Update in lung cancer: epilogue to a modern review series (2016)

Despite commendable tobacco control efforts in various jurisdictions, unfortunately, lung cancer in 2016 remains the biggest cause of cancer deaths in many countries and a major burden on global health, as a major non-communicable disease. Indeed, the World Health Organization and other organizations are actively addressing the burden of non-communicable diseases.1 Furthermore, the Forum of International Respiratory Societies (FIRS), which includes the Asian Pacific Society of Respirology is taking a major initiative in addressing the global impact of lung cancer as one of the five main respiratory diseases. In recognition and support of these worldwide efforts to address this global health concern, Respirology has commissioned a modern series of reviews of lung cancer. These narrative reviews draw on the expertise of key leaders in lung cancer research and practice, in order to address the complexity of up-to-date lung cancer diagnosis and treatment, multidisciplinary team care and local and regional factors that influence knowledge translation. Moreover, the impact and benefits of state of the art health technologies are clearly placed in perspective, with counterbalancing issues of cost and performance. We sincerely thank the authors of these Respirology reviews who have provided valuable insight into contemporary management of lung cancer and have kindly draw our attention to gaps in knowledge and important future research areas for lung cancer. Lau and colleagues in their paper ‘Diagnostic evaluation for interventional bronchoscopists and radiologists in lung cancer practice’ discuss some of the major advances in the modern evaluation of suspected and diagnosed lung cancer to make sure that the right patient will receive the right procedure at the most appropriate time.2 The paper highlights include the role of computed tomography and positron emission tomography with computed tomography and the game changing place of endobronchial ultrasound in addition to classic flexible bronchoscopy. ‘Lung cancer staging now and in the future’ by Liam and colleagues,3 gives recommendations for cost-effective staging and optimal selection for personalized treatment. They underline the importance of economic resources and to use them cost effectively while pointing to the important role of medical societies to strive for uniform standards of care. An excellent example of how lung cancer management is becoming personalized comes from Japan. The paper by Nakanishi, ‘Implementation of modern therapy approaches and research for non-small cell lung cancer in Japan’ reinforces the need for a strong knowledge base in local epidemiology illustrated by ethnic differences in molecular lung cancer perturbations, such as in the EGFR gene.4 Further, it provides a clear insight on how practice is affected by policy and health care funding in an era characterized by rapidly rising health care expenditure. It is likely that a recalibration of community expectations against the costs of personalized treatment approaches will be needed as novel costly medications are expected to be provided for extended periods as these medications may push progressive cancer into a state of chronic disease. The benefits of molecular treatments and the need for tumour (geno) typing are comprehensively reviewed by Kumarakulasinghe et al. ‘Molecular targeted therapy in the treatment of advanced stage non-small cell lung cancer (NSCLC)’. They nicely describe how advances in the understanding of molecular genetics have led to the recognition of multiple molecularly distinct subsets of non-small cell lung cancer and sometimes enabling precision medicine.5 So far, this has become reality in a steadily increasing but still relatively small group of patients and we all look forward to the day when actionable molecular targets will enable precise and less toxic treatment for metastatic lung cancer patients. It is generally accepted that multidisciplinary team (MDT) care represents current best practice; nonetheless it remains vital to understand where MDT care has provided enhanced outcomes as well as the difficulties in the implementation of proper MDT care. Campbell and team's paper on ‘Multidisciplinary Lung Cancer Meetings: Improving the practice of radiation oncology and facing future challenges’ delineate potential areas for research that may lead to improvement of care from radiation oncological perspective.6 Prabhakar and colleagues discussion in their paper, ‘The effectiveness of lung cancer MDT and the role of respiratory physicians’, extend these observations and highlight the respiratory physician's perspective.7 A key contribution to the MDT comes from the discipline of surgical oncology providing treatment with curative intent and important stakeholder in the CT screening process of individuals at high risk for lung cancer. With particular relevance to the latter, the Kidane et al. paper entitled ‘MDT lung cancer care: Input from the Surgical Oncologist’ provides a comprehensive review of technologies to improve surgical excisional biopsy as well as discussing the current debates on the use of sublobar resections for stage I lung cancer.8 They also reflect on the role of surgery in locally advanced disease and highlight potential advanced approaches to complex T4 cancers. Hot on the heels of molecularly targeted therapies comes immunotherapies. Steven's team brings us a timely review of cancer immunotherapy and why they hold an optimistic view for future prospects in lung cancer immunotherapy.9 They discuss immune checkpoint blockade therapies, cancer vaccines and the concept of personalized immunotherapy and point to the potential of combination therapy. Several immune-based therapies have just reached our patients, and we eagerly await the results of additional important comparative trials that might broaden immunotherapy approaches in lung cancer. Noting gaps in health-care coverage and insurance and also considering the impact on low resource countries, we are looking forward to positive outcomes from pharma/government deliberations on the affordability of these new medications. Thus, in conclusion, we remain a long way from making lung cancer the rare disease that it was in the beginning of the 1900s. However, working together in effective MDTs should lead to better outcomes if we can learn how to harness effective health technologies to best treat each individual patient in the context of precision medicine and increasing health-care costs. No one deserves lung cancer, and no one deserves to miss out on quality evidence-based lung cancer care.