Dec 11, 2020
In today’s episode, Dr. Anne S. Tsao, a renowned thoracic medical oncologist at the University of Texas MD Anderson Cancer Center and a member of the Cancer.Net editorial board, shares the story of her late grandmother’s experience with lung cancer, and how it propelled her to pursue a career in oncology. Dr. Tsao describes her mission to raise awareness about molecular profiling to improve survival outcomes for patients.
ASCO Daily News: Welcome to the ASCO Daily News podcast. I'm Geraldine Carroll, a reporter for the ASCO Daily News. I'm delighted to welcome Dr. Anne Tsao to the podcast today. Dr. Tsao is a thoracic medical oncologist, professor, and director of the mesothelium program at the University of Texas M.D. Anderson Cancer Center.
Dr. Tsao decided to pursue a career in oncology because of her grandmother's experience with lung cancer 20 years ago. Today, we'll hear about how she turned her family's tragedy into a passion for raising awareness about molecular profiling and educating patients about the importance of advocating for themselves in their cancer journey. Dr. Tsao reports no conflicts of interest relating to our topic today. Full disclosures relating to all episodes of the Daily News podcast are available at ASCO.org/podcasts. Dr. Tsao, welcome to the ASCO Daily News podcast.
Dr. Anne Tsao: Thank you so much for having me.
ASCO Daily News: Dr. Tsao, I would love to hear about your grandmother and how her experience influenced your decision to pursue a career in oncology.
Dr. Anne Tsao: Thank you for the opportunity for sharing. It's my family's tragedy. But I think it's an important story that I like to tell to try to get people to understand the importance of genetic profiling their cancers.
So my grandmother, she lived on a mountainside in this island Taiwan. Women weren't allowed to go to school. She lived through two world wars. She lived through occupation of the country.
But she made sure that education, particularly for her daughters and granddaughters, was a priority. And so I've always admired my grandmother for that. And so it was really devastating for me to hear, when I was in my internal medicine residency, that she had been diagnosed with lung cancer.
She had never smoked before. It was unheard of, at least, through most people I spoke to. She was actually treated in Taiwan. And she underwent surgery. Unfortunately, she had multiple sites of disease. So technically, she would have been stage IV at the time they did that, but they were trying to be aggressive with her. And she went through chemotherapy, which was incredibly difficult.
My grandmother loved to paint. And so the neuropathy from the chemo[therapy] made it really tough. And so unfortunately, she died very shortly after her treatments. I think from the time of her first getting sick to the time that she passed away, it was 11 months. And it was small comfort at the time that most of what my family was told then was that most patients only lived 6 to 9 months. So she did quite well in their opinion.
Now, it was really tragic for me because, within a year, there was this big surge of interest in a targeted therapy that specifically hit a mutation called epidermal growth factor receptor. And there were pills that could potentially change outcomes for patients. And so my grandmother never had that genetic profiling. But I have no doubt, because she was a female Asian never smoker, which is exactly the phenotype that you tend to see [in] patients [who] have this mutation, I have no doubt that she could have had her life extended and certainly potentially not had those side effects from those treatments, so that she could have enjoyed the duration of the life that she had left.
ASCO Daily News: Thank you, Dr. Tsao, for sharing your grandmother's story. You were motivated by her experience to build a career in oncology. And then as a fellow at MD Anderson, you were paired with the late Dr. Waun Ki Hong, a thoracic head and neck medical oncologist, who served as your mentor. How did he influence your career path?
Dr. Anne Tsao: In everybody's life, there's usually just a handful of people that really influence or shape your life dramatically. And for me, Dr. Wuan Ki Hong was one such individual. I miss him a lot.
I met him my very first day of my fellowship program at MD Anderson. We talked about my grandmother. And this was why I was going into oncology. I was determined to find a cure for cancer. This was what I wanted to do.
And he was very interested in helping me. I told him that, as far as I knew, leukemia was the only cancer that maybe was close to being able to be cured. And so I wanted to be a part of that. It was very uneducated decision, at the time.
But certainly, he got me set up with doing clinics with the chairs of the leukemia and stem cell transplant departments. And I worked with Dr. Moshe Talpaz also for some of the early studies in Imatinib for CML. And so it was an exciting time for myself as a first year fellow.
But somewhere along my first year, because Dr. Hong served as my mentor, he basically convinced me that lung cancer needed people who had the energy to look into treatments and research. And essentially, he, 1 week, said to me, I think you should just come start doing my clinic and transition over to lung cancer. And that was that. And everything basically took off from there.
ASCO Daily News: Indeed. Well, you see patients from all ethnic backgrounds and from all over the world. I'd like to focus, for a moment, on female Asian nonsmoker patients with lung cancer. We know that 60% to 70% of these patients have a tumor mutation. EGFR being one of the predominant oncogenic driver mutations that can be treated with targeted therapy. So naturally, you'd like all patients to be aware of this. So why do some patients pursue molecular profiling of their tumors and others don't?
Dr. Anne Tsao: Yes, 100%. I try to advocate. And it's sort of a passion of mine that everybody get genetic profiling, molecular profiling of their tumor. And by that, I mean having genetic sequencing of the tumor and also having protein expression assessment to see whether or not you would be a high responder to certain immunotherapies.
So part of the issue that we have seen is that there are some places, even in the United Stats still, where molecular profiling is not commonly offered to patients when they're first diagnosed with lung cancer. And also, if you look across the United States, there are patients who get diagnosed with lung cancer that still never make it even to an oncologist. I think that there's been this nihilism surrounding lung cancer.
And having experienced it myself when my grandmother was first diagnosed and I didn't know better, it's shocking. And your first thought is that there's a very short time span that you have left with this individual. And so people sometimes don't proceed to get oncology opinions. And they don't get that molecular profiling. And so one of my greatest missions and passions is to try to get the word out and make sure that every single patient with lung cancer has molecular profiling done.
ASCO Daily News: You feel very strongly that patients need to advocate for themselves. And that has been a tougher challenge during the COVID-19 pandemic. How has the pandemic impacted molecular profiling for patients with lung cancer?
Dr. Anne Tsao: Oftentimes, particularly during the pandemic, we did see this, where a patient is diagnosed with a lung cancer. But unfortunately, there's not enough tumor tissue to send for molecular profiling. You do need to have a significant enough amount of tumor to be able to send it for these tests.
And rather than put the patient through another biopsy, with the pandemic, it took even longer to get a biopsy scheduled, sometimes treating physicians would just start a patient on chemotherapy or chemoimmunotherapy. And there are certain areas where some rural regions where it's very difficult to get molecular profiling done. And so all of these are obstacles that we need patients to stand up and say, we want to get molecular profiling. We'll take that additional week or 2 time to get the biopsy, get the diagnosis, get some molecular profiling, and optimize my treatment plan.
ASCO Daily News: Can you tell us about therapies to target some of the newer genetic alterations in the lung cancer setting, KRAS, for example?
Dr. Anne Tsao: One of the most recent genetic alterations that I really want to call some attention to is the KRAS mutation. And that's because, for decades, we have not been able to identify treatments that will target KRAS mutations. And this is found not just in Asian patients but also across the entire ethnic spectrum. And especially, we see this in women with minimal smoking histories.
The KRAS mutations, we now have a whole host of new drugs that can target these different alterations. So there's G12C novel therapies that recently were published in the New England Journal of Medicine (DOI: 10.1056/NEJMoa1917239). And there's a whole host of pipeline agents that we now can target that specific alteration as well as a G12D. Those are all coming.
Certainly, the molecular profiling has led to other new targets that have been identified. And so there are now agents being developed for ATR, ATM. I've already mentioned the KRAS G12C mutations and those targeted therapies. And so without a doubt, I think molecular profiling and genetic sequencing is the way that we eventually turn lung cancer into a chronic disease.
Again, it's important to remember that all of these different genetic alterations can be found in smoking patients and also never smoking patients. One of the things that we've also been able to make major headway in is incorporating immunotherapies for our patients that tend to have not one oncogenic driver mutation but tend to have significant smoking histories and maybe many different gene alterations in their tumors. These patients respond beautifully, in many cases, to immunotherapy. And this is what I was referencing earlier that we do have a protein biomarker, a PD-L1 that we look at on their tumor tissue.
And when you have high expression of PD-L1, you tend to have great responses to some of the checkpoint inhibitors. And so I want our patients to know that there is hope, that we are moving so quickly with our science and technology, and that I do believe, strongly believe, that, in our lifetime, we'll be able to make major survival benefits across the spectrum of patients with lung cancer.
ASCO Daily News: MD Anderson is conducting some innovative clinical trials for all the different genetic alterations. Can you tell us about some of these studies?
Dr. Anne Tsao: Well, we certainly do have clinical trials. That's one of our main focuses at MD Anderson. We have, in the earlier stage setting, we have several neoadjuvant immunotherapy trials. These will be featured in many of our society meetings.
In addition, we do have clinical trials that are replacing chemotherapy even with immunotherapy, with radiation in the stage III setting. And then in the metastatic setting, we try to have clinical trials for all the different genetic alterations. We're looking at resistance mechanisms to the standard of care tyrosine kinase inhibitors. And then in addition, we, of course, are doing dual combination immunotherapy studies, along with the chemotherapy immunotherapy trials for our patients who tend to progress through the front line and second line therapies.
ASCO Daily News: Can you tell us the names of those trials?
Dr. Anne Tsao: Of course. So in the early stage setting, we have the NEOSTAR trial, which is a neoadjuvant (NCT03158129). We also have a NeoCOAST study (NCT03794544) and then also the AEGEAN (NCT01884350). In stage III, we have a NRG-LUN-004 trial (NCT03801902). And we also have the PINX trial both of which replaced chemotherapy with immunotherapy in stage III disease.
And then in the metastatic setting, we have a trial called LONESTAR in our front line metastatic, which is looking at dual immunotherapy combinations with and without radiation consolidation (NCT03391869). And then we also have in the different front line settings for all of our mutated genes, we have trials that are probably too long to list. But certainly, for EGFR ALK, ROS1, also BRAF V600E, KRAS G12C we have many trials for now, and also our RET patients. And so certainly, these are featured on the clinicaltrials.gov website as well as our MD Anderson site.
ASCO Daily News: Thank you, Dr. Tsao. Is there anything else you'd like to mention before we wrap up this episode of the podcast?
Dr. Anne Tsao: I would love to just get the word out for the patients. It matters what your treatment is. It makes a difference. We can now prolong the life of a patient with lung cancer significantly. And if we can identify what drives your cancer, we can give you excellent quality of life for years.
And this is not false hope. This is reality. And so please ask your doctor to do molecular profiling. Please do make sure that they look for a genetic alteration.
ASCO Daily News: Thank you so much, Dr. Tsao, for sharing your story and incredible insight with us today on the ASCO Daily News podcast.
Dr. Anne Tsao: Thank you so much for having me.
ASCO Daily News: Thank you to our listeners for joining us as well. If you're enjoying the content on the podcast, please take a moment to rate, review, and subscribe wherever you get your podcasts.
Disclosures: Dr. Anne Tsao
Consulting or Advisory Role: Novartis, Boehringer Ingelheim, Genentech/Roche, MedImmune, Imedex, Lilly, Bristol-Myers Squibb, Epizyme, AstraZeneca/MedImmune, ARIAD, EMD Serono, Takeda, HERON
Research Funding: MedImmune, Merck, Genentech/Roche, Seattle Genetics, Millennium, Bristol-Myers Squibb, Boehringer Ingelheim, Polaris, EMD Serono, Seattle Genetics, Takeda
Patents, Royalties, Other Intellectual Property: UptoDate
Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.