You have to start a marathon to finish it
Published 7 November 2021
How step-by-step improvements in the diagnosis, treatment and care of lung cancer are offering hope to patients and their families.
Mark Brooke, CEO of Lung Foundation Australia talks with great passion and empathy for the families his organisation supports: “I came to the role as someone who had experienced both the great sadness and the great privilege of caring for someone living with lung cancer. My mother Roberta was diagnosed with small cell lung cancer in July 2012 and sadly passed in January 2013. Being the CEO gives me a great privilege to bring that personal insight but more importantly to represent the 13,000 Australians diagnosed with lung cancer every year.”
That representation of the lung cancer community has never been more important. Over the past few years, significant progress has been made in the diagnosis and treatment of lung cancer and, as a result, lung cancer mortality is declining.1 However, lung cancer remains one of the most prevalent and the deadliest forms, with just one in five patients still alive five-years after diagnosis.2
There is still a long way to go, but Mark is optimistic for the future. “I think in the past three to five years, there is a sense of optimism creeping into lung cancer. While the five-year survival rates remain woefully low, what we are seeing with the age of precision medicine is more treatment options being available to patients and certainly with the increased number of biomarkers and targeted therapies available, more opportunities to beat that terrible survival statistic.”
Treatment advances are moving at pace, but we mustn’t leave patient and physician communities behind
Lung cancer appears in multiple forms, affecting everyone in different ways. Each person receiving a diagnosis therefore has unique needs requiring tailored, innovative solutions. With advances in treatment and increasing numbers of treatment options, involving people with lung cancer and their families in making treatment decisions is critical to improving outcomes of people with lung cancer.
I had a lovely chat with a lung cancer patient and their family, I used the term adjuvant and they said, “What’s that Mark? Is that something new? Should I be on that?” I had to apologise - it’s almost natural for us to use language that is hard for people to understand.
As Mark notes, many patients don’t fully understand their disease, what stage they’re at or what the different treatment options are. “I had a lovely chat with a lung cancer patient and their family, I used the term adjuvant and they said, “What’s that Mark? Is that something new? Should I be on that?” I had to apologise - it’s almost natural for us to use language that is hard for people to understand”. Mark strongly advocates for greater patient empowerment by increasing the amount of reliable information and for physicians and patients to have open conversations to support informed decisions around treatment. “Ideally, I want everybody to be an advocate for their own healthcare.”
A typical treatment journey for people with early-stage non-small cell lung cancermore
"Historically, cancer drug discovery has been almost exclusively about developing new molecules in palliative settings," comments Charlie Fuchs, MD, MPH, Head of Oncology and Haematology Global Product Development, Roche. "There is a great unmet need in these settings as these patients are largely out of therapeutic options. Then, maybe 10 years after its first approved, drug developers contemplate investigating these medicines in earlier stages of disease. But while the goal is to evaluate if a new treatment may offer patients a higher chance of “cure,” these studies are also very long and expensive because they tend to be quite large.
As an organisation, Roche has committed to "mission cure", where we’re taking the risk in moving our cancer medicines into the earlier-stage settings. We know that people with lung cancer who undergo surgery have a 50% chance of their disease returning. In this situation, what we try to do is find if there is an additional adjuvant therapy, so that even if we don’t see any evidence of cancer today, we can reduce the likelihood of it coming back.
This is a fundamentally different approach to developing medicines, and the availability of new adjuvant treatments really are game changers for patients in this setting."
Endpoints and outcomes
There continues to be significant advancements made, with ongoing clinical trials exploring the use of targeted therapies and cancer immunotherapies in the adjuvant (after surgery) and neoadjuvant (before surgery) treatment of lung cancer.
In clinical trials, overall survival (OS), the time between a patient starting treatment and their death, is considered to be the “gold standard” endpoint, or measurement, to determine whether a treatment is working. While OS data can be available in just a few years for people with advanced-stage lung cancer, for studies in the earlier treatment setting it can take 7-10 years for mature OS data to be available.
This is where additional endpoints like ‘disease-free survival (DFS)’ may give a good indication of the patient benefit from treatment.6 DFS is the length of time after primary treatment for cancer ends that the patient survives without any signs or symptoms of disease.7 Before mature OS data is available, there is an opportunity for DFS to act as an indicator of efficacy and provide increased clarity for people with lung cancer and their families.
Measuring patient outcomes in clinical trials
Today, approaches that measure cancer treatment are more comprehensive – they look to extend patients’ lives and maintain quality of life.more
However, while DFS is becoming more widely accepted by health authorities and healthcare professionals as an endpoint of clinical studies to measure efficacy of new treatment options, there is a question over how well patients understand this terminology. Mark comments: “I think terms like ‘overall survival’ and ‘disease-free survival’ are confusing and patients don’t always understand what it means, however for me endpoints like DFS are really important and our patient community think it’s really important.”
As Mark notes, “I’ve met patients who have said, “I just want to be here for the birth of my grandchild so if you can get me another six months that’s my goal.”
The future is looking bright, but we must work together
Mark is hopeful that progress will continue to be made in earlier diagnosis, screening and the development of lung cancer medicines: “You would never have heard me talk about treatment with the intention of cure in lung cancer 10 years ago and here I am more optimistic than I’ve ever been about this.”
It will take a collective effort to continue to make a real difference to the lives of people living with lung cancer and to ensure that people get access to the individual support, care and education that they need. Mark draws inspiration from a moment that he has never forgotten: “On the day I started my job, some flowers arrived on my desk. I thought they were from my wife, but they were from one of our lung cancer patients - Carolyn Riordan. A passionate champion of our work in lung cancer and someone who always put others first, Carolyn sent me the flowers as a symbol of hope for all the patients and families we support. She knew that together we could change the world if we tried”.
- National Institutes of Health. Annual Report to the Nation on the Status of Cancer. [Internet. Cited October 2021]. Available from: Annual Report to the Nation: Cancer deaths continue to drop - National Cancer Institute
- Cancer.net. Lung Cancer - Non-Small Cell: Statistics. [Internet. Cited October 2021]. Available from:https://www.cancer.net/cancer-types/lung-cancer-non-small-cell/statistics
- Raman V et al. Surgical treatment for early stage non-small cell lung cancer. J Thorac Dis. 2018;10(Suppl 7):S898–S904.
- Uramoto H and Tanaka F. Recurrence after surgery in patients with NSCLC. Translational lung cancer research, 2014;3(4):242-249.
- CONQUER: Treatment of Non–Small-Cell Lung Cancer: A Guide for Patients. [Internet; cited October2021] Available from: https://conquer-magazine.com/issues/2020/vol-6-no-2-april-2020/1240-treatment-of-non-small-cell-lung-cancer-a-guide-for-patients
- FDA. Clinical Trial Endpoints for the Approval of Cancer Drugs and Biologics Guidance for Industry [Internet; cited October 2021]. Available at: https://www.fda.gov/media/71195/download
- NIH. National Cancer Institute. NCI Dictionaries - DSFS [Internet; cited October 2021]. Available at: https://www.cancer.gov/publications/dictionaries/cancer-terms/def/dfs