Dr Kenderian on the Efficacy of Liso-Cel in R/R CLL/SLL

Neel P. Chudgar, MD, assistant professor, Cardiothoracic and Vascular Surgery, Albert Einstein College of Medicine; thoracic surgeon, associate director, Clinical and Translational Research, Thoracic Surgery, attending physician, Montefiore Medical Center, discusses his presentation on resectability in non–small cell lung cancer (NSCLC) 

?' delved into the rationale behind exploring this concept and examined the current controversies surrounding it, Chudgar begins, adding that crafting this presentation proved challenging due to the abundant controversies within this space. While considering the definition of resectability, factors such as patient-related medical operability were relatively less contentious, thus not extensively covered. However, emphasis was placed on technical aspects, evaluating whether a tumor could be safely and effectively removed, along with assessing oncologic factors crucial for a patient's overall outcome, Chudgar reports. Despite efforts to focus on these aspects, data remains limited, hindering the establishment of definitive guidelines regarding resection for specific disease stages or patient profiles, he notes

Regarding the consideration of surgery for patients with clinical T4 disease, the Albert Einstein College of Medicine conducted a study utilizing the National Cancer database, Chudgar expands. This analysis revealed instances where tumors clinically classified as T4 were found to be non-T4 upon surgical exploration. This discrepancy suggests a potential overestimation of tumor invasion preoperatively, he adds, noting that in clinical practice, physicians may be more cautious and not operate on a clinically classified T4 tumor, even though some of these tumors may not actually reach this threshold. However, the study demonstrated the feasibility and safety of resection for such patients, evidenced by favorable outcomes such as low 30- and 90-day mortality rates and promising remission rates, Chudgar reports.

Furthermore, the study underscored the safety of minimally invasive resection procedures, indicating that this type of surgery can be conducted safely with reasonable survival rates, Chudgar continues. These findings provided valuable insights into the considerations surrounding surgical interventions for patients with clinical T4 disease, emphasizing the importance of accurate preoperative assessment and the potential benefits of minimally invasive approaches in ensuring patient safety and favorable outcomes, Chudgar concludes.

Videos

Neel P. Chudgar, MD,  discusses his presentation on resectability in non–small cell lung cancer at the 21st Annual Winter Lung Cancer Conference®.


Dr Chudgar on Defining Resectability in NSCLC 

Dr Chudgar on Resection Eligibility in NSCLC

Neel P. Chudgar, MD, assistant professor, Cardiothoracic and Vascular Surgery, Albert Einstein College of Medicine; thoracic surgeon, associate director, Clinical and Translational Research, Thoracic Surgery, attending physician, Montefiore Medical Center, 

discusses patient considerations when determining eligibility

 and highlights how neoadjuvant immunotherapy may affect resectability in this patient population.

Determining the resection eligibility of patients with stage IIIB non–small cell lung cancer (NSCLC) presents a complex challenge due to the heterogeneous nature of this patient population, Chudgar begins. The classification of resectability encompasses a diverse range of patients, including those with positive mediastinal nodes (N2), further stratified into single-station N2 vs multi-station N2, as well as patients with bulky or invasive N2 disease, he reports. A lack of definitive data regarding resection candidacy complicates surgical decisions, he adds.

Patients with single-station N2 disease generally face less contention for resection if they meet standard criteria for surgical operability, Chudgar expands; however, challenges escalate in cases involving bulky, multi-station N2 disease. Recent neoadjuvant trials, such as those combining chemotherapy and immunotherapy like the phase 2 NADIM II trial (NCT03838159) in patients with resectable stage IIIA disease, demonstrate promising outcomes even in cohorts of patients with multi-station N2 disease, he explains. Notably, patients enrolled in these trials exhibit favorable 2-year overall survival rates, indicating the potential for surgical intervention in NSCNC cases that were previously deemed unresectable, Chudgar reports.

The integration of neoadjuvant immunotherapy further complicates resectability assessment, he continues. As response rates to neoadjuvant immune checkpoint inhibitors combined with chemotherapy show promise, the definition of resectability undergoes continual re-evaluation, Chudgar elucidates. Despite initial doubts regarding resectability based on radiological and oncological perspectives, a patient with bulky N2 disease demonstrated an exceptional response to chemotherapy/immuno-oncologic treatment, he says. Subsequent restaging revealed a favorable position for safe resection, resulting in complete pathological response.

Such instances highlight the NSCLC paradigm shift facilitated by immunotherapy, challenging traditional boundaries and extending surgical options to previously ineligible patients, Chudgar concludes.

Neel P. Chudgar, MD, discusses considerations for determining lung cancer resection eligibility and how neoadjuvant therapy may affect resectability.

Lung cancer remains the most common cause of cancer death in the United States. Individuals who identify as Black and/or Hispanic are at even greater risk of mortality. Lung cancer screening (LCS) has been recommended since 2013, but remains underutilized, especially in economic and socially marginalized communities. Incidental lung nodules, commonly found on imaging done for other purposes, such as trauma evaluations, are often diagnosed later as cancers and represent a source of morbidity and mortality. 

Many vulnerable groups and marginalized communities receive care in the emergency department setting, where follow-up of incidental nodules is fragmented and incomplete. Low rates of LCS and inappropriate follow-up of incidental pulmonary nodules (IPNs), thus, represent 2 significant drivers of cancer care inequities. Research initiatives aimed towards understanding and combating systemic inadequacies contributing to these inequities have the potential to improve outcomes in populations that are in need.

Addressing Morbidity and Mortality in Minority Populations

Data from the Commission on Cancer demonstrates a large proportion of individuals diagnosed with non–small cell lung cancer over a 4-year period identified as Black (39%) or Hispanic (33%), compared with 23% who identified as White at the Montefiore Einstein Cancer Center (Montefiore) in the Bronx, New York. These figures are in stark contrast to other New York health care settings, where 81% of patients are White. Our patient population is also more likely to be diagnosed at later stages. When compared with other New York hospitals, the proportion of patients at Montefiore who are diagnosed with stage I lung cancer is markedly lower (25% vs 31%), and the proportion of those with stage IV disease is higher (45% vs 37%) (FIGURE

TABLE. Demographics of Patients With Lung Cancer Who Were Eligible for LCS in the Montefiore Health System

Other data from Montefiore have demonstrated additional inequities in patients with primary lung cancers diagnosed between 2013 and 2016. Only 417 (55%) were found in patients with an in-network primary care provider, illustrating the need for a better support system and for a systematic approach to identify and guide these patients. Furthermore, of the 175 of these patients who were eligible for LCS, only 33 had completed appropriate screening. A large proportion of this population with lung cancers that were identified outside of screening was composed of Black (46%) and Hispanic (34%) patients with a median per capita income of approximately $20,000 (TABLE).

Addressing Inadequacies of Lung Cancer Screening

Screening is particularly challenging in individuals from racial and ethnic minority groups and in those who have been socioeconomically marginalized. For example, of more than 50,000 people enrolled in the seminal National Lung Screening Trial, only 4.5% of participants identified as Black and 1.7% as Hispanic. This is in sharp contrast to the screening population described at our institution.

FIGURE. Stages of NSCLC Diagnosed Between 2016-2019 at Montefiore Vs Other Hospitals in the United States

More work needs to be done to study and implement LCS in these patient populations. To this end, we have formed a collaboration with the LUNGevity Foundation with the objective of, “Increasing access to lung cancer screening in the Bronx in Latino and African American communities.” Known as Project URBANA, the initiative seeks to increase uptake of, and compliance with, LCS through educational initiatives and engagement with a unique community peer navigation program—the Bronx Oncology Living Daily (BOLD) program. Drawing from the principles of Community-Based Participatory Research, Project URBANA focuses on increasing access to care among African American and Latino community members. At its core, this project is targeted outreach with educational materials developed in partnership with communities with content that is both relevant and language appropriate. This content coupled with trained peer navigators from within the community strives to address social constructs of health care often overlooked in daily practice.

Reducing the Burden of Incidental Pulmonary Nodules

Each year, more than 1.5 million individuals are diagnosed with an IPN.

 Guidelines exist for the follow-up of IPNs; however, treatment adherence is often poor.

 This is especially true in Black and Hispanic populations where approximately 50% of patients are notified of IPNs and have significantly lower rates of adhering to follow-up imaging. This population also has increased odds of delaying follow-up appointments.

With continued support from LUNGevity, we have devised a multipronged approach to develop an incidental pulmonary nodule management program for our community. Through the incorporation of software to automatically detect notation of lung nodules in radiology reports, we will shift to more active identification of people with concerning nodules who will be proactively referred to our high-risk lung nodule clinic. Individual risk for malignancy will be evaluated using artificial intelligence–based calculators derived from the electronic medical record to facilitate guideline concordant care. 

Finally, we will evaluate a blood-based cancer biomarker to further risk stratify patients and will prospectively apply it to individuals already enrolled in our nodule clinic. Our overall objective is to facilitate earlier diagnosis of lung cancer in our community and decrease risk of advanced disease and death.

Research initiatives provide us with the ability to advocate for historically marginalized people by generating hypotheses that seek to increase knowledge of inequities of care. Studies focusing on implementation of care in the setting of racial and ethnic inequities are critically needed.

Deficiencies in lung cancer care are multifactorial, and occur at the levels of screening, diagnosis and management. Through research that incorporates culturally sensitive patient navigation, use of available technologies and a multidisciplinary approach to patient care, there are significant opportunities to improve screening, cancer care, and outcomes for everyone.

Su CT, Bhargava A, Shah CD, et al. Screening patterns and mortality differences in patients with lung cancer at an urban underserved community. Clin Lung Cancer. 2018;19(5):e767-e773. doi:10.1016/j.cllc.2018.05.019  

National Lung Screening Trial Research Team; Aberle DR, Adams AM, Berg CD, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395409. doi:10.1056/NEJMoa1102873 

Gould MK, Tang T, Liu IL, et al. Recent trends in the identification of incidental pulmonary nodules. Am J Respir Crit Care Med. 2015;192(10):1208-1214. doi:10.1164/rccm.201505-0990OC 

Farjah F, Monsell SE, Gould MK, et al. Association of the intensity of diagnostic evaluation with outcomes in incidentally detected lung nodules. JAMA Intern Med. 2021;181(4):480-489. doi:10.1001/ jamainternmed.2020.8250 

Schut RA, Mortani Barbosa EJ Jr. Racial/ethnic disparities in follow-up adherence for incidental pulmonary nodules: an application of a cascade-of-care framework. J Am Coll Radiol. 2020;17(11):1410-1419. doi:10.1016/j.jacr.2020.07.018

Articles

Lung cancer remains the most common cause of cancer death in the United States. 

Neel P. Chudgar, MD

Articles

Dr Chudgar on Defining Resectability in NSCLC

Dr Chudgar on Resection Eligibility in NSCLC

Beyond the Clinic: Leveraging Research to Tackle Lung Cancer Disparities