The European Lung Cancer Congress (ELCC) is here, offering an unparalleled chance to discuss lung cancer care for all those involved. It is a place to exchange ideas with those who share a passion for care, a love of science, and an appreciation for a multidisciplinary approach to lung cancer more than ever before. There will doubtlessly be many at ELCC who are excited about how precision medicine continues to drive change for thoracic oncology specialists and patients worldwide. I’m looking forward to learning more about what the latest developments mean for lung cancer and collaborating with the community to drive advancements.

Precision medicine has transformed drug development in oncology

Over the last three decades, there have been significant scientific advances which have dramatically improved lung cancer care. In the 1990s, you could expect a response rate of around 5% to a new chemotherapy in a phase 1 trial.^[1] Now, drugs designed to match specific biomarkers can offer response rates of more than 30% in phase 1.^[1] Given these responses, it’s no surprise that of more than 840 oncology drugs in development in 2018, over 90% were estimated to be biomarker-dependent.^[1],[2] The shift towards a focus on tumour agnostic care, using precision medicine, is associated with improved patient outcomes in comparison to treatments targeting specific tumour types.^[3]

Let’s consider this in the context of non-small cell lung cancer (NSCLC). NSCLC is the leading cause of cancer deaths worldwide, where there are now 10 distinct molecular subtypes with effective therapies, accounting for more than 50% of all affected patients.^[1],[4] Cancer has long been referred to as a ‘genetic disease’, with good reason.^[5]Tumours are highly effective at hiding tremendously complex and unique genomic landscapes.^[5] As we look to provide the right treatment to the right patient at the right time, we need to consider biomarkers unique to patients and adjust treatment accordingly.^[3] And we must ask the stark question: are we giving patients the best care if their treatment isn’t utilising the potential of precision medicine?

Are patients well informed about precision medicine?

Imagine you’re a patient at the crucial moment of diagnosis. You’ve been called in to see a specialist and heard the word ‘cancer’ from someone who you know has diagnosed it many times before. These are the questions that will probably matter the most to you:

• Am I being given a death sentence, or do I have a fighting chance of remission?
• If I only have limited time left, how much time do I have left with a decent quality of life?

You probably won’t ask your doctor, ‘Will you give me the best care possible?’ because it’s assumed they will. But what’s not assumed is that ‘best’ is specifically unique to each patient’s genomic composition. Having a uniform standard-of-care is not giving some biomarker-carrying patients the best possible chance of survival.

As drug trials assess biomarker-specific responses, we should continue a holistic approach to education, educating patients on the potential of precision medicine, whilst educating ourselves by asking patients key questions to help us better understand barriers that may exist. Do they know what precision medicine is? How do they feel about testing? Do they think that biomarker or genetic testing is invasive or scary? Most importantly, do they think it affects the treatment assigned to them? To accelerate tailored cancer care, education and awareness needs to be increased not only amongst providers, but patients as well.

Be honest about second chances and those who don’t get one

With a cancer diagnosis, life can become a race against the clock: oncologists wrestle with providing the right treatment at the right time, as patients hope to receive the right treatment at the right time.  While the frontline therapy may be best practice, we must pause to ask ourselves whether best practice means the best fit for all?

A thorough assessment is needed to determine how many patients who receive frontline therapy don’t get a second chance to try another treatment option. While we know some patients have less of a fighting chance than others, biomarker-based treatment and survival results tell us just how much less of a chance they may have –  and give these numbers meaning –  so healthcare professionals have the best chance to beat the clock by making informed decisions.

For example, we know from NSCLC alone that those with an EGFR ex20ins mutation are at around a 75% increased risk of death compared to patients with common EGFR mutations who are sensitive to treatment with standard tyrosine kinase inhibitors.^[6]

It’s time to combine biomarkers, targeted treatments, and real-world evidence

Lung cancer is the leading cause of all cancer-related deaths worldwide and NSCLC is the most common, accounting for 80 to 85% of cases.^[4],[7] We know that standard treatments of NSCLCs exist, including tyrosine kinase inhibitors, but these may fail a subgroup of patients. The case for applying precision medicine to the lung cancer treatment landscape is a strong one.

Real-world clinical studies are more powerful now than ever before, with integrated electronic health-care records supporting in the collection of this data.  While we will see a continued discovery of targetable driver pathways in lung cancer and with this a continued personalization of therapy, collecting evidence in genetically rare disease entities will become more of a challenge in classic designed clinical studies. Real-world clinical studies can be one way to ensure we learn from each and every patient and can ultimately accelerate drug development and access to new medicines.

For decades, a one-size-fits-all approach to cancer care has meant that patients may have been sub-optimally treated, given our lack of deep understanding of disease biology (at that time), but more so today lack of education and lack of evidence.^[8] Now, we can address these factors via precision medicine, patient education and real-world data to level the playing field when we decide on the right treatment at the right time.^[8] Let’s combine all these factors into a richer conversation about how precision medicine is a powerful backbone of equality in health care for all.