CURE Media Group

Treatment for cancer is tough, but treatment for cancer during COVID-19 times is even tougher. The infusion unit waiting room was full of vacuous eyes and silence. No support partners were allowed. 

Enter my nurse nominee, Jyl Dedier, B.S.N., RN. She was light in darkness. Jyl looked at me with kind eyes, which were the only part of her face I could see. 

She wasn’t allowed to hug me, but her voice and eyes made a connection. She was genuinely interested in my life, my family and my career. She went out of her way to ensure I was comfortable, and she connected me with support services. She remembered my details from week to week, a connection that helped to soften isolation during long infusions. We were both women, working moms, humans — not just a patient and her nurse.

One day is particularly memorable for me. I was struggling with loneliness. I had just had my port placed. I was not only mentally exhausted but physically hurting. My mother-in-law, the one relative who was retired and able to visit us to help, had come down with COVID-19, so she cancelled her trip. 

My relatives were a thousand miles away, friends couldn’t visit, and we were isolated at home 24/7. Jyl sat with me and listened. She squeezed my shoulder. She made me feel like I was her only patient when I knew she had many more to serve that shift. It was that connection again, the one I needed, that Jyl provided.

I’m forever grateful that Jyl was my chemotherapy nurse. She has been making these connections with patients for more than 20 years. I’m grateful I was one of the lucky ones to connect with her.

Jyl Dedier was nominated by Tiffany Hogan for CURE®’s 2022 Extraordinary Healer in oncology nursing award.

For more news on cancer updates, research and education, don’t forget to 

Articles

My oncology nurse has been making connections with her patients for more than 20 years. I’m forever grateful I was lucky to be her patient. 

I Wasn’t ‘Just a Patient’ to My Oncology Nurse

CRANBURY, N.J., Jan. 7, 2022 /PRNewswire/ -- 

, the industry-leading multimedia platform devoted to cancer updates, research and education that reaches over 1 million patients, survivors and caregivers, is pleased to announce the winners of the annual 

® Calendar Contest. The 12 selected artists will have their artwork displayed in the 2022 calendar, titled "Healing Through Hues."

 of Dunedin, Fla., for "The Caribou Lookout"

 of Hillsdale, N.J., for "Squirrels in Winter"

 of Hollywood, Fla., for "Through the Storm"

 of Scottsdale, Ariz., for "Pali Lookout"

 of Calabasas, Calif., for "Prelude to New Life"

 of Lancaster, Pa., for "Forever Hopeful"

 of Annapolis, Md., for "Sailors Take Warning"

"It is my pleasure to congratulate the winning artists for the outstanding work that has been selected to be featured 

® magazine's "Healing Through Hues" calendar," said Mike Hennessy Jr., president and CEO of MJH Life Sciences™, parent company of CURE Media Group. "We received so many powerful and moving submissions from across the United States and would like to thank everyone that submitted their artwork for consideration."

CURE Media Group is the leading resource for cancer updates, research and education. Launched in 2002 and now celebrating its 20th anniversary, 

® has become the most widely distributed and read consumer publication in the United States for patients with cancer, survivors, and their caregivers. The platform combines a full suite of media products, including its industry-leading website 

; innovative video programs, such as "CURE Connections®"; a series of educational and inspirational events; and 

® magazine, which reaches more than 1 million readers. CURE Media Group is a brand of 

™, the largest privately held, independent, full-service medical media company in North America, dedicated to delivering trusted health care news across multiple channels.

Twelve winners were selected from 113 submissions to have their artwork featured in its annual calendar contest.

CURE Media Group Announces Winners of 2022 Calendar Contest

Kristie Kahl: Hi everyone. And welcome to today’s live broadcast, the Educated Patient Webinars: Testing and Treatment for Non-Small Cell Lung Cancer. I’m Kristie Kahl, vice president of content of CURE. We are pleased to bring you this webcast presented by CURE and sponsored by Regeneron. We have a few important announcements before we begin. We'd encourage you to ask questions during the event which you can submit by typing them in the Q&A box. You'll be receiving a survey via email tomorrow. As a thank you for watching the full webinar and completing the survey, you'll be entered to win a Visa gift card. We're pleased to be joined today by our moderator, Dr. Roy Herbst, Ensign Professor of Medicine and Professor of Pharmacology; Director of the Cancer Center for Thoracic Cancers; Chief of Medical Oncology at Yale Cancer Center and Smilow Cancer Hospital; as well as Associate Cancer Center Director of Translational Science at Yale School of Medicine. He'll be joined by Dr. Chaitali Nangia, Associate Professor of the Hematology & Oncology Division at Hoag Cancer Center Irvine; Beth Sandy, a Nurse Practitioner of Thoracic Medical Oncology at Abramson Cancer Center at the University of Pennsylvania; and Isabella De La Houssaye, a patient advocate. Thank you for joining us today and I'll now pass things off to our moderator to begin the discussion.

Dr. Roy Herbst: Thank you very much, it's really a pleasure to be here today. And we're all here. It's lung cancer awareness month, so it's a very good time to talk about lung cancer and the many things we're doing. Why don't we just start by having everyone tell them just a little bit about their background and why they're here today. Do you want to start, Isabella?

Isabella de la Houssaye: Sure. I am – I was diagnosed with stage IV non-small cell lung cancer EGFR+ in February 2018. And the testing, the biomarker testing has been a huge part of my treatment over the past four years. And so I'm here to share my experiences.

Dr. Chaitali Nangia: Yeah. Hi, there. I'm Chaitali Nangia, a medical oncologist. I'm involved a lot with research in lung cancer, especially in the immuno oncology space and run a bunch of clinical trials, especially in this targeted therapy space and have been involved in lung cancer story for quite some time.

Beth Sandy, CRNP: Yeah, I'm Beth Sandy. I'm a nurse practitioner in the cancer center at the University of Pennsylvania in Philadelphia. And my practice is lung cancer and have been doing that about 20 years as a nurse practitioner.

Dr. Roy Herbst: I'm Roy Herbst, I'm a medical oncologist, here at Yale Cancer Center, Smilow Cancer Hospital. I lead the lung cancer disease center, and also the chief of oncology. I'm happy to be your moderator tonight. OK, glad you're all here. Let's talk about biomarkers. So the first thing is why is it important, Chaitali, to have biomarker testing before treating for lung cancer?

Dr. Chaitali Nangia: [00:03:00] Yes, I think just to kind of take a deeper dive into this, I think biomarkers, what we're trying to see is when you get diagnosed with lung cancer, we want to do more personalized treatments. We want to give you therapy that's going to spare you more toxicity and hopefully spare you chemotherapy and get more targeted drugs. And so the step one is to recognize which are the patients who are going to benefit from this therapy and how do we best decide which patients should get a combination approach or should get just immunotherapy or like in Isabella's case, get a targeted drug. So it starts by testing. And nowadays, these testing have become quite sophisticated. You can do it either in the tissue or you can do it in just a blood draw. And that helps guide the physicians to see what would be the best first line therapy or what should we start out with to give you the best outcome, both in the short run and in the long run, because it makes a difference with what you got started with.

Dr. Roy Herbst: Absolutely. And Isabella as a patient, what do you understand about this? This is precision medicine, the right drug for the right person at the right time. But how much did you understand about this when you started your care? And how has that evolved?

Isabella de la Houssaye: I didn't understand anything. And what was quite frightening as a patient who was stage IV and declining rapidly was how long it took to process the information. And I had the tissue biopsy and that took almost a month, and I didn't understand what's – can't we just start treating? Why do I have wait? And at the end of the day, I did a blood biopsy and things moved more quickly because then they could recognize that I was EGFR+ and I was able to start a TKI more quickly. But it was – I didn't understand it, I have come to understand it. And in my kind of cancer, EGFR+, it's important to have the biomarker testing after every bit of progression to see how the cancer's evolving because it does change overtime as it gets treated.

Dr. Roy Herbst: Right, that's well said. I've seen biomarker testing evolved when I first started working in this field in 1993-94, and then we didn't even get biopsies sometimes. And now, of course, the first EGFR inhibitor trials, I remember leading some of those when I was in the Anderson in Houston, 1996-97. It's amazing that now, you are now most advanced generation drugs and you've found those drugs and you're treated. So Beth, as an advanced care provider and working in the clinic, how do you work with the patients when they come in, they knew diagnosis of this disease, they're going to have to get a biopsy, sometimes it's needles, sometimes it's liquid, how do you educate them as to what's going on?

Beth Sandy: Yeah, I think that's really complex sometimes. There's a whole lot of different things that can happen here. Number one, you're telling them, "I'd really like to wait for these results until we start treatment." And no one wants to wait, you want to get treated right away. So [00:06:00] this idea of waiting for the results to come back can be really hard, but it is really important that we know these results. To Isabella's point, we'd like to do it, both the blood and tissue because the blood comes back faster. If it's negative, we do like to wait for the tissue, if we can, depending on if we have enough of it. So these are all things that I end up explaining to patients that we're going to wait for these results until we start therapy. And we may start therapy and then test again later depending on the circumstances. Maybe we didn't have enough tissue, and our test results were inconclusive. The thing I would say is that I want patients to be advocates for themselves, make sure that you are being tested, if you have non-small cell lung cancer, especially a non-squamous type, the most common is adenocarcinoma. Because, really, everyone in that category should have a full biomarker panel done.

Dr. Roy Herbst: Absolutely. We're getting some questions from the audience. And we're so happy to have a live audience tonight. Here's a question. At this point, is biomarker testing standard of care in cancer centers for non-small lung cancer, I felt a lot of resistance about this with my mom's diagnosis. Sherry Baker points out. Chaitali, is it standard of care, you're in Hoag, that's – you're in California, you're in Southern California?

Dr. Chaitali Nangia: It's pretty much standard of care. Especially if we're talking about advanced lung cancer patients, it's definitely standard of care. Even in early stages now, we pretty much want to know because of the role of neoadjuvant/adjuvant, that means do need treatment before definitive surgeries. It's becoming standard of care. So pretty much in your first visit when you see your provider, you should be drawn for the liquid and tissue be submitted.

Dr. Roy Herbst: Isabella, you have some thoughts on this.

Isabella de la Houssaye: I do. What I see in my face group book, a group of people with non-small cell is that the operative board is in a cancer center, and so many people are not treated. And in the first instance, we've been, at any point, in a true cancer center, and they're being treated by the local doctors, local oncologists. And actually, they're not being – the biomarker testing is not widely used in a lot of places, even in the United States. And so, unless you're treated at a cancer center, you may not be getting that.

Dr. Roy Herbst: Right. I think that's, unfortunately, it is true. Some people don't get to set into have the test done. There's also a lot of disparities in the care of patients around the United States, sadly. People that don't ever get advised to have the test or from under representative minority groups. And it's really a shame because as you've told us, Isabella, these drugs do work when you're matching their – you say they're more specific and less toxic, because you're matching the drug with the biomarker, right?

Dr. Roy Herbst: [00:09:00] Excellent. And then Beth, your perspective on this. You're at Penn, I know Isabella's in New Haven, we better do the biomarker testing at my place, so I'll have to – the heads will roll here. But, Beth, what's happening at Penn, you and Dr. 

Beth Sandy: Yeah, it's absolutely standard of care at the University of Penn. But exactly what Isabella said. I talked to some of colleagues around the country and it may not be done everywhere. There used to be, years ago, this thought, "It's mainly in the non-smoker, so we're just going to test them." But that's not true, really. And the majority of the newer biomarkers that we know about are more common actually in smokers. So it doesn't matter whether you're a smoker or non-smoker, everyone needs to be tested for these biomarkers. Because like you said, Dr. Herbst, if you don't find it, you can't actually use the targeted drug to manage that, which will work best for the cancer.

Dr. Roy Herbst: We're on the CURE webinar now. And Isabella, how important your advocacy that works like this? So patients are watching, I'm sure, you said, face group, so you have a group that you're online with. Do patients talk and advocates talk and advise people? At least someone in that room is asking about biomarkers, it's the physicians or the advanced care provider or one of the nurses does it, as suggested. And hopefully the patient will ask about it, right?

Isabella de la Houssaye: Right. One of the things that with lung cancer and particularly biomarker testing is it's so individualized that it's actually more effective when you break into groups that are specific to the different biomarkers, because then patients can relate better and ask more relevant questions. So that's why I tend to go to the Facebook group more, because it's an EGFR specific, there are RAS specific and ALK specific groups as well. And organizations, like CURE, are awesome. There are resources, but I find the most effective are when they break into specific to my kind of cancer or within kinds of cancer.

Dr. Roy Herbst: Got it. Chaitali, there's a question here. How much more effective is tissue biomarker than blood biomarker? Do you do one, the other or both?

Dr. Chaitali Nangia: If you look at the data, the liquid, which is the blood biomarkers, quite specific. So that means that if it's positive, it truly is positive, sometimes we debate the question, could it miss a task? Or could it falsely be negative that you actually have it, it's just not shedding it in the bloodstream? So I think a tissue is the gold standard, but liquid is pretty close to it. And it's more easy to do, easy to navigate through, so I think that's how it plays was if I get my answer in the liquid? Then yeah, the tissue can [INAUDIBLE] but if I don't get my answer, if it's negative, I shouldn't always assume that that would be the case in the tissue, if that answers your [00:12:00] question.

Dr. Roy Herbst: Absolutely, and I would agree. We had a good first discussion, let's move on to another topic. Topic two, understanding the results. It's one thing to do the testing but then you've got to understand what to do, so some patients apparently are overwhelmed by the results. How do we work with the team? How does the teamwork with the patient understand it? So I'll start with you, Chaitali, again. And that you get the result back, how does your office work with the patient? How do you work with a patient? Could you explain to them what it means and what needs to be done?

Dr. Chaitali Nangia: For me, anytime is a – when you're just starting out your journey, there's a lot of apprehension, there's a lot of confusion, there's so much information. It's always difficult to sought out for the non-medical people. Even for us, it's difficult. So I like to invite the family, the caregivers and the patient to come and definitely for the subsequent needing when I have the results to go over. Because it really is a team effort, it's not just one person doing it, it's not even just the patient and the provider doing it, it's the whole care of team that needs to be involved in it. And as you know, that once after 10 minutes, the patients, what I always teach my followers, they stop listening, it's too much for them. So if they have more family members with them, then hopefully everybody [INAUDIBLE] there's a piece of that information. So I like to work it as a team approach. Obviously, from our side, we will always have our entire team present in that meeting as well.

Dr. Roy Herbst: What's your experience, Isabella, with this?

Isabella de la Houssaye: It's complicated. I know in my own, my own understanding has grown tremendously over the past four years and what I thought I understood at the beginning. I've – that's evolved tremendously. And that's why – and your time with your care team can be limited, so I think there's a huge role for support organizations to help patients in this area.

Dr. Roy Herbst: Thanks. Another question. Patients, Beth, might ask you. Is there additional information, other sources where I can go to to learn more about these biomarkers, what they mean? What do you tell them?

Beth Sandy: I think that's hard, because there are some sites that will give complex information. There's a website that I use a lot called mycancergenome.com. And you can look at your molecular pathology report and type in whatever it says there, and it will give you an explanation. But a lot of times, that explanation is in medical terms, and that can be hard for a patient who doesn't understand the terminology. So I think going back to what Isabella said, is that a lot of times, look – going to online support groups is maybe sometimes a better way to get more down to earth information. That being said, I would ask your care provider, ask your nurse, ask your doctor, because it's really our responsibility [00:15:00] to relay that information to patients in an understandable way, in a way that they understand what is happening and what we're going to use to treat their cancer based on that report, or what we're not going to use, based on that report. So, unfortunately, it is complex like Isabella said, so there's not really an easy place to go online that'll spell it out in layman's terms for you. So I still think going back to your care of team and saying, "I really don't understand what K-RAS G12D means, as oppose to K-RAS G12C." And let us explain that to you.

Dr. Roy Herbst: Great. OK, we have tons of questions here. Anyone can take it, first one to hit the buzzer. If a patient doesn't feel the care of team is adequately informing them about the results or they weren't even referred to get tested, what advice do we have for those patients? Who wants to take that one first? I'm going to ask you all, but – Isabella?

Isabella de la Houssaye: I'll just say I would tell anybody, no matter how great your care of team is, to get a second opinion no matter what. And I've found that very helpful and sometimes, it's the same sort of answer but explained differently, but I think it's just very important sometimes to hear from different people on the same topic when your health is involved.

Dr. Chaitali Nangia: I think I agree with Isabella. It's nothing – I agree that patients should get a second opinion because it also tells them, reassures them that this is how the whole medical community is answering them. But obviously, the catch being, what if you don't hear exactly the same thing? So you have to be kind of know that before you go in, that you will be emotionally OK handling that kind of information, because there's certain places that are standard of care, this is how we do it. But then there's definitely gray zones and complex patients that it can be done more than one way. So I just want my patients to be aware of that. And then, depending on which provider you're seeing, you may have clinical trials that may be completely different at two different providers. So you also want to see which one would you want to go with. But no, I think it's good to hear, especially if it's standard of care.

Dr. Roy Herbst: Right. Beth, someone asks, is it better to have a mutation discover than finding them? If no mutation is standard chemo than better than targeted therapy?

Beth Sandy: Yes, I think, there's no right answer here. So I wouldn't necessarily say it's better to have one thing or the other. It's better to know what you have and then treat appropriately. So if you have a mutation but you don't know it because you were never tested for it, and we go straight to immunotherapy, it's probably not going to work very well for you, because your cancer's driven by that mutation and we should [00:18:00] be treating you based on that. And the vice versa the same. If somebody has a mutation, we need to know about it so we don't start them on the wrong therapy. So depending on certain mutations, sometimes it's better to have one that responds very, very well, so that may be better prognostically. But now in the era of immunotherapy, my goodness, we see patients living years and years with immunotherapy, so I don't necessarily think it's better or not, it just guides our therapy. So what's not good is to not know. Because then, we don't – it's like we're just going to throw this out there and hoping it works.

Dr. Chaitali Nangia: And if I may add, the way the field is progressing, because today, liquid doesn't show blood, the chances are a fast forward [INAUDIBLE] Even that blood will show mutations, it's just how the technology's progressing and how the drugs that we can use for targeting is progressing.

Dr. Roy Herbst: Exactly. We have a lot of questions now, people are asking about minimal residual disease, meaning when you know if you've had enough therapy, do blood tests help? They're also asking about resistance. A couple of stories here in the chat, where patients get these drugs and then they become resistant, what do you do next? I guess that's something everyone has a perspective on this, why don't we start with Beth this time?

Beth Sandy: Yeah, so you can – and I would advocate for if their cancer is worsening to test for resistance mutations. For certain things, we have treatments or even mostly clinical trials to evaluate for this. So I would definitely recommend re-testing at that point. I would also maybe even recommend if the first time around, you didn't have a mutation. You do your standard treatment, then the cancer's worsening, maybe consider re-testing at that point. Especially if the original tissue was not sufficient, that didn't mean that you don't have one, it just means we didn't have enough tissue in order to do it. This is where the liquid biopsy comes in really handy, because then we don't have to go in with a needle and do an invasive procedure, we can just send a blood test off. And I know someone asked the question, is there a gold standard for which company? I don't really think so, I think there's a few out there, a handful, that we use a lot. I'm going to refrain from making suggestions about different companies, but I think there's a handful that or have very good reputations, that generally, we use.

Dr. Roy Herbst: Great, any other comments here?

Dr. Chaitali Nangia: I think this is a very active area of academic interest because we've seen that if you stopped with certain drugs, you get resistant to that medication. The question rises, what's the next best therapy? And what best to combine it with, and then sometimes the resistance matters with what you're starting out with, for example, if you take a case of EGFR, which is a kind of bio-marker and depending on what resistance you may have either at the get-go or subsequently, they may be in the same tree different branches that you should get as a treatment, and even in the space of [INAUDIBLE] and all this now there are so many clinical trials that are trying to address resistance mechanisms and how best to overcome them, so I think if you've not had a clinical trial opportunity at the first line while we're talking, consider that as second line that means you progressed on first line treatment to see if you can better understand that.

Dr. Roy Herbst: Very good, let's move on to another – Isabella, sorry.

Isabella de la Houssaye: Sure, I would – so I get a blood biopsy quarterly and it tells me how well the current treatment I'm working – I'm on is working, so that for me at least the mutations don't show up if the treatments are working and they begin to show up when they're not, and sometimes that gives me a heads-up before tumors progress, which is good information to have, otherwise people tend, in my world of EGFR, to get bio-marker testing every time you have progression to see what new mutations might have evolved and how that affects treatment and the other ways in terms of trials that they're using it in my community is to see whether – rather than put someone on a tough treatment and test and not know whether it's working safe for three months a blood biopsy might be able to show you in six weeks or three weeks even whether or not you're responding to that, so it can help patients determine treatments more effectively.

Dr. Roy Herbst: Absolutely, guide the therapy with bio-marker testing, so before we move on to the next section, someone has asked us why isn't everyone tested? What do you think?

Dr. Chaitali Nangia: I think that's an access to care, it depends on way you practicing, it depends on how fast you can get those turnaround tests, what the institutional practice may be, but I think it's pretty standard of care, it's covered by most insurances if done at the right indication, so it should be really, I think there's a big push to make it almost universal for the right settings.

Beth Sandy: I will say we don't test small cell lung cancer routinely because we don't generally find these bio-markers there, and at my institution we don't routinely test squamous non-small cell lung cancer because again the majority of these bio-marker question – or these bio-marker results are not found in those patients, that being said, I would test certainly squamous patients that particularly have a [00:24:00] characteristic like being a never smoker, something like that. Doctor Herbst, I would throw that back to you, do you test all non-small cell patients, or do you test the majority of non-squamous, which are predominantly at no carcinoma, what are your thoughts on that?

Dr. Roy Herbst: Well, I happen to believe you should test all non-small cell lung cancer patients, because even if it's not read as an ano-carcinoma, it can have mixed features, or it could be missed read, so we try – you should get it covered to test all patients with a diagnosis of non-small cell lung cancer, small cell I would agree with you, I think the bio-markers, think like the PDL1, which we're about to get to in a moment, but we probably wouldn't be – the actual indications there are still quite rare. Let's move on the next section, which is different options based on PDL1, very nice question Beth, you led us into the next section. First question: do we have any indication of how often PDL1 is expressed in patients with lung cancer, specifically non-small, if so what can we share about that information? So PDL1 is actually compared to the testing we give 

actually pretty easy to get, you actually get it back much quicker, how often is PDL1 expressed in lung cancer, Chaitali?

Videos

View the full CURE® Educated Patient® Webinar: Testing and Treatment for Non-Small Cell Lung Cancer on demand.

Educated Patient® Webinar: Testing and Treatment for Non-Small Cell Lung Cancer

Ryan McDonald: Hello everyone and welcome to today’s live broadcast, the CURE Educated Patient Webinar: Meet the 2021 Lung Cancer Heroes. I am Ryan McDonald, Associate Editorial Director of CURE. We are pleased to bring you this webcast presented by CURE, sponsored by Takeda Oncology. Through CURE’s Lung Cancer Heroes award ceremony, which was held on Thursday, October 28, CURE, Takeda, and the advocacy community brought together the lung cancer community to end the stigma, inform, connect, and empower anyone who has been impacted by lung cancer. Together as one community, we can raise awareness of lung cancer, and most importantly, we were able to recognize and celebrate the esteemed individuals contributing to improving the lives of patients with lung cancer. There are a few important announcements before we begin. We encourage you to ask questions during the event which you can submit by typing them in the Q&A box on your screen. You will be receiving a survey via email tomorrow. As a thank you for watching the full webinar and completing the survey, you will be entered to win a Visa Gift Card. And now I would like to introduce this year’s lung cancer heroes. Dr. Hossein Borghaei, Chief of the Division of Thoracic Medical Oncology, a professor in the Department of Hematology/Oncology and co-director of the Immune Monitoring Facility at Fox Chase Cancer Center. Heidi Nafman-Onda, a lung cancer survivor and advocate and founder of The White Ribbon Project along with her husband Pierre. And Dr. Kenneth Rosenzweig, a professor and system chair of radiation/oncology in the Mount Sinai Health System. Before we began I would like to congratulate our heroes and thanks them for all they have done for the lung cancer community. Now, to start, we will open the conversation talking about early detection in lung cancer. I would like to start with you Heidi. As a survivor and lung cancer advocate, why do you think early detection is key for patients?

Heidi L. Nafman-Onda: I am also a health educator and a lifelong health enthusiast, so I didn’t even know that I could be susceptible to lung cancer and didn’t qualify for any screening. In all other cancers, prevention is equal to screening and early detection and in lung cancer it’s only been equated with don’t smoke and this doesn’t happen to you. So, lung cancer has been I think lagging behind in even getting people who are eligible screened and we need to get the word out. We need more awareness, so we could have a better chance of catching things early when there is a higher likelihood of being cured and having a really good outcome.

Ryan McDonald: And also to Heidi, you mentioned – you didn’t even necessarily know that you could get lung cancer, so as someone who has had it and gone through treatment and everything, how would you advise patients to act upon any site or experience of any type of symptoms. Maybe they want to brush it off but how would you advise them [00:03:00] to act upon that?

Heidi L. Nafman-Onda: In my particular situation, I didn’t have any symptoms. Mine was an accidental catch but listen to your body. If something doesn’t feel right, you’re normally in shape and you suddenly feel short of breath or you have a cough, really-really push and advocate for yourself. Listen to your body, get in touch with her doctor.

Ryan McDonald: Pierre, from a caregiver perspective, what advice would you give to others who may be trying to encourage their significant others to get screened? I know Heidi’s situation was different in that it was accidental diagnosis but for someone out there who maybe wanting their significant other to get screened, what are some suggestions you would have for them?

Pierre: I would definitely encourage them to seek advice from their doctors and ask them whether or not they currently qualify for lung cancer screening. There are national guidelines that are available and certainly if you have a history of smoking you definitely need to ask your doctor whether or not you qualify but there are other risk factors. And even if you don’t currently meet the current guidelines, I think you should have a discussion with your primary care physician about how to mitigate any other risks.

Ryan McDonald: In terms of detecting lung cancer, Dr. Borghaei, where are we in terms of detecting it at earlier stages?

Dr. Hossein Borghaei: First of all, good evening everybody and thank you for having us on to talk about this really important issue. As you heard from Heidi, at this point we do not have a general population type approach to lung cancer screening. What we do have is lung cancer screening with what we call a low dose CAT scan, I can explain that little bit more, for a patient population or a subject population I should say whom we think are at a higher risk of developing lung cancer and that includes patients in a certain age group, 50 to 80 years of age who have had either a prior history of heavy smoking or have quit within the last 10 to 15 years. And if they meet these certain criteria plus a couple of other additional criteria, these individuals can actually qualify to be screened with a low dose CAT scan once a year for three years. We would consider this to be a patient population who is at risk of developing lung cancer based on one or two actually more than that [00:06:00] but a couple of really large randomized trials that look that the utility of a CAT scan for detecting lung cancer. If you are thinking about lung cancer detection and are general patient population at this point we really don’t have a legitimate approach to this. Unfortunately, as you heard, many of our patients now are not really in a high risk category by the traditional definition for this disease and therefore we are struggling with how else or what other methodology can be used for this early detection which again I keep going back to what Heidi said in the beginning, it’s really important because we can have the biggest impact on the disease course if we find it early on. That is where our CURE rates are higher, that is where we can have a lot more impact and therefore it is a question that I think the community in general is trying to deal with, what else can we do which will have a more applicable screening test, if you will, for everybody who might be at risk.

Ryan McDonald: As a follow-up to that, you mentioned we are all wondering what else can we do. In your opinion, what are some things that could be done or are needed in this space to get the ball rolling so to speak?

Dr. Hossein Borghaei: Clearly identifying markers that can be detected with a simple test, perhaps a blood test or a urine test or something to that affect that is cheap, that is available easily across the country and to everyone which obviously brings in a lot of regulatory insurance coverage and all of that with it. But the first step in this process is to be able to identify a biologic protein or a screening test or something to that affect that can be proven to be effective in this setting. I think we have to keep in mind that every time we mention a detection test whether it is PSA for men with prostate, whether it is mammography for women with breast cancer, that comes with a certain amount of anxiety for the person who is undergoing that screening test. It is also very important to keep in mind that if we’re thinking about a population based screening we need to have access to something that is available to everyone. We have heard about all the disparities that exist, therefore, having a task that has been proven in large studies to be affective in predicting early disease and it is accurate is really-really important because the last thing I want to do is to order a test for a patient inducing anxiety, getting back something that is not interpretable or we don’t know what to do with it, therefore, this really is a huge task that we’re asking our [00:09:00] scientists and clinicians and other people who works in this field to come up with. I think there are very important efforts on the way to have a blood based assay that perhaps hopefully soon we’ll know and going to be able to detect various cancers including lung cancer but this is actually quite an important project, quite an important step to be undertaken. I think there is lot that rides with this kind of detection methodology. I think it’s just going to take time and we have to be cognizant of all of these issues that is associated with it but the work is ongoing. At least I am really hopeful that fairly soon we will have access to something that can be applied to a general population in terms of screening and that time frame of course is not immediate, it’s not like tomorrow, it’s not next week but I think the work has started and everybody realizes the importance of it.

Ryan McDonald: Dr. Rosenzweig, part of your clinical focus is on mesothelioma. We know this disease is quite rare but, in your opinion, as we talk about early detection and screening and making sure patients are perhaps aware of the risks, what should patients be aware of so that this disease can be caught early?

Dr. Kenneth Rosenzweig: Thank you and also thank you for allowing me to participate in this webinar. As you said mesothelioma is a very rare tumor, so much less prevalent than lung cancer. It makes it a little bit more challenging to find. It’s a little bit more of a needle in haystack. Of course, with mesothelioma we know that there is a huge risk factor to developing mesothelioma and that exposure to asbestos, so obviously there are some professions which have a lot more asbestos exposure than others. And a lot of those groups either they are trade group or they are union or just even a loose group does do some screening and some monitoring for mesothelioma. But clearly anyone who has a history of asbestos exposure who develops shortness of breath should not let it - see what happens and if there is ever any fluid around the lung – that can be a challenging situation for some physicians who aren’t used to seeing that. I would advocate that person get into a center that does have some expertise in mesothelioma. It’s not that doctors aren’t smart or don’t know what they are doing but they are so few cases in this country that even some of the most experienced lung cancer physicians out there and some of the greatest minds just never really [00:12:00] see that many patients who suffer from this disease. So, getting to a center that has some expertise which can cut through some of the stats and get a diagnosis earlier and talk about some treatment options I think is very important for this disease. But still there is a lot of mesothelioma in patients who don’t have a known history of asbestos exposure. They might have been exposed to it but just not aware of it at an earlier age and there is a long latency between when you were first exposed and until the disease shows up. There is not a whole lot to do and you really can’t do screening exams and just like Dr. Borghaei was talking about I think the anxiety and the expense that that would cause to catch so few cases just doesn’t make any social sense. There is a high likelihood you might hurt more people than help if you screen too many because it’s such a rare disease. Really, just I think mostly for people who have known exposure pattern who are in some profession that might have a high risk to it. There is a weird subgroup of people where mesothelioma might run in the family, so if there is a family history of mesothelioma or another type of cancer melanoma of the eye, again these are very rare conditions but if this is something you have heard in your family it might be worth getting some genetic counseling to see if you have this gene that might predispose you to mesothelioma. Again, that’s going to be a very small subset of people in this country but might be worthwhile if you’ve heard that in your family history.

Ryan McDonald: We just had a question coming from the audience that I like to open this up to both Dr. Rosenzweig and Dr. Borghaei is, looking at lung scars or lung damage how likely are these to cause lung cancer and if so how should these patients be monitored and screened.

Dr. Hossein Borghaei: Ken, do you want to take that?

Dr. Kenneth Rosenzweig: Yes, thank you Dr. Borghaei. It’s very challenging. When there are abnormalities on the lung, it can be very difficult and again like we were talking, you always want to have the correct threshold because you don’t want to call everything an abnormality and send everyone for a biopsy and people can be hurt from biopsies. It’s not a completely procedure free of side effects, lung collapse, chest tubes, things like that. Very unlikely to have a lethal side effect to it but still you don’t want people sticking needles in you unless you need to. I think the best way is [00:15:00] just following people over time and see if there are any changes from every six months, every year, and clearly if something is growing and looking more suspicious then that needs to be evaluated but sometimes that’s difficult too. The analogy I sometimes I use, it’s like watching your children grow, day-to-day it doesn’t look like your child has changed at all but clearly over a year or over two years it could be a big difference. If you get scans too frequently you might not be able to appreciate a small sub mm difference but over time you go back a few years you might be able to see something happening.

Dr. Hossein Borghaei: I agree and it also depends on how the scar is formed. Is it from an infection, prior surgery, prior radiation. There are number of different reasons why something like this could happen and I would agree with Dr. Rosenzweig that actually following these abnormalities on CT at regular intervals is probably the best way to do it. If things don’t change over a period of time perhaps reducing the amount of CT scan for evaluation would not be inappropriate, however, if there are changes then by all means other steps should be taken to investigate them.

Ryan McDonald: Just a reminder to everyone who is out there listening. If you have a question, please submit it on the Q&A box on your screen and we will be sure to try and get to as many of those as we possibly can. Moving on quickly here, talking more about biomarker testing and making personalized treatment decisions. Dr. Borghaei, you touched on it a little bit earlier about biomarker testing. Can you expand a little bit more about what it is and explain and describe it and also why patients should just be advocating for themselves to be tested?

Dr. Hossein Borghaei: If I go a little long-winded on this please stop me. I don’t want to take up all the time. This is a topic that has been discussed at various meetings and programs over the past decade or so. Basically, the concept of biomarker testing is looking for specific changes, alterations, mutations, things that we describe with the scientific sounding names like translocation within the tumor itself. I think we have to emphasize that these are not necessarily genetic changes that we’re talking about being hereditary genetic alteration passing from one person to another, although I have to say for lung cancer there is a lot that we don’t know regarding the hereditary nature of the disease or anything. But these are actual changes that we can detect within the DNA of a particular tumor. For the most part these are applicable [00:18:00] to tumors that we classify as being adenocarcinoma or non-squamous which fall under the broad category of non-small cell lung cancer. These are essentially markers that allow the physicians to choose very specific what we label as targeted therapy for patients that have these alterations. It’s called targeted therapy simply because we can identify the target in DNA of the tumor and we have very specific medications that are designed to attack that particular target. Therefore, we think this is the best way of personalizing the delivery of care instead of using chemotherapy that can hit everything that is growing. These drugs are designed to go specifically to the particular tumor that has that particular alteration. Therefore, the treatment can be more effective and also the side effects can be far lower than the traditional chemotherapy or other non-specific treatments that we tend to use in the past. Therefore, finding these can have significant implications for the treatment decision making process. You go with the targeted therapy. You can for the most part be treated with specific oral agent, it does not require IV administration, does not have to come to the cancer center or the doctor’s office every two or three weeks or whatever the duration of the chemo is. And also as I said because it’s more directed, the side effect profile is less. Unfortunately, we haven’t been able to come up with an anticancer drug that doesn’t have any side effect. They all unfortunately have adverse events associated with them but these side effects are a lot easier to manage for the most part than traditional chemotherapy or other anticancer treatments. To me finding a biomarker for treatment or molecular testing as we call it is as important as knowing what the stage of the cancer is because without knowing the right stage, it’s hard to coming up with the treatment option for the patients that we see. I think it’s the same thing with these biomarkers. If we don’t know it we are guessing. At the end of the day, that might not be the best treatment option. Therefore, I think it’s imperative that when you’re meeting with a physician or physician group, ask what is the biomarker status and if it is applicable to [INAUDIBLE] your physician will go over how it is done, why we do it, and how to obtain it. I actually think this is one of the more important questions that patients should ask an oncologist when they have a diagnosis of advanced lung cancer. The other thing is that I did say I was going to be long-winded, I am sorry. The other important thing is that even though we started in the advance and metastatic setting with these targeted therapies, we are beginning to have evidence that even an early stage disease, some [00:21:00] of these can be very relevant and able to control the disease and prevent recurrences so that becomes a little bit more of a technical discussion but the evidence is beginning to accumulate that maybe even at an early stage disease, some of these drugs can be highly effective.

Ryan McDonald: OK, thank you for that. Heidi, on the patient side of things was we talk about biomarkers and biomarker testing. Were you aware of biomarker testing when you first diagnosed and if so how did you learn more about this process?

Heidi L. Nafman-Onda: Well first of all, my head was spinning that I was told I had lung cancer, and I didn't know really anything about lung cancer other than what I said and my husband's a primary care physician. Pretty much don't smoke, this doesn't happen. My husband reached out to his colleagues to find out what do we need to do next and I'll let you take it from there.

Pierre: Well by colleagues it was colleagues or acquaintances that I knew were subject matter experts in lung cancer, so we sought opinions from thoracic oncologists who then notified us about the importance of biomarker testing. But then, as Heidi will tell you, at the time this was three years ago I think we still needed to advocate for ourselves to understand which biomarkers were going to be drawn, were they going to go the lab, there were some difficulties in that sense. But I can't stress enough seeking the opinion of experts in the field I think particularly in lung cancer it's appropriate, if possible, to get the second opinions particularly from thoracic oncologists.

Heidi L. Nafman-Onda: As a patient I was just terrified and I just wanted to get started right away. What I'd learned is you need to find out this information, like you were saying Doctor Borghaei, for being able to target something that might be there and you don't want to rush into the wrong treatment. So that's an agonizing wait those extra weeks but it's very important to know you're getting off to the right start. In my case though we were told where specifically to send the tissue and it didn't happen. I mean it went just for basic testing based on what there were FDA approved targeted treatments for already. So I didn't get the whole comprehensive next generation sequencing done. I had no PD-L1 and I was inoperable stage three so I had chemoradiation and a year of immunotherapy and I've been no evidence of disease for it'll be two years in January since [00:24:00] I finished treatment but I still feel like there's this unknown about do I have some sort of targetable mutation and it just feels like unfinished business. And it always will. I mean, having cancer there's always this lurking around and when will it show up is the question. So education about biomarker testing is so important and to get to those patients and some sort of readable language for laypeople to be able to understand I think would be very helpful.

Dr. Kenneth Rosenzweig: Ryan if I could just-

Dr. Kenneth Rosenzweig: So just another point is the therapies are changing all the time so if a patient is told they have a certain biomarker years ago, the doctor might not remember that because a lot of that is discussed at the initial consultation. Doctors are obviously very well-meaning but might not remember that detail four or five years later. It might have significant implications, actually obviously Doctor Borghaei is more of an expert on this but a patient who might have had a specific mutation called a KRAS mutation six years ago would have been told oh there's no therapy for that and now there's a certain subset of KRAS where there might be effective therapies. I think a patient should be an advocate for themselves if there's a treatment decision being made, oh can you look back at my biomarkers or if hopefully this doesn't happen or if there's a new decision can we get a biopsy of it so we know what's going on it and maybe there's something that can be attacked because the state of the art in 2021 is much different than 2016 and worlds different from 2011. Things are changing that quickly.

Ryan McDonald: OK so kind of as a follow up as you mentioned that with things changing so quickly and things are different in 2011 than they are today. Say you had that biomarker test a few years ago, does it make sense to get another test or like you said do you just ask you physician hey can we look back at my results to see if there's something targetable now?

Dr. Kenneth Rosenzweig: Hos, I think that's for you.

Dr. Hossein Borghaei: OK so I am personally in favor of always repeating the test and making sure nothing has changed but for a lot of these genetic alterations to be honest with you, there's very little evidence that over time with treatment or anything like that, the genetic alterations are going to go away. So if the KRAS or the particular KRAS mutation that we're talking about was present three or four years ago regardless of what has happened in between as far as I know, there's very [00:27:00] little to tell us that that's going to disappear all of a sudden. However the importance of all of this is that just as the practices changed and KRAS wasn't targetable before but now a subset is, molecular testing has also changed. Now the more comprehensive testing that we do can give us a little bit more information about the cancer and its genomic alterations and some of these could be important for clinical trial participation or other drug selection. So in my view if somebody has some testing done three or four years ago and now we are unfortunately dealing with recurrent disease I would like to have confirmation and perhaps repeat the molecular testing with a more modern and more comprehensive panels that we use now to make sure that we're covering all the bases. For instance maybe four or five years we wouldn't look for an in track alteration, it's very rare but now we have drugs for it. So if I don't have that information before I kind of want to have it now. So just relying on something that was done several years ago sometimes is not the best option so in my view and in my practice if it's been several years since the last testing and if I know that testing wasn't quite up to what we do now I would like to get the confirmation and repeat everything.

Ryan McDonald: OK thank you and one question Heidi, someone may have joined the discussion a little late. Can you reiterate or remind the audience some people have been asking what diagnosis or stage you were diagnosed with.

Heidi L. Nafman-Onda: So I was diagnosed with stage IIIA adenocarcinoma of the lung, inoperable because of lymph nodes in my mediastinum. I had one in one station and the other one in another station so that took me off the surgical candidate list. I then had chemoradiation, three cycles of Cisplatin and pemetrexed or Alimta is also another name for it and then I had 30 radiation treatments at the same time and after that was complete I had a year of immunotherapy every other week for a year.

Ryan McDonald: OK thank you and to remind everyone out there again to use that opportunity. There is the Q and A box on your screen so please continue to filter those in. We're going through those and making sure we can get to as many as possible. Now kind of moving ahead as we've been talking about biomarker testing and using that kind of as personalized treatment decisions, there's this topic of precision medicine. So Doctor Borghaei using some examples can you kind of explain to the audience what precision medicine is and how it works to treat lung cancer?

Dr. Hossein Borghaei: Sure I'd be happy to. By the way I did get a sneak peek of one question that came out and I think we should address this. The question was, is tumor [00:30:00]tissue the only way to define marker testing and the answer is no. Liquid biopsy panels have become very popular and very accurate and we are incorporating those into our evaluation more and more. So no, tissue is not the only way to get the molecular testing so blood-based assays can work. So in my view precision medicine is exactly what we were talking about. It's a way of personalizing delivery of care. So to some extent precision medicine is what we said; let's find out a little bit more about the cancer, let's figure out what it is that this tumor is telling us and let's see if there are specific ways that we can address the cancer itself and a lot of that is done through some of the mechanisms that we've talked about, the molecular testing, finding these genetic alterations and finding the best appropriate therapy for that particular genetic alteration. So the concept to me in my mind, precision medicine is very much similar to this personalized medicine. So why do we call it precision is because again as I described it's a target that goes specifically towards the cancers expressing and therefore it's a more precise way and is a more accurate way of trying to address the tumor. I think to me the concept is very much hand in hand with what we have been just talking about for the past 10, 15 minutes.

Ryan McDonald: So kind of Doctor Rosenzweig one of your focuses is radiation oncology so as we talk about precision medicine and the development of it, how has the way radiation therapy been developed to patients? How has that changed over time as we've focused more on precision medicine?

Dr. Kenneth Rosenzweig: When radiation oncologists talk precision, we kind of mean it literally. We want to precisely aim at the tumor not as much of the sophisticated work that Doctor Borghaei and his colleagues do. So I'm making a little bit of a joke there, but in reality, radiation's still a little bit blunt force. We see a tumor, we give it radiation and then we try not to damage the normal tissue around it but that being said our big challenge is how do we integrate with the amazing things that are happening in medical oncology and systemic therapy. So the successes that we've seen from the new generation of precision medicines, targeted therapies, immunotherapies, has really created a whole new type of patient that we're seeing where they have minimal disease, where someone's doing very well for a long period of time despite the tumor having spread and we have to tailor our radiation around the systemic therapy to try to help out, add to the quality of patients' lives and add to their outcomes without causing an side [00:33:00] effects. So even though we're not directly involved in what we typically talk about as precision therapy has had a drastic effect on our day to day practice. And even this is the concept of let's say what we call, it's kind of a complex word, oligoprogressive disease just for example. That's where Doctor Borghaei might be treating someone and there's one spot that just doesn't seem to be responding but other spots seem to be doing well. Well that's the situation now where very frequently we'll give some very spot radiation just to that area because it's resistant to treatment and take care of that one spot and then send the patient back to continue on systemic therapy. The joke we sometimes use is called whack-a-mole if something ops up we just kind of knock it down like the arcade game and that's been a very successful strategy to use and that's something that's only been possible because of precision therapy and precision medicine.

Ryan McDonald: OK now Heidi kind of getting your perspective on this; you mentioned you were diagnosed a little more than three years ago so in your opinion as a patient, survivor and advocate, how far do you think we've come with treatments that fit under this umbrella?

Heidi L. Nafman-Onda: Well it is amazing to see what's happened just even six months after I was diagnosed that there's just more and more coming out which is so exiting and hopeful. Originally, I was told by a pulmonologist over the phone I have really bad news for you, you have a very grim prognosis, getting your affairs in order would be a good idea and I thought wow I don't even feel sick. I didn't have any symptoms. How could this be happening? Then I found out I was inoperable. I had one treatment option, one, I mean that was it. There was no decisions to make. It was chemoradiation and hopefully do well to qualify for the immunotherapy and get it and lucky for me it worked really well. I had an IMRT radiation it was very precise at the same time and we literally watched seven days so at the seventh radiation treatment my radiation oncologist wanted to show me the image and it was a third smaller. It was just amazing to watch this melt away through the course of the 30 treatments that I had and then to see what's happened post-immunotherapy as well. So I was scanned every three months and then they wanted to stretch it out to six and we compromised and went to four and then to five and now I'm on the six month schedule. There's no evidence of disease at this point and again I'm cautiously optimistic and I'm very hopeful and I also know that if this failed now there are other things [00:36:00]. There's also more extensive testing that however a patient can make sure their tumor goes to the right lab and get more extensive testing and blood biopsy. I mean three years ago they were saying well we're getting close with that and now it seems to be a more reliable and accessible alternative or in addition to, if people need.

Ryan McDonald: OK and Pierre kind of on your side of things as a trained primary care physician seeing what Heidi went through in the past couple years, what's your opinion on the treatment landscape or at least precision medicine over the past couple years in lung cancer?

Pierre: I mean one of my goals is to make sure that primary care physicians, there are a couple myths that have to be dispelled and that is therapeutic nihilism about lung cancer treatment. We are seeing people with advanced stages even incurable stage or stage four that are living for years and so I think the first thing to do is to ensure that if they have any patients who were diagnosed with lung cancer, that they ensure that those patients get to centers and oncologists that are familiar with the disease that have at least seen the volume of the disease and just be more hopeful about it. As Heidi said we are optimistic we have hope but we're realists. Lung cancer is obviously a very lethal disease, it's severe, but there are treatments, there are new developments and the physicians on this call and attest to, there are more in the pipeline. So the point is get to people who know how to treat this disease and retain some hope that there's things that can be done at any stage.

Heidi L. Nafman-Onda: I was told four to six months and here I am three years later so there is hope.

Ryan McDonald: Yes as you mentioned there have been people asking kind of about that throughout the Q and A and asking you Heidi about your journey so thank you for updating them. And everyone watching keep filtering your question in. We will do our best to get to as many as possible. Now as we kind of get into the second half of this conversation, one thing that we'd like to talk about is advocacy and the role that advocacy plays in lung cancer. We talked a little but about it earlier about being your own advocate. So Heidi you founded the White Ribbon Project a little more than a year ago. So can you talk about why you decided to start the project and what being a patient advocate has meant for your journey?

Heidi L. Nafman-Onda: Sure I never decided to start a project it just kind of happened. It was a reaction to just [00:39:00] feeling so frustrated by approaching cancer centers, not only me but other advocates across the country, and asking them what do you plan to do for lung cancer awareness month in November. This was months ahead of time and we were either ignored or dismissed until the final straw for me was just pure humiliation with references to doctors wearing white coats and they're being white lights in parking lots and I just had a meltdown. I was very upset and I asked Pierre to please make me a big white ribbon and I asked it to be in wood because I knew that he could woodcraft and I also knew, it's kind of morbid, it could last longer than me and that could stay on the door and he could still continue to advocate and educate and raise awareness for lung cancer. What started out as one white ribbon I took a picture of that and I put it on a private Facebook page for advocates here in Colorado to say look we can do something. We can start at home we're not powerless. We can start educating our own community. Look at the tree that I tied a ribbon around and my mailbox and what I got back was well what's on the door, that's really cool. It was screaming lung cancer awareness on it. Pierre said, well I'm happy to make some more. We would leave them on our front porch and people would come and pick them up because of Covid and we were all afraid to meet in person. What I saw happening then was just amazing. People were doing what they wanted to do with the ribbon, take pictures put them on social media and no one looked ashamed in those pictures. I thought wow could this be what we need to help crack the stigma. People are now ready to stand up, tell their stories and humanize this disease and demand care. I mean this is the number one cancer killer. Why does it have the least amount of awareness it there? We can change that. It was changed in the breast cancer community and the HIV/AIDS community, people stood up, told their stories, humanized this and when people understood that anybody could get these diseases they wanted these diseases to be funded and curable. This is the same model and I feel like I have a rowing army around me of people all over the country and now global. We're in 26 countries now with the help of the industry helping us get them there. I think it's very hopeful. We just need to talk. We need to talk about this disease. The time is now.

Ryan McDonald: Pierre, as Heidi alluded to, you created that original white ribbon. So as you've been alongside Heidi with her journey, how would you advise other caregivers or loved ones to become an advocate alongside that person who is going through cancer treatment, diagnosis, and reassure them that it's important to be there.

Pierre: Right, well I think my primary [00:42:00] goal initially was just to find a way that I could support Heidi. The irony was that I'm a physician but I was a primary care physician, so I certainly couldn't treat Heidi, I didn't have the skill set, so I had to find a way. I simply asked her, "What can I do to help you?" She had different coping skills - mechanism than I did, so frankly, that's what she told me. She said, "You can support me by making these white ribbons and supporting me as I become an advocate." So for me, advocacy came initially as I desire to support her. But I've found that now, it's a way for me to somehow participate as a caregiver. I don't have lung cancer but what can I do to help the community? And again, that doesn't mean that everybody has to be an advocate. It just means for me that is something that I choose that helps me, helps my wife and hopefully helps others. And I look at my own skill set, I want to try to reach primary care physicians low hanging free to screening. I believe the doctors can confirm screening rates for lung cancer for eligible patients is below 10% nationally. I think some states are 1%, other states higher, and it's clearly disease that if caught early, it's curable. Stage I has, I believe, at least non-small cell, above 90% cure rates. So, that's my goal.

Heidi Nafman-Onda: And I want people to understand there's a range of advocacy. You don't have to do what we've done and jump in with both feet. You can put the ribbon on the door and if someone comes to the door, start a conversation. Or you can go to Capitol Hill, anything, talking about the disease is advocacy.

Ryan McDonald: OK. And Dr. Rosenzweig, when the essay in which you were nominated in, it highlighted you, yourself, various ones of community service that you participated in. So looking at that aspect of things, why do you think it's important for a healthcare providers out there or as kind of Pierre, too, maybe some will not necessarily directly attached to lung cancer to become an advocate for others.

Kenneth Rosenzweig: So I think it's very important for physicians to get involved in their community and to try to become part of just the general conversation that's happening. And I took it a little bit further than most people do. I'm serving as a councilman in my town, and obviously, that's not for everyone and it's admittedly a little bit whacky on my part, but I enjoy it. But, we've seen, just even in the past two years, just when there are conversations about science, even though [00:45:00] I'm not the physician for my town, actually, we have someone in that role, but just there are issues of science and statistics that we have to discuss, and it's good to have someone part of the conversation who's used to dealing with that all day, even if it's a little bit outside of their field knowing what things that are statistically significant, what makes sense, what doesn't make sense. Now, of course, we're going to be working with public health experts and your municipal experts and as such, but just - it's never bad to have well rounded people as part of the discussion going on. And also, to much more general humanistic level, the physician-patient relationship is a very hierarchical one. I think it's good for physicians to get out in the community and be more on eye-to-eye with people or even kneading other people's health, as it just gives us different perspective that we can take back into the clinic. I think my - the work that I've done in my community and working with rotary in other organizations has made me a better physician. And I'd like to think that has helped in my growth and in my clinical practice.

Ryan McDonald: OK. And Dr. Borghaei, as we talk about advocacy, we can't forget about cancer research. So, can you speak to how important it is for advocacy to advance cancer research and what is being studied currently?

Hossein Borghaei: Sure, I'd be happy to, but I can't let this one go without a comment. Dr. Rosenzweig, you're my hero. I - this is wonderful how involved you are in your community. I don't think there's anything whacky about being a councilman for your town, I don't think I would ever have the courage to run for something like that, but I'm glad to see that there are physicians would get this involved in the community. And I'm frankly, I have to take some tips from you, I think, about how I can be a little more involved in my community. So thank you for bringing that up, I think that's just a beautiful thing that you're doing, so -

Kenneth Rosenzweig: Thank you, to have you say that means so much, because you've helped so many people throughout the world, so thank you, thank you.

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