China's Lung Cancer Burden Fuels Research
China's Lung Cancer Burden Fuels Research
Tony Mok, MD: Good morning. I am Professor Tony Mok from the Chinese University of Hong Kong, and I am a medical oncologist.
Welcome to Medscape Oncology Insights on lung cancer, taking place in Beijing at the 2012 annual meeting of the Chinese Society of Clinical Oncology (CSCO).
We have 2 honorable guests today. The first is Professor Yi-Long Wu, who is Professor at Guangdong Lung Cancer Institute at the Guangdong General Hospital in China. Our second guest is Professor Caicun Zhou, who is President of the Tumor Research Institute in the Tongji Hospital in Shanghai. Welcome, Professor Caicun Zhou and Professor Yi-Long Wu.
We are all lung cancer researchers. Our story breaks out with the high incidence of EGFR [epidermal growth factor receptor] mutations in Asia and China, and that helped us to develop personalized medicine for lung cancer. What is the situation in China, Yi-Long? In a sense, are we promoting EGFR mutation testing in all lung cancer patients in China?
Yi-Long Wu, MD: In China, the EGFR mutation rate is about 30% for all non-small cell lung cancers. Of all non-small cell lung cancers, the most common is adenocarcinoma. In China especially, squamous cell carcinoma also has the EGFR mutation. In Chinese guidelines we test every non-small cell lung cancer for these EGFR mutations.
Dr. Mok: Is it practical? Caicun, you are in Shanghai, one of the richest cities in China. What percentage of patients are tested in general?
Caicun Zhou, MD, PhD: In total, about 15% of our patients are tested for EGFR mutation.The incidence of testing may be higher in big cities such as Beijing, Guangzhou, and Shanghai. Testing may be a little bit rarer in the inner city.
Dr. Mok: So, testing is being done mostly in the major cities but less often in rural areas? How many centers in China have the capability to do EGFR mutation analysis?
Dr. Zhou: Most big hospitals have facilities to test EGFR mutations. The good news is that the State Food and Drug Administration (SFDA) has approved a kit for testing EGFR mutations. The kit will be available to all levels of hospitals in a few years.
Dr. Mok: Another important molecule is M4 ALK translocation mutation. Is this being tested in China as well?
Dr. Wu: For ALK testing,now only in the Society for Research, such as in our hospital, the ALK incidence is about 9%-11%. For ALK, in China, most centers cannot test for these mutations.
Dr. Mok: The standard testing method is fluorescence in situ hybridization (FISH). What is the more preferable way of testing in China? Would it be immunohistochemistry (IHC), FISH, or using the reverse-transcriptase polymerase chain reaction (RT-PCR)?
Dr. Wu: Personally, I like the RT-PCR because it is easier and quicker and requires no special equipment.
Dr. Zhou: It is a good idea to use IHC to screen, even for ALK translocations. IHC is widespread in China. Almost all facilities in China can do IHC. Multiplex RT-PCR is another good method of testing for ALK translocation. Multiplex RT-PCR is more sensitive than IHC.
Dr. Mok: Both of you are lung cancer experts, not only in China but on an international level as well. Your Chinese Thoracic Oncology Group (CTONG) has done a lot of great research, including the OPTIMAL study that helped the drug erlotinib become registered in first-line therapy. Can you tell us something about CTONG? How many centers are there, and what kind of activity is going on?
Dr. Wu: CTONG now consists of 20 large hospitals, so in CTONG hospitals every year we have 20,000 new lung cancer patients.
Dr. Mok: Twenty thousand -- that is unimaginable.
Dr. Wu: Consequently, we have huge numbers of lung cancer patient results, and now CTONG is developing biomarker-driving clinical trials, such as the OPTIMAL trial. We also had some special trials, such as in the EGFR wild-type patient -- we're comparing an EGFR-TKI with pemetrexed.We will probably publish these very important trials in the next year.
Dr. Mok: You were actually the first to publish the OPTIMAL study in Lancet Oncology. What was your experience working with CTONG?
Dr. Zhou: It was quite good. Each center was very cooperative to perform clinical studies. CTONG is a very good consulting group.
Dr. Mok: I know a good number of them, and we have had discussions about a potential biomarker bank. What is the plan? Are we going to set up a tumor bank within CTONG or set up other collaborative study in this regard?
Dr. Wu: In my personal field, I want to set up the first tumor tissue bank. This means that the different hospitals set up the same tissue bank, and then they are connected by computer system. Then with this information system we can search for each patient in each hospital.
Dr. Mok: Doing some simple calculations, you have about 20,000 patients annually, and presumably half of them have a tumor sample; you are going to accumulate almost 10,000 samples a year, which is tremendous.
Dr. Zhou: Maybe it's a good idea to have a tissue bank among the CTONG group. We have so many patient resources, and we have very good data of the follow-up in these cases. It's a very good idea.
Dr. Mok: With such a large tumor bank, we can potentially address some of the rarer mutations, such as a ROS1. Is there any specific plan with ROS1 in China?
Dr. Zhou: We are screening for ROS1 incidence in patients with non-small cell lung cancer. We used multiplex RT-PCR to screen for ROS1 and RET translocations among about 400 patients with non-small cell lung cancer. We found that the incidence of ROS1 is quite rare, about 1.5%. RET is also quite rare, with an incidence of 1.6%.
Dr. Mok: When you say 20,000 patients, you are still talking about a couple of hundred patients a year.
Dr. Zhou: Right -- we can do such a study. That means that we found many rare oncogene drivers, giving us a lot of opportunity to perform clinical studies among the CTONG group.
Dr. Wu: For the tissue bank, we are not only focused on ALK, EGFR, or ROS-1; now, we would like to better profile the Chinese lung cancer patients for driver genes. We need to test every potential biomarker.
Dr. Mok: You already published a very excellent article in PLoS One, with a description of 520 cases of the genetic profiles. Are you going to look at squamous cell as well as other cell types in the future?
Dr. Wu: This is a very interesting paper because we divided the patients into 4 groups: the nonsmoker with adenocarcinoma, the smoker with adenocarcinoma, the nonsmoker with squamous carcinoma, and the smoker with squamous carcinoma. We find that the 4 groups had different driver genes in the profile. Maybe in the near future we can use this model to enrich the patients in clinical trials.
Dr. Mok: That is really admirable. You also wear many hats. You are the President-Elect of CSCO and will take office in 2013. What are your future plans for CSCO? How will you develop this large society?
Dr. Wu: In the near future we want to develop CSCO into an international organization. We need much more cooperation with the international oncology organizations. This is the main goal. We want to push CSCO onto the international stage.
Dr. Mok: Both of you are doing a tremendous job in taking CSCO, and the Chinese investigator, to the international stage. Thank you for joining us in this edition of Medscape Oncology Insight. This is Tony Mok reporting from CSCO 2012 in Beijing.
Introductions
Tony Mok, MD: Good morning. I am Professor Tony Mok from the Chinese University of Hong Kong, and I am a medical oncologist.
Welcome to Medscape Oncology Insights on lung cancer, taking place in Beijing at the 2012 annual meeting of the Chinese Society of Clinical Oncology (CSCO).
We have 2 honorable guests today. The first is Professor Yi-Long Wu, who is Professor at Guangdong Lung Cancer Institute at the Guangdong General Hospital in China. Our second guest is Professor Caicun Zhou, who is President of the Tumor Research Institute in the Tongji Hospital in Shanghai. Welcome, Professor Caicun Zhou and Professor Yi-Long Wu.
China: Forerunner in EGFR Screening?
We are all lung cancer researchers. Our story breaks out with the high incidence of EGFR [epidermal growth factor receptor] mutations in Asia and China, and that helped us to develop personalized medicine for lung cancer. What is the situation in China, Yi-Long? In a sense, are we promoting EGFR mutation testing in all lung cancer patients in China?
Yi-Long Wu, MD: In China, the EGFR mutation rate is about 30% for all non-small cell lung cancers. Of all non-small cell lung cancers, the most common is adenocarcinoma. In China especially, squamous cell carcinoma also has the EGFR mutation. In Chinese guidelines we test every non-small cell lung cancer for these EGFR mutations.
Dr. Mok: Is it practical? Caicun, you are in Shanghai, one of the richest cities in China. What percentage of patients are tested in general?
Caicun Zhou, MD, PhD: In total, about 15% of our patients are tested for EGFR mutation.The incidence of testing may be higher in big cities such as Beijing, Guangzhou, and Shanghai. Testing may be a little bit rarer in the inner city.
Dr. Mok: So, testing is being done mostly in the major cities but less often in rural areas? How many centers in China have the capability to do EGFR mutation analysis?
Dr. Zhou: Most big hospitals have facilities to test EGFR mutations. The good news is that the State Food and Drug Administration (SFDA) has approved a kit for testing EGFR mutations. The kit will be available to all levels of hospitals in a few years.
Dr. Mok: Another important molecule is M4 ALK translocation mutation. Is this being tested in China as well?
Dr. Wu: For ALK testing,now only in the Society for Research, such as in our hospital, the ALK incidence is about 9%-11%. For ALK, in China, most centers cannot test for these mutations.
Dr. Mok: The standard testing method is fluorescence in situ hybridization (FISH). What is the more preferable way of testing in China? Would it be immunohistochemistry (IHC), FISH, or using the reverse-transcriptase polymerase chain reaction (RT-PCR)?
Dr. Wu: Personally, I like the RT-PCR because it is easier and quicker and requires no special equipment.
Dr. Zhou: It is a good idea to use IHC to screen, even for ALK translocations. IHC is widespread in China. Almost all facilities in China can do IHC. Multiplex RT-PCR is another good method of testing for ALK translocation. Multiplex RT-PCR is more sensitive than IHC.
20,000 New Lung Cancer Patients Each Year
Dr. Mok: Both of you are lung cancer experts, not only in China but on an international level as well. Your Chinese Thoracic Oncology Group (CTONG) has done a lot of great research, including the OPTIMAL study that helped the drug erlotinib become registered in first-line therapy. Can you tell us something about CTONG? How many centers are there, and what kind of activity is going on?
Dr. Wu: CTONG now consists of 20 large hospitals, so in CTONG hospitals every year we have 20,000 new lung cancer patients.
Dr. Mok: Twenty thousand -- that is unimaginable.
Dr. Wu: Consequently, we have huge numbers of lung cancer patient results, and now CTONG is developing biomarker-driving clinical trials, such as the OPTIMAL trial. We also had some special trials, such as in the EGFR wild-type patient -- we're comparing an EGFR-TKI with pemetrexed.We will probably publish these very important trials in the next year.
Dr. Mok: You were actually the first to publish the OPTIMAL study in Lancet Oncology. What was your experience working with CTONG?
Dr. Zhou: It was quite good. Each center was very cooperative to perform clinical studies. CTONG is a very good consulting group.
China's First Tumor Tissue Bank
Dr. Mok: I know a good number of them, and we have had discussions about a potential biomarker bank. What is the plan? Are we going to set up a tumor bank within CTONG or set up other collaborative study in this regard?
Dr. Wu: In my personal field, I want to set up the first tumor tissue bank. This means that the different hospitals set up the same tissue bank, and then they are connected by computer system. Then with this information system we can search for each patient in each hospital.
Dr. Mok: Doing some simple calculations, you have about 20,000 patients annually, and presumably half of them have a tumor sample; you are going to accumulate almost 10,000 samples a year, which is tremendous.
Dr. Zhou: Maybe it's a good idea to have a tissue bank among the CTONG group. We have so many patient resources, and we have very good data of the follow-up in these cases. It's a very good idea.
Dr. Mok: With such a large tumor bank, we can potentially address some of the rarer mutations, such as a ROS1. Is there any specific plan with ROS1 in China?
Dr. Zhou: We are screening for ROS1 incidence in patients with non-small cell lung cancer. We used multiplex RT-PCR to screen for ROS1 and RET translocations among about 400 patients with non-small cell lung cancer. We found that the incidence of ROS1 is quite rare, about 1.5%. RET is also quite rare, with an incidence of 1.6%.
Dr. Mok: When you say 20,000 patients, you are still talking about a couple of hundred patients a year.
Dr. Zhou: Right -- we can do such a study. That means that we found many rare oncogene drivers, giving us a lot of opportunity to perform clinical studies among the CTONG group.
Dr. Wu: For the tissue bank, we are not only focused on ALK, EGFR, or ROS-1; now, we would like to better profile the Chinese lung cancer patients for driver genes. We need to test every potential biomarker.
Dr. Mok: You already published a very excellent article in PLoS One, with a description of 520 cases of the genetic profiles. Are you going to look at squamous cell as well as other cell types in the future?
Dr. Wu: This is a very interesting paper because we divided the patients into 4 groups: the nonsmoker with adenocarcinoma, the smoker with adenocarcinoma, the nonsmoker with squamous carcinoma, and the smoker with squamous carcinoma. We find that the 4 groups had different driver genes in the profile. Maybe in the near future we can use this model to enrich the patients in clinical trials.
CSCO Enters the International Arena
Dr. Mok: That is really admirable. You also wear many hats. You are the President-Elect of CSCO and will take office in 2013. What are your future plans for CSCO? How will you develop this large society?
Dr. Wu: In the near future we want to develop CSCO into an international organization. We need much more cooperation with the international oncology organizations. This is the main goal. We want to push CSCO onto the international stage.
Dr. Mok: Both of you are doing a tremendous job in taking CSCO, and the Chinese investigator, to the international stage. Thank you for joining us in this edition of Medscape Oncology Insight. This is Tony Mok reporting from CSCO 2012 in Beijing.
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