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  • WCLC 2018

    19th World Conference on Lung Cancer

    Access to all presentations that occur during the 19th World Conference on Lung Cancer in Toronto, ON

    Presentation Date(s):
    • Sept 23 - 26, 2018
    • Total Presentations: 2384

    To review abstracts of the presentations below, narrow down your search by using the Filter options below, and then select the session listing of your choice. Click the "+" for a presentation to expand & view the corresponding Abstract details.

    Presentations will be available 24 hours after their live presentation time

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    MTE14 - Nodule Management (Pro Con Debate and Case Presentations) (Ticketed Session) (ID 824)

    • Type: Meet the Expert Session
    • Track: Screening and Early Detection
    • Presentations: 1
    • Now Available
    • Moderators:
    • Coordinates: 9/25/2018, 07:00 - 08:00, Room 206 F
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      MTE14.01 - Nodule Management (Pro Con Debate and Case Presentations) (Now Available) (ID 11570)

      07:00 - 08:00  |  Presenting Author(s): Stephen Lam, Matthijs Oudkerk

      • Abstract
      • Presentation
      • Slides

      Abstract

      A recent observation study on the management of lung nodules 8 mm to 20 mm by community pulmonologists in the US showed a high benign biopsy rate of 62% and benign surgical resection rate of 35%. Furthermore, the surgical resection rates were similar irrespective of the pre-test probability of malignancy risk.1 The study suggested there is a lack of adherence to nodule management guidelines. However, there are a number of lung nodule management guidelines and lung nodule malignancy risk prediction tools.2-6 Some are based on 2D diameter size measurement while others used volumetric measurement or a combination of both. New nodules with a prior negative CT have a higher probability of malignancy even at a smaller size. 7-9 Compares to baseline screen, the malignancy risk of new nodules is higher for nodules <8mm.9 Computer assisted diagnostic (CAD) tools facilitates volume measurement and reduce inter-observer variability but they may not be generally available. Volumetric measurement is particularly useful for comparison of serial scans for evidence of growth. Growth independent nodule characteristics such as right upper lung and central distribution may further improve volume based new nodule malignancy prediction. Nodule size and growth are the most important parameters for malignancy.

      To measure size accurately especially to determine changes in volume, it is necessary to address standardization of technical requirements related to the scanners and image acquisition protocols.10 The action thresholds for early recall CT imaging study, PET/CT or biopsy vary in different guidelines with major differences for non-solid nodules making it difficult for clinicians to remember or apply. Therefore, a lack of adherence to guideline recommendations could be related to a lack of clarity of guidelines. To facilitate implementation, there is a need to have an integrated nodule malignancy risk tool that takes into account prior LDCT history when there is more than a baseline LDCT.

      In this session, the important issues regarding which risk model should be applied and which nodule management approach should be used (e.g. diameter or volume) for baseline and new nodules will be discussed through case presentations.

      References:

      1. Tanner NT, Aggarwal J, Gould MK, Kearney P, Diette G, Anil Vachani A, Fang KC, Silvestri GA. Management of Pulmonary Nodules by Community Pulmonologists. A Multicenter Observational Study. Chest 2015:148(6):1405-1414.

      2. MacMahon H, Naidich DP, Goo JM, et al (2017). Guidelines for management of incidental pulmonary nodules detected on CT images: from the Fleischner Society 2017. Radiology; 284; 228-243.

      3. American College of Radiology. Lung CT Screening Reporting and Data System (Lung-RADS). Accessed 23rd June 2017 from www.acr.og/quality-saftey/resources/lungRADS.

      4. Callister MEJ, Baldwin DR, Akram AR et al (2015). BTS guidelines for investigation and management of pulmonary nodules. Thorax; 70:ii1-ii54. Doi: 10.1136/thoraxjnl-2015-207168.

      5. Horeweg N, van der Aalst CM, Vliegenthart R, et al. Volumetric computed tomography screening for lung cancer: three rounds of the NELSON trial. Eur Respir J 2013;42:1659-67.

      6. McWilliams AM, Tammemägi MC, Mayo JR, et al (2013). Probability of cancer in pulmonary nodules detected on first screening CT. N Eng J Med; 369: 910-919.

      7. Walter JE, Heuvelmans MA, Bock GH, Yousaf-Khan U, Groen HJM, Aalst CMV, Nackaerts K, Ooijen PMAV, Koning HJ, Vliegenthart R, Oudkerk M. Characteristics of new solid nodules detected in incidence screening rounds of low-dose CT lung cancer screening: the NELSON study.Thorax. 2018 Apr 16. pii: thoraxjnl-2017-211376. doi: 10.1136/thoraxjnl-2017-211376. [Epub ahead of print]

      8. Walter JE, Heuvelmans MA, de Jong PA, Vliegenthart R, van Ooijen PMA, Peters RB, Ten Haaf K, Yousaf-Khan U, van der Aalst CM, de Bock GH, Mali W, Groen HJM, de Koning HJ, Oudkerk M. Occurrence and lung cancer probability of new solid nodules at incidence screening with low-dose CT: analysis of data from the randomised, controlled NELSON trial. Lancet Oncol. 2016 Jul;17(7):907-916.

      9. Paul F. Pinsky PF, Gierada DF, Nath PH, Munden R. Lung Cancer Risk Associated With New Solid Nodules in the National Lung Screening Trial. AJR 2017; 209:1009–1014.

      10. Alexander A. Bankier AA, MacMahon H, Goo JM, Rubin GD, Schaefer-Prokop CM, Naidich DP. Recommendations for measuring pulmonary nodules at CT: A Statement from the Fleischner Society. Radiology 2017 Nov;285(2):584-600.

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    MTE15 - Who is Too High Risk for a VATS Resection? (Ticketed Session) (ID 825)

    • Type: Meet the Expert Session
    • Track: Treatment of Early Stage/Localized Disease
    • Presentations: 2
    • Now Available
    • Moderators:
    • Coordinates: 9/25/2018, 07:00 - 08:00, Room 205 BD
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      MTE15.01 - Identifying High Risk Patients: What Makes a Patient Too High Risk for Surgery and Who Decides? (Now Available) (ID 11572)

      07:00 - 07:30  |  Presenting Author(s): Hisao Asamura

      • Abstract
      • Presentation
      • Slides

      Abstract

      Thoracoscope is, by its original meaning, defined as an endoscope to observe intrathoracic space, just like a bronchoscope for bronchial lumen. But today this endoscope has been widely accepted as a surgical instrument to perform various kinds of intrathoracic procedures which had been otherwise done with open thoracotomy. Video-assisted thoracic surgery (VATS) has been expected to reduce the surgical burden, and already applied for the complex surgeries such as those for lung cancer. It is now a part of our routine procedures. However, despite the minimally invasiveness of the procedure, VATS may become a risky surgery in several special situations. Not only the surgeons, but also pulmonologist, medical oncologist, or radiation oncologist should know the nature of the surgery, and the situations in which VATS should be rather avoided. In this MTE sessions, I would like to present the special situations in which the VATS procedures are at too high risk, and therefore, and are not considered to be performed.

      HIGH-RISK SURGERY

      When dose the surgery become at high risk? In what situation, we should think the surgery is at high risk? Generally, there must be two kinds of situations each alone or both combined, which make the surgery at high risk. One is the patients at high risk for surgery even for a routine lobectomy, with a limited pulmonary reserve. The other is the difficult, complex surgery such as the extended pulmonary resection. Technical limitations of a VATS procedure are generally related to several different situations, which are described below. In this MTE session, I would like to focus upon the surgical, technical risks for the VATS procedures.

      VATS LUNG RESECTRIONS AT TECHNICALLY HIGH RISK

      2-1. DIFFICULT ONE-LUNG VENTILATION. One-lung ventilation, collapsing the one entire lung of the operative side, is an indispensable part of the stable VATS procedure. Thoracic cavity is usually filled with expanded lung, and only very limited space is left when the lungs are airated. To make VATS procedures possible, deflation (collapse) of the lung on affected side is indispensable, which provides the space for observation and working of surgical instruments. Therefore, for patients who do not tolerate to the one-lung ventilation because of the limited pulmonary reserve or previous history of lung resection, VATS is generally not indicated. For these patients, we consider routine open thoracotomy with intermittent collapse of the operative side of the lung.

      2-2. TIGHT ADHESIONS. Tight adhesions might exist within the thoracic cavity, especially for patients with the history of pleurisy or surgery. As seen previously, the working pleural space is an indispensable element of a VATS procedure. Surgeons are concerned about such history in case VATS resection is indicated. There are several types of adhesions which make VATS procedure difficult. Examples for these conditions are as follows:

      1) Previous pleurisy. If intrathoracic adhesion, mostly due to the previous pleurisy, is extensive, it is impossible to have an enough working space. In fact, lysis under thoracoscopy can be done, but it is usually time-consuming with significant amount of blood loss. There might be even a higher risk of damaging the visceral pleura and lung parenchyma, which may cause prolonged air leakage especially in the elderly with bullous lung. Therefore, except for a localized one, the extensive symphysis of pleura should be respected as a contraindication and a case which should be converted to the open thoracotomy.

      2) Adhesions at pulmonary hilum (“Frozen hilum”). In some cases with past history of infection such as tuberculosis, the hilar nodes are tightly adhesive to the bronchovascular structures. This is extremely difficult situation even for routine lobectomy. VATS resection for such cases are hardly considered.

      3) Previous thoracotomy. Major lung resection after previous lung resection involving the hilum (for example, a completion right lower lobectomy after middle lobectomy) is one of the most challenging surgery even by open thoracotomy. Also, for these operations, VATS resection is rarely indicated.

      2-3. COMPLEX PROCEDURES. Among various procedures in thoracic surgery, complex procedures are thought to be done safely by open thoracotomy, and not by VATS. These might include the following: such as bronchovascular plasty, combined resection with neighboring structures, pneumonectomy, and pleuropneumonectomy.

      2-4. OTHER SITUATIONS WHICH MAKE VATS PROCEDURE AT HIGH RISK

      1) Complex anatomical variation. When complex anatomical variations are found during the surgery, the procedure should be converted to open thoracotomy without hesitation.

      2) Large lesions. Any large intrathoracic mass, wherever it is located, have a trouble in being retrieved from the thoracic cavity. Not only they inevitably require enough extension of the trocar port or access thoracotomy, but also, they might be crushed during being extracted, which may result in tumor dissemination.

      3) Special locations. In the intrapulmonary and mediastinal lesions, there are special locations where the thoracoscopic instrumentation is quite difficult: Lesions located at mediastinal aspect of the lung, and those close to hilum. Mediastinal mass (swollen lymph nodes) adjacent to the vital structures such as great vessels is also least suitable for this technique because of danger of massive bleeding.

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      MTE15.02 - Who is Too High Risk for a VATS Resection? (Now Available) (ID 11573)

      07:30 - 08:00  |  Presenting Author(s): Pieter E. Postmus

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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    MTE16 - What Is Changing in the Management of Pulmonary Neuroendocrine Tumours? (Ticketed Session) (ID 829)

    • Type: Meet the Expert Session
    • Track: Small Cell Lung Cancer/NET
    • Presentations: 2
    • Now Available
    • Moderators:
    • Coordinates: 9/25/2018, 07:00 - 08:00, Room 205 AC
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      MTE16.01 - Proper Treatment of LCNEC; Chemotherapy or Targeted Therapy (Now Available) (ID 11579)

      07:00 - 07:30  |  Presenting Author(s): Sumitra Thongprasert

      • Abstract
      • Presentation
      • Slides

      Abstract

      Neuroendocrine Tumors of the Lung consisted of two subtypes which is small cell lung cancer (SCLC) and large cell neuroendocrine carcinoma (LCNEC). Both subtypes represent around 15% of all Lung Cancer. The incidence of LCNEC was quite low as compare to SCLC. However both are aggressive and poor prognosis. The treatment of LCNEC was usually followed the SCLC. In early stages (I-II-III), surgery is recommended but does not seem to be sufficient. Platinum-based adjuvant chemotherapy may be useful while the role of neoadjuvant chemotherapy is still not well defined. In patients with advanced stage LCNEC, the chemotherapy regimens used in SCLC which is cisplatin plus etoposide remain the standard of treatment, but results are not satisfactory. Due to their peculiar clinical and biological features and the lack of literature data, there is an emerging need for a consensus on the best treatment strategy for LCNEC and for the identification of new therapeutic options. In this review, we will discuss the key aspects of LCNEC management and the possibility of using the gene sequencing to clarify the selection of chemotherapy regimen.

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      MTE16.02 - The Management of Small Cell Lung Cancer following First Line Treatment Failure (Now Available) (ID 11580)

      07:30 - 08:00  |  Presenting Author(s): Glenwood Goss

      • Abstract
      • Presentation
      • Slides

      Abstract

      SCLC remains a clinical challenge that has not benefited from the same medical advances in recent years as non-small cell lung cancer (NSCLC). Beyond first line chemotherapy, there are few approved therapies for recurrent small cell lung cancer (SCLC). A multitude of agents have been tested over the past decades, yet little improvement has been made in survival rates. This talk will review previous efforts in treating SCLC upon progression after first-line therapy, the current science that is changing our understanding of the biology of SCLC and will discuss the evidence for new agents in this indication, by reviewing recent and current clinical trials.

      The addition of platinum agents to first-line chemotherapy regimens in the 1980’s improved overall response (OR) and complete response (CR) rates, and thus platinum doublet chemotherapy, most commonly in combination with etoposide, is the current standard of care.1 SCLC is initially very chemosensitive, OR rates to platinum-etoposide chemotherapy in the first line setting for limited disease (LD) are between 60-90% with CR rates of 40-70%2, and one third of patients will survive 5 years and be considered cured. The prognosis is far less optimistic for the two thirds of patients with SCLC who are diagnosed with extensive-stage (ES) disease. OR rates for ES SCLC are 40-70%2, and CR rates are 10-20%.3,4 The median progression-free survival (PFS) in the first-line setting is in the order of 15 months for LD5 and 6 months for ES.6

      Unfortunately, the high response rate seen in the first line setting is not maintained when patients are retreated. Patients can be classified into three groups based on their response to initial chemotherapy: sensitive (tumor response ≥ 90 days), resistant (recurrence within 90 days of completing primary therapy) and refractory (non-responders and progression on treatment).2 Therapeutic options therefore include re-challenge for those patients with sensitive disease or a change of regimen. Topotecan has been approved by the FDA since 1996 for the second-line treatment of SCLC following first-line relapse.7 There are additionally several guideline-recommended therapies that are not FDA/EMA approved, such as cyclophosphamide/doxorubicin/vincristine (CAV), irinotecan (Japan), docetaxel, paclitaxel, gemcitabine, temozolomide and nivolumab with ipilimumab.8 Response rates to second line therapy are 27% at best and less than 15% in chemo-refractory cases9, with a median time to progression of only 13 weeks.10 Despite decades of testing with multiple agents, there have been no new drug approvals in over 20 years and improved therapy is urgently needed.

      With the advent of targeted therapies over the past decades, there has been no shortage of early phase clinical trials in SCLC. However, these agents have yet to demonstrate success in phase II-III evaluation. The lack of progress in improving survival rates for SCLC led to its inclusion in the U.S. Congress’ Recalcitrant Cancer Research Act in 2012. Subsequent comprehensive molecular characterization of the disease has led to a better understanding of known molecular vulnerabilities and has pointed to new areas requiring therapeutic interrogation. Examples include developmental regulatory pathway abnormalities, DNA damage repair aberrations, and the manipulation of the immune response. Fundamental to further therapeutic progress remains the challenge of understanding the mechanisms that underlie the rapid emergence of chemo-resistance in SCLC. Recent reports of early phase clinical trials with immune checkpoint inhibitors documenting important response and survival rates, provide tangible hope for the approval of new treatment options. However, immune strategies should exclude the empiric testing of new monotherapies and combinations in the absence of strong pre-clinical science. This will necessitate the development of next generation pre-clinical models, that are biologically representative of the human immune system and disease. Finally, improved translational research will inform more rational clinical trial design, and concentrate resources towards the most promising therapeutic avenues.

      References:

      1. Sundstrøm S, Bremnes RM, Kaasa S, et al. Cisplatin and etoposide regimen is superior to cyclophosphamide, epirubicin, and vincristine regimen in small-cell lung cancer: Results from a randomized phase III trial with 5 years’ follow-up. J Clin Oncol. 2002;20(24):4665-4672. doi:10.1200/JCO.2002.12.111.

      2. Cheng S, Evans WK, Stys-Norman D, Shepherd FA. Chemotherapy for relapsed small cell lung cancer: A systematic review and practice guideline. J Thorac Oncol. 2007;2(4):348-354. doi:10.1097/01.JTO.0000263720.15062.51.

      3. Alvarado-Luna G, Morales-Espinosa D. Treatment for small cell lung cancer, where are we now?-a review. Transl lung cancer Res. 2016;5(1):26-38. doi:10.3978/j.issn.2218-6751.2016.01.13.

      4. Van Meerbeeck JP, Fennell DA, De Ruysscher DKM. Small-cell lung cancer. Lancet. 2011;378(9804):1741-1755. doi:10.1016/S0140-6736(11)60165-7.

      5. Faivre-Finn C, Snee M, Ashcroft L, et al. Concurrent once-daily versus twice-daily chemoradiotherapy in patients with limited-stage small-cell lung cancer (CONVERT): an open-label, phase 3, randomised, superiority trial. Lancet Oncol. 2017;18(8):1116-1125. doi:10.1016/S1470-2045(17)30318-2.

      6. Foster NR, Renfro LA, Schild SE, et al. Multitrial evaluation of progression-free survival as a surrogate end point for overall survival in first-line extensive-stage small-cell lung cancer. J Thorac Oncol. 2015;10(7):1099-1106. doi:10.1097/JTO.0000000000000548.

      7. Ardizzoni A, Hansen H, Dombernowsky P, et al. Topotecan, a new active drug in the second-line treatment of small-cell lung cancer: a phase II study in patients with refractory and sensitive disease. The European Organization for Research and Treatment of Cancer Early Clinical Studies Group and New Dr. J Clin Oncol. 1997;15(5):2090-2096. doi:10.1200/JCO.1997.15.5.2090.

      8. Sabari JK, Lok BH, Laird JH, Poirier JT, Rudin CM. Unravelling the biology of SCLC: implications for therapy. Nat Rev Clin Oncol. 2017. doi:10.1038/nrclinonc.2017.71.

      9. Owonikoko TK, Behera M, Chen Z, et al. A systematic analysis of efficacy of second-line chemotherapy in sensitive and refractory small-cell lung cancer. J Thorac Oncol. 2012;7(5):866-872. doi:10.1097/JTO.0b013e31824c7f4b.

      10. von Pawel J, Schiller JH, Shepherd FA, et al. Topotecan Versus Cyclophosphamide, Doxorubicin, and Vincristine for the Treatment of Recurrent Small-Cell Lung Cancer. J Clin Oncol. 1999;17(2):658-667.

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    MTE17 - Living with and Beyond Lung Cancer: An Education for Advocates (Ticketed Session) (ID 827)

    • Type: Meet the Expert Session
    • Track: Advocacy
    • Presentations: 1
    • Now Available
    • Moderators:
    • Coordinates: 9/25/2018, 07:00 - 08:00, Room 206 BD
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      MTE17.01 - Living with and Beyond Lung Cancer: An Education for Advocates (Now Available) (ID 11575)

      07:00 - 08:00  |  Presenting Author(s): Winfield Boerckel, Maureen Rigney  |  Author(s): Aoife McNamara

      • Abstract
      • Presentation
      • Slides

      Abstract

      Who is this session for?

      This session is aimed at lung cancer advocates, including members of healthcare teams and advocacy organisations. The session will be an interactive discussion on living with and beyond lung cancer. Key topics include an introduction to survivorship, issues for lung cancer survivors, interventions and a global discussion on how advocates can address the needs of lung cancer survivors in their country. The session will be jointly presented by both authors.

      Background:

      Lung cancer has been the most common cancer in the world for several decades with an estimated 1.8 million new cases in 2012 (IARC, 2018). Sadly lung cancer is the leading cause of cancer deaths worldwide. Every year, lung cancer causes more than 1.6 million deaths; more than breast, colon and prostate cancers combined (IASLC, 2015).

      However there are lung cancer survivors. According to the Concord study (2015) 5-year net survival from lung cancer is typically low, in the range of 10–20% for most geographical areas. This study is the most comprehensive international comparison of cancer survival to date, covering countries that are home to two-thirds of the world’s population and shows extremely wide differences in survival between countries.

      Anyone who has been diagnosed with cancer is a survivor – from the time of diagnosis to the end of life. Caregivers and family members are also cancer survivors (National Coalition for Cancer Survivorship, 1986). For the purpose of this session, we will focus on lung cancer patients who are post treatment.

      Unmet needs:

      The impact of a cancer diagnosis can evoke a range of emotions, anything from fear, anxiety, anger or denial. There is no right or wrong way to feel and patients often describe it as being on ‘an emotional rollercoaster.’ A study performed by Zabora et al. in 2001 examined the prevalence of psychological distress by cancer site and found considerable variation. Of the patients surveyed, 43% of lung cancer patients experienced elevated levels of distress in comparison to 32% of breast cancer patients, 31% of bowel cancer patients and 30% of prostate cancer patients. Numerous studies have since replicated these results. And being off treatment does not imply less distress for lung cancer survivors (Eichler, 2018).

      Lung cancer survivors' health related quality of life is generally low; therefore, management is crucial during the posttreatment period. The experience of having unmet supportive care needs is most strongly associated with intrusive cancer-related thoughts, limitations in physical functioning, distress associated with physical symptoms, and health-care satisfaction (Sanders et al., 2010).

      Issues for post treatment survivors:

      The concept of quality of life has become a core concern for many healthcare professionals (Brennan, 2004). Surviving cancer does not always result in a return to ‘normal life’. The impact of a diagnosis can affect the overall quality of life of a survivor, including physically, psychologically and socially (Ivers, M. et al., 2009). For the purpose of this presentation, we will focus on post-treatment survivors and outline concerns real lung cancer survivors have expressed, including:

      Expectations

      Avoiding Triggers

      Anxiety Volume

      Guilt

      The Meaning of My Lung Cancer Experience

      Who/What Am I

      Social Disconnections

      Vulnerability

      Interventions:

      Psychosocial interventions with cancer patients usually focus on adaption and adjustment to diagnosis and treatment, helping the patient to engage in behaviours that are more conducive to better health (Neuz & Neuz, 2007). We will outline a variety of interventions that are successfully used to support lung cancer patients, including:

      CBT

      Focusing on Current Facts

      Staying In the Moment

      Talk Therapy

      Managing and Creating New Expectations

      Lowering the Anxiety Volume

      Re/Building Self-Esteem

      Socialization Exercises

      Global variations:

      There are wide variations in survival rates globally and this in turn impacts the work priorities of advocates. Both authors will present on lung cancer survival in their own country, demonstrating different unmet needs and priorities. The audience will then be invited to discuss key survivorship concerns within their organisations and given an opportunity to share their own survivorship initiatives and projects.

      Conclusion:

      Following group discussion, the authors will present some top tips on advocating for lung cancer survivors and direct the audience to useful resources.

      References:

      IARC (2018) Globocan 2012: Estimated Cancer Incidence, Mortality and Prevalence Worldwide. Available at: http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx

      IASLC (2015) 2015 Lung Cancer Factsheet. Available at: https://www.iaslc.org/lung-cancer-fact-sheet-2015-europe

      Allemani, C. et al. (2015) Global surveillance of cancer survival 1995 – 2009: analysis of individual data for 25 676 887 patients from 279 population-based registries in 67 countries (CONCORD-2). The Lancet, 385, March 14, 2015. Available at: https://www.ncri.ie/sites/ncri/files/pubs/papers/Globalsurveillance_CONCORD2.pdf

      National Coalition for Cancer Survivorship (1986) NCCS Charter. Available at: https://www.canceradvocacy.org/news/defining-cancer-survivorship/

      Zabora et al. (2001) The prevalence of Psychological Distress by cancer site. Psycho-Oncology, 10, 19 – 28.

      Sanders, SL. Et al. (2010) Supportive care needs in patients with lung cancer. Psycho-Oncology 19 (5) 480‐489.

      Eichler, M. et al. (2018) Psychological distress in lung cancer survivors at least 1 year after diagnosis—Results of a German multi-center cross sectional study. Psycho‐Oncology. 1–7.

      Brennan, J. (2004). Cancer in Context: A practical guide to supportive care. Oxford: Oxford University Press.

      Ivers, M., Dooley, B. & Bates, U. (2009) Development, Implementation and Evaluation of a Multidisciplinary Cancer Rehabilitation Programme. The CANSURVIVOR Project: meeting post-treatment cancer survivors’ needs. Dublin: Health Service Executive.

      Nezu, A.M., & Nezu, C.M. (2007). Psychological distress, depression and anxiety. In M.Feuerstein (Ed.), Handbook of cancer survivorship (pp. 323-338). New York: Springer.

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    MTE18 - Case-Based Management of Patients with Inadequate Tissue for Molecular Tests (Ticketed Session) (ID 828)

    • Type: Meet the Expert Session
    • Track: Advanced NSCLC
    • Presentations: 1
    • Now Available
    • Moderators:
    • Coordinates: 9/25/2018, 07:00 - 08:00, Room 201 F
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      MTE18.01 - Case-Based Management of Patients with Inadequate Tissue for Molecular Tests (Now Available) (ID 11577)

      07:00 - 08:00  |  Presenting Author(s): Benjamin P Levy, Adrian Sacher

      • Abstract
      • Presentation
      • Slides

      Abstract

      Plasma genotyping has rapidly evolved from an investigational technology into a standard-of-care tool with the potential to direct therapy in metastatic non-small cell lung cancer (NSCLC). Tissue genotyping has historically been considered the gold standard for genotyping in NSCLC both at initial diagnosis and acquired resistance to therapy. However, plasma genotyping is increasingly useful as a rapid alternative to tissue genotyping in certain clinical contexts. This technology is particularly applicable in patients with insufficient tissue available for genotyping at initial diagnosis as well as at the development of acquired resistance. The optimal use and interpretation of plasma genotyping requires understanding of cell-free DNA (cfDNA) biology, assay characteristics and the application of testing in different clinical scenarios.

      In newly diagnosed metastatic NSCLC, plasma genotyping is useful for the detection of targetable genomic alterations or non-targetable driver alterations (eg, KRAS) that are mutually exclusive with targetable alterations. The potential utility of plasma genotyping in newly diagnosed patients is particularly pronounced in patients with insufficient tissue from their diagnostic biopsies for genotyping, those with inaccessible or difficult to biopsy lesions and patients in which rapid initiation of treatment is needed due to clinical deterioration. The high positive predictive value of most modern plasma genotyping platforms for the detection of targetable genomic alterations means that positive results can be used to rapidly guide initial targeted therapy in metastatic NSCLC patients. However, the modest sensitivity of these assays requires that negative results be confirmed by tissue genotyping with repeat biopsy, if necessary.

      In patients with acquired resistance to targeted therapy, plasma genotyping can be utilized to detect resistance mutations at the time of progression. Furthermore, plasma genotyping may detect resistance mutations missed by standard tissue genotyping in this context due to tumor heterogeneity. Plasma T790M testing in patients with acquired resistance to first- and second-generation EGFR kinase inhibitors has been utilized extensively for selecting patients for treatment with second-line osimertinib. However, the utility of this technology in acquired resistance to EGFR therapy is likely to decrease as more patients are treated with front-line osimertinib without a targeted therapy option at development of acquired resistance. The recent explosion of multiple treatments for ALK acquired resistance has opened a new opportunity to apply plasma genotyping technology for the selection of second-line targeted therapy in these patients.

      While cfDNA technology has aided in the detection of actionable mutations, there remain challenges at present related to modest assay sensitivity, standardization of both analytic and clinical validation across testing platforms and adapting this technology to the ever-changing treatment landscape of metastatic NSCLC. In addition, DNA captured in plasma may be from multiple sources other than tumor, including germline, fetal, post-organ transplantation and clonal hematopoiesis of indeterminate potential (CHiP). These mixed sources have been routinely detected in commercial-based assays and can affect the interpretability of assay results.

      Despite potential limitations, cfDNA platforms offer immense promise in serving as an accurate molecular proxy for tumor biology. There is considerable potential for plasma genotyping in the detection of early-stage disease and for patients at risk for disease recurrence post curative intent therapy. In addition, there may be future utility with these assays in the detection of tumor mutational burden (TMB) and other predictive biomarkers of immunotherapy. Future prospective efforts that mandate plasma interrogation both as a static and dynamic biomarker will enable a firmer understanding of how best to utilize this unique technology.

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    SH01 - Highlight of the Previous Day Sessions (ID 884)

    • Type: Highlight of the Day Session
    • Track:
    • Presentations: 4
    • Now Available
    • Moderators:
    • Coordinates: 9/25/2018, 07:00 - 08:00, Plenary Hall
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    SH02 - Highlight of the Previous Day Sessions (ID 994)

    • Type: Highlight of the Day Session
    • Track:
    • Presentations: 4
    • Now Available
    • Moderators:
    • Coordinates: 9/25/2018, 07:00 - 08:00, Room 202 BD
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    PL02 - Presidential Symposium - Top 5 Abstracts (ID 850)

    • Type: Plenary Session
    • Track: Advanced NSCLC
    • Presentations: 10
    • Now Available
    • Moderators:
    • Coordinates: 9/25/2018, 08:15 - 09:45, Plenary Hall
      • Abstract
      • Presentation
      • Slides

      Background

      In the global, Phase 3 PACIFIC study (Antonia 2017; NCT02125461), durvalumab significantly improved progression-free survival (PFS) versus placebo in Stage III, unresectable NSCLC patients without progression after chemoradiotherapy (CRT) (stratified HR, 0.52; 95% CI, 0.42–0.65; P<0.001). This was the first major advance in this disease setting for many years. Here we report the second primary endpoint overall survival (OS) for PACIFIC.

      Patients with WHO PS 0/1 (any PD-L1 tumor status) who received ≥2 cycles of platinum-based CRT were randomized (2:1) 1–42 days post-CRT to durvalumab 10 mg/kg IV Q2W or placebo up to 12 months, stratified by age, sex, and smoking history. Primary endpoints were PFS from randomization (blinded independent central review; RECIST v1.1) and OS (interim analysis reported). Secondary endpoints included time to death or distant metastasis (TTDM) and PFS2 (time to second progression) from randomization and safety. Time to first/second subsequent therapy or death (TFST/TSST) were supportive assessments for PFS/PFS2.

      Between May 2014 and April 2016, 713 patients were randomized of whom 709 received treatment (durvalumab, n=473; placebo, n=236). As of March 22, 2018 (data cutoff), median follow-up duration was 25.2 months (range, 0.2–43.1). After discontinuation, 41.0% and 54.0% in the durvalumab and placebo groups received subsequent anticancer therapy; overall, 8.0% and 22.4% received additional immunotherapy. Durvalumab significantly improved OS versus placebo (stratified HR 0.68, 99.73% CI, 0.469–0.997; P=0.00251), with the median not reached (NR; 95% CI, 34.7 months–NR) and 28.7 months (95% CI, 22.9–NR), respectively. Durvalumab improved OS in all pre-specified subgroups. Updated PFS remained similar (stratified HR 0.51, 95% CI, 0.41–0.63), with medians of 17.2 and 5.6 months with durvalumab and placebo, respectively. Durvalumab improved the updated TTDM (stratified HR 0.53, 95% CI, 0.41–0.68), as well as PFS2 (stratified HR 0.58, 95% CI, 0.46–0.73), TFST (stratified HR 0.58, 95% CI, 0.47–0.72) and TSST (stratified HR 0.63, 95% CI, 0.50–0.79). Within the durvalumab and placebo groups, 30.5% and 26.1% had grade 3/4 any-causality AEs, 15.4% and 9.8% discontinued due to AEs, and no new safety signals were identified.

      Durvalumab demonstrated statistically significant and clinically meaningful improvement in OS compared with placebo, supported by secondary endpoints such as PFS2. PACIFIC is the first study to show a survival advantage following CRT in this population, providing compelling evidence for the unprecedented benefit of durvalumab treatment as the standard of care.

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      PL02.02 - Discussant - PL02.01 (Now Available) (ID 14736)

      08:25 - 08:30  |  Presenting Author(s): Everett E Vokes

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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      PL02.03 - Brigatinib vs Crizotinib in Patients With ALK Inhibitor-Naive Advanced ALK+ NSCLC: First Report of a Phase 3 Trial (ALTA-1L) (Now Available) (ID 11155)

      08:30 - 08:40  |  Presenting Author(s): Ross Camidge  |  Author(s): Hye Ryun Kim, Myung-Ju Ahn, James Chih-Hsin Yang, Ji-Youn Han, Jong-Seok Lee, Maximilian Johannes Hochmair, Jacky Yu-Chung Li, Gee-Chen Chang, Ki Hyeong Lee, Cesare Gridelli, Angelo Delmonte, Maria Rosario Garcia Campelo, Dong-Wan Kim, Alessandra Bearz, Frank Griesinger, Alessandro Morabito, Enriqueta Felip, Raffaele Califano, Sharmistha Ghosh, Alexander Spira, Scott N. Gettinger, Marcello Tiseo, Jeff Haney, David Kerstein, Sanjay Popat

      • Abstract
      • Presentation
      • Slides

      Background

      Brigatinib has robust efficacy in crizotinib-resistant ALK+ NSCLC, exhibiting median progression-free survival (mPFS) of 16.7 months. We report results of the first interim analysis from the ALTA-1L study of brigatinib vs crizotinib in ALK TKI-naive, ALK+ NSCLC (NCT02737501).

      This open-label, multicenter study enrolled patients with stage IIIB/IV ALK+ NSCLC based on local ALK testing (FDA approved/other). Eligible patients had ECOG PS 0–2, ≤1 prior systemic therapy for locally advanced/metastatic NSCLC, and no prior ALK inhibitor. Asymptomatic CNS metastases were allowed. All patients had systematic CNS imaging. Patients were randomized 1:1 to brigatinib 180 mg QD with 7-day lead-in at 90 mg or crizotinib 250 mg BID. Primary endpoint: blinded independent review committee (BIRC)-assessed PFS (RECIST v1.1). Secondary efficacy endpoints included BIRC-assessed objective response rate (ORR), intracranial ORR (iORR), and intracranial PFS (iPFS). Interim analyses were planned at 50% and 75% of planned PFS events (n=198).

      275 patients were randomized (brigatinib/crizotinib, n=137/138); median age (years) 58/60. 26%/27% received prior chemotherapy for advanced disease, and 29%/30% had baseline brain metastases. At data cut-off (19 February 2018), median follow-up brigatinib/crizotinib: 11.0/9.25 months; with 99 PFS events, brigatinib met the prespecified threshold for statistical superiority vs crizotinib in the primary endpoint, BIRC-assessed PFS (HR 0.49, 95% CI 0.33–0.74, log-rank P=0.0007); brigatinib mPFS was not reached (95% CI NR–NR) vs crizotinib 9.8 months (95% CI 9.0–12.9). Investigator-assessed PFS HR 0.45 (95% CI 0.30–0.68), log-rank P=0.0001. Table shows additional efficacy data. Most common treatment-emergent AEs grade ≥3: brigatinib: increased CPK (16.2%), increased lipase (13.2%), hypertension (9.6%); crizotinib: increased ALT (9.5%), AST (5.8%), and lipase (5.1%). Any grade ILD/pneumonitis: brigatinib, 3.7%; crizotinib, 2.2%. Discontinuations due to AE (brigatinib/crizotinib): 11.8%/8.8%.

      Brigatinib showed a statistically and clinically significant improvement in PFS compared with crizotinib in ALK inhibitor–naive ALK+ NSCLC.

      BIRC-Assessed Endpoint, %

      Brigatinib

      (n=137)

      Crizotinib

      (n=138)

      P-Value
      All patients
      ORRa 76 (68–83b) 73 (65–80b)
      Confirmed ORR 71 (62–78b) 60 (51–68b) 0.0678
      With any intracranial CNS metastases
      (n=43) (n=47)
      iORRa 79 (64–90b) 23 (12–38b)
      Confirmed iORR 67 (51–81b) 17 (8–31b) <0.0001
      Median iPFS, months NR (11–NRb) 6 (4–9b)
      1-year iPFS 67 (47–80b) 21 (6–42b)
      HR 0.27 (0.13–0.54) <0.0001c
      With measurable intracranial CNS metastases
      (n=18) (n=21)
      iORRa 83 (59–96b) 33 (15–57b)
      Confirmed iORR 78 (52–94b) 29 (11–52b) 0.0028
      aResponse, ≥1 assessment; b95% CI; cLog-rank.

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      PL02.04 - Discussant - PL02.03 (Now Available) (ID 14737)

      08:40 - 08:45  |  Presenting Author(s): Fiona Blackhall

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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      PL02.05 - Effects of Volume CT Lung Cancer Screening: Mortality Results of the NELSON Randomised-Controlled Population Based Trial (Now Available) (ID 14722)

      08:45 - 08:55  |  Presenting Author(s): Harry J De Koning  |  Author(s): Carlijn M. Van Der Aalst, Kevin ten Haaf, Matthijs Oudkerk

      • Abstract
      • Presentation
      • Slides

      Abstract

      The NELSON-trial is a population-based RCT using nodule volume management for referral, initiated to show a 25% LC mortality reduction in males at 10-years of follow-up.

      606,409 persons, aged 50-74, in the Netherlands and Leuven were sent a general questionnaire about risk factors, leading to 150,920 responders. 30,959 responders were eligible and invited to participate, of which 15,822 gave informed consent and were randomized (1:1). CT-screening was offered to study arm participants at baseline and 1, 3 and 5.5 years after randomization, whereas no screening was offered to control arm participants. Participant’s records were linked to national registries with 100% coverage regarding cancer diagnosis (Netherlands Cancer Registry), date of death (Centre for Genealogy) and cause of death (Statistics Netherlands). Medical files for deceased lung cancer patients up to 2013 were reviewed by an expert panel (blinded to study arm); cause of death reported by Statistics Netherlands was used thereafter. Follow up to 31.12.2015 comprised a minimum duration of 10 years for 98.7% enrolled (unless deceased). A pre-determined 9-year analysis was also considered due to dilution effects by screening design given growth rate of LC.

      CT screening compliance was 94% on average, leading to a total of 29,736 scans. In 9.1% of the participants additional CT scans within 2 months were performed to estimate nodule Volume Doubling Time, leading to an overall referral rate of 2.1% for suspicious nodules. Detection rates across the rounds varied between 0.8-1.0%, and 69% of screen-detected LC were detected at stage IA or B. 261 lung cancers (52 interval cancers) were detected before the 4th round. In a subset of analyzed patients, surgical treatment was 3 times significantly more prevalent in study LC patients than in control arm patients (67.7% versus 24.5%, p<0,001). In total 934 participants have died in the control arm (NL), versus 904 in the study arm (NL). In the Dutch female enrolled participants, the rate-ratio of dying from lung cancer was 0.73 at 10-years, and 0.58 at 9-years FU.

      The minimum 10-year FU for NELSON has been realized, and full data on incidence, mortality and cause of death are equally available for both arms. A (non- significant) 41.8% lung cancer mortality reduction has been achieved in the small subset of 2,382 Dutch women. Post-hoc analysis shows a 51.4% (p=0.04) LC mortality reduction at 8 years of FU. Data for the full cohort will be presented on behalf of NELSON-investigators.

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      PL02.06 - Discussant - PL02.05 (Now Available) (ID 14738)

      08:55 - 09:00  |  Presenting Author(s): John Kirkpatrick Field

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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      PL02.07 - IMpower 133: Primary PFS, OS and Safety in a PH1/3 Study of 1L Atezolizumab + Carboplatin + Etoposide in Extensive-Stage SCLC (Now Available) (ID 12892)

      09:00 - 09:10  |  Presenting Author(s): Stephen V Liu  |  Author(s): Aaron S. Mansfield, Aleksandra Szczesna, Libor Havel, Maciej Krzakowski, Maximilian Johannes Hochmair, Florian Huemer, Gyorgy Losonczy, Melissa L. Johnson, Makoto Nishio, Martin Reck, Tony S. Mok, Sivuonthanh Lam, David S. Shames, Juan Liu, Beiying Ding, Fairooz Kabbinavar, Wei Lin, Alan Sandler, Leora Horn

      • Abstract
      • Presentation
      • Slides

      Background

      First-line (1L) standard-of-care treatment for extensive-stage small cell lung cancer (ES-SCLC) is platinum (carboplatin or cisplatin) with etoposide. Despite high initial response rates, there has been limited progress in the last two decades and outcomes remain poor with a median overall survival (OS) of ~10 months. IMpower133 (NCT02763579), a global Phase 1/3, double-blind, randomized, placebo-controlled trial evaluated efficacy and safety of adding atezolizumab, a humanized monoclonal anti–PD-L1 antibody, or placebo to 1L carboplatin and etoposide in ES-SCLC.

      Patients with measurable (RECIST v1.1) ES-SCLC, ECOG performance status 0 or 1, who had not received prior systemic treatment for ES-SCLC were enrolled. PD-L1 immunohistochemical testing was not required. Patients were randomized 1:1 to receive four 21-day cycles of carboplatin (AUC 5 mg/mL/min IV, Day 1) plus etoposide (100 mg/m2 IV, Days 1-3) with either atezolizumab (1200 mg IV, Day 1) or placebo, followed by maintenance therapy with atezolizumab or placebo until intolerable toxicity or progressive disease per RECIST v1.1. Patients meeting predefined criteria could receive treatment beyond progression. Co-primary endpoints were OS and investigator-assessed progression-free survival (PFS). Adverse events (AEs) were graded per NCI-CTCAE v4.0. Blood-based tumor mutation burden (bTMB) was assessed using prespecified cutoffs of ≥16 vs. <16 and ≥10 vs. <10 mutations/Mb.

      In total, 201 patients were randomized to the atezolizumab group, and 202 to the placebo group. Median follow-up was 13.9 months. Median OS was 12.3 months in the atezolizumab group and 10.3 months in the placebo group (hazard ratio [HR] 0.70 [95% confidence interval (CI): 0.54, 0.91; P=0.0069]). Median PFS was 5.2 months and 4.3 months, respectively (HR 0.77 [95% CI: 0.62, 0.96; P=0.017]). OS and PFS benefits were consistent across key patient subgroups. Investigator-assessed confirmed objective response rates were 60.2% and 64.4% in the atezolizumab and placebo groups, respectively; median duration of response, 4.2 and 3.9 months. Exploratory analyses showed OS survival benefits in subgroups above and below prespecified bTMB cutoffs. Grade 3-4 treatment-related AEs were reported in 56.6% vs. 56.1% patients in atezolizumab vs. placebo groups, respectively; serious treatment-related AEs occurred in 22.7% and 18.9% patients, respectively.

      Addition of atezolizumab to carboplatin and etoposide provided a significant improvement in OS and PFS in 1L ES-SCLC in an all-comer patient population. No unexpected safety signals were identified. Atezolizumab plus carboplatin and etoposide may represent a new standard regimen for patients with untreated ES-SCLC.

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      PL02.08 - Discussant - PL02.07 (Now Available) (ID 14739)

      09:10 - 09:15  |  Presenting Author(s): Natasha B Leighl

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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      PL02.09 - Nintedanib + Pemetrexed/Cisplatin in Patients with Unresectable MPM: Phase III Results from the LUME-Meso Trial (Now Available) (ID 11192)

      09:15 - 09:25  |  Presenting Author(s): Giorgio Vittorio Scagliotti  |  Author(s): Rabab Gaafar, Anna K. Nowak, Takashi Nakano, Jan Van Meerbeeck, Sanjay Popat, Nicholas Vogelzang, Federica Grosso, Rasha Aboelhassan, Marko Jakopovic, Giovanni L Ceresoli, Paul Taylor, Francisco Orlandi, Dean A Fennell, Silvia Novello, Arnaud Scherpereel, Ute Von Wangenheim, Miyoung Kim, José Barrueco, Anne S. Tsao

      • Abstract
      • Presentation
      • Slides

      Background

      Nintedanib targets VEGFR 1–3, PDGFR α/β, FGFR 1–3, Src and Abl kinases, all implicated in malignant pleural mesothelioma (MPM) pathophysiology. This global Phase II/III, randomised, double-blind study investigated pemetrexed/cisplatin in combination with nintedanib or pemetrexed/cisplatin in combination with placebo, followed by nintedanib or placebo maintenance, in patients with unresectable MPM. In the double-blind, randomised Phase II part, nintedanib plus pemetrexed/cisplatin improved PFS vs placebo (HR=0.56; 95% CI: 0.34–0.91; p=0.017; median 9.4 vs 5.7 months).

      In Phase III, chemotherapy-naïve patients with epithelioid MPM (ECOG PS 0–1) were randomised 1:1 to receive up to six cycles of pemetrexed (500 mg/m2)/cisplatin (75 mg/m2) on Day 1, plus nintedanib (200 mg bid) or matched placebo on Days 2–21. After combination treatment, patients without disease progression received nintedanib or placebo maintenance. The primary endpoint (PFS by investigator assessment) and key secondary endpoint (OS) were planned to be analysed by hierarchical testing, with an interim OS analysis at the time of the primary PFS analysis. PFS was also assessed by independent central review. Based on the assumed treatment effect (HR=0.63), the study had 90% power to detect a statistically significant and clinically meaningful improvement in PFS.

      In total, 458 patients were randomised. Baseline patient characteristics and oncological history were similar between treatment arms. Median duration of nintedanib or placebo administration was 5.3 and 5.1 months, respectively. After 250 events, there was no difference in PFS between nintedanib and placebo arms (HR=1.01; 95% CI: 0.79–1.30; p=0.91; median 6.8 vs 7.0 months, respectively). PFS by central independent review was similar (242 events; HR=0.99; 95% CI: 0.77–1.28; p=0.96; median 6.8 months in each arm). In the interim OS analysis (127 deaths [28% of events]), median OS was 14.4 vs 16.1 months (nintedanib vs placebo; HR=1.12; 95% CI: 0.79–1.58; p=0.54). There were no unexpected safety findings. The proportion of patients with Grade ≥3 AEs was higher with nintedanib than with placebo (72% vs 62%). The most frequently reported Grade ≥3 AE by medical concept in both treatment arms was neutropenia (nintedanib: 32%; placebo: 24%). The proportion of deaths due to serious AEs was 4.0% (nintedanib) and 7.5% (placebo).

      The primary endpoint of the Phase III part of LUME-Meso was not met ‒ Phase II findings were not confirmed. The reported safety profile was consistent with the known safety profiles of nintedanib and pemetrexed/cisplatin.

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      PL02.10 - Discussant - PL02.09 (Now Available) (ID 14740)

      09:25 - 09:30  |  Presenting Author(s): Ross Soo

      • Abstract
      • Presentation
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      Abstract not provided

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    PR02 - Press Conference (ID 1000)

    • Type: Press Conference
    • Track:
    • Presentations: 0
    • Now Available
    • Moderators:
    • Coordinates: 9/25/2018, 09:45 - 10:30, Plenary Hall
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    ES02 - Quality Care in Lung Cancer (ID 770)

    • Type: Educational Session
    • Track: Nursing and Allied Professionals
    • Presentations: 5
    • Now Available
    • Moderators:
    • Coordinates: 9/25/2018, 10:30 - 12:00, Room 206 BD
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      ES02.01 - Expanding PROs in Daily Practice (Now Available) (ID 11356)

      10:30 - 10:45  |  Presenting Author(s): Kahren White

      • Abstract
      • Presentation
      • Slides

      Abstract

      Lung cancer remains the leading cause of cancer deaths internationally (1). There have been recent improvements in the early diagnosis of lung cancer, with the implementation of lung cancer screening programs in a number of countries and the addition of targeted therapies, which may improve progression free survival for some patients. However, mortality remains high and people living with a lung cancer diagnosis have some of the highest symptom burden experienced across all cancer diagnoses (1,2).

      Patient reported outcome measures (PROs) can be defined as “any report on the status of a patient’s health condition that comes directly from the patient, without interpretation of the patient’s response by a clinician or anyone else” (3). PROs have been systematically embedded into clinical trials to track side effects and to measure the health related quality of life (HRQOL) of participants. Internationally we are seeing the use of PROs moving into daily clinical practice (4, 5). What are the benefits of using PROs in clinical practice and can they be introduced and embedded into daily practice?

      PROs can allow patients to highlight to their health care team their current physical and psychosocial issues. In a short clinic appointment with a health care provider the patient may not feel there is time to discuss the most important issues that are affecting them. The health care professional may not ask to right questions to understand the key issues for that person at that time in the context of a short clinic appointment. What is an issue for the patient may not be what the health professional perceives is an issue, leading to barriers in providing truly patient centred care and ensuring shared decision making (6). The utilisation of PROs prior to a clinic appointment can facilitate the therapeutic conversation to ensure the main issues for the patient are addressed at that time.

      The use of PROs recorded directly into the electronic health record can facilitate communication with the health care team through the receipt of notifications about patient symptoms and function. This can facilitate the management of patient’s symptoms in real time, also allowing for the review longitudinal data about a patients PROs over time (7). An RCT into systematic electronic collection of PROs during chemotherapy treatment with automated health care professional e-alerts found the intervention group had better HRQOL, fewer emergency visits and hospitalisations, as well as improved quality-adjusted survival (8).

      The European Organisation for Research and the Treatment of Cancer (EORTC) QLQ-C30 and the Functional Assessment of Cancer Therapy (FACT-G) are two of the most commonly used general PROs. Both of these PROs have lung cancer subscales, with questions developed and validated for the lung cancer population. In New South Wales, Australia the Edmonton Symptom Assessment Scale (ESAS) and the Hospital Anxiety and Depression Scale (HADS) are being piloted for collection electronically into oncology medical information systems across the state as part of the state-wide collection of PROs in a number of chronic health conditions. Information from these scales will be available for health professionals at the point of care and will also be linked to the NSW Cancer Registry to allow for longitudinal analysis of PROs with specific cancer treatment protocols. The International Consortium for Health Outcomes Measurement (ICHOM) have also developed a lung cancer standard set, using the EORTC QLQ-C30 and EORTC QLQ-LC13 as measures of the degree of health for people with a lung cancer diagnosis (9).

      With the increasing use of technology, linked e-health records and the understanding of the benefit of the use of PROs in clinical practice cancer centres should be implementing PROs as standard practice in clinical care. This will ensure health care professionals are able to identify and address physical and psychosocial issues for people living with lung cancer at the point of care.

      References:

      1. Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. International journal of cancer. 2015;136(5):E359-86.

      2. Mohan A, Singh P, Singh S, Goyal A, Pathak A, Mohan C, et al. Quality of life in lung cancer patients: impact of baseline clinical profile and respiratory status. Eur J Cancer Care (Engl). 2007;16(3):268-76.

      3. U.S. Department of Health and Human Services. Guidance for industry patient-reported outcome measures: Use in medical product development to support labeling claims. Silver Spring, MD: Food and Drug Administration; 2009.

      4. Chen J, Ou L, Hollis SJ. A systematic review of the impact of routine collection of patient reported outcome measures on patients, providers and health organisations in an oncologic setting. BMC Health Serv Res. 2013;13:211.

      5. Girgis A, Durcinoska I, Levesque JV, Gerges M, Sandell T, Arnold A, et al. eHealth System for Collecting and Utilizing Patient Reported Outcome Measures for Personalized Treatment and Care (PROMPT-Care) Among Cancer Patients: Mixed Methods Approach to Evaluate Feasibility and Acceptability. Journal of Medical Internet Research. 2017;19(10):e330.

      6. Büttner M, Zebralla V, Dietz A, Singer S. Quality of Life Measurements: Any Value for Clinical Practice? Current Treatment Options in Oncology. 2017;18(5):30.

      7. Basch E. Patient-reported outcomes - Harnessing patients' voices to improve clinical care. New England Journal of Medicine. 2017;372(2):105-8.

      8. Basch E, Deal AM, Kris MG, Scher HI, Hudis CA, Sabbatini P, et al. Symptom Monitoring With Patient-Reported Outcomes During Routine Cancer Treatment: A Randomized Controlled Trial. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2016;34(6):557-65.

      9. International Consortium for Health Outcomes Measurement. Lung cancer data collection reference guide. International Consortium for Health Outcomes Measurement; 2017.

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      ES02.02 - PRO: To Medicate: Managing Breathlessness (Now Available) (ID 11357)

      10:45 - 11:00  |  Presenting Author(s): Alexandre Chan

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      Abstract

      Breathlessness is a severe symptom that is associated with suffering at end of life. Moderate to severe breathlessness is observed in 20-80% advanced cancer patients, and this symptom is considered as a poor prognostic factor. Currently, opioids (such as morphine) are widely used as first line treatment for reducing the severity of breathlessness in advanced cancer patients. In this session, I will discuss the clinical evidence, involving both efficacy and safety aspects, supporting the routine use of opioids for managing breathlessness.

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      ES02.03 - CON: Not to Medicate: Managing Breathlessness (Now Available) (ID 11358)

      11:00 - 11:15  |  Presenting Author(s): Catherine L Granger

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      Abstract

      This presentation will discuss dyspnoea in lung cancer with a focus on non-pharmacological management strategies. Lung cancer is associated with high disease burden and physical hardship. People with lung cancer experience complex symptoms, which can include dyspnoea, fatigue, cough and pain. In lung cancer, multimorbidity is also common, particularly chronic obstructive pulmonary disease (COPD) which is seen in 40-70% of patients, and itself is also associated with chronic dyspnoea.

      Dyspnoea is the “subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity and vary in their unpleasantness and in their emotional and behavioral significance” [1, 2]. It is common in lung cancer, affecting up to 60% of patients. It varies in intensity and is associated with significant unpleasantness [3]. A recent systematic review found that the distress associated with dyspnoea in lung cancer is variable, and there does not appear to be a relationship to disease stage [3]. There are a wide variety of instruments available to measure dyspnoea. It is recommended that assessment includes intensity and sensory quality, distress or unpleasantness, and impact on health-related quality of life [1].

      Dyspnoea results in an emotional response and functional consequences [4], including distress and interference with daily activities [5]. Avoidance of triggers, including avoiding physical activity, promotes a vicious cycle of inactivity and functional decline [6]. Whilst the initial focus of managing dyspnoea is to optimise medical and pharmacological management of the underlying lung cancer and comorbid conditions, if dyspnoea persists, there are a range of non-pharmacological strategies that can be considered.

      There is high level evidence that pulmonary rehabilitation reduces dyspnoea in chronic respiratory diseases, particularly COPD and interstitial lung disease [7]. Similarly, in chronic heart failure, cardiac rehabilitation is also effective at reducing dyspnoea [7]. These outpatient-based exercise rehabilitation programs usually run for 6 to 12 weeks in duration, and include aerobic and resistance exercise training, education and behaviour change. They are associated with reduced self-reported dyspnoea, reduced exertional dyspnoea during exercise, and improved exercise tolerance [1]. The mechanisms in which exercise is thought to reduce dyspnoea in these settings is through system efficiency, reduced dynamic hyperinflation and reduced sensitivity to dyspnoea.

      There are a range of other strategies for dyspnoea which have been used in a variety of conditions. For short term relief, there is high level evidence for the use of chest wall vibration or walking aids (such as walking frames) [8]. Other strategies, with lower-level or unclear evidence, include breathing exercises (such as pursed lip breathing, breathing control and inspiratory muscle training), music, hand-held fans and acupuncture [8].

      Specifically in lung cancer there is less research regarding non-pharmacological interventions for dyspnoea. In lung cancer, there is growing evidence supporting the role of pulmonary rehabilitation to improve a number of patient outcomes including exercise capacity, muscle strength and fatigue [9]. Studies consistently demonstrate that pulmonary rehabilitation can be applied safely and effectively at all stages of disease [9]. In terms of improving dyspnoea, pulmonary rehabilitation and exercise programs have been shown to be effective, however the impact on dyspnoea has only been studied in a small number of studies to date [10].

      Complex interventions for dyspnoea in lung cancer have been successfully tested in a small number of randomised controlled trials. These interventions use a combination of techniques such as patient and carer education, breathing control, activity pacing, relaxation techniques, hand-held fans, psychosocial support and multi-disciplinary input, and are run through nursing or breathlessness clinics.

      Despite promising evidence regarding the use of non-pharmacological interventions for dyspnoea in lung cancer, these have not been sufficiently implemented into practice [4]. A number of barriers exist including lack of funding for services, the current structure of the multi-disciplinary team, and the need for adequate staff training [4]. Further work is needed to look at how such services can be embedded into lung cancer care.

      References

      1. Parshall, M., et al., An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med, 2012. 185(4): p. 435-52.

      2. Banzett, R., et al., Multidimensional Dyspnea Profile: an instrument for clinical and laboratory research. Eur Respir J, 2015. 45(6): p. 1681-91.

      3. Kathiresan, G. et al., Dyspnea in lung cancer patients: a systematic review. Lung Cancer, 2010. 1: p. 141-150.

      4. Johnson, M. and D. Currow, Treating breathlessness in lung cancer patients: the potential of breathing training. Expert Review of Respiratory Medicine 2016. 10(3): p. 241-243.

      5. Cheville, A., et al., The value of a symptom cluster of fatigue, dyspnea, and cough in predicting clinical outcomes in lung cancer survivors. Journal of Pain and Symptom Management, 2011. 42(2): p. 213-221.

      6. Granger, C., et al., Low physical activity levels and functional decline in individuals with lung cancer. Lung Cancer, 2014. 83(2): p. 292-299.

      7. Man, W., et al., Building consensus for provision of breathlessness rehabilitation for patients with chronic obstructive pulmonary disease and chronic heart failure. Chronic Respiratory Disease, 2016. 13(3): p. 229-239.

      8. Bausewein, C., et al., Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database Syst Rev, 2008(2): p. Cd005623.

      9. Granger, C., Physiotherapy management of lung cancer. Journal of Physiotherapy, 2016. 62(2): p. 60-67.

      10. Bade, B., et al., Increasing physical activity and exercise in lung cancer: reviewing safety, benefits, and application. J Thorac Oncol, 2015. 10(6): p. 861-71.

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      ES02.04 - Molecular Testing 101 for Nurses (Now Available) (ID 11359)

      11:15 - 11:30  |  Presenting Author(s): Beth Eaby-Sandy

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      Abstract

      Molecular testing in NSCLC is now a standard of care for newly diagnosed non-squamous NSCLC. There are guidelines detailing the appropriate population to test and which tests should be preformed. However, several barriers exist to testing including both medical as well as administrative, making testing rates less than optimal. Several testing platforms exist, and vary internationally.

      Other challenges for nurses include interpretting the testing results and relaying appropriate information to patients. Also, counseling patients on the value of waiting for results of testing prior to starting therapy can be difficult, and is often performed by the oncology nurse. Utilization of a clinical tissue navigator can make this process more seamless and ensure testing is performed.

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      ES02.05 - Structured Approach For Developing and Implementing and Advanced Practice Nursing Role in Lung Cancer (Now Available) (ID 11360)

      11:30 - 11:45  |  Presenting Author(s): Andrea Serena  |  Author(s): Solange Peters, Manuela Eicher

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      Abstract

      Background: Lung cancer patients experience significant physical symptoms, psychological distress and have many supportive care needs impacting their quality of life. In recognition of the complex health needs of patients with lung cancer and the European Partnership for Action Against Cancer recommendations, the University Hospital of Lausanne (CHUV) (Switzerland) aimed to integrate an Advanced Practice Nurse in Lung Cancer (APNLC) within the specialized Multidisciplinary Team (MDT) of the Thoracic Cancer Center. To date, there are limited data on the effectiveness of APNLC interventions for improving lung cancer patient outcomes. Introducing a new Advanced Practice Nursing (APN) role is a complex process and the full integration of this role depends both on successful role development and implementation. International recommendations for developing APN roles recommend pilot testing to assess the feasibility and acceptability of novel APN roles prior to formally assessing the effectiveness of the these roles for patients, providers and organizations. This study aimed to 1) develop and implement an APNLC role within the context of the CHUV Thoracic Cancer Center, 2) explore the acceptability of the new APNLC role from the perspective of a MDT and patients cared for by the APNLC, 3) assess the feasibility of the APNLC consultations and the ability to collect patient-reported outcome measures (PROMs) during first-line treatment, 4) describe changes in self-efficacy for managing lung cancer-related symptoms, symptom intensity/burden and unmet supportive care needs of APNLC patients during first-line treatment.

      Methods: To develop and implement the APNLC role we employed the first 7 phases of the “The Participatory, Evidence-based, Patient-focused process for APN role development, implementation, and evaluation” (PEPPA framework). Focus groups were conducted with nurses (n=5 nurses) and physicians (n=6 physicians) to explore the acceptability of the APNLC role. Additionally, semi-structured interviews were conducted with lung cancer patients (n=4) and the APNLC. The others aims were addressed using a convenience sample of newly diagnosed lung cancer patients receiving systemic therapy with/without radiotherapy. In order to assess the feasibility of the APNLC consultations and the ability to collect PROMs, an exact single-stage phase II design was applied. The study was considered as feasible if at least 55% of patients received all the scheduled APNLC-led consultations and completed PROMs assessments at the three time-points [Baseline, T1 (between day 4-50) and T2 (between day 71-95)]. Descriptive statistics were used to summarize the data and mixed effect models was applied to explore changes in perceived self-efficacy for managing lung cancer-related symptoms, symptom intensity/burden and unmet supportive care needs during first-line treatment.

      Results: Following the first seven phases of the PEPPA framework, the APNLC role was designed based on consensus of key stakeholders within the MDT. The APNLC role focused on providing psychological support, enhancing symptom self-management as well as providing therapeutic education and information about disease/treatments to patients and families. The APNLC role is also tasked with facilitating communication and information exchange within the MDT to improve collaboration and promote continuity of care. The designed APNLC-led intervention included four systematic, alternate face-to-face/telephone consultations with lung cancer patients during first-line treatment. Three main themes emerged describing the acceptability of the APNLC role: “role identification”, “role-specific contributions” and “providing flexible service”. Physicians and patients alike clearly recognized the APNLC role and emphasized the contribution to continuity of care, providing psycho-social support and enabling symptom self-management. Oncology nurses within the MDT perceived the APNLC role as overlapping with their own role and they expressed concern about losing part of their traditional role. Flexibility in providing care was seen as strength of the APNLC role yet this also posed organizational challenges related to work-load. Among the 46 patients enrolled in the feasibility study, 35 met the feasibility criteria receiving the four APNLC consultations (76%, 95% CI: 0.61-0.87) and 26 completed PROMs assessments at the three timepoints (56%, 95% CI: 0.41-0.71). These initial findings were promising for the feasibility of APNLC consultations and the ability to collect PROMs during first-line treatment. Longitudinal analysis of patient outcomes showed a trend towards improved patient self-efficacy for managing symptoms between baseline and T1, which remained stable at T2. Notably, the intensity of predominant symptoms increased over time yet unmet information needs decreased significantly between baseline and T2 (OR= 0.15 [95% CI: 0.03-0.68] p<0.01).

      Discussion/Conclusions: For the first time in Switzerland, we describe the development process of an APNLC role within a multidisciplinary thoracic cancer team. Findings highlight the applicability and the utility of the PEPPA framework as a structured approach for developing and implementing new APNLC roles - particularly in the context of the Swiss health care system where APN roles are yet in early stages of development. Barriers identified during the implementation of the APNLC role were primarily related to intra-professional rather than inter-professional factors. In light of these observations of intra-professional tension, study results underscore the importance of developing a national definition of APN role and regulations guiding APN roles to support their expansion in the country and enhance acceptability of these roles. Initial results were promising in terms of feasibility suggesting that APNLC-led consultations were appropriate and perceived as beneficial for many patients. Indeed, implementation of the APNLC role in the MDT seems to contribute to the improvement and maintenance of patient’s perceived self-efficacy for managing symptoms and decreased unmet supportive care needs. However, to better support lung cancer patients in their symptoms self-management and decrease their symptom burden, findings of this research point to adjustments that could be made to improve the effectiveness of the APNLC role. First, we propose to adjust the dose of APNLC intervention by increasing the frequency and intensity of consultations. Second, we propose to develop an interdisciplinary approach involving joint APNLC-physicians consultations for managing complex lung cancer patients.

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