February 9–10, 2017
Vancouver, BC

Introduction

As the most commonly diagnosed cancer in Canada, lung cancer is the cause of roughly 25% of cancer-related deaths per year for both men and women.1 Each year in February, Canadian scientists, clinicians, and other healthcare professionals who are committed to improving outcomes for patients with lung cancer gather in Vancouver to attend The Canadian Lung Cancer Conference (CLCCO). First held in 2000 as a regional meeting with 32 participants, the CLCCO is now a national conference that offers general and specialized sessions where research advances and clinical experiences are shared among colleagues from across the spectrum of lung cancer research, treatment, and management.

The CLCCO continues to grow steadily in both attendance and multidisciplinary content. On February 9th and 10th, 2017, this year’s conference brought together a diverse group of 330 participants that included physicians, nurses, residents, students, pharmacists, and industry representatives. The main program was held on Friday, February 10th and featured a breakfast symposium, general and breakout presentation sessions, a series of debates, and two award presentations. The main program was followed on Saturday, February 11th by the offsite Pulmonary Nodule Management and Pleural Disease Workshop (held with separately registered delegates at the BC Cancer Research Building, Vancouver); and was preceded on Thursday, February 9th by the CORE Meeting for Residents and Fellows (chaired by Dr. Randeep Sangha, Cross Cancer Institute, Edmonton, Alberta; and Dr. Devin Schellenberg, BC Cancer Agency) and the official CLCCO Welcome Reception and Dinner.

This report briefly summarizes the sessions and content that composed the main CLCCO program on Friday, February 10th, and highlights the key themes raised.

There is always some fun at the opening dinner – just the right balance for the meeting.

Dr. Jeffrey Rothenstein

R.S. McLaughlin Durham Regional Cancer Centre, Oshawa, Ontario

Symposium Breakfast

Early-rising participants kicked off a packed Friday program during breakfast, with an education program titled “What I-O Really Means for Your NSCLC Patients.” Accredited by the Office of Continuing Professional Development in McGill University’s Faculty of Medicine and supported by an education grant from Bristol-Myers Squibb Canada, this session was led by Dr. Solange Peters (University of Lausanne, Switzerland) and Dr. Sunil Verma (Tom Baker Cancer Centre, Calgary, Alberta), and featured a presentation by Christina Sit of Lung Cancer Canada.

Ms. Sit set a thoughtful tone by examining lung cancer immunotherapy as seen “Through the Eyes of the Patient.” Dr. Peters followed with a comprehensive review of issues around translating the recent advances in immunotherapy for non-small cell lung cancer (NSCLC) into clinical practice. She considered questions such as “What is unique about immuno-oncology?”, “Do we know how to select the best patients?”, “Should we test for PD-L1 expression?”, and “How long should we treat?”, using case studies drawn from real clinical experience and updates on data from relevant clinical trials to enhance the discussion. Dr. Peters and Dr. Verma then closed the program by engaging the audience in a conversation about the challenges and best practices involved in integrating novel immunotherapies into clinical care. Key questions from the audience focused on drug reimbursement and guidelines for programmed death-ligand 1 (PD-L1) testing.

General Sessions

With all participants assembled for the main conference sessions, CLCCO Co-chair Dr. Barbara Melosky (BC Cancer Agency) officially opened the meeting by welcoming everyone in attendance on behalf of herself and her Co-chair, Dr. Cheryl Ho (BC Cancer Agency). Dr. Melosky then invited Canadian Cancer Trials Group (CCTG) Thoracic Oncology Site Committee Chair Dr. Glenwood Goss to speak. After also welcoming the participants, Dr. Goss reviewed a number of CCTG lung cancer studies currently underway or planned for activation in 2017, offered an update on funding recently secured by CCTG, and ended by acknowledging the thousands of Canadian patients who participate in CCTG clinical trials each year.

Medical Oncology Session – Chair: Dr. Barbara Melosky
Dr. Ross Camidge (University of Colorado Cancer Center, U.S.) presented a broad overview of current knowledge about NSCLC treatment and some predictions for (near) future directions, focusing on trends in personalized medicine and immunotherapy. In particular, he noted that an increasingly informed patient population presents both challenges (e.g., patients can access lists of all mutations associated with their cancer and all potentially relevant trials, but lack information clarifying which trials – if any – may be appropriate for them) and opportunities (e.g., recruiting for clinical trials can be facilitated when patients “come to us” after doing their own research). He also cautioned that, despite the potentially broad utility of immunotherapy, some cancers, such as those harbouring epidermal growth factor receptor (EGFR) mutations, will always show weakened responses to these treatments.

Dr. Natasha Leighl (Princess Margaret Cancer Centre, Toronto, Ontario) followed with a Canadian perspective on key issues in medical oncology, including molecular testing, access to treatment, and clinical trials in lung cancer. She noted that each of these issues is affected differently by Canada-specific challenges, such as financial and human opportunity costs and sampling and level-of-evidence requirements, but ended by stating that the outlook for systemic lung cancer therapies in this country “has never been brighter.”

Radiation Oncology Session – Chair: Dr. Devin Schellenberg
Dr. Morten Høyer (Aarhus University Hospital, Denmark) outlined key ways in which stereotactic body radiation therapy (SBRT) technologies are advancing the treatment of early stage lung cancer. He reviewed several emerging techniques developed to improve the quality of, for example, image co-registration or guidance, motion management, or precision delivery. He then presented data benchmarking the effectiveness of new SBRT technologies relative to conventional approaches (like radiofrequency ablation or surgical resection), and supporting their use in unfit patients and potential as an alternative to resection in fit patients.

A local perspective on some “hot topics” related to SBRT in lung cancer treatment in Canada was provided by Dr. Houda Bahig (Centre hospitalier de l’Université de Montréal). Dr. Bahig summarized a number of clinical trials and presented research data focusing on the use of SBRT in early-stage or oligometastatic NSCLC and in patients with interstitial lung disease (ILD). She showed that SBRT appears to be a safe early-stage NSCLC treatment for tumours located centrally, and explained that an ongoing study aims to identify the specific subgroup of patients with oligometastatic NSCLC who may derive clinical benefit from a local consolidative approach to therapy. She also cautioned that, in patients with ILD, stereotactic ablative radiotherapy may carry increased risks of severe or fatal toxicities like radiation pneumonitis.

Respiratory Oncology Session – Chair: Dr. Stephen Lam (BC Cancer Agency)
Dr. Felix Herth (Translational Lung Research Center, Heidelberg, Germany) began his talk by briefly recounting the development of interventional pulmonology as a discipline, and continued by describing recent research advances in the specialty area that may contribute to the development of advanced diagnostic options and new therapeutic interventions for lung cancer patients. He concluded by emphasizing that the field of interventional pulmonology is growing.

Surgical Oncology Session – Chair: Dr. John Yee (Vancouver General Hospital, B.C.)
The surgical session featured a talk from Dr. Sebastien Gilbert (The Ottawa Hospital, Ontario). Dr. Gilbert discussed innovations in lung cancer surgery, focusing specifically on uniportal anatomic pulmonary resection.

Dr. Ross Camidge gave a brilliant talk that covered not only novel targets in NSCLC, but also the methodological approach to novel targets with new agents in general.

Dr. Mark Vincent

London Health Sciences Centre, Ontario

Breakout Sessions

The Radiation Oncology Breakout, chaired by Dr. Devin Schellenberg, began with an overview of ongoing and upcoming lung cancer trials delivered by Dr. Alex Louie (London Health Sciences Centre, Ontario). The session continued with a talk considering what the field of interventional radiology can offer to the approach of ablation for lung cancer (Dr. Brad Halkier; Royal Columbian Hospital, New Westminster, B.C.); and two presentations examining key issues in medical care as they relate to radiation oncology: quality assurance oversight (Dr. Anand Swaminath; Juravinski Cancer Centre, Hamilton, Ontario) and medical assistance in dying (Dr. Chad Lund; Fraser Valley Centre, BC Cancer Agency).

The Oncology Nursing Breakout was chaired by Karen Remo and Kelly Zibrik (BC Cancer Agency, Vancouver Centre) and featured presentations by physicians and nursing professionals working in the fields of oncology, palliative care, or acute care. Dr. Hannah Carolan (BC Cancer Agency) covered radiation oncology basics for nurses; Dr. Martin Chasen (William Osler Health System, Toronto, Ontario) discussed exercise, nutrition, and other considerations for rehabilitation in patients with advanced cancer; and Jessica LePage (Vancouver Island Health Authority) shared her experience with medical assistance in dying and reflected on the nurse practitioner’s role in this process.

The Medical Oncology Breakout, chaired by Dr. Paul Wheatley-Price (Ottawa Hospital Cancer Centre, Ontario), featured a talk from Dr. Mary Redman (Fred Hutchinson Cancer Research Center, U.S.) on strategies to improve clinical trial design. Dr. Redman argued that expediting drug development is not necessarily done by completing studies faster, but rather, by designing trials that consider the possible outcomes of a trial and the potential value of these. She recommended reducing reliance on tissue-based analysis, developing intermediate (surrogate) endpoints, and allocating sufficient time to the discovery phase of drug development. Dr. Keith Kerr (Aberdeen Royal Infirmary, U.K.) and Dr. Brandon Sheffield (Abbotsford Regional Hospital and Cancer Centre, B.C.) then provided overviews and updates on key biomarkers as prognostic factors and therapeutic targets in NSCLC. Dr. Kerr covered the programmed death 1 (PD-1)/PD-L1 axis, and Dr. Sheffield covered mutations in the receptor tyrosine kinase mesenchymal-epithelial transition factor (cMET) that lead to the skipping of exon 14.

The breakout sessions focus on topical and relevant challenges that we face in clinic. It is really interesting to hear our colleagues’ perspectives.

Dr. Jeffrey Rothenstein

R.S. McLaughlin Durham Regional Cancer Centre, Oshawa, Ontario

Debates

Often the highlight of the CLCCO program, the Debate session features humorous-yet-educational intellectual exchanges on current “hot topics” in lung cancer treatment, and sees winners determined by audience voting – often with unexpected results. This highly anticipated annual event reliably draws a large crowd and stimulates audience input. The 2017 edition was chaired by Dr. Ronald Feld (Princess Margaret Cancer Centre, Toronto, Ontario) and featured three engaging debates, each followed by touch-pad voting and an audience discussion.

First, Dr. Scott Laurie (Ottawa Hospital Cancer Centre, Ontario) and Dr. Rosalyn Juergens (Juravinski Cancer Centre, Hamilton, Ontario) debated the merits of biopsy at progression of EGFR mutation-positive NSCLC after first-line treatment with an EGFR tyrosine kinase inhibitor. Dr. Laurie argued that biopsy is usually the best choice, while Dr. Juergens countered that an evidence-based approach with educated tests-of-therapy may suffice.

Next, Dr. Normand Blais (Centre hospitalier de l’Université de Montréal) and Dr. Charles Butts (Cross Cancer Institute, Edmonton, Alberta) considered the benefits of PD-1/PD-L1 combination immunotherapy as first-line therapy for advanced NSCLC. Dr. Butts highlighted the versatility and “personalizability” of combination immunotherapy and the potential for this approach to generate durable responses. In response, Dr. Blais raised questions of cost and efficacy, and stressed that chemotherapy is well-confirmed as an effective treatment for all NSCLC indications.

Finally, Dr. Patrick Cheung (Sunnybrook Health Sciences Centre, Toronto, Ontario) and Dr. Harold Lau (Tom Baker Cancer Centre, Calgary, Alberta) debated the best treatment for stage IIIb EGFR mutation-positive NSCLC in a relatively young and fit patient: in this case, a 60-year-old female with Eastern Cooperative Oncology Group performance score of 1 and adequate pulmonary function. Dr. Cheung argued for a course of high-dose radiotherapy (e.g., 60 Gy in 30 fractions) along with chemotherapy, while Dr. Lau held that the best option would be a short course of low-dose radiotherapy (e.g., 20 Gy in 5 fractions) followed by systemic treatment with chemotherapy.

The debates were both informative and entertaining. The injection of mild humour into high-quality, efficient reviews kept the debates engaging.

Dr. Robert El-Maraghi

Simcoe Muskoka Regional Cancer Centre, Barrie, Ontario

Summary

CLCCO 2017 facilitated a valuable exchange of ideas among experts who represent multiple disciplines but share the common goal of CLCCO: to improve the care of patients with lung cancer. Dr. Melosky closed this year’s meeting with thanks to the generous sponsors and hard-working conference committee members who made the meeting possible, and to the guest speakers and participants who made it successful. She adjourned by enthusiastically encouraging all participants to save the date for CLCCO 2018, which will be held in Vancouver in February 2018.

CLCCO is a fantastic meeting that I look forward to during the year. It is a great opportunity to meet with colleagues who specialize in thoracic oncology from across the country. The venue is superb. The speakers are world-class.

Dr. Jeffrey Rothenstein

R.S. McLaughlin Durham Regional Cancer Centre, Oshawa, Ontario

Reference: 1. Canadian Cancer Society’s Advisory Committee on Cancer Statistics. Canadian Cancer Statistics 2016. Toronto, ON: Canadian Cancer Society. http://www.cancer.ca/en/cancer-information/cancer-type/lung/statistics/?region=on. Accessed April 11, 2017.