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SERIES EDITORIAL—PROLOGUE: LUNG CANCER PRACTICE, IMPLEMENTING EVIDENCE AROUND THE WORLD SERIES EDITORS: KWUN M. FONG AND NICO VAN ZANDWIJK
Update in lung cancer: Prologue to a modern review series Key words: bronchoscopy, early detection of genomics, lung cancer, non-small-cell lung carcinoma.
cancer,
Abbreviation: EGFR, epidermal growth factor receptor.
Many years ago, lung cancer was a rare disease. While tobacco control efforts have helped reduce the number of smokers in many jurisdictions, lung cancer sadly remains the biggest cause of cancer deaths in many countries. The huge reservoir of former smokers who have done the right thing and given up smoking but still have an elevated risk of developing lung cancer compared with never smokers means that numerically, lung cancer may be more frequently diagnosed in former than current smokers. Thus, contemporary lung cancer screening studies target people at high risk, such as those recruited to the largest randomized controlled trial of computed tomography screening, the United State National Cancer Institute National Lung Cancer Screening Trial.1,2 This was the first study to show a benefit on mortality from a screening modality and is hotly debated and discussed in terms of effectiveness, cost-effectiveness and implementation. In addition, advances in health technologies have resulted in new and improved ways of investigating suspected lung cancers. Such advances include endobronchial ultrasound, navigation bronchoscopy, ultrafine bronchoscopy and others. In addition to diagnostic improvements, staging continues to evolve and consolidate its place as the most important prognosticator and factor influencing treatment planning once a bronchogenic cancer has been diagnosed. The old paradigm of only needing to diagnose lung abnormalities as cancer versus benign, and nonsmall-cell lung carcinoma versus small-cell lung carcinoma is also challenged as molecular testing comes to the fore, given the demonstrable benefit from targeted agents such as epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors for those people whose cancers harbour activating EGFR mutations,3,4 and similarly for anaplastic lymphoma kinase inhibitors.5,6 On the other hand, chemotherapy alone or as adjuvant or in combination still remains a vital tool in the therapeutic armamentarium. Furthermore, the combination of systemic chemotherapy with molecular-based therapies and different forms of immune therapeutics are being evaluated. Therapeu© 2015 Asian Pacific Society of Respirology
tic innovations are not limited to systemic therapies; modern radiotherapy and surgical techniques should mean better local treatments, less toxicity and improved outcomes. Indeed, the complexity of diagnosis, pathological and molecular typing and systemic treatment choices mandates an effective multidisciplinary approach to lung cancer care, which more and more is becoming standard practice. How to do this well remains a challenge given the large numbers of lung cancer, especially in countries where there are significant rural and remote populations. We are a long way from making lung cancer a rare disease again, but the investment and modern innovations in the biomedical and technological domain are finally starting to bring benefit to the clinic. No longer can it be said that we have no effective prevention, screening and therapeutic strategies. Today, we can say to the patient and their families that we have effective treatments, and the challenge is to choose wisely those that will serve to benefit them in terms of patient-centred outcomes. Personalizing choices and the use of precision medicine for lung cancer is on the horizon, and it is incumbent on clinicians to keep abreast and learn how best to exploit these tools to benefit our patients. Genomics including next-gen or more accurately termed massively parallel sequencing is just starting to make its impact felt in the clinic.7,8 Thus, we commend to you this state of the art review series from key clinicians and scientists from around the world, who have toiled long and hard to help change the reputation of lung cancer being the biggest cause of cancer deaths in many parts of the world. It is our greatest pleasure to help Respirology introduce these timely educational reviews with the sincere hope that many lung cancer patients will benefit from our communal effort, coupled with the clinical skills and expertise of our readers. No one deserves lung cancer; every patient deserves effective treatment! Nico van Zandwijk1 MD, PhD, FRACP, FCCP and Kwun M. Fong2 MBBS(Lon), FRACP, PhD, FAPSR 1 Asbestos Diseases Research Institute, University of Sydney, Concord, New South Wales and 2University of Queensland Thoracic Research Centre, The Prince Charles Hospital, Brisbane, Queensland, Australia Respirology (2015) 20, 183–184 doi: 10.1111/resp.12457
184
REFERENCES 1 National Lung Screening Trial Research Team, Aberle DR, Adams AM, Berg CD, Black WC, Clapp JD, Fagerstrom RM, Gareen IF, Gatsonis C, Marcus PM et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N. Engl. J. Med. 2011; 365: 395–409. 2 Aberle DR, DeMello S, Berg CD, Black WC, Brewer B, Church TR, Clingan KL, Duan F, Fagerstrom RM, Gareen IF et al. Results of the two incidence screenings in the National Lung Screening Trial. N. Engl. J. Med. 2013; 369: 920–31. 3 Maemondo M, Inoue A, Kobayashi K, Sugawara S, Oizumi S, Isobe H, Gemma A, Harada M, Yoshizawa H, Kinoshita I et al. Gefitinib or chemotherapy for non-small-cell lung cancer with mutated EGFR. N. Engl. J. Med. 2010; 362: 2380–8.
Respirology (2015) 20, 183–184
4 Mok TS. Personalized medicine in lung cancer: what we need to know. Nat. Rev. Clin. Oncol. 2011; 8: 661–8. 5 Soda M, Choi YL, Enomoto M, Takada S, Yamashita Y, Ishikawa S, Fujiwara S, Watanabe H, Kurashina K, Hatanaka H et al. Identification of the transforming EML4-ALK fusion gene in non-smallcell lung cancer. Nature 2007; 448: 561–6. 6 Shaw AT, Solomon B. Targeting anaplastic lymphoma kinase in lung cancer. Clin. Cancer Res. 2011; 17: 2081–6. 7 Daniels M, Goh F, Wright CM, Sriram KB, Relan V, Clarke BE, Duhig EE, Bowman RV, Yang IA, Fong KM. Whole genome sequencing for lung cancer. J. Thorac. Dis. 2012; 4: 155– 63. 8 Daniels MG, Bowman RV, Yang IA, Govindan R, Fong KM. An emerging place for lung cancer genomics in 2013. J. Thorac. Dis. 2013; 5: S491–7.
© 2015 Asian Pacific Society of Respirology
SERIES EDITORIAL—PROLOGUE: LUNG CANCER PRACTICE, IMPLEMENTING EVIDENCE AROUND THE WORLD SERIES EDITORS: KWUN M. FONG AND NICO VAN ZANDWIJK
Update in lung cancer: Prologue to a modern review series Key words: bronchoscopy, early detection of genomics, lung cancer, non-small-cell lung carcinoma.
cancer,
Abbreviation: EGFR, epidermal growth factor receptor.
Many years ago, lung cancer was a rare disease. While tobacco control efforts have helped reduce the number of smokers in many jurisdictions, lung cancer sadly remains the biggest cause of cancer deaths in many countries. The huge reservoir of former smokers who have done the right thing and given up smoking but still have an elevated risk of developing lung cancer compared with never smokers means that numerically, lung cancer may be more frequently diagnosed in former than current smokers. Thus, contemporary lung cancer screening studies target people at high risk, such as those recruited to the largest randomized controlled trial of computed tomography screening, the United State National Cancer Institute National Lung Cancer Screening Trial.1,2 This was the first study to show a benefit on mortality from a screening modality and is hotly debated and discussed in terms of effectiveness, cost-effectiveness and implementation. In addition, advances in health technologies have resulted in new and improved ways of investigating suspected lung cancers. Such advances include endobronchial ultrasound, navigation bronchoscopy, ultrafine bronchoscopy and others. In addition to diagnostic improvements, staging continues to evolve and consolidate its place as the most important prognosticator and factor influencing treatment planning once a bronchogenic cancer has been diagnosed. The old paradigm of only needing to diagnose lung abnormalities as cancer versus benign, and nonsmall-cell lung carcinoma versus small-cell lung carcinoma is also challenged as molecular testing comes to the fore, given the demonstrable benefit from targeted agents such as epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors for those people whose cancers harbour activating EGFR mutations,3,4 and similarly for anaplastic lymphoma kinase inhibitors.5,6 On the other hand, chemotherapy alone or as adjuvant or in combination still remains a vital tool in the therapeutic armamentarium. Furthermore, the combination of systemic chemotherapy with molecular-based therapies and different forms of immune therapeutics are being evaluated. Therapeu© 2015 Asian Pacific Society of Respirology
tic innovations are not limited to systemic therapies; modern radiotherapy and surgical techniques should mean better local treatments, less toxicity and improved outcomes. Indeed, the complexity of diagnosis, pathological and molecular typing and systemic treatment choices mandates an effective multidisciplinary approach to lung cancer care, which more and more is becoming standard practice. How to do this well remains a challenge given the large numbers of lung cancer, especially in countries where there are significant rural and remote populations. We are a long way from making lung cancer a rare disease again, but the investment and modern innovations in the biomedical and technological domain are finally starting to bring benefit to the clinic. No longer can it be said that we have no effective prevention, screening and therapeutic strategies. Today, we can say to the patient and their families that we have effective treatments, and the challenge is to choose wisely those that will serve to benefit them in terms of patient-centred outcomes. Personalizing choices and the use of precision medicine for lung cancer is on the horizon, and it is incumbent on clinicians to keep abreast and learn how best to exploit these tools to benefit our patients. Genomics including next-gen or more accurately termed massively parallel sequencing is just starting to make its impact felt in the clinic.7,8 Thus, we commend to you this state of the art review series from key clinicians and scientists from around the world, who have toiled long and hard to help change the reputation of lung cancer being the biggest cause of cancer deaths in many parts of the world. It is our greatest pleasure to help Respirology introduce these timely educational reviews with the sincere hope that many lung cancer patients will benefit from our communal effort, coupled with the clinical skills and expertise of our readers. No one deserves lung cancer; every patient deserves effective treatment! Nico van Zandwijk1 MD, PhD, FRACP, FCCP and Kwun M. Fong2 MBBS(Lon), FRACP, PhD, FAPSR 1 Asbestos Diseases Research Institute, University of Sydney, Concord, New South Wales and 2University of Queensland Thoracic Research Centre, The Prince Charles Hospital, Brisbane, Queensland, Australia Respirology (2015) 20, 183–184 doi: 10.1111/resp.12457
184
REFERENCES 1 National Lung Screening Trial Research Team, Aberle DR, Adams AM, Berg CD, Black WC, Clapp JD, Fagerstrom RM, Gareen IF, Gatsonis C, Marcus PM et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N. Engl. J. Med. 2011; 365: 395–409. 2 Aberle DR, DeMello S, Berg CD, Black WC, Brewer B, Church TR, Clingan KL, Duan F, Fagerstrom RM, Gareen IF et al. Results of the two incidence screenings in the National Lung Screening Trial. N. Engl. J. Med. 2013; 369: 920–31. 3 Maemondo M, Inoue A, Kobayashi K, Sugawara S, Oizumi S, Isobe H, Gemma A, Harada M, Yoshizawa H, Kinoshita I et al. Gefitinib or chemotherapy for non-small-cell lung cancer with mutated EGFR. N. Engl. J. Med. 2010; 362: 2380–8.
Respirology (2015) 20, 183–184
4 Mok TS. Personalized medicine in lung cancer: what we need to know. Nat. Rev. Clin. Oncol. 2011; 8: 661–8. 5 Soda M, Choi YL, Enomoto M, Takada S, Yamashita Y, Ishikawa S, Fujiwara S, Watanabe H, Kurashina K, Hatanaka H et al. Identification of the transforming EML4-ALK fusion gene in non-smallcell lung cancer. Nature 2007; 448: 561–6. 6 Shaw AT, Solomon B. Targeting anaplastic lymphoma kinase in lung cancer. Clin. Cancer Res. 2011; 17: 2081–6. 7 Daniels M, Goh F, Wright CM, Sriram KB, Relan V, Clarke BE, Duhig EE, Bowman RV, Yang IA, Fong KM. Whole genome sequencing for lung cancer. J. Thorac. Dis. 2012; 4: 155– 63. 8 Daniels MG, Bowman RV, Yang IA, Govindan R, Fong KM. An emerging place for lung cancer genomics in 2013. J. Thorac. Dis. 2013; 5: S491–7.
© 2015 Asian Pacific Society of Respirology
