‘It's a Big Deal’

lung cancer: lung cancerIn the 1980s, a group of surgeons and oncologists joined forces, calling themselves Lung Cancer Study Group. The group collaboratively studied lung cancer, creating their own protocols and recruiting patients from across the country into large trials. Their studies were influential, cited thousands of times. But eventually, the group disbanded after losing funding—the idea of the group lay dormant for years. “Lung cancer just became part of collaborative groups,” said Harvey Pass, MD, Division Director of General Thoracic Surgery and Surgical Chief of Thoracic Oncology at NYU Langone's Perlmutter Cancer Center. Knowledge of thoracic surgery hasn't stalled in the years since, Pass noted, but surgeons have been “silent witnesses” in their collaborations with medical oncologists. In 2017, the idea behind the Lung Cancer Study Group was resurrected. The Thoracic Surgery Oncology Group (TSOG), sponsored by American Association for Thoracic Surgery, was formed with the goal of becoming a network of thoracic surgeons performing clinical trials at universities across North America. Recently, the group expanded from nine to 25 sites, including the recent addition of Pass's institution, the Perlmutter Cancer Center at NYU. So far, TSOG has opened three trials and is currently recruiting patients. The overarching goal of TSOG is to better understand thoracic oncology diseases and improve patient care by performing trial studies across its member sites. TSOG will recruit patients into trials led by thoracic surgeons, focusing on recent advances such as immunotherapy, precision medicine, and intraoperative imaging. The group will perform phase I and II studies, window-of-opportunity trials with corrective analyses, relevant registry studies, and multidisciplinary study designs. Pass noted that the group will also do some exciting work on new agents, as well as validating certain kinds of thoracic surgeries. “It's a big deal,” Pass said. “Unless you have really forward-thinking individuals that want to collaborate and work with people, it takes a lot of work to be able to get people together. ... By definition, we'll collaborate with each other on projects that they're able to add value to. That's completely different than what we've had in the past.” David Jones, MD, Chair of the TSOG and Chief of the Thoracic Surgery at Memorial Sloan Kettering Cancer Center, said the advantage of having multiple sites collaborating is that the group can more rapidly accrue patients, getting faster results than they would as a single site or a one-off collaboration. Thoracic cancer research didn't fall behind in the years without this kind of group effort, he says, but less collaboration means that the learning process was likely slowed. With TSOG, he hopes to speed up the learning process. “In the near term, we want to make sure that these trials that we open are accruing, which means patients are starting these trials, that we can quickly complete enrollment, then do the analysis and publish the work,” he stated. “Longer term, I think we want to have more sites, probably collaborate more with medical oncology, radiation oncology and with industry. We want to just build it out and make it more robust.” Currently, other member sites include Duke University, Mayo Clinic, and University of Toronto. Jones hopes to add an additional 5-10 sites in the next year. For new institutions to be considered for the TSOG, they must be high-volume centers for thoracic oncologic procedures that focus on lung, esophageal, and other thoracic malignancies. Potential member sites must also show that they're financially stable and have an infrastructure that will allow them to actively participate in and complete clinical trials led by expert thoracic surgeons. “You have to have a central core of investigators who have the interest to do this,” Pass stated. “And they should be, at least at this point, a fairly large volume academic institutions that have a track record of at least applying for and getting grant funding.” The Most Exciting Trial Both Jones and Pass say that they're excited by a current TSOG trial that is examining the use of circulating tumor DNA as a biomarker for predicting residual disease after chemotherapy and surgery. No longer silent witnesses, studies like this give thoracic surgeons the ability to examine new cancer treatments to figure out what happens to the tumor as the treatment progresses. Instead of looking at CT scans to see whether the tumor is back, Jones says that they may be able to know if it's back by looking at a blood test. “It's very amazing technology,” he noted. “And we just need to see if this use will be helpful here.” Surgeons will be able to give patients the new agent before they operate, Pass says, comparing preoperative and postoperative biopsies. “You can study the mechanism from the pathways that are affected by the drug,” Pass stated. “A surgical trial that looks at those mechanisms would be very useful to figure out how the drug works and how to make it even better.” Pass believes that the trails the group works on must answer a clinical question and provide materials to scientists interested in further study. “I'm most excited to see what the new proposals are,” he noted, “to see whether the proposals that will be accepted will be doable. In other words, you cannot be too ambitious, because if you've become too ambitious, you may not be able to accomplish the task.” But Pass also believes that TSOG will be able to answer important questions that have clinical relevance that involve science at the bench. And it will be easier for everyone to have surgeons leading these studies. For example, in trying to validate a tumor through biomarkers, Pass says that there's no one better to get blood samples before and after a surgery than a surgeon. “And that involves collaborating with the scientists who develop that biomarker, whether they're in or out of the system,” Pass said. “That opens up a wealth of possibilities, both for the scientist as well as for the clinician.” Both Pass and Jones are also excited about the infrastructure in place and potential for new technology, but both want to be sure the technology will work for everyone in TSOG. “If only two or three people can do it, that defeats the purpose of the whole group,” Pass stressed. “It needs to be something that is common, relevant, and can be answered quickly. And that would be a great project.” Hal Conick is a contributing writer.

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