Lung Cancer Awareness Month: A Fellows Forum Panel With Waqas Haque, MD, MPH; Samuel Kareff, MD, MPH; and Matthew Hadfield, DO

Oncology Data Advisor: Hi, everyone. Thanks so much for tuning in tonight for this Lung Cancer Awareness Month panel discussion. I'm joined by a few members of our Fellows Forum. We have Dr. Sam Kareff, who is a Hematology/Oncology Fellow at the University of Miami; we have Dr. Waqas Haque, who is a third-year Internal Medicine Resident at New York University; and we have Dr. Matt Hadfield, who is a Hematology/Oncology Fellow at Brown University.

We'll be talking today about some recent research in lung cancer diagnosis and screening, disparities, as well as ways to raise awareness for both patients, the public, and the health care community. I'm really looking forward to having this conversation today, and with that, Dr. Kareff, I will turn the conversation over to you.

Samuel Kareff, MD, MPH: Thanks so much, Keira, and thank you all for tuning in. It's a humbling day. It's the start of Lung Cancer Awareness Month. We have a love-hate relationship with this disease. We love to take care of the patients who are afflicted by it, and we hate the disease and try to get rid of it. I'm really honored that we're able to kick off this month.

One of the topics that I was hoping to bring to the panel and the public's attention, and we've discussed it in previous episodes, is the changing face of lung cancer. I'll never forget my first encounter with a lung cancer patient. I was a second-year med student in 2015. She was a young Latina patient down here in South Florida without any smoking history. In fact, she had never even touched a cigarette in her life, and she had stage IV lung cancer. I was shocked at how someone who had never touched a cigarette could be diagnosed with stage IV lung cancer. I had entered medical school with a lot of preconceived notions. There's a lot of stigma, both in society and even within the profession. That's something that's always been of interest to me, to see how the face of lung cancer is rapidly changing.

What does the rest of the panel have to think about this, or maybe share their experiences with the changing face of lung cancer?

Matthew Hadfield, DO: I think from my perspective training in the last couple of years, it's been pretty remarkable to hear stories from attendings that have trained in the early 2000s into the last five to seven years about how rapid the field of lung cancer has evolved. There are targeted therapies, first with epidermal growth factor receptor (EGFR) and now ROS and MET inhibitors, and with KRAS being a drug-able target now. In the treatment of non–driver-mutated non–small cell lung cancer (NSCLC), we have the addition of immunotherapy to chemotherapy, and we've seen just how much that's impacted overall survival for that patient population. Like you said, it's a disease where we like to take care of the patients; it's a horrible disease, but we've made such huge strides and it's been pretty remarkable to see how it's evolved.

Dr. Haque: Thanks for sharing those insights, Dr. Hadfield. To me, what's really interesting with the shifting demographics of cancer incidence is really the change based on age. Now we're seeing females at age 30-49 in the United States outpace the number of males in that same age range that are being diagnosed with cancer, even though the decline in smoking has been a pattern both for males and females. Although, interestingly, at least from the data we have, the peak and decline in smoking in males actually occurred around the year 1965, about two decades before women in 1985. Just thinking about this from a global trend, what's interesting is that even though there's a decline in the percentage of smokers in the world by 10%—just due to urbanization, industrialization, and population growth—there are actually more smokers in 2020 than there were in 1990. There's still a lot of basic primary and primordial prevention that we need to work on.

Dr. Kareff: I think those are both really great points. To build on Dr. Haque's a little bit, it's really fascinating to have the numbers in terms of epidemiology that we're seeing, with the changing face. The Lancet just released a large global report outlining the incidence and prevalence of lung cancer by histology. Like he alluded to, what we're seeing is that adenocarcinoma, which is traditionally less affiliated but not exclusively unaffiliated with tobacco exposure, is being seen more commonly in young patients and women over men. I don't think that only smoking trends can explain this, I think that has a little bit of stigma associated with it as well. We've got to better understand what's going on, and this is one of the research aims I've shared with this Forum before.

Dr. Hadfield: I think you raise a great point too. I was just thinking of a patient that I took care of as a first-year fellow, a 43-year-old teacher who developed metastatic lung cancer. He developed back pain and had to have surgery, and he was found to have EGFR-mutated non–small cell lung cancer. One thing that didn't really dawn on me until I began my training in oncology fellowship was the stigma that you allude to. He would constantly come to see me for appointments and talk about how people would say, "Oh, I didn't know you smoked," or "It's too bad, maybe you shouldn't have smoked." He never smoked in his entire life. It was something that he really carried with him that people would feel this way, and it's an important part of taking care of this population that I don't think we appreciate enough.

Dr. Haque: I'm still a resident, and we have a Veterans Affairs (VA) primary care clinic where I have the privilege of treating the veteran population, which is sort of a 50-, 60-, 70-year-old male population. A lot of them, of course, had gotten to smoking at a time when there was less public health awareness and data about how bad smoking is for you. I think there can be different challenges with talking about screening and talking about quitting smoking based on the patient population that you have.

Dr. Kareff: Absolutely, both great points as well. To build on that and switch the gears a little bit, let's talk about lung cancer screening. I actually just saw a tweet about 15 minutes ago from the White House Office of Scientific Technology Policy reminding the public that November 11th is National Lung Cancer Screening Day. Here in the US, we have both funded and encouraged programs in lung cancer screening, though we've seen uptake very slowly in the majority of the country, unfortunately. How have both of you integrated lung cancer screening into your personal practice, and what changes would you like to see with the guidelines perhaps?

Dr. Hadfield: One thing that I could speak to here is that in Rhode Island, we have an enormous deficit in the amount of patients that are eligible for screening for lung cancer, actually getting the testing done. One of the attendings here, Nazia Khan, got a grant from Bristol Myers Squibb (BMS) and subsequently a clinical trial to work on access to screening for lung cancer through different initiatives and outreach programs. We've actually seen an uptick of almost 80% more patients now getting lung cancer screening than before. What we've really demonstrated is that outreach to primary care clinics and having dedicated coordinators to try and get these tests on people's radars, as well as scheduled, really made a huge difference. But I think on a whole, being more involved in the treatment of lung cancer side of things, we see people that end up having lung cancer detected, but I still think that we have leaps and bounds ahead of us to get more and more people screened. It's something that we all have to work on.

Dr. Haque: I was actually walking just the other day in Manhattan, and I saw a poster of a person going through a computed tomography (CT) scanner and getting screened for lung cancer. It was sort of interesting, because it doesn't really talk about the caveats of lung cancer screening or about the inclusion/exclusion criteria for different patients. I think what's important from a primary care perspective is really just finding the appropriate patient to screen. If you have a patient that's not taking their hypertension medications, if they're missing follow-ups, that's very different than a patient who is going to all their appointments and who you know is going to be reliably screened and getting their annual low-dose CT scan.

I think what's really been effective for me is a shared decision-making approach where we can talk to about the costs and the risks and benefits of lung cancer screening. One of the great things we have about the VA-integrated care is that I don't always have to have this conversation. Usually, I can just put an order, and then the patient will have a dedicated appointment where they'll get a call from a counselor who can actually talk more about the merits of lung cancer screening, and then they can go from there. So, it's a little bit different in the VA system.

Dr. Kareff: Absolutely, those are both nice real-world anecdotes there. I think that the screening and identification pieces are super important because in a busy primary care clinic, there are a lot of problems to go through in very limited time. I think that problem is well-known, although less well-addressed. But even looking one step forward, looking at folks who are possibly eligible for lung cancer screening, at least according to current Centers for Medicare and Medicaid Services (CMS) criteria, I'm not sure we're going far enough. We've shown in some research at my previous institution that folks, especially of racial and sexual minorities, are not necessarily always included. That being said, it needs to be balanced, right? If you've got a big, convoluted model through which you have to put a bunch of variables and see if your patient does or does not qualify, that adds time. That takes away from shared decision making, as you alluded to. It's tough. I know the field is working towards being more inclusive, but it's just taking its time, unfortunately.

All right, one last topic I was hoping to address with the panel today is looking at biomarker testing and how we're doing here, both nationally and globally. Do either of you have thoughts on that?

Dr. Hadfield: Yes, Dr. Kareff and I were speaking offline before the talk started, and there's an enormous deficit in the amount of biomarker testing that's happening globally right now, particularly in the United States outside of large academic medical centers. At our center, we have in-house reflex paneling, so anyone who has a histological diagnosis of non–small cell lung cancer automatically gets an actionable mutation panel including KRAS, EGFR, MET, et cetera. It really is remarkably important. If you think about these patients who can receive targeted therapies, I mean, 20% of patients have EGFR mutations. If you think about the number of patients that are getting that testing done throughout the country, it's a really, really important thing. I think that's something that we all need to keep in mind and that we all need to try and raise awareness about, because it does make a huge difference for patients.

Dr. Haque: Following in along with what Dr. Hadfield said, I think there's a lot of work that we still have to do. I think one of the encouraging points is that over the recent years, we have seen an increased global presence in cancer research of trying to find patients from other countries and trying to increase this trend into precision medicine. A second thing is the role of artificial intelligence (AI) and machine learning to help use natural language processing and other kinds of methods to automatically identify patients by chart who might be eligible for pre-cancer screening, especially patients who are from underrepresented demographics. There's a lot of work that we can do, but I think the future is bright.

Dr. Kareff: I love to hear the idea of applying AI into that space. It certainly would be helpful, especially if there are issues in access to either cancer treatment generally or in specific areas, wherever that patient might be.

I think another point that we have to address, even at our fellowship level, as we enter into the market of health care, is payer reimbursement for biomarker testing. A lot of insurance policies, or even lack thereof, don't necessarily allow for comprehensive biomarker testing. I know in my state specifically, our advocacy organization, the Florida Society of Clinical Oncology (FLASCO), in conjunction with the American Cancer Society's Cancer Action Network, is appealing to make sure that all health plans, such as Medicaid, are reimbursing this appropriately to make sure that folks have trial access open to them. If we translate that point on the global scale, like we were also mentioning, that becomes even more complicated, because then we're getting into single payer models, limited resources, and that sort of thing. But at the end of the day, as physicians, I think it's our duty and our moral obligation to advocate for our patients and make sure we can get that reimbursed or paid for in whatever way possible, because it's the best thing for them.

Dr. Hadfield: Absolutely.

Dr. Haque: I totally agree. Just adding onto that, I think the example of colon cancer is really cool because we saw Cologuard and different kinds of non-invasive tests for colon cancer that were very expensive, costing over a thousand dollars, and now there are increasing patient eligibility rules under Medicare and other groups to cover it. Hopefully we can transfer the same thing to lung cancer.

Dr. Kareff: Absolutely. I know our time is running slightly short, but I was wondering if any of the panelists had any other points they were hoping to make today.

Dr. Hadfield: No, I think these were some remarkable discussion points. I'll reiterate that biomarker testing is important in non–small cell lung cancer, and I'll just say again that this patient population deserves the best care regardless of whether they have smoked or not. There is a large stigma around funding cancer research for lung cancer patients, and we have to work really hard to break that stigma.

Dr. Haque: Just to add on to Dr. Kareff's points from the beginning, there's a stigma that smoking equals lung cancer, but there are a lot of other variables that we still need to identify in literature and real-world data. Chronic obstructive pulmonary disease (COPD), for example, is an independent risk factor for lung cancer separate from smoking. There's actually a lot of work in radiomics where we're looking at adiposity and other measures of body size tags, not just to predict response to immunotherapy for lung cancer, but also, in particular, mortality for lung cancer as well. If we can really hone in on this data, we might be able to find screening parameters for patients who don't fall into that sort of conventional box where they quit 15 years ago, smoked this many pack-years, and are above 55 years old. I think the future is bright.

Dr. Kareff: Absolutely. As I reflect on our discussion today, I have two take-home points. One is for the public, which is just to remind everyone that anyone with lungs can get lung cancer. That could include tobacco exposure, or that could not include tobacco exposure. But that is the point here, and that's what we're trying to raise awareness of today. For the physicians and other providers who are listening today, I think what we've heard is that we are moving the needle, we have a lot more to go. If you can contribute in any way, whether that's through your community, through your research, or through both, go ahead and do it. Now's the time.

Well, I guess that's it for our panel today. Thank you all for listening, and happy Lung Cancer Awareness Month. I hope you're able to improve the life of a patient with lung cancer or any cancer this month.

Oncology Data Advisor: Awesome, thank you all so much for participating in this discussion today. I'm glad we're able to raise awareness of these topics, and it's great to hear about all the research directions that are being taken to address these disparities. Thank you again to everybody for tuning into the discussion today, and stay tuned throughout the month of November as we'll be posting some more Lung Cancer Awareness Month content. Thank you again and have a great night.

About the Panelists

Waqas Haque, MD, MPH, is a third-year Internal Medicine Resident at New York University in a Clinical Investigator Track. Dr. Haque has balanced his patient care work with a variety of research projects. He hopes to begin fellowship training next year in Medical Hematology/Oncology at an academic program with opportunities to further his work in innovative clinical trial design, value-based care delivery to cancer patients, and becoming an early-stage clinical investigator.

Samuel Kareff, MD, MPH, is a Medical Oncologist and a Hematology-Oncology Fellow at the University of Miami's Sylvester Comprehensive Cancer Center and Jackson Memorial Hospital in Florida. He has special research interests in health advocacy, public policy, and the development of cancer therapies.

Matthew Hadfield, DO, is a Hematology/Oncology Fellow at Brown University/Legoretta Cancer Center in Providence, Rhode Island. His research focuses on melanoma and early-phase clinical trials. To date, he has published numerous peer-reviewed articles and studies and has presented his research at multiple national and international meetings. His main areas of interest include early-phase drug development, novel immunotherapeutic combinations to overcome therapeutic resistance, and predictive biomarkers for immunotherapy toxicities.

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Transcript edited for clarity. Any views expressed above are the speakers' own and do not necessarily reflect those of Oncology Data Advisor.