Virtual Library

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1. Introduction of CT screening and showing its value. First to introduce CT screening in a novel cohort design comparing CT with chest radiography, providing a workup strategy for screen-detected nodules. Predicted outcome of well-designed and correctly powered RCT studies Henschke C, McCauley D, Yankelevitz D, Naidich D, McGuinness G, Miettinen O, Libby D, Pasmantier M, Koizumi J, Altorki N, and Smith J. Early Lung Cancer Action Project: overall design and findings from baseline screening. Lancet 1999; 354:99-105. 2. Long-term survival rates of patients diagnosed with lung cancer in a program of CT screening. First to provide estimated cure rates under screening by measuring long-term survivial. The International Early Lung Cancer Action Program Investigators. Survival of Patients with Stage I lung cancer detected on CT screening. NEJM 2006; 355:1763-71 3. First to provide information on the value of CT scans in delivering smoking cessation advice. Ostroff J, Buckshee N, Mancuso C, Yankelevitz D, and Henschke C. Smoking cessation following CT screening for early detection of lung cancer. Prev Med 2001; 33:613-21. Anderson CM, Yip R, Henschke CI, Yankelevitz DF, Ostroff JS, and Burns DM. Smoking cessation and relapse during a lung cancer screening program. Cancer Epidemiol Biomarkers Prev 2009; 18:3476-83. 4. First to introduce computer-assisted CT determined growth rates into the workup of pulmonary nodules. Yankelevitz DF, Gupta R, Zhao B, and Henschke CI. Small pulmonary nodules: evaluation with repeat CT--preliminary experience. Radiology 1999; 212:561-6. Yankelevitz DF, Reeves AP, Kostis WJ, Zhao B, and Henschke CI. Small pulmonary nodules: volumetrically determined growth rates based on CT evaluation. Radiology 2000; 217:251-6. Kostis WJ, Yankelevitz DF, Reeves AP, Fluture SC, Henschke CI. Small pulmonary nodules: reproducibility of three-dimensional volumetric measurement and estimation of time to follow-up CT. Radiology 2004; 231:446-52. Henschke C, Yankelevitz D, Yip R, Reeves A, Farooqi A, Xu D, Smith J, Libby D, Pasmantier M, and Miettinen O. Lung cancers diagnosed at annual CT screening: volume doubling times. Radiology 2012; 263:578-83. 5. Development of size threshold values and short-term followup and importance of a regimen of screening. Henschke C, Yankelevitz D, Naidich D, McCauley D, McGuinness G, Libby D, Smith J, Pasmantier M, and Miettinen O. CT screening for lung cancer: suspiciousness of nodules according to size on baseline scans. Radiology 2004; 231:164-8. Libby DM, Wu N, Lee IJ, Farooqi A, Smith JP, Pasmantier MW, McCauley D, Yankelevitz DF, and Henschke CI. CT screening for lung cancer: the value of short-term CT follow-up. Chest 2006; 129:1039-42. Henschke C, Yip R, Yankelevitz D, and Smith J. Definition of a positive test result in computed tomography screening for lung cancer: a cohort study. Ann Intern Med 2013; 158:246- 52. Yip R, Henschke CI, Yankelevitz DF, and Smith JP. CT screening for lung cancer: alternative definitions of positive test result based on the national lung screening trial and international early lung cancer action program databases. Radiology 2014; 273:591-6. Yip R, Henschke C, Yankelevitz D, Boffetta P, Smith J, The International Early Lung Cancer Investigators. The impact of the regimen of screening on lung cancer cure: a comparison of I-ELCAP and NLST. Eur J Cancer Prev. 2015;24(3):201-8. 6. Nomenclature and management protocols for nonsolid and part-solid nodules. Henschke C, Yankelevitz D, Mirtcheva R, McGuinness G, McCauley D, and Miettinen O. CT screening for lung cancer: frequency and significance of part-solid and nonsolid nodules. AJR Am J Roentgenol 2002; 178:1053-7. Yankelevitz DF, Yip R, Smith JP, Liang M, Liu Y, Xu DM, Salvatore MM, Wolf AS, Flores RM, Henschke CI, and International Early Lung Cancer Action Program Investigators Group. CT Screening for Lung Cancer: Nonsolid Nodules in Baseline and Annual Repeat Rounds. Radiology 2015; 277:555-64. Henschke CI, Yip R, Wolf A, Flores R, Liang M, Salvatore M, Liu Y, Xu DM, Smith JP, Yankelevitz DF. CT screening for lung cancer: part-solid nodules in baseline and annual repeat rounds. AJR Am J Roentgenol 2016; 11:1-9. 7. Differences in management of nodules found in baseline and annual repeat rounds of screening. International Early Lung Cancer Investigators. Baseline and annual repeat rounds of screening: implications for optimal regimens of screening. Eur Radiol 2017. In press. 8. Assessment of risk of lung cancer among women and never smokers. International Early Lung Cancer Action Program Investigators. Women’s susceptibility to tobacco carcinogens and survival after diagnosis of lung cancer. JAMA 2006; 296:180-4. Yankelevitz DF, Henschke CI, Yip R, Boffetta P, Shemesh J, Cham MD, Narula J, Hecht HS, FAMRI-IELCAP Investigators. Second-hand tobacco smoke in never smokers is a significant risk factor for coronary artery calcification. JACC Cardiovasc Imaging 2013; 6:651-7. Henschke CI, Yip R, Boffetta P, Markowitz S, Miller A, Hanaoka T, Zulueta J, Yankelevitz D. CT screening for lung cancer: importance of emphysema for never smokers and smokers. Lung Cancer 2015; 88:42-7 PMID:25698134. Yankelevitz DF, Cham MD, Hecht HS, Yip R, Shemesh S, Narula J, Henschke CI. The Association of Secondhand Tobacco Smoke and CT angiography-verified coronary atherosclerosis. JACC Imaging. 2016. 9. Determination of cardiac risk on nongated, low-dose CT scans and development of an ordinal scale. Shemesh J, Henschke CI, Farooqi A, Yip R, Yankelevitz DF, Shaham D, and Miettinen OS. Frequency of coronary artery calcification on low-dose computed tomography screening for lung cancer. Clin Imaging 2006; 30:181-5. Shemesh J, Henschke CI, Shaham D, Yip R, Farooqi AO, Cham MD, McCauley DI, Chen M, Smith JP, Libby DM, Pasmantier MW, and Yankelevitz DF. Ordinal scoring of coronary artery calcifications on low-dose CT scans of the chest is predictive of death from cardiovascular disease. Radiology 2010; 257:541-8. 10. Recommendations for reporting findings of emphysema, coronary arteries, breast, and abdomen on low-dose CT scans. Zulueta JJ, Wisnivesky JP, Henschke CI, Yip R, Farooqi AO, McCauley DI, Chen M, Libby DM, Smith JP, Pasmantier MW, and Yankelevitz DF. Emphysema scores predict death from COPD and lung cancer. Chest 2012. Henschke CI, Lee IJ, Wu N, Farooqi A, Khan A, Yankelevitz D, and Altorki NK. CT screening for lung cancer: prevalence and incidence of mediastinal masses. Radiology 2006; 239:586-90. Salvatore M, Margolies L, Kale M, Wisnivesky J, Kotkin S, Henschke CI, and Yankelevitz DF. Breast density: comparison of chest CT with mammography. Radiology 2014; 270:67-73. Hu M, Yip R, Yankelevitz D, and Henschke C. CT screening for lung cancer: frequency of enlarged adrenal glands identified in baseline and annual repeat rounds. Eur Radiol 2016. Chen X, Li K, Yip R, Perumalswami P, Branch AD, Lewis S, Del Bello D, Becker BJ, Yankelevitz DF, and Henschke CI. Hepatic steatosis in participants in a program of low-dose CT screening for lung cancer. European Journal of Radiology 2017. In Press. 11. Quantatative assessment of the vascular system on low-dose CT scans. Fully automated evaluation of quantitaive image biomarkers for multple organs and anatomic regions including: pulmoanry nodules, lungs (emphysema, ILD, major airways), coronary arteries, aorta, pulmoanry artery, breast, and vertebra. Kostis, W. J., Reeves, A. P., Yankelevitz, D. F., and Henschke, C. I. Three-dimensional segmentation and growth-rate estimation of small pulmonary nodules in helical CT images. IEEE Transactions on Medical Imaging 2003; 22: 1259-1274. Enquobahrie, A., Reeves, A. P., Yankelevitz, D. F., and Henschke, C. I. Automated detection of small solid pulmonary nodules in whole lung CT scans from a lung cancer screening study. Academic Radiology 2003; 14, 5: 579-593. Keller, B. M., Reeves, A. P., Henschke, C. I., and Yankelevitz, D. F. Multivariate Compensation of Quantitative Pulmonary Emphysema Metric Variation from Low-Dose, Whole-Lung CT Scans. AJR 2011; 197, 3: W495-W502. Xie Y. Htwe YM, Padgett J, Henschke CI, Yankelevitz DF, Reeves AP. Automated aortic calcification detection in low-dose chest CT images. SPIE Medical Imaging 2014; 9035:90250P. Xie Y, Cham M, Henschke CI, Yankelevitz DF, Reeves AP. Automated coronary artery calcification detection on low-dose chest CT images. SPIE Medical Imaging 2014; 9035:90250F.

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Around one billion people on the planet are regular smokers. And lung cancer is one of the biggest killers. We all now know that there is a direct connection in many cases. Non-smokers do get lung cancer, but the risks if you are a smoker are significantly. Undoubtedly, tobacco smoking is the major risk factor for lung cancer, although passive smoking, and a family history of lung, head and neck cancer are, among other factors, also important. Figures show that lung cancer causes almost 1.4 million deaths each year worldwide, representing almost one-fifth of all cancer deaths. Within the EU, meanwhile, lung cancer is also the biggest killer of all cancers, responsible for almost 270,000 annual deaths (some 21%). It is at the very least surprising that the biggest cancer killer of all does not have a solid set of screening guidelines across Europe, Doctors need to quickly identify high quality, trustworthy clinical practice guidelines, in order to improve decision making for the benefit of their patients. The Alliance has turned its attention to need for more guidelines across the arena of healthcare, especially in screening for lung cancer. There is a need for agreement and coordination across the European Union’s 28 Member States. In the US, the American Cancer Society has stated that it had “thoroughly reviewed the subject of lung cancer screening” and issued guidelines that are aimed at doctors and other health care providers. Europe, among other things, is looking at risk prediction models to identify patients for screening, plus determination of how many annual screening rounds is enough. Of course, cost-effectiveness questions arise whenever population-wide screening is considered, especially in relation to frequency and duration. Yet, the potential benefit of low-dose CT lung cancer screening would almost certainly see an improvement in the lung cancer mortality rate in Europe. Stakeholders are aware that screening for lung cancer also has potential harms. These include radiation risks (increased risk of other cancers), identification of often harmless nodules, which could lead to further evaluation (including biopsy or surgery), unnecessary fear in the patient and those close to him or her, and over-diagnosis and possibly subsequent treatment of cancerous cells that would cause no ill effects over a lifetime. Often, malignant small lesions are found that would not grow, spread, or cause death. This could lead to over-diagnosis or over-treatment, bringing about extra cost, anxiety and ill-effect (even death) caused by the treatment itself. On the other hand screening can help to ensure that surgery in lung cancer’s early stages can continue to be the most effective treatment for the disease. As it stands, most patients are diagnosed at an advanced stage - usually non-curable. EAPM, along with other aforementioned stakeholders, believes that there is a strong case for lung cancer screening programmes across the 28 EU Member States to reduce the cases of advanced-stage lung cancer. Among recommendations currently being discussed in European forums are the setting of minimum requirements, which should include standardised operating procedures for low-dose imaging, criteria for inclusion (or exclusion) for screening and, of course, smoking cessation programmes. Also important are improving the quality, outcome and cost-effectiveness of screening, reducing radiation risks, and making thorough assessments of other risks, such as co-morbidities. ERS and ESR have stated that “the establishment of a central registry, including biobank and image bank, and preferably on a European level, is strongly encouraged”, and EAPM is in full support of this. Current situation In the US, lung cancer screening has been the subject of major policy decisions and investigations. One finding showed that a screening trial brought about a 20% drop in lung cancer mortality. On the back of this, several mainstream clinical and professional organisation recommended the implementation of screening. In Europe, the Dutch and Belgian NELSON lower-dose computed tomography (CT) trial is producing data on mortality rates (and, of course, cost effectiveness). The NELSON study was designed to investigate whether screening for lung cancer by low-dose CT in high-risk subjects would lead to a decrease in 10-year lung cancer mortality of at least 25%. This to be looked at in comparison to a control group which was not undergoing screening. The NELSON study began in 2003, using men aged 50–75 years from seven districts in the Netherlands and subjects from both sexes from 14 close geographical areas in Belgium. Initially, these subjects were sent a questionnaire about general health, how much they smoked, their cancer history, and several other lifestyle and health factors. Based on the smoking history, the estimated lung cancer mortality risk of the respondents was determined. Next, the required sample size including required participation rate was determined. Thirteen years on and the results from the final, fourth round of what is EU’s largest trial have found that leaving a two-and-a-half-year interval reduced the effect of screening. In essence this means that the cancer rate showed higher levels than found with one-year and two-year screening intervals. Crucially, in the final round, occurrences of the advanced-stage disease were higher than previous rounds and, as discussed above, that invariably means more deaths. Further EU pooled trial results are expected to come along soon, in the wake of NELSON.Conclusions Findings in both Europe and the US strongly suggest that lung cancer screening works. Current evidence is, as yet, limited and the discussion continues. But there is hard evidence, although debate continues about the best way to implement screening of this kind, and even how to properly evaluate ‘cost effectiveness’ - who should decide? Of course, guidelines could help to tether costs, by bringing in improvements to the efficiency of screening methodologies and, thus, programmes themselves. Key to such a situation would be making the best use of efficient risk-assessment methods, top-of-the-range imaging technology, and guidelines that encourage the minimisation of invasive procedures and risk to the patient.

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Are we screening the at risk population? How can we bring imaging and molecular tools to improve the early detection/treatment rates of lung cancer and decrease the false positive rates? The National Lung Screening Trial (NLST) demonstrated that low dose CT screening among high risk individuals reduces the relative risk for lung cancer mortality by 20%. Yet the poor specificity of chest CT, which forces us to deal with large proportions of false positive results, morbidity and cost, pushes us to improve the risk assessment and diagnostic accuracy of the tests offered. A large proportion of individuals will be diagnosed with lung cancer and still do not meet the population criteria studied in NLST trial. So the scientific community is charged to improving early detection of invasive lung cancers to a definitive treatment. An estimated 43% of individuals diagnosed with lung cancer meet the NLST criteria, thus missing an opportunity to screen another large at-risk population. There are currently no accepted strategies for screening patients who fall outside of these criteria. Therefore tools of risk assessment and early detection could profoundly reduce lung cancer mortality. Considerations for familial history with or without germline DNA mutation carriers, exposure to carcinogens, chronic pulmonary obstructive lung disease, are being proposed for integration in risk prediction strategies. The reporting tools for findings at the time of CT screening have been replaced by the American Radiology Association’s LungRADS score which reduces the false positives rate among the most highly suspicious lesions from 27% to 13%. On the imaging diagnostic side, the emerging field of radiomics involves computational analysis of extracted quantitative data from clinical radiology images. Rapid progress in this field offers the promise of diagnostic accuracies that will surpass the one of expert radiologists. On the molecular diagnostic side, diagnostic tools for risk adjustment and to augment current lung cancer detection strategies are urgently needed. Circulating tumor cells are shed from primary tumors into the blood stream, so is circulating tumor DNA naked or in microvesicles. Proteins, RNA moieties and epigenetic changes can be captured in the circulation and also have the promise of changing the landscape of non-invasive diagnosis of early lung cancer. Some of these strategies will be discussed to illustrate the impressive and rapid progress soon coming to the clinic to address the primary goals of early detection.

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Computed Tomography (CT) imaging of the lung has been routinely used over the last few decades to detect and treat early lung cancer and other related diseases. As CT image acquisition technology has improved, the use of CT for quantitative and precise lung imaging clinical applications has greatly expanded. High resolution CT studies, which now easily obtain sub-millimeter resolution of the entire chest within a breath-hold, are now widely used to detect and measure changes in early lung cancer lesions and COPD. Traditionally, several concurrent methods have been used to ensure that the quality of acquired CT images is adequate for general clinical use. This includes regular scanning and analysis of CT quality control phantoms from ACR (as well as from individual CT scanner manufacturers) and visual inspection of acquired images by radiologists for significant image artifacts. While these methods have served the field of radiology well for identifying and correcting major image quality issues, there has not been standard image quality assessment methods available for specific clinical applications that require precise image-based measurements. To improve global quality control of lung imaging studies, several clinical societies and organizations have provided image acquisition and measurement guidance documents intended to be followed by clinical sites [1, 2, 3]. We are entering a new era of quantitative imaging where easy to use tools are available that ensure that precise quantitative image measurements can be routinely and reliably obtained. To achieve this goal, a new set of task-based image quality control measures is being developed by research groups and radiology societies such as the RSNA’s Quantitative Imaging Biomarkers Alliance [4]. Each major quantitative imaging-based clinical task is being extensively studied to determine the fundamental image quality properties needed (e.g. resolution, sampling rate, noise, intensity linearity, spatial warping) to achieve a minimum level of measurement performance. In addition, new low-cost phantoms are being developed that can be quickly scanned and automatically analyzed to estimate these fundamental properties throughout the full three-dimensional CT scanner field of view. Deploying these low-cost phantoms and automated phantom analysis software on the cloud further enables global clinical sites to quickly and easily verify the quality of a CT scanner and acquisition protocol for a specific quantitative clinical task. In addition to providing a fast method for verifying conformance with minimum quantitative imaging performance standards, the reports generated can provide guidance as to the best protocols observed for a particular CT scanner model, thereby allowing a clinical site to optimize image acquisition protocols with the best evidence obtained through crowd-sourcing task-specific image quality information. The QIBA CT lung nodule task force is now preparing to launch a pilot project to evaluate the utility of these new image quality control measures for the quantitative measurement of the change in volume of solid lung nodules (6mm to 10mm diameter) [5]. Over the coming months this new “active” and cloud-based analysis approach will be deployed at international lung cancer screening institutions and use statistics will be assembled. The data collected has the potential not only to inform the lung cancer screening community on the global quality of lung cancer screening imaging, but also to establish early data on whether these new methods can one day serve as a more effective approach to providing quality control for quantitative imaging methods. References 1. Kauczor HU, Bonomo L, Gaga M, Nackaerts K, Peled N, Prokop M, Remy-Jardin M, von Stackelberg O, Sculier JP; European Society of Radiology (ESR); European Respiratory Society (ERS), ESR/ERS white paper on lung cancer screening, ESR/ERS white paper on lung cancer screening. 2. IELCAP, IELCAP Protocol Document, http://www.ielcap.org/sites/default/files/I-ELCAP-protocol.pdf Accessed May 31, 2017. 3. Fintelmann FJ, Bernheim A, Digumarthy SR, Lennes IT, Kalra MK, Gilman MD, Sharma A, Flores EJ, Muse VV, Shepard JA, The 10 Pillars of Lung Cancer Screening: Rationale and Logistics of a Lung Cancer Screening Program, Radiographics. 2015 Nov-Dec;35(7):1893-908. 4. https://www.rsna.org/QIBA/ 5. RSNA QIBA, Draft QIBA Profile: Lung Nodule Volume Assessment and Monitoring in Low Dose CT Screening, http://qibawiki.rsna.org/images/e/e6/QIBA_CT_Vol_LungNoduleAssessmentInCTScreening_2017.05.15.docx, May 15, 2017.

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Lung cancer screening offers a unique opportunity for medicine to closely partner with nursing in detecting lung cancers at earlier, treatable stages, address other tobacco related diseases, and assist patients in smoking cessation efforts. Foundational nursing principles are universal around the world with an emphasis on clinical care, research and implementation science, patient education and health coaching, performance improvement and quality outcomes processes, and patient-centered care. Given this preparation, nursing professionals can be potent if positioned predominantly at the helm of lung cancer screening programs with the most touch-points and direct interaction with screening recipients, over the screening continuum. Lung cancer screening encounters present an opportunity for early rather than late detection of preventable and treatable diseases through low dose CT scan. Additionally, lung cancer screening can be utilized as a transformational health tool by positioning nursing at the center of the integrative care delivery model and drive beneficial health outcomes through direct counseling, and health coaching. This includes facilitating preventive measures that directly impact the natural history of tobacco related diseases through smoking cessation counseling and treatment services and health coaching as it relates to the individual patient, their current health state, and low dose CT scan results. The professional services that nursing is keenly positioned to offer within the multidisciplinary lung cancer screening setting hold great potential for an international sustainable screening model. This presentation will discuss pragmatic, approaches to evidence based screening programs, led by nursing, in which high-risk patients receive the care they need and deserve, encourages active engagement in the critical continuum of screening and opens opportunity for improvements in individual and population health.

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Decision making in life is not always easy. This is applicable not just for patient care but also for matters related to our own-self and is particularly true in the context of career options in medicine. Over the past few decades, the level of expertise provided by health-care providers has enhanced considerably from having comprehensive ‘all-in-one’ doctors to specialists to super-specialists and currently focused super-specialists. This has been associated with the practice of medicine having changed from ‘evidence-based-medicine’ to ‘personalized medicine’ and currently of ‘precision medicine’ and ‘tailor-made’ therapies. This has largely been based on an increase in the quantity and quality of research being conducted worldwide. A majority of this research occurs in academic medical centers/university hospitals wherein faculty/attending consultants are not just involved in patient care but have to devote a substantial percentage of their time in planning and conducting research as well as teaching undergraduate/postgraduate residents and fellows. So the natural questions that crop up for someone in training are: 1) ‘How do I decide whether I am inclined to be working in an academic institute?’ [Will I be able to ‘gel-in’ or be a complete misfit?] ‘2) What is the time-point during my training/post-training period when I need to take the decision of pursuing an academic career?’ 3) ‘What are the essential and desirable qualities/traits that are conducive to working in an academic set-up?’ There are no straightforward answers to any of these. However, generally during the final year of fellowship, most individuals are able to decide whether they would like to continue working in an academic centre or not. This is often possible with guidance from course faculty. The chief-guide under whom the individual has been pursuing research (thesis/dissertation) may be able to identify if the latter has an ‘academic bent of mind’ and provide mentorship and help the transition from ‘fellow’ (in-training) to full-time faculty [‘attending’ consultant]. It is important for anyone intending to pursue an academic career to realize that conducting and participating in research is an integral part as opposed to working in non-academic centers where patient care is the primary focus. Inclination towards research may sometimes manifest as being able to identify ‘grey’ areas in practice of medicine (clinical situations for which there are no clear-cut answers). The best researchers are and often have been those who are able to identify these areas of uncertainty related to diagnosis and treatment of a particular condition or disease and carry out research directed to answer the queries that they had in their minds when picking up these uncertainties. Keeping abreast of the latest developments in one's focus area (by regularly accessing and reading the latest publications in peer reviewed journals) as well as publishing one's own experience/research in such journals is thus part and parcel of one's job profile while working in an academic center. For lung cancer – a disease that carries the highest cancer-related mortality amongst both gender combined and the commonest cancer in males, there have been very encouraging developments in the last couple of decades and especially the last five years. We now have five pillars for treatment – targeted therapy and more lately immunotherapy coming in as very useful additions to traditional modalities (surgery, chemotherapy and radiotherapy). And these are truly exciting times for carrying out research in lung cancer in several ways: 1) Number of investigational molecules (targeted therapy and immunotherapy) being developed/tested in preclinical/clinical trials is increasing at an unparalleled rate 2) Conventional pathway followed for testing [preclinical, phase-1, phase-2, phase-3 clinical trials] is being modified to reduce time to clinical approval for successful drugs by having combined phase 1/2 or phase 2/3 trials. 3) Intense efforts are being made to expand indications for already approved/available drugs e.g. assessing utility of targeted agents in early stage/resectable NSCLC and of combination regimens (EGFR-TKIs/ALK inhibitors+ chemotherapy, PD-1/PD-L1 immune check-point inhibitors+ chemotherapy). Several unaddressed issues exist in lung cancer currently which require concerted efforts and inputs from researchers worldwide including: 1) Improving the screening algorithm for early detection such that false positive results and need for/number of invasive procedures required is reduced. Development of blood, sputum or exhaled-breath based screening tests could find greater acceptability and applicability worldwide. 2) Improving the genomic understanding of SCLC – a histological subtype without significant advances in the past leading treatment to be essentially with two modalities (chemotherapy and radiation). Identifying ‘targetable’ molecular aberrations can revolutionize management of this aggressive histological type while ongoing efforts to establish the role of immune check-point inhibitors continue. 3) Detection of EGFR sensitizing mutations and acquired T790M resistance-conferring mutation (for initiating 1[st]/2[nd] generation EGFR-TKIs and osimertinib respectively) in circulating tumor DNA (ctDNA; sometimes called circulating free tumor DNA - cfDNA) is already applicable in clinical practice and potentially can be used for monitoring treatment responses also. Next-generation-sequencing(NGS) platforms appear promising in detecting both somatic point-mutations and rearrangements/fusions with minimal tissue and/or ctDNA. Development and validation of methods for non-invasive biological monitoring of responses to chemotherapy, radiation, immunotherapy and non-EGFR targeted therapies in the complete spectrum of histological types (SCLC, squamous and non-squamous NSCLC) and disease stage distribution (neoadjuvant treatment preceding surgery, post surgery – adjuvant setting, locally advanced NSCLC following induction concurrent chemo-radiation and metastatic setting) will make it more convenient for patients and treating oncologists alike. The advantages of working in an academic setup in lung cancer are apparent both for the clinician and his/her colleagues in other clinical departments/basic sciences. Current research and clinical practice requires collaboration of different disciplines [pulmonology, diagnostic and interventional radiology (including nuclear imaging), pathology (histopathology, cytopathology, molecular pathology), thoracic surgery/surgical oncology, radiation oncology and medical oncology]. Based upon the academic institute’s geographical location, the number/work profile of departments that exist for a given discipline may vary considerably. These variations notwithstanding, the bottom-line is that reaching out to and working together with colleagues from other departments and disciplines [multidisciplinary team approach] is mandatory for attempting conduct of high-quality research and delivery of high-quality patient care in thoracic oncology. This potential advantage and benefit also comes with several challenges. One is required to carefully balance and utilize working hours for patient care, research and training while attempting to do the best in all three fields. This invariably, if not mandatorily, leads to spill-over of work into ‘off-work’ hours and impinges on ‘family-hours’ or ‘personal-time.’ The support of one's spouse, parents and children in such settings cannot be undermined or understated. One needs to keep a balance between ‘All-work-and-no-play makes Jack a frustrated man’ versus ‘Jack-of-all-trades and master-of-none’. Neither is desirable and the ultimate aim is to have a satisfying career in thoracic oncology while working in an academic setting wherein one is able to: 1) provide patients (often under-privileged and belonging to poor socio-economic strata) the best diagnostic and treatment facilities (despite presence of resource constraints) – Patient Care 2) be involved in clinically relevant basic and translational research that has the potential to improve patient care in one’s own geographical location – Research 3) share one’s experience with residents/fellows and colleagues within the institute and outside – Medical Education Navneet Singh MD DM Email: [The author is a thoracic medical oncologist-cum-pulmonologist currently working as an Associate Professor of Pulmonary Medicine at the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. He is a member of IASLC’s Staging & Prognostic Factors Committee; Publications Committee and is IASLC’s Regent for the Indian Subcontinent. Additionally, he is Chair-Elect of the American Society of Clinical Oncology’s (ASCO) International Development and Education Award (IDEA) Working Group and a member of its Multidisciplinary Cancer Management Course Working Group and Thoracic Cancer Guideline Advisory Group. His detailed profile is accessible at http://www.linkedin.com/in/navneet-singh-160012.]

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Relatively little information is available for hematology oncology fellows to inform their choice for an academic oncology(AO) vs a community oncology(CO) career. In 2006, Desch and Blayney(1) described practical differences between AO and CO careers which are still pertinent today. A more recent report from Vanderbilt(2) describes factors which appear to influence oncology fellows’ career decisions. Once a career path has been selected, does this choice affect career and work-life balance satisfaction? Shanafelt and his colleagues have described the impact of career choice and related factors on job satisfaction(3,4). This review will summarize the results of these reports and share a perspective regarding possible changes in oncology practices which could impact career choice. Desch and Blayney(1) describe mission, governance, patient care, financial considerations, referral bases, career flexibility, and determinants of success. The mission for community oncologists(COs) consists of delivering excellent patient care and running a successful business. In contrast, the mission for academic oncologists(AOs) encompasses patient care, research and teaching. CO governance offers more autonomy and usually consists of a doctor owned corporation with equal ownership. AOs work in a hierarchical system with multiple levels between the physician and senior leadership. There are significant differences in delivering patient care. Desch and Blayney point out that “ COs are intern, resident, fellow, and attending all rolled into one. ” COs have more weekend and night call. In addition, COs provide care for multiple types of cancer patients , while AOs’ practice is usually limited to one or two types of malignancy. Patient referrals for COs depend upon building relationships with primary care physicians and surgeons in their community. AOs also get patient referrals from primary care physicians and surgeons, but they rely heavily on institutional reputation, the reputation of disease specific experts, and a robust clinical trial program. Publishing and giving presentations at local and national meetings establishes AOs as disease specific experts which results in physician referrals and in patient initiated consultations. Revenue for COs depends upon fees for physician services, for administration of intravenous treatment , for laboratory tests, for imaging, and revenue from chemotherapy/immunotherapy treatments. For AOs, revenue comes from fees for physician services, grants, clinical trial revenue, and philanthropy. In some academic institutions, revenue may also come from the ancillary sources, similar to private practice. Starting and subsequent compensation is higher for COs who receive significant salary increases when they become full partners in the corporation, 2-5 years after joining the practice. Salary for AOs increases with increasing academic rank and may be supplemented with bonuses and honorariums for lectures and participation in advisory boards. Desch and Blayney(1) suggest that there are critical success factors for COs and AOs. . Building a reputation as a local expert and being readily available to referring MD’s and partners is essential for COs. . They also point out that it is essential for COs to invest time to understand bonuses and to show that they value and support the practice staff. AOs must focus on area of expertise, choose a good mentor, publish results of research, and apply for grants. It is not realistic to expect AOs with a large clinical practice to be the principal investigator on a grant. However, these clinicians can learn the concepts of basic science and partner with laboratory investigators in translational research grant proposals. Horn and her collegues(2) studiedfactors associated with selecting an AO or CO career. They invited program directors at 56 NCI designated and National Comprehensive Cancer Network cancer centers. Fellows at these institutions were asked to complete a questionnaire regarding their interest in AO vs CO careers. . Fellows with a high interest in AO were more likely to be women, have an additional graduate degree, and to have participated in basic research. Also fellows who were more interested in AO gave more presentations at scientific meetings and had more publications. Having an influential mentor and a desire to teach were also related to pursuing a career in AO. . Fellows who were more interested in CO were motivated by work-life balance and autonomy. This study suggest that fellows who are primarily motivated by being involved in identifying new information and teaching are more likely to pursue AO , while fellows who are motivated by favorable work-life balance and having more autonomy are more likely to pursue a CO career. How do practicing oncologists feel about their careers? Shanafelt and colleagues(3,4) have published two reports describing results of a survey which evaluated burnout, career satisfaction, life – work balance satisfaction and retirement. They(3) found that COs spent more time in clinic and saw more patients.. Younger age and more hours in clinic were associated with increased risk of burnout, which was defined as a combination of emotional exhaustion and depersonalization (loss of concern for patients),. There was a trend for higher rate of emotional exhaustion and a significantly higher rate of depersonalization in community oncologists. Although the majority of oncologists would choose a career in oncology, there was a higher number of COs who stated they would not choose an oncology career. In the second report(4), they did not compare AOs and COs. They saw that although most oncologists find meaning in their work, 52% were dissatisfied with work-life balance. “They like their work but want to do less of it.” Work-life balance was affected by more night and weekend call, while method of compensation salary +/- bonuses (most AOs) versus incentive (most COs) was not related work-life balance. For oncologists who planned to reduce work hours, the most common reason was to spend more time with family. In summary, when making a career choice, oncology fellows should identify what motivates them. I suspect that the majority of oncologists will continue to be happy with their career choice and that the current differences between AO and CO careers may decrease because more COs will be employed by hospital systems. References 1.Desch CE, Blayney DW. Making the Choice Between Academic Oncology and Community Practice: The Big Picture and Details About Each Career. Oncol Pract 2:132-138, 2006 2.Horn L, Koehler E, Gilbert J, et al. Factors Associated with the Career Choices of Hematology and Medical Oncology Fellow Trained ar Academic Insitutions in the United States. J Clin Oncol 29: 3932 - 3938, 2011 3.Shanafelt TD, Gradishar WJ, Kosty M, et al.Burnout and Career Satisfaction Among US Oncologists. J Clin Oncol 32: 678-686, 2016 4.Shanafelt TD, Raymond M, Kosty M, et al.Satisfaction with Work-Life Balance and the Career and Retirement Plans of US Oncologists.J Clin Oncol 32:1127-1135, 2014

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I received the WCLC 2016 Young Investigator Travel Award for my presentation entitled “Immunogram for cancer-immunity cycle towards personalized immunotherapy of lung cancer”. It was my great honor to receive the award, and I want to thank the conference committee and all the conference attendees. This was my first time to attend the WCLC, and I enjoyed the conference and my stay in Vienna. I was given the opportunity to join the Faculty Dinner held in Vienna City Hall. It was a fabulous experience, and I thoroughly enjoyed sitting at the same table as world-renowned surgeons and oncologists. During the conference, I mainly attended immunotherapy sessions where I learned about the results of the most recent clinical studies. Furthermore, while attending the biomarker session, I realized that biomarkers in this field are still inadequate and the development of useful biomarkers in immunotherapy is an urgent need. Receiving the young investigator scholarship has encouraged me to continue our efforts to unveil the tumor microenvironment in each patient using individual next-generation sequencing data in order to develop “next-generation biomarkers” and achieve optimal personalized immunotherapy. Last year, in a Perspectives article in Science, Blank et al. proposed the concept of the cancer immunogram, a framework to illustrate multiple parameters that influence the cancer-immunity interaction (1). In their article, the concept was applied theoretically to patients but not tested in practice. To accomplish this, we developed an immunogram reflecting the cancer immunity cycle using next-generation sequencing data, and applied it to real patients with lung cancer. An immunogram for the cancer immunity cycle is a radar chart that consists of eight molecular profiles relevant to the development of T-cell immunity to tumor cells. We sought to translate cumbersome omics data into easily comprehensible “report cards” for clinicians. Immunograms can be used as integrated biomarkers, and may become a valuable resource for optimal personalized immunotherapy. After the presentation at the WCLC 2016, our findings were published in the Journal of Thoracic Oncology in May (2). It was an honor that our article was chosen by the Editor to be a featured article and was introduced by an elegant review (3). We recently updated our method by normalizing the immunogram score using TCGA data. We are pleased to share the details of this improvement during the present conference. Although we are working in a challenging field and there is still a long way to go, we are encouraged by the award and will continue to struggle toward further breakthroughs.　 References (1) Blank CU, Haanen JB, Ribas A, Schumacher TN. Cancer immunology. The “cancer immunogram” Science. 2016;352:658-60. (2) Karasaki T, Nagayama K, Kuwano H, et al. An Immunogram for the Cancer-Immunity Cycle: Towards Personalized Immunotherapy of Lung Cancer. J Thorac Oncol.2017;12(5):791-803. (3) Botling J, Sandelin M. Immune Biomarkers on the Radar-Comprehensive "Immunograms" for Multimodal Treatment Prediction. J Thorac Oncol.2017;12(5):770-2.

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The IASLC (International association for the study of lung cancer) WCLC (World Conference on Lung Cancer) is world’s largest academic platform dedicated for the study of lung cancer and other thoracic malignancies which not only caters to physicians but also includes active participation from each discipline of medicine involves in patient care. In addition health advocacy groups and patients will also join WCLC to obtain and exchange the information. The focus of the meeting is on the biology, diagnosis, pathogenesis, treatment and management of lung cancer so to begin from active prevention and accurate diagnosis to advanced care. Because of advancing science of lung cancer, IASLC decided to hold WCLC every year so people will be kept abreast with the current knowledge and updates in this field. There are many academic opportunities for the young investigators or first-time attendee to pursue their career in the field of thoracic oncology. They can meet the experts during the conference, attend various educational sessions and take guidance in the field of basic, translational and clinical research. There are many awards which help in not only enhancement of academic career but also in attending conference from resource poor countries. Travel awards given to developing nation investigators so that they can attend the conference and present their latest research in addition to make collaborations and academic networking. International mentorship program of IASLC is very useful professional development and education program for early-career doctors from economically-developing countries in which you get an opportunity to spend a week time in a well established hospital or laboratory under the mentorship of an international expert in that field. This year, the Core Program Committee has organized a scientific program that includes more than 450 presentations. The conference motto is “Synergy to Conquer Lung Cancer” which will be very overwhelming at both scientific and educational fronts. The education sessions include state-of-the-art talks by experts on academically challenging and evolving topics. The scientific program includes research presentations in the form of posters and platform formats. There are many events and platforms where first time attendees can interact and do networking for future collaborations. It is certain that the 18[th] WCLC will help young investigators and first time attendees to build and shape-up their career in thoracic oncology.