Really wonderful to see so many
of you here and and virtually
thank you all so much for coming,
taking the time to to join
us for this this great event,
lung Cancer Awareness Month event.
We have I think a really amazing plan
for the evening and hopefully we'll be
able to educate you and enlighten you
and we can have some really great discussion.
We left lots of time at
the end for questions.
So, so really looking forward to
the evening to introduce myself,
I'm Sarah Goldberg,
I'm a medical oncologist.
Here I'm one of the thoracic oncologists,
most of the research director for
the Center for Thoracic Cancers and.
Let Dan introduce himself,
Dan Boffa. I'm one of the thoracic
surgeons and I'm the clinical
director for the thoracic disease
team and thank you for coming.
I I've heard we have something
like 10,000 people online that
maybe that may be an estimate,
there may be a couple of zeros off.
But the the whole point of this is to to
address questions and so that everybody
feels they know more about lung cancer,
lung cancer screening,
how we're doing and where we're going
then before you came here and so.
There's no question that's too off base.
I mean this is probably the 10th time we've,
I've been a part of event like this and we've
heard some really interesting questions.
I don't think we've ever heard
a really a bad question.
There is no bad question.
So please, if you're, if you're at home,
chat in your questions through
the chat function on zoom.
I'm going to be sitting in the corner
here monitoring chat diligently,
but after the speakers go we'll
open it up to questions.
If if something comes up during
a a talk and you're like,
I really need to know the answer to that,
you can interrupt the speakers.
It's OK.
We're they're intentionally short
talks and the people are used
to being interrupted.
So again,
thank you so much for coming.
OK. So I'm just going to give a
very brief introduction to who
we all are and what we're doing
here today and then we're going
to start with our our speakers.
OK. So first who we are we meaning
we mostly in the front row here,
so we are, we have a lot of different
people and have they who have different
specialties and different interests
and different roles in our team.
And I put in the middle of this this
figure as a Center for thoracic cancers.
That's kind of our umbrella term.
But as you can see, there's so many
different people that comprise our team.
You probably see if you're a patient here,
if you're a family member of a patient here,
you probably met many of these
people we have.
Dan and others at thoracic surgeons,
medical oncologist,
radiation oncologist, social workers,
research staff pathologist, I mean so
many different people comprise our team.
Here's a picture from a
couple of years ago now,
which isn't even our full team.
There's just so many people
who who kind of go into this,
this group that we call the
Center for thoracic cancers.
So where are we?
We're really all over the state of
Connecticut and also into Rhode Island.
You could see all the stars that have
all of our, our sent our centers.
This is our kind of main hub.
And and smilo in New Haven,
but so many different centers
providing care for lung cancer and
all different cancers all over
the state and into Rhode Island.
And so why are we here tonight?
We mentioned this a little bit already.
It's lung Cancer Awareness month.
This is a the ribbon that.
Denotes lung cancer awareness.
So it's clear or white I guess
is like the lung cancer color.
I'm not sure who made that one up but fine.
And I just wanted to show this.
So when I was looking I was trying
to find some some interesting things
to show about lung Cancer Awareness
Month and I found this online.
This was posted just a few days
ago and it's a proclamation on
national Lung Cancer Awareness
Month this year and it's probably
maybe a little too small to to read.
So I'll just read it for you.
It says during national
lung Cancer Awareness Month,
and this is from the White House,
we are inspired by the courage and
fight of the millions of patients.
Survivors, caregivers, doctors,
researchers,
and advocates battling this terrible disease,
the leading cause of cancer deaths
in the United States.
For the loved ones we have lost
and all those we we can save,
we recommit to investing in
cutting edge screening,
prevention and treatments.
Making them more affordable and
effective and uniting this country in
our movement to end cancer as we know it.
So I thought really nicely said
and really kind of highlights
what we're doing this month,
you know,
thinking about lung cancer and and
here tonight.
So here's the what's on the agenda
for the evening?
I and we we put this together because
we think it's some topics that are
really important and exciting and
we hope you will think so too.
First, we're going to hear from Lynn Tanui.
She's a pulmonologist here at Yale.
She's going to talk about the
latest on lung cancer screening.
Then we're going to hear about
personalized lung cancer treatment.
You could think about this
in a lot of different ways.
We'll hear from Gavitt Woodard,
who's a thoracic surgeon from Tom Heymann,
who's at the radiation
oncologist from Soyoung Kim,
a medical oncologist.
So across the spectrum of care,
thinking about personalized
lung cancer treatment.
Then we're going to hear from Scott
Gettinger, a medical and Cologist,
and Justin Blasberg,
a thoracic surgeon,
on how immune therapy has
impacted lung cancer.
And then last,
Rick Wilson is going to tell us about new
treatments on the horizon for lung cancer.
So again, the talks will be fairly short,
saving lots of time for questions.
So think about your questions.
If you're online, put them in the chat
and we'll be happy to answer them
either after each talk or at the end.
We'll have some time as well.
We also have some amazing people
in the audience, both in person.
Again, this like whole front area.
Here are people as part of the long team
and also some people who are virtual.
Here's a list of people that
we have joining us.
So you know who's here and so you
know who you can ask questions to.
We have,
I'll just kind of briefly go
through to introduce them.
Hallie Robinson,
you probably many of you know her.
She's our social worker.
She's here joining us.
Sonia Deistic is a pathologist here.
Lisa Fucito, I think she's online.
She's the director of the
Tobacco Treatment Service.
She also has some people from her team here.
Andrew Dennis Open is a thoracic surgeon.
He's up here in the front.
Vinnie Mays is also a thoracic surgeon.
Jennifer Possick is a
pulmonologist joining us.
Vita Gary I believe is online.
She's the chief of clinical cancer genetics.
So if you have questions about
genetics of lung cancer,
she's the person we can ask.
Anna Bader is the a radiologist
specializing in in thoracic radiology and
Chang is here towards the front here.
Hi Anne, a medical oncologist and Roy Herbst,
medical oncologist and chief
of medical oncology.
I believe he's joining us online as well.
So really an amazing.
Team,
it's really fun to see all of you in person.
I have to say we don't do this
enough and hopefully it will
spark some great discussions.
So I'm going to turn it over to Doctor Tenui,
AP pulmonologist we all look to,
to help us with our patients with lung
cancer and other pulmonary diseases
and expert on lung cancer screening.
So thank you so much, Lynn.
No questions on chat so far. That's good.
Hello, everyone.
It's really nice to see so many people here.
Before I get started,
I want to introduce Polly Sather.
Polly, if you just raise your hand,
who's our nurse practitioner who runs
the lung cancer screening program
and Christa Casey right next to her
who is our nurse who helps in the
screening program and actually really
facilitates our home any part of the
thoracic oncology program clinic.
So I'm going to talk to you very
briefly about lung cancer screening.
Sarah told me to just make
three slides and I did.
More, but everybody else
looks like they did more.
So I can at least follow some instructions.
So basically cancer screening
in general is done because it saves lives.
And the purpose of any screening,
whether it's blood pressure, cancer,
skin examinations, is really so
that we can detect disease early,
before there are any symptoms and before it
can cause harm and in the case of cancer.
We really wanted to detect cancer early,
before any symptoms occur
because symptoms often,
unfortunately indicate that the
cancer is starting to spreads.
We really want to find it at a time
when there are no symptoms that would
alert anybody that there is a problem.
And Sarah already told you that lung cancer.
Well, the White House told us that
a lung cancer is a leading cause
of cancer death in the United
States and actually in the world,
and 150,000 Americans will
die of lung cancer.
This year, 2022,
and actually 1.8 million people in the world.
And so this is a huge problem
that I think has not gotten as
much attention as it could have,
perhaps because of the stigma of smoking.
And yet a very large percentage of people
who didn't smoke do get lung cancer as well.
And we really need to destigmatize
the cigarette piece of it because
it's nobody's fault that they
smoked and it's definitely nobody's
fault that they get lung cancer.
And so the really important news this.
Check the last decade.
Scott Ganninger,
one of the medical oncologists.
The really important news about
screening is that it can happen.
And we've been waiting decades as lung
doctors for screening to become in
lung cancer because screening has been
an important part of identification
of early stage breast cancer,
colon cancer,
prostate cancer for a very long time.
It's embedded into most medical practices
and lung cancer was very late to this.
This sandbox essentially because
we were really looking at chest
X-ray as a screening tool and it
turns out that's not good enough.
And so there were huge studies done
in the United States and elsewhere in
the world showing that CT scanning.
Is actually a very effective
tool for lung cancer screening.
And the ability to use that as a
screening tool in healthy people really
relates to the fact that the amount of
radiation needed for a screening CT
scan for lung cancer is really small.
CT screening and CT scanning in general
doesn't invoke a lot of radiation exposure,
but lung cancer screening is very,
very little.
So that allowed us to use that
tool for lung cancer screening.
It turns out that it saves lives and in 2013,
the United States Preventive Services.
Task Force,
which is the agency that informs
Medicare on what Medicare should pay
for approved lung cancer screening.
And so we've really been trying to
get the word out that screening
for lung cancer is available,
it should be done.
It's really an easy test as low
dose CT takes less than 5 minutes.
It's one breath through the scanner.
It doesn't require anesthesia.
Doesn't require a blood draw.
So compared to colonoscopy,
for instance, it's a much,
much easier test and it's paid
for now for people who qualify.
And so of the currently 14 to
15 million people in the US to
qualify for lung cancer screening,
less than 10% eligible are
actually getting screened.
And I think we really need to use
opportunities like this to get the
word out that you should be screened
if you're at risk for lung cancer.
It's a much easier test than many
of the other lung cancer screening
examinations and and we really have
to do better at this if we're going to
impact those numbers of people dying.
Potentially unnecessarily from this disease.
So that I just want to show
you what we look like compared to
breast cancer, because the people
who have who are doing screening
and breast cancer now have been at
it for decades and the benefit from
screening is really evident when you
look at the breast cancer population.
They have pink ribbons.
I think you all know that.
And so if you look at this, this,
this chart on the left side,
the blue piece are the people
who are diagnosed at stage one.
This is like there's a small thing
in the breast often the woman
is not even aware of.
That gets picked up on mammography.
The green piece of this pie chart are
people who are diagnosed at stage two
where maybe there is one lymph node involved,
but it hasn't spread beyond that.
And people who have more advanced disease are
in the blue and purple pieces of this pine.
So you can see that the majority
of people who are women who are
diagnosed with breast cancer and a
few men are diagnosed at early stage.
And that has everything to do with
screening mammography and the really
important message that is not on this slide.
Is that those people in the blue,
they're five year survival after diagnosis
and treatment and that's kind of a
gold Standard Time point for cancers.
If you get to five years is a really
good chance you've had a cure.
It's 99%,
so 99% of people who are diagnosed
with breast cancer by mammography.
Essentially are cured.
That's unbelievable.
And the five year survival overall for
the entire breast cancer population
is more than 90% of five years.
In contrast that that blue
piece for lung cancer,
the early stages is only about 20%.
And then the people who have a small
cancer and maybe 1-1 lymph node
add a little bit more than that.
So we're only diagnosing 1/4 of
people with lung cancer at that
early stage where their,
the benefit from treatment is going
to be huge and their survival for
long term is going to be much,
much higher than unfortunately the
majority of people in the purple and
blue right now who are diagnosed at
early stage and my colleagues in
medical oncology have come a huge long way.
Treating patients with advanced disease,
that's a whole different landscape
that you're going to hear about that
has made phenomenal advances in,
in the last really decade, 15 years.
But it's this group that I think we
could do this simple intervention
for where we could really change
the landscape of lung cancer and
make it turn into what breast cancer
now is already achieving.
And so the original recommendation
for lung cancer was in 2013.
And last March that same group,
the USPSTF that advises the government
on what should be covered by insurance,
expanded the recommendations for
lung cancer screening to include
adults ages 50 to 80 with a 20
pack year smoking history.
And this this actually they
made it younger and less
smoking. And that expanded
the population by twofold.
So double the number of people now
are eligible and so if you have
friends or family or if you fit this.
Go get screened.
It could really save your life.
And one thing that's important to
understand is that for lung cancer,
the ability to personalize
treatment now has really exploded
and you'll hear about that.
But it is also possible to personalize
an assessment of an individual
person's risk for lung cancer.
And so people who come to our
program to get screened talk to
Polly or Krista to do a a a visit
on the phone essentially to talk
about the screen that's coming up,
what to expect.
And what to expect afterwards
in case there is an abnormality,
because there's a lot of trepidation about
undergoing any kind of screening examination,
particularly if you're doing
it for the first time.
And what's important is that they
go through an individualized risk
prediction because there are patients
who are afraid that they have a
risk for lung cancer and that fear
is driving stress and anxiety.
And we can do this with them and
show them maybe that their risk is
not so high and they don't have
to be so worried and maybe they
don't even need to be screened.
But for patients where the risk is high
based on their personal attributes,
we really are going to try to get
that patient to the screen because
the benefit to them is going to
be potentially enormous. So.
Talk to your friends and family.
You can save somebody's life by
encouraging to go get screened.
It doesn't hurt. There's no blood test.
There's you just take a breath and
zip through the scanner and I'm
making it sound much easier than is.
You do have to get to the scanner
in your car,
but it's really pretty simple once
you once you're there and I'll
take any questions.
I'm sorry, Vinny,
do you want to come down and just
talk about your veterans program?
This is Doctor Vinny Mays,
who is a thoracic surgeon.
In our group.
Hello. Thanks for
the opportunity to talk.
And for the for some of the
patients that came down here
and some of the patients on chat,
thank you for taking the time as well
and congratulations because in many
ways you're a survivor of lung cancer.
Just to kind of lead off with what
doctor Chenoy said, screening saves
lives specifically with regards to
veterans and lung cancer, there's about
8000 veterans that are diagnosed
with lung cancer annually every
year about 900. Thousand of those.
Veterans that are out
there have an elevated risk
compared to the normal population
because of the exposures went
from either when they're deployed
or from, you know, the bases,
you know, around the United States. And
in fact in the DOD's
congressionally mandated research,
it also shows that the five year
survival for veterans is a little
less than the general population.
So we're trying to take a targeted
ability to kind of, you know,
screen veterans next Saturday,
which is the day after
veteran's day on November 12th.
From 9 to 12.
Uh, I'll be doing some screening
with Megan and Carino at the Park
Ave Medical Center in Trumbull,
where we'll be offering free
screening as well as scans
for veterans. So if you are a veteran,
please, there's Flyers in
the back that look like this.
Or if you know a veteran you know,
please grab one to have him or her
come out next Saturday.
I'll be there to screen them.
Thank you very much.
And let me just add,
just because this, this, I mean,
is this is such a big deal that that if so,
10% of people that are eligible for lung
cancer screening are getting screened
less than 10% for breast cancer.
It's 76% of eligible people get screened.
For colon cancer, it's 70%.
If you just took that number up to 50%,
you would save 20,000 lives.
So if you're a church and you get
300 people screened for lung cancer,
you're going to save one life.
So there's Toys for Tots.
There's all of these things you
know what a great gift around the
holidays just get people screened.
It's it's a really big deal and if you
take away one thing and and and so
we're we're doing a big campaign with
the American College of Surgeons and
we're we're making it really simple.
If you're 50 or older and you smoked
for 15 years or more ask your doctor.
So 50 and 15 so it's super easy to
remember 50 and 15. Ask your doctor.
I ask you a question, sorry, don't go yet.
I have a question for you.
What about people who maybe
don't have that smoking history
or who smoked like decades ago,
but maybe they have a family
history of of smoking, you know,
parent or or sibling who had lung
cancer or maybe they, I don't know,
had secondhand smoke exposure.
How do you, how do you cancel those people?
So it's we
use this kind of risk assessment and
there are lots of these sorts of tools
and models available for those patients
who don't fit squarely into the,
you know, the box of the USPSTF.
Many of those people are worried and don't
have as high a risk as they think they do,
and so to some extent this is to reassure
them that they don't have to live in fear.
But I think if somebody is
perceived by us as having big risk
and they have a substantial risk,
they really need to come in
and and really be evaluated.
Whether or not that will lead to a screen
or a CT or just a medical assessment
at that point can be decided based on
that person's individual situation.
Yeah, and you have to come up
because online they won't hear you
unless you come up.
Thanks so much. I just have a question
I get from my patients a lot that is
you know what's the radiation exposure
and and because people are are concerned
about. So as I think I said,
the radiation exposure from a low
dose screening CT scan is really low.
And when I say really low,
I'm going to compare that
to like ambient radiation.
So just living on Earth,
you we get radiation every day.
We get less in Connecticut than if we were
in Denver or living at the top of the Andes.
The closer you are to the sun,
the more radiation there is.
So how many people in here flew in an
airplane in the last three years, right?
And so you were actually much closer to
the sun and we don't think about that.
Radiation, but it's kind of on that scale.
You know a few airplanes flights worth
I this has been looked at because
certainly we as a medical community
we're really concerned about the
radiation exposure and for I think
every 10 to 100,000 screens there's
enough radiation collectively that
you might worry about one lung cancer.
And so you have to think about the
benefit to the population is quite
sizeable and then there's one,
there's one issue with one patient.
In that many thousands,
and we certainly have to accept risks of
all medical interventions and radiation is 1.
But the amount of radiation that's
been given for these scans is so
low and it gets lower every year.
So from the time that we started screening
back actually in 2011 twelve to now,
we know because we measure this in our
scanners that the amount of radiation
has gone down like to such small
doses that the old predictions of.
What's the harm?
Probably should all be redone
again because the risks
would be much lower.
We do have a chat question
for our radiologist, Anna.
How do you know? So Anna is our
chief of thoracic imaging and.
And there is a question,
when do you give contrast?
So if you if you want to add anything
that doctor Shenoi said about the
radiation or how do you know when
it's time to give IV contrast?
Hi, excellent question. Thank you.
So in lung cancer screening,
we in for a screening CT
we never give contrast.
So usually in the for chest
imaging we give contrast.
If we have a specific question
that would better be evaluated by
opacifying the vasculature better.
So I would say we probably in all
of chest imaging we probably give
contrast less than half the time
and for lung cancer screening never.
And just to support Doctor Tanouye's
statements about the radiation dose,
absolutely the dose has gone
much lower even since we started,
since we started screening for lung cancer.
And many of the estimates are in
terms of risk of radiation are
are quite outdated at this time.
And so just for example, we get a,
a lung cancer screening CT is.
Less than the amount of radiation
that we get just by living on earth,
like in Connecticut,
for about three to four months.
So it's it's less than the radiation
we get in a year.
And it's about 10 transatlantic flights,
so not local flights,
but long distance high up in the
atmosphere for many, many hours.
OK.
All right. Oh, great.
Yes, you could say your question
there and I'll repeat it for
the online people. Go ahead.
Right, so.
Yeah, so.
Just repeat the question.
So the question, because I want
to make sure I understand this,
does your risk change over time,
your personal risk or do these
models change over time?
So that these models were actually
developed in really big populations
that were being monitored over time.
So they do. This one happens to be
for lung cancer risk assessment,
some for screening purposes,
but there are models that look
at people who never smoked,
you know, and so it not every
patient variable is on there,
which is why I think if there's
a question about personal
risk, you should go in
and get seen so that you can have that
discussion with somebody who knows.
You know what they're talking about.
I want to just bring up something
you said I was found by accident.
So we shouldn't depend on accidents.
And so you were a hope lucky that you know
something was found because you had an
X-ray done for a completely other reason.
And up until screening started,
that was the only way we found these
early lung cancers is by serendipity.
Somebody was lucky enough to be
unlucky enough to have a scam and then
there was found to have a spot and so
they then they got seen and and it's
terrible to be waiting for somebody.
Just stumble into a chest X-ray or a CT scan.
It should be part of our routine so that we
routinely find lung cancers that are early,
not wait for an accident.
So thank you for bringing that up.
This is the question.
Along the screening is based on demographics.
Has ever been consideration based on
a profession like a construction work?
Who's been exposed with the best?
That's a veteran who's been deployed
firefighter exposed to Chef,
exposed to cooking oil absolutely.
So that it's hard to quantify that
risk because they're not populations
of people who who are being studied
longitudinally that way but but it is
definitely the case that their occupations.
With carcinogenic exposure,
the reason cigarettes are problem
is they have tons of carcinogens,
cancer causing chemicals in them.
And so firefighters are exposed to
particulates that often carcinogens
in the air will adhere to or to diesel
or or things that by themselves
have little risk for lung cancer.
But it's a cumulative process and we
know that lung cancer like Melanoma,
you know cancer of the skin is
accumulative genetic alteration.
Kind of malignancy in many cases,
not all, but many.
And so the best model would have
all of those things in them.
And the challenges that we don't
have the ability to gather a
population of thousands and millions
of people and follow it,
follow that population forever.
Having said that, this is not the end.
And so screening eventually really is going
to involve much more than demographics.
How old are you?
How much did you smoke?
What did you do for your job,
how much education and so on and so on.
It will include blood markers,
for instance.
And so we should at some point in the not
too distant future be able to add that.
And the best model would really
include factors of the patient that
they can tell us that we can know
because we've read their history
and factors related to their,
you know,
their makeup of proteins and
genetics and their metabolism
and we're not so far from that.
It's like right over the horizon.
So I think hopefully within.
Not months but years.
We will see that added to this to screen
in terms of assessing risk of then a
broader population than just smokers.
I'm going to ask one more question.
In part to you, but also I think Doctor
Geary is here to talk to us about genetics.
Hi, can I ask you a question
now that related to this topic?
So there there are some genetic mutations
that people can have that put them at
risk for certain cancers and I wonder if.
And that's, you know,
if if someone has one of those
mutations or or if there's a,
there's certain characteristics.
Family history or or mutations that that
might make someone need to be screened
more often or how you think about that
and then if you wanted to comment as well,
do you want to come up here
and and tell us, yeah.
Thank you so much guys.
Yeah, nice to meet you.
So it's great to be here.
Thank you so much.
Great presentation and yeah,
that's a really good question.
And as far as lung cancer
genetic testing goes,
it's it's an evolving field,
but there is a known recognition of.
Hereditary familial lung cancer.
And so some of those
features would be of course,
you know recognizing that there were
blood relatives that had lung cancer.
So oftentimes we look at the
closeness of those relationships.
So for example, siblings,
parents would be considered some
of the closest blood relatives and
then even expanded blood relatives.
So uncles and aunts,
grandparents.
So looking at the full family history
can become really important when
thinking about is there a suspicion for.
Hereditary risk for lung cancer
in a family that always has to be
factored in with the fact of all
of the other kinds of questions
that are always asked, you know,
was there smoking and and etcetera,
etcetera.
But family history itself becomes
really important.
Other things that become important were
the age of diagnosis of lung cancer.
So typically for hereditary syndromes,
the younger the age of diagnosis,
the greater the suspicion that
it's linked with a genetic mutation
that could have been inherited.
So ascertaining the age of diagnosis for
lung cancer is also really important.
And I say this is an evolving field
because there are a few genes that
have been reported and published
about contributing to inherited lung
cancer and there's three that are
typically more cited in the literature.
So or B2, EGFR, yap,
one.
These are some of the ones that are
reported and sort of verified as far
as contributing to inherited lung cancer.
You know that's supposed to a
lot of other cancers that we
can do genetic testing for.
There's many,
many more genes you know and so this
is an active area of discovery of
research to try to find many other
genes and they can be tested for and
oftentimes we will insurance cover it.
These questions have to be
discussed with patients if they're
interested in genetic testing.
Typically out of pocket costs
have come down significantly.
So where it used to be in the thousands,
we can do genetic testing now
for about $250 out of pocket so.
Still expensive,
but it's it's become more doable
and then what to do with that
information is the next step.
You know in terms of do we do
the low dose CT screening,
you know going forward what
are we looking for,
there's a lot more to be learned
because lung cancer is also
has different types of.
Features like different pathologies
as they're called.
So some of these genes might be
linked with certain pathologic subtypes.
So we're learning a lot more.
There are a few genes that are
available for testing.
I think looking at the family history
and thinking about who had lung cancer,
what ages were the diagnosis,
was their smoking,
really helps to kind of
bring that to the forefront.
At the end of the day,
I think if there's any question,
it would be really helpful
to see a genetic specialist,
genetic counselor to have
a discussion about that.
All right. Amazing discussion.
I think we're going to move on as we have a
lot of other amazing topics to talk about.
Thank you all so much. Thank you.
Thank you, Doctor Shanwei. All right.
So we're going to talk next about
personalized lung cancer treatment.
Hopefully at the end of this discussion
you'll understand what we mean by this.
And 1st we have Gavett Woodard,
thoracic surgeon coming to talk to us.
Thank you, Sarah and thanks for
everyone for being here today.
I wanted to call out in the
audience our surgical AP team.
Could you guys waive if you end up
having surgery for lung cancer?
They are a critical part of your care
both in clinic and in the hospital.
And so we really appreciate them
being here and thanks to all the
patients who are here as well.
So we personalize every patients
approach to treatment and that's really
important and that's a reason why
it's great to come to a Cancer Center
like smilo where you're going to get
the top of the line care for surgery,
radiation and oncology.
These are our three main kind of
weapons that we have when we have
a patient who's been diagnosed
with lung cancer and we combine
them in different ways depending
on the stage of your cancer.
We typically think of surgery
and radiation as being a good
way to treat local disease.
So if you have early stage cancer,
cancer within one part of your chest,
those are the tumors where we think
that surgery is a good tool or that
radiation is a good tool because
they're a very focal approach and
we're really only treating what
we're either taking out with surgery
or targeting with our radiation.
For patients that have potentially
more widespread or systemic disease,
this is where the oncologists come in
with systemic therapy and there are
a lot of different options for that.
Chemotherapy is one that's kind of
the classic cytotoxic lose your hair
sort of therapy that people think of.
But now in lung cancer,
we have so many other really
exciting options for treatment.
And these have all been breakthroughs
in the past decade or so,
and it's really changed.
What treatments we have available,
so I'll let our oncologist get
more into those.
We have targeted therapy which goes
after a specific mutation within a
tumor and then immunotherapy which gets
at you know how getting our body's
own immune system to fight off a tumor.
So how do we personalize your treatment?
A lot of this comes down to stage
and what stage you might have kind
of determines the main ways that
we would approach your treatment.
So for stage one disease,
we're thinking of these local therapies,
either surgery or radiation treatment.
When you start to have stage two disease,
maybe you have a local lymph node within
the lung that's found to have cancer in it.
We start thinking about combining local
therapy to address the primary tumor.
Self and maybe lymph nodes in that
area and possibly tying in some of
our systemic options which might
be used to mop up any cancer cells
that may have spread outside of
our field stage three disease.
We start to focus a little bit more
heavily on the systemic therapies just
because we know that these patients are
more likely to have cells that have spread
kind of outside of their main chest cavity.
And then for stage four, we primarily
rely on these systemic therapies.
Chemotherapy,
targeted therapy and immunotherapy.
How we make these decisions about
what is the best option for you?
Obviously,
patient preference plays a big role.
I I'm a surgeon,
so I love to operate on people,
but if I'm seeing someone in clinic who
says there's no way I'm having surgery,
they're obviously not going
to make it into the OR.
And so we like to hear from you
about your preferences for your own
treatment and then use our medical
knowledge to help guide you to make
what is the best informed decision
that you can about your care.
When we're thinking about
certain therapies versus others,
we do take into account other medical
conditions that you have and a lot of
our more complex cases are presented
at tumor board where we all get to
meet now over zoom once a week and we
talk about anybody that's outside of
really a run-of-the-mill sort of case.
We discuss a lot of cases just
to get input from each other.
We all get along very well and are
used to collaborating on patient care.
To focus on surgery,
generally this is being used
for stage one to three tumors.
So there are exceptions to these rules,
but generally it's the more
early stage disease.
Frequently our operations these days
are minimally invasive and robotic.
So it's no longer the big rusty
chainsaw incision on the side.
We use small ports,
small incisions and this is used
for the vast majority of our cases
and obviously these decisions.
Are made when we look at your
scans and talk to you in clinic,
if it is a minimally invasive operation,
patients are typically in the
hospital for about one to three days.
They go home fairly quickly.
The recovery is quick.
It still is surgery.
I don't want to undersell it,
but people do quite well and most
people are off of most painkillers
when I see them in clinic about
2 weeks later. During surgery,
what's unique to that is that we are
physically removing the tumor itself and
any draining lymph nodes from your body,
we get a section of healthy lung around it.
The point of these margins of healthy
lung is to catch any cells that
are potentially in transit that
we can't see with our CT scans.
So it has the benefit of potentially catching
cells that might be spreading other places.
And that's why we think of surgery as
primarily being the best treatment
you can have.
If you just have a disease in one spot in
your lung from our surgical specimens,
they all go to pathology where
they're evaluated.
We then will give you staging information
for patients that don't have surgery.
We stage their cancers based on imaging
and sometimes invasive biopsies.
But we think of the pathologic stage
from surgery as really being our best way
that we can accurately stage your cancer.
The other thing that's really useful
about surgery is that we get you
know the cancer out and we have large
chunks of tissue that can be used
to do all sorts of studies that get
at what mutations your tumor might
have special stains for matching
you with certain therapies.
And often tissue like this is needed
to participate in clinical trials.
We also run a lot of research studies
here at Yale and if your tissue is not
being used for your clinical care,
this tissue can also help a lot of our.
Cancer researchers do lung cancer work,
which is important.
Like I said,
it's considered kind of our best
form of local treatment.
How we personalize this you'll
meet with a surgeon and clinic.
They'll go through your medical records,
talk to you about your history and
very importantly review your CT scans,
which give us a sense for what anatomy
is and whether or not we think that
you would tolerate the lung cancer
surgery that would be needed to treat you.
We use small incisions and do this
minimally invasively with cameras
whenever possible for patients
who do have much larger tumors or
tumor that's close to vessels are
very centrally located.
We often find that these are still
best approached with a thoracotomy
which is an incision on the side.
We'll talk to you about what
we think is the best approach
in your specific situation.
And then we have a really
collaborative environment,
more complex cases are discussed at
our weekly surgeon kind of only group
meeting and and then we also talk
about cases at tumor board and any
really complex case you'll probably
have more than one attending surgeon.
I'm doing the case at that time.
Some of these questions,
what does healthy enough for surgery mean?
You know we want to make
sure you're not bed bound,
really struggling with other medical
comorbidities that would make it
unreasonable to operate on you,
make sure that your heart is healthy
enough to have the anesthesia
required for lung surgery.
So we typically get a cardiac evaluation,
we can do a perfect operation,
but if it if you have a heart
attack as part of that,
we haven't done you very much
good and then lung function test.
And these tests,
also called pulmonary function tests PFTS,
give us a sense for how much
lung can be safely removed.
Who can have minimally invasive
or robotic surgery.
Smaller tumors typically are
removed robotically and peripheral.
So if it's a central or larger tumor,
these tend to be done open.
These are some pictures of the da Vinci
robot that's used in a lot of our cases.
And then finally,
we are now in this big new era
of combining newer therapies
before surgery and this is a a
hot topic for discussion among
physicians as well as patients.
As a general rule,
you know we tend to give therapies
up front or before surgery if you
are slightly more advanced stage.
There are lymph nodes involved and we
think that giving you these therapies
in advance might help us you know
have an easier time in the operating room.
And there has been a lot of new
data coming out that giving these
therapies before surgery can help
improve your survival long term.
So with that,
I'm going to turn it over
to my radiation colleagues,
but thank you and happy to
answer any questions at the end.
You all know this is a two day event, right?
When does it become a hostage situation?
Thanks so much for the invitation to talk
and thank you for everyone joining us today.
So I'm Tom Hammond, one of the radiation
oncologists here at Yale and just
wanted to 1st briefly just discuss
radiation specifically here at Yale
Cancer Center and Smiling and how how
things have evolved and and how we can
personalize patients radiation therapy.
So when we think about
radiation therapy from a,
from a radiation oncologist perspective,
we're thinking about primarily 22
approaches and this is brachytherapy
and external beam radiation therapy.
And primarily in the context of lung cancer,
we are thinking about external
beam radiation.
And this is radiation that's
delivered from the outside using
machines called linear accelerators.
And this is really used for patients
with all stages of lung cancer this.
So this is from our very early stage
lung cancer patients with stage one
disease all the way up to our patients.
Have more widespread metastatic disease
where attempting to help control symptoms.
And from a.
Evolution of radiation perspective,
things have come a long way and
you're going to hear you've heard
about that in the context of surgery
and minimally invasive surgery,
you'll hear about this in the context
of evolving systemic therapies.
This is radiation is.
This has also been the case
for radiation therapy, right.
So even 10 or 15 years ago
when we talked about radiation,
we were talking about radiation that
was delivered with one or two beams
of radiation coming in from the front
to the back and maybe the side.
And this is called 2D or
three-dimensional radiation therapy.
And this really while effective
did expose a lot of normal tissue
to radiation dose that didn't need
to happen and so with the advent
of IRT or intensity.
Modulated radiation therapy,
we're now able to deliver very high
doses of radiation primarily to
the tumor and minimize radiation
to to the normal tissue.
So the heart, the healthy lung,
esophagus,
all the things that cause patient
side effects from our treatment.
And so this really is the standard of
care for patients particularly with
early stage and curable lung cancer.
And and this is sort of a more
advanced version of this is what we
call SBRT or stereotype stereotactic
body radiotherapy and this is
very high dose focused radiation
is delivered primarily for early
stage lung cancers and I have up
here proton therapy.
This is an area of active research
in the radiation oncology community
where we're evaluating whether
this is something that that has a
place in lung cancer group therapy,
but it's not really the forefronts of,
of standard of care at this point so.
How do we personalize radiation therapy
for for our patients here at smilo?
And as you've heard and I'll
and I'll echo this sentiment,
everything really starts with a
multidisciplinary evaluation for
our patients.
So this is again evaluation in
collaboration with pulmonologists,
thoracic surgeons, medical oncologists,
radiation oncologists because
input from all of these different
physicians really helps
to to define the treatment that's going
to offer the best chance of cure and
and really minimize treatment morbidity.
Their side effects for our patients, right.
And so as Doctor Walter was mentioning for
early stage patients in the context of of
radiation therapy or local therapy, we're
thinking about surgery versus radiation.
In terms of radiation therapy,
we have a number of different tools that
we can utilize and and some of these
are things like SBRT which is high dose
focal radiation that's delivered in
between one to five outpatient treatments
depending upon anatomic location.
Prior radiation therapy, prior surgery,
we do have to sometimes adjust
the radiation plan to involve more
protracted type radiation regimens,
but we're now delivering radiation
over several weeks and and that's
again a decision that's made at the
time of consultation with our with
radiation oncology.
And so this is just an example of
that where this is a patient who's
received three different courses
of radiotherapy SBRT for three
different early stage lung cancers.
Now as we move into the more
advanced disease setting,
so we're talking about patients with
now stage two through four therapy.
We're now beginning to integrate
our radiation therapy with systemic
therapies and this is again done in
collaboration with our medical oncologists.
We're looking at other medical
conditions and how we may choose our
radiation dosing regimens based upon
integration with those other therapies.
From a a purely technical perspective
in radiation perspective every
patient that comes into our.
Power is being treated with radiation
has a customized radiation plan
that's developed for them, right.
This starts with custom and mobilization
that's done when they're when they're
radiation planning scans are done,
we're doing things 4 dimensional CAT scans.
We're able to visualize every
patient's tumor move as they breathe.
And then once we begin the planning process,
we involve a team of physicians,
physicists and dosimetrist to develop a a
customized radiation plan for that patient.
To really maximize our chance of cure
and to minimize treatment side effects.
And then lastly,
another benefit of being at an
academic institution such as Yale
Cancer Center is that all of our
radiation plans for our patients
being treated with lung cancer are
reviewed by its team of Yale Lung
cancer specialist radiation oncologists
for both quality and safety.
And so with that, I'll turn it over.
I mean, let me just ask a couple questions,
you and Gavin just from the chat.
So the local therapies are
the more dangerous obviously.
So Andrew? Done.
Stop on one of our thoracic surgeons.
I've heard you operate on people that
were told that they were inoperable.
How how could that be like how do
you decide who is operable and
how is it that one surgeon says
they're inoperable and another
surgeon says they're operable.
How do you, how do you make that decision?
And Tom and same with you,
you know I've I've had patients that
you were able to treat that weren't
and so how is that determined?
So like Doctor Woodard mentioned,
when we meet with you in clinic,
we go over the details of
the pulmonary function test,
cardiac testing and the other
comorbidities in addition to the staging.
So we take all that into consideration
when we say that this cancer is operable.
Sometimes it does come down to some.
Uh, Gray areas and some judgment calls.
And I think the advantage that you
have here at our Cancer Center
is that we do have the experience
to do more advanced cancers,
more complex operation on on these
advanced cancers and patients with
who aren't the healthiest either.
And you know that's really a
testament to the staff that we
have in the operating room.
The staff that we have. As
Doctor Woodard had pointed out, AP's.
Taking care of you post-op and on the
surgical floor, the nursing staff,
everybody contributes to getting
you through your operation.
Yeah, I'll I'll echo a lot of that,
that sentiment and that you know again a lot
of this starts from collaboration with our,
with our colleagues and other disciplines,
right. So if I have concerns about patients
in terms of their ability to tolerate
for instance SBRT or or more broad
conventionally fractionated radiation,
one of the benefits of being at
smilo is being able to reach out to
our pulmonology colleagues or other
colleagues who are really able to help us.
Assess risk of of our treatment
to to our patients and this is
a benefit of being here at Yale.
Additionally from a radiation
oncology perspective,
another benefit that I alluded to
earlier is that you know I'm one of
several radiation oncologists who who
primarily treat lung cancer patients.
And so having that expertise available
to discuss amongst ourselves for for
our treatment of patients really
does help us to to push the envelope.
And have a little more experience and
expertise in terms of coming up with
treatment plans for our patients.
One of my favorite quotes is from
Henry Ford who says whether you
think it can be done or it can't,
you're probably right and I I do think that
you know there and it's not just Yale.
This isn't a sales pitch for us.
I think big hospital versus small
hospital if if you're told you're
not operable and it hasn't spread,
I do think that's a good indication
to get a second opinion.
And it's the same thing with radiation.
I think if you're told if it's one
thing if if local therapy doesn't make
sense because of where the disease is.
You know, then that's one thing.
But if, if they if it's a safety thing
or just a technical complexity thing,
I would personally or have somebody
that I cared about have a consultation
at another at a bigger hospital.
Any other questions?
All right, chat. Anybody seen?
Oh, hi, everyone. I'm so young.
I'm one of the new medical oncologists
that just freshly graduated and
just started this year at Yale.
So I'll be talking a little bit about
targeted treatment and what that means.
So lung cancer is no longer one
disease and just want to take
you back to the 1960s and give
you a little bit of a history.
So back in 1960s if you were to
present to a doctor with lung cancer,
we had two different flavors,
kind of like how we have two flavors
for ice cream, vanilla, chocolate.
So there were small colon cancer and
non small cell lung cancer and the
distinguishment was based on how
they looked under the microscope.
So small cell lung cancer,
they look like oats like in
the oatmeal and the breakfast.
And not small cell lung cancer was
more of a glandular subtype and the
treatment was chemotherapy and now
moving on towards the Millennium.
In 2004 we have discovered new subtypes
of lung cancer within the non small
cell lung cancer subtype which makes
up more about 85% of the lung cancer
types there were what's called driver
alterations that have been discovered.
And I guess to give a better idea
of what a driver alteration is,
is I guess if you think
about driving in a car,
you're on I-95,
you're speeding 75 mph and you're
trying to get to North Haven
to see Doctor Sarah Goldberg.
So you have to take an exit on exit
10 to get to North Haven clinic
and you have to press on the brake
right to swerve into the right exit,
but on the your foot stuck
on the accelerator,
so you can't get to the break and you're
just accelerating and accelerating.
And this is kind of what a driver
alteration does in which the
tumor cell continues to grow
based on these growth signals.
Now they're necessary for normal cell growth,
but if it's too much then
that will lead to tumor.
And we've discovered a number
of driver alterations.
So K Ras B RAF her two and the
pieces of this pie get smaller
and smaller and now this is 2022
where we have a number of different
driver alterations that's driving
the cancer and I think one person
from the audience mentioned that
they were never smoker and they
were diagnosed with lung cancer if.
People don't mind.
I just wanted to see would anyone
be able to raise their hands on who
were diagnosed with lung cancer who
are not smokers, just out of curiosity.
So there's a quite a handful.
So a lot of these driver alterations
are present in patients who have
been non-smokers and we've kind
of you know through advances in
research trying to think about
what treatment options are best
for these targeted mutations.
So now that we know that there
are different driver alterations
that are driving these cancers,
how do we change the focus
of targeted therapies?
So before we were maybe blindfolded on
what would be causing these tumors to grow?
And now we're trying to
find more targeted options.
So I wanted to share with you a patient I
saw during fellowship before I
started my job here at Yale.
And this is a patient.
She was in her 40s,
she was a school teacher,
she was a non-smoker like a lot of you guys.
And she presented with shortness of breath,
went to the emergency room,
she had a CAT scan because everybody was
worried about potentially a lung clot.
And when they did a CAT scan they found
that she had not a blood clot in the lungs,
but she had a spot in her left lung.
And also spots in the lymph nodes,
and she had a couple other spots in
her bones as well and some blood
testing was sent to look for these
mutations and her blood testing came
back positive for Ross 1 Fusion.
So there was a targeted treatment for
this Rosslyn fusion called Entrectinib
and she was started on entrectinib and
this is her scan three months later.
So this is a PET scan and you see that
the parts of the scan where it's not
lighting up like a Christmas tree.
So you see that she has responded to
this treatment and she had a pretty
good response where a lot of the
tumor that we've seen in the scan has
pretty much dissolved and disappeared.
So this is one of the success stories.
I think of using targeted treatment
options and there have been a number
of different targeted treatments
that have been approved by the FDA
or are under accelerated approval,
some of them being osimertinib
for EGFR mutations,
COMANAV for met mutations,
alectinib and her two,
so to resub over certain nib and
there's a lot more.
OK. So we did well and how do we do better?
And I just wanted to share
with you some of the research
that's being done here at Yale.
It's called a Lung master
protocol or in short lung map.
And this is a clinical trial that's
been pioneered here at Yale under
Doctor Roy Herbst and also in
collaboration with the Southwestern
Oncology group called SWAG and a
number of other other institution in
which patients are screened for these.
Mutations in their tumors and they
try to match basically treatments
targeting these tumor mutations and
this was opened in 2014 and the in
2019 it's been expanded to include
other subtypes of lung cancer.
And so far about more than 4000
patients have been screened and
they all have mutational profiling.
So I think you know from medical and
college perspective we see a lot of
patients with advanced lung cancer.
And I think that the take home message
is that you know we're all hoping that
one day we can just take the tumor,
send it for mutational profiling and
then give you guys more of a unique
treatment that's specific for the patient.
That we're seeing in clinic and
I'd be happy to answer any questions
about target treatment.
Be there. You have some sections in the chat.
OK, I I see Doctor Roy herbs on online here.
Roy, are you available to take questions?
You're muted though. Absolutely.
Hello everyone. Hello.
I wonder if they can see you somewhere.
I don't think they can see you.
I can see you though.
Hello. He's very handsome.
I know this big. They can.
Can you all hear him?
OK. They can hear you.
So doctor so young,
just Doctor Kim just showed or
maybe you could see the slide is
showing the the slide of lung map.
I was wondering if you wanted to
make a comment of of how this study
has gone what we've learned from it
and kind of where it's going because
it really is just as she said.
You know we've done so well with
targeted therapies but how are we
going to advance things further
and I think this is one of the
ways that wanted to see if you
wanted to comment on that, right.
Well it's great to see everyone.
I'm Roy Herbst, I'm actually a deputy
director at the center right now and
I work in lung cancer for many years.
This trial has been open now almost
eight years at Yale and we've many
of some of you may have been on it.
The idea here is to get drugs
to patients where they live.
You can get this trial at
any of our sites here in.
And then it came,
but it's also open at about
700 sites around the country.
And what we're trying to do is find,
as you hear,
we're talking about precision medicine.
So for precision medicine,
we have to find the cancer and find the
abnormality in that cancer and match it
to the right drug at the right time.
The problem is some of these abnormalities
are only present in 2 to 3% of people,
4%, it seems quite small.
However,
if you've got an umbrella of a
trial where you have drugs for
these different abnormalities,
you can funnel patients.
From around the country.
So if if you get your your cancer
profile here at Yale we send it to
a central facility and then we can
match you where the with the right drugs.
We've learned a lot from this trial
some of the drugs have worked some
have not but it's it's we just had
a very nice result where two drugs
one drug called pembrolizumab some
of you might know it as Contrada
when Contrada was was added to.
An antibody,
a drug that blocks growth factors.
It actually worked in people
who had failed the cruder.
So we're continuing to have
studies like this and we can talk
more in the questions later,
but we have studies like this
and This is why when you come to
the the center like ours, we can,
we can try to find something
not the standard of care,
but what will hopefully be the
standard of care in the future.
That's where clinical trials are so
important under very safe guidance.
So thanks for calling on me,
Sarah.
I'll stay here for the rest of the meeting.
OK. Thank you so much. Good.
So Justin, one of the one of the
virtual attendees had surgery in 2017
and is is still alive obviously,
but has a lot of symptoms and
has a lot of difficulties.
And how are you balancing quality of
life with quantity of life when you're
talking about surgery and talking about
multiple modalities of treatment,
how are you thinking about it come on down?
Question. How do you think about it?
How do you, how do you,
how does that become a part of
your decision making and and is
there anything new that's helping
you preserve quality of life?
Hi guys, Justin Blasberg,
Dan, thanks for that
question or the the person who asked it.
So I think quality of life is an
important part of what we talk
about when we discuss surgery.
When we talk about the
you know the potential challenges
of surgery, the short term expectations
of surgery as it relates to recovery and
how that impacts quality of life that
then naturally becomes a a conversation.
About long term quality of life.
And so I think we stick to a lot
of the tenants that we've sort of
discussed earlier in Gavin's talk.
We focus a lot on risk stratification,
making sure that patients are
appropriate for the type of procedure,
the type of treatment that we're
thinking about offering minimally
invasive surgery is a big part of
how we improve quality of life.
And and on the surgery side in terms of
getting patients back to you know their,
their baseline functional status,
how they feel before surgery is how
we want them to feel after surgery.
And sometimes that takes time and
everyone's a little bit different.
So we focus on understanding where
they are before they started surgery
and then working towards getting them
back to where they were after surgery.
Some patients that's a couple weeks,
some patients that takes longer.
It depends on what kind of surgery
is required.
It depends on you know,
what what the postoperative period is like.
But we really focus on,
on hitting all those milestones
after surgery,
making sure that patients are
getting out of the hospital and
the timely and safe way.
And then working towards reestablishing
that baseline quality of life so
that we can move on to some of these
other opportunities like surgery
like a chemotherapy or radiation
or even just surveillance,
which is a
big part of what we do.
Maybe maybe we'll have Doctor
Passik come up as well and and
help us with that type of question
as well because the pulmonologist,
I'm sure you see a lot of people after
surgery who have symptoms or after some
of our other treatments, radiation.
So tell us your perspective.
I'm sure. Hi, I'm Jennifer Possick
from a pulmonologist in the group.
I think that that's an excellent
question and one thing to consider
is that each patient's experiences,
individual recovery and survivorship
isn't linear and lung cancer
doesn't exist in isolation.
It's just one facet of a person's life right?
They have different medical conditions,
they have different demands on their time,
different acute illnesses may arise,
and all the pre planning.
We do, as a multidisciplinary team,
is aimed at trying to come up with the
safest plan and to implement it safely.
But in the postoperative period,
that multidisciplinary team is there too.
And so part of it is aimed at managing
any immediate complications that arise.
Some of it is aimed at managing
people's other pulmonary conditions,
which can be an important feature
for patients with lung cancer or
their non pulmonary conditions.
And so we approach things on
a case by case basis.
We evaluate people's symptoms and
try and come up with a plan for them.
Sometimes that involves time,
sometimes it involves.
Further evaluation medications,
but we have to think about other
non medical therapies too.
And so I want to give a shout out
for pulmonary rehabilitation which
I think is a really important
aspect of recovery and survivorship
for a lot of our patients.
And we have an excellent pulmonary
rehabilitation program affiliated
with Yale called Lung Life,
but there are many around the state
and many in other areas as well.
Yeah, I mean I think we're we're trying
to take as little long as possible.
I think the field is moving towards taking
as little long as possible through this,
the least traumatic approach is possible.
But I, you know, I think the real
key is to get to know your patient
and what are their goals of care.
And I had a patient who had a curable
lung cancer who it would have kept
him from doing one activity that
he really liked doing and and he
chose to go a different direction.
And so I do think you have to
try to really help people and
understand what their goals of.
There are along those lines on one of
the chat questions was what is the
difference between SBRT and surgery.
I did not plant that question it
but you had mentioned what SBRT is.
Maybe give a just a couple of more
seconds about that and maybe we
can just talk about what is the
difference about that for this is
treatment for early stage lung cancer?
Yeah.
So, Umm,
SBRT
is again it's, it's a sort of a
specialized version of intensity
modulated radiation therapy.
So as opposed to other types of MRT SRT,
the the radiation oncologist is actually
present at the at the treatment console
every single treatment for the patient,
which allows us to actually reduce the
area of lung that we're treating and allows
us to increase the dose of radiation.
To the tumor and this is a big advance
that's happened over the last decade or
so and has really increased our ability
to to to cure early stage lung cancers
and this was getting a doctor office
question about about surgery versus SBRT.
SBRT was actually primarily or patients
that were treated with SBRT were primarily
patients who were not able to get surgery.
So patients who had lung function
that would have precluded them from.
Proper operations required to
treat their lung cancer.
So primarily we think that SBRT has
the advantage of having a lesser
impact on on lung function than
surgery for patients who may have
underlying more significant COPD or
or other pulmonary comorbidities.
Yeah, I I agree with that.
The so this is a big debate between
surgery and radiation oncologists.
We yeah if you guys can just buckle
up here nobody's hungry the so the
from from I think there's a tradeoff I
think that there surgery generally is
associated with a longer survival that
but there are more complications and
there's an investment in a recovery
whereas SBRT there is generally no
recovery in in minimal complications and
and minimal disruption to your life and so.
All my patients with early stage lung cancer,
we have a conversation about both
treatments and we try to come up
with what makes the most sense.
Yeah.
Cancer.
It started out with lung cancer.
You can get it whatever stage,
but eventually it made
more into something else.
I was curious your definition of
input new neural hormonal, you know?
And you know, with with the translated.
That's certainly worth. Individualized.
Eventually failed. You have to
be personal with your therapy,
which I really appreciate the
place to do that and I appreciate
everybody. It's gone up.
Hmm. You didn't even think that.
Specifically, I'm looking.
Yeah.
Yeah. So that that's a great
question and we have a perfect
person to answer that question.
We have a pathologist here, Doctor Dasik.
I'm hoping you can help
us with this question.
So just to repeat the question
while she comes up,
the question is that just summarizes
sometimes lung cancer can change.
And so it sounds like in this case
maybe it started out as a disease
that was able to be treated with
a targeted therapy and then it
changed to something that as as
as he's saying is a neurohormonal.
Cancer. And so, Doctor Daisy,
can you tell us what the differences
between the types of lung cancer and
how sometimes cancers can change?
Thank you. Thank you so much.
I'm a pathologist.
I'm one
of those people behind the scene. You'll
never see me and you'll never hear me.
So, but I'll look at your tissues.
So I'm the first step when the tissues
taken out and I made the diagnosis.
And usually the first step is has been
heard to make a right histological
diagnosis. So it's your. Type of the cancer,
it could be glandular one,
it could be squamous.
We heard a lot about Glendora
that have those targets and
we we make the diagnosis,
we send the tissue for
the molecular testing,
we identify those targets and
you get treated and
you do have response through some
time and then cancer may come
back or it may stop responding.
And at that point
we can get another tissue sample
and we look at it under the scope
and it looks different, it looks.
Completely different than the first time.
It's different histological
type and we usually see this
transition from adenocarcinoma
to small cell carcinoma or
old cell carcinoma.
Then there are other options.
We are going to test it again molecularly.
We may find new targets we can treat again.
There is other possible appearance.
It could be like very ugly
looking circumvented carcinoma.
Again we send it for the testing,
again we can find another target. So
they do change.
They're like wild animals, you know,
they're they're like chameleons.
They they change their look,
they change their genotype and, you
know, hopefully we can
target them and treat them.
Yeah. And I think more and more we're,
we're we're getting another biopsy
especially after targeted therapies,
not they don't always change,
but they sometimes do.
And so we we more and more are looking to
see if there's been a change and if we
could treat it differently because of that.
Thank you. OK.
So we're going to move on because
we still have a few more talks,
believe it or not,
a couple of really exciting things.
So I don't know why I can't.
Click on the slides anymore.
OK, great. Yes. Yes.
So long map study is still open,
it's changed over the years, right.
So there were a set of
studies that you can come up,
you're going to go next.
There were a set of studies within
lung map for a few years and then as
those studies close new ones have
opened new targets as the as the
field has evolved and we've learned
more new things have come into it.
So yes, it's still open,
it's different than it was,
but it's still going strong.
OK.
Next we have someone many of you
probably know Doctor Scott Gettinger,
medical oncologist who's going to talk to
us about immune therapy and lung cancer.
Thanks,
Scott.
So let me just figure out how to do this.
So nice to see some of you here.
We've been doing this.
I'm excited to see, well,
there are certain people.
Anyhow, so, so Dan and and Sarah
asked Justin and I to comment on how
immunotherapy has impacted lung cancer.
And it certainly has.
So we've already heard about some of
the traditional therapies that we use
to treat our patients with lung cancer.
We've heard about surgery,
we've heard about radiation.
We haven't really heard too
much about chemotherapy,
but chemotherapy does target rapidly
dividing cells, but it does.
So non specifically in the last 20 years,
the real advances at least in advanced
stage disease have been personalizing
therapy and then immunotherapy and
doctor Kim talked to us about how we can use.
Personalized medicine to target.
Characteristics that are unique to a
tumor and the hope there is that we
have better therapies with less toxicity.
I would venture to say that the
biggest advance in the last couple
decades for lung cancer would be
immunotherapy and not just for lung cancer.
I think for all cancers,
immunotherapy has revolutionized the way
we think about and the way we treat cancer.
So for for the immune system
to effectively attack tumor,
there's a couple of things.
There's three things,
three basic things that need to happen.
First, the immune system needs
to recognize the tumor.
As foreign as not self so it
can initiate attack.
Second it needs to recruit forces
so it can overcome that tumor and
then finally once it has its army
it has to be able to penetrate
into the tumor and kill it.
So tumors have a way of hiding
themselves from the immune system
and we have some strategies to try
to overcome that and these are
basically vaccine type strategies.
So here you can see in the first first
row we see a tumor that has all these
little red and blue things and these
are unique proteins that are expressed
by the tumor that the immune system,
if they can see these things they can say,
oh, this is not supposed to be there,
we cannot attack but again tumor hides it.
So if you radiate this tumor,
you kill the tumor.
When you expose these proteins,
so now the immune system can see
the cancer and it can actually
go to other places now that it's
primed and hopefully attack cancer.
Another way to do this is we can
synthesize these abnormal tumor
associated proteins and then we can
inject into the body making it easier
for the immune system to see them.
And finally,
we can take immune cells out from
a patient through the veins.
And then we can coculture them
with these synthesized proteins,
allowing them to process and
and present these proteins,
and then we can inject them
back into the into the body.
So here you can see an immune cell
that has been vaccinated and has this
infrared goggles and he's ready to to
expand and expanding means recruit other
members and to weaponize yourself.
And we can augment this process by
adding nonspecific immune stimulators.
And these really the first immunotherapies
that were approved for cancer,
not for lung cancer but for
Melanoma and renal cell carcinoma,
you might have heard of interleukin
and interferon.
So now you have your army,
it's armed and it's ready to go
and it gets the tumor.
But the tumor can put brakes on
the on the immune cells sort
of like a barrier around it.
So even though you have this
army that recognizes the tumor,
it can't get in and one of the main
breaks that the tumor uses and
we use the same breaks to protect
ourselves from excessive inflammation
and what we call autoimmunity is
something called PD one and you
might have heard of program death.
Ligand one,
it's something that we check in your tumors.
So the advances the major advance
in immunotherapy over the last
decade has been targeting this
pathway with antibodies,
either anti PD one or anti PD1 antibodies,
essentially relieving these brakes
and allowing the immune system to to
get into the tumor and to kill tumor.
So over the last seven years,
we've seen the approval of five
different PD1 blocking drugs and also
cruel of another drug that blocks a
different break called the CTA 4.
And we have been fortunate enough
here at Yale to run several trials,
including the first trial
for patients with this drug.
And you think about first trials,
first in man trials,
patients who go into these trials
really have no other options.
They've exhausted all standard
therapies and their prognosis is
on the order of maybe six months.
So back in 2009, 2010,
we had our first trial,
the drug called Opdivo wasn't
called Opdivo back then.
It was called NDX 1106.
And there are two things that
really struck me.
Over the first couple of years of
treating patients first that these
drugs were tolerated incredibly well,
much better than chemotherapy
with the majority of patients
having little or no side effects.
And this was very important because
these patients had a prognosis that
was poor and I didn't want to interfere
with any quality that they had.
And and I felt good because
the first goal of patients,
they didn't really have side effects.
So then we put 40 patients on the trial.
The second observation was that if
the tumor responds to immunotherapy,
it's going to last much longer than
chemotherapy. Maybe even indefinitely.
The first trial that we put patients on 2010,
we we are still following patients
from this trial and that trial you
had two years of immunotherapy
and then you you had observation.
We have patients from that first
trial now 12 years out from starting
immunotherapy with the prognosis
of six months,
10 years after stopping all
therapy with no evidence of cancer.
So are these patients cure you
know we don't know but we hope so.
So how do you quantify how
immunotherapy has impacted lung cancer.
So we heard about five year
survival earlier from Lynn,
See if Lynn still here and we use five
year survival as a surrogate for cure,
although it's not the perfect surrogate
because there is the rare patient
who recurs later than five years.
But for our patients who have
early stage lung cancer,
Dan does a surgery or just does
a surgery and went five years,
champagne is open and we say
you're cured of your.
For lung cancer,
So what if we look at advanced
lung cancer and unfortunately
majority of patients present with
either advanced or locally advanced
lung cancer in the past we would
never think of five year survival,
maybe one year survival, two year survival.
And if you look back in the chemotherapy
trials it was great if we you know
big milestone was 50% to one year survival.
But if you look at the immunotherapy trials,
we see five year survivals on the order
of 15 to 20% unheard of are these patients.
Cured.
We don't know.
You know,
there's not enough time.
But I can tell you from
the patients that I've treated,
if I don't see the disease
progressing after about three years,
almost all of them continue to
have no evidence of disease.
Now 567 years later.
So are these patients
cured? The problem that we have is that
immunotherapy really only helps 15 to 20%
of patients with advanced lung cancer.
And and so that leaves a lot of patience.
And so at Yale we're conducting several
different clinical trials to try to
find other parts of the immune system
that we can wake up to fight cancer.
And I think over the next years we'll
see many more immunotherapies and
that 15 to 20% will go up steadily
year by year. So
Justin, looks like you're next.
Thanks, Scott. Justin
Blasberg again.
I'm one of the thoracic surgeons.
Thanks to this group for
having me talk to you about,
Umm, early stage lung cancer,
surgical lung cancer and the role
of immunotherapy, which is a really
exciting space for all of us.
As you can see from this figure there
and as we've discussed a few times,
there are a number of different
ways of treating lung cancer.
I'm a thoracic surgeon,
so surgery is part of my
day-to-day chemotherapy,
radiation, we've sort of talked
about these different options.
And you know I think over the
past decade the real advancements,
the really exciting stuff is Scott
alluded to is looking at how
these tumors work genetically, whether
lung cancers have genetic mutations and these
are opportunities for us to think about
treating patients well beyond the surgery,
chemotherapy and radiation sort of arms here.
This includes you know targeting specific
mutations but also immunotherapy which
got touched on a little bit how we
trigger our immune system to fight cancer
is usually by stimulating or boosting.
Or any immune system so they can work,
work harder and immune system could
work smarter to attack cancer cells.
So you know although immunotherapy was as
discussed studied mostly in advanced disease,
I think there are now opportunities at
Yale for us to incorporate this kind of
treatment into earlier stage patients,
patients who are candidates for surgery.
So we can consider immunotherapy prior
to surgery potentially to reduce the
risk of disease spreading to think
about reducing the stage of of disease.
And ultimately to improve the outcome
for our patients,
we know immunotherapy is really well
tolerated in our surgery patients in
a clinical trial that we conducted
here at Yale and we identified that
these treatments don't delay surgery,
they don't impact how we do the surgery
and that patients respond to those
treatments in a very favorable way.
So we've been fortunate to be a part
of immunotherapy trials including other
cancer centers across the country.
You know,
we recently finished enrolling patients
in the study and the sort of the outline
of that study is a screen right here.
But basically what that means
is patients would come in,
get 2 treatments of their immunotherapy,
they'd go on to have surgery and
then after surgery,
the opportunity to have immunotherapy
for an additional 12 months.
We learned a lot from this trial.
We were enrolled a number of
patients in this trial.
Uh and a lot of patients across the country,
you know we have,
we had a really nice representation of Yale
patients in this trial and we learned a lot.
As I said,
we learned that immunotherapy is
safe in this setting.
It's an exciting opportunity
for our patients.
Tumors respond to immunotherapy in
our surgical population and we think
this represents an exciting time and
an exciting opportunity for patients
who are in our lung cancer program.
I'm going to be brief because
I know we're short on time.
Do you have any questions?
Probably for Scott.
Yeah. Maybe we'll take one question and
then we'll move on to our last speaker.
Anybody have any questions?
All right. Let's, let's hear from.
Thank you so much, Justin.
Let's hear from our last
speaker so and then we can.
Probably say a couple minutes extra
and answer questions for these last
couple of talks at the end. Great.
So Doctor Wilson is going to talk to
us about new treatments on the horizon.
You've kind of heard about where
we are today, where the kind of the
current state-of-the-art treatment
and management of lung cancer.
Now we're going hear about
new treatments on the horizon.
Thanks so much.
Great. Thanks, Sarah. You know,
so one of the really exciting things
for us in terms of being able to
work in the field of lung cancer is
that we often get the opportunity to
see new treatments being developed
and introduced into clinical care.
One of the recent really exciting
breakthroughs in lung cancer has
been the development of new targeted
treatments for a specific gene
alteration in a gene called kyras.
Now, we've known for decades
that K Ras is an important target
not only in lung cancer,
but in other cancers as well.
But for decades,
we've never had any good
targeted treatments against KRS.
But that's now changed in the last
couple of years with the development
of new treatments for a specific
alteration in K Ras, known as K Ras G12C.
We see this KSG 12C alteration in
about 12% of lung adenocarcinomas,
which is the most common subtype
of lung cancer.
And importantly,
just last year the FDA approved one of
these targeted KRAS G12C treatments,
a drug called soda acid for
patients with lung cancer.
And so currently right now,
research is going on both here
at Yale and elsewhere.
With clinical trials looking at
Sodor acid in combination with
other treatments and lung cancer,
which could include chemotherapy or
immunotherapy or any of the agents
shown in the diagram on the right there.
And so the goal is really to see if
we can cause even better outcomes
for our patients when treated
with the KSG 12C inhibitor in
combination with other treatments.
And importantly,
additional new treatments targeting K Ras
are also in development and are starting
to enter a clinical study as well.
So clinical trials like this
are exciting because they offer
an opportunity to bring cutting
edge new treatments to patients,
while also providing researchers with
an opportunity to learn from our
patients who are treated on clinical studies.
One of the things
that we're always looking for are
opportunities to bring some of the exciting
scientific discoveries that are made in
research laboratories at Yale into the
clinic for the benefit of our patients.
So we've heard already tonight from
Doctor Gettinger that immunotherapies
have really transformed lung cancer care,
but he also told us that these
therapies don't work for everyone.
And so a really important area of
research investigation is trying to
develop strategies to get immunotherapies
to work better and for more patients.
And so we're fortunate here at
Yale to have a new clinical trial
developed by Doctor Goldberg and.
Colleagues,
which combines immunotherapy with a
drug called pembrolizumab together
with an experimental targeted
therapy called Citra Vatnik.
And part of the,
the rationale for this clinical
trial was based on laboratory work
done by investigators here at Yale
that showed that a citrobacter nib
appears to be able to modify the
environment around the tumor to make
it more conducive to immunotherapy.
And so one of the goals of this trial
is to determine if immunotherapy might
work for more people if it's given together.
With Citron Apatinib,
so we're excited to have this as
a new potential treatment option
for eligible patients with advanced
non small cell lung cancer who are
interested in receiving their lung
cancer care as part of a clinical study.
And while a clinical trials like this,
as we've heard on multiple times tonight
represent an important component of
the research enterprise here at Yale,
there are actually other opportunities
for us to learn from our patients
as at Yale through research as well.
So we're very fortunate here that many
of our patients provide permission
for us to use some of their tumor
material for research studies.
They could be studies to help us
to try to understand factors that
contribute to lung cancer growth
and development or opportunities to
look for new potential treatments.
And so we recently found a new potential
target that was actually identified
from a lung cancer of a research
study participant here at Yale.
What we found is shown there in
the upper right.
We found that there was an alteration
in this patient's tumor that
abnormally brought together and
joined two separate genes,
which gives rise to what
we call a gene fusion.
And this sort of caught our
attention because we know that.
Gene fusions like this are important
in contributing to the development
of certain lung cancers.
And so when we we can then sort
of take that potential target and
now introduce it into cell models,
which allows us an opportunity to
study the potential target and to
ask questions like what is the new
target do and where is it located.
So if you look at the bottom on the far
right there with this particular gene.
Fusion.
What we saw when we put it into
cells is that it actually goes
to the plasma membrane,
so that surrounds and outlines the cell.
You can see that with that
green circular rim there.
But just below that,
with a slightly different
version of the target,
you can see that it's localization
completely changes and now it's located
throughout the inside of the cell.
So insights like this are important
because they help us understand what a
potential target might be doing in the cell.
And we can also use these models to
be able to test different treatment
strategies to try to find ones that
might be able to work against the target.
So you know, research like this is really
only possible with the participation
of our patients here at Yale.
And so you know,
we're always excited by the opportunity
and privilege to be able to partner
with our patients to help us to try
to better understand how lung cancers
can develop and to hopefully better
develop better treatments for patients.
So I'm happy to take questions.
Thank you so much, Rick.
That's so cool. I love those pictures.
Well, we are past the hour.
So many amazing questions and discussions
and talks that we went past our time.
I I will just leave the floor open
for questions for another few minutes.
If people want to stay or if
you need to go, we understand.
Any last questions?
Anything in the chat down?
We need to address.
Thank you all for coming.
Thank you for participating in research
for those that have and thank you for
letting us care for you if that's
been the case and. We're
always available for questions and
always available to look after
anybody that that's interested
in having this be involved.
Doctor Herbst, did you want to say something?
I see you on on your video still.
No. Well I I watching here by
video and I'm very proud and
honored to be part of this team.
I think that the key to the
best care is innovation,
but also a multi modality approach
and I think what we've seen tonight
is that we really need to combine.
Surgery, radiation therapy,
chemotherapy,
pulmonology and supportive care.
Altogether we're the best
molecular diagnosis,
the best drugs to try to you
know really push progress forward
and and it's great to see so
many people in the audience.
I wish I was there tonight.
I'm actually at a conference in Washington
you know designing new clinical trials.
But thank you Sarah and and Dan
for a wonderful moderating.
And thank you to all of our speakers
and also to Renee Goddard and.
And Nelson Dagada,
for all their work on this.
Yes, I second that.
Thank you to everyone,
to all of our speakers and participants.
I think people will probably
stick around for another minute
or two if anybody has questions
and wants to come up to the front.
Thank you all so much again for joining
in person and virtually and see you
next year or maybe next week. OK.