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What Are the Advantages of Seeking Care With a Lung Cancer Specialist? from Patient Empowerment Network on Vimeo.
What are the benefits of seeing a lung cancer specialist? Dr. Thomas Marron discusses the key advantages of specialty care, the value of a second opinion, and options for seeing a lung cancer specialist via telemedicine.
Dr. Thomas Marron is Director of the Early Phase Trials Unit at the Tisch Cancer Institute at Mount Sinai Hospital. Dr. Marron is also Professor of Medicine and Professor of Immunology and Immunotherapy at the Icahn School of Medicine at Mount Sinai. Learn more about Dr. Marron.
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Katherine Banwell:
What’s the advantage then of seeking care with a lung cancer specialist?
Dr. Thomas Marron:
So, I think it’s extremely important. Unfortunately, a lot of the country, there are not lung cancer specialists available around the corner. But in large cities, there’s typically many lung cancer specialists, but I think it’s extremely important, at least as a second opinion, even if you’re not going to be treated locally by a lung cancer specialist, to seek out expertise.
And often times, I’ll have patients that come from more rural areas outside of New York and they’ll come, and they’ll see me and then I’ll work with their local provider to come up with a treatment plan. Because the fact of the matter is, is that in every cancer type, but particularly in lung cancer, the field is moving so quickly. So, the treatment options that we have available today were not available in 2022.
And we’re going to have probably five to 10 drugs that’re going to be FDA-approved in the next year. And it’s typically the lung cancer specialist where it’s all that we do, we eat, breathe and live lung cancer, we’re the ones that really are up to date on everything. While if you’re seeing a general hematology, oncology provider who I’m always in awe of, they have to stay up to date on lung cancer, breast cancer, lymphoma, leukemia, everything under the sun.
And when you have so much development in the research that’s happening, you really want to be talking to somebody, at least as a second opinion that knows exactly what the most latest data is and what the best options are available. And also, those lung cancer providers are usually the ones that will know exactly where you can go to get access to certain clinical trials.
Katherine Banwell:
In seeking a second opinion, can somebody do a tele-visit, or do you have to actually, physically go to see the specialist?
Dr. Thomas Marron:
So, it depends on the specialist that you’re trying to see.
There are certain institutions that will allow you to do televisits. Oftentimes doctors, at least for their first encounter with a patient really want to see somebody in person, just so that we can really evaluate how functional somebody is. There’s a lot that I cannot tell through my computer screen, through my Zoom call with a patient.
And so, it can be a little bit difficult, but there are many centers, including our own that will offer patients televisits as a second opinion, for us to get a chance to talk to them about their medical history, review, the treatment decisions that they’ve had in the past or the current treatment decision that they’re dealing with and give our own opinion on what they should do.
Lung Cancer Treatment Plan Advice | Where Do Clinical Trials Fit In? from Patient Empowerment Network on Vimeo.
What questions should patients ask about a lung cancer treatment plan? Lung cancer expert Dr. Thomas Marron shares key considerations when choosing therapy and discusses where clinical trials fit into planning.
Dr. Thomas Marron is Director of the Early Phase Trials Unit at the Tisch Cancer Institute at Mount Sinai Hospital. Dr. Marron is also Professor of Medicine and Professor of Immunology and Immunotherapy at the Icahn School of Medicine at Mount Sinai. Learn more about Dr. Marron.
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Katherine Banwell:
What questions should patients be asking about their proposed treatment plan?
Dr. Thomas Marron:
I think that in lung cancer, most patients are going to get the same therapeutic approach offered to them wherever they go.
It’s not like certain types of cancer where there’s 10 different ways to treat it. But there are some nuances and depending on the location in which you’re getting treated, whether it be in an academic hospital or a community setting, you may have different chemotherapies offered, immunotherapies offered. You may have different combinations offered. And so, I think it’s important to always ask your provider what other options are there, and why are they recommending one option over another. But I think it’s also really important that patients get second opinions.
A lot of my patients, even my in-laws are always very skittish about getting a second opinion because they don’t want to insult their doctor, who they feel very close to. And I would say, it couldn’t be further from the truth. Any good doctor is 100 percent okay with a patient going and getting a second, third, fourth opinion because to us, the most important thing is that you have confidence in the decisions that we’re making about your treatment.
I always tell patients, I’m basically a waiter here offering you a menu of options and giving you my recommendation. But it is up to the patient in the end what treatment they receive and how long they receive it for.
And if they decide ever to discontinue it. And I think that the more information, the more smart people looking at you, the better.
Katherine Banwell:
Where do clinical trials fit into a non-small cell lung cancer treatment plan?
Dr. Thomas Marron:
So, that’s a phenomenal question and one that I hope that everyone asks their providers when they see them because the reality is that while we are curing some patients, the vast majority of patients are not cured. And I think that all patients should at least consider a clinical trial, whether it be a first line clinical trial. So, the first medicine that you receive for your cancer, or at the time of progression.
I think particularly, once patients progress on the first line therapy, those patients we really don’t have a cure for, even if we have some palliative chemotherapies or eventually these antibody drug conjugates to treat them.
And so, I think everybody who is progressing on first line therapy should always consider a clinical trial. And I think it’s extremely important that patients realize the need to ask their providers about clinical trials, but also be an advocate for themselves and go out and get second opinions, get third opinions and see what trials are available in the community and even in other cities.
Because often times in New York City, I’ll have completely different clinical trials than my colleagues at the other five institutions in the city. And it’s really important that patients advocate for themselves, and they identify everything that’s available.
Expert Perspective | New and Emerging Progress in Lung Cancer Treatment from Patient Empowerment Network on Vimeo.
What’s the latest in lung cancer research? Dr. Thomas Marron from the Tisch Cancer Institute at Mount Sinai Hospital discusses the advances in targeted therapy and immunotherapy and what this progress means for patients with lung cancer.
Dr. Thomas Marron is Director of the Early Phase Trials Unit at the Tisch Cancer Institute at Mount Sinai Hospital. Dr. Marron is also Professor of Medicine and Professor of Immunology and Immunotherapy at the Icahn School of Medicine at Mount Sinai. Learn more about Dr. Marron.
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Katherine Banwell:
Dr. Marron, you’re a leading researcher in the field. What new and emerging progress in lung cancer care are you excited about?
Dr. Thomas Marron:
So, there’s many extremely exciting, targeted therapies that’re in development. And so, as I mentioned, we do genetic sequencing, and we get three to 500 genes’ worth of data. But we only have drugs to target around 10 of those.
So, hopefully in the coming years, in the next three to five years, we’ll have many more options based on somebody’s genetic profile of their tumor. I think that also, within the field of immunotherapy, which typically are given to patients who don’t have those targetable mutations.
Immunotherapy is really, has revolutionized the treatment of lung cancer and with immunotherapy, we’re actually able to cure a subset of patients while in the past, we always said patients with metastatic disease had incurable disease, but it was treatable disease, just not curable.
Now, we are curing a subset of patients. Unfortunately, we’re not curing the majority of patients. But the field of immunotherapy is evolving very quickly with new therapies targeting new parts of the immune system.
So, similar with targeted therapies, it’s really an umbrella term. So, targeted therapy is an umbrella term for dozens of different drugs. Immunotherapy, similarly, is an umbrella term for dozens of different approaches to the immune system. So, dozens of different ways to turn on the immune system so that the immune system does its job and recognizes and kills cancer. Because your immune system is in your body to tell the difference between foreign things like COVID and normal things like your lung.
And cancer is somewhere in between and there’s probably hundreds of different ways in which cancer finds an ability to hijack our immune system and then turn our immune system off. And so, I think with these emerging therapies that we’re developing now and will be further developed in the next five to 10 years, I think we’re going to see another revolution happen in the setting of immunotherapy.
Katherine Banwell:
So, what do these advances mean for non-small cell lung cancer patients?
Dr. Thomas Marron:
So, in non-small cell lung cancer, immunotherapy has really changed the way that we’re treating patients from 10 years ago when we were giving chemotherapy alone, or maybe 15 years ago. Ten or 15 years ago, when I saw a patient with metastatic disease, I would have to have a very frank conversation with them and tell them that the median survival was 10 months and that this was an incurable illness that would eventually take their life. Now, with the introduction of immunotherapy, patients are living more than twice as long on average.
And there are a subset of patients, somewhere between 10 to 20 percent of people that go into remission and stay in remission. And so, that really has revolutionized the treatment. Obviously, we’re not done, because we still have to help the remainder of those patients and our goal is 100 percent cure. But the fact that we’re even using the C-word, cure in our cancer clinics is really amazing.
Antibody Drug Conjugates for Lung Cancer | Advances in Research from Patient Empowerment Network on Vimeo.
What are antibody drug conjugates, and how are these new agents changing lung cancer care? Lung cancer expert Dr. Thomas Marron defines antibody drug conjugates and explains how they work to treat lung cancer.
Dr. Thomas Marron is Director of the Early Phase Trials Unit at the Tisch Cancer Institute at Mount Sinai Hospital. Dr. Marron is also Professor of Medicine and Professor of Immunology and Immunotherapy at the Icahn School of Medicine at Mount Sinai. Learn more about Dr. Marron.
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Katherine Banwell:
What are antibody drug conjugates, and how do they treat lung cancer?
Dr. Thomas Marron:
So, antibodies are proteins that have been manufactured. They’re a synthetic version of something that happens in our own body And they’re very specific for a very unique protein. And so, there are certain cancer proteins, there’s proteins on the surface of cancer that really aren’t expressed anywhere else in your body. And so, what we can do is we can develop these antibodies that basically are a heat-seeking missile. So, you inject them like chemotherapy, through an IV. But they’re a heat-sinking missile, and they go throughout your body, and they stick themselves to the cancer.
And hopefully, they don’t stick anywhere else. And basically, antibody drug conjugate means the drug is conjugated to the antibody, meaning you basically have glued chemotherapy onto that antibody.
And so, what it allows us to do is, instead of giving chemotherapy through the IV like we normally would, where that chemotherapy goes everywhere in your body, and that’s the main reason that you have toxicity.
It doesn’t just go to the cancer, it also goes to your bone marrow, to your hair, to your intestines, has side effects. Antibody drug conjugates, the goal of them is to really deliver the chemotherapy directly to the tumor and spare the rest of your body, the toxicity from the chemotherapy that’s glued onto the antibody.
It’s important to note that they still do have side effects. So, some of that chemotherapy, for lack of a better term falls off the antibody or it might leak out of the tumor after it kills the tumor cells. And so, there is still the potential for toxicity, very similar to the toxicities that we see with chemotherapy.
But so far, the data is very encouraging, both in lung cancer and other cancer types that antibody drug conjugates might be a superior formulation of chemotherapy, so better able to treat lung cancer. And we have a few drugs that’re actually probably going to be FDA-approved in the second line setting for non-small cell lung cancer. So, that’s for patients who have received standard first-line therapy and unfortunately, their cancer has progressed.
And we actually already have one drug that was, it’s called Enhertu that was developed for breast cancer. And that’s now FDA-approved for lung cancer, for a rare subset of lung cancer patients who have an exon-20 HER2 mutation.
And the patients I’ve treated with that drug do extremely well, and so I think it’s a very encouraging sign of what’s to come using more and more of these targeted chemotherapy regimens.
Katherine Banwell:
Yeah. Well, that leads me to the next question, is there a patient type that ADCs are right for?
Dr. Thomas Marron:
So, maybe is the question, answer. So, I don’t know because we don’t have good biomarkers right now to identify the patients that’re going to respond best to the drugs that’re in development, at least those ones that’re furthest along in development.
And we’re always searching for biomarkers, which basically just means a test that we do on the patient’s biopsy or in their blood to tell us who’s going to respond to a therapy and who’s not. Unfortunately, right now we don’t have a good biomarker for these drugs.
Hopefully as we do larger trials and we study biopsies and blood from the patients on those trials, we can identify the subset of patients that will do best with the therapy. Because we always want to make sure we’re getting patients the best therapy for them and we’re avoiding giving these therapies, because there are some toxicities to patients that aren’t going to respond to the therapy. So, it’s definitely a work in progress.
How Has Lung Cancer Molecular Testing Evolved? from Patient Empowerment Network on Vimeo.
What are the latest advances in lung cancer testing? Dr. Thomas Marron discusses the role of molecular testing when choosing therapy and how innovations in technology have revolutionized lung cancer care.
Dr. Thomas Marron is Director of the Early Phase Trials Unit at the Tisch Cancer Institute at Mount Sinai Hospital. Dr. Marron is also Professor of Medicine and Professor of Immunology and Immunotherapy at the Icahn School of Medicine at Mount Sinai. Learn more about Dr. Marron.
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Katherine Banwell:
What should patients understand about the results of molecular testing?
Dr. Thomas Marron:
So, molecular testing is extremely important and anybody who has metastatic non-small cell lung cancer should get it. And increasingly, with the new drug approvals, even patients that have earlier stage disease, stage II and III disease should also get molecular testing. Molecular testing is important to identify if there is a potential therapeutic target.
But it’s also important to know that it may predict a response to a therapy, whether that be a targeted therapy or something like immunotherapy. But there is no guarantee. So, there’s no specific result from a molecular test that tells you there’s 100 percent chance you’re going to be cured by Drug X.
And so, it’s important to always know that we’re following the data and we’re giving patients the drugs that, based on the knowledge we have today is the best option for them, based on their molecular test. But it isn’t a guarantee. And sometimes these drugs will work transiently.
And so, they may work for weeks, months, year but then they might stop working. And it’s also important to understand that the mutational profile may change over time, which is one of the reasons why we do these genetic tests. Oftentimes multiple times. Not just at the time of diagnosis, but also when patients’ cancer starts to grow so that we can see if there’s a new molecular target that we might be able to identify and treat with a novel therapy.
Katherine Banwell:
Dr. Marron, are there innovations in technology that are aiding in the advancement of lung cancer research?
Dr. Thomas Marron:
Yeah, so there’s lots of developments in the molecular tests that we’re doing. One of them is that we’re able to track circulating tumor DNA. So, as cancer is growing, it grows in this very unorganized aberrant way, because the on and off growth switches within the cancer, within the DNA are very dysregulated. And what happens is that often times, they’re releasing a lot of cancer cells as they’re growing or also dying and releasing their DNA into the blood.
And so, through blood tests, we’re now able to identify the mutations in a patient’s cancer. And this is a real revolution in the initial diagnosis of metastatic lung cancer because in the past, we had to wait for three, four, five weeks in order to know whether a patient had a targetable mutation like an EGFR mutation. Or if we should use a more agnostic approach, immunotherapy or chemotherapy to treat the patient.
But now when I see a patient, typically I see lung cancer patients on Fridays, I will take some of their blood, I send it off for the liquid biopsy analysis. And by that following Friday, so just one week later, I typically have an answer of if the patient has a mutation that I can target, let’s say with an oral medicine or if they’re a patient that I should be treating with immunotherapy. Additionally, circulating tumor DNA, increasingly we can use it to identify or track a patient’s progress, as far as response to therapy.
And so, this has really been developed in other tumor types, but increasingly we’re using it in lung cancer where we can either track how much cancer they have in their body. So, very early on, we can see if the cancer is shrinking or growing. And additionally, we can use it to detect patients after surgery, whether or not they have residual disease in their body.
And so, a lot of the times patients will undergo surgery because let’s say on a CAT scan, you might only see one large, isolated tumor. But after we take that tumor out, now we can do a blood test to see if there might be microscopic bits of that cancer that were left over, that we weren’t able to see on a CAT scan or PET scan.
And it’s that patient population that we think benefits most from either chemotherapy or targeted therapy after surgery. So, we’re using circulating tumor DNA, both in the metastatic setting, where cancer has already spread to other parts of the body. And also, in the perioperative setting, around the time of surgery or radiation where we’re trying to cure patients. And we’re now able to use this technology to hopefully increase the likelihood that we’re curing them.
Advances in Targeted Lung Cancer Treatments | What You Should Know from Patient Empowerment Network on Vimeo.
Dr. Thomas Marron discusses how these therapies work to treat lung cancer, how the presence of certain mutations can impact care and treatment choices, and the research being done on new therapies to target specific lung cancer biomarkers.
Dr. Thomas Marron is Director of the Early Phase Trials Unit at the Tisch Cancer Institute at Mount Sinai Hospital. Dr. Marron is also Professor of Medicine and Professor of Immunology and Immunotherapy at the Icahn School of Medicine at Mount Sinai. Learn more about Dr. Marron.
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Katherine Banwell:
Welcome, Dr. Marron. Would you introduce yourself, please?
Dr. Thomas Marron:
Sure, I’m Tom Marron. I’m the Director of the Early Phase Trials Unit at the Tisch Cancer Institute at Mount Sinai Hospital. I’m a Professor of Medicine and also a Professor of Immunology and Immunotherapy at the Icahn School of Medicine at Mount Sinai. And I’m trained as both an oncologist and an immunologist.
Katherine Banwell:
Excellent. Thanks for joining us today.
Dr. Thomas Marron:
Thank you for having me.
Katherine Banwell:
We know that the presence of certain mutations can affect lung cancer treatment options. Can you share the latest updates in targeted therapies?
Dr. Thomas Marron:
Sure, so there’s been a lot of developments in targeted therapies as of late.
Mutations in a patient’s cancer can represent a potential therapeutic target, and we have increasing numbers, every year we have new FDA approvals for typically pills that target very specific mutations and are able to either control cancer or even kill cancer. Additionally, we use DNA sequencing of tumors to identify mutations that could be predictive of a response to certain therapies. So, even though we don’t have a specific drug to target that mutation in their DNA, that change in their DNA that’s making the cancer grow, we do know that patients with certain DNA mutations do better on certain therapies than other therapies.
And so, we can use mutations specifically to help guide therapy, even if we don’t have a targeted therapy for something like EGFR mutation or a KRAS mutation. And additionally, one of the things that we do as we’re treating patients is, often times we will give a patient with lung cancer a therapy and then their cancer may respond for weeks, months, even years.
But then it might recur, or it might just start growing if it never went away entirely. And at that time, we’re oftentimes repeating the genetic sequencing, whether doing a biopsy or sometimes we can do what we call a liquid biopsy, which is just taking some blood and looking for some of the DNA from the cancer floating around in the blood.
And the reason we do that is that if you see a change in the mutations, it might represent either a change in the type of cancer or it might represent what we call an escape mutation, or an escape mechanism where the cancer that had been responding to therapy X is now not responding because it changed its DNA to overcome the therapy you were given. And that might suggest that we try a specific new therapy, or that we just change our approach entirely.
Katherine Banwell:
You’ve answered my next question to some degree, but I’m going to ask it anyway. How do these therapies work to treat lung cancer?
Dr. Thomas Marron:
So, cancer is caused by changes in your DNA. So, your DNA is your instruction booklet on how cells should grow and when they should grow. And every cell in your body theoretically has the same DNA, except for, because of a variety of things like smoking or exposure to radon or just living in a large city full of pollution. As we get older, we basically accrue more and more mutations and changes in our DNA, our instruction booklet. And while most of these changes really don’t have any sequela, and they’re not going to affect the ability for the cancer, or for normal cells to grow.
Sometimes you’ll get a mutation in a very specific gene that’s important for telling cells when to divide and when to grow and when not to grow. And you can think of it as a light switch where the light switch gets stuck in the on position and constantly, cells are growing and growing and growing and that’s when you have cancer. So, when you have these mutations, one of the approaches that we’ve been working on for the last few decades, in particular in the last few years.
We have lots of these new drugs that target these mutations, and they basically turn that on signal off. So, they disrupt, it’s like turning the light switch off. You’re disrupting the constant grow, grow, grow signal and keeping the cancer from growing. Typically, we think of these targeted therapies that do this, not as cures for cancer, at least when patients have metastatic disease, but they’re very good at controlling cancer. And some of these therapies can work for years, even a decade and control the cancer. But often times, unfortunately cancer always finds a way to outsmart us, even when we’re outsmarting it.
Katherine Banwell:
Right. Are there new mutations being discovered that can impact the future of small cell lung cancer care?
Dr. Thomas Marron:
Well, I’m not sure I would say that there’s a lot of new mutations that’ve been discovered, per se. Every time that you come in and get a diagnosis of lung cancer, we typically will take the tissue and like I said, sometimes we’ll take some blood and do a liquid biopsy and look for a slew of different known mutations.
And typically, we’ll look for anywhere from three to 500 known mutations in the cancer, even though we only have drugs to treat about 10 of those three to 500. The nice thing though is that as we learn more and more and more about these mutations and we study them, we are developing more and more drugs to address specific mutations. So, five years ago we really only had three different mutations that we could target.
Now, we have around 10 because we have all these new drugs that target very specific mutations whether they be in genes like MET or RET or KRAS or BRAS.
So, I think that while we aren’t necessarily discovering that many new genes, we’ve been looking at the genetic sequence of cancer and also, just the human genome for 20 to 30 years at this point, we’re discovering lots of new drugs that can target those specific mutations that we know patients have, but that most of the mutations we identify are not necessarily druggable targets.
Understanding Oncogene-Driven Lung Cancer: Targeted Therapy Advances and Challenges from Patient Empowerment Network on Vimeo.
How do the genetic mutations of EGFR and exon 20 impact lung cancer? Expert Dr. Christina Baik from Fred Hutchinson Cancer Center discusses oncogene-driven lung cancer and how it differs from other lung cancer types.
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Lisa Hatfield:
What exactly is oncogene-driven lung cancer, and how does it differ from the other types of lung cancer?
Dr. Christina Baik:
So in lung cancer, there are certain lung cancers where the growth of the cancer is dependent on a particular genetic abnormality. So there is one gene that makes that cancer grow. And because of that, there have been treatments that are developed against that particular genetic abnormality. So, it is referring to lung cancers that have that particular genetic abnormality. A prime example of this is lung cancers that have what we call an EGFR mutation.
That means that there is this gene called EGFR that is abnormal, and that’s making the cancer grow. Now, not everyone has a cancer gene that is driving that cancer. I would say about 30 percent or for 30 percent to 40 percent of patients would have an oncogene-driven cancer for which there may be treatments either as a standard treatment or in clinical trials. But the majority of patients do not have an oncogene, meaning that genetic abnormality where there is a targeted therapy option. So that’s the distinction we make. And I know this term or phrase is used a lot, but that’s what it means. And if you want to know if one has an oncogene-driven lung cancer, you would know based on the genetic test results.
Lisa Hatfield:
Okay. Great. Thank you. And just for clarification too, the genetic mutations are found in the cancer cells, not in their body, the cells? So that’s what the genetic testing is done just on the cancer cells. Is that correct?
Dr. Christina Baik:
Yes. Yes.
Lisa Hatfield:
Okay, great.
Dr. Christina Baik:
Thank you for clarifying that. That’s a very important distinction.
Lisa Hatfield:
Yeah. Thank you. So that leads right into the next question, and it’s kind of a lengthy question. And this person is asking, “Dr. Baik, you have done considerable research around EGFR exon 20 insertion mutations in non-small cell lung cancer, considering their association with poor survival outcomes, what are the survival implications of having EGFR exon 20 insertion mutations compared to other types of EGFR mutations?”
Dr. Christina Baik:
Now this gets a bit complicated, but not all EGFR lung cancers are the same. And there are patients who have what we call EGFR mutation that is a classical mutation. And I throw out that term, because that’s how it’s written on the Internet and a lot of papers. And then, so that’s one group, and the other group are patients who have this exon 20 insertion mutation. And the reason these are separated is because the treatments that work very well in the classical mutations do not work very well in this particular exon 20 mutation.
So when we look at all patients with EGFR mutation, it is true that the prognosis is poor in exon 20 patients just because there are no great targeted therapy options. That said, I am very hopeful that this is changing. There are a number of targeted therapies for exon 20 that are in trials, and I think these are going to be FDA-approved in the future, not too far off in the future, I believe. So I think the survival implications will start to hopefully equalize amongst all the EGFR-mutated lung cancer patients.
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Newly Diagnosed Non-Small Cell Lung Cancer | Key Advice for Patients from Patient Empowerment Network on Vimeo.
What’s key advice for newly diagnosed non-small cell lung cancer (NSCLC) patients? Expert Dr. Christina Baik from Fred Hutchinson Cancer Center discusses genetic testing, essentials to know about your lung cancer, and patient tips to ensure your best care.
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Lisa Hatfield:
When a patient is diagnosed with non-small cell lung cancer, is genetic testing always done on the tumor, or do patients know what their mutations are right upon diagnosis if testing is done?
Dr. Christina Baik:
So, as a rule of thumb, they should, all patients should be tested, and there are exceptions. So, for example, in lung cancer, there’s the type that we call small cell lung cancer, and there’s non-small cell lung cancer. So we often, we usually do not do genetic testing on small cell lung cancer, because often these tumors do not have a genetic abnormality that for which we can actually give treatment for. But for non-small cell patients, I would say, if most, my personal opinion is that everybody should be tested with the genetic test and really advocate for that. You know, there are certain types of non-small cell lung cancer where there are genetic targets that are rare, however, you don’t know unless you test. So I would say yes to that question of testing for genetic abnormalities.
Lisa Hatfield:
Okay, thank you. So can you speak to the priorities for newly diagnosed patients, particularly populations who may have poor outcomes?
Dr. Christina Baik:
So, I think there are priorities when it comes to research, and then there are priorities for individual patients, right? So from a research standpoint, as I mentioned before, I think really the priorities, the priority is to develop strategies so that we’re truly personalizing treatment for each patient, and we’re not giving this kind of generic treatment for a bulk of the patients. So from a research standpoint, really understanding the biology, understanding what works for what patient, I think that’s extremely important.
On the individual patient level, we sort of alluded to this earlier, but really knowing the cancer we’re dealing with is extremely important. Know your cancer stage, ask what your cancer stage is, know the type of lung cancer that you have. So I will say as of now, there are, I can think of 12 or 13 different types of lung cancer that I want to make sure I know that patients, you know, what their subtype is.
So know your subtype of lung cancer. Ask those questions. If the knowledge is not known, if they say, “You know your stage is not very clear, your subtype is not clear,” then ask why that is, what type of additional testing that needs to be done. So I think those are the type of questions that each patient and their family member should really ask. And in terms of the poor outcome question, I think the first thing I would say is if a doctor tells you, you belong to a group of patients who are going to have a poor prognosis, then ask why that is, right? And understand the reasons for that.
And if that’s, once you understand, I think I’m a big proponent of getting second opinions, because a lot of these treatments and there’s a lot of medical judgment involved when we recommend treatments, and you just want to get a different perspective with the same type or set of information. So really being an advocate for yourself, I think that’s extremely important when you’re first diagnosed.
Lisa Hatfield:
Great, thank you. You mentioned two things I also feel strongly about, I don’t have lung cancer, I have a different type of cancer, but you said that patients and family members can ask questions. Having an advocate with you at all times, if that’s possible, a family member, a friend going with you, I think is super important.
And also getting a second consult to understand your diagnosis better. I appreciate you saying that, because some of us are a little bit reluctant to do that, maybe afraid of offending our doctors. So, I appreciate that as a patient myself, so thank you. Okay. So talking about disease progression and recurrence, particularly for metastatic non-small cell lung cancer, what should patients know?
Dr. Christina Baik:
Okay. So when a cancer initially responds to a treatment and it stops responding, there can be many reasons for that. So the first question to really think about is is there another test we can do to identify the reason for the progression? And can we personalize a treatment according to that resistance pattern or the change that occurs in the tumor? This is more relevant to patients who get a targeted therapy, but I think it’s a good sort of rule of thumb in terms of asking your doctor why that is, and is there more testing that’s required?
And the second I would say is once the cancer progresses after the initial treatment, then, unfortunately, in lung cancer the treatment options are much more limited, and the effectiveness is very limited as well. So, it’s really at that juncture to really seek out clinical trials. There are many trials that are out there. So really working with your doctor in identifying these trials. If there is an academic center that’s close to you, at least inquiring about that. In lung cancer, fortunately, there are many wonderful advocacy groups and these advocacy groups can be great resources in finding out about clinical trials and where to seek out opinions. So, I think it does require some homework at the time of progression but really seek those out.
Lisa Hatfield:
Okay. Thank you. Now, if a patient does have an interest in a clinical trial, say maybe they have, their cancer has progressed, would they seek out that trial through the academic center itself? If, say they live in a rural area and they don’t have access, would they contact the academic center itself, or would they seek out a specialist like you first to ask about those clinical trials?
Dr. Christina Baik:
So they sort of come together in a way, because a lot of the specialists are in academic centers. So I think there are two ways to go about it. One is to meet with the specialist who can give you kind of the landscape of where things are and what might be appropriate. So, that’s one way to do it. The other way to do it is if there’s a particular clinical trial that you’re really interested in based on discussions with other patients or through advocacy groups, if there are particular clinical trials, usually the contact information is listed on the clinicaltrials.gov website, and the contact number is usually for the research team who can give you more information about that particular trial.
Lisa Hatfield:
Okay. That’s very helpful, thank you. And thank you for this overview. I just want to recap a couple of points that you made that’s really important for patients to know. You had mentioned knowing their type, their subtype of lung cancer, knowing their stage, and knowing their mutations and having an advocate. I think those are all really great tips that you gave.
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Advancing Lung Cancer Treatment: Bridging the Gap in Personalized Care? from Patient Empowerment Network on Vimeo.
What should lung cancer patients know about the latest treatment and research news? Expert Dr. Christina Baik from Fred Hutchinson Cancer Center discusses immunotherapy, targeted therapy, and resistance mechanisms for treatment.
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Newly Diagnosed Non-Small Cell Lung Cancer | Key Advice for Patients |
Understanding Oncogene-Driven Lung Cancer: Targeted Therapy Advances and Challenges |
Lisa Hatfield:
Dr. Baik, can you speak to the latest news and priorities for the treatment of non-small cell lung cancer? And what are the notable advancements in understanding resistance mechanisms or novel therapeutic targets?
Dr. Christina Baik:
So it’s a good time to be a lung cancer doc, I would say, just because there’s so much advance. We’re seeing different treatments be FDA-approved every other year, if not every year. So it’s really good to have all these options to offer our patients. Now the priority, however, is that not everyone is benefiting in an equal way from all these advances. And really the research priority, including my own personal research, is to really understand why some patients are benefiting and why some are not.
So, for example, in the immunotherapy world, which is a big advance we’ve had in lung cancer in the last 10 years, we know that some patients respond very well, some do not. Yet we give the same sort of treatment to patients. So one thing to understand is who are…and one thing I would say is we don’t personalize immunotherapies for our patients.
So one of the research priorities is to really understand where the different subgroups of patients who are going to benefit from this one treatment type…one type of immunotherapy treatment versus the other. So I would say that’s a big priority for me as well as for the field and all the researchers so that we’re giving the right treatment to the right patient. Now, there have been advances, I would say, in this theme in those patients who are able to receive a targeted therapy. So that is a type of treatment that we give to target the genetic abnormalities that exist in a particular patient’s tumor.
And these treatments work very well. But at some point, it stops working. But nowadays, there are certain sorts of resistance mechanisms as we call it. These are changes that occur in the tumor when a targeted therapy stops working. And we’re starting to understand better in terms of reasons for that and actually develop treatment options for those mechanisms of resistance. So I think we are starting to understand better, and I think we’re going to get there in terms of personalizing immunotherapy. But there’s still a lot of work to be done.
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Lung Cancer Patient Expert Q&A: Dr. Christina Baik from Patient Empowerment Network on Vimeo.
In this START HERE lung cancer webinar, Dr. Christina Baik, Associate Professor of Medicine at the University of Washington and Fred Hutchinson Cancer Center, provides valuable insights into priorities for newly diagnosed patients. Dr. Baik also discusses essential tools for managing disease progression and recurrence.
Watch the program and download the guide for tips on creating an actionable pathway to optimize lung cancer care for yourself or your loved one.
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Lisa Hatfield:
Hello and welcome. My name is Lisa Hatfield, your host for this Patient Empowerment Network Start Here program where we bridge the expert and patient voice to enable you and me to feel comfortable asking questions of our healthcare teams. The world is complicated, but understanding your lung cancer doesn’t have to be. The goal of this program is to create actionable pathways for getting the most out of lung cancer treatment and survivorship.
Today, I’m delighted and excited to welcome Dr. Christina Baik, a distinguished expert in the field of lung cancer. Dr. Baik serves as an associate professor in the Clinical Research Division at Fred Hutch. She also holds the position of clinical research director of thoracic head and neck oncology at University of Washington. Additionally, she has an associate professor, or she is an associate professor in the Division of Hematology and Oncology at the University of Washington School of Medicine. We’re so happy she’s joining us today. It’s a pleasure to have you with us, Dr. Baik.
Dr. Christina Baik:
Thank you for having me.
Lisa Hatfield:
Okay. Before we dive into today’s discussion, please take a moment to download the program Resource Guide using the QR code. This guide contains pertinent information to guide you both before and after the program. In this program, we’ll provide you with a comprehensive update on the latest lung cancer news and its implications for you and your family.
Following that, we’ll launch into questions we have received from you. So let’s start here. Dr. Baik, can you speak to the latest news and priorities for the treatment of non-small cell lung cancer? And what are the notable advancements in understanding resistance mechanisms or novel therapeutic targets?
Dr. Christina Baik:
So it’s a good time to be a lung cancer doc, I would say, just because there’s so much in advances. We’re seeing different treatments be FDA-approved every other year, if not every year. So it’s really good to have all these options to offer our patients. Now the priority, however, is that not everyone is benefiting in an equal way from all these advances. And really the research priority, including my own personal research, is to really understand why some patients are benefiting and why some are not.
So, for example, in the immunotherapy world, which is a big advance we’ve had in lung cancer in the last 10 years, we know that some patients respond very well, some do not. Yet we give the same sort of treatment to patients. So one thing to understand is who are…and one thing I would say is we don’t personalize immunotherapies for our patients.
So one of the research priorities is to really understand where the different subgroups of patients who are going to benefit from this one treatment type…one type of immunotherapy treatment versus the other. So I would say that’s a big priority for me as well as for the field and all the researchers so that we’re giving the right treatment to the right patient. Now, there have been advances, I would say, in this theme in those patients who are able to receive a targeted therapy. So that is a type of treatment that we give to target the genetic abnormalities that exist in a particular patient’s tumor.
And these treatments work very well. But at some point, it stops working. But nowadays, there are certain sorts of resistance mechanisms as we call it. These are changes that occur in the tumor when a targeted therapy stops working. And we’re starting to understand better in terms of reasons for that and actually develop treatment options for those mechanisms of resistance. So I think we are starting to understand better, and I think we’re going to get there in terms of personalizing immunotherapy. But there’s still a lot of work to be done.
Lisa Hatfield:
Great, thank you. So just a follow-up question to that, when a patient is diagnosed with non-small cell lung cancer,is genetic testing always done on the tumor, or do patients know what their mutations are right upon diagnosis if testing is done?
Dr. Christina Baik:
So, as a rule of thumb, they should, all patients should be tested, and there are exceptions. So, for example, in lung cancer, there’s the type that we call small cell lung cancer, and there’s non-small cell lung cancer. So we often, we usually do not do genetic testing on small cell lung cancer, because often these tumors do not have a genetic abnormality that for which we can actually give treatment for.
But for non-small cell patients, I would say, if most, my personal opinion is that everybody should be tested with the genetic test and really advocate for that. You know, there are certain types of non-small cell lung cancer where there are genetic targets that are rare, however, you don’t know unless you test. So I would say yes to that question of testing for genetic abnormalities.
Lisa Hatfield:
Okay, thank you. So can you speak to the priorities for newly diagnosed patients, particularly populations who may have poor outcomes?
Dr. Christina Baik:
So, I think there are priorities when it comes to research, and then there are priorities for individual patients, right? So from a research standpoint, as I mentioned before, I think really the priorities, the priority is to develop strategies so that we’re truly personalizing treatment for each patient, and we’re not giving this kind of generic treatment for a bulk of the patients. So from a research standpoint, really understanding the biology, understanding what works for what patient, I think that’s extremely important.
On the individual patient level, we sort of alluded to this earlier, but really knowing the cancer we’re dealing with is extremely important. Know your cancer stage, ask what your cancer stage is, know the type of lung cancer that you have. So I will say as of now, there are, I can think of 12 or 13 different types of lung cancer that I want to make sure I know that patients, you know, what their subtype is.
So know your subtype of lung cancer. Ask those questions. If the knowledge is not known, if they say, “You know your stage is not very clear, your subtype is not clear,” then ask why that is, what type of additional testing that needs to be done. So I think those are the type of questions that each patient and their family member should really ask. And in terms of the poor outcome question, I think the first thing I would say is if a doctor tells you, you belong to a group of patients who are going to have a poor prognosis, then ask why that is, right? And understand the reasons for that.
And if that’s, once you understand, I think I’m a big proponent of getting second opinions, because a lot of these treatments and there’s a lot of medical judgment involved when we recommend treatments, and you just want to get a different perspective with the same type or set of information. So really being an advocate for yourself, I think that’s extremely important when you’re first diagnosed.
Lisa Hatfield:
Great, thank you. You mentioned two things I also feel strongly about, I don’t have lung cancer, I have a different type of cancer, but you said that patients and family members can ask questions. Having an advocate with you at all times, if that’s possible, a family member, a friend going with you, I think is super important.
And also getting a second consult to understand your diagnosis better. I appreciate you saying that, because some of us are a little bit reluctant to do that, maybe afraid of offending our doctors. So, I appreciate that as a patient myself, so thank you. Okay. So talking about disease progression and recurrence, particularly for metastatic non-small cell lung cancer, what should patients know?
Dr. Christina Baik:
Okay. So when a cancer initially responds to a treatment and it stops responding, there can be many reasons for that. So the first question to really think about is is there another test we can do to identify the reason for the progression? And can we personalize a treatment according to that resistance pattern or the change that occurs in the tumor? This is more relevant to patients who get a targeted therapy, but I think it’s a good sort of rule of thumb in terms of asking your doctor why that is, and is there more testing that’s required. And the second I would say is once the cancer progresses after the initial treatment, then, unfortunately, in lung cancer the treatment options are much more limited, and the effectiveness is very limited as well.
So, it’s really at that juncture to really seek out clinical trials. There are many trials that are out there. So really working with your doctor in identifying these trials. If there is an academic center that’s close to you, at least inquiring about that. In lung cancer, fortunately, there are many wonderful advocacy groups and these advocacy groups can be great resources in finding out about clinical trials and where to seek out opinions. So, I think it does require some homework at the time of progression but really seek those out.
Lisa Hatfield:
Okay. Thank you. Now, if a patient does have an interest in a clinical trial, say maybe they have, their cancer has progressed, would they seek out that trial through the academic center itself? If, say they live in a rural area and they don’t have access, would they contact the academic center itself, or would they seek out a specialist like you first to ask about those clinical trials?
Dr. Christina Baik:
So they sort of come together in a way, because a lot of the specialists are in academic centers. So I think there are two ways to go about it. One is to meet with the specialist who can give you kind of the landscape of where things are and what might be appropriate. So, that’s one way to do it.
The other way to do it is if there’s a particular clinical trial that you’re really interested in based on discussions with other patients or through advocacy groups, if there are particular clinical trials, usually the contact information is listed on the clinicaltrials.gov website, and the contact number is usually for the research team who can give you more information about that particular trial.
Lisa Hatfield:
Okay. That’s very helpful, thank you. And thank you for this overview. I just want to recap a couple of points that you made that’s really important for patients to know. You had mentioned knowing their type, their subtype of lung cancer, knowing their stage, and knowing their mutations and having an advocate. I think those are all really great tips that you gave. So thank you for that overview. It’s that time now where we answer questions that we’ve received from you.
Please remember, this is not a substitute for your medical care. Always consult with your own medical team, and, Dr. Baik, we have some questions here that people have sent in from patients. So I’ll just jump right into the first question. “What exactly is oncogene-driven lung cancer, and how does it differ from the other types of lung cancer?”
Dr. Christina Baik:
So in lung cancer, there are certain lung cancers where the growth of the cancer is dependent on a particular genetic abnormality. So there is one gene that makes that cancer grow. And because of that, there have been treatments that are developed against that particular genetic abnormality. So, it is referring to lung cancers that have that particular genetic abnormality. A prime example of this is lung cancers that have what we call an EGFR mutation. That means that there is this gene called EGFR that is abnormal, and that’s making the cancer grow.
Now, not everyone has a cancer gene that is driving that cancer. I would say about 30 percent or for 30 percent to 40 percent of patients would have an oncogene-driven cancer for which there may be treatments either as a standard treatment or in clinical trials. But the majority of patients do not have an oncogene, meaning that genetic abnormality where there is a targeted therapy option. So that’s the distinction we make. And I know this term or phrase is used a lot, but that’s what it means. And if you want to know if one has an oncogene-driven lung cancer, you would know based on the genetic test results.
Lisa Hatfield:
Okay. Great. Thank you. And just for clarification too, the genetic mutations are found in the cancer cells, not in their body, the cells? So that’s what the genetic testing is done just on the cancer cells. Is that correct?
Dr. Christina Baik:
Yes. Yes.
Lisa Hatfield:
Okay, great.
Dr. Christina Baik:
Thank you for clarifying that. That’s a very important distinction.
Lisa Hatfield:
Yeah. Thank you. So that leads right into the next question, and it’s kind of a lengthy question. And this person is asking, “Dr. Baik, you have done considerable research around EGFR exon 20 insertion mutations in non-small cell lung cancer, considering their association with poor survival outcomes, what are the survival implications of having EGFR exon 20 insertion mutations compared to other types of EGFR mutations?”
Dr. Christina Baik:
Now this gets a bit complicated, but not all EGFR lung cancers are the same. And there are patients who have what we call EGFR mutation that is a classical mutation. And I throw out that term, because that’s how it’s written on the Internet and a lot of papers. And then, so that’s one group, and the other group are patients who have this exon 20 insertion mutation. And the reason these are separated is because the treatments that work very well in the classical mutations do not work very well in this particular exon 20 mutation.
So when we look at all patients with EGFR mutation, it is true that the prognosis is poor in exon 20 patients just because there are no great targeted therapy options. That said, I am very hopeful that this is changing. There are a number of targeted therapies for exon 20 that are in trials, and I think these are going to be FDA-approved in the future, not too far off in the future, I believe. So I think the survival implications will start to hopefully equalize amongst all the EGFR-mutated lung cancer patients.
Lisa Hatfield:
Okay. Another question, Dr. Baik, from a patient, “For someone who is newly diagnosed with non-small cell lung cancer, what should be the top priorities in understanding and navigating treatment options, especially if I’m in a group that tends to have poorer outcomes?”
Dr. Christina Baik:
So the really, the priorities, when someone is first diagnosed, is really understanding what we’re dealing with and know what they’re dealing with. Now, if you don’t have all this information, I think it’s extremely important to ask. And if you get an answer that indicates that it’s not very clear, and they don’t know, then ask why.
And what are some of the follow-up tests that need to be done so that you can really know. So, I think really the knowledge is extremely important. One thing that I will expand on is that patients, when they’re first diagnosed with non-small cell lung cancer, they should get testing of the cancer, the genetic testing of the cancer to identify the subtype.
And often, it can’t be completed because there’s a lack of biopsy material. So that is often a common situation. So, if that’s a common situation, then ask, “Is there room for another test? Should I get another biopsy? Is there a blood biopsy that will be helpful in this setting?” So really be an advocate for yourself to complete the testing, because the treatment options are drastically different, whether there’s a genetic target in the cancer or not.
The other thing I would say in terms of poor outcomes is that, if you’re told that you’re in a group that has poor outcomes, I think the first question would be to ask why. “Why am I in that group? What makes…what about the cancer that makes it a poor outcome?” And I think this is a setting where you do want to especially get a different opinion potentially just so that the other doctors also agree that you’re in that group. And if so, are there other treatments outside of the standard treatments that you can take advantage of so that it could potentially work better?
Lisa Hatfield:
Okay, thank you. So this patient mentioned that they are newly diagnosed. And I’m wondering if you can just in really general terms explain what treatment and monitoring might look like. For example, how often might this patient have to come in for treatment? What type of monitoring might be done? I know it has to be really general because every patient is so different. But can you just give a really kind of a high level overview of what that might look like for a newly diagnosed patient?
Dr. Christina Baik:
Yes. So I can speak for patients who have advanced non-small cell lung cancer, which is, unfortunately, still the majority of patients who are newly diagnosed. Most of them have advanced or metastatic lung cancer, meaning that the cancer has gone outside of the original area to other parts of the body. In those settings, if there is a genetic target on the cancer, often the treatment is a pill, which is great. And often, they are fairly tolerable, of course, there are exceptions, but for the most part it is a tolerable type of treatment. So for those patients who have a pill option and they’re tolerating it well, the pills are taken at home, right? They don’t have to come to a hospital for that.
Initially, at least in my personal practice, we do see patients fairly often just so that we can make sure the side effects are being managed and patients are doing well. So initially, it might be every other week type of visits for the first two or three sort of first visits, so the first month or two may be more frequent. But once we get to a point where the treatment is working and side effects are manageable, then I’m essentially seeing them every three months, and they can go. I have patients who travel internationally and just come check with me every three months or so.
So that’s one type of monitoring that we do and in this setting, we would get imaging often with CT scans, every three to four months or so, that number is not exact, there’s no science behind that three to four months. But we would…the point is that we will monitor the cancer using imaging, often with CT scans every three to four months in that setting. Now, and I do want to emphasize that that’s my own personal practice, every doctor does it a little bit differently in terms of intervals. Now, for patients who do not have a targeted therapy option, meaning there’s no pill option, then often patients are receiving some form of infusional treatment. And the infusional treatments vary in terms of the frequency. So some treatments are every three weeks, some are every four, some maybe every six.
Lisa Hatfield:
Okay, thank you. That’s helpful. So another question, which is a big concern for many patients, I’m sure. “What signs should I watch for that might indicate the cancer is coming back or progressing? And what steps can I take if I notice any concerning symptoms?”
Dr. Christina Baik:
Right. So the signs are often difficult to identify, mainly because the symptoms can be very similar to kind of normal symptoms, meaning so, for example, one thing we watch out for is back pain, for example, because we worry that the cancer may be going into the bone in the back. However, many of us have back pain chronically, so often it is difficult to tease out what’s what. That said, what I tell my own patients as a rule of thumb is if anything is persisting, so, for example, you have your usual back pain, you know that typically after some rest and some exercise it usually gets better after about a week. The severity may fluctuate a little bit, but most of muscle back pains will change or lighten up after some time if you strained it.
But if there’s a particular pain in a particular part of the body that is just not going away, that’s something to watch out for. Same thing with symptoms like cough, right? So I’ve had many patients who are diagnosed after COVID, where they would have this persistent cough after COVID, but they sort of blamed it on COVID and after a while, since it was not going away they sought medical care. So same thing there, if you had a viral infection, over time the cough should get better.
And if it’s not or if it’s getting worse, then we really have to…really need to investigate the reason for that. So anything that’s persistent, I would say that’s when you want to alert your team. What I tell my own patients is that just tell us, and we’ll figure it out for you or with you. Don’t try to kind of figure it out on your own. I do notice that I do have some patients who tell me that they feel bad about calling and “complaining,” right? And we tell them it’s not complaining, you’re just reporting to us, and we tell you it’s nothing to worry about just watch or something that you need to come in for. So really work closely with your oncology team.
Lisa Hatfield:
Okay, thank you. Well, that’s all the time that we have for today’s Start Here Lung Cancer program. Dr. Baik, you’ve been a phenomenal guest, thank you so much for sharing your experience and expertise with us.
Dr. Christina Baik:
Thank you so much. It’s been great.
Lisa Hatfield:
Yeah, we really appreciate your time. And thank you all for tuning in, it’s these conversations that make a world of difference for patients and their families, particularly when we can hear it from researchers on the ground floor. I’m Lisa Hatfield, and I’ll see you next time.
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How Can We Leverage Lung Cancer Biomarker Data to Address Health Disparities? from Patient Empowerment Network on Vimeo.
How can biomarker disparities be overcome by data collection? Experts Dr. Joshua Sabari from NYU Langone and Dr. Eugene Manley from SCHEQ Foundation discuss the status of biomarker data sharing, biobanks, and improvements that can be made toward the future.
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Lisa Hatifeld:
Are there any national or international databases that collect information from those biopsies, like a biopsy data bank of some kind so they can look at this disparate group of mutations? Or is it just institutional, like if an institution collects that tissue, they keep that information? I’m just wondering if that could help in any way with the disparities we see in those biomarkers.
Dr. Joshua Sabari:
Yeah, it’s a great question. AACR American Association for Cancer Research, a nonprofit, has started a biobank called the Genie Biobank, where you can input clinical as well as genomic information from patients. But to be honest, it’s very scattered. I mean, most of the databases that we have are individual institutions. There is very little sharing of data from institution to institution. There’s very little sharing of data from pharmaceuticals to institutions and vice versa.
I think everybody really needs to work in and pitch in together here that this is a common theme that comes up at a lot of our national meetings is how do we get everyone on the same page as opposed to everybody working in their different silos. It would be very helpful if all genomic data at every institution was available to everybody, but you can understand how that could be both confidential as well as proprietary. So, unfortunately in 2024, we don’t have broad biobanks or databases that are available publicly for consumption of investigators.
Dr. Eugene Manley:
And I think on top, beyond there not really being a massive biobank, there are still differences in what we can capture in race/ethnicity in the U.S. versus Canada and Europe. Sometimes they don’t even consider race as a category, which sometimes people think race is a social construct, but at the same token, there are distinct disparities we see in the U.S., because we capture this data, and it’s hard to then do this globally when we aren’t able to capture all it does.
But if you think about it, if you look across there are even genetic differences across each of those countries, we just don’t routinely think about it. So it’s really, we need to work on developing one, but it takes time, money and groups willing to work together, and we just, unfortunately, are not there yet.
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