotherapy in resectable non-small cell lung cancer (NSCLC). Journal of Clinical Oncology 2018;36:8532-8532.

      10. Provencio M. NEO-adjuvant chemo-immunotherapy for the treatment of STAGE IIIA resectable non-small-cell lung cancer (NSCLC): A phase II multicenter exploratory study—Final data of patients who underwent surgical assessment. J Clin Oncol 2019;37:abstr 8509.

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      PL03.03 - The Disparity of Lung Cancer Prevention, Diagnosis and Treatment Around the World…What Is the Role of IASLC (Now Available) (ID 3593)

      09:15 - 10:45  |  Presenting Author(s): Suresh S Ramalingam

      • Abstract
      • Presentation
      • Slides


      Lung cancer is a global health problem that results in over 1.8 million deaths globally each year. Diagnosis at an advanced stage, lack of effective treatment options and disabling co-morbid conditions, have all contributed to the poor outlook for patients with lung cancer. However, there is now new hope in the global fight against lung cancer. Improved understanding of the biology of the disease, early diagnosis and effective therapies have contributed to growing optimism. The International Association for the Study of Lung Cancer (IASLC) has been at the forefront of research and education by bringing together committed scientists, physicians, care providers, epidemiologists, nursing staff and patient communities to increase awareness, develop improved staging systems, fund research for early career researchers, promote development of novel therapies, and educate healthcare professionals at all levels.

      Tobacco smoking contributes to approximately 85-90% of all cases of lung cancer; while the prevalence of smoking has reduced in many developed countries, it appears to be on the upswing in developing nations. More recently, the introduction of electronic nicotine delivery systems (ENDS) has raised the possibility of creating a new generation of the population addicted to nicotine. Any efforts to reduce the burden of lung cancer has to start with educating the public about the health hazards related to smoking, tobacco cessation programs and reducing the access of teenagers and young adults to tobacco products.

      Early detection by adopting screening programs will be another important strategy to reduce the burden of lung cancer. In recent years, the reduction in mortality related to lung cancer by adopting low dose CT screening in high risk individuals has been proven beyond doubt. Despite this evidence, only a minority of eligible patients are being screened for lung cancer, even in developed nations. To increase adoption of screening, we have to collectively engage in educating the primary care physicians, subjects at risk and the entire health care community. Diagnosis of lung cancer at earlier stages will result in greater likelihood of cure due to the exciting advances that have taken place in the management of patients with stages I, II and III NSCLC.

      Even for patients diagnosed with advanced stage lung cancer, long term survival is possible; precision therapies directed to oncogenic molecular events, immune checkpoint inhibitors and multi-modality treatment approaches have all contributed to the recent progress. For patients with mutations in the epidermal growth factor receptor and aberrations in the anaplastic lymphoma kinase gene, the median survival for stage 4 disease is now measured in years with the use of specific targeted treatment approaches. There are at least five genomic targets in lung adenocarcinoma that can be treated with specific tyrosine kinase inhibitors. It is likely that more genomic mutations will join the list of treatable aberrations, thanks to the rapid pace of drug development. Molecular testing remains critical to the ability to personalize therapies for patients with lung cancer. A recent survey conducted by the IASLC across the world noted several barriers to routine adoption of molecular testing.

      Finally, access to cutting-edge therapies is a major challenge in several parts of the world. Rising costs of healthcare and medicines have resulted in the inability for patients to receive optimal care.

      Our efforts to improve lung cancer outcomes and reduce the burden of this disease will have to address every one of these issues. The IASLC is launching an ambitious program to double the 5-year survival rate for patients with lung cancer later this year. This will be accomplished by a multi-pronged approach to promote early detection, optimal staging and diagnostic testing and by addressing survivorship issues. A new staging system seeks to integrate molecular knowledge to traditional clinical staging in order to provide precise prognostic information. Investments in improving the sensitivity of CT screening, promoting universal standards for CT imaging and partnering with other societies to increase awareness regarding early detection will all be important components of this strategy.

      The IASLC has made major contributions to diagnosis of lung cancer by developing a new pathology classification system for lung cancer; it has also conducted original research to improve biomarker testing and promote education on molecular diagnosis. In the upcoming years, the IASLC will seek to study the correlation between major pathological response with neo-adjuvant therapy and overall survival. This will allow for earlier utilization of exciting novel agents to be used as part of curative therapies for early stage NSCLC.

      The IASLC will also promote research on issues specific to survivorship; as long-term outcomes for lung cancer patients becomes a reality, it is important to learn about coping with physical and emotional challenges that can be related to their journey. Very little work has been conducted to date on this topic.

      In conclusion, the time is ripe for us to launch a collective campaign to reduce the burden of lung cancer globally. The IASLC will partner with like-minded organizations, and engage its membership to aggressively pursue innovative approaches that will ultimately result in lower number of patients diagnosed with lung cancer, and improved survival and quality of life for patients afflicted with lung cancer.

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      PL03.04 - Lung Cancer and Tuberculosis: Parallel Lives (Now Available) (ID 3594)

      09:15 - 10:45  |  Presenting Author(s): Tamas F Molnar

      • Abstract
      • Presentation
      • Slides


      It is a Battlefield

      Searching for parallelisms, using historical analogies is a well established method in many fields of soft sciences, medical humanities included. A challenge of seemingly repetitive failure patterns and paradigm shift structures are to be answered in the following imaginary experiment. The aim is the creation of a mental model where understanding of developments and mistakes in treatment of tuberculosis might support our fight against lung cancer (1).

      The two diseases are existing parallely – one mainly for the poor and young and the other for the richer and older. History of tuberculosis follows the classic algorhythm: diagnostic (Villemin, Virchow), casuistic (Koch) and therapeutical (Waksman/Streptomycin) stages. The therapeutical phase of lung cancer has been reached without identified cause of the disease. Eradication of the macrosocopic focus by physical interference with the involved tissue mass, in both diseases preceeded medical treatment. Causation is not an absolute sine qua non of an effective treatment, as the tuberculosis-lung cancer analogy also proves. While lung cancer seems to be controlled by an emerging array of new drugs, tuberculosis poses a new challenge.

      Tuberculosis of the lung is a systemic disease, best treated by drugs with additional surgical removal of the focus of the disease as a last option. The disease has a fairly good chance of around 90% of to be cured (2). The prognostic factors include the functional and immunological reserves of the patient.

      Stage I to III lung cancer is a local manifestation of a systemic disease without sufficiently identified aetiology. Therapy response is understood at cohort level, but it is unpredictable where the individual patient’s fate is concerned. For reasons unknown, mechanical eradication offers the best chance for cure in early stages of the tumour.

      Some parallelism between tuberculosis and lung cancer might be of interest..

      In Search of a Character

      If progress takes a standstill categorization, fever takes over. Lymphnodes are the central elements of the Ghon and Ranke complexes.(3) of the tuberculous lung. The TNM system , a topology approach gyrates around the N status as well. (4). The desire to find a strong characteristic prognostic/predictive element resulted in the Gaffky index (5). The number of Koch bacillus in the sputum as a prognostic tool failed to validate the theory. The discussions of stations and size of lymphnodes in lung cancer (6) might share the fate of the Gaffky index. .

      A Burnt out Case?

      There are disturbing similarities in the phenomenon of a late relapse/recurrence in both diseases. The dormant Koch bacillus vs exogenous reinfection debate (7) is paralleled by the dormant cancer cell hypothesis (8).

      Journey without Maps

      Circulating Koch bacillus, and their prognostic value hotly debated in the 1920s, are comparable to the circulating tumor cell question. The bloodstream journey polemic settled down by 1950, the “seed and and soil” theory of cancer cells is subject of intense research.

      The Heart of the Matter

      Till the 1960s all tuberculosis cases seemed to be the same, until atypical tuberculosis was identified and the Mycobacterium xenopi lost its stigmatising power (95). Certain phenotypes of the adenocarcinoma in situ behaves definitely in a more benign way than any other cell type NSCLC. In 2019, we still do not know what is the single causative agent (if it exists at all) of NSCLC (if it exists at all as a single entity). The Copernican revolution in tumour biology is still awaited.

      The Power and the Glory

      Tuberculosis taught us, that the disease affects the body and the soul as well, reflecting to the society around the patient as well. Lung cancer treatment also depend on the immune status of the individual as well as on the protective capabilities of the science and the society. . Affordability and avaibility of anticancer treatments/drugs are key words yet not interchangeable (8). Onco-economy is as a powerful factor as gene sequencing.

      A scalpel for sale

      Our techniques to treat lung cancer are rooted in surgery for tuberculosis (1). VATS techniques take their origin in Jacobeus’ thoracoscopy and Veress needle. Modern thoracic surgical staplers are derivates of the “Russian machines”, Petz staplers adjusted to tuberculotic bronchi. Thoracic surgery practiced in local anesthesia for many decades, is genuine awake/non-intubated thoracic surgery of today. The recent debate over neoadjuvant vs. adjuvant therapy reflects to the bygone dispute on resection before or after antituberculous medical treatment. The different modalities are no mutually exclusive options, but complementary ones.

      The End of the Affair: Conclusion.

      The main message of tuberculosis to present day oncopulmonologists is that no one can forget the interaction between tumour and patient and his/her socioeconomic status around the pathologically identified focus.



      Molnar TF.,Tuberculosis: mother of thoracic surgery then and now, past and prospectives: a review J Thorac Dis 2018;10(Suppl 22):S2628-S2642


      Silva VD, Mello FC, Figueiredo SC. Estimated rates of recurrence, cure, and treatment abandonment in patients with pulmonary tuberculosis treated with a ¬four-drug fixed-dose combination regimen at a tertiary health care facility in the city of Rio de Janeiro, Brazil. J Bras Pneumol 2017;43:113-20.


      Ober WB. Ghon but not forgotten: Anton Ghon and his complex. Pathol Annu 1983;18:79-85.


      Rusch Crowley J, Giroux DJ, et al. International Staging Committee The IASLC Lung Cancer Staging Project: Proposals for the revision of the N descriptors in theforthcomingseventheditionoftheTNMclassification for lung cancer. J Thorac Oncol2007;2:603-12.


      Gaffky GTA. Scale or Table. JAMA 1913;61:359.


      Rami-Porta R, Asamura H, Brierley J, et al. Staging, tumor profile and prognostic groups in lung cancer or the new of Babel. J Thorac Oncol2016;11:1201-3.


      Lillebaek Dirksen A, Baess I, et al. Molecular evidence of endogenous reactivation of Mycobacterium tuberculosisafter33yearsoflatentinfection.JInfect2002;185:401-4.


      Molnar TF, Szipocs A, Szalai Z Neoadjuvant Crizotinib for ALK Re-arranged NSCLC?

      J Thorac Oncol. 2019;14(4):574-576.

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    EP1.18 - Treatment of Locoregional Disease - NSCLC (ID 208)

    • Event: WCLC 2019
    • Type: E-Poster Viewing in the Exhibit Hall
    • Track: Treatment of Locoregional Disease - NSCLC
    • Presentations: 1
    • Now Available
    • Moderators:
    • Coordinates: 9/08/2019, 08:00 - 18:00, Exhibit Hall
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      EP1.18-14 - Algorithm for Deciding Radiotherapy Technique in Stage III Non-Small Cell Lung Cancer (Now Available) (ID 2560)

      08:00 - 18:00  |  Author(s): Rakesh Kapoor

      • Abstract
      • Slides


      Concurrent chemoradiotherapy has shown superior survival outcomes in inoperable, Stage III non-small cell lung cancer (NSCLC) with good performance status. Usage of 3-dimensional conformal radiotherapy (3D-CRT) technique is commonest with intensity modulated radiotherapy (IMRT) gaining popularity owing to its ability to spare normal tissues. In our study we analysed the tumour and nodal characteristics of patients to predict which technique maybe beneficial by generating optimised plans of both 3D-CRT and volumetric modulated arc radiotherapy (VMAT), a type of IMRT.


      A total of 27 Stage III NSCLC patients underwent PET-CT (in the treatment position) co-registered treatment planning using either 3D-CRT or VMAT. The total prescription dose was 60 Gy in 30 fractions over 6 weeks with concurrent cisplatin based chemotherapy. Retrospectively alternate treatment plans were generated to obtain two sets of plans (3D-CRT and VMAT) of each patient for dosimetric comparison. The tumour and nodal characteristics and treatment technique were analysed to identify predictive factors limiting total dose delivery. The angle of contact of the PTV with the circumference of the vertebral body was calculated for patients where the tumour or nodal mass was in contact with the vertebral body (Figure 1).



      Of the 27 patients enrolled, 6 patients could not be planned to the complete dose of 60 Gy in a single phase by 3D-CRT. Dose limiting factors were high spinal cord doses due to vertebral body erosion (2 out of 6) and bilateral bulky mediastinal lymphadenopathy (4 out of 6). Alternate VMAT plans for these patients could achieve the dose constraints in all but the two patients with vertebral body erosion. Differences in the normal tissue doses of bilateral normal lungs, esophagus, heart and spinal cord were compared between both techniques to ascertain statistical significance.


      The spatial location of the tumour and nodal burden rather than the volume limited the maximum dose delivered. For tumours with vertebral body contact of more than 90 degrees, VMAT should be used. With gross vertebral body erosion, even VMAT falls short if the PTV includes the spinal cord. In view of high patient volume and limited resources, VMAT is not an economical option for all patients. A simple clinical algorithm is outlined (Figure 1) which will help select patients who will best benefit from VMAT.

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