The Thoracic Oncology Group of Australasia (TOGA) was established in 2020 as the lead independent entity and lung cancer charity for conducting investigator-initiated thoracic cancer clinical trials in Australia and New Zealand. The inaugural TOGA Annual Scientific Meeting (ASM) was held virtually in July 2021.
With a theme of ‘Equity and Innovation in Multidisciplinary Lung Cancer Care’, the program featured diverse topics designed to appeal to the multidisciplinary audience. Up to 234 registrants viewed the live program throughout the two days, cementing the TOGA ASM as one the highlights in the thoracic cancer event calendar.
‘One of the most important norms to shatter is the idea that the only way a patient can receive care is to physically visit a cancer center and sit in the same room as their clinician’- Alexandra Golledge, Teletrials participant
Following a welcome by ASM 2021 convenor and Deputy Chair, TOGA Board of Directors, Dr Emily Stone, Alexandra Golledge, patient research advocate and lung cancer ‘thriver’, delivered the opening address. Alexandra chose to describe how teletrials can simplify one aspect of clinical trial participation for patients residing in regional Australia, among the myriad of challenges presented by a lung cancer diagnosis.
International guest speaker, Prof Pan-Chyr Yang from National Taiwan University College of Medicine, presented on the TALENT study, a lung cancer screening study in a Taiwanese non-smoking population with either a family history of lung adenocarcinoma, environmental exposure to tobacco or cooking fumes, or chronic lung disease. The TALENT study detected a positive rate for lung cancer of 2.6%. Significantly, this study identified a family history as a strong predictive factor for lung cancer.
Prof Jay M Lee, Surgical Director, UCLA Santa Monica Medical Center, USA, gave a comprehensive presentation drawing together the current evidence for both neoadjuvant (NA) immunotherapy and NA targeted therapy. While NA immunotherapy or targeted therapy have shown promising results in Stage I-III NSCLC patients, a limitation of many of these studies is the use of major pathological response as an endpoint. In order to change practice, longer follow up of the NA clinical trials is required to demonstrate efficacy with standard clinical endpoints such as event-free survival. Moreover, specific biomarkers are needed to identify the patients that will benefit most from NA therapy.
Prof Ramaswamy Govindan, Chair in Medical Oncology and the Director of Section of Medical Oncology at Washington University School of Medicine, USA, presented an insight into the potential of proteogenomics to predict lung cancer treatment pathways. The last decade of advances in lung cancer treatment have relied predominantly on the identification of genomic alterations to identify druggable targets.
Proteogenomics uses a combination of proteomics, genomics and transcriptomics to identify peptides, and can profile translated proteins, their phosphorylation status and the immune landscape, potentially identifying biomarkers, drug resistance mechanisms, disease or host heterogeneity, and any alterations in tumours derived from the metastatic site. Proteogenomics has already led to a Phase II clinical trial in lung cancer using personalised vaccines comprised of neo-antigens that are designed to stimulate a uniquely tailored personal immune response.
The afternoon sessions saw a changed focus with A/Prof Shankar Siva, known both locally and internationally for his work in high technology radiotherapy delivery and SABR, summarising current evidence and ongoing trials investigating the optimal timing and objectives of SABR in treatment of 
oligometastatic NSCLC. Presenters in the oral abstracts session were all vying for the New Investigator Award. The judges commended the standard of all presentations, covering diverse topics such as lung cancer screening, the treatment burden experienced by patients, a review of neoadjuvant immunotherapy in patients with resectable NSCLC, potential biomarkers or radiological features that may predict response to treatment, risk for lung cancer or local disease recurrence. The TOGA ASM21 New Investigator Award was ultimately awarded to Dr Monica Tang for her presentation on ‘Generalisability of Phase III Immunotherapy Trials in Advanced Lung Cancer to Real-World Patients’.
A predominant focus of the TOGA clinical trial program in recent years has been examining treatment options following disease progression after targeted therapies. Prof Nick Pavlakis described the evolution and current role of precision medicine in treatment of metastatic NSCLC, and the TOGA ASPiRATION cohort study that is evaluating the benefit of comprehensive genomic profiling to identify actionable biomarkers to guide therapy including clinical trial participation. The value of ASPiRATION to the patient community was demonstrated with the identification of Ret mutations in two patients with subsequent referral to a clinical trial to access a Ret-specific targeted therapy.
In two clinical trials evaluating alternating drug therapy to mitigate drug resistance, Prof Ben Solomon presented OSCILLATE and Dr Malinda Itchins presented ALKTERNATE. The trials ‘oscillate’ between osimertinib and gefitinib therapy cycles in metastatic EGFR+ NSCLC patients, or ‘alternate’ crizotinib and lorlatinib in metastatic ALK+ patients respectively, in an attempt to limit the selection of drug-resistant clones. OSCILLATE has completed recruitment and results show that the treatment regimen is safe and feasible with PFS similar to continuous osimertinib. ALKTERNATE remains open to recruitment.
A/Prof Chee Lee presented on ILLUMINATE, a single arm trial conducted in parallel with Taiwan that examines tremelimumab and durvalumab in conjunction with chemotherapy in EGFR+ metastatic NSCLC patients who have progressed on earlier lines of TKI therapy. The trial has recently undergone an interim futility analysis and will continue to recruit to completion.
The final session of the day provided ‘quick bites’ of research proposals endorsed by TOGA. From examining cognitive function after systemic treatment for metastatic NSCLC, describing the critical role of the specialist lung cancer nurse on patient outcomes, to illustrating the need for a clinical quality data platform in lung cancer and outlining several collaborative radiation oncology trials, this session displayed the breadth of research being undertaken in thoracic cancers.
Day two commenced with a breakfast symposium featuring Dr Melissa Moore debating A/Prof Jaclyn Yoong (standing in for Prof Julie Brahmer) on whether two immunotherapies are better than one. Both presented relevant data, particularly the CheckMate 227 trial, noting that this trial was not actually designed to test the double vs single immunotherapy treatment regimen in metastatic NSCLC. The final result was unanimous with insufficient current evidence to warrant delivery of double immunotherapy without chemotherapy, but single agent immunotherapy was regarded as beneficial in patients whose tumours expressed PDL1 >50% compared to chemotherapy alone.
The next session examined inequities in lung cancer care. Lung cancer results in the highest number of cancer-related deaths, and carries a significant public health burden, but this is not evenly distributed in population groups. Patient research advocate, Lillian Leigh set the scene discussing inequity and inequality in health and focusing on the greater lung cancer burden in lower socioeconomic, regional and remote and indigenous populations. This was followed by Dr Nicole Rankin discussing the challenges of implementation in disadvantaged groups, particularly focusing on lung cancer screening, and Prof Barbara McPake illustrated barriers to lung cancer care that have been identified in England and Indonesia. An Australian lung cancer screening program is expected to save 12,000 lives in 10 years (1), but the discussion of inequities quickly highlighted that this benefit would not be realised unless concerted efforts are made to remove barriers and access disadvantaged populations.
Prof Anna Nowak detailed the evolution of immunotherapy treatment in mesothelioma, from single agent immunotherapy to the addition of chemotherapy, as was used in the DREAM and PrE0505 clinical trials, to the recent PBS approval of ipilimumab and nivolumab. Prof Nowak emphasised that enrolling patients on the TOGA Phase III randomised DREAM3R clinical trial, conducted in collaboration with PrECOG in the USA and the NHMRC Clinical Trials Centre, and that investigates the addition of durvalumab to chemotherapy, does not preclude access to dual immunotherapy as a second line treatment.
In a session designed to provide practical tips for embedding thoracic cancer research and quality care, attendees heard about diverse topics ranging from biobanking, teletrials, smoking cessation, clinical quality registries, patient-reported outcomes, how to put together a business case to request a specialist lung cancer nurse and RAPID, a collaborative, international quality improvement program studying the prospective use of medications and non-pharmacological interventions commonly used in palliative care and cancer symptom management.
Following a TOGA Scientific Committee meeting where TOGA members proposed new research ideas and clinical trial concepts to benefit from collaborative discussion, review and development, Prof Nick Pavlakis, Chair, TOGA Board of Directors, presented an update on the genesis of TOGA and the first year of operations. Notably TOGA has formed governance and scientific committees, established a comprehensive educational program and now has more than 250 members.
The final session of the ASM was an MDT Masterclass encouraging multidisciplinary team discussion on some particularly interesting presentations. This session drew on the expertise and varied experience of several lung cancer experts and perfectly illustrated why multidisciplinary care is the gold standard for lung cancer care.
‘This mock multidisciplinary team meeting has demonstrated that multidisciplinary team meetings are crucial for patients to have the best outcome possible’- Lillian Leigh, Patient Research Advocate
Upcoming events in the TOGA education calendar include the post ESMO and WCLC 2021 symposia and the Lung Cancer Preceptorship for advanced trainees and junior fellows. General enquiries for these events can be directed to mailto:[email protected] or find more information at www.thoraciconcology.org.au
Contributed by:
Dr Emily Stone, ASM21 Convenor and Deputy Chair, TOGA Board of Directors
Professor Nick Pavlakis, Chair, TOGA Board of Directors
References:
1. Cancer Australia, 2020. Report on the Lung Cancer Screening Enquiry, Cancer Australia, Surry
Hills, NSW
