GRACE :: Lung Cancer

Screening Issues and Controversy

Screening debate, pros and cons

Panel Q&A Session on Patient Access and Survivorship

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Dr. Jack West, Brendan Bietry, and Janet Freeman-Daily take questions from the audience about financial assistance, legal protections, and patient support.

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Living with Lung Cancer

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Janet Freeman-Daily, a ROS1 lung cancer patient since 2011, talks about the importance of patients’ involvement in their own health care and the support that exists online to help patients navigate the system.

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Access & Assistance for ALK+, ROS1 & EGFR Patients

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Brendan Bietry of the Patient Advocate Foundation discusses the financial assistance programs available to lung cancer patients who receive targeted therapies.

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Time to Response to Immunotherapy and the Concept of Pseudoprogression

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Dr. Eddie Garon reviews the pattern of response to immunotherapy in lung cancer, along with the concept of “pseudoprogression”.

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So, we have seen, certainly, some variability in the time to response; we have seen some people who will even have palpable lesions that will shrink, you know, within days — although that is rare. In general, what we find is that, generally, somewhere around 6 to 8 weeks is when we see patients who are having response to drug. It tends to be quite rapid — when you look at the clinical data, you can see that probably most of the patients who have what we call a clinical response to these drugs, that response occurs probably at the first imaging analysis, usually somewhere about two months after starting. Although there has always been this sense that it will take a long period of time for someone to respond to an immune therapy, and that is true, for instance, compared to a standard chemotherapy, where the effects are often seen within a couple of weeks, here it tends to be delayed from that, but it doesn’t tend to be delayed for months and months.

One other important issue to address is this issue of pseudoprogression, and this is something that people in the immunotherapy field have talked about for a long time, that if you have an effective immunotherapy, that you may have immune cells that infiltrate into the tumor and, as a result, rather than getting smaller, that the tumor would actually get larger. That could certainly happen over a short period of time, but what I would say, to date, is it’s not something we’ve seen a lot in lung cancer. Our colleagues in melanoma certainly report this as being a significant issue — patients who will have initial growth of their tumor on imaging, and then, afterwards, will have shrinking. We certainly do have several intriguing anecdotes, sort of individual patients that people will describe who have had, sort of, increases in their tumor volume, but then get better, but I would say that it is actually quite uncommon in lung cancer.

What we do see with some frequency is someone who will develop a new lesion. So, for instance, maybe they’ll have three areas that you’re following, all of them will get a little bit better, but then you will find one area that is a new area, that’s, you know, a centimeter and a half, that shows up on scans. By our typical way of evaluating radiographs, we would consider that to be progression. In my clinic, and as part of clinical trials, we’ve incorporated sort of different evaluations, that have, in some cases, allowed patents in that setting to continue on therapy. And, what I would say is, in somebody who is feeling good, who has an ambiguous response, one like what I mentioned, where several areas got better, but one area is new, or one area grew while other areas got better, but is clinically doing well — it may be worth continuing that patient on drug. But, when I see patients in second opinion and things like that, I will say that I much more frequently tell them that it is time to stop the immune checkpoint inhibitor, than to continue and hope for pseudoprogression. That, I would say, is very rare to see; we treated 98 patients at UCLA on the KEYNOTE-001 study, and I can’t think of a single patient that had, what we would call, sort of a flare response, where everything on the scan got worse, and then subsequently got better. So, I can’t give you an exact percentage, but what I would say is that it is rare. The thing that’s going to be more important is trying to interpret some of these ambiguous radiographic responses, which can be seen, but if everything is getting worse on the scan, what I’ve told people is, almost certainly, it means that the drug is not working.


How Important is the Impact of Smoking Cessation on Survival?

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Drs. Ben Solomon, Leora Horn, & Jack West review impressive data demonstrating a striking survival improvement from successful efforts at smoking cessation among smokers undergoing lung cancer CT screening.

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Dr. West:  Finally, there’s a fair bit — we cover a lot of ground at the World Conference on Lung Cancer, and one of the topics that I think is good to have gotten airplay is smoking cessation, and tobacco interests and policy. I was surprised, and it was sobering to see a presentation at the Presidential Symposium that suggested that smoking cessation efforts, in the process of lung cancer screening, makes a bigger interest — has a bigger impact on patient survival, not necessarily from lung cancer, but potentially from cardiovascular issues, than picking up lung cancer. Were there things about the smoking cessation discussions during this meeting that had an impact for you, or that you found particularly surprising?

Dr. Solomon:  I’m not surprised with those findings, I think smoking has a huge range of detrimental health effects, even outside lung cancer — other types of cancer, as you pointed out, cardiovascular disease as well, and I think it’s important to have strong smoking cessation measures, both at the levels of doctors and patients, but also as a society, and at a governmental level. In Australia, we’ve recently introduced plain paper packaging of cigarettes, so instead of having very attractive, different colored cigarette boxes, the government has chosen that the nastiest shade of green, sort of a puke-colored, green-brown color, to wrap cigarette packets in now. Tobacco companies are taking the government to court because they know that it will impact on sales, but I think those sorts of measures together with, as unpopular as it may be, taxes on tobacco, are things that have real impacts on smoking rates in the population, and in young people.

Dr. West:  Yeah, absolutely. It turns out the biggest impact you can have is raising taxes, especially in young smokers. Your thoughts — anything to add?

Dr. Horn:  So, I think what Australia is doing is incredible, and I remember hearing about it at the last meeting. You know, the study that they presented with smoking cessation screening — the problem is, most patients who are being screened are over age 55, so they’ve been smoking for thirty years. And so, you know, the more that we can do to stop young people from ever starting is really going to be the key to reducing smoking-related cancers.

Dr. West:  Thank you so much for joining me.

Dr. Solomon: Thanks, Jack.

Dr. Horn: Thanks, Jack!


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