Dr. David Ross Camidge: Lung Cancer Patients Should “Rediscover the Feeling of Hope” (VIDEO)

Recorded on September 7, 2015

David Ross Camidge, MD, PhD

Professor of Medicine, Division of Medical Oncology
Director, Thoracic Oncology Clinical and Clinical Research Programs University of Colorado Denver

Andrew Schorr:

Hello and welcome. I'm Andrew Schorr on location in Denver, Colorado, at the World Conference on Lung Cancer. And with me is Dr. Ross Camidge, who is the director of the lung cancer program at the University of Colorado here.
Dr. Camidge, welcome.

Dr. Camidge:

Thank you.

Andrew Schorr:

Dr. Camidge, it is a really just a trem—time of tremendous change in lung cancer, at least in research, but it sounds like still there are so many more questions to be answered and so many more lives to be saved. How would you first describe where we are now when you think about it?

Dr. Camidge:

Well, I agree. Over the last less than 10 years, there have been a series of real breakthroughs, not just, you know, this sounds like a breakthrough to sell a newspaper but real changing the quality of people's lives, their longevity. But it's not one answer for everybody. There isn't a miracle cure for cancer.

What we're finding [are] different miracles for different groups of somebodies. So we've seen within the last five years treatments for ALK-positive lung cancer in the first line, and then when that treatment fails, in the second line. Now people are working on other lines in the third line—EGFR, the same. First-line treatment already established with first-line EGFR inhibitors, and now we have next generation inhibitors working for about 60 percent of the people who become resistant.

But when I say 60 percent, I'm obviously saying there's a 40 percent, so starting to—we start to see that everything starts to fragment. What about the people who don't have an EGFR, the people who don't have an ALK? Some of those will define personalized lines of therapy, some of them are still works in progress.

Some of the developments, for example immunotherapy, a lot of people are hoping this will be much more of the panacea, something that will be much broader based. That is true, yet the tools that we have, we are just scratching the surface, and so our tools of inhibiting one particular molecular pathway, something called PD-1, works really, really well in about 20 percent of people. Trouble is we don't entirely know who that 20 percent are, and not knowing who the drug works in is not the same thing as saying that it works in everybody.

So there's still a lot of work that's going to come in the future, both defining the slices of the pie, how do you expand the slice of the pie? Do you have to combine drugs together? So there's a lot of work to do.

Andrew Schorr:

So you understand the frustration maybe more broadly in the lung cancer patient community to hear that researchers are excited and there's more to talk about, but they're not sure whether it applies to them.

Dr. Camidge:

Well, so the classic thing is every time there's a new story about a breakthrough a patient will come into the clinic saying, I saw about this, you know, is this for me? Sometimes it's not even in lung cancer. Sometimes it's only been done in mice. But, you know, yes, there isn't going to be one answer for everybody, and so we have to—we have to go towards a much more personalized approach.

Andrew Schorr:

All right. So that requires tests, some tests you don't even have yet, some biomarkers and identifying genes. You're a researcher. Where are we now with kind of unlocking the biologic secrets, if you will, of lung cancer so you can then have patients where you understand their specific situation?

Dr. Camidge:

So we've made, if you like, a personalized treatment pathway for probably close to about 30 percent of people with what is called adenocarcinoma, which is the dominant type of lung cancer when you look at it down the microscope. It's a kind of cancer that has glands in it. That's what adenocarcinoma means.

And so that would be ALK and EGFR we know about and people are commonly testing for, but there is a large number of things which are—you can test for and which there are treatments for which are active. And that would include ROS1 gene rearrangements, RET rearrangements, BRAF mutations, HER2 amplification, HER2 mutations, MET X-114 splice mutations, MET gene amplification.

And so this, these little slices of pie do add up, and maybe it's an approaching, you know, maybe one in three people if you look hard enough, you can find it. One of the problems is getting the word out that you shouldn't just look at the top two and then say you don't have a biomarker-driven cancer. You have to make sure you're looking at all of these other things.

Andrew Schorr:

Now, some of the tools you have to treat those aberrations in the cell are investigational, so it sounds like we should make a pitch for people at least finding out about clinical trials, whether it applies to them. I mean, with the changing landscape to see maybe there are certain approved therapies, but there are others that you're working on.

Dr. Camidge:

So I would agree. I think in particularly non-small cell lung cancer, more than in almost any other cancer that's out there the case has really been made that you should as soon as possible after diagnosis get some kind of specialist opinion. And they may say you're going to get a standard treatment, you'll have it delivered closer to home by your local oncologist. But the breakthroughs that are happening, which, as you say, aren't in everybody, so you do have to find out, you know, what is the pathway for you, you're going to need some expert help to do that. And I think lung cancer is really leading the field in that.

Andrew Schorr:

Knowing that most people go to a community oncologist, they don't always get to your big medical center or others around the country, what should they be asking of their physician to make sure that the treatment is personalized as best they can, or they find out about clinical trials? What questions should they be asking?

Dr. Camidge:

So one of the things, I mean, we talked about, you know, is there a kind of cheat sheet that every patient should have so that when they're first diagnosed they're handing it out to somebody to check that these things are done? Are they getting appropriate staging investigations? Are they getting at least in the United States a PET CT scan, an MRI of the brain? Are they getting molecular testing done, which for my money would include most of those things that I just described?

Because there tends to be, you know, my doctor looked for these things, and I don't have it. And the real question to ask is, well, what have you looked for? You know, if you haven't looked for these things, you haven't really ruled them out. If you've looked for them all and they're all negative, then you've done, you know, due diligence there, and maybe you're not going to have a personalized tablet-based therapy. There are still other breakthroughs happening, but at least you've done the due diligence.

Andrew Schorr:

A minute ago when you rattled off all these mutations, some of them I've heard in other cancers, breast cancer and some others. Will we get to the point where somebody has lung cancer, somebody has another cancer, but the biology, the aberrations that have gone on are the same, and those medicines may apply across many cancers?

Dr. Camidge:

So that's what many of us believe, and there are certainly key examples where that's happening. So, for example, ALK rearrangements, ROS1 rearrangements can happen in other cancers, and they respond just as well to ALK and ROS1 inhibitors.

The one example which is always brought up as the exception is BRAF mutations. In melanoma, where they were first described, they respond beautifully to BRAF inhibitors. In colon cancer, where they're relatively common as well, they didn't. And so when they were found in lung cancer, the question is which way would lung cancer look? Would it look more like melanoma than colorectal cancer? In fact, it looks a lot more like melanoma, so there's something very specific about the biology.

So, yes, can you say it's always going to apply regardless of the environment it's in? No. But most of the time it will. So I think you're going to start to see clinical trials which are molecularly driven. Indeed, there's one for these things called NTRK gene rearrangements, which is you can go in with any tumor so long as it has an NTRK gene rearrangement.

Andrew Schorr:

So are you encouraged? I mean, we're talking about a very lethal condition, we have a long way to go, but it sounds like for some percentage of patients you've made really almost a—certainly a life-extending difference. Are you encouraged? What do you want to say to people knowing that some are being helped miraculously but others that aren't there?

Dr. Camidge:

So it's hard. You know, I guess I'm a glass-half-full person, so for me every person who does well, even if they're 1 percent or 2 percent or 5 percent of the population, prove to me that it's possible. Now, maybe it's not going to be the same solution for everybody, but there's a—there's a statement I think by Nelson Mandela that says, “Everybody thinks it's impossible until it's done.”

So nobody believed you could be a five-year survivor with non-small cell lung cancer that was stage IV, and now we have them. We have people who have stage IV, they've gone down mentally, and then, to put it bluntly, they've said, “Well, I'm not dead, I'm still here. I'm going to plan my vacation for next year. I'm going to get married. I'm going to adopt a child. I'm going to seek promotion in my job.” And that is happening. There are people who have rediscovered the feeling of hope, even though they're still living technically with a terminal disease, but we're moving it more into a chronic disease.

I mean, if you said to me—if you were suddenly diagnosed tomorrow with diabetes, at no point would you say, “Well, I've got to sell my house and put my affairs in order.” You just go, “Well, it's a pain in the butt, but I'll figure out a way of managing it.” And it's that mindset that I think we're heading towards at least for some achievable goals within lung cancer.

Andrew Schorr:

Okay. Now, don't mean to—for anybody to sound sort of greedy. But if they're getting that result, then they say, “Well, how long will it last?” You're coming out with new medicines. We've seen in cancer where medicines can make a huge difference for a little while, but the cancer outsmarts it. With some of the new medicines that you're working on developing or coming out, could they be lasting results for the people that they help?

Dr. Camidge:

Well, until we get a medicine or a treatment that kills a hundred percent of the cancer cells in an individual, and therefore you can stop the treatment, because there's nothing left to treat. Whatever is left behind will adapt to that environment. So we have not yet been able to cure advanced-stage lung cancer.

Now, that's kind of why I use the diabetic analogy. That may seem frivolous, but nobody's cured diabetes. You find a way of controlling it, and sometimes you have to tweak the medication and add other stuff in. And that's the same analogy that's going on with some kinds of lung cancer. So you do have to be vigilant, you do have to change the treatment, but gradually you can extend it out.

Andrew Schorr:

Hmm. Well, let's hope that that chronic cancer if it can't be cured, can apply to more with lung cancer. And I want to thank you for all the research that you help lead the way on and the progress, and if you're encouraged, we're encouraged. So thank you, Dr. Ross Camidge, for being with us.

Dr. Camidge:

My pleasure.

Andrew Schorr:

Appreciate it. All right. So a hopeful message in a changing landscape for lung cancer. Let's hope that the benefits apply to you early and if not that they soon will.

On location in Denver, I'm Andrew Schorr. Remember, knowledge can be the best medicine of all.