ISSUE 2

14TH MAY 2016

APLCC 2016
INSIGHT
APLCC 2016 | IASLC ASIA PACIFIC LUNG CANCER CONFERENCE

SBRT HOLDS THE PROMISE

OF CURING EARLY STAGE
NSCLC
reducing the inconvenience of six week
courses of conventionally fractionated
radiotherapy. This is a treatment which
requires considerable precision and accuracy
because it is a very high dose of radiation
and is not suitable for every type of cancer.
What is important to ensure is that cancer is
not near vital organs and the patient should
not have had previous radiation to that area
before. We have been using stereotactic
radiotherapy to treating brain tumours for
about 20 years but for lung cancer it is only
in the past 10 years that it has become a
popular method of treatment. It is usually
preferred for cancers under 5cm in
diameter, so for very large cancers it is not
a very suitable treatment said Professor
David Ball, Chair of Lung Service,
Peter MacCallum Cancer Centre, Australia,
and Member, APLCC 2016 International
Committee. Prof Ball is also the recipient
of IASLC Merit Award (2011) and
Editor-in-Chief, Journal of Medical Imaging
and Radiation Oncology.

Prof Ball
Stereotactic Body Radiation Therapy
(SBRT), also known as stereotactic ablative
body radiotherapy (SABR), has been a
major development in treatment of lung
cancer in last few years. It holds the promise
of not only curing early stage operable non
small cell lung cancer (NSCLC) but doing so
with patient comfort and convenience; and
minimal toxicity.
SBRT is a course of very high dose radiation
treatment capable of sterilizing or getting
rid of the cancer with 1-5 abbreviated
doses over one to seven days, dramatically
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One of the problems in using this method

in treating lung cancer is that the cancer is
usually moving during treatment as patient
is breathing in and out. Therefore giving a
highly focused and precise form of treatment
to something that is moving is not a straightforward problem. We overcame this problem by using four-dimensional CT scanning
which can map all the positions the cancer
will occupy during the breathing process and
to target all possible positions, or only those
positions for part of the breathing cycle (a
process called gating) added Prof Ball.
(Continued on page 2)
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ENTERING THE
IMMUNOTHERAPY
ERA
In the past two decades, chemotherapy
and targeted therapy have established
their major milestones in lung cancer
management. Recently, the strong evidence
of checkpoint inhibitors has emerged as
the coming of immunotherapy era in
cancer therapy. This therapy promises to
be a groundbreaking new approach to lung
cancer. But this new science also poses new
questions: it works incredibly well for only
some of the patients, so identifying a robust
biomarker will be essential.

Prof David Carbone

At APLCC 2016, we spoke with Professor
(Dr) David Carbone who is a globally
recognized expert in this field. Prof Carbone
is the current President of the International
Association for the Study of Lung Cancer
(IASLC); Professor in the Division of
Medical Oncology and leads the James
Thoracic Oncology Center at the Ohio
State University in USA. He has an active
research lab and has published a few hundred
research papers on lung cancer in his career.
(Continued on page 3)
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ISSUE 2

14TH MAY 2016

(Continued from page 1: SBRT Holds The Promise Of Curing Early Stage NSCLC)

which can be considered for a dose of SBRT. We need to do randomized clinical

trials to make sure that this approach does lengthen survival said Prof Ball.

Is the science of today, the technology of tomorrow?

There is emerging evidence of benefits of SBRT in managing early stage NSCLC
but lack of randomized clinical trial will keep raising valid questions, answers to
which can only be found by science!

Prof Ball

Can SBRT help in patients where

cancer has spread to few sites?
It is also feasible to give SBRT
in cases where lung cancer has
only spread to a very few sites
(Oligometastatic disease), is smaller
than 5cm in diameter and is in a
location away from the heart or
major blood vessels and airways which
could be damaged with this very high
dose technique said Prof Ball.
We have been commonly using
SBRT for treating patients with
oligometastases in the lung, as well
as to oligometastases in the bones
or adrenal glands, which in 90% of
cases will sterilize the cancer. It might
not stop the cancer from developing
in other parts of the body but it will
lengthen the period before the patient
needs an additional treatment.

SBRT and targeted therapies:

Boon or bane?
We have patients where cancer is
effectively controlled by one of the
new targeted drug therapies. However
if the cancer has spread to a few sites
there is a possibility that one of the
secondary cancers becomes resistant
to the therapy, while the others
continue to respond. We call this type
of cancer oligo-progressive. In such
cases we do not want to change the
medication as it is working on most of
the secondary cancers except one site

There have been two randomized clinical trials in US and the Netherlands to
evaluate if using SBRT is as curative as surgery in early stage NSCLC which is
not near heart or major blood vessels or airway, but these trials had to be closed
prematurely due to slow accrual. Surgery has a well-established role dating
back decades for the management of early stage operable NSCLC and so some
patients may like to stick with surgery. On other hand some patients may opt out
of surgery because SBRT is painless (like an x-ray) and does not involve any
anaesthesia or the risks and dangers of surgery, and has minimal toxicity with
better patient comfort and convenience.
Unfortunately these clinical trials were too small to be conclusive and we need
further studies to be done advocated Prof Ball.

There are SBRT related clinical trials

commencing in North America and Europe and
we may be joining one of these trials in Australia
too. Currently we have a research trial going on
in Australia where we are comparing one dose of
SBRT with four for oligometastatic lung cancer.
We hope to show that one dose of SBRT is as good
as four, which will be very convenient to the patient: each treatment only takes under an hour to
be delivered, no surgery or no anaesthetic is required, and there is a 90% chance that cancer may
be controlled

concluded Prof Ball.

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ISSUE 2

14TH MAY 2016

(Continued from page 1: Entering The Immunotherapy Era)

Immunotherapy era: New revolution in lung cancer treatment

Prof David Carbone

Added Prof Carbone: Driver oncogene targets are only found in

about quarter of patients of lung cancer in US. So still there are a large
number of patients who do not have these genetic targets. Excitingly
in the last couple of years we have a new treatment modality that may
be particularly effective in patients without these driver mutation this
is called immunotherapy. This is a type of therapy that harnesses your
own bodys immune system to attack your cancer. Current drugs that
are approved for this therapy are generally very well tolerated with
serious-adverse-events rate of less than 5%.

2nd & 3rd generation inhibitors reduced toxicity and Significant clinical activity is seen in about 25% of patients, or even
improved efficacy
higher if patients are selected for those with tumors over-expressing
When he started treating lung
cancer 25 years ago, there were
very few treatment options
available. Most patients of lung
cancer had no treatment at all.
Treatment options for lung cancer
back then were very toxic and not
very effective. About ten years
ago we discovered driver genetic
mutation that could be specifically
inhibited by drug and showed
dramatic responses in patients
in terms of improved symptoms
and prolonged survival. This was
a big revolution in lung cancer
therapy! Today we do not treat
non-small cell lung cancer
without knowing the genetic
profile of the patient. In last
couple of years we had the
introduction of new second and
third generation inhibitors for
these targets that have even better
efficacy and reduced toxicity for
lung cancer patients said Prof
David Carbone.

PDL-1. This clinical response is unusually long-lasting as well, with

many of these responding patients having very durable shrinkage
of their cancers with minimal toxicity. It clearly is a revolution in
treatment of lung cancer.

We still do not have all answers, research is on!

What we are striving to do now is to figure out the best way to select
patients for this therapy and to figure out additional immunotherapies
that may work in a patient who does not respond to PD1 pathway
inhibitors. One exciting thing about the discovery of mutations in EGFR
and targeted therapy was the possibility that we may uncover other
molecular targets. And we did just that with BRAF, ROS, ALK, Trk,
and many others! I have the hope that the efficacy of PD-1 pathway
therapy is just the tip of the iceberg, and that there may be many
potential immunotherapy targets that are yet to be discovered for
patients who do not benefit from targeted therapies for PD1 pathway
inhibitors shared Prof Carbone.
These are exciting times where we have new agents and we are trying
to learn on how to best combine them with targeted therapy,
chemotherapy, radiation, or surgery, and meetings like the APLCC 2016
are the perfect place to allow investigators to gather and share the latest
data available on these therapies and their combination. This will help
lead delivery of these state-of-the-art therapies to patients throughout
the world and IASLC is proud to be supporting this process concluded
Prof Carbone.
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ISSUE 2

14TH MAY 2016

DR LAM KAI
SENG, Consultant
Clinical Oncologist,
Malaysia

DR LE HONG
MINH, Clinical
Oncologist,
Vietnam

There needs to be more awareness about pre disposing

factors, like smoking, that contribute to lung cancer. Early
detection improves prognosis. Those diagnosed should
have access to the most advanced treatment available but
very high costs involved poses a challenge! We doctors in
third world countries are often faced with this challenging
real life situation - most often we are not able to offer the
best treatment to our patients simply because they cannot
afford it. So developed countries need to look at ways
to break this treatment divide between the haves and
have-nots. Pharmaceutical companies also should keep
humanity above self-interest and find a way out. Unless
this happens, costs will continue to escalate and patients in
low/middle income countries will never be able to afford
the latest optimum treatment

Vietnam has a very incidence of lung cancer. Main reason

for this is tobacco smoking and perhaps air pollution. There
are many diagnostic and treatment programmes available
to lung cancer patients. But lung cancer treatment costs are
very high and the poor cannot afford it. Treatment with the
tyrosine kinase inhibitor (TKI) afatinib costs about $2000
a month. The government pays about 50% of this. That still
means the patient pays about $1000 per month. This cost
towards lung cancer treatment is very high for people in
Vietnam keeping in mind that economy in the country is
not good. If prices are brought down even by 15% more
patients will be able to access good treatment. We need to
make affordable standard care a reality!

APLCC 2016 opens in Chiang Mai Thailand

APLCC 2016 opening ceremony

700+ delegates registering at APLCC 2016

Prof Sumitra Thongprasert at APLCC 2016 opening ceremony

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APLCC 2016 opens in Chiang Mai

ISSUE 2

DR WADE FANG,
Taiwan

DR YAO YINAN,
Lung Cancer
Researcher,
China

In Taiwan 99% patients are covered by the national

insurance system, but there is lack of awareness about
updated information on lung cancer diagnostics and
treatment - especially about immunotherapy and targeted
therapy. So very often, physicians are hesitant to provide
the latest options to the patients, as the cost is very high
and is not reimbursed by the government. Once these drug
costs are reimbursed, the situation will change. Let me take
the example of ALK inhibitor drug in targeted therapy
(TI). Earlier, most patients could not afford this type of
treatment, except those in clinical trials or those eligible
for compassionate use of it. But once the cost was reimbursed by government more people took it. Currently, more
than 80% of patients in Taiwan, who meet the criterion for
TI, are receiving it as first line treatment with very good
results

APLCC 2016 Chair Prof Sumitra Thongprasert

welcoming lung cancer experts

14TH MAY 2016

I do basic research in lung cancer, in the field of

immunotherapy and some immuno mechanisms of lung
cancer. Immunotherapy field holds a lot of promise for
lung cancer patients as gene mutations and changes in the
immune system are important causative factors for lung
cancer. I think immunotherapy and immuno regulations
of lung cancer is very important. Mechanisms of immune
response regulation in lung cancer need to be explored
further, especially for the adenocarcinoma - the most common
type of non-small cell lung cancer. Immunotherapy is still
not very much used in China. PD1 inhibitor has just been
introduced in China and is very expensive right now. So
costs will have to be brought down to be able to effectively
use the latest technology for diagnosis and treatment

Interactive sessions at APLCC 2016

Prof Sumitra Thongprasert APLCC 2016 Chair

welcomes all delegates

Delegates being welcomed at APLCC 2016

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Plenary and parallel sessions on Day 1 of APLCC 2016

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14TH MAY 2016

The treatment of locally advanced Non

Small Cell Lung Cancer (NSCLC) is
becoming a significant challenge because
of a growing proportion of patients with
unresectable stage III disease. Despite a
multimodality approach consisting in concurrent chemo-radiotherapy, the prognosis
remains poor. Before starting treatment,
the stage IIIA or IIIB status of the patients
need to be confirmed. They should have
had their CT scan, brain MRI and PET
scan done and, additionally, if possible,
their N2 status must have been proven either by mediastinoscopy or by endotracheal or endo-esophagus endoscopy. This

senior thoracic surgeon in Thailands oldest

and largest hospital - Siriraj Hospital,
Faculty of Medicine, Mahidol University
- and member, APLCC 2016 Local
Organizing Committee. Just like other
cancers, if lung cancer is diagnosed when
the disease is in an early stage then there
are more chances of cure with surgery. If
it is an advanced case of lung cancer then
chances of cure are less. Hence the first
thing is to identify whether N2 lymph
nodes are involved or not only then we
should progress ahead and manage patients properly. If it is N2 disease then we
need to further classify if it is bulky N2

DEALING
WITH STAGE
IIIA N2 NON
SMALL CELL
LUNG CANCER
(NSCLC)
ensures that they do not have metastasis,
their N2 status is known and the size of
the tumour is in the stage IIIA or IIIB said
Dr Francoise Mornex, Professor of
Oncology at the University Claude Bernard
in Lyon, France. She is also the Chairman
of the Radiation Oncology Department in
Lyon, Centre Hospitalier Lyon Sud, and
member of Board of Directors of IASLC
and APLCC 2016 Committee.

Investigative staging for mediastinal

node is key
Agrees Dr Punnarerk Thongcharoen, a

disease (advanced stage) or non-bulky N2

disease. For bulky N2 lung cancer, probably
appropriate chemotherapy and radiation
therapy might be a better option. For
non-bulky lung cancer disease, surgery
may still have a role. Usually we start with
chemotherapy and radiotherapy first and
then reassess if we are able to resect the
tumour said Dr Thongcharoen.
Some physicians and surgeons are still
relying on non-invasive staging approach
like CT scan or PET scan. We should
encourage treating doctors to get the status
confirmed whether it is N2 disease or not.
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So the key is to do investigative staging

for mediastinal node. We also need to
train more doctors to be able to do these
investigative staging procedures well and
encourage all healthcare professionals to
stay updated with the latest guidelines in
lung cancer management, he said.

Do not lose hope if NSCLC is

unresectable!
The focus of Dr Mornex is specifically on
those patients of stage IIIA N2 NSCLC who
are unresectable (cannot be operated upon)
because either their tumour is too big to be

surgically removed or they are inoperable

because of their local conditions due to
comorbidities. Most of these are fragile and
old patientstheir median age is 71 years
and they suffer from a lot of comorbidities,
because of their age and also because many
Dr Punnarerk
of them
are smokers. Thongcharoen
Dr Mornex explained that The current
treatment regimen for these patients
is concurrent chemo-radiation. But
unfortunately less than 50% of them are
able to tolerate this regimen because of
their advanced age and comorbidities.
For patients who cannot be treated with
concurrent
chemo-radiation,
mostly
induction chemotherapy, followed by full
dose of radiation, is done. This is called
a sequential treatment - chemotherapy
followed by radiation.
In those less than 50% of the patients who
can be put on concurrent chemo-radiation,
there is a choice of several drugs. Most
of the time we use a doublet - meaning 2
agents of chemotherapy - one of which
usually is cisplatin, if the patient is less
than 70-75 years old, and this can be joined
with another drug like Vinorelbine, VP16,
gemcitabine, or taxol. In case the patients
are fragile or of age 70-75 years or more,
we will use carboplatin instead of cisplatin.
So, if the patients condition permits, we
mostly use two agents of chemotherapy one of them being a platinum agent said
Dr Mornex.
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(Continued from page 6: Dealing with stage IIIA N2 NSCLC)

Regarding radiation, there is still a question
mark on what radiation dose is appropriate
to be delivered. But based on the results of
a large randomised controlled study called
RTOG 0617 that were presented in 2015, a
lower dose of standard radiation of 60 Gray
(Gy) gave better outcome in terms of median
survival when compared to the high dose
radiation. So the current recommendations
are to combine 2 agents of chemotherapy and 60 Gy of radiation, said Dr Mornex.

extremely important to compare the results of the same trial designed in Asia with those in other
parts of the world, because it is important to have responses of different tumours and a precise
tolerance profile to these new agents, especially when combined with radiation.

Changing scenario
Dr Mornex shared that,

What radiation technique should be

used?
There is a choice of using either the
technique of 3D conformal therapy or
Intensity Modulated Radiation Therapy
(IMRT). Dr Mornex informed that, In
the RTOG 0617 trial, 47% of the patients
received IMRT technique that gave better
results, even though the tumours on which it
was used were larger compared with those
on whom conformal 3D therapy was used.
Moreover IMRT has shown to also better
protect the normal organs, especially the
heart. So now for patients of stage IIIA N2
of NSCL cancer we should use 2agents of
chemotherapy, 60 Gy of radiation and, if
possible, IMRT technique for radiotherapy.

The way forward

The question for this stage of lung cancer is
to know how to integrate correct systemic
adjuvants, and more specifically, the targeted
therapy and immunotherapy. We have
some trials combining targeted agents and
concurrent chemo radiation, or trials
introducing targeted adjuvants before
concurrent chemo radiation or after chemo
radiation. We have tried GKI, Erlotinib,
Gefitinib and Cetuximab. But so far, for
tyrosine kinase inhibitor (TKI) therapy, none
of these agents, when used with concurrent
chemo radiation, have helped in improving
the results.
Added Dr Mornex: There are several
ongoing trials with new agents that might
hopefully improve the results. Some of these
trials are dedicated to Asia, because Asian
patients do not have the same mutations as
European or American patients. It will be

Dr Francoise Mornex

Now we are observing more nonsmoking and young patients

with this type of cancer - something which I did not
see 20 years ago in my clinical practice.
Obviously there are some changes in the chromosomes,
and we are not sure about the factors which are affecting the
genes in the mutations of our patients.
It has not yet been possible to show whether or not
this cancer in young patients or in nonsmokers will be
different in terms of outcomes for the same cancer in smoking
patients. But the good news is that for these patients we can
identify if they have some known mutations or not and if they
have this mutation we can propose to them very specific
treatments with good outcomes. So we will be able to personalise
the treatment that we are offering to our patients and by this way
also we should be able to improve the survival. One of the big
questions will be to know how to combine the new agents (which
are driven by the mutations of the patients) with chemo radiation
to improve results without increasing toxicity. I think with the
new agents and the combination of the new agents and the recent
radiotherapy treatments we should be able to dramatically
improve the results for this disease in a near future. Targeted
therapies and immunotherapy are likely improve the
management of locally advanced NSCLC in the future.

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14TH MAY 2016

QUOTES FROM KEY APLCC LEADERS

As in Western countries, lung cancer is the
leading cause of cancer death in many Asian
countries too. However, lung cancer in East
Asia is somewhat different from that in Western
countries. Typical examples are high prevalence
of EGFR gene mutations, or lung cancer in
non-smoking patients and low prevalence of
KRAS gene mutations. On the other hand,
healthcare system, for example, is heterogeneous
among different Asian countries. Therefore, to
hold a scientific meeting on lung cancer in Asia
like the APLCC is very important.
After the turn of this century, management of lung cancer evolved so
quickly. APLCC will provide a nice opportunity to catch up with the
latest advances of lung cancer research

"Greetings to the Delegates of APLCC 2016.

It is an honour for me to participate as faculty
and to address the topic of the emerging role
of immunotherapy of small cell lung cancer.
The partnership between APLCC and IASLC
continues to be highly successful. This 2016
meeting builds on that success. The meeting
will be far ranging in covering topics from the
molecular biology of lung cancer to immune
biology and immunodiagnostics as well as new
therapies and practical lectures for day-to-day
management of patients with thoracic malignancies. I look forward to
learning much at this meeting and I am pleased to be in attendance."

Dr Tetsuya Mitsudomi

Member APLCC 2016 International Committee and former
Member, Board of Directors, IASLC
President, Japanese Lung Cancer Society (JLCS)

Professor, Thoracic Surgery, Kindai University Faculty of
Medicine, Japan

Dr David R Gandara
Editor-in-Chief, Clinical Lung Cancer
Director, Thoracic Oncology Program; Professor and Senior
Advisor to Director, UC Davis Comprehensive Cancer Center, USA
Treasurer and member Board of Dirers, IASLC

I would like delegates to focus upon the

development of new surgical techniques for
treatment of lung cancer in its early stages;
and also how surgical procedures can help the
patients to improve their quality of life in later
stages of the disease, as surgery is mostly
used in early stages of the disease. In our
hospital we are now moving towards
screening patients early on. We would like
other oncologists to motivate and help people
to look for early symptoms and go for early screening. Mostly patients come to us in advanced stage of the disease when surgery is
not possible

A common mutation is ALK Translocation

which has resulted in aggressive type of lung
cancer, many of them are metastatic. We had
good drugs for such cases of lung cancers: 1st
generation drugs have been in the market for 4
years, and 2nd and 3rd generation drugs are also
being used now. At APLCC 2016 we should also
look at progress of 2nd and 3rd generations of
ALK inhibitors. At APLCC 2016 there will be
must-attend sessions related to immunotherapy
as well.
Palliative treatment is also an important part of lung cancer care. At
APLCC 2016 we will have several sessions on all kinds of palliative
treatments and care too

Dr Somcharoen Saeteng, co-chair of APLCC 2016 and Division

of Thoracic Surgery, Department of Surgery, Faculty of Medicine,
Chiang Mai University, Chiang Mai, Thailand

Dr James CH Yang, Director, Cancer Research Center, National

Taiwan University College of Medicine
Member, APLCC 2016 International Committee
Associate Editor (Asia), Journal of Thoracic Oncology

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