Dr Jessica Paulus: Despite Treatment Advances, Progress in Lung Cancer Will Continue to Take Time

In part 2 of our interview with her (click here for part 1), Jessica K. Paulus, ScD, senior director of real-world research, Ontada, a business of McKesson, addresses potential reasons why despite progress in treatment paradigms and updates to screening recommendations, a majority of lung cancers, both non–small cell (NSCLC) and small cell (SCLC), continue to present at advanced stages. As a result, treatments are more comprehensive and no longer strictly surgical.

A major victory, Paulus highlights, has been the accumulation of data on the benefits of CT screening, but “the screening victory there is going to take some more time to show its benefit at the population level,” she adds.

Transcript

Can you discuss how NSCLC and SCLC differ, as well as their treatment paradigms and primary goals of treatment?

One of the reasons that we stratified our analysis by non–small cell vs small cell lung cancer is because the treatment paradigms differ for each of those cancers. There are also important differences in how they present at diagnosis, the severity and the prognostic profile. But a lot of the advances in lung cancer treatment that have happened over the last 2 decades, some of the massive discoveries, especially with regard to targeted therapies and immunotherapies, some of the ones that have gotten the most limelight have been for non–small cell lung cancer. Having said that, for both non–small cell and small cell lung cancer, our focus for this study was less on the treatment side and more on describing stage at diagnosis. Unfortunately, for both cancers, in 2023, which was the end of our data, we still see that the vast majority of these cancers are advanced stage upon diagnosis or upon presentation.

There are some differences between the 2 cancers there as well. In our data, we found that approximately 70% of the non–small cell lung cancer patients were stage 3 or 4 upon presentation to the network [The US Oncology Network]. That number was even higher for small cell lung cancer; it was more like 80%, approaching 90% in some years of our data, for patients that have either stage 3 or stage 4. So in spite of updates to the screening paradigm, there still remains this massive problem for both cancers in that by the time that most patients present for treatment for their cancer, the treatment modalities that are available are no longer just surgical—or strictly surgical—because there has been regional or distant metastatic spread for both of them.

In that setting, prognosis is quite worse, and the treatment modalities inherently tend to be multimodal in the sense that there could be radiation therapy and also different chemotherapeutic approaches, both old-school approaches, as well as some of the more new-school targeted immunotherapy approaches. So we have a long way to go to really move the needle on this disease. There's been incredible advances since, in particular, I remember 2003, which is when I just first entered this field and some of these targeted therapies became available for the first time. Also, over the last 2 decades, the development or the accumulation of evidence about the efficacy of CT screening to reduce mortality for lung cancer, that's been corroborated, validated in clinical trials. All of those are huge victories.

I think, in particular, the screening victory there is going to take some more time to show its benefit at the population level. Some of these things are just going to be reductions in mortality that we have to wait to observe over time.