Lung Cancer Awareness Month: Global Perspectives on Treatment and Equity With MedNews Week and Oncology Data Advisor
In this Lung Cancer Awareness Month video, members of Oncology Data Advisor and MedNews Week join forces to share global perspectives regarding treatment, equity, and patient advocacy in lung cancer.
Oncology Data Advisor: Hi everyone, and welcome to this latest podcast collaboration between Oncology Data Advisor and MedNews Week. I'm Keira Smith, I'm the Senior Editor at Oncology Data Advisor. We have a pretty exciting episode today planned in honor of Lung Cancer Awareness Month. We'll be discussing some of the global perspectives in lung cancer that everybody brings to the table here. To start off, we'll go around and have everyone introduce themselves. Starting with the OncData side, Dr. Kareff?
Samuel Kareff, MD, MPH: Hi, good afternoon, everyone. I'm reporting here from the East Coast of the United States. My name's Dr. Samuel Kareff. I'm one of the Chief Fellows at the University of Miami Sylvester Comprehensive Cancer Center at Jackson Memorial Hospital. I'm pleased to be joined by my international colleagues today.
Gayathri Pramil Menon: Hi everyone, my name is Gayathri Pramil Menon. I'm a fifth-year medical student from the country of Georgia. I'm also an Associate Director here at MedNews Week along with Muskan and Maduri. I'm really happy to be here and so excited to be learning a lot from Dr. Kareff as well.
Muskan Joshi: Hi everyone, my name is Muskan. I too, like Gayathri, am a fifth-year medical student at Tbilisi State Medical University in Georgia. I'm super excited and happy to be here, see what we can bring to the table with Oncology Data Advisor, and see what global perspectives we all can share today. Thank you so much, I'm looking forward to our discussion today.
Maduri Balasubramanian: Hi everyone, my name is Maduri. I'm also a medical student from the same university as Gayathri and Muskan. I'm really excited for today's session. Like Gayathri mentioned, all three of us are Associate Directors as well at MedNews Week. I'm really looking forward to learning a lot from Dr. Kareff as well as learning a lot more from the whole discussion today.
Dr. Kareff: Awesome. In honor of Lung Cancer Awareness Month, like we mentioned, this is a great collaboration between not only our networks but also our countries. Thinking globally, it's important to mention that lung cancer has many faces, not only in terms of the patients that it afflicts, but also the types of cancers it includes. I'd be remiss not to mention that today is November 10th, which is also International Neuroendocrine Cancer Day, of which we know lung cancers tend to be the second most common site of disease outside the gastrointestinal (GI) tract. With that perspective as we start the day, I was hoping we could talk a little bit about lung cancer patient advocacy and how that looks either in your institution, country of origin, et cetera. I'd like to open that question up to the panelists.
Gayathri Pramil Menon: I think in terms of patient advocacy, it's really a unique perspective for all of us because we are Indian, but we were born and brought up in different countries outside of India. We're in the Gulf Cooperation Council (GCC), so I live in the United Arab Emirates (UAE) right now. It's very different in the Middle East versus how it is in India. In terms of advocacy, we have certain nonprofit organizations in both countries, but in India, there's a lot of stigmatization, I would say, when it comes to lung cancer patients. There are a lot of cultural and societal differences, as I'm sure you're aware. In Western medicine, you guys have allopathic medicine, but in India, we have a lot of traditional medicines; we have homeopathy, we have Ayurveda, and it's really different. A lot of people go for different sort of medicines.
When we look at patient education and disease progression, it all depends on when you catch the disease. A lot of people aren't educated enough about lung cancer symptoms, and when they are, it's already too late. It's a really sad thing to see. But definitely, we have rural areas and urban areas, and in urban areas, patient advocacy is significantly well-developed. In the UAE, it is amazing. It's so vast, and it's exactly the same as Western medicine. Patient advocacy is one of the biggest things that you can see over there. Our professors say that we are not just treating the disease, we're treating the patient as a whole. I think that's really amazing to see both sides of the spectrum, be aware of how you see both sides, and be well-educated. You get the best of both worlds basically.
Maduri Balasubramanian: To add on to what Gayathri said, something that I have noticed that's different between India, the UAE, as well as now currently in Georgia, is that in the UAE in specific, there is a focus not specifically on lung cancer, but oncology-related issues in general. They have a lot of key organizations, such as the Emirates Oncology Society, where they manage different kinds of oncology-related issues in care. They focus not just on the topic itself, but also prioritize awareness, education, and support equally. Something that we commonly see over there is that there's good support from both health authorities, governments, as well as patient support groups. It's like a good triage, in a way.
I think that is something that's very important, whereas in India, something that I know personally that I've seen is control initiatives. In many places, especially rural areas, there's a lot of tobacco use, so there are a lot of tobacco control initiatives that are being bought about. Also, given the strong link that we are seeing with smoking and cancer, there are more policy changes rather than awareness alone and more government-related initiatives. For Georgia, since it follows a lot of the European patterns, we see not only foundations, but we see more clinical networking, research opportunities, and policy advocacies. That's something I've noticed that's a big difference between these three countries in my perspective. Maybe you guys will change my perspective, as well.
Muskan Joshi: I definitely have to agree with what Maduri said, and she brought up a very interesting point about India—how, rather than screening for and preventing lung cancer, there's more of a control scenario and more policymaking changes. I feel like one of the reasons perhaps could be the sheer size of the population. There are just too many people and not enough oncology specialists. The specialists that are there in the country are some of the most talented and most brilliant oncologists all over the world, for sure. But I don't believe that it is what is required for the huge volume of population. India in general does have a huge problem of tobacco, as well as a huge consumption of so many different types of Ayurvedic medicine or herbal medicine, which may not be as great. There is just a lot of misinformation.
When you couple that with the huge population, the lack of specialists, and the volume of specialists that we need for treating such a huge epidemic, there is a huge problem. I truly believe the one way to bridge this gap is to, first of all, have education programs, which they do. I have seen it. Whenever I have been to India, I have seen the education programs, and I've seen the awareness, but we need to go a step beyond just putting a certain advertisement or a certain thing in a movie. We need to go a step beyond that, and we need to be personally involved with patients and people who we believe are at risk. We need to educate them and their families. Rather than shaming these people and telling them to stop, we need to genuinely intervene and help, because I truly believe prevention is always better than a cure. If we can't get to that step of having a cure, why can't we prioritize prevention? I believe India has a lot to develop in that sense.
When I talk about UAE, I personally have not observed that many cases of lung cancer. The last statistic I read said that there were about 265 new cases of lung cancer in the country in the span of a year, so there's not a huge volume. At the same time, I believe UAE has great patient advocacy. Again, I feel like it really comes down to the population. There are a lot of great specialists and great facilities which can help facilitate proper treatment and proper diagnosis, which is the gamechanger for all of this. In general, UAE does have very high-precision, minimally-invasive techniques. Patient advocacy is great. It's very much like the American health care system, I would say, in terms of the research that goes on.
In Georgia, as Maduri and Gayathri said, they follow more of the European approach. There's a lot of novel research. When I have been on rotations with my professors, I see genuine care, and I see that these doctors genuinely want to help. I have definitely seen that in Georgia, that the treatment is high quality. The problem is that that European countries in general have a huge smoking problem. Lung cancer cases are quite high here. Smoking is incredibly normalized, so the volume of cases is high, which is why I believe the doctors here are very well-equipped and the research here is very well-centered for lung cancer therapies and diagnosis.
You're really able to see how these three countries differ in their approach to treatment of the same disease. It's interesting getting to be at this international platform. I really believe it's so important to have a very global perspective, especially when it comes to treatment. I would say we're truly privileged to be in this position.
Dr. Kareff: Wow, I'm humbled to hear about all the experiences that the three of you bring and to hear about not only country systems, but patient populations you've been able to learn about through your training. I think that's really excellent. One adage that comes to mind is, "An ounce of prevention equals a pound of cure." I think that's something that holds truer and truer every day. On the North American front, we have several patient advocacy groups in the lung cancer space as well. Several come to mind, but for example, EGFR Resistors and KRAS Kickers. They provide that education piece that the three of you alluded to and how important that is to make sure that stigma and discrimination are minimized. Also, things like just being aware of your own body, being aware of side effect and toxicities and that sort of thing, are just so important as we think about patients with lung cancer. Thank you for sharing your perspectives, that was truly wonderful.
The next thing I was hoping we could talk about—and we have addressed it a fair amount in the first round, but maybe we could dive in a little bit more, if possible—is lung cancer and recent updates in equity, especially in lower/middle-income countries. I don't know if any of the three of you have seen, in any of the countries that you've worked and lived in, any updates in lung cancer in this space?
Gayathri Pramil Menon: In terms of equity in different populations, we definitely have different subsets of populations. We have the very affluent people and we have the lower socioeconomic areas in a particular country. In terms of equity, there's no debt discrimination when it comes to national policies or advocacy groups that the national government puts out. But we do have certain issues in equity when it comes to the lower socioeconomic areas where people aren't really educated and don't get the treatment that they need. We know that treatment is not one-size-fits-all, which is why we have personalized care and targeted therapies. They came about for a reason. My concern in terms of inequity or equity in general is the risk of screening. Everyone shouts, "Screening's the one thing you have to do, you have to screen," and all that. But there are many dangers when it comes to screening as well in terms of, let's say, false positives or over-diagnoses. There are definitely cases of lung cancer where someone who is not exhibiting any symptoms but still gets diagnosed with cancer might not benefit or even need treatment. But because of that so-called screening and guidelines that people have kept in place, people still get those treatments, and that impact does more harm than good.
All these things come to mind when we talk about equity, and I definitely think that the government and national organizations need to take a closer look at this and show that it's not, again, one-size-fits-all. We need to screen each and every person, and we also need to figure out when to screen that person and see when does a particular person needs treatment? At the end of the day, we're not just carrying the person's burdens; we are also carrying their family and friends. Cancer is something that affects a family, a community, as a whole. I think all these things have to be kept in mind, and this is just my perspective. I would love to hear what you guys think as well.
Muskan Joshi: Adding on to that, there are some pretty interesting statistics that highlight the disparities that exist between lower/middle-income countries and high-income countries and the cancer detection rate and survival. Recently, I read that around 70% of cases and 70% of deaths that occurred due to lung cancer worldwide are in lower/middle-income countries. Another very interesting statistic that came to my awareness was that only 26% of lower/middle-income countries reported to have a pathology lab in their hospital settings, while in higher income countries, it was 90%.
When I read these statistics, I sat down for a moment, because that's something really terrible. That's not even getting to the inequity in treatment; this is just having a pathology lab. A pathology lab, you would think, would be a bare minimum. You take an average American hospital, they will have a pathology lab. You take an average university hospital, they will have a pathology lab. It is something that is the key for confirmation of diagnosis, but only 26% of lower- and middle-income countries report having a pathology lab. I feel like we need to get back to the very bottom, which is to ensure that there are proper facilities and proper labs, which can at least help in the diagnosis of lung cancer—and not just lung cancer, any form of cancer. I cannot imagine someone being so sick with cancer and not knowing about it, and potentially passing away from it after suffering for years before that.
Diagnosis is the key. Diagnosis brings closure to people. Diagnosis brings peace in some way or another. But it's a sad reality that so many people in lower/middle-income countries don't have, which higher income countries have. This was something that really stood out to me. Some things that you would think are the bare minimum do not even for many people and many countries. And this is just about the diagnostics and the pathology lab; we also have to realize that so much of the latest research and clinical trials that are happening do not even get to those countries in many cases. Immunotherapy is something that really interests me, and I have realized that immunotherapy and combinations of chemotherapy and immunotherapy are a farfetched reality for so many lower/middle-income countries.
The US is at the forefront of research, but it's going to take decades for these latest technologies to even get to one big hospital in some lower/middle-income countries. I believe everyone deserves to have a fair shot at life. But seeing the income disparities, and seeing that the resources for health care facilities in these countries don't even reach hospitals, really angers me, because lives are precious. Research is important, research is happening, and I truly hope that in the coming years, we're able to somehow bridge this gap and ensure that there's a fair distribution and that the world moves together rather than some countries ahead while some people suffer, just because they are not from that certain country. There are so many advancements that are happening in oncology every single day, and it's a gap we have to bridge. Statistics are there, we know the reality, and I have seen so many programs working toward it, which I'm so happy about. I'm pretty early on in my career, I'm still a med student, but it's something that I'm passionate about, so I hope I can follow this route when I am in my clinical practice.
Maduri Balasubramanian: You've both honestly covered everything, but something I would add is that to say that something is completely an equitable landscape is going to be very difficult, because it's a complex and an ongoing effort. Since there are multifaceted challenges that contribute to disparities, there are many steps that need to be taken to achieve the perfect landscape for individuals affected by lung cancer or those who have a history or need screening. I think it requires collaboration on various levels of health care delivery, community engagement, policy development, transport, finance, and so much more, even cultural aspects. This is going to be a very long process, but we can see how there are a lot of different distribution stages and a lot of opportunities that are coming up right now with so much awareness happening, in this current generation especially. We might see better changes as we go forward, but it's definitely going to be a long and hard road.
Dr. Kareff: Again, I'm really awestruck by the contributions here, because there are just so many aspects of each of these perspectives we can comment on. Reflecting on my own experience, I feel quite privileged. I work in a public hospital in the United States which has access to a pathologist, lung cancer screening, and things like advanced diagnostics. The majority of my patients who come from countries that are traditionally thought of as low/middle-income—predominantly Latin American and the Caribbean—actually have access to at least basic services here in a US-based system as a high-income country. I wonder if there's more we could do. I guess stay tuned. We've got organizations like the Union for International Cancer Control and initiatives like Access to Oncologic Medicines which are striving to bridge that gap, but there's clearly a lot more to do. Thank you for sharing that.
The last topic I was hoping we could address while we're here on the call today is discussing any advances in either COVID therapeutics or related research as they relate to lung cancer patients. We know that the virus is generally thought to be endemic in most parts of the world now, but there are still high-risk populations, including patients with cancers like lung cancer and patients with immunosuppressed immune systems, like those on chemotherapy. Do any of you have any new insights to share related to this area of research?
Gayathri Pramil Menon: In terms of research that's really big in India right now, is people are really interested in anti–programmed death-ligand 1 (PD-L1) monotherapy, especially in older populations with non–small cell lung cancer. There's a lot of research that is going on, although it hasn't progressed far into clinical trials. If you think bureaucracy is bad in US, you should see India. It takes a while. A lot of people are interested, but there are only a few centers in a population of 1.2 billion, so we have very few resources to cater to everyone. That's something that's definitely holding us back. In terms of research and COVID, mid-2020 is when everyone felt the full wave and the influx of COVID was just massive. There are people still recovering from COVID. There was a huge rate of national deaths that were recorded. Those are the stats that were released, but I'm sure if you look at rural areas, there were a lot of deaths unaccounted for by the national census.
When you take all into account, there are people still feeling the repercussions of COVID. Even now, a lot of people who still have COVID but are asymptomatic, and a lot of people don't even know that they are carriers of it and haven't been vaccinated. The anti-vax community is not as big in India as it is in certain other parts of the world, because in India, when you get a cure, you're just really happy that it's there. That's not something that holds us back. But in terms of other research, when someone has COVID as well as cancer, the main thing that they go for is radiation as well as chemotherapy. The problem in certain populations is that there were cases, especially people who were inflicted with non–small cell lung cancer, where even after immunotherapy, it progressed past the post-radiation therapy. Now people are considering if it would be beneficial to give radiation as well as chemotherapy in tandem, and how can that be administered? That's something that people are fielding questions left and right as to how it can be implemented.
I think when it comes to cancer and research, again, it really depends. I would say the root cause of why a lot of deaths occur in our country is because of the lack of patient education. It depends on when you catch the disease. Disease progression, we can't control that. Everyone's body is different. Again, as I said, one size does not fit all in this case, but I would definitely say that patient education is crucial and something that we have to strive for. Otherwise, in terms of international oncological research, it's absolutely amazing what a lot of countries are doing. We have molecular and genetic testing in terms of EGFR, ALK, and KRAS testing, as you said. I think that's phenomenal. We definitely have a lot of imaging procedures, as well. But when it comes to implementing and enrolling these patients in clinical trial and considering the progression rates in different patients, that's something we need to keep a lookout for, especially in Georgia, as well as India. These two countries have very high smoking rates, so patient education, as I said, is something we need to prioritize as well.
Muskan Joshi: I completely agree with what Gayathri said with regards to COVID and lung cancer and the latest therapies. Speaking about COVID and lung cancer, I saw a very interesting statistic that in 2020, there was a significant drop in the diagnosis of COVID, which completely makes sense because we were overwhelmed. The health care systems were completely overwhelmed. We did not have places to admit people because all the doctors, all the nurses, all the health care workers were exhausted in the fight against COVID in that moment. Our health care systems in Georgia had a huge volume of cases.
In Georgia, the UAE, and India, one common factor was definitely that all the health care systems, all the hospitals, everything was exhausted. There was no manpower that they had for diagnosis. This was something common in all three countries. So, the diagnosis was low, and the amount of people diagnosed with lung cancer in 2020 to 2021 was actually decreased compared to that. And an interesting statistic is that from 2021 to 2023, there was a significant jump in diagnosis, which again, makes sense because now we are back on track and we are diagnosing cases that we woul have maybe caught in 2020, which would have increased patient survival. This was something similar that I noticed and have seen in my reading regarding lung cancer.
This is not related to any of the three countries, India, Georgia, or the UAE, but I also noticed that immunotherapy was a very popular therapy used during the COVID pandemic, especially for lung cancer patients. As I said, I find immunotherapy really interesting. It's something novel, and seeing its potential is something I'm really looking forward to. It was actually noticed that immunotherapy for lung cancer was one of the more popular therapies compared to pre-COVID times. There has been a lot of research lately, especially this year, which has talked about the great efficacy of using immunotherapy in small cell lung cancer and non–small cell lung cancer, especially treatment-resistant small cell lung cancer. That was quite interesting to me and was something that stood out to me.
Although we do know that COVID is a multisystem disease, its infection and its pathogenesis mostly begin from the lungs, and this is where the dissemination happens. You'd think you would see more research on the exact pathogenesis. I have done research in severe COVID in cancer patients, and there are many different mechanisms. Gayathri and I have worked on it, and it is something truly interesting. There are so many different immunologic markers and so many different immune responses that can describe and determine the patient's survival and disease progression, especially in cancer patients. But I have yet to see some study that truly elucidates how exactly the pathogenesis exists in lung cancer patients. There are so many different drugs that we can use, especially in patients who have severe COVID and cancer. It's truly something amazing .I would love to see more research and information on the pathogenesis, considering that one is lung cancer, and one is a disease that starts from the lungs.
Maduri Balasubramanian: Something I can further add to that is, like Muskan mentioned, it was a very difficult time, so nothing could be guaranteed. Because we only gained information as the disease progressed, the first thought was, "Oh, it's going to affect the immunocompromised, the old, or the very, very, young, and they're going to be the first ones affected." But later on, we saw that it affects pretty much everyone. We see different cases, different scenarios, and nothing can be guaranteed. Things are still being researched about it. A lot of the evidence that came out regarding cancer treatment and COVID-19 infection was mixed and contradictory in a way, because we would say that chemotherapy being an immunosuppressive factor could increase the risk of infection. But then later on, there were also cases studies saying that even after 30 to 60 days of patients being on chemotherapy, there was no change or difference in their prognosis or risk.
Then there were also cases regarding how diagnosis and imaging follow-up in COVID-19 and lung cancer patients also differ. Radiotherapy and pneumonitis can also be a factor, so nothing was really fixed. Right now, we're going into a stage where it's far easier to get diagnosed, like Muskan said, and far easier to get to the doctor once you have symptoms. Since we are learning so much more about it, we're starting to see a lot of initiatives. We don't really know what is exactly true yet, so I think that's what makes this a very interesting discussion, because there are still no facts that are known to be true. We want to keep researching it and identify more theories and facts. We are still talking about how pneumonia and influenza affects lung cancer patients, so I think that's why this is important to keep reading about, because it is something we will always be researching.
Muskan Joshi: We also have to recognize the psychological distress that lung cancer patients are in. I cannot imagine putting myself in a patient's shoes, especially during 2020 when everything was closing down. The world was on hold, and everyone was getting sick. So many millions of people were dying every day. Lung cancer patients are immunocompromised, and they knew that they could not get the treatment they needed because health care services were overwhelmed. It was just such a stressful and such a distressing time, and I cannot imagine the amount of psychological distress these patients must have gone through. I believe having some form of psychological counseling or therapy is very, very important for lung cancer patients, considering the distressing statistics that exist for these patients, especially in terms of mortality.
Even though we are at this point where we have amazing therapies, the mortality still isn't the greatest. I believe that these patients deserve support. Also, considering that psychological wellbeing is one of the key prognostic factors in survival, it's important that apart from therapies and the latest research and studying the latest developments, they also take care of their wellbeing. The COVID pandemic hit us all really hard, and it was especially hard for immunocompromised patients, especially lung cancer patients. When we talk about advocacy, when we talk about helping them, psychological factors and understanding the psychiatric distress that they must have been in is something very, very important to remember while treating and interacting with them.
Dr. Kareff: Again, there's a plethora of knowledge and experience that has been shared in these three perspectives. I think one unifying theme I've heard from the three of you is the importance of statistics and how this helps guide patients at any time, but especially patients with lung cancer in these difficult COVID times. We mentioned the issues with delayed diagnoses and delayed presentations, but one positive statistic that has remained true throughout the epidemic is that lung cancer patients' prognosis and overall treatment options have improved during the COVID epidemic. I can only cite data confined to United States, as that's in my expertise, but we know that the five-year survival rates of lung cancer have increased substantially in the last decade or so. Is immunotherapy the only reason? No, but it's surely a big one that's been contributing to that. We've had other advances in things like palliative care referrals, psychologic support, and that sort of thing, but overall, the horizon is bright despite the bleak times we've recently passed through, for sure.
To that end, thank you all so much for your cooperation with us on this unique partnership between our organizations. I really enjoyed learning from your global experiences. You have such a wealth of knowledge to share, and it's very exciting to see all the countries you've touched and those that you'll go on to help in the future. With that, I'll thank you again for your time. This was a wonderful international and global oncology collaboration. Thank you so much.
Transcript edited for clarity. Any views expressed above are the speakers' own and do not necessarily reflect those of Oncology Data Advisor.