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    ES05 - Joint Session GLCC/IASLC: Hot Topics for Lung Cancer Advocates (ID 8)

    • Event: WCLC 2019
    • Type: Educational Session
    • Track: Advocacy
    • Presentations: 5
    • Now Available
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      ES05.01 - Lung Cancer Survival: Progress and Challenges (Now Available) (ID 3175)

      10:30 - 12:00  |  Presenting Author(s): Marianne Coutts Nicolson

      • Abstract
      • Presentation
      • Slides

      Abstract

      Background

      Between 1970s and 2011, many tumour 10-year survival rates increased significantly (eg prostate cancer from 25% to 84%) yet lung cancer lags behind with 5-year survival below 20%.1, 2 Most countries have no lung cancer screening programme and >80% of patients are diagnosed with advanced disease. A significant challenge for the United States lung cancer screening programme is poor uptake by low income but high risk candidates.3 To optimise results from potential curative radical radiotherapy and surgery, accurate staging of patients is vital; modern staging can improve patient selection for radical treatment, with stage 1 lung cancer 4-year overall survival (OS) increased in one study by 14.3% between 2001 and 2010, and postoperative survival improved from 51.5% to 66.5%.4 Over 80% of patients diagnosed with lung cancer are active or past cigarette smokers, and the need to maximise prevention remains. Government implemented smoking bans and funding of smoking cessation programmes are important, despite sketchy evidence for the latter being of benefit to lung cancer patients.5

      Radiotherapy progress

      Improved techniques allow accurate targeting with stereotactic ablative radiotherapy (SABR) for patients with a small tumour who are unfit for surgery. In stage III NSCLC, CT simulation results in a smaller tumour target, better dose delivery and fewer side-effects. The immune stimulating effect of radiotherapy may increase effectiveness of immunotherapy (IO) on which further research continues. Radiotherapy ablation of oligometastatic tumours is also under investigation in ongoing attempts to improve survival in advanced disease.

      Systemic therapies improving survival

      There has been little improvement in small cell lung cancer (SCLC) outcomes the since 1980s, but progress for the 85% of patients with non-small cell lung cancer (NSCLC) is impressive, resulting from improved understanding of tumour molecular biology. Chemotherapy combinations seemed equivalent in NSCLC until groundbreaking results showed better survival in non-squamous NSCLC who received platinum with pemetrexed over gemcitabine.6 Maintenance pemetrexed improved survival still further in patients with NSCLC stable or responsive to induction chemotherapy.

      Controversy over patient selection for targeted therapy with tyrosine kinase inhibitors was resolved by the IPASS study which confirmed that testing for a sensitising EGFR mutation status was mandatory to ensure benefit.7 Patients inevitably develop resistance to EGFR TKIs and tumour rebiopsy is encouraged to determine the new molecular profile to optimise subsequent treatment. The new generation TKI osimertinib gave superior survival as first line therapy compared with erlotinib or gefitinib. In patients with ALK translocated NSCLC (approximately 5% of tumours), crizotinib was better than chemotherapy. More recently alectinib or brigatinib superceded as survival improved through their enhanced effectiveness in the CNS.8

      Drugs are available to treat lung cancers with less common genetic drivers like ROS1 and BRAF but the commonest NSCLC mutation KRAS - in up to 30% cases - is not yet amenable to specific therapy, although several drugs are in development. Reflex testing by pathologists of non-squamous NSCLC is recommended with squamous tumours tested only in never smokers or mixed adenosquamous lung cancer.9 Identification of EGFR or ALK oncogene addicted lung cancers is vital to ensure delivery first line of appropriate targeted therapy since this increases patients' survival.

      NSCLC response to IO drugs targeting PD-1 and PD-L1 has revolutionised systemic therapy. Nivolumab was effective in relapsed squamous NSCLC, then first line pembrolizumab superceded chemotherapy in patients with >50% PD-L1 expressing non-squamous tumours. Atezolizumab (second line) and pembrolizumab-chemo (first line) efficacy are independent of PD-L1 expression. In stage III NSCLC, patients with no tumour progression following combination chemoradiotherapy have better OS with maintenance durvalumab.10 An important feature is the durable response to IO seen in some patients, with toxicity usually manageable and less than many chemotherapies. Studies with IO as adjuvant and neoadjuvant treatments are ongoing. Since IO treatment may continue every 2-3 weeks by intravenous infusion for up to two years, there is a significant impact on pharmacy, hospital time for patients and healthcare costs. More research is ongoing to mitigate these burdens.

      Conclusion

      Improving survival in lung cancer patients remains a challenge dependent on prevention, screening, optimal surgery, modern radiotherapy and improved systemic therapies targeted through understanding the molecular biology of these heterogenous tumours. Despite clear progress to date, there is much need for improvement, offering ample opportunity for future research.

      References

      1 Quaresma M, Coleman MP, Rachet B (2015) 40-year trends in an index of survival for all cancers combined and survival adjusted for age and sex for each cancer in England and Wales 1971-2011: a population-based study. Lancet 385:1206-1218

      2 Allemani C, Weir HK, Carreira H et al (2018) Global surveillance of trends in cancer survival 2000-14 (CONCORD-3): analysis of individual records for 37513025 patients diagnosed with one of 18 cancers from 322 population-based registries in 71 countries. Lancet 391:1023-1075

      3 Schutte S, Dietrich D, Montet X and Flahault A (2018) Particiation in lung cancer screening programs: are there gender and social differences? A systematic review. Public Health Reviews 39: 23-35

      4 Boyer MJ, Williams CD, Harpole DH et al (2017) Improved survival of Stage I Non-Small Cell Lung Cancer: A VA Central Cancer Registry Analysis. J Thorac Oncol 12:1814-1823

      5 Zeng L, Yu X, Xiao J, Huang Y (2019) Interventions for smoking cessation in people diagnosed with lung cancer. CochraneSystematic Review https://doi.org/10.1002/14651858. CD011751.pub3

      6 Scagliotti G, Hanna N, Fossella F et al (2009) The differential efficacy of pemetrexed according to NSCLC histology: a review of two Phase III studies. Oncologist 14:253-263

      7 Mok TS, Yi-Long W, Thongprasert S, Chih-Hsin Y (2009) Gefitiib or carboplatin-paclitaxel in pulmonary adenocarcinoma. N Engl J Med 361:947-957

      8 Peters S, Camidge DR, Shaw AT et ak (2017) Alectinib versus crizotinib in untreated ALK-positive nono-small cell lung cancer. N Engl J Med 377:829-838

      9 Planchard D, Popat S, Kerr K et al (2018) Metastatic non-small cell lung cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol 29 (suppl4):iv192 - iv236

      10 Antonia SJ, Villegas A, Daniel D et al (2018) Overall survival with durvalumab after chemoradiotherapy in stage III NSCLC. N Engl J Med 379:2342-2350

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      ES05.02 - From Living Longer to Also Living Better – the Role of Communication and Interprofessional Collaboration in Metastatic Lung Cancer (Now Available) (ID 3176)

      10:30 - 12:00  |  Presenting Author(s): Matthias Villalobos

      • Abstract
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      Abstract

      Despite ongoing progress in diagnostics and treatment, many patients with metastatic lung cancer still harbor a limited prognosis that may lead to existential uncertainty. These patients and their caregivers are confronted with a complex situation as burden comprises physical, psychosocial and spiritual needs [1]. During the illness trajectory they are exposed to different multiprofessional healthcare settings and providers that challenge the continuity and coordination of care. Therefore, the care of these patients and their relatives is often characterized by discontinuity, lack of coordination and insufficient communication [2]. Additionally, shared decision-making between active cancer treatment and end-of-life care constitutes a continuous and challenging balancing act for all who are involved in the process. Several studies have shown that early integration of palliative care (EPC) and adequate advance care planning (ACP) improve quality of life and satisfaction with care. Two studies evaluating EPC have even shown positive results in survival [3,4]. In the recommendation of the American Society of Clinical Oncology concerning the integration of palliative care into standard oncology care, the following were defined as essential components: “rapport and relationship building with patients and family caregivers; symptom, distress, and functional status management; exploration of understanding and education about illness and prognosis; clarification of treatment goals; assessment and support of coping needs; assistance with medical decision making; coordination with other care providers” [5]. This underlines the importance of communication in this setting and defines it as a central element for the effective provision of early palliative care. Another central element is interprofessional collaboration. Studies incorporating interprofessional involvement (notably physicians and nurses) showed more consistent results regarding the positive effects of EPC [6]. Through the different perspectives of the involved professions towards care needs, healthcare delivery may be enriched and become more holistic. Additionally, nurse navigation supports orientation in the healthcare system and provides continuity and coordination of care. For this strategy communication skills of healthcare providers and interprofessional collaboration should be strengthened. Joint communication training may play an important role to overcome interprofessional barriers and sharpen communication skills. Advanced communication techniques are essential for early integration of palliative care, facilitation of prognostic awareness, and by this means introduction or adaptation of advance care planning [7]. An interprofessional, longitudinally structured communication approach should improve the experience and outcomes of patients with advanced lung cancer and their caregivers [8]. Further research should address the feasibility of institutional strategies for implementing this approach.

      References:

      1 Baile WF, Palmer JL, Bruera E, Parker P: Assessment of palliative care cancer patients’ most important concerns. Support Care Cancer 2011;19:475-481.

      2 Gagliardi AR, Dobrow MJ, Wright FC: How can we improve cancer care? A review of interprofessional collaboration models and their use in clinical management. Surg Oncol 2011; 20:146–54.

      3 Bakitas MA, Tosteson TD, Li Z, Lyons KD, Hull JG, Li Z, Dionne-Odom JN, Frost J, Dragnev KH, Hegel MT, Azuero A, Ahles TA: Early Versus Delayed Initiation of Concurrent Palliative Oncology Care: Patient Outcomes in the ENABLE III Randomized Controlled Trial. J Clin Oncol 2015;33:1438-1445.

      4 Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, Dahlin CM, Blinderman CD, Jacobsen J, Pirl WF, Billings JA, Lynch TJ: Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer. N Engl J Med 2010;363:733-42.

      5 Ferrell BR, Temel JS, Temin S, Alesi ER, Balboni TA, Basch EM, Firn JI, Paice JA, Peppercorn JM, Phillips T, Stovall EL, Zimmermann C, Smith T: Integration of palliative care into standard oncology care: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol 2017;35:96-112.

      6 Hui D, Bruera E: Integrating palliative care into the trajectory of cancer care. Nature Reviews Clinical Oncology 2016;13:159-71.

      7 Jackson VA, Jacobsen J, Greer JA, Pirl WF, Temel JS, Black AL: The cultivation of prognostic awareness through the provision of early palliative care in the ambulatory setting: a communication guide. Journal of Palliative Medicine 2013;16:894-900.

      8 Villalobos M, Siegle A, Hagelskamp L, Jung C, Thomas M. Communication along milestones in lung cancer patients with advanced disease. Oncology Research and Treatment 2019;42:41-46.

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      ES05.03 - From Living Longer to Also Living Better; Managing Lung Cancer as a Chronic Disease - the Principle of Survivorship (Now Available) (ID 3177)

      10:30 - 12:00  |  Presenting Author(s): Maureen Rigney

      • Abstract
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      Abstract

      With exciting advances in lung cancer screening, diagnosis, and treatment, those diagnosed are living longer than ever before. Around the globe, more and more people are balancing the great hope and vast uncertainty of living with advanced lung cancer as a chronic disease.

      A chronic disease is one that lasts three months or longer, doesn’t disappear, and is not preventable by vaccines nor curable by medicine. (US National Center for Health Statistics). Uncontrolled, any chronic disease can be life threatening.

      The 2008 IOM report, Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs, outlined the physical, emotional, social challenges, and financial stressors that result from living with a chronic disease. Cancer as a chronic disease increases anxiety, adds fear of recurrence, causes difficulties in making life plans, affects interpersonal relationships and prompts existential questioning. People diagnosed with lung cancer may additionally experience a myriad of distinct stigma-related challenges, including guilt, shame and increased isolation.

      Over ten years after the IOM report, cancer as a chronic disease remains a relatively unexamined area of study and, as Dr. Ross Camidge has said, “The rulebook hasn’t been written.” This presentation seeks to help us, the loved ones, advocates, clinicians, organizations and researchers begin to understand the unique needs of this population as we consider lung cancer as a chronic disease through:

      -- The lens of the ecological concept of the ecotone

      -- Recognizing the effects of months or years of continuous or intermittent treatment on the individual

      -- A commonly accepted model of chronic disease management and coping

      -- The lived experiences of those effected, gathered through focus groups and one-to-one conversations

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      ES05.04 - Social Media and Lung Cancer - a Global Picture (Now Available) (ID 3178)

      10:30 - 12:00  |  Presenting Author(s): Christina Sit  |  Author(s): Jesme Fox, Simon Malia

      • Abstract
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      Abstract

      The use of social media in lung cancer: an evaluation of global trends, themes and demographics.

      Social media has transformed the health communication landscape. It is evident in the rise of social media groups that social media is an important communications and connection tool for the community impacted by lung cancer. Individuals across the cancer continuum use social media for a myriad of purposes and there are differences between user profiles. For example, physicians and academics use social media to announce new innovative treatment options, for debate, and to highlight the successes and failures of lung cancer research. The general population utilizes social media to fundraise, garner support, and share their personal experiences with cancer. Social media may now be one of the most common communications vehicles for global campaigns concerning lung cancer, impacting education, fundraising and advocacy.

      In order to more optimally use social media to further objectives for patient organizations, it is integral to understand global trends in social media usage and what users are saying online. This global research project aims to answer these questions, as possessing more information on user trends will better inform those that are trying to reach and engage with these individuals.

      This global research project will also provide an opportunity for lung cancer professionals and organizations to refine their social media communications strategies. The research will identify best practices for organizations in engaging their lung cancer communities, as well as content strategies to boost reach, engagement and community size.

      Purpose:The objective of this research project is to evaluate the use of social media platforms, including Twitter, Facebook, and blogs, to understand howand whyindividuals are using each platform and whatis being said.

      Methodology:Through the social listening tool Brandwatchthis study will analyze social media usage between November 2018 to May 2019 in eleven (11) countries: Canada, United States, United Kingdom, Russia, Brazil, China, India, Israel, Australia, South Africa and Poland. This study utilizes topic analysis to understand the qualitative themes that are currently happening in the online conversation.

      These eleven (11) countries have been chosen due to high incidents of lung cancer, confidence in government data on lung cancer statistics, and frequency of social media use.

      In each jurisdiction, Brandwatchmonitors the use and flux of specific key terms relating to lung cancer. In analyzing the data that Brandwatch generates, the team can effectively monitor the conversations (frequency, subject, emotion, and corresponding debate) that happen at a grassroots level.

      In a parallel research method, the project will gather data from over forty (40) lung cancer organizations’ social media accounts across all major platforms including Facebook, Twitter, LinkedIn, Pinterest and YouTube. This data will be analyzed quantitatively and qualitatively to identify which social media strategies work best to engage members of the online lung cancer communities globally.

      Analysis:Preliminary findings indicate that the conversations occurring on social media across jurisdictions are both profoundly different yet have underlying similarities. Data will be extracted from initial findings to target populations with campaigns on issues that matter distinctly to them. As technology continues to drive decision-makers, organizations must adapt to foster the best results. In understanding who and how to target populations, it is expected that global lung cancer campaigns—for awareness, public policy changes or research funding—will reach, and hopefully exceed, their targets.

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      ES05.05 - Still Struggling for Traction - from Proving Lung Cancer Screening Works to Global Practical Implementation, Including Engagement of the Target Population (Now Available) (ID 3179)

      10:30 - 12:00  |  Presenting Author(s): James L Mulshine

      • Abstract
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      Abstract

      Still Struggling for Traction-from Proving Lung Cancer Screening Works to Global Practical Implementation, Including Engagement of the Target Population
      James L. Mulshine, Rush University, Chicago, IL 60612

      Based on the results of the National Lung Screening Trial, United States Preventive Services Task Force (USPSTF) reviewed and recommended low-dose CT screening for lung cancer. Next the Centers for Medicaid and Medicare reviewed this service and after February 5, 2015 issued a National Coverage Decisions to add coverage under Medicare Part B to allow low-dose CT screening in high-risk populations began (1, 2). A few years on, articles are frequently reporting that screening uptake in the United States is anemic. In a setting where enthusiasm differs about the prospects for lung cancer screening, issues of cost and bandwidth loom large (3, 4).

      Realistically, cancer screening whether cervical cancer, breast cancer or colon cancer all took extended periods of time to become established and problems of compliance with all three measures still exist. However, the results of the National Lung Screening Trial are now buttressed with the results of Dutch/Belgian trial (NELSON), as well as the 10 year follow up of the Milan randomized cohort experience (MILD) (4-5). Consequently, we are now seeing national screening not only being implemented in the United States but and with similar activity moving forward in Canada, Poland, the United Kingdom, South Korea as well as other nations. It is heartening to see evidence of careful planning to define the optimal screening programs for national implementation ongoing in a number of countries such as the United Kingdom, Canada and Poland. Cautious optimism that lung cancer screening may have turned a corner seems justified.

      These early adaptor national screening programs will provide an opportunity to evaluate national statistics for the annual distribution of stage frequencies. As it is a critical measure of public health progress to have falling national smoking rates, now we can also look for national level stage shifts to determine if the detection rates of Stage I cases rise along with corresponding drops in Stage III/IV frequencies. Furthermore, critical information about actual experience in these large national settings can inform the discussion about the realities of harms experienced in the screening process and this information would be useful in advancing lung cancer screening participation.

      Communication disseminated by venues like IASLC and GLCC will be essential to encourage efforts to enhance the process of screening to sustain the brisk pace of research focusing on screening management optimization. The efforts of the American College of Radiology in adapting breast cancer screening process for managing the lung cancer screening process has been important as it creates a much more familiar transition for institutions attempting to launch lung cancer screening services (6). This ACR process, called LungRADS leverages a management approach that is already well established in the radiology community and makes for a smooth transition in defining a systematic screening management approach for lung cancer. This recent development has addressed a major concern relative to the rate of false positive screening cases that was dampening screening enthusiasm for some healthcare professionals.

      Fortunately, there are even more advanced developments in the offing for more effective and workflow friendly software tools. If best-practice nodule management of I-ELCAP, NELSON, and UKLS using software-driven direct measurement of lung cancer volume become more generally available, these tools can further reduce the rate of false-positive diagnosis and improve the efficiency of the case finding process (7-11). Fortunately, in collaboration with I-ELCAP and the Veterans Administration in the US, activities are underway to address this complex issue.

      Annual lung cancer screening has also provided an opportunity to re-consider how to best encourage more effective smoking cessation. The National Cancer institute in the United States launched a number of studies to experiment with more intensive approaches to smoking cessation specifically in the setting of screening. These studies will be completed over the next few years and these new approaches can be applied to help more people overcome this dangerous but deeply additive behavior and in a complementary fashion improve the prospects for more favorable health outcomes.

      Quietly over the last decade, we have witnesses continuous refinements in the surgical approach to resecting early lung cancer (12). We would expect further evidence to accrue informing the most favorable approach to curative resection. Within this time window, we expect to also start seeing more experimental approaches to managing small, favorably located lung cancers with inter-luminal approaches.

      In the wake of recent cardiology guidelines revisions to include low-dose thoracic CT as a biomarker for managing coronary calcium deposition, we would expect to see greater awareness of other routine tobacco-related findings seen in the course of a thoracic CT screening (13). Together lung cancer, coronary artery disease and COPD constitute the three most lethal diseases across the world. The pathogenesis of all three of these diseases is greatly accelerated by tobacco-combustion product deposition in the lungs. As the prevalence of lung cancer screening evolves, considerably more cases of coronary artery disease and COPD cases will come to clinical attention than lung cancer, so collaboration across relevant disciplines will increase to provide thoughtfully integrated management of CT screen identified consequences of prolong tobacco exposure (13). The bulk of the preventive managements of these three most lethal diseases detected in high risk but asymptomatic individuals will include more concerted tobacco cessation support, advice to enhance levels of physical activity and to improve the quality of dietary consumption. Through time, CT-informed lung cancer screening will create an annual opportunity for a health check to improve the health of tobacco-exposed individuals. This possibility could great enhance the support of low-dose CT evaluation of thorax in smokers across many communities.

      In parallel, targeted drug development guided by information derived from systematically examining resected screen-detected cancer looking for signatures of aggressive behaving cancers that will need adjuvant interventions beyond surgery to ensure curative outcomes. In this strategy, lung cancer care may follow breast cancer care and we will see the emergence of neoadjuvant and adjuvant early lung cancer therapies as a critical part of ensuring favorable individual outcomes.

      In closing, screening is a complex process with many moving parts. Establishing this process with careful attention to quality and then testing to see how to optimize the delivery as outlined in a recent I-ELCAP report, takes time (14). Participation in lung cancer screening is low. Given the recent strong screening results from multiple international sites especially with the NELSON trial as well as contributions such as LungRADS, and process research such as with I-ELCAP, there is a basis for optimism that significantly greater uptake will be occurring in large measure due to mutually beneficial collaborations.

      References:

      National Lung Screening Trial Research Team, Aberle DR, Berg CD, Black WC et al. The National Lung Screening Trial: overview and study design. Radiology. 2011 Jan;258(1):243-53. doi: 10.1148/radiol.10091808. Epub 2010 Nov 2.

      National Coverage Decision, low-dose CT screening for lung cancer, https://www.medicare.gov/coverage/lung-cancer-screenings

      Bach PB. Perilous potential: the chance to save lives, or lose them, through low dose computed tomography screening for lung cancer. J Surg Oncol. 2013 Oct;108(5):287-8. doi: 10.1002/jso.23389. Epub 2013 Aug 27. PMID: 23983184, DOI: 10.1002/jso.23389

      Mulshine JL, D'Amico TA. Issues with implementing a high-quality lung cancer screening program. CA Cancer J Clin. 2014 Sep-Oct;64(5):352-63. doi: 10.3322/caac.21239. Epub 2014 Jun 27. Review. PMID: 24976072.

      De Koning HJ, Van Der Aalst C, Ten Haaf K, et al: Effects of volume CT lung cancer screening: Mortality results of the NELSON randomized-controlled population based trial. 2018 World Conference on Lung Cancer. Abstract PL02.05. Presented September 25, 2018.

      Pastorino U, Silva M, Sestini S, et al. Prolonged lung cancer screening reduced 10-year mortality in the MILD trial. Ann Oncol. 2019 Apr 1. pii: mdz117. doi: 10.1093/annonc/mdz117.

      Martin MD, Kanne JP, Broderick LS, Kazerooni EA, Meyer CA. Lung-RADS: Pushing the Limits. Radiographics. 2017 Nov-Dec;37(7):1975-1993. doi: 10.1148/rg.2017170051. Epub 2017 Oct 20.

      Yankelevitz DF, Gupta R, Zhao B, and Henschke CI. Small pulmonary nodules: evaluation with repeat CT--preliminary experience. Radiology 1999; 212:561-6.

      van Klaveren RJ, Oudkerk M, Prokop M, et al. Management of lung nodules detected by volume CT scanning. N Engl J Med. 2009 Dec 3;361(23):2221-9. doi: 10.1056/NEJMoa0906085.

      Horeweg N, van Rosmalen J, Heuvelmans MA, et al. Lung cancer probability in patients with CT-detected pulmonary nodules: a prespecified analysis of data from the NELSON trial of low-dose CT screening. Lancet Oncol 2014;15:1332–41.

      Field JK, Duffy SW, Baldwin DR, et al.The UK Lung Cancer Screening Trial: a pilot randomised controlled trial of low-dose computed tomography screening for the early detection of lung cancer.Health Technol Assess. 2016 May;20(40):1-146. doi: 10.3310/hta20400. PMID: 27224642

      Altorki N, Lee B.Commentary: Lobectomy or sublobar resection for early lung cancer: One small step for surgeons, one giant step for patients. J Thorac Cardiovasc Surg. 2019 Apr 24. pii: S0022-5223(19)30903-1. doi: 10.1016/j.jtcvs.2019.04.010. [Epub ahead of print] No abstract available. PMID: 31160116

      Mulshine JL. One Screening for Ischemic Heart Disease, Lung Cancer, and Chronic Obstructive Pulmonary Disease: A Systems Biology Bridge for Tobacco and Radiation Exposure. Am J Public Health.2018;108:1294-1295. doi: 10.2105/AJPH.2018.304655. PMID: 30207781

      Henschke CI, Li K, Yip R, Salvatore M, Yankelevitz DF. The importance of the regimen of screening in maximizing the benefit and minimizing the harms. Ann Transl Med. 2016 Apr;4(8):153. doi: 10.21037/atm.2016.04.06. Review. PMID: 27195271.

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    ES15 - The Management of Cancer Treatment in Thoracic Malignancy (ID 18)

    • Event: WCLC 2019
    • Type: Educational Session
    • Track: Nursing and Allied Professionals
    • Presentations: 7
    • Now Available
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      ES15.01 - Management of Cognitive Changes in Oncology Patients (Now Available) (ID 4063)

      11:00 - 12:45  |  Presenting Author(s): Lauren Urwin

      • Abstract
      • Presentation
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      Abstract not provided

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      ES15.02 - Mary Duffy's Topic (Now Available) (ID 4058)

      11:00 - 12:45  |  Presenting Author(s): Mary Duffy

      • Abstract
      • Presentation
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      Abstract not provided

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      ES15.03 - Toxicities of Radiation and Immunotherapy: What We Know (Now Available) (ID 3237)

      11:00 - 12:45  |  Presenting Author(s): Benjamin Lok

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      Abstract

      Radiotherapy is one of the longstanding pillars of cancer treatment. Immunotherapy is being established a new cancer treatment pillar and represents a momentous advance in the armamentarium of the cancer care health professional. As such, how these two modalities interact with each other is important to understand to allow the healthcare team to identify and manage the accompanying side effects. The objectives of this session are to cover a brief overview of basic radiotherapy, basic tumor immunology, followed by a more extensive review on the current status of radiotherapy and immunotherapy in clinical practice with a significant focus on reviewing the toxicities of radiotherapy, immunotherapy and their combination. The goal is to equip all members of the healthcare team to delivery optimal care for patients that receive these treatment modalities.

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      ES15.04 - Managing Sleep Difficulties and Cancer (Now Available) (ID 3238)

      11:00 - 12:45  |  Presenting Author(s): Maria Ftanou

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      Abstract

      This paper discusses evidence-based interventions for managing sleep difficulties in people with cancer.

      Insomnia is a common sleep problem in people with cancer. Insomnia refers to the difficulty of falling asleep, staying asleep and early morning awakenings. It causes distress or impairment in important areas of functioning, such as relationships and employment. It is estimated that between 30-60% of cancer survivors experience significant sleep disturbances that can persist for up to five years post treatment. Aside from greatly impacting on quality of life, poor sleep is associated with anxiety, depression, concentration and memory difficulties, higher rates of pain, increased use of sedatives and poorer work performance [1-3]. People with lung cancer are at an increased risk of experiencing sleep difficulties because of their generally older age, compromised respiratory function, increased disease burden and the impact of treatments [4]. Sleep difficulties also have economic and social impacts on the broader community, due to increased health system costs, productivity losses and wellbeing costs [5].

      Cognitive Behaviour Therapy (CBT) is considered to be the first-line treatment for insomnia [6]. CBT targets dysfunctional attitudes, beliefs and habits that interfere with sleep. CBT for insomnia commences with a comprehensive assessment about the nature and duration of sleep complaints, the impact on daytime functioning, compensatory behaviours, the person's beliefs about sleep and any other biopsychosocial factors that might be impacting on sleep. Common screening tools used to assess the impact of sleep difficulties include the Insomnia Severity Index (ISI), the Epworth Sleepiness Scale (ESS) and the Pittsburgh Insomnia Rating Scale (PIRS). These tools are self-reporting and easy to administer. CBT for insomnia is a multi-component intervention and includes psychoeducation, sleep hygiene, stimulus control, sleep restriction, relaxation, cognitive strategies and relapse prevention strategies. It is usually delivered between four to eight session modules.

      CBT is effective in improving sleep disturbance, fatigue, pain and quality of life. The effects of CBT are durable, with benefits lasting up to three years post-treatment [7, 8]. CBT is suitable for most adults with insomnia, however, it works best with people who are motivated and have the cognitive capacity to learn and adopt CBT strategies. CBT can be effectively provided in group settings, individually, via telephone, video or online methods. Over three quarters of patients achieve remission or significant reduction of sleep disturbance after CBT treatment [9]. CBT has been found to be more effective than mindfulness, massage, exercise and acupuncture intervention. CBT has been found to be as effective as pharmacological intervention in the short-term and more beneficial than medication in the longer term. CBT is also more cost-effective than pharmacological or non-treatment of sleep difficulties [10].

      Despite the benefits of CBT, access for people with cancer is limited due to lack specialist availability, cost and awareness of the benefit of CBT. To improve access to evidence-based interventions for people with cancer, stepped-care approaches (where face-to-face CBT is reserved for the most complex cases while less burdensome and less costly self-managed interventions are available for less complex cases) could help translate evidence into clinical practice.

      Conclusion

      Sleep difficulties are highly prevalent in people with cancer, however, access to evidenced-based interventions are limited. Embedding evidence based-screening and CBT into routine care is essential to improving quality of life and care for people with cancer.

      Savard, J., Simard, S., Blanchet, J., Ivers, H. & Morin, C.M. Prevalence, clinical characteristics, and risk factors for insomnia in the context of breast cancer. Sleep 24, 583-590 (2001).

      Davidson, J.R., MacLean, A.W., Brundage, M.D. & Schulze, K. Sleep disturbance in cancer patients. Social science & medicine (1982) 54, 1309-1321 (2002).

      Howell, Doris, et al. "A Pan-Canadian practice guideline: prevention, screening, assessment, and treatment of sleep disturbances in adults with cancer." Supportive Care in Cancer21.10 (2013): 2695-2706.

      Halle, Ingrid Helene, et al. "Trajectory of sleep disturbances in patients undergoing lung cancer surgery: a prospective study." Interactive cardiovascular and thoracic surgery 25.2 (2017): 285-291.

      Deloitte Access Economics. Re-awakening Australia: the economic cost of sleep disorders in Australia C, Australia: Deloitte Access Economics, 2011. . Re-awakening Australia: the economic cost of sleep disorders in Australia, 2010.Canberra, Australia; 2011.

      Morin CM, Benca R. Chronic insomnia. Lancet (London, England). 2012;379(9821):1129-41

      Arico D, Raggi A, Ferri R. Cognitive Behavioral Therapy for Insomnia in Breast Cancer Survivors: A Review of the Literature. Frontiers in psychology. 2016;7:1162.

      Blom, K., Jernelöv, S., Rück, C., Lindefors, N., & Kaldo, V. (2016). Three-Year follow-up of insomnia and hypnotics after controlled internet treatment for insomnia. Sleep, 39(6), 1, 1267-1274. doi: 10.5665/sleep.5850

      Fiorentino L, McQuaid JR, Liu L, Natarajan L, He F, Cornejo M, et al. Individual cognitive behavioral therapy for insomnia in breast cancer survivors: a randomized controlled crossover pilot study. Nature and science of sleep. 2009;2010:1-8.

      Reynolds S, R. M. The Cost of Insomnia and the Benefit of Increased Access to Evidence-Based Treatment. Sleep Medicine Clinics,. 2017;12(1):39-46.

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      ES15.05 - Nursing Role in Managing Toxicity and Expectations of Treatment (Now Available) (ID 3239)

      11:00 - 12:45  |  Presenting Author(s): John McPhelim

      • Abstract
      • Presentation
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      Abstract

      This presentation will discuss the clinical patient care and management of patients receiving immunotherapies. A team approach to patient management including patient education, pre asessment, toxicity management and follow up will be presented. This team consists of Oncologists, specialist nurses and cancer care pharmacists, who work together in a dedicated clinic. The benefits to patients will be presented as well as demonstrating efficient use of clinical time.

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      ES15.06 - The Role of Microbiome Restoration in Chemotherapy and Immunotherapy (Now Available) (ID 3240)

      11:00 - 12:45  |  Presenting Author(s): Alexandre Chan

      • Abstract
      • Presentation
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      Abstract

      Microbiomes are composed of bacteria, viruses, fungi, protozoa and archaea that reside on the surface of our body’s epithelial barrier. There is increasing evidence to suggest microbiomes’ role in carcinogenesis as well as cancer treatment efficacy and toxicity. In this presentation, we will focus on the impact of gut microbiome on efficacy of chemotherapy and immunotherapy. We will also discuss strategies to restore gut microbiome, with the potential on improving the delivery of chemotherapy and immunotherapy.

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      ES15.07 - Achieving Holistic Care in Hard to Reach Patient Cohorts (Now Available) (ID 4087)

      11:00 - 12:45  |  Presenting Author(s): Phemelo Martha Magabanyane

      • Abstract
      • Presentation
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      Abstract not provided

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    ES24 - Diagnosis and Management of Side Effects of Immunotherapy (ID 363)

    • Event: WCLC 2019
    • Type: Educational Session
    • Track: Immuno-oncology
    • Presentations: 3
    • Now Available
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      ES24.01 - Recognizing Toxicities in an Early Phase in PDL1 Treatment (Now Available) (ID 3905)

      11:30 - 13:00  |  Presenting Author(s): Hossein Borghaei

      • Abstract
      • Presentation
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      Abstract not provided

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      ES24.02 - Renal Toxicities in Combination I/O Chemotherapy Treatment (Now Available) (ID 3906)

      11:30 - 13:00  |  Presenting Author(s): Joachim G.J.V. Aerts

      • Abstract
      • Presentation
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      Abstract not provided

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      ES24.03 - Management of Immunerelated Toxicities Unresponsive to Steroids (Now Available) (ID 3907)

      11:30 - 13:00  |  Presenting Author(s): Anne Tsao

      • Abstract
      • Presentation
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      Abstract not provided

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    IBS04 - Hyperprogressive Disease (Ticketed Session) (ID 35)

    • Event: WCLC 2019
    • Type: Interactive Breakfast Session
    • Track: Immuno-oncology
    • Presentations: 2
    • Now Available
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      IBS04.01 - Biological Mechanisms (Now Available) (ID 3325)

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

      • Abstract
      • Presentation
      • Slides

      Abstract

      Inhibitors of programmed cell death 1 (PD-1) and one of its ligands, PD-L1, have rapidly been incorporated into the treatment of patients with lung cancer and other malignancies. In lung cancer, when used as single agents, a minority of patients respond to PD-1 or PD-1 inhibitors. Although some patients now receive these agents along with chemotherapy, many patients still receive single agent inhibitors of immune checkpoints such as PD-1 or PD-L1. A phenomenon of hyperprogression has been described among patients undergoing therapy with immune checkpoint inhibitors. There is a great deal of literature describing the radiographic criteria associated with hyperporgression. Although there is wide agreement that a portion of patients do meet these radiographic criteria, the extent to which inhibitors of PD-1 and PD-L1 can induce the growth of lung cancer is a topic generating a great deal of interest. Studies are beginning to assess potential mechanisms underlying this pnenomenon. Assessment is complicated by the fact that some patients are likely to rapidly progress based solely on lack of effective therapy, and therefore, the group of patients meeting the described radiographic criteria for hyperprogression may be heterogeneous.

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      IBS04.02 - Clinical Characteristics (Now Available) (ID 3326)

      07:00 - 08:00  |  Presenting Author(s): Benjamin Besse

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      Abstract not provided

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    IBS11 - Electronic Cigarettes and Heat-Not-Burn Tobacco Products - How Are They Different (Ticketed Session) (ID 42)

    • Event: WCLC 2019
    • Type: Interactive Breakfast Session
    • Track: Prevention and Tobacco Control
    • Presentations: 3
    • Now Available
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      IBS11.01 - Electronic Cigarettes and Heat-Not-Burn Tobacco Products - How Are They Different (Now Available) (ID 3347)

      07:00 - 08:00  |  Presenting Author(s): Maciej L. Goniewicz

      • Abstract
      • Presentation
      • Slides

      Abstract

      Introduction: Although combustible tobacco cigarettes remain the most popular nicotine-containing products worldwide, non-cigarette products are evolving rapidly. Use of combustible tobacco remains the number one preventable cause of disease, disability, and death, however the effects of non-cigarette products on population-level health is unknown. Over the last 10 years electronic cigarettes (e-cigarettes) have gained considerable popularity, especially among smokers and youth. With the introduction of the ‘Heat-not-Burn’ (HnB) products (iQOS from Philip Morris International, Ploom TECH from Japan Tobacco International, and Glo from British American Tobacco) the landscape of tobacco product exposure has changed yet again.

      Population studies: Some early models of HnB products were developed in the late 1980s; however they did not reach a significant number of consumers and were withdrawn from the market. The introduction of HnB products in Japan in 2014 has been accompanied by an enormous decline in combustible cigarettes. Results from an international survey (International Tobacco Control (ITC) project) showed that that a high percentage of respondents believed HnB and e-cigarettes to be less harmful than cigarettes. Interestingly, smokers in Japan were most likely of 22 countries to believe that HnB were less harmful than cigarettes. Relative harmfulness beliefs of HnB may be both a cause and an effect of their popularity in Japan, fueled by marketing efforts. Ongoing studies will relate these beliefs to reasons for using HnB products, and, with future cohort data, transitions to/from HnB and cigarettes. Concerns have been raised that novel HnB tobacco products may be appealing to youth. Our research have showed that awareness and interest in HnB products among youth in Canada, England and USA was stable between 2017 and 2018, and concentrated primarily among smokers. Perceptions of HnB products are more similar to e-cigarettes than combustible tobacco.

      Toxicity: HnB tobacco products purport to deliver nicotine while reducing exposure to toxicants compared with combustible nicotine products such as tobacco cigarettes by avoiding directly burning tobacco and instead heating tobacco. We measured nicotine in HnB product and found that it delivered 1.4 mg nicotine from a single cartridge, while e-cigarette and tobacco cigarettes delivered 1.3 mg and 2.1 mg nicotine, respectively. In conventional cigarettes, once tobacco is heated above 600°C, combustion occurs, and smoke containing harmful chemicals is released. HnB have an electrical heating component, like e-cigarettes, that heats processed tobacco to 350°C releasing volatile components that often are not detectable in e-cigarettes. In general, yields of carbonyl and aromatic compounds and amines (except for nicotine) in HnB products have been shown to be between one and two orders of magnitude lower than yields of combustible cigarettes, but relatively similar to those of e-cigarettes. Hypothetically, reducing the aerosol generation temperature can result in lower emissions of tobacco combustion byproducts and reduced toxicity as compared to conventional tobacco cigarettes. Although many combustion by-products may be eliminated in HnB devices, carcinogenic nitrosamines are generated in the process of tobacco curing rather than during combustion, and may be transferred from the HnB into the aerosol that it generates. Our group tested nicotine and four Tobacco-Specific Nitrosamines (TSNAs), potent lung carcinogens, in HnB product iQOS. We compared TSNA levels in aerosols from HnB, e-cigarette and cigarette smoke. TSNA yields were significantly higher in the HnB product than those found in e-cigarettes but significantly lower than those found in tobacco cigarettes. TSNA yields in a smoke from single tobacco cigarette were between 7-17 times higher than TSNA yields in emissions from a single HnB cartridge.

      Potential health effects: Claims of lowered risk or health benefits for HnB compared to conventional cigarettes are based almost exclusively on industry-funded research, and except limited number of product testing studies, independent research is not available to support these claims as of 2019. To determine the cytotoxic and proinflammatory effects of HnB products, we exposed bronchial epithelial cells aerosol generated from HnB, e-cigarette aerosol, tobacco smoke or air (control) using an air–liquid interface system. Exposure to HnB resulted in decreased cell viability and increased release of pro-inflammatory interleukins as compared to air controls. Tobacco cigarette was the most toxic product. Interestingly, HnB product showed reduced toxicity as compared to tobacco cigarettes but increased toxicity compared to e-cigarettes. Finally, we used animal model to evaluate if short term in vivo exposure to HnB aerosols has the potential to recruit immune cells into the lung. We exposed mice to emissions from HnB, e-cigarette, and tobacco cigarettes. After 2-week exposure, we have made the novel observation that there was a hierarchy in the inflammatory response in the lung following exposure to the different products, with tobacco cigarettes causing the strongest and e-cigarette the weakest responses.

      Summary: HnB are different from conventional cigarettes and overall appears to deliver less of some toxicants. It is currently not clear whether HnB products may pose lower, the same or higher health risks than combustible cigarettes depending on the disease. HnB products emit more of several important toxicants and carcinogens with more adverse health effects than e-cigarettes.

      Comparison of tobacco cigarettes, Heat-Not-Burn (HnB) products, and e-cigarettes.
      Tobacco Cigarettes (TC) Heat-not-Burn (HnB) E-cigarettes (EC)
      Nicotine YES YES YES (most products)
      Tobacco YES YES NO
      Combustion YES NO NO
      Temperature YES (very high during puffs) YES (lower than TC)

      YES (lower than TC; can be overheated)

      Electronic system NO YES YES
      Relative risk (hypothetical) Higher than HnB and EC

      Lower than TC but higher than EC

      Lower than TC and HnB

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      IBS11.02 - E Cigarettes/ Electronic Nicotine Delivery Systems: A Word of Caution on Health (Now Available) (ID 3348)

      07:00 - 08:00  |  Presenting Author(s): Michael Unger

      • Abstract
      • Presentation
      • Slides

      Abstract

      This presentation discusses the introduction, development, and proliferation of new
      electronic nicotine delivery systems (ENDS) including E-cigarettes and Heat Not Burn
      Tobacco products. The use of these products is considered a means for improving public
      health and reducing the mortality attributed to cigarette smoking. The epidemiology and
      effects of use of various ENDS and their components are described. To date, multiple
      studies indicate that, despite differences in toxicity, there is insufficient evidence
      that use of ENDS leads to effective smoking cessation. Research questions will be proposed
      to address key unanswered questions about the effects of such systems and their role in
      tobacco risk mitigation in various populations.

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      IBS11.03 - Cannabis and Lung Cancer (Now Available) (ID 3349)

      07:00 - 08:00  |  Presenting Author(s): James Jett

      • Abstract
      • Presentation
      • Slides

      Abstract

      Cannabis is a generic term that includes cannabinoids, marijuana (MJ) and hemp derived from the plant Cannabis sativa. Documented use dates back several centuries BC. In 1970 the Controlled Substance Act classified cannabis as a Schedule I drug with high abuse potential and no medical use. Other Class I drugs are heroin, LSD and cocaine. Similarly, cannabis is illegal in many other countries. There are many different cannabinoids in cannabis but the two main ones are delta-9-tetrahydrocabinol (THC) and cannabidiol (CBD). The THC is associated with psychoactive effects of euphoria and relaxation and CBD is not associated with the euphoric effects but is associated with anxiolysis. Pharmaceutical grade cannabinoids are scheduled/classified differently and there are several FDA approved medicines in the USA and available is many other countries. Dronabinol (THC) and nabilone are available for chemotherapy induced nausea and vomiting (CINV). Nabiximol (1:1 mixture of THC and CBD) is used for analgesic effects and spacicity due to multiple sclerosis. It is approved for use in many countries but not the USA. (NASEM; Jett et al)

      Cannabis products can be smoked, vaporized, ingested or applied topically. Smoked or vaporized cannabis reaches the brain within 30 seconds to a few minutes and the effects subside over 1-3.5 hours which makes it easier to titrate the dose/effects than ingested products which results in effects 30 minutes to 2 hours after ingestion and may last 5-8 hours. The average THC levels in MJ were 4% in 1995 and increased to 12% in 2012. However, in recent years with new products such as wax, honey oil, dabs etc that may have concentrations of THC of 40-80% so the effects on the user may be more psychologically and physically intense and effects may include paranoia, anxiety, panic attacks and hallucination.

      Cannabis containing many of the same toxins and carcinogens as tobacco smoke. Regular smoking of MJ is associated with airway inflammation similar to cigarette smoking and regular use of cannabis alone (without tobacco) may result in symptoms of chronic bronchitis. (Douglas IS et al) There is no conclusive evidence that cannabis smoking is associated with an increased incidence of lung cancer. The best available evidence comes from six case-control studies within the International Lung Cancer Consortium (Zhang LR et al, NASEM). An epidemiologic review of six lung cancer studies concluded that these studies did not support an association of MJ use and lung cancer (Huang Y-HJ et al). A limitation of these pooled studies is the small number of heavy and chronic users of cannabis. The National Academy of Science, Engineering and Medicine (NASEM) expert panel concluded that there is moderate evidence of no statistical association between cannabis smoking and the incidence of lung cancer.

      There is an increasing body of evidence that cannabinoids have some anti-cancer effects in cell cultures and animal studies. However, there are no convincing clinical trials demonstrating that cannabis is effective in cancer patients.(NASEM) There is insufficient evidence to support the use of cannabinoids in cancer patients, in spite of claims on the web/internet that concentrated cannabis oils can cure cancer.

      There is evidence that use of cannabinoids are of benefit for treating chronic pain, including neuropathy. Whiting et al performed a meta-analysis of 28 studies that mainly used pharmaceutical grade (Schedule III) cannabinoid based drugs such as nabiximol or nabilone and some smoked or inhaled THC trials. All but one was placebo controlled. The odds ratio was 1.4 of reporting 30% or more improvement in pain with cannabinoids. The NASEM concluded that there is substantial evidence that cannabis is an effective treatment for chronic pain. There have been patient reported outcomes that suggest that cannabis is beneficial for pain, anxiety and depression and may reduce the use of prescription drugs. ( Corroon JM et al; Zaki P et al; Anderson SP et al).

      The NASEM panel concluded stated that there is conclusive evidence that oral cannabinoids are effective antiemetics for treatment of chemotherapy induced nausea and vomiting (CINV). Nabilone and dronabinol are FDA approved drugs for CINV. Good quality studies of inhaled or ingested plant based cannabis for CINV are limited. Most of these randomized trials for CINV were before the use of 5-hydroxytryptamine (5HT3) receptor antagonists. Accordingly, many oncologists would use a 5HT3 antagonist initially. Nabilone or dronabinol may be used for rescue or refractory nausea and vomiting as backup treatment options. Patient reported outcomes have noted benefit from medical marijuana products for nausea and vomiting (Anderson SP et al).

      The FDA has approved use of dronabinol for human HIV induced anorexia but there is currently insufficient evidence to support or refute the effectiveness of cannabinoids for cancer associated anorexia-cachexia (NASEM). However, cannabis has been reported to increase appetite and patient reported outcomes have again suggested benefit from medical marijuana.

      In summary, there is no current evidence that smoking MJ results in an increased incidence of lung cancer. However, the landscape is changing rapidly with the legalization of medical and recreational cannabis. This along with the increasing concentration and dose of the available products may result in an increased number of heavy and chronic users. This will require careful follow-up. Other areas of urgent need, as related to this review, for controlled clinical trials include: 1) Do cannabinoids have any role in treatment of cancer? 2) Do cannabinoids have any efficacy in reduction of opioid use or dose? 3) Is there any role for cannabinoids in treatment of cancer anorexia-cachexia.

      References:

      NASEM: National Academies of Sciences, Engineering and Medicine

      Jett JR et al; J Thorac Oncol 2017; 13:480-487

      Douglas IS et al; Ann Am Thorac Soc 2015; 12:1700-1710

      Zhang LR et al; Int J Cancer 2015; 136:894-903

      Huang Y-HJ et al; Cancer Epidemiol Biomark Prev 2015; 24:15-31

      Whiting PF et al; JAMA 2015; 313:2456-2473

      Corroon JM et al; J Pain Res 2017; 10:989-998

      Zaki P et al; J Pain Manage 2017; 10:353-362

      Anderson SP et al; J Oncol Prac pub online March 12, 2019

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    IBS31 - Trial Design and Novel Drug Accessibility (Ticketed Session) (ID 62)

    • Event: WCLC 2019
    • Type: Interactive Breakfast Session
    • Track: Targeted Therapy
    • Presentations: 2
    • Now Available
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      IBS31.01 - Endpoints and Trial Design for Oncogene Addicted NSCLC (Now Available) (ID 3412)

      07:00 - 08:00  |  Presenting Author(s): Stefan Michiels

      • Abstract
      • Presentation
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      Abstract

      The availability of targeted anticancer drugs or immunotherapies and the relative affordability of genomic analyses has led to a growing expectation that treatments can be chosen based on the molecular biomarkers of their tissue or blood samples. In this talk Dr. Michiels will provide an overview of the endpoints and contemporary clinical trial designs that can be used in the era of stratified medecine.

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      IBS31.02 - Novel Drug Access: Dream Versus Reality (Now Available) (ID 3413)

      07:00 - 08:00  |  Presenting Author(s): Rafal Dziadziuszko

      • Abstract
      • Presentation
      • Slides

      Abstract

      The number of targeted agents registered for treatment of non-small-cell lung cancer (NSCLC) has increased exponentially over last decade as a result of improvements of molecular biology, clinical pharmacology, and clinical research. Molecularly defined subsets of NSCLCs are now recognized from the perspective of these improvements, which directly affect survival of large unmber of NSCLC patients. These innovations are associated with exponential increase of costs to health care, resulting in inequalities among, and often within, countries and societies. Landscape of access to innovative drugs and novel approaches to maximize the access to new therapies will be presented from European perspective.

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    MA22 - Partnering with Patients to Understand Stigma, Disparities and Values Leading to Improved Lung Cancer Care (ID 154)

    • Event: WCLC 2019
    • Type: Mini Oral Session
    • Track: Advocacy
    • Presentations: 12
    • Now Available
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      MA22.01 - Lung Cancer Patients’ Unique Values and Preferences Lead to Clinical Trial Preferences (Now Available) (ID 2639)

      15:45 - 17:15  |  Presenting Author(s): Andrew Ciupek  |  Author(s): Cara Kraft, Jennifer C. King

      • Abstract
      • Presentation
      • Slides

      Background

      Only about 5% of cancer patients participate in clinical trials. We previously conducted a survey of U.S. lung cancer patients and found that only 22% reported discussing clinical trials with their oncologist at the time of making treatment decisions. We hypothesize these low rates of trial discussion and participation may be due in part to current clinical trial designs not reflecting unique values and preferences of lung cancer patients that differ from other non-cancer conditions.

      Method

      Utilizing an online survey inquiring about clinical trial attitudes of patients with several different clinical diagnoses in the United States, we chose to compare a group of lung cancer patients (LC group) to patients diagnosed with a non-cancerous condition (chronic allergies or asthma) (AA group). 229 participants in the LC group and 367 in the AA group were asked to indicate the personal impact of several information sources for finding out about clinical trials and several potential motivators for clinical trial participation.

      Result

      The LC group reported the doctor’s office as their main information source for clinical trials, while the AA group indicated advertisements as their primary source for finding out about trials. In terms of motivation to join trials, 60% of the LC group said having their doctor’s support for joining a given trial was very important to them (only 33% of the AA group said so). Being paid for participation was reported as being motivating by 69% of the AA group versus only 23% of the LC group. When asked about what they valued when looking for a clinical trial, the LC group said extending quality and length of life and receiving access to otherwise unavailable therapy options were very important. The AA group placed much less importance on these same values.

      Conclusion

      We should consider the unique ways lung cancer patients seek information and what they value when designing a strategy to recruit to or educate about a clinical trial. Effective, tailored strategies may include increasing the use of providers as primary trial educators and focusing outreach surrounding trials on lung cancer patient motivators that differ from those with other diagnoses.

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      MA22.02 - The Impact of Patient Engagement on Study Design and Patient Recruitment in a Pragmatic Trial to Improve Cancer Care Delivery (Now Available) (ID 2388)

      15:45 - 17:15  |  Presenting Author(s): Bernardo Haddock Lobo Goulart  |  Author(s): Ari Bell-Brown, Sean D Sullivan, Gary Lyman, Dawn L Hershman, Kate Watabayashi, Karma Kreizenbeck, Sarah Shirley, AnneMarie Ciccarella, Guneet Walia, Judy Johnson, Carol Seigel, Ginny Mason, Florence Kurttila, Barbara Segarra-Vazquez, Scott D Ramsey

      • Abstract
      • Presentation
      • Slides

      Background

      SWOG trial S1415CD is a pragmatic study comparing outcomes of Colony Stimulating Factor (CSF) use in usual care with care that uses guideline-informed standing CSF orders. A 21-person External Stakeholder Advisory Group (ESAG), including 10 patient partners, has informed the design, implementation, recruitment and dissemination planning for the study. Recruitment has been a challenge for study sites, specifically around approaching and consenting patients in the window between diagnosis and first cycle of chemotherapy. This abstract explores the impact of the ESAG patient partners on the patient recruitment process for S1415CD.

      Method

      Patient partners are convened each year over monthly teleconferences, one in-person meeting and targeted email communication. Patient partner input from 2014-present has been tracked and reviewed for impact on the patient recruitment process. After the start of accrual in October 2016, a teleconference was held in spring 2017 focused on barriers to patient accrual, specifically patient approach. Study sites submit monthly screening logs detailing reasons for patient ineligibility.

      Result

      Prior to the start of accrual, patient partners collaborated with the research team to create 2 resources to assist clinic staff with presenting the trial in lay terms: a patient brochure and a summary handout for clinical research associates (CRAs). CRAs reported high use of the brochure as a valuable, simple tool for explaining the trial to eligible patients. Patient partners were also engaged in developing consent forms for trial participants. In addition, patient partners developed strategies for approaching patients in the timeframe between diagnosis and first cycle of chemotherapy which were compiled into a document for study sites and incorporated into the trial’s frequently asked questions. Between October 2016-June 2017, the approach and consent process (i.e. the inability to consent patients in the narrow timeframe) accounted for 22% of all reported ineligible patients, however after the implementation of patient-formulated strategies, during June 2017-December 2018, the approach and consent process has accounted for only 10% of all reported ineligible patients.

      Conclusion

      Sustained engagement and active participation of patient partners throughout S1415CD has provided unique experiential knowledge and feedback to improve the patient approach and consent process across study sites, leading to increased opportunities for patient recruitment. Engaging patient partners early and throughout the study design and conduct phases of the research has been successful in providing patient-centered solutions to recruitment and implementation challenges, including the challenge of timing, to ensure success in reaching the study accrual goals.

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      MA22.03 - The ROS1ders: Partnering to Drive Research and Improve Outcomes in ROS1+ Cancers (Now Available) (ID 2751)

      15:45 - 17:15  |  Presenting Author(s): Janet Freeman-Daily  |  Author(s): Lisa Goldman, Lysa Buonnano, Tori Tomalia

      • Abstract
      • Presentation
      • Slides

      Background

      ROS1 fusions are found in a dozen types of cancer. However, these fusions are rare, occurring in a small fraction of patients (e.g.,1%-2% of non-small cell lung cancer). The small population hampers gathering sizeable patient cohorts and investment in medical research. The ROS1ders are a group of patients and caregivers dealing with ROS1-positive (ROS1+) cancer who strive to better outcomes for all ROS1+ cancers by supporting patients and caregivers, increasing awareness and education, accelerating research, and improving access to effective diagnosis and treatment.

      Method

      We created a private ROS1+ Facebook group for sharing personal information and support among patients and caregivers. We created a public Facebook group for outreach. We launched a website at ROS1cancer.com to share sourced information about ROS1 drugs, clinical trials, expert clinicians, and research developments as well as patient blogs and tips for living with our disease. We attended medical conferences and met with cancer advocacy organizations, clinicians, researchers, and industry; we collectively began working on projects to accelerate research into our disease through the Global ROS1 Initiative. We are active in developing and implementing our projects as well as serving as fundraisers and the ROS1+ public face.

      Result

      The ROS1ders is the largest cohort of ROS1+ patients and caregivers ever collected. We add new members weekly, and have grown to include 400+ members from 28 countries. We network with ROS1+ communities who communicate in languages other than English in Europe, China and Japan. Expert ROS1 clinicians collaborate with us to ensure we provide accurate information about our disease in our Facebook groups and our website. ROS1+ patients have donated fresh tissue and pleural fluid specimens to the ROS1 Cancer Model Project to create cell lines and patient-derived xenograft (PDX) mice; the resulting cell lines have been shared with several institutions in academia and industry. We have contributed data to an epidemiological study. We are collaborating to develop a registry-based study of blood clots in ROS1+ and other lung cancer patients. Some ROS1ders are developing new projects in their home countries.

      Conclusion

      The ROS1ders are breaking new ground, sharing current information, collecting data and biospecimens from ROS1+ patients, and enabling research and development of treatments for our cancer in ways that were not possible before. The Global ROS1 Initiative is truly a partnership between patients, caregivers, advocacy organizations, clinicians, researchers, and industry.

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      MA22.04 - Discussant - MA22.01, MA22.02, MA22.03 (Now Available) (ID 3809)

      15:45 - 17:15  |  Presenting Author(s): Kazuo Hasegawa

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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      MA22.05 - Assessment of Gender Differences in the Psychosocial and Economic Impact on Patients with Stage IV Non-Small Cell Lung Cancer (Now Available) (ID 718)

      15:45 - 17:15  |  Presenting Author(s): Pilar Garrido  |  Author(s): Rosario Garcia Campelo, Margarita Majem, Enric Carcereny, Dolores Isla, Jose Luis Gonzalez Larriba, Juan Coves, Javier De Castro Carpeno, Manuel Dómine, Pilar Lianes, Oscar Juan, Josefa Terrassa, Mariano Provencio, Ana Blasco, Jose Garcia, ramon Garcias De Las Peñas, Angel Artal, Jordi Remon, Silvia Catot, Enriqueta Felip, Nuria Viñolas

      • Abstract
      • Presentation
      • Slides

      Background

      Incidence of lung cancer in women is rising overtime reporting evident gender-based differences in epidemiology, biology, and treatment outcome. However, little is known about gender-differences regarding psychological, economic and social aspects. The objectives of this prospective study are to evaluate the psychosocial and economic impact of metastatic non-small cell lung cancer (NSCLC), according to gender. Additionally, to assess the emotional burden and the economic impact of the disease on the primary caregiver from a gender perspective

      Method

      Multicenter, prospective, observational, study of two cohorts of patients with metastatic NSCLC (male and female) in Oncology departments of 20 Spanish hospitals. The following measurement tools were used: the APGAR questionnaire (family functionality: adaptability, partnership, growth, affection, and resolve), the Relationship impact scale, the DUKE-UNC scale (perceived socio-affective support), the patient and the caregiver economic impact scale and the Zarit scale (caregiver burden). All questionnaires were performed at the first visit, repeated 4 months later and following the first and second disease progression.

      Result

      Of the 333 pts included, 104 were females and 229 male, of whom 63% and 97%, respectively, were smokers/ex-smokers (p=0.0001). More women than men (85% vs 70%) had adenocarcinomas . The median overall survival was longer in women but did not reach statistical significance [17.1 vs 11.0 months, HR 0.732 (95% CI 0.534 to 1.005), p=0.0524]. Most families considered themselves functional (high score in APGAR questionnaire) with no changes in their partner relationship and social support was evaluated as optimal for majority of patients. Around a quarter of interviewed patients said their economic situation was a little worse after the lung cancer diagnosis, without remarkable differences by gender. Statistically significant differences were found between both groups regarding the caregiver´s relationship to the patient (more parents were the caregiver in females than in males) (p <0.0001) and the caregiver’s employment situation (more employed caregivers in females) (p<0.0001). Most caregivers of both sexes considered that taking care of their relative did not pose a significant burden. No remarkable differences by gender were found between the different variables across the study.

      Conclusion

      This study provides a preliminary insight into gender-related characteristics in the management of advanced NSCLC and its impact on the emotional, social and economic burden of patients and their caregivers, and recall the high priority of researching in cancer from a gender perspective

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      MA22.06 - Longer Lung Cancer Time Intervals Amongst Culturally and Linguistically Diverse Patient Than Anglo-Australian Patients  (Now Available) (ID 3103)

      15:45 - 17:15  |  Presenting Author(s): Kenneth John O’Byrne  |  Author(s): Danielle Mazza, Xiaoping Lin, Jon Emery, Fiona Walter, Jane Young, David Barnes, Paul Mitchell, Bianca Brijnath, Andrew Martin

      • Abstract
      • Presentation
      • Slides

      Background

      Lung cancer is the leading cause of cancer mortality worldwide. Culturally and Linguistically Diverse (CALD) patients are especially vulnerable, with poorer outcomes than non-immigrant patients. The LEAD (Lung cancer diagnostic and treatment pathways: A comparison between CALD and Anglo-Australian patients) study aimed to measure and compare the lung cancer diagnostic and treatment pathways between CALD and Anglo-Australian patients.

      Method

      LEAD is a mixed-method, observational cohort study. The presentation reports findings from the quantitative arm comprising a patient questionnaire and reviews of patients’ hospital and general practice records. A total of 577 (407 Anglo-Australian and 170 CALD) patients were recruited from Melbourne, Sydney and Brisbane, and their hospital records were reviewed. The questionnaire was returned by 189 patients (135 Anglo-Australian and 54 CALD) and a record review was completed by the General Practitioners (GPs) of 99 patients (76 Anglo-Australian and 23 CALD). Survival and Cox regression analyses were conducted to examine differences in time intervals between the two groups. LEAD is funded by Cancer Council Australia with the assistance of Cancer Australia.

      Result

      CALD patients reported longer time intervals from referral to diagnosis (Median = 30 days, 95% CI = 26 - 34) than Anglo-Australian patients (Median = 17, 95% CI = 14 - 20), p =. 003, Exp (B) = 1.32. This difference persisted after the impact of relevant factors, such as age and stage of lung cancer, was taken into consideration. CALD patients also reported longer time in five other intervals, including from 1) symptom notification to GP presentation, 2) GP presentation to referral, 3) referral to treatment, 4) symptom notification to treatment, and 5) symptom notification to diagnosis. However, the differences in these five intervals failed to reach significance.

      Conclusion

      LEAD is the first Australian study to comprehensively measure and compare the time intervals along the lung cancer pathways amongst CALD and Anglo-Australian patients. It found that CALD patients have longer time intervals from referral to diagnosis than Anglo-Australian patients.

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      MA22.07 - A Culturally Safe Advocacy Model of Care for Inuit Cancer Patients and Their Families (Now Available) (ID 448)

      15:45 - 17:15  |  Presenting Author(s): Carolyn Roberts  |  Author(s): Chantal Bornais, Paul Wheatley-Price, Tim Asmis, Garth Nicholas, Gwen Barton

      • Abstract
      • Presentation
      • Slides

      Background

      The Ottawa Hospital is the tertiary care center for Inuit living in the Baffin Island region of Nunavut, in Canada’s far North. Inuit – once relatively cancer free – now have among the highest lung cancer rates in the world (Young et al., 2016). Approximately 30% of Inuit diagnosed with cancer between 2000 and 2010 did not access any cancer services (Asmis, 2016), for which they must travel thousands of kilometers where they are displaced from family, community and culture.

      Colonization has had a detrimental impact on the social determinants of health for Inuit in Nunavut and has created a lack of trust in government institutions. This context creates an advocacy need at the individual and systems level to address access and equity issues, with the goal of advancing positive health outcomes.

      Method

      The Champlain Indigenous Cancer Program (CICP) team has developed a patient-centered, culturally appropriate, land-based approach to support Inuit patients using the principles of the “Supportive Care Framework” (Fitch, 1994) as a guiding ideology. Recognizing the social and economic inequities (Inuit Tapiriit Kanatami, 2019), the Nurse Navigator developed an unconventional approach to connect with Inuit patients. She prioritizes developing therapeutic, trusting relationships with patients and families based on the observation that Inuit patients often feel most comfortable outside the confines of a hospital office. Developing these relationships on the land has become a cornerstone of her work.

      Result

      The approach that the CICP has implemented has achieved far-reaching success. Between the first six months and latest six months of tracking (through 2017-2018) there has been a 400%+ increase in patient encounters with the Nurse Navigator role. Clinicians report an increased awareness and understanding of the unique context of Inuit patients and families, resulting in increased numbers of referrals to CICP. Within the Inuit community, there is a recognition and appreciation of the Inuit-specific approach, leading to an increase in self-referrals.

      Conclusion

      The CICP is continuing to actively pursue tracking and reporting initiatives to demonstrate a shift in access to cancer care and the long-term outcomes for Inuit patients and families. The program is also continuing to increase access to cultural awareness education for staff to combat misunderstandings about Inuit. By sharing experiences and stories garnered through this work, the Nurse Navigator will help attendees to question and redefine the perception of the traditional role of a cancer nurse.

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      MA22.08 - Discussant - MA22.05, MA22.06, MA22.07 (Now Available) (ID 3810)

      15:45 - 17:15  |  Presenting Author(s): Clarissa Baldotto

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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      MA22.09 - Challenging Negative Stereotypes Around Lung Cancer in Ireland (Now Available) (ID 1849)

      15:45 - 17:15  |  Presenting Author(s): Anne-Marie Baird  |  Author(s): Jennifer Cimerman, Helen Forristal, Liz Yeates

      • Abstract
      • Presentation
      • Slides

      Background

      In excess of 2,500 people in Ireland receive a lung cancer diagnosis each year, with over 1,800 people dying from the disease. However, general awareness around lung cancer and its associated symptoms are low. This combined with a lack of screening, and the perceived stigma around the disease contributes to the majority of patients presenting with late stage disease. With this in mind, the Marie Keating Foundation launched the ‘I Am Lung Cancer’ campaign to challenge negative stereotypes and perceptions around lung cancer and increase awareness of early signs and symptoms.

      Method

      This project consisted of (i) an online survey to assess knowledge of, and attitudes towards lung cancer and (ii) an awareness campaign. The survey was designed by the Marie Keating Foundation and conducted by Empathy Research across a nationally representative sample of 1,017 adults aged 18 or older. Quotas were placed on gender, age, social class and region with weighting applied to ensure final data was representative of these quotas. The multifaceted ‘’I Am Lung Cancer’ campaign was headed by three ambassadors who have been impacted by lung cancer, and included a radio advertisement, video, updated website content and a social media campaign to promote key campaign messages.

      Result

      Data from the survey demonstrated that less than one in five (16%) Irish adults claim to be well informed when it comes to the signs and symptoms of lung cancer. In terms of attitudes around lung cancer, over a quarter (27%) believe that non-smokers who developed lung cancer should have their treatment prioritised over those who had a smoking history. Almost a fifth (17%) of the Irish public believe that health insurers shouldn’t cover treatment for patients with lung cancer who smoke. Just over a third (34%) agreed that patients with lung cancer face stigma from the public that other patients with cancer don’t face; with one in 10 finding this stigma acceptable. The three ambassadors were central to all aspects of the #IAmLungCancer campaign, with good coverage across national print and broadcast media (reach over 3 million) and online media. On Facebook the campaign reach was over 190,000 and 48,000 on Twitter, with good engagement from the public.

      Conclusion

      This research identified a worrying lack of symptom awareness as well as distressing attitudes towards people impacted by lung cancer. We believe that the campaign, which humanises lung cancer helped to tackle both of these important issues.

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      MA22.10 - The Role of Stigma in Differential Care for Lung Cancer Patients: A Decade of Patient and Oncologist Attitudes (Now Available) (ID 2540)

      15:45 - 17:15  |  Presenting Author(s): Jennifer C. King  |  Author(s): Eleni Rapsomaniki, Maureen Rigney

      • Abstract
      • Presentation
      • Slides

      Background

      The presence of lung cancer stigma is well documented (Chapple et al, 2004; Chambers et al, 2012; Marlow et al, 2015) and has been shown to impact the care and treatment of lung cancer survivors (Tod et al. 2008; Carter-Harris et al 2014). In 2008, a large survey of over 200 patients, 200 oncologists, and 1000 members of the general population revealed that most participants felt that lung cancer was principally caused by external factors, that it was preventable, and that lung cancer patients were at least partly to blame for their illness (Weiss et al. 2014; Weiss et al. 2017). The last decade has brought significant changes in the treatment paradigm for lung cancer but it was unknown if the perceptions that affect the care of lung cancer patients have changed.

      Method

      1001 members of the general public, 208 patients with lung cancer, and 205 oncologists who treat lung cancer were surveyed with the identical survey instrument from 2008 survey along with 5-15 additional questions at the end. The survey was carried out by phone and online between June 6 and July 26, 2018. Statistical analysis was performed comparing 2008 and 2018 datasets using paired t-tests if normally distributed or Mann-Whitney U tests for continuous data and Chi-squared or Fisher’s exact test for categorical data.

      Result

      In 2018, significantly more oncologists feel they have adequate treatment options for metastatic lung cancer (67% vs 36%, p<.001) and the majority of patients report being satisfied with their medical care (87%) and treatment options (71%).

      Nevertheless, significantly more patients felt that there was a stigma associated with having lung cancer (70% vs. 54%, p<.0001) and that society treats them differently (63% vs 45%, p<.0001). There was a non-significant increase in oncologists indicating that there is a stigma associated with lung cancer (68% in 2018 vs 60% in 2008) and that patients blame themselves (67% vs 57%).

      Despite the improvements in lung cancer treatment over the past decade, stigma is still evident in care for those with lung cancer. Similar to 2008, 57% of oncologists indicated that patients with different types of cancer were thought about, approached, or handled differently and lung cancer patients were most frequently cited. In 2018, more patients reported that patients with lung cancer are treated differently by doctors and nurses (40% vs. 26%, p=.01). For both groups, the most common differential treatment referenced was “received less sympathy from medical staff.”

      Conclusion

      After a decade of research progress in lung cancer, stigma surrounding the disease remains a critical problem even in a healthcare setting. Patients are perceiving stigma at higher levels and oncologists are not reporting any improvement. This work underscores the need to address stigma with proactive multilevel approaches including the need for medical providers to practice empathic communication.

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      MA22.11 - An Empathic Communication Skills Training Module to Reduce Lung Cancer Stigma in Patients with Lung Cancer: Pilot Results   (Now Available) (ID 1725)

      15:45 - 17:15  |  Presenting Author(s): Jamie Ostroff  |  Author(s): Smita Banerjee, Noshin Haque, Carma Bylund, Megan Shen, Maureen Rigney, Heidi Hamann, Patricia Parker

      • Abstract
      • Presentation
      • Slides

      Background

      Most patients diagnosed with lung cancer report experiencing stigma, with 48% reporting stigma attributable to interactions with health care clinicians. Lung cancer stigma may result in multiple negative psychological outcomes such as misreporting and underreporting of symptoms and smoking behaviors and avoidance of help-seeking. One promising intervention strategy for reducing patients’ experiences of lung cancer stigma is improving empathic communication in lung cancer patient-clinician interactions. This abstract describes the conceptual model, development, and preliminary evaluation of a clinician-targeted empathic communication skills training to reduce lung patient’s experience of stigma.

      Method

      The goal of this new training module was to enhance responsiveness to lung cancer patients’ expression of stigma and psychological distress focusing on greater use of seven communication strategies: agenda setting, history taking, recognizing or eliciting a patient’s empathic opportunity, shared understanding of the patient’s emotion/experience, empathic responding, coping and connection to social support, and closing the conversation. Participating cancer care clinicians learned specific communication skills such as providing a rationale for tobacco use discussion, normalizing, acknowledging, preparing patients for recurring smoking questions, and encouraging expression of feelings. The 2-hour training module was delivered to thoracic oncology clinicians (physicians, advanced practice clinicians) (n=28) using a brief didactic presentation (30 min) with exemplary video demonstrations, followed by experiential role play exercises (90 min) with standardized patients.

      Result

      We examined preliminary efficacy of the empathic communication module by assessing participant evaluation of the training and their perceived self-efficacy before and after the training. Overall, participating clinicians reported favorable evaluations of the training, with 93% participants agreeing or strongly agreeing to all 12 training module evaluation items. Of note, perceived self-efficacy to communicate empathically with lung cancer patients increased significantly, t(27)=-4.42, p<.001 from pre- (M=3.64,SD=.68) to post-training (M=4.36,SD=.49).

      Conclusion

      Overall, results indicate that the new empathic communication skills training module was well received by thoracic oncology care clinicians and demonstrated significant improvements in self-efficacy from pre- to post-training. Examination of patient outcomes is needed.

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      MA22.12 - Discussant - MA22.09, MA22.10, MA22.11 (Now Available) (ID 3811)

      15:45 - 17:15  |  Presenting Author(s): Lisa Carter-Harris

      • Abstract
      • Presentation

      Abstract not provided

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    MS03 - Workup and Management of Small Anterior Mediastinal Masses/Lesions (ID 66)

    • Event: WCLC 2019
    • Type: Mini Symposium
    • Track: Thymoma/Other Thoracic Malignancies
    • Presentations: 5
    • Now Available
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      MS03.01 - Differentiation of Small Anterior Mediastinal Lesions Using Imaging (Now Available) (ID 3449)

      13:30 - 15:00  |  Presenting Author(s): Edith Michelle Marom

      • Abstract
      • Presentation
      • Slides

      Abstract

      Mediastinal masses are relatively uncommon in the general population and no specific algorithm exists for the evaluation and diagnosis of these lesions. Most mediastinal masses occur in the anterior, or prevascular compartment and these lesions demonstrate tremendous heterogeneity in clinical and pathologic features. The selection of laboratory tests, whether to perform a biopsy, immediate surgery, follow-up imaging or order further imaging investigation varies between medical disciplines, and patients’ clinical features. The use of CT has grown exponentially over the last decade. This has led to an increasing amount of incidental prevasscular mediastinal lesions encountered, often smaller than those encountered in symptomatic patients.

      There is no agreement as to what defines a mediastinal lesion as ‘small’. For the radiologist, this usually constitutes a lesion, which is too small to characterize, perhaps smaller than 1cm. For the surgeon, this may be a lesion, which could be approached with minimally invasive surgery, or perhaps a lesion which one may suspect is benign. When dealing with the incidental prevascular lesion, the most important role for the radiologist is to correctly identify a “no touch lesion”: a benign lesion or normal variant that should not be treated. The second task the radiologist must face is diagnose correctly a lesion or at least narrow the differential to tailor the diagnostic approach causing minimal harm in the process.

      The imaging modality of choice for identifying, localizing, and characterizing most mediastinal masses is CT. Most clinicians and radiologists are most familiar with this imaging modality and it has the ability to accurately locate, identify densities such as fat, bone, calcification and fluid. There are some prevascular mediastinal lesions that have a pathognomonic appearance on CT, which may obviate the need for a biopsy, such as goiter, mature teratoma or thymolipoma. However, CT has two major drawbacks: it does expose individuals to a relatively large amount of ionizing radiation, and it is not as good as MRI in tissue characterization. Thus, when a prevascular lesion measures as fluid, it is sometimes difficult to identify nodular thickening within the fluid to distinguish a benign cyst for example, from a cystic thymoma. Similarly, cysts may seem solid on CT. Proteinaceous cyst, when measured by CT, have Hounsefield Units, which measure as soft tissue rather than fluid. MRI overcomes these issues, with its better contrast resolution.

      MR imaging is not routinely performed to evaluate all mediastinal masses; however, it is the best modality for distinguishing cystic from solid masses (e.g., thymic cysts from solid tumors), identifying cystic and/or necrotic components within solid lesions, demonstrating septations and/or soft tissue within cystic lesions, and distinguishing thymic hyperplasia and normal thymus from soft tissue tumors.

      Tissue characterization, whether using CT or MRI, relies on visible assessment or measuring the density/intensity of the lesion. When a tissue is measured, a region of interest (ROI) is placed in the lesion. For the measurement to be accurate, the ROI should include more pixels, should be about 1cm in diameter and not include soft tissue around the lesion. It is because of this, that in small lesions, smaller than 1cm, the density/intensity cannot be accurately measured. Another example is the use of MRI to distinguish thymic hyperplasia from a soft tissue malignancy. The MRI chemical shift sequence shows a signal drop when fat and soft tissue abut each other. This causes the fat-soft tissue interface to appear as a dark linear outline on this sequence. Since thymic hyperplasia contains a combination of fat and soft tissue, there is a signal drop in thymic hyperplasia using this sequence, not seen with other masses in the prevascular mediastinum. However, when a soft tissue lesion in the prevascular mediastinum is too small, chemical shift imaging is not useful. The periphery will drop out due to the soft tissue interface with the surrounding mediastinal fat, leaving insufficient amount of tissue centrally for investigation.

      Positorn emission tomography (PET) integrated with CT using fluorodeoxyglucose as the isotope, is commonly used in staging different malignancies. Its role however in differentiating benign from malignant masses is limited. That is because some benign entities, such as thymic hyperplasia may be FDG avid, whereas some malignancies, such as some types of thymoma, are sometimes not FDG avid. Also, the FDG uptake of commonly encountered malignancies in the prevascular mediastinum is high, so that it is impossible to distinguish between them. For example thymic carcinoma, paraganglioma and non-seminomatous germ cell tumor show similar FDG uptake. In addition, the spatial resolution of PET is low, much lower than CT or MRI so that small lesions, those smaller than 1cm, are not accurately assessed by this modality.

      We will review the imaging approach to the incidentally discovered, usually small, prevascular mass. How to identify the ‘no touch lesion’, when to order additional imaging and which imaging modality to select in order to prevent futile surgery.

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      MS03.02 - Resection, Biopsy or Observation of Small Anterior Mediastinal Lesions (Now Available) (ID 3450)

      13:30 - 15:00  |  Presenting Author(s): Frank Detterbeck

      • Abstract
      • Presentation
      • Slides

      Abstract

      With greater prevalence of CT scanning for many reasons, the incidental detection of a prevascular lesions has increased markedly. 3 sources of data show the incidence to be around 0.5-1% in asymptomatic adults. There is no accepted standard for how to manage these patients, and until recently there was little data to base an approach on. Recently, examination of scans done for lung cancer screening provide some answers. The majority of these lesions have CT characteristics that are consistent with a thymic epithelial tumor (TET). However, the vast majority are stable over a median follow-up of approximately 5 years. While a minority exhibit growth, on further observation most of these do not continue to grow or decrease in size. It is well documented that thymic cysts and other benign lesions sometimes grow slightly. The overall incidence of a malignancy is around 2%. Even after a prolonged period of observation, when resection is undertaken for a TET, the vast majority are stage I (8th edition of TNM) and there have been no recurrences over a median follow up of approximately 5 years. This has been the case even with thymic carcinoma. In summary, simple observation of incidentally discovered prevascular lesions appears to be safe, without losing a window for intervention in the small percentage of patients that need this.

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      MS03.03 - Minimally Invasive Surgical Strategies and Considerations for Small Anterior Mediastinal Lesions (Now Available) (ID 3451)

      13:30 - 15:00  |  Presenting Author(s): Benny Weksler

      • Abstract
      • Presentation
      • Slides

      Abstract

      Minimally Invasive Surgical Strategies and Considerations for Small Anterior Mediastinal Lesions

      Thymomas are the most common anterior mediastinal masses. These are slow growing relatively indolent tumors that are often curable with surgical resection. Thymomas are often detected in asymptomatic patients who had a computed tomography of the chest for other reasons. Until recently, the surgical standard of care for curative surgery was resection of the thymus en-bloc with the mass through an open sternotomy. Advances in video surgery have allowed resection of the thymus and the anterior mediastinal masses through small incisions.

      Currently, there are multiple minimally invasive approaches to the anterior mediastinum, including thoracoscopy though the chest wall, thoracoscopy through a subxiphoid incision, and robotic assisted thoracoscopy. Although data comparing the techniques is sparse, there is no reason to believe that one has oncologic or survival advantages over the other. Data comparing minimally invasive approaches with open approaches have shown better short-term outcomes such as postoperative complications and blood loss, and similar long-term survival.

      Several authors have questioned the need for a complete thymectomy in patients with small anterior mediastinal lesions, hence the term thymomectomy. Thymomectomy involves the removal of the thymoma only, with margins around it, but without a formal complete thymectomy. Data comparing complete thymectomy with thymomectomy is sketchy and likely unreliable. Another area of intense investigation is the role of nodal dissection or sampling in the surgical management of thymomas. Data from multiinstitutional database suggests that the incidence of nodal metastases is higher than previously thought. Although data is lacking, removal of enlarged nodes, or sampling of nodes in the anterior mediastinum is likely indicated.

      In summary, small anterior mediastinal masses can be removed using minimally invasive techniques. The need for complete thymectomy, and nodal sampling are areas of investigation. Until more data is available, complete thymectomy with nodal sampling appears prudent.

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      MS03.04 - Followup/Surveillance of Small Anterior Mediastinal Lesions (Now Available) (ID 3452)

      13:30 - 15:00  |  Presenting Author(s): Wentao Fang

      • Abstract
      • Presentation
      • Slides

      Abstract

      With increasing popularity of CT screening for early stage lung cancers, there is a tendency toward increased detection of small anterior mediastinal nodules. However, work-up and management strategy for such incidentally found small mediastinal lesions remains to be established.

      During 2013-2018, 415 patients with incidentally found small anterior mediastinal mass less than 3 cm in diameter were retrieved from a prospectively kept database at the Division of Mediastinal Surgery, Shanghai Chest Hospital. A marked increase was seen in the annual number of such cases detected (Figure 1). MRI was used in addition to CT scan for differential diagnosis in 413 cases. The other 2 patients could not receive MRI because of metal implantation at previous surgery.

      Eight-nine patients received surgery, 82 (92.1%) of them turned out to have thymic epithelial tumors (Table). Among thymic tumor patients, 36 had a follow-up history for a median of 18 months, and 27 (75%) of the lesions increased in size. Thymic carcinomas and neuroendocrine tumors enlarged more rapidly than type B2/B3 thymomas, and the latter more rapidly than type A/AB/B1 tumors (Figure 2). Two of the seven thymic carcinomas were upstaged to UICC T3 lesions, and nodal involvement was found in two thymic carcinoma and one atypical carcinoid patients. The other 33 tumors were all in UICC stage Ia. Seven patients turned out to have bronchogenic cysts (3) or thymic cysts (4). None of them had follow-up history and 5 of them received surgery because of MR suspected thymomas. Thus the accuracy of MRI for diagnosing thymic tumors was 94.1% (80/85).

      Three-hundred-twenty-six patients are still under follow-up, 311 of them were diagnosed of having benign lesions (cysts, hyperplasia, lymph nodes) by MRI. With a median follow-up of 33 months, none but one MRI diagnosed cyst increased by 0.3 cm after 3 years. Two MRI diagnosed cystic and two hyperplasic lesions decreased in size during follow-up. Thirteen patients with MRI diagnosed clinical stage I thymomas refused surgery. Only two of the lesions increased in size by 0.2-0.3 cm after 2 years (Table).

      In conclusion, MRI is highly useful in differential diagnosis of small anterior mediastinal lesions. Follow-up could be safely recommended for those MRI diagnosed benign lesions.

      Table. Change in size during follow-up for small anterior mediastinal lesions.

      Diagnosis

      Patient

      Size

      Follow-up

      Size (+)

      Size (-)

      (Number)

      (Mean, cm)

      (Median, month)

      (Number)

      (Number)

      Surgery (TET)

      36

      2.4

      18

      27

      0

      AB

      11

      2.4

      36

      2

      0

      B

      11

      2.5

      12

      4

      0

      Ca

      7

      2.3

      24

      6

      0

      NETT

      3

      2.3

      15

      3

      0

      Metaplastic

      2

      1.1

      36

      2

      0

      Micronodular

      2

      2.1

      5

      0

      0

      No-surgery

      326

      2.2

      33

      3

      4

      TET

      13

      1.5

      18

      2

      0

      Cyst

      267

      2.3

      36

      1

      2

      LN

      24

      1.2

      24

      0

      0

      Hyperplasia

      22

      2.4

      24

      0

      2

      Figure 1. Increasing incidence of incidentally detected small anterior mediastinal lesions at Shanghai Chest Hospital.

      figure 1.png

      Figure 2. Trends of increase in size during follow-up in different subtypes of thymic epithelial tumors.

      figure 2.png

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      MS03.05 - Relevance of Nodal Involvement and the Thymic Lymph Node Map (Now Available) (ID 3453)

      13:30 - 15:00  |  Presenting Author(s): Jhingook Kim

      • Abstract
      • Presentation
      • Slides

      Abstract

      Thymic epithelial tumors (TET) including thymoma, thymic carcinoma, and thymic neuroendocrine tumors are rare cancers, accounting for less than 1% of all tumors. No official staging system was defined by the Union Internationale Contre le Cancer and the American Joint Commission on Cancer (AJCC) until 2017. This led to several proposals being published over the years, but few received clinical validation. Unlike lung cancer, where regional spread through the lymphatics has been proved, most common patterns of recurrence in TET are local failure, or dissemination into the pleural or pericardial spaces. Therefore, the role of additional intraoperative nodal assessment is uncertain in TET, for which total thymectomy is the standard procedure.

      Lymph node metastasis in TET is more common with thymic carcinoma. Kondo et al. reported in their retrospective study (n=1320) that lymphogenous spread with or without distant metastasis was found in 3.2% of thymomas, and more commonly in 33% of thymic carcinomas.1 In particular, anterior mediastinal lymph nodes were thought to be the primary drainage location for TET. Anterior mediastinal lymph nodes were involved in approximately 90% of thymomas, 70% of thymic carcinomas, and 90% of thymic neuroendocrine tumors with lymph node metastasis. Furthermore, a cadaveric study found that the anterior mediastinal nodes are the primary drainage basin and the intrathoracic lymph node group are secondary.2

      In 2017, the first TNM classification of TET was announced in the 8thedition of the AJCC Cancer Staging Manual, based on proposals made through a collaboration between IASLC and ITMIG.3 A new N category was presented based on the lymph node drainage pattern found in anatomic studies and international databases. Prominent nodes defined by anatomic studies are included as regional nodes in the lymph node map (Table 1).2 In addition, the IASLC lymph node map of lung cancer and AAO-HNS/ASHNS node map were referenced to define boundaries. This new N category classifies the node involvement into three groups according to a region-based system: N0, N1 (anterior region: anterior mediastinal and anterior cervical nodes), and N2 (deep region: middle mediastinal and deep cervical nodes) (Fig. 1). However, this classification is limited by the fact that the amount of data included was too limited to determine statistical significance.2,4,5

      Although the first official N category has been published, controversy still remains over the lymph node involvement in TET. The prognosis with nodal metastasis is clearly poor, but the clinical significance of the criterion dividing the current N1, and N2 groups is uncertain. Moreover, the treatment strategy according to each stage is not yet fully defined. ITMIG recommends removal of anterior mediastinal nodes at the time of resection for thymoma.6 This fits into the generally accepted definition of an extended thymectomy which includes anterior mediastinal nodes. For locally advanced thymomas (Masaoka stage III or IVA) and thymic carcinoma, a systematic removal of intrathoracic nodes is encouraged (i.e., those corresponding to the deep region). However, for minimally invasive surgery, which is currently in widespread use, the extent and level of lymph node removal should be discussed further. It also remains to be determined whether different treatment strategies should be adopted according to the histological classification of thymomas, as well as whether it is appropriate to apply the same staging for the different TET pathological entities (i.e. thymoma, thymic carcinoma, and thymic neuroendocrine tumor). Therefore, the current official staging system will play a major role in settling these debates through collection from appropriate databases under uniform definitions. Further research is needed to establish the relevance of the node map, the prognostic role of nodal involvement, and the clinical implications of node dissection.

      Reference

      1. Kondo K, Monden Y. Lymphogenous and hematogenous metastasis of thymic epithelial tumors. Ann Thorac Surg. 2003;76(6):1859–64

      2. Bhora FY, Chen DJ, Detterbeck FC, et al. The ITMIG/IASLC Thymic Epithelial Tumors Staging Project: A Proposed Lymph Node Map for Thymic Epithelial Tumors in the Forthcoming 8th Edition of the TNM Classification of Malignant Tumors. J Thorac Oncol. 2014;9(9):S88–S96.

      3. Amin MB, Edge SB, Greene FL, et al, eds. AJCC Cancer Staging Manual. 8th ed. New York:Springer; 2017

      4. Detterbeck FC, Stratton K, Giroux D, et al. The IASLC/ITMIG Thymic Epithelial Tumors Staging Project: Proposal for an Evidence-Based Stage Classification System for the Forthcoming (8th) Edition of the TNM Classification of Malignant Tumors. J Thorac Oncol.2014;9(9):S65–S72.

      5. Kondo K, Van Schil P, Detterbeck FC, et al. The IASLC/ITMIG Thymic Epithelial Tumors Staging Project: proposals for the N and M components for the forthcoming (8th) edition of the TNM classification of malignant tumors. J Thorac Oncol. 2014;9(9 Suppl 2):S81–7.

      6. Toker A, Sonett J, Zielinski M, et al. Standard Terms, Definitions, and Policies for Minimally Invasive Resection of Thymoma. J Thorac Oncol. 2011;6(7):S1739–42.

      figure 1.png

      table 1.png

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    MTE01 - Meet the JTO Editor (ID 385)

    • Event: WCLC 2019
    • Type: Educational Session
    • Track:
    • Presentations: 1
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      MTE01.01 - Meet the Editor (ID 4055)

      14:00 - 15:30  |  Author(s): Alex A Adjei

      • Abstract

      Abstract not provided