SECTION 1 – The current state of UK lung cancer care

SANJAY POPAT:
Well, hello everyone, and welcome to this special edition of Lung Cancer Sessions hosted by Video Journal of Oncology. My name is Sanjay Popat. I’m consultant medical oncologist at the Royal Marsden Hospital, and I’m joined with my colleagues today with three experts in the field of thoracic malignancies, and we are going to be discussing a, the fallout of the BTOG annual meeting.

We have three experts here today, my colleague, Professor Robert Rintoul, who is a thoracic respiratory physician at Cambridge, my colleague, Dr. Anna Minchom, who is a thoracic medical oncologist and Phase one doctor at the Marsden, and my colleague, Dr. Alastair Greystoke, who is at the Northern Cancer Center in Newcastle, who is also a thoracic medical oncologist and Phase one expert.

So as ever, there’s a lot going on in the world of lung cancer, and we’ve just come back from a very exciting, albeit virtual BTOG 2022 meeting, and I just wanted to start by talking about the highlights, and for me, one of the highlights has been led and spoken to by Robert at the annual meeting. Robert, at the annual meeting in the opening session, my colleague Neal Navani talked about the state of lung cancer in the UK. One of the great credits we had in the UK is very good data capture, and we’ve had the National Lung Cancer Audit Report, which really showed the impact of COVID. I don’t know if you can speak to a bit about that, what it showed and the current status of lung cancer, Robert.

ROBERT RINTOUL:
Yes, thank you very much, Sanjay. Well, indeed, as we know, it’s been an extremely difficult two years in many areas of life, and lung cancer is no exception. We were aware early on in the pandemic at the beginning of it, back in early 2020 in wave one, that there was a big reduction in two week wait referrals, urgent referrals for lung cancer, and of course, many cancers, in fact, but lung in particular was badly hit. Many of the symptoms that people have with lung cancer were similar to the symptoms that they might have with COVID, such as a cough, feeling unwell, and so on and so forth. People were very good at taking advice initially, stay at home, protect the NHS, et cetera, and we immediately, very rapidly knew in the early months of 2020 that this could have a big impact on lung cancer, and we saw a big, say a big reduction in referrals, you know, 50, 60, 70% in some areas, and when we did start seeing people later in the year, we were seeing more people with more advanced stage disease. And in fact, the statistics from that year show that there were many people who were missing completely from the records, and we suspect may have died with lung cancer, but may have been labeled as having COVID, or may have had both, of course.

So this data that’s recently come out from the National Lung Cancer Audit has in fact, unfortunately, confirmed many of our fears. The National Lung Cancer Audit this year did their, used their data in a slightly different way. They used the rapid registration dataset, which is very dependent on C O S D data. It wasn’t quite as complete a data set as we normally have. They recognized that. It was done by a fantastic team under really difficult circumstances collating the data, but the rapid registration data set does give us data much more quickly than we previously had, although it is cleaned, and carefully curated. Normally the NLCA data may be 18 months or so behind, but this data was much newer, so we were seeing data for 2019 and 2020.

Just to give you some headline figures, prior to the pandemic, things were continuing to improve. For instance, the one-year survival of patients in England and Wales in 2019, immediately prior to the pandemic was about 40.7%, and that had gone up from 39% in 2018. So we knew things were on the up, and they have been on the up for one, three and five-year survivals over the last 10 years or so. But unfortunately, what we are seeing in 2020 is a big drop in the curative treatment rates for early stage, good performance status patients. So in 2019, patients with early stage disease, performance status one and two, about 81% were being offered treatment with curative intent, and that fell to 73% in 2020. And also in 2020, we saw a drop in the surgical resection rate. It went from 20% down to 15%, and of course, our big concern is that this, the ramifications of these drops will play out over the next few years in poorer outcomes and survival. And again, compared with 2019 data, in 2020, patients were appearing with poorer performance status. They were more likely to be diagnosed through an emergency presentation, and less likely to have histological diagnosis. And this data was really mirroring and confirming what many chest physicians and many oncologists up and down the country has been, have been seeing.

SANJAY POPAT:
So this is a huge issue, and, you know, Anna and I, you know, we’ve seen this in our center, and we’ve seen more patients with stage four disease coming through. I’m sure you’ll agree. Has it been the same in the Newcastle area, Alastair?

ALASTAIR GREYSTOKE:
Yeah, so, you know, I think we’ve seen what people describe as a stage shift, so more patients presenting with stage four disease, a performance status shift, and what a number of centers have reported both in this BTOG and last BTOG was more patients presenting with symptomatic brain metastasis, which obviously limits our treatment options as well.

SANJAY POPAT:
Certainly does, and Robert, you chair the Clinical Council of the UK Lung Cancer Coalition, and your solo report, 25 by 25 surmised a number of proposals to try and improve this. Do you wanna just highlight, you know, the top things that you think we can do?

ROBERT RINTOUL:
Yes, absolutely. So if we rolled the clock briefly back to the beginning of this century, as it were, at that time, the five-year survival rate for all-comers from lung cancer was about 7 or 8%. By 2016, we got that up to about 16%, so more or less a doubling. And at that point, in 2016, the UK Lung Cancer Coalition published a report called 25 by 25, which is an ambition to push up five-year survival from lung cancer to 25% by 2025. And immediately prior to the pandemic, our estimated five-year survival outcomes was running at about 17.9%, so again, a steady trajectory in the right direction. We fear that as a result of the pandemic, for people diagnosed during the pandemic, that survival rate may have dropped by up to five percentage points.

So we have put together a report recently, published very recently, called Route Back to 25 by 25, which as you say, is guidance on how we can get back, and there are 10 points. I’m not gonna go through all of them, but one of the ones I will, I’ll pick out one or two things.

We feel that, probably the one thing that we can do to improve survival for lung cancer going forward, across all four of the UK nations, is to put in place a CT lung cancer screening program. We know that CT screening for lung cancer works. Very large trials, most recently the Nelson trial, have demonstrated that, and there’s the UK Lung Cancer screening study, which has also just done a meta-analysis with other studies, and again, confirming this survival benefit. So there’s currently being looked at by the National Screening Committee. We have had the recent rollout of total lung health checks, but that, above everything else, we think is the main thing we can do.

The other important things, just briefly, are awareness campaigns. Awareness campaigns work. They’ve been demonstrated to work. They’re a bit ad hoc at the moment, but we need regional and national sustained, probably every six months campaigns to help encourage people who are at risk to go forward for screening. And another idea that is being suggested is to have a dedicated help line, where people can ring, and say, “I, or my loved one, or family member have worrying symptoms, might they have lung cancer? What should I do, what should we do?” And again, this is being put forward as one of our suggestions.

There are a number of others we might come back to with around advanced disease, and also workforce. I’ll just mention workforce briefly. The workforce, you know, has taken a real battering in the last couple of years across the NHS, all areas of the NHS. Again, it’s difficult to single out one area when we’ve had such a difficult time, and people have rallied so well, and put in so much extra time and effort. But even prior to the pandemic, we knew that maintaining the workforce within the Lung Cancer MDT was gonna be challenging going forward. The MDT is yes, chest physicians, radiologists, pathologists, oncologists, clinical nurse specialists, and many other coordinators, administrators, and so on, are complex interactive teams, you know, often have got to into their positions after many years of experience, and we need to ensure that there’s plenty more people coming up behind them being trained in order to take the place that we, you know, currently hold in our MDTs. So workforce issues going forward have been a big issue, a big sort of ticket agenda, and it’s only been magnified because of the pandemic, so we’ve really got to address this.

SANJAY POPAT:
I totally agree, and I’m really pleased to see your report, and I really do hope that that helps stimulate a package where we can really improve the current status that we have. And of course, it’s not just service that has had problems with workforce, but the research workforce has also been decimated similarly, and in the first wave, as we all know, research essentially stopped, other than patients that were already on investigative medicines to maintain their safety. And Annie you’ve been involved in a lot of research, and you’re an expert drug developer, as well as the thoracic oncologist. We’ve seen, in your field, huge not only impact, but huge benefits from the outputs of your research with the immune checkpoint inhibitors totally transforming the face of stage four disease. And perhaps Robert, maybe some of that stage four impact of immunotherapy may come through to the five-year survival rate at some point, as we’ve seen in the US data.

SECTION 2 – Novel IO targets & therapeutic cancer vaccines

SANJAY POPAT:
Anna, I wanted just to ask you about immune checkpoint inhibitors. You know, the PD-1, PDL-1 inhibitors have totally transformed our clinics, and you know Robert, you said in BTOG that you were getting letters about your patients that were still doing well many years after, which is really lovely to hear. So Anna, what are the new kids on the block? You know, there’s so much hype going on with immune, new novel immune checkpoints, you know, what should we be looking out for?

ANNA MINCHOM:
Yeah, well, BTOG is a really great opportunity to review what’s coming through, and as you say, maybe flag up a few contenders that might be changing practice over the next years, as well as look at new trials that are opening up in the UK in the research setting. I think if I was gonna pick two contenders that will be making waves over the next years in terms of targets, it would probably have to be TIGIT and LAG-3.

And TIGIT is an inhibitory molecule found on T cells binding to CD-155 on cancer cells, and the front-runner in terms of TIGIT targeting is tiragolumab. So a lot of people might be familiar with the CITYSCAPE data that was presented last year in ESMO IO, which randomized, Phase II randomized, compared to placebo in combination with atezolizumab. It was a reasonably large trial of 130-odd patients, and was striking in its OS and PFS benefit seen, which was statistically significant, but only in the PDL-1 and greater than 50% group. So it will be very interesting to see that data coming through further. There are some, several interesting points about tira, first is that it seems to be well-tolerated, you know, in comparison to the placebo arm, it was very similar rates, of treatment-related adverse events, and that’s certainly not been our experience with other novel combinations using PD-1 and PDL-1 as a backbone. So tira is one to watch. There’s lots of combination trials ongoing, both in the non-small cell space, and the small cell space as well, but that’s not the only TIGIT-targeting molecule. There’s others, which vary in terms of their drug design, subtleties of monoclonal antibody design and structure. So there are other ones coming up further behind, and we’ll see if they, if any of them are a contender, and fight for the TIGIT space against tira.

The second molecule second target is LAG-3. This is a marker expressed in exhausted T-cells, and we haven’t really got any direct lung data, but often we find that drugs developed in melanoma have this translation to lung, lung and melanoma really being the poster children of IO, IO targeting…IO drugs, and there’s an interesting drug, relatlimab, which has been investigated in melanoma, in a first-line setting RELATIVITY trial. There was a PFS benefit seen, and we will hope to see, that the ongoing trials of relatlimab in non-small cell, which are coming through, whether they will replicate these effects in non-small cell lung cancer, so a little bit further behind development, but certainly one to watch.

SANJAY POPAT:
And, you know, the, I see a lot of activity with both of these targets going on. I’ll bring Alastair into the conversation. Alastair, you’re a fellow drug developer in Newcastle. So are these really gonna pan out, do you think? I always say that, you know, melanoma’s a good weather child, weather vein of what’s going on in terms of immune sensitivity, but we’ve been here before in the IO space.

ALASTAIR GREYSTOKE:
Yeah, yeah, indeed.

SANJAY POPAT:
And IO was huge, and then it just, you know, suddenly disappeared. So what, what are your thoughts in the excitement that we should be garnering for these two targets? Should Robert be really quite excited, or is this not really, you know, one thing to bother about yet?

ALASTAIR GREYSTOKE:
So I think these are important agents coming through, in that they may help nuance where we go with checkpoint inhibitors looking for either slightly better efficacy in the high PDL-1 tumors, or may be regimens that use combinations of checkpoint inhibitors that may have less toxicity than some of the ones that were explored in melanoma, like CTLA-4 combinations. To me, I still think looking at these checkpoint inhibitors probably is not going to be the most suitable approach of using the immune system for all lung cancers. You know, we need better biomarkers to work out which ones it is. You know, we use PDL-1 high at present time, but even if you just use PDL-1 high, that leaves two thirds of our patients where we’re using chemotherapy-immunotherapy combinations to try and maximize the benefit from immunotherapy, and we still know that the majority of these patients will progress, and then we’ve got really limited options. And a lot of these come forward to Anna and I, and I think this is an area where we’ve still got a lot of drug development to do, quite frankly.

SANJAY POPAT:
And one of the areas that we heard about at the BTOG meeting is the development of vaccine technology, and, you know, this has totally transformed all of our daily lives with the COVID vaccine, especially the RNA therapeutics, and I understand, Anna, that there’s RNA vaccine being developed against cancer, which is being led by Cancer Research UK. Can you speak to that at all? Is this something that we are excited about, or is this another flash in the pan?

ANNA MINCHOM:
I think it was very interesting to hear about this. This was news to me as well in BTOG, and so really interesting to see Professor Fiona Blackhall presenting on that. So this is a CRUK sponsored Phase I/II study, and it’s of a cancer, therapeutic cancer vaccine, rather than a preventative cancer vaccine. It’s a viral vector, and it’s a viral vector containing DNA to cancer-specific antigens. There’s two viral vectors that are being used in this study. One is ChAdOx1, which is chimpanzee adeno Oxford one virus, which is the same virus back used in the AZ-Oxford COVID vaccine, so that’s interesting. And there’s a second vector, which is an MVA vaccine, which is a inactivated pox vaccine. There’s two viral vectors, there’s, and they have put two, two antigens, NY-ESO-1 and MAGE-A3, and these are interesting targets, ’cause these are CTAs of cancer, cancer/testis antigens, which are antigens which are, have high specificity to be expressed on cancer cells, but expression is variable, so I think it’s less than 50% of non-small-cell express MAGE-A3, and less than that NY-ESO.

So interesting scientifically, but also a practically very interesting trial, and it’s got quite a pragmatic design. Patients with diagnosed non-small-cell lung cancer, going onto first line therapy with chemotherapy immunotherapy are pre-screened in the first cycles of their systemic treatment to see the expression of the MAGE, MAGE expression, and if they meet the criteria to go on trial, they are randomized to start their vaccine, or not start their vaccine at cycle three. So that’s interesting, because it is, it’s very challenging to get patients on for a pre-screened protocol which relies on tissue testing in a short period of time, so this is a way of getting these first line patients onto a trial. As to whether it will work or not, well, that’s why test is being done. That’s why the research is being run in this way. But certainly, these are CTAs that have, are being investigated in multiple other settings, given their specificity to cancer cells, and also this is using, you know, very well-developed vaccine technology, which has really developed hugely in the last 10 years or so, so yeah, I look forward to seeing this trial of great interest.

SANJAY POPAT:
So great excitement, and I guess it’s perhaps maybe one of the jewels that comes out of the COVID pandemic is the ability to bolt on additional targets of using this viral vector. And Alastair, are you excited about this as well, or is this strategy of vaccination really one that we’ve been dabbling with for a while, and it never really panned out, so we should be a bit skeptical? You know, where do you sit on this fence?

ALASTAIR GREYSTOKE:
Yeah, so 10, 15 years ago, I was incredibly skeptical about vaccination and very recruited to some of the studies that unfortunately were negative, but I think there’s been a step change in the technology, and we saw that, you know, with the rapid production of the AstraZeneca vaccine, although, this study was being planned well before that use in the pandemic. So you, you know, I think the approach is very interesting, the use of the two different vectors, the use of the two different antigens. I think it’s one to watch with interest. I think either way, we’ll learn a lot, both in terms of looking for the clinical efficacy, but also how to actually run some of these vaccine studies. And as Anna said, it’s a really pragmatic design, and one that we might use, if this one doesn’t work well, maybe for future vaccines coming forward, but I really hope this one does work.

SANJAY POPAT:
Yeah, and so we’ll keep an eye on that very interesting space.

SECTION 3 – Deployment of genomic testing in the UK

SANJAY POPAT:
And the other area that is really happening in the UK is the deployment of genomic technology. Genomic medicine is a key strategy for implementation in NHS, by NHS England at the very least, and I’m sure similarly by the other devolved nations, and Alastair, you’re strongly involved in the implementation at your genomic laboratory hubs, so just give us a brief overview of the changes in genomics, and where we are in the different parts of England with the genomic testing landscape.

ALASTAIR GREYSTOKE:
Yeah, so the genomic laboratory hubs have been a long time coming, and unfortunately, were delayed. You know, they came out of a very, an aspiration from NHS England to reduce the postcode testing for genomic testing that was happening around the country with different patients getting access to different tests. And it was recently planned to sort of be implemented around about 2017, and it got delayed, and unfortunately, it came in in just around about 2019, just as we were about to go into the COVID pandemic.

In brief, what has happened is that all genomic testing within England has been organized into seven genomic laboratory hubs that are responsible for providing all the genomic testing for all cancers, and this is particularly important for lung cancer, as we seen over the last few years, a huge range of potential targets coming through that we can now target. And we heard a lot about this in BTOG, so, you know, 10 years ago, it was just about testing for EGFR, and then ALK came along, and people sort of bolted on an immune history chemistry, but we’ve now realistically got, I think, Dr. Shah pointed out nine FDA-licensed biomarkers, which we could potentially access either NHS treatments, or trial treatments, or compassionate access, or early access schemes. And the only way that we are going to be able to do that for our patients is using next generation sequencing using some form of panel approach.

SANJAY POPAT:
Yeah, I think I agree with your conclusion on that. I dunno if you caught it, but our fellow, the Dr. Hazel O’Sullivan and our team presented some EGFR data basically, just simply showing that if you use NGS, you pick up a whole load of different mutations, which you’ll just miss if you use a traditional EGFR single EGFR testing approach. I’m sure you have similar data, Alastair, in your laboratory. But to me, that highlights really, we need to go away from this single gene testing, and really start doing next generation sequencing. Is that your thoughts as well?

ALASTAIR GREYSTOKE:
Yeah, so we have to be doing multi-gene testing, you know, you just can’t treat your patient correctly without the information. So what we now need to do is to just accept that we need to do that, and work out how we can do this in the timelines that are set within the optimal lung cancer pathway, okay? So the first thing is to accept that, and then to work out how we can do it, and unfortunately, as I said, the reorganization of the genomic laboratory hubs happened at the same time as COVID. That led to problems with staffing, led to problems with reagents. There was also this aspiration within NHS England that we should be moving all cancer patients to large panels, probably irrespective of tumor type, and that this would be the most cost-effective and time-efficient way of doing that, and I think that leads to challenges in lung cancer. A lot of patients don’t have adequate tissue for a large panel approach, and so I think we need to look to see whether we can realistically get a large panel for most of our patients, or whether we should be thinking about a small, rapid panel that can give us the data that we need very quickly. Still has to be next generation sequencing, and maybe thinking about a large panel for the research approach, or later on, if we don’t find anything in that small panel. One of the other things I guess we might want to talk about is the circulating free DNA analysis, and how that might fit into the pathway. I dunno if you want me to go into that just now.

SANJAY POPAT:
I mean, that’s not unreasonable thing to say, so liquid biopsies, I mean, you and I have discussed this several times. They have their pros and cons.

ALASTAIR GREYSTOKE:
Yeah.

SANJAY POPAT:
You know that I’m a great fan of them. I think many of us are great fans of them, recognizing their limitations. The key issue is, you know, where do we go with this? And how do we implement them in the UK? What are your thoughts, Alastair?

ALASTAIR GREYSTOKE:
So the, you know, I think we saw some nice data showing that circulating free DNA or liquid biopsy can pick up these abnormalities, and the number of the drugs coming through, including one that was presented at industrial symposium had prospective data on patients just picked up on circulating free DNA. So we know it works, okay? There’s no technical issues in terms of the sense, in terms of the commercial providers, so there’s a number of commercial providers out there who will do this routinely and have FDA-licensed biomarkers. The problem is that the genomic laboratory hubs, as part of everything else going on, haven’t had time to fully validate this technology, and in particular, at present time, I think we all accept they’re struggling to pick up the fusions, the orogenic fusions, the ROS, the RETs, the ALKs, and these are some of the most important targets that we don’t want to miss in the first line setting.

So what we need to do now is a couple of things. So number one is we need to work with the commercial providers, probably to embed the pathways in, to get used to reading these complicated reports, getting used to understanding when we might see a false positive, when we see the false negative. At the same time, we need to be getting our genomic laboratory hubs up to speed, so that they can do this analysis for us, and that we can send a blood sample to our local laboratory, and they can, at the time that somebody’s presenting with a stage four cancer, and when they’re seeing the chest doctor, and that we can get the results back of a molecular testing by the time they’re first discussed at MDT. That’s the way we need to get forward, and that’s how we’re gonna improve the care of stage four lung cancer, or one way.

SANJAY POPAT:
Yeah, I totally agree with that, and I think, but you know, part of that is a relationship, I think, that the diagnostician has with the pathologist, and I’ll bring Robert to this as well, because you know, to run tissue NGS, we’ve gotta have adequate tissue going into the pipeline, which means that there’s gonna be enough of a discourse between, in this case, the respiratory physician, perhaps doing EBUS, or deciding between EBUS and a lung biopsy, and a pathologist, and having that interplay, so that pathologists can feed back, you know, the adequacy of the specimen, which then goes to the NGS lab. Robert, how do we improve things in this two-way, or even sometimes three-way discourse?

ROBERT RINTOUL:
Absolutely, you’re quite right, Sanjay, and I think you’ve hit the nail on the head there by saying the key thing is communication. I think many chest physicians, historically, who have taken, for instance, bronchoscopic biopsies, have never, many of us probably don’t understand, or don’t appreciate how few cells a pathologist may be making a diagnosis on. What the chest physician hears in the MDT is the biopsy from the right upper lobe showed squamous cell carcinoma, tick, job done. What he or she doesn’t hear is, “You sent me an appalling sample, a few scrappy bits. I did multiple sections through it, and eventually I found a cluster of 15, you know, atypical cells, and I could just about see some intercellular bridges, and so on, and I’ve called it squamous cell carcinoma.” So one thing I always teach my trainees is to get them to go and spend some time with the pathologist, and follow some biopsies through. So I’ve sent chest physician trainees in the past with samples from my bronchoscopy list or EBUS list, take these to the pathologist yourself, and spend the next day or so following through the pathway, and seeing what happens them. And of course, we’re now putting huge, not only increasing numbers of immunos on panels, particularly if it’s a difficult diagnosis, and then all the requests for the molecular work as well, and PDL-1, and so forth.

So this dialogue to understand what’s required, we now routinely and have been now for a long time, in my center, taking extra biopsies. Of course, you can’t tell immediately in the room how, you know, how good your samples are, but it is very important to get constant feedback. Yes, often in medicine, people want to do things, either through a smaller and smaller incision, or with fewer and fewer biopsies, and I’ve seen papers and publications, you know, abstracts coming out saying, “Oh, we can, we only need to do one pass with EBUS now to get the diagnosis. Why are you wasting time with three or four?” In fact, I’m going in the opposite direction, and giving five or six, because if a pathologist comes back to me and says, “Robert, sorry, I can’t do all the work required. You need to go back and re-biopsy that patient,” putting this poor patient through another EBUS, which is not, you know, they’re not particularly pleasant procedures, however good you are at doing them, is just not fair on the patient, and if it’s for an extra 10 or 15 minutes in the room at the time, it’s an extra biopsy, so it’s really, really important. And the same goes for my, you know, colleagues in radiology doing CT-guided needle biopsies. They’re always worried about pneumothoraces, and hemolysis and so on, but taking those extra biopsies downstream can pay huge dividends, so I think we’re getting there. I think that the, there’s recent work I’ve seen on people looking at EBUS samples, and for, you know, quality control for molecular testing, and I think that message is getting out there now.

SANJAY POPAT:
I totally agree, and I think, you know, we’re coming to together more as a diagnostic, and pathology, and oncology, and genomics community, really, just trying to map out what we need to do to provide the best samples for our pathology colleagues, to then result in the best samples for molecular analysis, to then result in the best genome study, then to result in the best information, because at the end of the day, this used to be stage four disease, but, you know, Robert, we are now talking about EGFR mutations in the adjuvant setting, and on the Friday of BTOG, we heard about PDL-1 positivity, and the approval for adjuvant atezolizumab as well for our patients. So biomarkers are coming to the radical setting as well.

ROBERT RINTOUL:
Yes.

SANJAY POPAT:
And I honestly don’t think it’ll be long before we are doing a NGS, you know, needing to do NGS for many different biomarkers in patients that have had resections, or even perhaps in the new adjuvant setting.

I’d like to thank all of my colleagues for your excellent contributions. We’re coming to the end of this session. I think we could go on for another half an hour with lots more to deep dive into, and I’d like to close by thanking my colleagues for their time, and their expertise, and their wisdom, and thanking the audience for listening to me, and thanking our hosts at Video Journal of Oncology for hosting this post-BTOG Lung Cancer Session, and I hope you found this of interest, and look forward to chatting to you about other details in the thoracic malignancies field at another meeting at another time. Thank you, and goodbye.

[END]

Recording date: 02-Feb-2022; Webinar broadcast date: 09-Feb-2022; Feature publication date: 10-Feb-2022.

Sanjay Popat

Personal financial interests:

• • Consultancy/Honoraria: Amgen, AstraZeneca, Bayer, BeiGene, Blueprint, BMS, Boehringer Ingelheim, Daiichi Sankyo, Guardant Health, Incyte, Janssen, Lilly , Merck KGaA, MSD, Novartis, Roche, Takeda, Pfizer, Seattle Genetics, Turning Point Therapeutics, Xcovery
  • Leadership: Nil
  • Stock: Nil
  • Licencing: Nil
  • Direct funding: Elsevier

Institutional financial interests:

• • Institutional research funding: Amgen, AstraZeneca, Blueprint, BMS, Boehringer Ingelheim, Daiichi Sankyo, GSK, Guardant Health, Janssen, Lilly, MSD, Novartis, Roche, Takeda, Trizel, Turning Point Therapeutics, Seattle Genetics

Non-financial interests:

• • Advisor: ALK Positive UK, Lung Cancer Europe, Ruth Strauss Foundation
  • Board of directors: Mesothelioma Applied Research Foundation
  • Leadership: BTOG Steering Committee, ETOP Foundation Council

Alastair Greystoke

Consultancy and speaker fees: AstraZeneca, Amgen, Boehringer-Ingelheim, Bristol-Myers Squibb, Janssen/ J and J, MSD, Novartis, Pfizer, Lilly, Takeda and Roche

Research Funding: AstraZeneca

Additional disclosures: Alastair Greystoke is the Clinical Lead for Cancer North East England Hull and Yorkshire Genomic Laboratory Hub. He is also a member of the National Test Directory Evaluation Working Group. Views expressed are personal.

Anna Minchom

Anna Minchom has served on advisory boards for Janssen Pharmaceuticals, Merck Pharmaceuticals, Takeda Pharmaceuticals and Genmab Pharmaceuticals. Has received honoraria from Chugai Pharmaceuticals, Novartis Oncology, Faron Pharmaceuticals, Bayer Pharmaceuticals and Janssen Pharmaceuticals. Has received expenses from Amgen Pharmaceuticals and LOXO Oncology.

Robert Rintoul

Robert Rintoul is the Chair of the Clinical Advisory Group of the UK Lung Cancer Coalition.