Virtual Library

Abstract:
Background: The Global Lung Cancer Coalition (GLCC) is a unique partnership dedicated to improving disease outcomes for all lung cancer patients worldwide. The GLCC has a clear objective to place lung cancer on the global agenda. There are known to be significant variations both between and within countries in terms of: lung cancer incidence, mortality and survival; access to the latest treatments and to high quality specialist healthcare professionals; and investment in research and clinical trials. Evidence of variations can be a powerful tool for advocates – both clinicians and patient advocacy groups – to use to engage with policymakers about the ways in which legislative or regulatory policies can be shaped to optimise treatment and care for people living with lung cancer. However, there was no single statistical resource for the global lung cancer community to use in comparing countries, benchmarking progress, and campaigning. In 2014, therefore, the GLCC created the Global Lung Cancer E-Atlas, making accessible in one place the latest published information about lung cancer's global impact and outcomes, in an interactive format. Creating the E-Atlas: Potential data sources were mapped to identify the most current and comparable available. Incidence and mortality data were drawn from GLOBOCAN 2012[i], which provides contemporary estimates of the incidence, mortality and prevalence from major types of cancer, at national level, for 184 countries. The estimates are based on the most recent data available at the International Agency for Research on Cancer (IARC) though more recent figures may be available directly from local sources. Survival data were drawn from a variety of sources, where available. These included: CONCORD-2[ii], which includes data provided by 279 cancer registries in 67 countries; the EUROCARE-5 study[iii], which provides the most up-to-date survival analysis for patients diagnosed with cancer across 29 European countries; and the International Cancer Benchmarking Partnership (ICBP)[iv], which includes data from population-based cancer registries in 6 countries – Australia, Canada, Denmark, Norway, Sweden and the United Kingdom. The E-Atlas also details whether each country operates a cancer plan or has implemented the World Health Organization Framework Convention on Tobacco Control with data drawn from responses to the World Health Organization Noncommunicable Diseases Country profiles[v], covering 184 countries. GLCC members were invited to validate data for their country and identify any more recent national data. If more recent data were found then these were added. Using the E-Atlas: The E-Atlas allows anyone to compare statistics for lung cancer across the world. It is publically accessible on the GLCC’s website: http://www.lungcancercoalition.org/atlas/ (Figure 1): Figure 1 Figure 1: GLCC Global Lung Cancer E-Atlas home page By clicking on individual countries, or using the search function, users can 'zoom in' on different areas to see the figures for that nation. The E-Atlas also has a comparison tool, enabling the user to select up to four countries and directly compare the figures for them (Figure 2). Figure 2 Figure 2: the comparator tool GLCC campaigners have been using the E-Atlas to support engagement with national policy-makers and influencers. To support this, the project team produced a campaigning toolkit, giving headline figures, tips for engagement and template materials (press releases, briefing documents and a presentation for adaptation). Conclusions: Feedback from GLCC members confirms that the E-Atlas is a helpful resource in their campaigning and advocacy. The GLCC is continuing to develop the E-Atlas, and it will be updated with breakdowns by age and gender. The GLCC is also keen for the E-Atlas to be shared and to receive feedback (via http://www.lungcancercoalition.org/atlas/contact.php) on additional national data for inclusion or suggestions for further development. References: [i] GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC Cancer Base No. 11, Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. Lyon, 2013, France: International Agency for Research on Cancer. Available at: http://globocan.iarc.fr/Default.aspx [ii] Global surveillance of cancer survival 1995–2009: analysis of individual data for 25 676 887 patients from 279 population-based registries in 67 countries (CONCORD-2), C Allemani, H Weir, H Carreira, R Harewood, D Spika, X Wang, et al. The Lancet, Volume 385, No. 9972, p977–1010, 14 March 2015. [iii] EUROCARE-5-a population-based study of cancer survival in Europe 1999-2007 by country and age. Available at: https://w3.iss.it/site/EU5Results/ [iv] Cancer survival in Australia, Canada, Denmark, Norway, Sweden and the UK, 1995-2007 (the International Cancer Benchmarking Partnership): an analysis of population-based cancer registry data, MP Coleman, D Forman, H Bryan, J Butler, B Rachet, C Maringe, et al. The Lancet Volume 377, No. 9760, p127–138, 8 January 2011. [v] Noncommunicable Diseases Country Profiles 2011, World Health Organization (WHO), 2011. Available at: http://whqlibdoc.who.int/publications/2011/9789241502283_eng.pdf

Abstract not provided

Abstract:
Background Despite recent advances, lung cancer remains a disease characterised by negativity, late diagnosis and poor outcomes. The need for advocacy in lung cancer is obvious. Recent years have seen an increase in the number of organisations and individuals advocating for improvements in this disease. All organisations engaging in lung cancer advocacy are different and respond to the particular cultures and needs of their regions or countries. However, there are a number of common campaign themes: Integrated Tobacco Control programs. Increased funding for lung cancer research Increase in the number of patients enrolled in Clinical Trials Earlier diagnosis Equitable access to best practice treatment and care The Need for High Quality Data Underpinning advocacy in all of the above, is the need for advocates to access high quality, timely data on survival, quality of life and patient experience. Such data, not only provides a benchmark for the quality and outcomes of lung cancer services, but also provides advocates with a tool to campaign for improvement and showcase good practice. A good example is the work of the International Cancer Benchmarking Partnership [1], which has shown huge variation in one year and five year survival in lung cancer across the study countries, prompting health policy makers to investigate differences. The publication of the recent CONCORD- 2 data [2] has had a similar effect, with advocates highlighting 5 years survival inequalities. In November 2014, the Global Lung Cancer Coalition launched it’s online e-atlas [3 ], bringing together international lung cancer data sets and information, where available, in every WHO country. An important national initiative is the UK’s National Lung Cancer Audit [4], which is examined in further detail The UK’s National Lung Cancer Audit (NLCA) – Example of a tool for advocates The NLCA has taken around 20 years from conception to its establishment as a gold standard national clinical audit. The first discussions around the need to audit services and patient outcomes took place among a small group of UK lung cancer clinicians, in 1994. Since then, the NLCA has developed into a national audit which captures information on almost every case of lung cancer and mesothelioma that reaches hospital in the UK. It captures data on a range of demographics, clinical features and key process measures in treatment and care, spanning the patient journey. The NLCA is used by a wide variety of stakeholders within the lung cancer community to understand how care is being delivered across the country and to drive improvements to services. It includes data which are as close to real-time as possible. As contained in the Roy Castle Lung Cancer Foundation’s 2014 report on the NLCA [5], this audit has been vital to lung cancer advocates in driving improvements in lung cancer service provision. Findings of this Report highlight the NLCA’s vital contribution to: Improving clinical practice – average rates of active treatment, surgery, histological diagnosis and access to lung cancer nurse specialists have all improved during the lifetime of the audit Creating further advocacy tools - this audit data has been extensively used by UK advocacy groups, as in the web based ‘Smart Map’ [6], displaying the data in a patient friendly, easily accessible format. Supporting clinical research –The 2014 RCLCF Report [5] notes that there were at least 13 clinical research projects ongoing across the UK which were making use of NLCA data. Also, 175 key clinical journal articles published between 2006 and 2013 referenced the NLCA. Informing cancer policy and guidelines – the NLCA has been cited in much policy documentation.. The 2014 RCLCF Report [5] notes that the National Institute for Health and Care Excellence (NICE) references the NLCA at least 36 times in documents ranging from guidance, implementation guides, and audit tools to briefings. Also. the National Cancer Intelligence Network (NCIN) references the NLCA 32 times in the documents currently available on its website and uses most of the NLCA’s ‘headline indicators’ in its on-line lung cancer service profiles Raising awareness of lung cancer issues - the annual NLCA report helps to raise awareness of lung cancer issues among national and local decision-makers and the general public. It has been used almost exclusively to positively evaluate the major clinical impact of the 2011 and 2012 national public awareness campaigns (the Be Clear on Cancer campaign for lung cancer [7]), relating to persistent cough as an early warning symptom of lung cancer. Roy Castle Lung Cancer Foundation has used data from the NLCA to raise awareness of lung cancer, and variations in lung cancer care and outcomes across England and Scotland, through the publication of two reports[i] on variations in lung cancer care across the country [8,9]. Learnings for all lung cancer advocates There is a need for high quality, timely, lung cancer data on incidence, mortality, survival. Also, a need for high quality, timely data to assess health services – on diagnositics, treatment availability and support/care provision. If the above is not available – advocates need to ask why not and campaign for data collection Quality data provides lung cancer advocates with a key tool to highlight good practice, variation and inadequacies. Thus, advocating for change and improvement. References 1. Coleman MP et al, ‘Cancer survival in Australia, Canada, Denmark, Norway, Sweden, and the UK 1995-2007 (the international Cancer Benchmarking Partnership): an analysis of population-based cancer registry data’, The Lancet, Vol. 377, January 2011 2. Allemani C, Weir HK, Carreira H, et al., and the CONCORD Working Group. Global surveillance of cancer survival 1995-2009: analysis of individual data for 25,676,887 patients from 279 population-based registries in 67 countries (CONCORD-2). Lancet 2015; 385: 977–1010 3. GLCC website – Global Lung Cancer e-Atlas. http://www.lungcancercoalition.org 4. Health and Social Care Information Centre, National Lung Cancer Audit annual reports, via: http://www.hscic.gov.uk/lung 5. Roy Castle Lung Cancer Foundation, Leading the information revolution in lung cancer intelligence: why the National Lung Cancer Audit is the key to transforming lung cancer outcomes, January 2014. 6. Roy Castle Lung Cancer Foundation’s Smart Map. http://roycastle.org/news-and-campaigning/campaigns/interactive-map 7. Be Clear on Cancer – Lung Cancer campaign, via http://www.campaigns.dh.gov.uk/category/beclearoncancer/ 8. Roy Castle Lung Cancer Foundation, Explaining variations in lung cancer in England, July 2011 9.Roy Castle Lung Cancer Foundation, Explaining variations in lung cancer in Scotland, 2011

Abstract:
Lung cancer was a rarity a century ago. A dramatic increase in the use of tobacco, in the form of cigarettes, and the science-based reformulation of tobacco that renders the modern cigarette so addictive, the world would not be in the grip of the current lung cancer epidemic. Several other critical factors contributed. These include ready access for sale and purchase, few limitations on time and place of tobacco use and highly skilled promotion and marketing. This combination of corporate success and health tragedy was supported by carefully orchestrated public disinformation and the achievement and maintenance of political influence. It follows from these observations that reversing the course of this epidemic requires that each of these be addressed. Now that legislation for the introduction of mandatory plain packaging of tobacco products has been passed in Ireland and the United Kingdom, Australia is not unique in any single tobacco control action. However, it has been innovative and the extent and breadth of activity is world-leading. A non-exhautive list of innovations includes Pack warnings and regulation Simple text messages(1972) Rotating text messages Graphic health warnings(2004) Mandatory plain packaging(2012) Product and sale restrictions Public information on tar content Restrictions on sales to minors Prohibition of "kiddy-packs" with <20 cigarettes Smoke-free indoors policy - non smoking in Workplaces (Federal Government initially in 1985) Domestic aircraft(1987) Public transport vehicles (bus/train/tram) Large shopping centres Motor vehicles carrying cars Indoor restaurants/bars Hospitals and health centres Smoke-free outdoors policy Al fresco dining Sports stadiums Children’s play areas Beaches and parks Railway stations and bus/tram stops Counter-advertising First TV campaign in late 1970's. Several innovative TV and radio campaigns since including "Every cigarette is doing you damage". Aims were to broaden knowledge of harms and bring risk into the present Tobacco Advertising and Promotion Restriction Voluntary banning of tobacco advertsing by the Medical Journal of Australia Banning TV and radio and later print advertising Elimination of sports and arts sponsorships Price and taxation Introduction of hypothecated tax to replace tobacco sponsorship income Removal of tobacco from consumer price (inflation) index calculation Aggressive tax increases (current Marlbro 20's > $US25) From time to time, opportunistic targetting a single state or local government entity, aimed at a specific innovation, has established a policy precedent. This has been achieved with a relatively small group of tobacco control advocates and effective health NGOs. Effective use of media has been critical in the process. The tobacco industry, in tactics used to oppose effective interventions, is quite predictable. Separate from simplistic themes of civil liberties, crystallised in the absurdist “nanny-state” concept. Common themes used to oppose evidence-based actions, include the threat of large legal penalties, spectre of illicit tobacco sales and the harm potentially caused to Australia more generally as a place to do business. Effective lobbying campaigns can be transplanted. For example, promoting the right of workers to work long hours in safe workplaces can aid arguments in favour of smoke-free dining and other public places. All of the policy victories achieved are within the scope of aims of the Framework Convention on Tobacco Control. This remains the international template and its objects are proven able to be implemented. These policy innovations have been achieved despite tobacco industry interference via the political process and well-documented donations to major political parties. Although major parties have eschewed tobacco company donations by law or choice in recent years, influence is still peddled. To counter interference, the case for tobacco control was made politically impelling. That is, the community was perceived by political decision takers to have a desire to be rid of the harms of smoking that exceeds any concerns about restrictions that need to be imposed to achieve this. A lesson from Australia is that health professionals interested in tobacco control must educate communities at the same time as they seek to alter public policy.

Abstract not provided

Abstract:
Purpose: The purpose is to discuss how to advocate to make a Responsible Case for the Screening of lung cancer high risk group. Background and fact: Screening is looking for cancer at an early stage before a person has any symptoms. For the better screening, efficiency is determined as well as sensitivity and specificity. In these forty years, three screening tests have been studied to find if they decrease the risk of dying from lung cancer. Chest X-rays were evaluated at the earliest time in the lung cancer screening history while it is no longer recommended for screening.. Sputum cytology is a procedure in which a sample of sputum is viewed under a microscope to check for cancer cells, so it is required to good mucus that is coughed up from the lungs. Now, it is used as a non-invasive examination of a patient with a sputum symptoms rather than screening. Low-dose spiral CT (LDCT) scan is a special kind of x-ray that takes many pictures as you lie on a table that slides in and out of the machine. A computer then combines these pictures into a detailed picture of a slice of your body. In this procedure, low-dose radiation is used to make a series of very detailed pictures of areas inside the body with reduction of radiation exposure.. The National Lung Screening Trial (NLST) provided the first evidence that lung screening can reduce cancer deaths, when data from the study was published in 2011. The National Lung Screening Trial began in 2002 and enrolled more than 53,000 participants who were current or former heavy smokers, ages 55 to 74. The trial randomly assigned people to receive lung screening either by low-dose helical CT scans or chest X-rays. The trial was sponsored by the National Cancer Institute, and the University of Michigan was one of 33 places across the country to take part. U-M enrolled 850 participants. The study found that screening individuals with low-dose CT scans could reduce lung cancer mortality by 20 percent compared to chest x-ray. Now, it is concluded that the only recommended screening test for lung cancer is LD-CT, which result Medicare's decision to cover lung cancer screening in US. However, the evidence at the present time in LD-CT screening is only one report from US, the results of additional studies from Europe (NELSON) and Japan (Sagawa team) is awaited. Discussion: To raise up the efficiency of screening, It is important who is suitable as subjects. According to “ the Lung Cancer Screening Guidelines and Recommendations” by CDC, many organizations in US definite that lung cancer screening with LDCT is recommended for people of age 55 to 74 years with ≥ 30 pack year smoking history, who either currently smoke or have quit within the past 15 years while some difference of subjects who are in relatively good health or age 55 to 80 years across organizations. However, major obstacles are lying that smokers are lack of awareness or information for risks and benefits with attention to the specifics of each person making a decision about screening as well as the risk of lung cancer, in order to operate LD-CT screening effectively. GLCC poll in 2013 showed that in Australia and Great Britain current smokers are less aware of the symptoms of lung cancer than former smokers and people who have never smoked regularly. Even if screening system was developed, the risk of death due to lung cancer can not be reduced unless the people of high risk group do not visit to appropriate screening service that has been ensurring quality. In addition, Assessment of smoking and the provision of smoking cessation services must be part of any lung cancer screening program. Advocate movement based on research is urgently needed to develop approaches that will maximize cessation rates among smokers undergoing screening. Even more, it is required to enlightenment for smokers in cooperation with the international community by utilizing a variety of public relations means. In November 2014, lung cancer awareness month, Japan Lung Cancer Society approved the Kyoto Declaration. This declaration has been included that the tackle in the prevention of lung cancer and development of effective treatment by alliance with lung cancer Society, lung cancer patient, government, people, medical personnel, advocacy organizations, and healthcare industry. While the evidence from the NLST supports the implementation of lung cancer screening for high-risk individuals via LDCT, the experience to date also must validates the prior recommendations around institutional approaches to lung cancer screening, including the need for the availability of multidisciplinary clinical teams. In order to advocate making responsible case, several ways should be developed like a “Shared Decision-Making” toolkit(s) by the Lung Association that would act as a “consumers’ guide” for those considering lung cancer screening. After examine such a tool, it is also one of the ideas to take advantage according to the circumstances of each country.

Abstract:
The development and release of scientific validation and national guidelines and recommendations for lung cancer screening over the past several years has resulted in a profound paradigm shift in clinical opinion and outcomes for those at high risk for lung cancer. No other cancer is poised to realize the scale and magnitude of benefit that is now being reported for the lung cancer community. Given the import and potential of this opportunity, it was evident that there was a lack of vigor and focus by public health leadership to move aggressively and to take the next steps to develop programs and guidance to ensure the safe, responsible and equitable implementation of lung cancer screening and to bring proper health messages to those at risk. Lung Cancer Alliance (LCA), a national non-profit cancer advocacy organization, recognized this absence and stepped in to bridge these gaps and create an environment to support the adoption of best practices and consumer safety measures, as well as public service messaging about screening risk and benefit. Immediately upon the scientific validation of the mortality benefit of lung cancer screening, LCA moved rapidly to convene a multi-disciplinary team of health care professionals to devise a blueprint or framework to guide the responsible implementation of screening. The overarching goal embedded in this discussion was to ensure the public understood that they had right to know they could be risk for lung cancer and that they had a right to responsible care. This was particularly important after the National Cancer Institute (NCI) announced it was halting the National Lung Screening Trial (NLST) as the end point was reached proving at a minimum a 20% mortality benefit. And thus, the LCA National Framework for Excellence in Lung Cancer Screening and Continuum of Care was born in February 2012. Embedded within this National Framework are the following guiding principles and elements: 1. Increasing the public’s awareness about risk and their rights to responsible care, including educational resources and campaigns to spread this message; 2. Creating a framework of agreed upon best practices to guide the safe and responsible development of a screening center of excellence medical center network that then leveraged member resources to support each other; 3. Creating collaborations and relationships with other professional and advocacy societies and outreach to public and private payers to effect change at the policy level. Today, there are currently 350 hospitals within the LCA National Network of Screening Centers of Excellence who have committed to following certain best practice principles of care. Dozens of other medical centers continue to contact LCA for technical assistance and are in varying stages of program development. LCA launched an ad campaign in 2014 to raise risk awareness which received 90 million impressions through TV, print, and social media in 15 paid markets and about 20 PSA markets. In addition, LCA has helped successfully lead first-ever public health coalitions to advocate for coverage and other policy changes linking together diverse partnerships. This has included engaging the current screening centers of excellence in communication with the US Preventive Services Taskforce (USPSTF), Congress and other regulatory agencies, working with an alliance of stakeholders including ACR and STS to encourage swift action on the part of Centers for Medicare Medicaid Services (CMS) to ensure coverage for at-risk seniors, and communicating with lawmakers and encouraging them to take oversight action to ensure public health strategies by our Health and Human Services (HHS) Departmental move forward as efficiently, effectively and equitably as possible. With the finalization of the USPSTF recommendation for lung cancer screening and coverage for Medicare beneficiaries, lung cancer screening is now a covered benefit for those at high risk, with no cost sharing, co-pays or deductibles. The LCA experience is an example of how an agile and responsive patient advocacy charity can provide critical institutional support and a national public health blueprint for the scale up of a new preventive service – that is patient focused and patient driven. By creating what in effect is a national pilot program for lung cancer screening, LCA proved that responsible screening and outreach could be reproduced in medical centers all across the country at the community level. And by working closely and directly with screening centers – we have established a deeper understanding of their needs which in turn has helped us tailor our continued outreach and support to better suit their needs. Our consumer-targeted awareness campaigns have shape a culture of consciousness among the public which in turn have allowed us to better design educational materials. LCA is committed to continuing to build knowledge about the importance of screening among the at-risk public, healthcare providers, and policymakers alike. LCA is proud to have seized an important moment in time to have built a foundation for responsible care when people at risk for lung cancer needed it most. Figure 1

Abstract:
For a long period of time, lung cancer has been considered a malignancy affecting only men, but epidemiological data have shown a dramatic increase of the incidence among women and the gender gap has been narrowing steadily since the 1980s,mainly as a consequence of the huge spread of tobacco consumption during the past 60 years. Although more men are diagnosed with lung cancer, incidence is leveling off or decreasing in men, but is increasing among women.Lung cancer is the leading cause of cancer death for women in the United Statesand other countries, with about 105,600 new cases and 71,000 estimated deaths in 2015 for the female gender, whereas in European countries lung cancer is predicted to kill 87,500 women in 2015, but such predictions require caution. In Europe, for the first time in 2015 (unlike in the U.S. where it has been happening for some decades)lung cancer death rates in females are expected to overtake those of breast cancer. This trend is largely driven by women in the UK and Poland, confirming that the continuous increase in lung cancer mortality among women represents a challenge for cancer control. This disease is classified as a significant global women’s health issue. Unfortunately, women still lack awareness and knowledge about lung cancer, it is not considered a priority because most of them still believe that breast cancer is the number one cancer in women. They have misperceptions and in most cases they are not concerned because they are too young or are non-smokers. Gender differences in terms of susceptibility to carcinogens have been reported and several studies suggestthat women are more vulnerable to tobacco carcinogens than men, however this data remains controversial. Although smoking increases the risk of lung cancer dramatically, it's not the only cause. Freedman et Al reported on a cohort of nearly 500,000 individuals aged from 50 to 71 years, in which asignificant increase of cases occurred in women who never smoked, compared with male non-smokers. The rate of lung cancer in those who never smoked is higher for women in every population, counting approximately 20% of women who never smoked. The reason is unclear, but studies suggest that the hormonal status may be one potential explanation and researchers are devoting energies in this area to better understand the implication of gender differences in epidemiology, pathogenesis, prognosis and tumor response, considering that women have better survivalrates than men at any stage regardless of the type of lung cancer and the therapeutic approach. At the moment there are no gender-based approaches on diagnosis and treatment for lung cancer, but an improvement in understanding genetic, metabolic and hormonal factors could stimulate research towards further personalized gender-based investigations. Despite recent advances in treatment, lung cancer still remains a largely incurable disease with a physical impact upon women, as well as social, psychological, practical and emotional consequences. The diagnosis and subsequent treatments are traumatic events for patients and their loved ones. Serious disruptions in social and psychological aspects of their quality of life have been reported and younger women are most at risk. This type of cancer is normally associated with older people, where the disease is often diagnosed accidentally, while in young adults it is relatively rare, the incidence has been found to be around 1.2% to 6.2% (under 40 years), 5.3% (under than 45 years), and 13.4% (under 50 years),but previous reports have shown trends of increasing incidence rates of lung cancer among young patients. Unfortunately in this group this malignancy is more common in women, who are diagnosed at an advanced stage and normally receive aggressive treatments. It can be very difficult to cope with a diagnosis of lung cancer, both practically and emotionally, because the news can generate a wide range of emotions: fear, anxiety, anger, confusion, that could worsen the situation if patients are younger women because they often have to face challenges different than other patients. The worst are mothers of children or teenager, telling them the diagnosis is hard and traumatic, it means dealing with their emotions and reactions and helping them to face a daily routine affected by this event. Many feel unable to manage changes caused by lung cancer and this may create a state of distress that is increasingly recognized as a factor that can reduce the quality of life of patients. Moreover they feel hopeless, worried and sad about the uncertainty of their future and their children’s future. The disease and its treatments often may cause physical changes in the way they look, which is difficult to cope with and may affect the way women feel about themselves. Such body changes can diminish their self-esteem and change the way they relate to other people, especially family and friends. Disease progression, symptoms orside effects may force women to change the daily management of their family and house. The consequence is the inability to keep the pace of motherhood and to keep on doing things like they were used to do (for example working around the house), especially if children are young and energetic.These physical issues may also jeopardize their career and in many situations forcing them to quit job, increasing the frustration of losing their independence. Lung cancer may affect the dynamics of intimate relationships. This is connected to body image changes,in whichwomen may feelless attractive or desirable by their partner. Common symptoms of lung cancer, such as cough, fatigue or shortness of breath may affect their sexual life. Women with lung cancer have a number of unmet needs that require assistance. It is important to identify them efficiently and effectively so that patients can be provided with appropriate resources so they can find help. Physical needs are experienced by the majority of women, but emotional, psychological, social, spiritual, practical and informational needs are also present for some. Interventions must be developed to assist these women to cope with these needs and worldwide several gender focused educational and support programs have already been designed with this purpose. References: Silvia Novello & Tiziana Vavalà Lung cancer and women, Future Oncology Vol. 4, No. 5, Pages 705-716 Cancer 2010, 116(15):3656-3662. PubMed Abstract | Publisher Full Text Subramanian J, Morgensztern D, Goodgame B, Baggstrom MQ, Gao F, Piccirillo J, Govindan R: Distinctive characteristics of non-small cell lung cancer (NSCLC) in the young: a surveillance, epidemiology, and end results (SEER) analysis. J ThoracOncol 2010, 5(1):23-28. Ak G, Metintas M, Metintas S, Yildirim H, Erginel S, Alatas F: Lung cancer in individuals less than 50 years of age. Lung 2007, 185(5):279-286. Skarin AT, Herbst RS, Leong TL, Bailey A, Sugarbaker D: Lung cancer in patients under age 40. Lung Cancer 2001, 32(3):255-264. Bourke W, Milstein D, Giura R, Donghi M, Luisetti M, Rubin AH, Smith LJ: Lung cancer in young adults. Chest 1992, 102(6):1723-1729. Schnoll RA, Patterson F, Lerman C. Treating tobacco dependence in women. J Womens health 2007;16:1211-1218 Freedman ND, Leitzmann MF, Hollenbeck AR et al. Cigarette smoking and subsequent risk of lung cancer in men and women: analysis of a prospective cohort study.Lancet Oncology 2008;9:649-656 Donington JS, Colson YL. Sex and gender differences in non-small cell lung cancer. Seminars Thoracic Surgery2011;23:137-145 American Society of Cancer Oncologists. 2009. Women and Lung Cancer. Margaret I. Fitch, Rose Steele Supportive care needs of women with lung cancer- Canadian Oncology Nurses Vol 18, No 1 (2008)

Abstract:
The Community Hospital Centers of Excellence (COE) seal and program is a paradigm shift in lung cancer care to greatly increase positive patient outcomes. This necessity is driven by the reality that the 5-year patient survival rate has remained unchanged and abysmally low at approximately 16% for 40+ years. 80% of lung cancer patients in the US receive treatment by a general oncologist at community hospitals, most often without disease-specific cancer doctors. Unfortunately, generalists lack access to the most up-to-date knowledge to specifically treat lung cancer, the world’s number one cancer killer that takes more lives annually than the other top five cancer killers combined. Because of the tremendous volume and pace of scientific discovery, it is impossible for community general oncologists to stay abreast of emerging treatment options, the complexities of each disease state (lung, breast, colon, etc) and practice-changing clinical information. Due to this gap generalists cannot fully inform patients about all treatment options that exist, are expected and used every day by specialists at academic institutions where the enhanced standard of care includes molecular testing, tumor board review, clinical trials, personalized/targeted treatment, multi-disciplinary care, etc. Health literacy of physicians and patients impacts survival. The lung cancer knowledge gap especially affects patients who have limited education, are low income, ethnic minorities, recent immigrants and non-native English speakers. Knowledge and access are the currency of success and the pathway for all patients/physicians to get the right information leading to the right treatment at the right time. Information is also key for patients and their families to act as their own advocates. EVERY PATIENT NEEDS TO KNOW EVERY OPTION. ALCF acknowledges this problem and provides an innovative, first-of-its-kind solution – Community Hospital Centers of Excellence (COE) – to give all patients 360[0] care. Our solution provides community hospitals access to the same standard of care used at academic institutions to ensure that every physician and patient has access to and is educated about the newest, most effective diagnostic and therapeutic techniques, clinical resources, partners and people. Increasing lung cancer patient survival to the same high level as other cancers (breast/89.2%; prostate/98.9%) depends upon addressing disparities at the root – community hospitals – and to providing access to multi-institutional, collaborative, comprehensive care based on existing best practices. Equalizing access benefits all populations – insured, uninsured, underserved, geographically disadvantaged – fighting this disease. Physicians/hospitals in the COE national network commit to being fully informed partners with their patients in understanding, sharing and discussing treatment options. ALCF lung-specific community centers of excellence will be tracked by metrics to improve outcomes and reinforce ALCF’s belief that enhanced standard of care can extend survivability, improve quality of life, and some cases, save lives. ALCF, along with GE Healthcare and El Camino Hospital in California, has already shown success in its pilot program launched in 2012. Simultaneously, underlying research projects will be conducted to achieve milestones and increase discovery of treatment regimens for individualized therapy and survival acceleration through ALCF’s sister organization, the Addario Lung Cancer Medical Institute (ALCMI). At Centers of Excellence an on-site Patient Navigator oversees each patient’s care from the initial diagnosis. Care includes molecular testing for all patients to determine the unique genetic profile of the individual’s lung cancer. This knowledge will determine the best first-line treatment to achieve a positive outcome and will ensure that the right patient gets the right treatment at the right time. Community Hospital Centers of Excellence (COE) – Primary objectives are: ● Provide lung cancer patient program participants with multi-disciplinary, multi-institutional, collaborative, extensive, and comprehensive access to best care available. This “big picture” approach includes a Patient Navigator overseeing each patient’s care to include prospective tumor board review, molecular testing, targeted radiation therapy, and access to clinical trials, from a fully integrated team (oncologist, pulmonologist, radiologist, pathologist, immuno-oncologist, etc). ● Establish and implement improved standard of care (SOC) at community hospitals nationwide by giving patients and physicians access to the SOC used at academic institutions. This standard will be measured through patient data tracking, follow-up and patient surveys, and benchmarked against national data and statistics. In addition, ALCF will actively support the adoption and scaling of its lung cancer “standard of care” model to apply across the cancer spectrum and to other diseases and disciplines, as applicable. ● Improve progression free and overall survival rate and quality of life for patients. ● Implement best practices with expected outcomes being a new patient-centric paradigm for lung cancer patient treatment with best practices managed and documented by ALCF and findings shared with ALCF key partners and prospective Community Hospital COE sites. Because outcomes/data are essential to determine program success, tracking and measurement of all COE patients will include: Method of Diagnosis Early Detection vs. Incidental Findings Diagnosis Date Lung Cancer Type Lung Cancer Stage at Diagnosis Molecular Testing - % of Patients Received Tumor Board Review 30 Day Survival Number of ER Visits 1 and 5 Year Survival (Progression Free and Overall) Clinical Trial Referral Quality of Life (i.e. Pulmonary Function, Neuropathy, Fatigue, Appetite etc) Patient Satisfaction Survey Line of Treatment Where Applicable: Dollars Lost/Impact on Community due to Early vs. Late Stage Diagnosis Business Impact on Hospital During our pilot program's first year (El Camino Hospital, Mtn View, CA) metrics have already shown a dramatically improved standard of care (diagnosis to treatment time improved from a national average of 40+ days to 14.5 days; 100% of patients have had molecular testing; 61% have had tumor board review vs. 15% pre-program; 26% diagnosed at stage 2b or below). In adopting this collaborative, integrated standard of care, each hospital must have capacity to enroll at least 200 patients yearly. At minimum, ALCF excpects 10,000 patients will be served by 2015 end thriough 20 COEs. By equalizing physician/patient access to education and a standard of care, all populations affected by lung cancer--insured, uninsured, underserved, geographically disadvantaged--will benefit. COE will clearly be able to track outcomes and will define success through lives extended and in some cases, saved. By redesigning lung cancer patient health care delivery, COE provides an unprecedented coordination of care using technology and access to existing expertise/knowledge.

Abstract not provided

Abstract:
Evidence for clinical benefit from new treatment approaches is derived from phase III randomised clinical trials, which generate ostensibly unbiased data regarding the efficacy, benefit and safety of new therapeutic approaches. The potential benefits of a new treatment can be summarised as either living longer and/or living better, evaluated in clinical studies through the treatment effect on overall survival (OS) and/or quality of life (QoL), and their surrogates. In studies of interventions with curative intent in which mature survival data is not yet available disease-free survival (DFS), recurrence-free survival (RFS), event-free survival (EFS), distant disease free survival (DDFS), and time to recurrence (TTR), are used as surrogate measures. The validity of this approach, though not uncontroversial is well supported by data. In studies evaluating therapies in non-curative settings, progression-free survival (PFS), and time to progression (TTP) provide information about biological activity and may indicate benefit for some patients however they are not reliable surrogates for improved survival or QoL. Indeed in studies in which PFS benefit is observed, but because of subsequent treatments or crossover OS is not improved, QoL data is critical to evaluate the real meaning of the PFS. When QoL has been evaluated and there is either improvement or delayed deterioration this augments the significance of the PFS finding. Where is measured and PFS does not demonstrate improvement in QoL, this diminishes from the meaning of the PFS finding. QoL measurement has been widely adapted in the recent generation of lung cancer research and it has made a major contribution in verifying and amplifying the major clinical benefit conferred by Gefitinib, Afatanib and Crizotinib all of which were evaluated in PFS studies with crossover allowed. QoL has also been a critical primary outcome in an important study that demonstrated the QoL can be improved by initiating early palliative care for patients with metastatic lung cancer. 1. Fukuoka M, Wu Y-L, Thongprasert S et al. Biomarker analyses and final overall survival results from a phase III, randomized, open-label, first-line study of gefitinib versus carboplatin/paclitaxel in clinically selected patients with advanced non–small-cell lung cancer in Asia (IPASS). Journal of Clinical Oncology 2011; 29: 2866-2874. 2. Mok TS, Wu Y-L, Thongprasert S et al. Gefitinib or carboplatin–paclitaxel in pulmonary adenocarcinoma. New Engl J Med 2009; 361: 947-957. 3. Sequist LV, Yang JC-H, Yamamoto N et al. Phase III study of afatinib or cisplatin plus pemetrexed in patients with metastatic lung adenocarcinoma with EGFR mutations. Journal of Clinical Oncology 2013; 31: 3327-3334. 4. Yang JC-H, Hirsh V, Schuler M et al. Symptom control and quality of life in LUX-Lung 3: a phase III study of afatinib or cisplatin/pemetrexed in patients with advanced lung adenocarcinoma with EGFR mutations. Journal of Clinical Oncology 2013; 31: 3342-3350. 5. Shaw AT, Kim D-W, Nakagawa K et al. Crizotinib versus chemotherapy in advanced ALK-positive lung cancer. New Engl J Med 2013; 368: 2385-2394. 6. Solomon BJ, Mok T, Kim DW et al. First-line crizotinib versus chemotherapy in ALK-positive lung cancer. The New England journal of medicine 2014; 371: 2167-2177. 7. Temel JS, Greer JA, Muzikansky A et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010; 363: 733-742.

Abstract:
Lung cancer is the leading cause of cancer death in Aboriginal and Torres Strait Islander people in Australia, with Indigenous Australians 70% more likely to die from lung cancer than non-Indigenous Australians. (1) Lung cancer is the most common cancer in Indigenous men and the second most common cancer in Indigenous women. In fact, the incidence and mortality rate of lung cancer is higher for Indigenous than for non-Indigenous Australians. (1)Figure 1Evidence indicates that Indigenous people experience poorer outcomes following a cancer diagnosis because this population has later presentation to healthcare and later diagnosis. In 2012, Lung Foundation Australia, a national non-government lung health organisation, in partnership with Hume Regional Integrated Cancer Services (Hume RICS) led a community engagement and cancer education program within the regional Indigenous community of Albury/Wodonga situated on the New South Wales and Victorian state borders. At the time, Albury/ Wodonga had a population of 4,000 Aboriginal people and Hume RICS Cancer Support Nurse had only cared for three identified Aboriginal cancer patients in the last five years. The Let’s yarn about lung cancer” project was a 2 year project that aimed to raise awareness and understanding of lung cancer risks and symptoms within the Indigenous community in Albury/Wodonga and to encourage those who have concerns about their lung health or the health of community members to take action. At the same time, the project team developed innovative and culturally sensitive ways to educate Aboriginal Health Workers and local community health providers in the early diagnosis, treatment and supportive care needs of local Aboriginal cancer patients and their families - with a focus on lung cancer. A suite of culturally sensitive, evidence based patient resources were produced including :- a lung cancer symptoms and risks community education DVD entitled “Let’s Yarn about lung cancer” 3 patient DVD stories around being proactive about potential symptoms, curative treatment away from “country” and life after treatment including a survivor story from highly respected Indigenous singer/songwriter, Archie Roach. an Aboriginal lung cancer awareness pin Integral to the success of this project was the appointment of a local Aboriginal Project Officer who had strong relationships within the local Aboriginal and community health sector, was well respected in the local Aboriginal community and who ensured that culturally sensitivity was a key component of the project deliverables. National cancer control agency, Cancer Australia acknowledges that “there is no word meaning “cancer”, in most, if not all Indigenous Australian languages. Unlike many other illnesses, the concept of cancer is not embedded in the traditional Indigenous Australian story-telling”. (2) Prior to the “Let’s yarn about lung cancer” project, cancer was not a topic that was on the “radar” for local Aboriginal Health Workers or the Albury/Wodonga Aboriginal community. Cancer was not openly discussed. Let’s yarn about lung cancer project deliverables and highlights included: Establishment of a dynamic project advisory group with strong representation from the local Indigenous health and community health services. Delivery of a series of culturally sensitive cancer education sessions on lung cancer, treatment options and palliative care services to local Aboriginal Health Workers within existing Chronic Health events. Local Aboriginal health workers attended interactive educational sessions at the local radiation, chemotherapy and palliative care units. These “walk-thru” visits provided an understanding of treatment options, referral pathways and the supportive care services available. Provision of training for key Aboriginal Health Workers in culturally sensitive cancer support group facilitation and palliative care training. In summary, the Let’s yarn about lung cancer project partners (Lung Foundation Australia and Hume Regional Integrated Cancer Services) developed a stronger collaborative relationships with the Aboriginal Health Workers and the local Aboriginal community, resulting in barriers to treatment and care being reduced. In turn, local cancer services have become more culturally aware, with health workers and community members feeling more comfortable accessing the local cancer services with their clients.Figure 2 References Cancer Australia. Report to the Nation - Lung Cancer 2011. Cancer Australia, Sydney, NSW, 2011. Cancer Australia, 2015. Lung cancer in our mob: a handbook for Aboriginal and Torres Strait Islander Health Workers. Cancer Australia, Surry Hills, NSW.

Abstract:
When I heard the words "lung cancer" at age 55, I could barely believe the diagnosis. The facts I found online were not encouraging. As we moved through the various staging procedures, my family and I experienced increasing levels of fear. Within sixteen months I had two chemo regimens, two radiation protocols, and two progressions. Fortunately, my online patient community informed me about mutation testing and the new ROS1 translocation. My tumor tissue tested positive for ROS1, and I started taking crizotinib in a clinical trial in November 2012. I’ve had No Evidence of Disease for 30 months and counting. More new treatments have become available for lung cancer patients in the past four years than in the past four decades. Precision medicine, clinical trials, reliable online information sources, supportive online patient and caregiver communities, and care teams that engage in shared decision making have enabled me and many other metastatic lung cancer patients to beat the odds and live with metastatic lung cancer as a chronic illness instead of a death sentence. No therapy offers a permanent cure. We live from scan to scan. Yet we’re happy to be alive and have a relatively normal life for as long as it lasts. What are the keys to living with and beyond lung cancer? To live successfully with lung cancer, patients need access to appropriate and affordable treatment from compassionate, capable healthcare providers. We need those healthcare providers to stay current with treatment guidelines and use precision medicine best practices such as genomic sequencing to find effective treatments for our individual cancers. But we metastatic patients – who make up a majority of lung cancer patients -- need more than this. We need consultations with experts who have knowledge about our individual types of lung cancer. We need help accessing second opinions and clinical trials. We need plans for the next steps in case treatments aren’t effective. We need access to support services that improve our quality of life. Connecting stage IV patients to palliative care services early in the diagnosis and treatment process improves quality of life, gives us resources for dealing with treatment side effects and pain, and develops relationships which can help us and our family members consider our goals in pursuing further treatment. We need psychosocial supports for ourselves and loved ones to cope with depression and facilitate important conversations on difficult topics. After successful curative treatments, we need survivorship plans, and possibly rehab to deal with side effects. In addition to treatments, we need help to break through the shock of diagnosis, to become activated and engaged patients who participate in our own care--engaged patients tend to have better outcomes. We need people to dispel the stigma associated with lung cancer and treat us with respect and compassion regardless of our smoking history. After cancer forces us to realize how little control we truly have in life, we need to regain some sense of control. Choosing treatment options using a shared decision making process with our healthcare providers ensures our priorities and values are considered, and helps us understand the risks and benefits of each option. Connected health resources can help more lung cancer patients become engaged and participate in shared decision making. Trusted websites hosted by the NCI, cancer centers, medical societies, and advocacy organizations help inform us about our disease and our options. Patient success stories on personal blogs and social media offer us hope. Talking with other patients and caregivers who are sharing the same experiences lifts our spirits and helps us deal with side effects and losses. When both patients and healthcare providers embrace molecular and genomic testing, clinical trials as treatment options, online resources, connected patient and caregiver communities, and shared decision making, more lung cancer patients will successfully live with and through lung cancer. Barry MJ, Edgman-Levitan S. Shared Decision Making — The Pinnacle of Patient-Centered Care. N Engl J Med 2012; 366:780-781. DOI: 10.1056/NEJMp1109283. http://www.nejm.org/doi/full/10.1056/NEJMp1109283 accessed 7/2/2105. Cataldo JK, Brodsky JL. “Lung cancer stigma, anxiety, depression and symptom severity.” Oncology. 2013;85(1):33-40. doi: 10.1159/000350834. Epub 2013 Jun 29. http://www.ncbi.nlm.nih.gov/pubmed/23816853 accessed 7/1/2013. Glattki GP, Manika K, Sichletidis L, Alexe G, Brenke R, Spyratos D. Pulmonary rehabilitation in non-small cell lung cancer patients after completion of treatment. Am J Clin Oncol. 2012 Apr;35(2):120-5. doi: 10.1097/COC.0b013e318209ced7. http://www.ncbi.nlm.nih.gov/pubmed/21378541 accessed 7-1-2015. Health Policy Brief: Patient Engagement. Health Affairs. February 14, 2013. Institute of Medicine (US) Committee on Psychosocial Services to Cancer Patients/Families in a Community Setting; Adler NE, Page AEK, editors. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington (DC): National Academies Press (US); 2008. 1, The Psychosocial Needs of Cancer Patients. Available from: http://www.ncbi.nlm.nih.gov/books/NBK4011/ Jean-Pierre P, Johnson-Greene D, Burish TG. Neuropsychological care and rehabilitation of cancer patients with chemobrain: strategies for evaluation and intervention development.. Support Care Cancer. 2014 Aug;22(8):2251-60. doi: 10.1007/s00520-014-2162-y. Epub 2014 Mar 27. http://www.ncbi.nlm.nih.gov/pubmed/24671433 accessed 7/1/2015. Kvedar J, Coye MJ, Everett W. “Health Policy Brief: Connected Health: A Review Of Technologies And Strategies To Improve Patient Care With Telemedicine And Telehealth." Health Affairs. February 2014. Temel JS, Greer JA, Muzikansky A, Gallagher ER, et al. Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer. N Engl J Med 2010; 363:733-742 DOI: 10.1056/NEJMoa1000678. http://www.nejm.org/doi/full/10.1056/nejmoa1000678 accessed 7/1/2015. Wheler, J, Yelensky R, Stephen B, Hong D, et al. Prospective study comparing outcomes in patients with advanced malignancies on molecular alteration-matched versus non-matched therapy. Poster session presented at: ASCO 2015. 2015 Annual Meeting of the American Society of Clinical Oncology; 2015 May 29-Jun 2; Chicago, IL. http://meetinglibrary.asco.org/content/111990?media=vm&poster=1 accessed 7/1/2015.

Abstract:
Subsolid is a relatively new descriptor for a pulmonary nodule. Subsolid nodules include nonsolid or ground glass nodules (GGN) or part-solid nodules (PSN). Pure Ground-Glass Nodule (synonym: nonsolid nodule) is a focal area of increased lung attenuation within which the margins of any normal structures, e.g., vessels or airways remain outlined. Solid Nodule is a focal area of increased attenuation of such density that normal structures are completely obscured. Part-solid Nodule (synonym: semisolid nodule) is a focal nodular opacity containing both solid and ground-glass components. Their relative slow growth and indolent behavior compared to the typical spiculated solid nodule has been recognized over time suggesting the possibility of overdiagnosis. Subsolid pulmonary nodules representing the adenocarcinoma spectrum represent the majority of screening CT detected lung cancers, and the behavior of these lesions seem to differ significantly from their clinically detected counterparts, although the data regarding the natural history of these lesions is limited. Because nodule size and growth are strong predictors for malignancy, the accurate assessment of size at baseline and growth on follow up CT is important in diagnostic work up of indeterminate nodules. Nodule growth can be quantified using either diameter or volume. Recently automated volumetric measurements have been suggested because malignant nodules may grow asymmetrically, and therefore, their growth may remain unnoticed with manual diameter measurements alone. Furthermore manual 2D measurements of small nodules have modest repeatability. It is important to differentiate part-solid nodules from pure ground-glass because a solid component typically represents invasion. Part-Solid nodules (PSN) had much higher malignancy rate (62.5 %) than GGN (19%) or solid nodules (7%) in a recent study (1). Given advances in imaging and molecular pathology, a new Classification of Lung Adenocarcinoma was proposed by the International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society in 2011 (2). The 2011 classification addressed three important weaknesses in the previous classification. First, it eliminated the term bronchioloalveolar carcinoma (BAC). Second, it added new terminologies of carcinoma-in-situ (CIS), and minimally invasive adenocarcinoma (MIA) to recognize that minimal invasion (< 5mm) had nearly similar clinical outcome as noninvasive nodules. Third, it replaced the terminology of mixed subtype of adenocarcinoma. The widespread availability of MDCT and abundance of new information obtained especially from low-dose CT lung cancer screening programs, have increased our understanding of the types and management of small peripheral lung nodules encountered in daily clinical practice, in particular, the importance and prevalence of subsolid pulmonary nodules (atypical adenomatous hyperplasia (AAH), ground glass nodules (GGN) and part-solid nodules). Thin-section CT has emerged as a new biomarker for lung adenocarcinoma subtypes. Finding a subsolid nodule is expected to increase as screening CT become more prevalent after CMS approval. The approval of CT as a screening tool for lung cancer was based primarily on National Lung Screening Trial (NLST) results. The NLST recently found that Low Dose Helical Computed Tomography (LDCT) reduces lung cancer specific mortality by 20% relative to chest x-ray screening in a cohort at high risk of lung cancer (3). Despite the decrease in lung cancer mortality by CT screening in the NLST, significant concerns remain regarding its high false positive rate, overdiagnosis, cost effectiveness and concerns related to radiation burden from repeat CT screens. Radiation dose saving is especially important in patients with lung nodules because of the frequent follow up examinations. There is a trade-of between early detection of lung cancer vs unnecessary work-up of indeterminate nodules resulting in many side effects including anxiety, radiation exposure from CT follow-up to assess for growth, cost and morbidity and mortality related to biopsy or resection of a benign nodule. This is a significant issue as there is high false positive rate greater than 95% reported in many screening CT studies (95% of 39% positive screen (3 rounds) were false positive and 24% underwent surgery for benign nodule and 73% nonsurgical biopsy revealed benign findings in NLST. It is expected that false positive rate would decrease by 50% using more accurate phenotyping of a nodule using the lung CT reporting and data system (Lung-RADS) appropriately (4). One of the major changes proposed in Lung-RADS is the size threshold for positive screen, from 4 mm in NLST to 6 mm for solid nodules and 20 mm for nonsolid nodules. Smaller nodules will continue annual screening with low-dose CT (LDCT) in 12 months. Nodules larger than 6 mm and smaller than 8 mm will get follow-up LDCT in 6 months and nodules between the sizes of 8-15 mm will get 3 month LDCT and PET/CT may be used when there is larger than 8 mm solid component. Tissue sampling would be used primarily for larger than 15 mm solid nodules or PET positive nodules with larger than 8 mm solid component. False positive rate would still be likely not acceptable for an individual using this approach. There is need for more accurate nodule assessment and risk stratification as given our current understanding that genetic make-up of a nodule is the ultimate determinant of clinical outcome (5). Further improvements in stage discrimination and management of lung nodules could be expected in the future, as more robust data related to texture analyses of tumors, their genetic profiles and impact of those on clinical outcome becomes available (6-8). Simple measuring the tumor size with one-dimentional (Response Evaluation Criteria in Solid Tumors (or RECIST) long-axis measurements do not reflect the complexity of tumor morphology or behavior. Also, it may not be predictive of therapeutic benefit. In contrast, the emerging field of radiomics is a high-throughput process in which a large number of shape, edge, and texture imaging features are extracted, quantified, and stored in databases in an objective, reproducible, and mineable form. Once transformed into a quantifiable form, radiologic tumor properties can be linked to underlying genetic alterations and to medical outcomes. Marked heterogeneity in genetic properties of different cells in the same tumor is typical and reflects ongoing intratumoral evolution. Clinical imaging is well suited to measure temporal and spatial heterogeneity. Subjective imaging descriptors of cancers are inadequate to capture this heterogeneity and must be replaced by quantitative metrics that enable statistical comparisons between features describing intratumoral heterogeneity and clinical outcomes and molecular properties. References: Henschke C, et al. AJR Am J Roentgenol 2002;178(5):1053–1057 Travis W, Brambilla E, Noguchi M, et al. IASLC/ATS/ERS International multidisciplinary classification of lung adenocarcinoma. J Thoracic Oncol 2011;6:244-285 Aberle DR, Adams AM, Berg CD, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011;365:395-409 American College of Radiology: Lung-RADS Version 1.0 Assessment Categories Release date: April 28, 2014. Accessed at www.acr.org/Quality Safety/Resources/LungRADS on 17 March, 2015 McWilliams, A. et al. Probability of cancer in pulmonary nodules detected on first screening CT. The New England journal of medicine 2013;369: 910-919, doi:10.1056/NEJMoa1214726 Lambin P, et al. Radiomics:extracting more information from medical images using advanced feature analysis. Eur J Cancer 2012;48 (4):441-446 Gatenby RA, Grove O, Gillies RJ. Radiology 2013;269:8-15 Bartholmai BJ, Koo CW, Johnson GB, et al. Pulmonary nodule characterization including computer analysis and quantitative features. J Thorac Imaging 2015;30 (2) 139-156

Abstract:
The advancements in CT imaging have allowed for faster and higher resolution imaging of the thorax. Unfortunately, this had led to an increase in purposely and incidentally detected nodules of which the etiology is uncertain. The management of these nodules is based on multiple factors, but primarily based on risk factors of the patient. Broad categories of risk include nodules detected in patients incidentally, in patients being evaluated for thoracic disease, in people undergoing lung cancer screening and in patients being evaluated and treated for a malignancy. Current recommendations for management of these patients will be reviewed.

Abstract:
Introduction: Lung cancer is highly curable if detected at an early stage. Screening with low dose CT (LDCT) has been shown to reduce lung cancer mortality, but largely detects peripheral tumours. Due to limitation of resolution, LDCT currently cannot detect early pre-invasive central lung cancers. Evaluation of the central bronchial tree remains important in populations where central squamous carcinoma remains a significant contributor to lung cancer incidence or in patients at high risk of developing synchronous or metachronous squamous cell cancers. Imaging Technology: The imaging modality most commonly used for evaluation of the central airways is white light flexible bronchoscopy (WLB). The ability of routine white light examination to detect small pre-invasive central lung cancer remains limited. A number of technological advances and development of alternative in vivo optical imaging modalities improve the detection and evaluation of central pre-invasive lesions. These techniques include high magnification WLB, autofluorescence imaging (AFB), narrow band imaging (NBI), optical coherence tomography (OCT), confocal microendoscopy/endocystoscopy and raman spectroscopy (RS). Management: There are multiple tools available to be used with a flexible bronchoscopic approach to treat pre-invasive central lung cancers once detected. These include endobronchial electrocautery, argon plasma coagulation, cryotherapy, photodynamic therapy, brachytherapy and laser therapy. Therapeutic outcomes are dependent on multiple factors but curative rates of >85-90% are achievable. Patients are at risk of recurrence or the development of metachronous lesions and require close surveillance. Summary: The detection of early central lung cancers often requires more sophisticated tools than conventional white light bronchoscopy. The multimodality utilisation of different technologies will enable the rapid detection and diagnosis of early curable central lung cancers in selected high-risk populations. There are multiple tools available for curative treatment of early central lung cancers. References 1. Sun J, Garfield DH, Lam B, et al. The value of autofluorescence bronchoscopy combined with white light bronchoscopy compared with white light alone in the diagnosis of intraepithelial neoplasia and invasive lung cancer: a meta-analysis. J Thorac Oncol 2011;6(8):1336-1344. 2. Lee P, van den Berg RM, Lam S, Gazdar A, Grunberg K, McWilliams A, LeRiche J, Postmus P, Sutedja T. Color fluorescence ratio for detection of bronchial dysplasia and carcinoma in situ. Clin Cancer Res 2009; 15:4700-4705. 3. Herth F, Eberhardt R, Anantham D, Gompelmann D, Zakaria M, Ernst A. Narrow-band imaging bronchoscopy increases the specificity of bronchoscopic early lung cancer detection. J Thorac Oncol, 2009;4:1060-1065. 4. Lam S, Standish B, Baldwin C, et al. In vivo optical coherence tomography imaging of preinvasive bronchial lesions. Clin Cancer Res. 2008; 14: 2006–2011. 5. Thiberville L, Salaun M, Lachkar S, Dominique S, Moreno-Swirc S, Vever-Bizet C, Bourg-Heckly G. Confocal fluorescence endomicroscopy of the human airways. Proc Am Thorac Soc, 2009;6:444-449. 6. Shibuya K, Fujiwara T, Yasufuku K, Mohamed Alaa RM, Chiyo M, Nakajima T, Hoshino H, Hiroshima K, Nakatani Y, Yoshino I. In vivo microscopic imaging of the bronchial mucosa using an endo-cystoscopy system. Lung Cancer, 2011;72:184-190. 7. Short M, Lam S, McWilliams A, Ionescu D, Zeng H. Using laser Raman spectroscopy to reduce false positives of autofluorescence bronchoscopy: A pilot study. JTO, 2011;6:1206-1214. 8. McWilliams A, Shaipanich T, Lam S. Fluorescence and Navigational Bronchoscopy. Thoracic Surgery Clinics, May 2013. 9. Wisnivesky J, Yung R, Mathur P, Zulueta J. Diagnosis and Treatment of Bronchial Intraepithelial Neoplasia and Early Lung Cancer of the Central Airways. Diagnosis and Management of Lung Cancer, 3[rd] Edition, ACCP Guidelines. Chest, 2013;143 (5)(Suppl):e263S-e277S. 10. McWilliams. Clinical Applications in the Lung. In: Diagnostic Endsocopy: Series in Medical Physics and Biomedical Engineering. Eds. Zeng, H. Taylor & Francis Group 2014:pp209-220.

Abstract:
Improvements in clinical management of lung cancer have been modest over the last 20 years, with an overall 5-year survival rate just above 10% in Europe and 16% in the United States. Treatment failure is mainly due to the presence of metastatic disease at diagnosis, occurring in 70% of all patients whereas in patients resected in stage IA the 5-year survival rate is higher than 70% [1]. Detection of lung cancer at an early stage offers the real potential to reduce mortality with new chances of cure. The outcomes of the National Lung Cancer Screening Trial (NLST) have highlighted favorable prospects for lung cancer low-dose CT screening (LDCT) but the cost benefit profile of screening is still matter of debate in the scientific community [2]. In particular, the high false positive rates of LDCT lead to multiple screening rounds, repeated radiation exposure, the use of invasive diagnostic follow–up procedures with associated morbidity as well as increased time and costs. In addition, LDCT screening showed a limited impact on the more aggressive lung cancers, achieving an overall mortality reduction of only 20%. Several studies have reported blood-based biomarkers for early detection of lung cancer but so far only few of them have proven useful in lung cancer clinical practice. Beside technical issues related to difficulties in protocol standardization and lack of large scale validation in clinical trials, genetic and biological tumor heterogeneity has likely limited the successful identification of tumor-specific markers. A ground-breaking way to identify novel and more reliable biomarkers is searching for candidates by looking not only at the tumor itself but also at the interplay between the tumor and the host with the aim to identify very early changes related to the biological reactivity of the host to a developing cancer. In this respect, epigenetic markers, above all circulating microRNAs (miRNAs), could represent ideal candidates since they act as extracellular messengers of biological signals derived from the cross-talk between the tumor and its surrounding microenvironment. MiRNA are short non-coding RNA emerged as critical regulators of gene expression playing a key role in physiological and pathological mechanism. Blood circulating miRNAs were also reported to be promising biomarkers for cancer detection and prognosis [3]. MiRNAs are released into the bloodstream by different mechanisms such as passive leakage of cellular miRNAs from broken cells or active secretion through microvesicles or protein complexes by several cell subtypes [4]. Although LDCT is currently the standard of care for early lung cancer detection, it results in a general over diagnosis of indolent nodules, thus increasing unnecessary confirmatory diagnostic procedures. Non-invasive circulating miRNA assays could overcome most of these problems by exploiting the synergy between the molecular and imaging tests to reduce the number of the false positives. Two groups, in 2011, identified specific plasma and serum miRNA signatures comparing samples from patients and disease free individuals collected in three independent LDCT screening trials [5;6]. Our group reported four signatures composed by reciprocal ratios among 24 miRNAs by comparing samples collected before (n=20) and at the time (n=19) of LDCT disease detection to those of 27 control samples belonging to the INT-IEO trial [7]. These signatures were initially validated in a subset of 88 samples collected from 22 patients and 54 controls enrolled in the MILD trial [8]. Three years later, the same group developed a miRNA signature classifier (MSC), containing the 24 miRNAs previously identified, and tested its performance in enlarged validation set composed of 85 patients and 1000 controls belonging to the MILD trial [9]. The results of this study showed that the combination of MSC and LDCT reduced LDCT false-positive rate from 19.4% to 3.7% and that the MSC risk groups were significantly associated with survival. In addition, MSC was high sensitive (87%) and specific (81%) and its predictive value was confirmed by time-dependency analysis. Bianchi et al. identified a 34 miRNA signature in serum samples from 59 patients enrolled in the COSMOS trial compared to 69 disease free individuals divided in training and testing sets. Globally, the test showed an AUC of 89% in the testing set, and it was also able to rule out cancer in 79% of benign lung nodules. In addition, the 34 miRNA signature did not discriminate benign or malignant breast nodules, emphasizing the specificity of the test for lung cancer. Finally, the test did not classify pre-disease plasma samples, thus limiting the capability of the test to predict the development of the disease. Very recently, the same group refined their signature to 13 miRNAs which was validated in an independent set of 1008 subjects enrolled in the COSMOS trial [10]. Interestingly, this signature displays overlap of five miRNAs with the MSC signature (38.5%), an encouraging finding given the well known difficulty in validating expression signatures in different studies and given the differences in samples collection between these two studies (i.e. plasma vs serum). More recently, taking advantage of two screening programs with a total follow up of 23,967 person-years and a median time follow-up of 5.9 years, we analyzed the prognostic value of MSC in 84 in lung cancer patients identified in LDCT screening programs. In addition, to test the ability of the plasma MSC to monitor the disease status and recurrence during follow up, the MSC test was employed to analyze 86 longitudinally-collected plasma samples obtained from patients before and after surgical resection of primary lung tumors with a follow up time up to 4.1 years. We demonstrated that the three MSC risk groups were associated with significant differences in overall survival for the 84 subjects examined, also when adjusting for tumor stage. Moreover, the MSC risk level significantly decreased in subjects who remained disease free whereas in all relapsing patients increase of the MSC risk level was observed at the time of detection of a second primary tumor or of metastatic progression. The results presented highlight the clinical usefulness of circulating miRNAs as diagnostic, prognostic and monitoring tool in lung cancer. References 1. Goldstraw P, Crowley J, Chansky K et al. The IASLC Lung Cancer Staging Project: proposals for the revision of the TNM stage groupings in the forthcoming (seventh) edition of the TNM Classification of malignant tumours. J Thorac Oncol 2007;2:706-14. 2. Aberle DR, Adams AM, Berg CD et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011;365:395-409. 3. Boeri M, Pastorino U, Sozzi G. Role of microRNAs in lung cancer: microRNA signatures in cancer prognosis. Cancer J 2012;18:268-74. 4. Schwarzenbach H, Nishida N, Calin GA, Pantel K. Clinical relevance of circulating cell-free microRNAs in cancer. Nat Rev Clin Oncol 2014;11:145-56. 5. Boeri M, Verri C, Conte D et al. MicroRNA signatures in tissues and plasma predict development and prognosis of computed tomography detected lung cancer. Proc Natl Acad Sci U S A 2011;108:3713-8. 6. Bianchi F, Nicassio F, Marzi M et al. A serum circulating miRNA diagnostic test to identify asymptomatic high-risk individuals with early stage lung cancer. EMBO Mol Med 2011;3:495-503. 7. Pastorino U, Bellomi M, Landoni C, De Fiori E, Arnaldi P, Picchio M, et al. Early lung-cancer detection with spiral CT and positron emission tomography in heavy smokers: 2-year results. Lancet 2003; 362(9384):593-597 8. Pastorino U, Rossi M, Rosato V et al. Annual or biennial CT screening versus observation in heavy smokers: 5-year results of the MILD trial. Eur J Cancer Prev 2012;21:308-15. 9. Sozzi G, Boeri M, Rossi M et al. Clinical Utility of a Plasma-Based miRNA Signature Classifier Within Computed Tomography Lung Cancer Screening: A Correlative MILD Trial Study. J Clin Oncol 2014;32:768-73 10. Montani F, Marzi MJ, Dezi F et al. miR-Test: A Blood Test for Lung Cancer Early Detection. J Natl Cancer Inst 2015; 107(6): djv063.

Abstract:
SCLC constitutes about 15% of all lung cancers and occurs almost exclusively in smokers. Clinical features of SCLC include rapid growth and the early development of metastases. The vast majority of SCLC patients present with either locally advanced or metastatic disease. Owing to high metastatic potential of SCLC, a careful mediastinum staging, along with brain, bone and abdomen imaging, is indicated to identify patients amenable to curative approaches. Traditionally, SCLC patients have been divided into limited stage (LS), defined as tumor confined to the ipsilateral hemithorax and regional nodes, and extensive stage disease, defined as tumor beyond these boundaries. In 2007, the International Association for the Study of Lung Cancer (IASLC) recommended TNM staging for SCLC similarly to NSCLC, and this change was incorporated in 2010 into the AJCC/UICC 7[th] edition. Chemotherapy remains the mainstay of treatment in all SCLC patients. The current standard of care for LS-SCLC patients includes 4 cycles of chemotherapy consisting of cisplatin and etoposide. Carpoplatin can be substituted to cisplatin if contraindicated or in patients with poor tolerance to cisplatin. In LS-SCLC patients chemotherapy should be accompanied by thoracic radiotherapy. The metaanalysis of randomized studies comparing chemotherapy with or without radiotherapy showed apparently increased local tumor control and increased overall survival in favor of combined treatment (relative risk of death 0.86 [95% CI, 0.78 to 0.94; p=0.001], corresponding to a an absolute benefit of 5.4% at 3 years), at the expense of slightly increased early toxicity.[1] Radiotherapy concurrent to chemotherapy is preferred to sequential approach, despite higher incidence of severe pneumonitis and oesophagitis.[2 ]Early introduction of radiotherapy (with 1 or 2 cycle of chemotherapy) may increase treatment outcome.[3 ]A critical factor in chemoradiation for LS-SCLC is a short time from to the start of any therapy to the end of radiotherapy.[4] The optimal dose of radiotherapy for patients with LS-SCLC remains a matter of debate. Hyperfractionated radiotherapy including 45 Gy in 3 weeks (1.5 Gy twice daily) has been shown to be superior to 45 Gy in 5 weeks (1.8 Gy daily),[5 ]and is currently used as an alternative to standard regimens (60-70 Gy, 2 Gy daily). The volume of thoracic radiotherapy should be defined based on CT or (whenever possible) PET/CT scan, obtained within 4 weeks before treatment, and on CT scan obtained in the therapeutic position at the time of radiotherapy planning. The target to be irradiated should include all gross disease present at the time of radiation planning (postchemotherapy volume), and all nodal regions involved at the time of initial diagnosis (prechemotherapy volume). The use of traditional larger fields including also elective nodal sites is currently not recommended. With more effective therapy of LS-SCLC and a decreased risk of a thoracic relapse, the brain has emerged as one of the main sites of relapse, with a cumulative incidence at 2 years higher than 50%. Owing to limited penetration of cytotoxic drugs through the blood-brain barrier, the brain is considered a pharmacologic sanctuary site. This observation led to the development of prophylactic cranial irradiation (PCI) aiming at prevention of clinically overt brain metastases. Several randomized trials showed that PCI in patients who achieved a complete remission with chemotherapy significantly decreases the incidence of brain metastasis. The metaanalysis of these studies also demonstrated a small but significant overall survival improvement with PCI (the relative risk of death in the PCI vs. non-PCI group was 0.84 [95% CI: 0.73–0.97, p=0.01]), corresponding to a 5.4% increase in the rate of survival at 3 years.[6 ]Based on these results, PCI is currently recommended as a routine part of management in LS-SCLC patients who achieve a response to initial therapy. The dose of PCI has long been a matter of debate. Results of the randomized study comparing a standard (25 Gy in 10 fractions) vs. higher dose (36 Gy in 18 fractions) of PCI in LS-SCLC showed no significant difference in the 2-year incidence of brain metastases between two groups, and a lower overall survival in the higher-dose group.[7] In consequence, 25 Gy in 10 fractions remains the standard of care in LS-SCLC. In summary, current management in patients with LD-SCLC and good performance status includes the combination of cisplatin and etoposide, along with early thoracic radiotherapy (45 Gy in 3 weeks, 2 fractions daily, or 60-70 Gy in 6-7 weeks, one fraction daily), followed by PCI (25 Gy in 10 fractions) in those who achieved response to initial chemotherapy. References 1. Pignon JP, Arriagada R, Ihde DC, et al. A meta-analysis of thoracic radiotherapy for small-cell lung cancer. N Engl J Med 1992;327:1618-24. 2. Takada M, Fukuoka M, Kawahara M, et al. Phase III study of concurrent versus sequential thoracic radiotherapy in combination with cisplatin and etoposide for limited-stage small-cell lung cancer: results of the Japan Clinical Oncology Group Study 9104. J Clin Oncol 2004;22:4837-45. 3. Pijls-Johannesma M, De Ruysscher D, Vansteenkiste J, et al. Timing of chest radiotherapy in patients with limited stage small cell lung cancer: A systematic review and meta-analysis of randomised controlled trials. Cancer Treat Rev 2007: 33: 461–473 4. De Ruysscher D, Pijls-Johannesma M, Bentzen SM, et al. Time between the first day of chemotherapy and the last day of chest radiation is the most important predictor of survival in limited-disease small-cell lung cancer. J Clin Oncol 2006;24:1057-63. 5. Turrisi AT 3rd, Kim K, Blum R, et al. Twice-daily compared with once-daily thoracic radiotherapy in limited small-cell lung cancer treated concurrently with cisplatin and etoposide. N Engl J Med 1999;340:265-71. 6. Aupérin A, Arriagada R, Pignon JP, et al. Prophylactic cranial irradiation for patients with small-cell lung cancer in complete remission. Prophylactic Cranial Irradiation Overview Collaborative Group. N Engl J Med 1999;341:476-84. 7. Le Péchoux C, Dunant A, Senan S, et al. Standard-dose versus higher-dose prophylactic cranial irradiation (PCI) in patients with limited-stage small-cell lung cancer in complete remission after chemotherapy and thoracic radiotherapy (PCI 99-01, EORTC 22003-08004, RTOG 0212, and IFCT 99-01): a randomised clinical trial. Lancet Oncol 2009;10:467-74. The author declares no relevant conflict of interest.

Abstract not provided