By Dr. H. Jack West
A couple of weeks ago, I described the new concept of a “tweetchat” about lung cancer, and we’re about to have our second of these tomorrow: Thursday, August 8th, at 8 PM Eastern, 5 PM Pacific time. The topic for this one will be about the growing trend toward personalized cancer care, breaking what was previously one broad category of “lung cancer” into a federation of smaller subgroups — defined by tumor histology, molecular marker results, smoking status, etc. But do we risk losing some hard fought unity by identifying “us” and “them” subgroups within the lung cancer community? Or can we subgroups who still come together toward a common goal of promoting lung cancer awareness, funding, and breakdown of stigma associated with the disease?
Specifically, we’re going to cover three subtopics that have led to identification of subgroups and the potential implications of this.
First, let’s consider smoking status, which certainly has biological relevance in predicting the probability of having certain clinically relevant molecular markers, but it’s also an emotionally charged variable. Lung cancer awareness campaigns often highlight that some victims of lung cancer never smoked, since so many people blame the victim with lung cancer as if they deserve it for smoking. Does this approach risk pitting smokers against never-smokers? Have we created antagonism within the lung cancer community between smokers and never-smoker, or is that increasingly likely as we focus on smoking status? Does the distinction of smoking status, which is relevant with regard to the biology of the cancer, cause people who smoked or continue to smoke feel worse?
Second, we’ve recently identified several important molecular markers present in only a small minority (1-10%) of lung cancer patients. In many cases, these have developed into major treatment advances, but just for these narrow patient subgroups. By testing for and identifying patients as having or not having an EGFR mutation, ALK rearrangement, etc., are we developing a lung cancer world of “haves” and “have nots”?
Finally, we now face the challenge of doing clinical trials in small subgroups that don’t have a critical mass of patients all in the same city or region with, say, an ALK or ROS1 rearrangement. We used to run broad trials for “all people with advanced non-small cell lung cancer” who have received a single line of chemotherapy. How can we feasibly do studies where there might be just 1-5 people in a single area who fit the requirements. Do those people with a rare mutation or acquired resistance to EGFR inhibitors, etc., need to travel to the handful of locations that have such trials? How can we best facilitate such trials being completed and new treatments becoming available for geographically dispersed small subgroups?
For those of you who already participate on Twitter and are able to join our live tweetchat, please join the conversation tomorrow: just filter for the hashtag “#lcsm”,follow the stream of comments that come in, and add that hashtag to your tweets. Otherwise, your insights and opinions would be very appreciated on all of these questions, whether before or after the live tweetchat, and I’d encourage you to share them here.