Update in lung cancer: Prologue to a modern review series (2015)

Many years ago, lung cancer was a rare disease. While tobacco control efforts have helped reduce the number of smokers in many jurisdictions, lung cancer sadly remains the biggest cause of cancer deaths in many countries. The huge reservoir of former smokers who have done the right thing and given up smoking but still have an elevated risk of developing lung cancer compared with never smokers means that numerically, lung cancer may be more frequently diagnosed in former than current smokers. Thus, contemporary lung cancer screening studies target people at high risk, such as those recruited to the largest randomized controlled trial of computed tomography screening, the United State National Cancer Institute National Lung Cancer Screening Trial.1, 2 This was the first study to show a benefit on mortality from a screening modality and is hotly debated and discussed in terms of effectiveness, cost-effectiveness and implementation. In addition, advances in health technologies have resulted in new and improved ways of investigating suspected lung cancers. Such advances include endobronchial ultrasound, navigation bronchoscopy, ultrafine bronchoscopy and others. In addition to diagnostic improvements, staging continues to evolve and consolidate its place as the most important prognosticator and factor influencing treatment planning once a bronchogenic cancer has been diagnosed. The old paradigm of only needing to diagnose lung abnormalities as cancer versus benign, and non-small-cell lung carcinoma versus small-cell lung carcinoma is also challenged as molecular testing comes to the fore, given the demonstrable benefit from targeted agents such as epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors for those people whose cancers harbour activating EGFR mutations,3, 4 and similarly for anaplastic lymphoma kinase inhibitors.5, 6 On the other hand, chemotherapy alone or as adjuvant or in combination still remains a vital tool in the therapeutic armamentarium. Furthermore, the combination of systemic chemotherapy with molecular-based therapies and different forms of immune therapeutics are being evaluated. Therapeutic innovations are not limited to systemic therapies; modern radiotherapy and surgical techniques should mean better local treatments, less toxicity and improved outcomes. Indeed, the complexity of diagnosis, pathological and molecular typing and systemic treatment choices mandates an effective multidisciplinary approach to lung cancer care, which more and more is becoming standard practice. How to do this well remains a challenge given the large numbers of lung cancer, especially in countries where there are significant rural and remote populations. We are a long way from making lung cancer a rare disease again, but the investment and modern innovations in the biomedical and technological domain are finally starting to bring benefit to the clinic. No longer can it be said that we have no effective prevention, screening and therapeutic strategies. Today, we can say to the patient and their families that we have effective treatments, and the challenge is to choose wisely those that will serve to benefit them in terms of patient-centred outcomes. Personalizing choices and the use of precision medicine for lung cancer is on the horizon, and it is incumbent on clinicians to keep abreast and learn how best to exploit these tools to benefit our patients. Genomics including next-gen or more accurately termed massively parallel sequencing is just starting to make its impact felt in the clinic.7, 8 Thus, we commend to you this state of the art review series from key clinicians and scientists from around the world, who have toiled long and hard to help change the reputation of lung cancer being the biggest cause of cancer deaths in many parts of the world. It is our greatest pleasure to help Respirology introduce these timely educational reviews with the sincere hope that many lung cancer patients will benefit from our communal effort, coupled with the clinical skills and expertise of our readers. No one deserves lung cancer; every patient deserves effective treatment!