February 2020

By Dr Antonia Field-Smith, Consultant in Palliative Medicine, West Middlesex University Hospital

Despite all the recent successes with immunotherapy, I am well aware that lung cancer remains the most common cause of cancer death in the UK. The patients with lung cancer that I see in hospital frequently present late in a crisis with poor performance status, co-morbidities, complex social issues and poorly controlled symptoms.  As the benefits of early palliative care in lung cancer are now well known and supported by RCT evidence, I needed little persuasion to attend BTOG and boost the palliative care presence. I was also keen to be better informed about current treatments to strengthen my role in supportive care and decision making in the lung MDT.

The star of the show and the pharma stands was clearly immunotherapy with updated data from the PACIFIC trial showing an improved three year overall survival in unresectable stage III NSCLC patients receiving consolidative durvalumab following chemoradiation. These are practice changing results for lung cancer, the first in decades and the oncologists are excited that they can now talk to these patients about a ‘cure’. The implication for palliative care teams is patients are living longer with greater uncertainty and we need to upskill in the identification of immunotoxicities and survivorship.

Highlights and messages from the sessions I attended:

  • Radiotherapy Symposium – “almost anything” can be zapped now by stereotactic radiotherapy with minimal toxicity and shorter treatment time. Don’t be hasty to pass patients over for treatment (but many will have to travel for access to SABR).
  • Managing brain metastases: The lively debate around the role of PCI and WBRT left me with more questions than answers. Importantly, the old data does not reflect today’s patients receiving new treatments with better CNS penetrance – a space to watch.
  • Sessions dedicated to complex case discussions based on feedback from last year’s conference. I found the speakers’ honesty refreshing – an armoury of viable treatment options but how to apply in a real-world setting.
  • Sponsored symposium on trial endpoints – the experts gave us their whistle-stop tour of statistics spiced up by voting on handheld devices! My friendly oncologist, Tom Newsom-Davis invited the audience to look at the shape of the survival curve as well as the numbers and use more meaningful outcomes such as landmark OS (proportion of patients with a durable response or ‘cure’).
  • Priorities from the National Lung Cancer Audit: focus on early diagnosis, optimise timely referral pathways and use multimodal treatments.
  • In Friday morning’s session, Joanna Bowden (Palliative Medicine Consultant) spoke about best supportive care models and how helpful patients, carers and community teams find a written summary of discussions outlining current and future plans. Charlie Hall (ST4 Palliative Medicine) presented the Energy Trial on exercise and nutrition in patients with incurable cancer and I commend him for successfully involving hospice volunteers in his research.

Other highlights to mention:

  • ‘A Question of Time’ hosted by John Humphries – an alternative live MDT debate around management of Stage III NSCLC. Big shout out to CNS Rachel Powell who was the voice of the patient on the panel (slightly disappointed no patient or palliative care representation!).
  • Recognition of the lung CNS role – the nursing community had a strong presence with a dedicated session and poster winners for their ‘Meet the Lung CNS’ study.
  • Buzz words in the breaks and themes from the poster displays: real world data, personalised care, PROMs, prehab and rehab, frailty assessment, re-biopsy
  • The impressive conference dinner enhanced by the tunes of the legendary Pop Gods – an opportunity to dress up, dance and celebrate the year’s successes with a fantastic group of colleagues who work and play hard.

What would I like to see more of next year?

  • Impact of frailty assessment on outcomes
  • Increased use of PROMs in clinical trials
  • Early and integrated palliative care models developing in the UK

Final thoughts?

To be honest after three days immersed in thoracic oncology, I still don’t understand all the acronyms (and they keep on coming!) however I was impressed by the collaborative spirit of the BTOG community and their commitment to improving UK outcomes in lung cancer. I felt welcomed into the tribe and was proud to be part of it. I was struck by the enthusiasm, expertise and teamwork being harnessed into education and research in lung cancer alongside ever busier clinical practice. I left better equipped to do my role, inspired to present a poster next year and bring on board more palliative care colleagues.