Jessica Donington, MD, MSCR: There is another factor that in 2021 plays a huge role in how we together determine initial treatment and treatment plans and that is called molecular testing. And that means taking the tumor and looking inside the tumor for what’s going on in the DNA of the tumor. And that’s because now we have a lot of molecular targeting drugs, drugs that were designed just for some of the mutations. And we also have cancer immunotherapies. But we need to know the DNA of the tumor to choose these treatments appropriately. And this is important, even for patients at an early stage, because we design a specific treatment for each patient.
Martin Dietrich, MD, Ph.D.: Getting back to how treatment will look like and its impact on quality of life and treatment options, in general terms, the early detection of lung cancer is often a coincidence. We aim to increase the screening rate for lung cancer in the same way we would encourage screening for breast and colorectal cancer. We especially know that for some high-risk patients, there is a place for lung cancer screening with an annual low-dose CT scan. [computed tomography]. There are pros and cons that need to be discussed. But in general terms, it’s a reasonable intervention that helps us catch cancer at an early stage. If we find cancer early in lung cancer, again there is a lot of discussion and planning, testing in advance to finalize the treatment plan for the disease. Obviously, surgery is still on the table. Radiation therapy and systemic therapy options that would involve chemotherapy, targeted therapy, and immunotherapy – all are now being combined. Ideally, you will find a table of experts for their respective specialties who simultaneously review the patient’s images, pathology and clinical condition and develop a common treatment plan. Early stage lung cancer doesn’t necessarily mean it’s easier to treat. And often the short term investment is quite large. We have made quite a bit of progress in treating early-stage lung cancer, surgical techniques have been significantly more refined, and endobronchial diagnostic approaches have been significantly better. I always tell my patients that when you have small robotic surgery it doesn’t mean it is small surgery because you are operating on a very large organ and you want to be sure you understand the anatomical extension. this certainly guides treatment options and radiation therapy under this consideration. And the impact of the radiation on the treatment is mainly guided by the organic structures that are nearby. Radiation therapists and radiation oncologists have improved a lot at delivering radiation in this precise way. But when you’ve spread to areas of lymph nodes, for example, you want to have precision blending by avoiding unnecessary tissue. And when I say scatter or wider distribution – because you are not covering one place but an entire field. Then the main concern here is usually irritation and inflammation of the digestive tract or esophagus, and swallowing issues are a problem. Other than that, it is very well tolerated. It is the localized collateral impact that determines the decision-making process for surgery and radiotherapy. I have to say that although most patients have a difficult time at some point for their treatment at an early stage, it is usually short-lived and can be recovered well. And it’s worth discovering early. This is a fair statement. When it comes to systemic therapy, as Dr Donington has already pointed out, molecular testing simply decides, in 2021, what your treatment will look like. At this point, we’re essentially looking at a genetic marker called EGFR first. [epidermal growth factor receptor]. If this is present, we would still consider chemotherapy, especially for high risk patients. But if a patient is not eligible for chemotherapy and chooses not to continue chemotherapy for personal reasons, then targeted therapy remains an option. We always knew that in the case of breast cancer for estrogen receptor positive disease, we would give an estrogen blocker for treatment after surgical resection, and we knew the patients would be better and their cancer would be better. would not come back or at least come back later. For EGFR, we have a similar EGFR blocker or inhibitor that can do similar things. Now not everyone has EGFR. That’s about 15-20%, depending on geography. We have many cancers that respond very well to immunotherapy. This has just been approved by the FDA [Food and Drug Administration] last month, options to introduce immunotherapy that was available for many years in stage 4 disease in early stage 1, 2 and 3 disease after surgery. There are many treatment options that can improve results and are well tolerated. It’s a bit of a mix, where you go from a very intense pace at the beginning where you control all the visible disease in a longer term, I call that the sprint and the marathon sequence of our patients, in systemic control disease thereafter. The prognosis of patients with early stage lung cancer, unfortunately, tells you that the systemic component is still of concern. That doesn’t mean you don’t want to remove the primary tumor, but you have to take into account that even in a stage 2 setting you are looking at, according to studies, you are looking at 30%, 40% disease recurrence. . And if you get into stage 3 of the disease, you can definitely see up to 70%, 80% of the patients coming back. This is a very high level of concern for the patients who have been treated. And if you have a chance after surgery to experience such a high recurrence of the disease, systemic therapy should be on the table for discussion and obviously should be tailored to your individual needs. We are very interested in immunotherapy, but again, not everyone qualifies for it. And these are risk factors. There are some pathological risk factors of lymph node size and involvement, followed by more refined histological features of pleural involvement and other microsatellites in the lungs. These are things your healthcare provider will discuss with you when making the decision for follow-up systemic therapy. We have a pretty good grasp and understand how high risk diseases are and what should be offered. In general terms, with the exception of very early stage disease, and Dr Donington mentioned the 4 cm [centimeter] tumors as a sort of threshold, unless you have a very small, isolated tumor, systemic therapy is on the table for discussion for virtually all early stage lung cancer at this stage.
Transcription edited for clarity.