Lung Cancer Heroes Award Presentation

October 16, 2020
CURE Media Group

Conference | <b>Lung Cancer Heroes</b>

Watch the entire Lung Cancer Heroes program here!

Watch the entire Lung Cancer Heroes program here!

MS. KRISTIE KAHL:Hi, everyone, and welcome to today's live broadcast, the CURE Educated Patient Webinar in Lung Cancer.My name is Kristie Kahl, editorial director of CURE.We have a few important announcements before we begin.

We encourage you to ask questions during the event, when you can submit by typing them in the Q&A box.You'll be receiving a survey via email tomorrow.And, as a thank you for watching the full webinar and completing the survey, you'll be entered to win one of three Visa gift cards.

Through CURE's Lung Cancer Heroes' award ceremony, held on Thursday, October 15th, CURE, Takeda, and the advocacy community brought together the lung cancer community to end the stigma and form, connect, and empower anyone who has been impacted by lung cancer.Together, as one community, we can raise awareness of lung cancer, and, most importantly, we were able to recognize and celebrate the esteemed individuals contributing to improving the lives of lung cancer patients, our lung cancer heroes, Carolyn Baggett, Jennifer Garst (phonetic), Fred Hirsch, and Deborah Pickworth, as well as our lifetime achievement award recipient, Bonny Adario (phonetic).

We are pleased to be joined today by our panel, Carolyn Baggett, registered nurse and lung-cancer screening program [garbled] Florida, Dr. Fred Hirsch, executive director of the Center for Thoracic Oncology in the Tisch Cancer Institute at Mount Sinai and the Richard Stein, Joe Lowe, and Louis Price Professor of Medicine at the Icahn School of Medicine at Mount Sinai in New York City, as well as Debra Pickworth, a stage IV [garbled]. --talking about early detection, biomarker testing, precision medicine, and how COVID-19 has affected lung cancer.Hi, and welcome everybody.


MS. KAHL:We'll jump in to early detection first.So, Debbie, as a patient, and having lost your mother and your grandmother to the disease, do you think that early detection [garbled]?

MS. PICKWORTH:I'm going to answer, because you're frozen there.For me, early detection looks like, to me, just like breast cancer.You go annually.You get a low-dose CT scan.That's the only way, in my opinion, that you would be able to catch something like that early enough.I was 43 when I was diagnosed and didn't meet any of the criteria for getting diagnosed or even--It wasn't even on my radar.So, if that would have been offered to me, knowing my family history, I might have been stage I instead of stage IV.

MS. KAHL:Definitely.Dr. Hirsch, where do you think that we are [garbled]?

DR. FRED HIRSCH:Hello, I can't--you're breaking up.I don't know if it's from me or from you.But, hello.

MS. KAHL:Hi, Dr. Hirsch.


MS. KAHL:Hi.I just asked where do you think that we are in detecting lung cancer earlier stages?

DR. HIRSCH:So, lung cancer screening has been demonstrated to reduce lung cancer mortality significantly from 20-25% in the defined high-risk group.But, currently, we don't implement lung cancer screening very well.Only 4-5% of the individuals who are eligible for lung cancer screening, meaning from 50 years on up to 75, undergo lung cancer screening.So, we need to do a much better job implementing lung cancer screening in the communities.So, that is where we are currently.We know that lung cancer screening identifies much more early-stage disease than a control group.

Anyway, there are other means on the way from the research spaces.That is, for example, using liquid biopsy in the early diagnosis testing.This is for research in this space, but it is encouraging in itself, so hopefully that can in the future be an adjunct to CT scan.But, currently, our challenge is to get implemented lung cancer screening in the well-defined, high-risk population.

MS. KAHL:Okay.Hopefully, I know there might have been some issues.Carolyn, can you hear me now?Possibly not.I'll give that a minute.Debbie, to kind of go back.I know you had mentioned that you could have, with early detection, you could have been maybe stage I.So, when it comes to early detection--

MS. CAROLYN BAGGETT:Can you hear me now.

MS. KAHL:Yes.Perfect.I'll just finish out my question to Debbie really quick.When it comes to early detection, what is your advice for other individuals who think that maybe they might be at risk for lung cancer?

MS. PICKWORTH:I would say, number one, trust your gut.Usually, if you feel something's wrong, it is.Don't give up getting your doctor to listen to you.I had bronchitis, and I went back to the doctor four times until I ended up in the hospital with pneumonia, and I kept saying something's not right.So, I would say, number one, that.Number two, if you have a family history, regardless of what--there's no genetic link to it right now.Push for that, push for early CT scan.If you've got a cough that doesn't go away, ask your doctor about it.I think more education with more family physicians is priority one.Because, they don't ask that.It's not on their radar.

MS. KAHL:Okay.Absolutely.That's great advice.So, Carolyn, can you kind of explain to our audience what maybe some early screening options are.And, if you could, even better, offer examples from the screening program that you work on.

MS. BATTETT:Currently, there is lung cancer for patients who have a smoking history.You have to be age 55-77, and you have to have a cigarette smoking history.So, unfortunately, this does not cover nonsmokers.But, like she was saying, if you are concerned, have family history, we do have a self-pay option that you can still get your low-dose lung cancer screening.I'd recommend getting a lung cancer screening every year.We've had many patients who have had cancer show up in their third or fourth annual screening.So, it's just like getting a mammogram.You get it every year, because you never know when it's going to pop up.

So far, in our program, we've found almost 70% in early stage.Before lung cancer screening, a majority of the patients were found in stage IV, when they had symptoms, which is pretty sad.So, that's why lung cancer screening is now highly recommended.Unfortunately, only about 6% of eligible people get it.So, spread the word and tell everybody about it and that it's an option.

MS. KAHL:Absolutely.So, we did have a question come in from the audience.Carolyn, what can we do to screen patients who don't fit the well-defined at-risk category?

MS. BAGGETT:So, we still offer lung cancer screening to individuals who do not meet the category.It's just not covered by insurance.So, it would be a self-pay option.For us, at Baptist MD Anderson in Jacksonville, it's $115, which covers the scan and the radiologist to read it.If you have any symptoms, then you can do to your doctor, and if they're lung-cancer symptoms, he can order a regular CT chest to evaluate.

MS. KAHL:Okay.And, Dr. Hirsch, we had another question come in asking, are lower lobe nodules anything to be concerned about?

DR. HIRSCH:Which kind of nodule was it?I didn't--

MS. KAHL:It was lower lobe nodules?

DR. HIRSCH:Lower lobe nodule?Is that what you're saying?


DR. HIRSCH:Well, it is not about the location of the nodules.It is more the size and the picture of the imaging which is important.But, a lower nodule, depending on the size, in my opinion should undergo some kind of biopsy.I leave it to the surgeons to figure out what kind of biopsy should be there.But, if it is a suspicious nodule, it should be biopsied.For lung-cancer-screening detected nodules, there are some nodules [garbled] semi-solid.There are several terms and several characteristics of the nodules, and radiology people, they know what kind of picture is at high-risk for developing or being a malignant nodule.But, a solid nodule in the lower left lobe should have a diagnosis, in my opinion.

MS. KAHL:Okay.Carolyn, we also had somebody ask about what about screening of those who were exposed to second-hand smoke for many years?

MS. BAGGET:Unfortunately, insurance is not covering that.My mom was--I lost my grandparents to lung cancer, so she was very concerned, and she went to her doctor and discussed it with her, and her doctor actually ordered a regular CT chest.So, if you have a lung cancer screening program in your area, and there's a self-pay option, then I would highly recommend that, and you can get it done very year.The low-dose CT is about a third, 20-30% of radiation of a regular CT chest, so it's much safer.So, if you have any concern of that, I'd highly recommend that.

MS. KAHL:Okay.Then, we also had a question come in, and Dr. Hirsch, I guess you could probably take this one.Should patients be concerned if they know they've had radon exposure, or should they seek screening if that's [garbled].I don't know if he can hear me.Carolyn, if you can answer that, if you know.

MS. BAGGETT:About 10% of lung cancers are caused by radon.So, yes, I would be concerned, and you can order a radon test online.I just ordered one for my new house.It's about $15, and then you send it in, and they'll test and see if you have any radon in your home.If you have any exposure, I would definitely talk to your primary care doctor or your pulmonologist, and they may consider doing annual screenings on you for that reason.

MS. KAHL:Okay.So, Debbie, this one you could probably fill in.From the patient perspective, how do you think that we can get physicians to be more proactive in checking patients, or recommending them for screening, whether it's maybe the primary care physicians that we start with?

MS. PICKWORTH: Well, I guess I would recommend--I mean when you go to your doctor's, you fill out all these forms.There might be some kind of form added to there, specific to lung cancer, to make the doctor more aware, the family practice doctors, that there might be a family history.I would say probably that would be my first thought.

MS. KAHL:Okay.Then, Carolyn, just one more question, before we move on to the next section.We had a patient ask how do they even go about this then?Do you just ask your doctor if you can go and have a scan or if you're eligible?

MS. BAGGETT:Well, ultimately it is, even though it's a lung cancer screening, it's a CT chest.So, you do need an order.So, you will have to go to your primary care doctor.They will review the strict criteria that insurances require.If you meet that criteria, they can order and insurance should cover it 100%.If you don't meet criteria, then he can still order.It'll just have to be a self-pay option.

MS. KAHL:Got it.Okay.So, I want to move on.At the end, we do have time for 15 minutes of Q&A, so we can jump back to this, if we have to.But, we're going to move on to talk about biomarker testing.To start with this topic, Dr. Hirsch, can you just explain what biomarker testing is and why patients should be asking for it?

DR. HIRSCH:Absolutely, yes.Biomarker testing is crucial these days.We've learned that, particularly for patients who are presenting with advanced disease, stage III and IV, IIIB and IV, and we know that we have identified numerous targets, molecular abnormalities, which can be targetable for specific drugs.And, if you happen to have this specific molecular abnormality, then you have a very good chance to have a good response and good outcome for certain drugs, and much better than when knew from chemotherapy alone.So, it is important to have the molecular profile for each patient, and what we have learned now in advanced-stage disease is rapidly moving in the direction of earlier-stage disease, so molecular testing might, in the short future, be very important also for patients with stage III disease.

We learned recently about what we call the ADORA study for patients with EGFR+ tumors, who are not resectable, but still local/regional.The outcome there was very good when you give an EGFR-directed therapy.But, you have many molecular abnormalities, most common is EGFR.You have ALK, you have ROS, you have MET, you have RET, you have NTRK, and most recently you have KRAS abnormalities.So, the proportion of patients with search and what we call molecular driver is rapidly increasing.And, as I said, if the patients are within those categories, there are very good therapeutic options.And, practically all of those treatments are tablets or pills, which is much easier, much more comfortable, much more convenient, and have less toxicity, compared with traditional chemotherapy.So, that is the reason why molecular characteristics, what you call biomarkers, are important.

MS. KAHL:Okay.Debbie, as a patient, were you aware of biomarker testing, and, if so, how did you learn more about it?

MS. PICKWORTH:When I was first diagnosed, I wasn't aware.I was lucky enough.I was at my local hospital where I was diagnosed, and they did send it out for biomarker.But, they only tested, at that time--in 2013 there was only like four they tested for that were FDA approved.That's all they sent it for was anything they could target.I was lucky enough to find the right website at the right time and ask the right questions.So, I went to the second opinion, and they send it out, and I ended up having the BRAF mutations. Although there wasn't anything at that time that targeted it, at least I was aware of it, and I can keep watching.

MS. KAHL:Absolutely.So, Carolyn, how do you think that we can help to educate patients, so they can better understand the importance of biomarker testing?

MS. BAGGETT:Well, I think it's important, if you have a lung cancer diagnosis, to see an oncologist, because an oncologist will be educated on all the new biomarker testings that are coming up.It's changing every year, sometimes a couple times in the year.So, lung cancer treatment is definitely every changing, so it's great to have a physician who's up-to-date on that.The American Cancer Society has an awesome website that breaks down each biomarker test and treatment options and side effects, etc.So, I would highly recommend going on there to educate yourself to ask your oncologist about it.

So, these targeted drugs now are amazing, because we don't even know how long patients are going to live.They're living 10+ years now, which in the old days for stage IV cancer was unheard of.So, it's great.

MS. KAHL:Absolutely.Dr. Hirsch, we have a question from the audience.Can you discuss the accuracy of a tissue biopsy?

DR. HIRSCH:Accuracy of which type of biopsy?

MS. KAHL:A tissue biopsy?

DR. HIRSCH:A surgical biopsy or a fine-needle biopsy?I apologize, I couldn't.

MS. KAHL:That's okay.A tissue biopsy.

DR. HIRSCH:A tissue biopsy.Okay.The accuracy, if you are positive for a biomarker, then you have what we call 100% specificity.That means that you have this abnormality.If the biopsy is negative, the sensitivity, what we call what is the precision of a negative results, it is probably on the level of 90%.It gets better and better.We have more and more, better and better technology.Next generation sequencing is what we recommend today.

So, I will say that if you are positive, you are 100% sure you have this abnormality.If you are negative, it's probably 90% correct that you are negative.A tumor can be heterogeneous in its composition.Even if on the imaging you see a tumor, it doesn't necessarily mean it could be a biological homogeneous tumor.So, heterogeneity is something we have to give it, and we need to figure out how we - -.

For tissue biopsy, it is good.Liquid biopsy, I don't know if you will come back to that later, but that is the new thing in the diagnostic scenario.Again, if you are positive on the liquid biopsy, you can be sure you have this abnormality.If you are negative, then the uncertainty is more than compared to tissue.Then, we recommend that you eventually get a tissue biopsy.Does that make sense, what I'm saying?

MS. KAHL:Yes, absolutely.So, Carolyn, we had someone ask if you could repeat the suggested places for biomarker testing, or another patient also asked how do I find a good lab to perform biomarker testing?So, if you could go over that again a little bit.

MS. BAGGETT:The place to find out about biomarker testing and educate yourself is the American Cancer Society website.They have a tremendous website that explains every biomarker and the treatment and side effects, etc.I would also, if you get a biopsy, it's important to see an oncologist.I think primary care doctors and pulmonologists may not be as well educated as an oncologist about biomarker testing.They can actually request the tissue from where you had the biopsy done and sent it off.You send it to an outside lab, typically, to have the biomarker testing done.Then, we'll know which ones to order as well.

MS. KAHL:Okay.So, we had a couple more questions come in, but I'm going to move on to the next topic, and then we'll get back to some of these biomarker questions towards the end of our Q&A.With biomarker testing, obviously, we want to talk about precision medicine, and the testing is what helps kind of determine the best treatment options for a patient.So, Dr. Hirsch, can you explain what precision medicine is and how it works in lung cancer?Maybe if you would just want to give a couple of examples of types of precision medicine.

DR. HIRSCH:Yes.I gave an explanation kind of before, when you asked about biomarkers.But, to make it more clear, eventually, precision medicine means that if you have identified a molecular abnormality in your tumor, and when I say molecular abnormality, it means a molecular abnormality which we believe is the driving force in the disease process.We call this a molecular driver.That can be, as I said, EGFR.It can be ALK.It can be ROS.It can be RET.It can be BRAF.It can be MET.It can be NTRK.We detect more and more of those molecular drivers.Precision medicine is that you do have medicine which targets specifically these molecular abnormalities and treats the tumor based on that.So, it is very specifically directed treatment to this molecular abnormality.

MS. KAHL:Okay.Carolyn, as a nurse navigator, what are some of the most common questions that patients come in and have about these targeted treatments?

MS. BAGGETT:I think the most common question is how it works.Traditional chemotherapy typically kills healthy cells and bad cells, but targeted therapy targets the bad cells, the cancer cells.So, how I like to explain it is like a light switch.When you have targeted therapy, it turns off that marker on the cancer cell.So, it's like turning off the light switch.For example, EGFR is a growth factor, so it makes cancer cells divide and grow and spread.The medication actually turns off that mechanisms, like turning off a light switch, so the growth factor doesn't work, so it doesn't grow, and it gets smaller, and it stops spreading.Another common question I get is what are the side effects.It's typically an oral chemotherapy, rather than an IV chemotherapy, so the side effects are different.Some of the common side effects are fatigue, diarrhea, and skin problems, but they're typically much milder than traditional IV chemotherapy.

MS. KAHL:Okay.Great.Debbie, you've seen lung cancer over various generations, from your family members to your own diagnosis.Looking back to where we are now, how far do you think we've come when it comes to treatment options and the addition of precision medicine now?

MS. PICKWORTH:My mom died in 1997.Then, I was diagnosed in 2013.From that time, there wasn't a whole lot of change.But, I'd say from about 2014 to now, it's been crazy.Crazy is the only word I can think to say, because it's progressing so fast now, it's like people are noticing lung cancer more.The difference between is night and day between the times, just in eight years.

MS. KAHL:Yes, absolutely.So, with such advances and how they happen so fast really, as a patient, how do you--do you have any recommendations for other patients and how they can learn more, so that way they're their own best advocate when it comes to deciding on their treatment options?

MS. PICKWORTH:I would recommend, number one, the American Lung Association.If anybody knows the most about lungs, it would be them.They also have a patient group called Inspire, and you can also find people that have your own, the same thing you're going through, and ask questions.That's actually where I got my questionnaire is on that site, to ask my doctor when I was first diagnosed, just because I was looking and I found it by accident.Then, find support groups, find other people that are going through what you're going through.It's the scariest time you're ever going to have, the day someone says you have lung cancer, and most of the time it is stage IV.So, I always tell people, when I know that they're recently diagnosed, find your people, ask questions, and be your own advocate, and never go to a doctor's appointment alone.My husband is the one always right there with his note pad.

MS. KAHL:Absolutely.That's fantastic advice.Dr. Hirsch, we had a question come in from the audience.Are there any new treatment options for EGFR when targeted therapies, like Tagrisso and Iressa have failed?

DR. HIRSCH:Well, when Tagrisso, or what we call osimertinib, has failed, that is still an open space.Many doctors will at that time give chemotherapy.We know that immunotherapy, which we haven't talked about here in the webinar yet, I guess you will come back to that later, we know that immunotherapy does not seem to be so effective for patients who have previously progressed on an EGFR treatment.But, there are many clinical trials currently in this situation, and what we are working on is also to do molecular profiling after Tagrisso treatment and see what is the molecular profile at that time.The industry today is trying to develop drugs which can target specific EGFR re-treatment mechanisms.That is the situation you are asking for, right?

So, the answer to your question today will be we don't have very specific therapies, unless the patient has a well-defined molecular abnormality after EGFR therapy.That could be a MET and MEK abnormality, or something.But, in general, most doctors will give chemotherapy after EGFR therapy.I guess that's also your question, right?

MS. KAHL:Yes.Okay.Great.So, I want to kind of move on to our fourth topic, and we'll definitely address some of these questions at the end.So, we're moving on to COVID-19, which I know has obviously affected a lot of individuals across the country, in particular with a lot of symptoms and signs that can be similar to a lung-cancer diagnosis.There's been lots of concern within the cancer community.

So, Debbie, can you just tell us a little bit about your experience throughout this pandemic and how you've stayed safe and healthy during these trying times?

MS. PICKWORTH:Well, I have a little bit of a different experience, because I actually progressed right when COVID locked everything down.So, my treatment plan was changed, because surgeries were being canceled, and I ended up having to do radiation rather than removing a gland.I think that's really scary for lung cancer patients right now.I think the one thing that makes me really nervous is not only for me, but all those stage I cancer patients whose surgeries got canceled, and at the most critical time.They should not have been cancelled.I get COVID, but I wish they would have done a better job figuring out, like separating COVID from cancer hospitals.So, my experience wasn't the best with COVID.Even now, I'm doing chemo, and I have a lung infection, but now I try to do all my stuff video, unless chemo, just so I don't have that slight chance of getting COVID.I see my family less.That's probably the hardest thing I would not even just say cancer patients, but anybody who's high risk.Just doing nothing but Zoom, because you can't really have people in your home.So, that is probably my big thing.

MS. KAHL:Absolutely.Do you have any advice for other lung cancer patients that are probably going and feeling the exact way you have this entire time?

MS. PICKWORTH:I would say I know--I would say make sure you find a support group that is--obviously, it can't be in person right now, but the Zoom support groups are excellent.I have monthly support groups.I have two of them, one for my BRAF group and one for--I run a Michigan lung cancer group.So, we do Zooms monthly.If you can come on my Zoom, you can.I invite other people in.I think it's important to have that one-on-one, even if it's just through a screen.It helps me tremendously.

MS. KAHL:Absolutely.So, Carolyn, with that, do you have any recommendations as a nurse that you can offer for patients with lung cancer during this time and how they can continue to stay safe?

MS. BAGGETT:I think Debbie put it perfectly.Virtual visits are wonderful.I know patients really like to keep a personal connection with their physician, and you tend to get pretty close to your oncologist, because you tend to see them a lot.But, you can have your visits virtually, and avoid that risk.

If you do have to go in to the office or to get treatment, like chemotherapy, like Debbie was saying, it is important to take all the necessary precautions, stay at least six feet away from people.Don't share elevators with other people.Go on an elevator by yourself.Wear a mask.Wash your hands.Don't touch your eyes or your nose.When you leave, make sure you wash your hands really well and be really cautious of what you touch afterwards.

Like Debbie was saying, having Zoom meetings with your family and your friends is great, because you can still keep that connection, but yet keep yourself safe.Unfortunately, with lung cancer, your immune system, or any kind of cancer, your immune system is compromised, and that makes you at higher risk to catch another infection, whether it's flu or COVID-19.So, it's important to take some extra precautions.

MS. KAHL:Absolutely.Dr. Hirsch, is there anything in particular that patients should know about the virus, and if or how it affects their lung cancer?

DR. HIRSCH:Say it again.There is something--

MS. KAHL:Yes.Is there anything in particular that patients should know about the coronavirus and how or if it affects their lung cancer?

DR. HIRSCH:Unfortunately, in the pandemic, patients who were hospitalized for lung cancer and COVID unfortunately there was an aggressive course of COVID injection.But, I think today, we know much more about the disease.We know much more about the virus, and we know also much more about how to handle, manage the situation.There are some treatment options.So, I think the situation today is much better than it was in the beginning of the pandemic.But, I have to say that we have still much more to learn how COVID-19 and lung cancer go together.That is exactly what my group is working on, which we just got a big grant from NIH to study the immune response, the immune defense, in lung cancer patients who are infected with COVID, and we will later study the same thing for patients who are vaccinated for COVID.

But, again, we need to be very preventative around our lung cancer patients.We need--they are very vulnerable in this situation, and we need to take the best measures, preventative measures, we can around the precautions, family members, etc., etc.That is the best advice I can give.

MS. KAHL:Okay.So, Carolyn, I think you touched upon this, and I know Debbie had mentioned telemedicine earlier as well.What do you recommend in making sure that patients are still keeping up with either their screening or their treatment while obviously still having to worry about social distancing and quarantining?

MS. BAGGETT:Well, it is certainly important to keep up with your visits with your doctor.I would not delay cancer treatment, just because you can't go in to see your doctor or you're scared about getting COVID and you don't want to get your treatment.Even delaying lung cancer screening, if you have lung cancer at an early stage, if you delay the screening and you delay the treatment six weeks, it increases mortality by 14%.So, I can't even imagine if someone has a later stage lung cancer.So, it's very important to take the active measures to fight your cancer, while taking the precautions to be safe.Virtual visits are certainly the best way to do that.Obviously, if you have to have chemotherapy or radiation, you must go in to the office, but take all the precautions that I suggested earlier.

MS. KAHL:Absolutely.This isn't exactly COVID related, but kind of, with flu season coming up, should a person who is going through chemo get a flu shot?

MS. BAGGETT:That might be a question for Dr. Hirsch.

DR. HIRSCH:I would say yes.I will definitely say yes.Whether you are a lung cancer patient or a cancer patient, or in another vulnerable category, yeah, I think it is important, particularly this year, to get the flu vaccine.

MS. KAHL:Okay.Great.Okay, so we're going to jump back in to some of our Q&A for everybody.I'm going to just kind of jump around a little bit.But, Carolyn, someone asked, if you have a BRCA-2 gene, does that qualify for insurance coverage for screenings?

MS. BAGGETT:It does not.The specific criteria are you have to be age 55-77, you have to be a current cigarette smoker or quit cigarettes in the last 15 years, you have to have a 30-pack-year history or more, and you have to be asymptomatic.So, the BRCA gene is not part of that criteria unfortunately.

MS. KAHL:Okay.Another question that came in, Dr. Hirsch, if you could take this one, do all stages of lung cancer need to get biomarker testing?

DR. HIRSCH:Well, the treatment related to biomarker testing today is mainly for patients with advanced disease.There are some data in patients with stage III disease.I mentioned the EGFR study earlier in this session.But, for patients with very early-stage disease, we have not yet a clear role for biomarkers and approved treatment.But, there are many studies going on currently for patients with very localized disease, so our policy in my institution is that we do biomarker testing on all patients.

And why do we also do it on early-stage disease patients?Well, unfortunately, many of them will sooner or later have the risk of recurrence of the disease.Then, we know their biomarker profile already from the early beginning.So, that could be a reason for doing biomarker testing on early-stage disease.But, the guidelines so far are focusing on biomarker testing for patients with advanced disease, meaning stage IIIB and IV, potentially IIIA.

So, what about histology?Does that matter whether you have an adenocarcinoma or squamous carcinoma?The answer is yes.The molecular abnormalities occur mainly adenocarcinomas.The targetable abnormalities do not occur--they do occur very rarely in squamous carcinomas.However, the recommendation is that if you have a young patient with squamous, if you have a patient who is never-smoker, the chance of having a mixed tumor is higher, and the chance for having a molecular driver is higher if you are a never smoker, if you are younger.So, for those patients, even if it is a squamous histology, we would recommend molecular testing.

MS. KAHL:Okay, great.Carolyn, we had a question come in.How do we go about changing the early screening criteria?

MS. BAGGETT:The USPSTF actually has some recommendations to expand the criteria, to lower the age to 50, and then to lower the pack-year requirement to 20-pack-year instead of 30.Those are in review right now.We hope that they approve them, because that will certainly increase the number of people that can get screened.After that, I think it's just being an advocate for lung cancer patients and being a strong voice for like Go To and other organizations to help them expand the criteria even more.

MS. KAHL:Absolutely.Debbie, as a patient advocate, how do you think, and why do you think others should get involved, so maybe we can change some of these criteria?

MS. PICKWORTH:Because, right now, I think the smoking stigma needs to change.Because, just based on what you said the criteria was, and I already knew that, but I didn't meet any of those criteria, because family history ain't one of those criteria, unless you also smoked.I smoked for less than six years when I was a teenager, less than a pack a week, so it wasn't under my radar at all, and I was only 43.And, I've met so many other young, we all them young lung cancer, patients that would never have met the criteria.

So, I think more people need to be involved just to advocate just for a change for that, because the more people who advocate for something, the higher your chances are of making it happen.

DR. HIRSCH:Yes.That is a very good point.As a matter of fact, only 20-30% of lung cancer fit in to this screening defined category.So, it is absolutely right.You see more younger patients, more never smoker or very little smoking history, and they are outside the range of the time category, and what are they doing with those?Well, I would like to see more studies, so we have a scientific background to recommend lung cancer screening in those groups.But, it is clear for me that lung cancer screening category should be expanded, but so far, we don't have the solely scientific data to base it on.

Another thing is also, and that is often clearly on the time, disparities, minorities, they are very vulnerable and the lung cancer screening data doesn't really take that in to account.There needs to be a much stronger focus in the future on disparities and all the challenging challenges related to that.We get more and more data saying that the lung cancer screening criteria does not favor at all the black community.They are out of this range, and they are not reached by our screening mechanisms.So, we need to put some effort, not only in younger and never or smaller amount of smoking history, but we need also to focus on minorities and diversity populations.

MS. KAHL:Dr. Hirsch, we also had a question come in, and I'm not even sure if there's enough research behind it, but someone did ask if vaping should also be added to the criteria?

DR. HIRSCH:What, excuse me?

MS. KAHL:Vaping, like v-a-p-i-n-g, vaping?

DR. HIRSCH:I apologize.I didn't catch the question.

MS. KAHL:If vaping, like with the e-cigarettes.

DR. HIRSCH:Oh, vaping.Okay.Is vaping a part of this, is that what you're asking?

MS. KAHL:Should it be a part of the criteria, yeah?

DR. HIRSCH:We don't know that.We don't have the scientific background.We certainly believe that vaping is not healthy.We have a focus on the research on the vaping, and we believe it is damaging, like smoking.But, we need much more data to answer that question.

MS. KAHL:Okay.So, I want to jump back to biomarker testing.Carolyn, and I think this is a question that we get a lot, just because there's so many terms that are out there for these different--some people call it biomarker testing, some people call it genomic testing.So, can you kind of dispel that myth and explain how they're kind of the same thing and maybe help patients better understand the terms?

MS. BAGGETT:Biomarker testing is we're basically testing certain genes, from what I understand, of the cancer.Then, the drug that you get is actually targeted to that particular gene to turn it off.Dr. Hirsch might be able to expand on that as well, if he'd like.

DR. HIRSCH:Well, in my opinion, the terminologies are saying the same thing.Biomarker testing, genomic testing, and molecular testing, what they all say, in my opinion, is that it associates the precision medicine, as we talked about, and all terminologies are identifying molecular abnormalities, which can be targeted with specific drugs.We call this, in the professional way, molecular testing, but there are several terms for the same thing, in my opinion.

MS. KAHL:Okay.We also had a question.Should annual biomarker testing be recommended for patients being treated with lung cancer?I guess the real question is, Dr. Hirsch, how often patients be getting their biomarkers tested?

DR. HIRSCH:There is no recommendations for follow-up testing.The recommendations currently are that the patient should have molecular testing at time of diagnosis for lung cancer.We are changing the culture currently to include molecular testing also if the patient progresses on firstline therapy.But, that is not yet fully implemented all over.After therapy, we don't have any recommendations for molecular testing, unless we are talking a patient who had surgery, and unfortunately, later on has a recurrence.Of course, at that time, it is needed for biomarker testing.Again, the research goes very much in the direction of liquid biopsy, which is blood based molecular testing, and that is so much easier to give than tissue testing.So, whether we need to follow patients in the future, I don't know.That will be based on the research.

MS. KAHL:Okay.Great.Unfortunately, we are out of time.Thank you so much for everybody who joined us today, as well as Debbie, Carolyn, and Dr. Hirsch.We really appreciate it.If you would like to watch this webinar on demand, it will be available on within the coming days.Again, thank you to our panelists and our audience for attending and participating in today's event.Don't forget to check your email tomorrow for the survey, and you'll be entered to win a gift card.Thank you all for joining, and we'll see you next time.Thank you and good bye.

MS. BAGGETT:Thank you.

DR. HIRSCH:Thanks.