In the name of time, I'm going to go ahead and get started. Good afternoon, everyone. Thank you for joining us after lunch for a session on lung cancer survivorship for pulmonologists, challenges, priorities, and the care model. I can't hear myself in the back. I hope it's OK. Historically, lung cancer care for pulmonologists is focused on identification, diagnosis, and staging. And as the survival in lung cancer patients continues to improve, there's a lot of opportunity for longitudinal and multidisciplinary care, so much so that there's been new survivorship models proposed. And that's largely what we're going to talk about today. I've organized, much like our cancer care clinics, a multidisciplinary panel. I'll use this as an opportunity to introduce everyone so that we don't have to interrupt between sessions. To my left is Dr. Carolyn Pressley, who's a medical oncologist at The Ohio State University. To the left of her is Dr. Sadia Fez, who's a pulmonary critical care and sleep physician from MD Anderson. And to her left is Dr. Hunter Groninger, who is a palliative care physician at MedStar in Georgetown. I'm Brett Beatty. I'm an assistant professor in the section of pulmonary critical care at Zucker Hofstra Northwell. And I work at Lenox Hill Hospital. I'm the director of lung cancer screening. And I have no disclosures, but I do want to remind everyone that next month, November, is Lung Cancer Awareness Month. And I hope we all remember to either wear or display or both the white ribbons to remember and recognize our patients with this condition. The learning objectives today are threefold. The first is to define survivorship, because I think it's often quoted and not often explained. And be familiar with available treatment guidelines. The second is to identify under-recognized factors related to outcomes in cancer survivors. And then to discuss evaluation and treatment opportunities for quality of life optimization. So let's start with some lung cancer background. I imagine this audience is pretty familiar with lung cancer survival. But we're getting better at lung cancer due to multifactorial advances. Tobacco, smoking, cessation and avoidance, early diagnosis with screening, and less invasive diagnostic approaches, and more and more treatment options that are increasingly targeted and better tolerated. As a function of all those advances, I think you can see mortality in the image on the right is steadily improving in both sexes and all ethnic and demographic groups. Looking at lung cancer compared to other cancer types, I'll call your attention to the red line here. We see cancer mortality in the most recent cancer statistics article highlighted in red. Men on the top, women on the bottom. And I think we can all see that deaths from lung cancer still outnumber those from all other cancer types. But the improvements over the last two to three decades have also been outpacing those other cancers with the improvements in overall cancer mortality really driven in the last several years by lung cancer improvement. As a function of that improvement, we're seeing increasing survival. Here's five year, what we used to call long-term survival. Now above 20% and steadily rising. And to finally show you that we're having some improvement in lung cancer survivors overall. So kind of a busy slide, but 2019 on the top, 2022 on the bottom. And we see numbers of lung cancer survivors in men and women highlighted in red with a 30,000 about increase in male lung cancer survivors in the last three years and 50,000 in women. So I hope you're convinced that we're getting better. To transition from the number of lung cancer survivors, now that patients are living longer, how are they living? So I want to focus a little bit on symptoms. Three points with this slide. One is patients with lung cancer have clinically significant symptoms. The statistic that you see there is from Zhang and colleagues last year where essentially all patients with advanced non-small cell lung cancer have symptoms. Most frequently dyspnea, fatigue, and cough. Focusing for a moment on cancer-related fatigue, the second point I wanted to make is that lung cancer survivors tend to have more abundant and more severe symptoms than other cancer types. You see again, most patients have fatigue. And in the image at the bottom, the lung carcinoma at the very bottom, odds ratio for patients with chronic fatigue with impairment is higher than most other. This is just one example. There are several. Finally, symptoms of lung cancer are multifactorial, which give us a lot of treatment opportunities, but make treatment a little challenging. This image is from a session that several of us on this panel had last year at ATS, looking at cancer-related fatigue in lung cancer. And there's more topics here than I can address in a brief session. But I will call your attention to symptoms related to the tumor itself, cancer treatment and associated toxicities, and comorbidities. So now let's get to the definitions that I referenced. These are from the National Cancer Institute and the National Coalition for Cancer Survivorship. The first is that of a cancer survivor. Quote, an individual is considered a cancer survivor from the time of diagnosis and throughout the balance of life. And then for cancer survivorship, living with, through, and beyond a cancer diagnosis, often focusing on care and experiences. Here's an example of that experiences. Here is a frequent course of patient with lung cancer, either early or advanced. It's often called the dyspnea spiral in COPD circles, but we see patients with either earlier advanced stage cancer develop symptoms as a function of their cancer, their treatment, their comorbidities, or more commonly, a combination therein, leading to increased symptoms. To avoid worsening those symptoms, patients are less active, which leads to weakness and decreased physical function. And often there's a spiral that develops with worsening physical function, worsening quality of life, and without interruption, disability and death. Our goal with this panel is what can we do to interrupt that spiral? I referenced a cancer survivorship care model that's relatively new. This is from Neko Yudof and colleagues several, three years ago now. And again, a pretty busy slide, but my point is to highlight that survivorship should prioritize more than surveillance. I think we're pretty good at, let me check time, I'm sorry. We're pretty good at surveilling for follow-up and recurrence of cancer. I think there are a lot of opportunities for us to focus on the top left, physical effects of cancer treatment, in the bottom, health promotion, that is tobacco cessation, weight maintenance, physical activity levels. And then on the right, comorbid chronic conditions and surveilling for both economic stressors of cancer care and psychological effects of cancer care. The NCCN guidelines published this year on cancer survivorship prioritize those topics. And this is a bit redundant, but I just wanna highlight that the cancer care model aligns with current NCCN guidelines. To focus on lung cancer survivors for a moment, there's precious little data on longer-term follow-up in patients with lung cancer, because historically there hasn't been a lot of long-term survival. This study is from Heckner and colleagues, showing us that the priorities for the guidelines actually do align with what patients are experiencing. The part I'll call your attention to is the bottom left, where we see patients with worsened quality of life, strongly associated with anxiety, depression, current treatment of their cancer, respiratory comorbidity, and living on disability pension. By contrast, patients with better quality of life are more active and have a higher income. This slide I hope convinces you why it's important to prioritize health promotion and maybe give us an idea what our follow-up visits should look like. These are all survival curves that I think get frequently overlooked in the setting of targeted therapy, immunotherapy, and surgery. Going from left to right, we see quality of life, physical activity, or in this case, exercise tolerance, and depression scores. And if it's not clear, patients with a baseline, better quality of life, higher activity tolerance, and either well-controlled or absence of depression symptoms all have longer survival. Two points from this slide. One, I think it's pretty clear that patients who have well-controlled quality of life and symptom burden live longer, much like the Jennifer Timmel article years ago that I'm sure we'll hear from Hunter. The second point is, this is maybe what we should be focusing on in addition to surveillance in our follow-up visits. How are we feeling? Quality of life. Is there depression? And what can we do in terms of physical activity? We'll get more on these topics in the next coming slides. So one of the final questions is, aren't we already doing that? A lot of us are practicing in multidisciplinary cancer clinics. And this study from Renke and colleagues, I think, highlights that we do a pretty good job, but there's a lot of room for opportunity. To orient you to this table here, the column on the far left is symptoms, and then in the top right row, we see specialists. And the percentages are how frequently we ask about individual symptoms over the course of six months after a lung cancer diagnosis. I won't go through all of the numbers with you, but I think it's clear that we're pretty good at some symptoms, but for example, anxiety and depression, there's a lot of opportunity. And since these correlate with survival, it's something I think we should be prioritizing a little more. The next point is that the bottom left, changes are infrequent. When we do find a symptom, it's only about 10 to 15% of the time that we make a change in someone's medication regimen. So to put the story together, we're inconsistent in how we're asking about things that correlate with survival, and when we do find challenges, we're less likely to actually make an intervention. So a lot of opportunity. And I'm kind of bringing up this session today that since symptoms and quality of life correlate so strongly with comorbid lung disease, as pulmonologists, there's a lot of opportunity for us to optimize some of these numbers. So to summarize my portion, lung cancer mortality and survival are steadily improving, and lung cancer survivors have high symptom burden and more impairments than other cancer survivors. In terms of survivorship care, we should be prioritizing not only surveillance, but symptoms, quality of life, and physical activity. And in terms of lung cancer teams, we should be screening for and addressing these impairments with pulmonologists pretty well suited, I think, to address some of these challenges. I will introduce, kind of digitally, patient perspective. When we designed this session, I asked a colleague of mine named Dawn Chamberlain, who's a member of the Patient Family Advisory Committee at Smilo Cancer Hospital in New Haven. Unfortunately, she couldn't join us in Nashville, but she was pretty insistent on participating, so we'll do so in a digital fashion. Here's an interview that I did with her where Dawn explains her course, symptoms, and some opportunities for cancer care to optimize quality of life that some of us wouldn't consider. Forgive the first moment, because I'm not very savvy digitally. Recording. Hi, I'm Dawn Chamberlain, and I'm a two-time lung cancer survivor. The first time I had lung cancer was in 2008, and I happened to be in New Hampshire during that year and was able to get the cancer treated at Brigham and Women's. I had a tumor in the top right lobe. That lobe was removed by Dr. Jakovits, and they did chemo and radiation just to get the rogue cells. I then returned to Connecticut to Dr. Gettinger's care at Smilow, and we were going along fine for over 10 years, and he walked in in 2019, and he said to me, Dawn, I see something I don't like. And as it turned out, it was cancer, and it was in my bottom left lobe. But because I was doing most of my breathing out of that lobe, surgery was out of the question. So his team came up with an aggressive chemo and radiation treatment program, and that went on until November of that year. But again, the effects of the treatment go long after the treatment actually stops. On February 28th, I had to give up my car keys. At that point, I had no appetite. I lacked interest and motivation in the things in my life. I was physically so weak, I could barely make it up a staircase, and if I did make it to the top of the staircase, I had to get to a bed or a chair quickly to catch my breath. If I lost a night's sleep, I was absolutely crippled the next day. So I was in to see Dr. Gettinger, and his oncologist, oncology nurse said to me, just gonna plow through this, Dawn? I said, yeah, I can do this, I can do this. Well, on February 28th, I went to my goddaughter's birthday party, and I couldn't drive, and her husband came to pick me up. And I sat there, and I realized that I would never be able to attend the last birthday party of hers that I would attend unless I began to fight the fight to win against this cancer. Her mother drove me home that night, and I told her, if this is what my life is going to look like, I don't want it. And I made a decision that night to try to make my life different. Milo provided me with opportunities to fight the fight, and the social worker there was wonderful. She helped me with the FMLA paperwork. Dr. Gettinger's office helped me with the sleep. Palliative care helped me deal with the symptoms. The lung cancer support group made me feel as if I wasn't alone in this. But the one thing that really made a tremendous difference was the pulmonary rehab clinic. I am not a gym kind of woman. I don't go to the gym. I'd never been in a gym until I got to palliative care, or until I got to the respiratory clinic, at which point I walked in, and it was all gym equipment. And I learned how to breathe, and exercise, and live my life. It empowered me. It got my strength to where it could be and should be, and just gave me the breathing techniques I needed to live a full life. Today I'm cancer-free. And when I last saw Dr. Gettinger, and he told me I was cancer-free, I asked him what the chances were that the cancer would return. And he said, 50-50. And I said, I'll take those odds, but I'm gonna tell you right now, don't bet against this force. I thank you all for your contribution to lung health. And I can tell you, I don't waste a breath. Thank you. Glad you could be here digitally. Watched that several times, and it's still pretty powerful. Thanks for your time with me. In the name of time, I think we're gonna go to our second speaker, and maybe save our questions till the end. Don't forget to evaluate us in the app, and please email me if anything comes up now or after. Okay, good afternoon. I'm Dr. Carolyn Pressley. I'm a thoracic and geriatric oncologist. So I'm actually boarded in both, and I'm at the Ohio State University, and these are my disclosures. So briefly today, I'm hoping to really demonstrate how lung cancer is really a disease of older adults, and that survivorship starts a diagnosis, like Dr. Beatty mentioned. But really, survivorship care plans need to be tailored for an aging patient population. So this is data from the UN World Population Aging Report, and it demonstrates that by 2050, there'll be 380 million octogenarians worldwide. So this is one of the fastest growing age demographics, not only in the United States, but globally. And really, this is increased from about 70 million in 2000, and 2050 is really just around the corner. So seeing patients like Ms. Smith in our office, whether we're pulmonologists, palliative care, critical care, medical oncology, surgery, radiation oncology, we're gonna be seeing more and more octogenarians. And so Ms. Smith came in in a wheelchair, she's 82. She was having a lot of shortness of breath, and her primary care physician got a chest X-ray, and then eventually she got a CT chest showing a four and a half centimeter right upper lobe lung mass, and a large pleural effusion. And then her PET scan was suspicious for liver and bone mats. And so one of our pulmonary colleagues did end up doing a thoracentesis, and we were able to determine her pathology as adenocarcinoma on the pleural fluid. And her wishes really were, she wanted to learn more about cancer treatment, and so she ended up in my office. And so how should we personalize survivorship care, specifically for older adults with advanced non-small cell lung cancer? Because in the current guidelines, she technically would be stage four, and I would complete her staging with a brain MRI to check for brain mats, and then I'd check PD-L1 and tumor genomic testing. But as Dr. Beatty mentioned, our paradigm of how we think about survivorship is really changing. And really, survivorship begins at diagnosis. And someone could be diagnosed early stage, more advanced or metastatic. They could be diagnosed with recurrence, like we just heard from Dawn, our patient. Or they could be diagnosed more at end stage. But regardless of where they are, we have to think of them as survivors. And this is a shift, because we used to really think about it in terms of after the active cancer treatment was finished, and they were in surveillance. And so now, lung cancer treatments, it's really, especially in the advanced setting, patients can be on these treatments for years. And so it's almost, for patients who have a response, and sometimes a durable response, they're on these medications for a long time. I have patients who are still on immunotherapies 10 years later, 10 years out from their stage four lung cancer diagnosis. And so we have to, in some cases, think about it as evolving into a chronic disease model. Unfortunately, their other chronic comorbidities don't end or go away, and they can also be exacerbated. So how could we personalize survivorship care, specifically for older adults? So when I think about survivorship planning, when that patient's sitting in my office, the first thing I'd ask them is, what's important to you? Is there an event you're trying to get to? Do you really wanna see a daughter or granddaughter graduate from high school, college? Or is there something that you really wanna make it to X? Or you really wanna do X before, or you just, but you don't feel well enough to be able to do those things. But I do ask them to prioritize their health goals, and I'll get into that in a little bit. The second thing I do is I assess their risk for anti-cancer treatment toxicity. So as a medical oncologist, we're often the first person these patients are seeing in terms of their cancer treatment planning. They may have seen a surgeon, they may have seen radiation oncology, but the medical oncologist is really the quarterback of the care team. And so as a Buckeye, you can see how important that would be, that's a football joke. I know, I'm not a football fan either. But we really are the quarterback of the team and end up doing a lot of care coordination along with all of our wonderful subspecialists that are up here as well. So often I'm the first one that's assessing their risk for toxicity. And the thing that I think that is crucial is actually their functional status. So what are you able to do on a typical day? Are you able to get outside your home or are you homebound? Are you able to do your meal prep, your medication management? Are you able to go out and get food from the store or are you savvy enough to order it on a food delivery app, right? And depending on the person, that could be very different. And so then the final thing is, I think of three main buckets in terms of survivorship care planning and that's the anti-cancer treatment, supportive care and palliative care. And these are really, I think, three distinct but overlapping buckets that we really have to make sure we're hitting something in each group. So when I ask them, I usually ask my patients, is it, what's the most important? Is it independence? So not having other people have to help you. Staying alive as long as possible, pain relief, symptom relief. And for Ms. Smith, she really wanted to stay alive as long as possible. And so, is there evidence for living longer with anti-cancer treatment versus without in this stage, in this setting? And the answer is, that's absolutely correct. And not only can patients live longer, but they can also feel better in the process because if we treat the cancer, a lot of times their symptoms can get better. However, some patients don't want anti-cancer treatment and that is incredibly important to address in that first visit and give them the opportunity to say, that's actually not within my preferences and within my goals. And so, because I practice in an academic setting, I really have no financial incentive to give patients medications, right? So I am not paid more or less, depending on what drug I prescribe or what infusion I give. And so, I really talk about three main buckets, which is targeted treatment, chemotherapy and immunotherapy, immunotherapy by itself, and the fourth option is really clinical trials. And it's ironic because I left clinical trials off of the bullet point here and that's because older adults are historically very underrepresented in clinical trials because the healthiest patients are put on the drug treatment trials that lead to the approval of the new cancer treatments. But this is the very basic algorithm that I actually draw out for my patients in the exam room. So Ms. Smith says, how will my cancer treatment affect me? And this elephant's saying, I'm right there in the room and no one even acknowledges me. And that's really the case because I don't know how many patients were in wheelchairs that were included on the cancer treatment clinical trials that were done, probably none. These are the healthiest patients that get included to then go get the drug approved. And so, we know that over 70% of all patients with cancer are treated in the community setting and they're not necessarily treated in an academic center. And that's where the drug trials are commonly done, though we're really trying to get better about with big N-Core community cancer clinical trials, trying to make that better. So why is it so hard? And really, I think about, there's so much heterogeneity among older adults and there's chronologic age, but there's also biologic age, right? And so we all age differently. Some of us develop mobility, disability, depression, cognitive impairment, and those aren't normal parts of aging. Being depressed is not a normal part of aging. Other people aren't depressed, they don't develop cognitive impairment, and they're doing yoga into their 70s, 80s, or 90s. And so we have to think about a lot of different things, but not only symptoms. I think in lung cancer, we've really focused a lot about aggressive symptom management and most of the data has been around aggressive symptom management, but we're really trying to broaden that definition in terms of functioning. So are these people able to do what matters most to them? So a sample survivorship care plan for Ms. Smith was concurrent oncology and palliative care visits. Another program that's a whole separate talk is we have an embedded palliative care team within our lung cancer clinic, which has been really incredible for patients and care partners, and I think actually helps with provider burnout as well, so that we are really delivering excellent symptom management in addition to anti-cancer treatment. And so we also have a social worker and a case manager. We're very, very fortunate. So I wanted them to help with housekeeping and meal prep because she actually does live alone, even though she does have family members who are within a 10-mile radius, there isn't somebody else physically in the home with her. We are able to bill now for advanced care planning based on time, and I also asked for home-based nursing support to help with medication management. Something as simple as having patients use a pillbox can really improve how and when they're taking their medications. And then I enrolled her in the ROAR LCT program, which I'm gonna talk about next for the remainder of the time. And so again, this is that trifecta that we're trying to really address today. So ROAR is a novel supportive care intervention that we developed at The Ohio State University. ROAR stands for Resiliency Among Older Adults Receiving Lung Cancer Treatment. And this is a combined physical therapy and progressive muscle relaxation intervention. And we chose these two things because we do know physical activity is one of the best things that we can prescribe to help with cancer-related fatigue, and that can be incredibly disabling. And then progressive muscle relaxation, we did a very small pilot study, but patients felt much less dysmic or short of breath when they were using a progressive muscle relaxation technique. And because shortness of breath is so disabling and can really be a deterrent to our patients actually trying to increase their physical activity, because if you think about it, if you try and go up a flight of stairs or if you go out for a brisk walk, you might actually get short of breath, especially if your heart rate's getting up, right? So that shortness of breath, though, if you have lung cancer, could remind you of maybe when you were first diagnosed and you couldn't breathe. So that can really be a vicious cycle. So we thought actually the combination of these two things together would really help patients rather than just one or the other. So ROAR, the pilot, included patients with advanced either non-small cell or small cell, and they could be 60 years of age or older. It was a 12-session intervention, and the first and last sessions were in clinic with an evaluation by the physical therapist in clinic, and then all the intervening sessions were done virtually. So we gave patients a tablet, and if they didn't have Wi-Fi at home, we actually also gave them a data plan with that tablet. We live in South Central Ohio, so we have a huge catchment area. And a lot of patients don't have access to outpatient physical therapy because they live in rural Ohio or West Virginia. But they would be able to use a tablet with a data plan. And so this really did improve access once we taught our older adults or a care partner to use the technology. So they do their 12 sessions, and basically our outcome was just to see if we could do this at all. And so we opened February of 2020, and then the world shut down in March of 2020. So we persisted despite the pandemic, and we were still able to accrue because we had already made that pivot to virtual health, not knowing the worst pandemic of 100 years would be coming and everybody would be switching or trying to switch to using virtual health. So we were actually able to complete our recruitment, and these are our pilot results. We consented 22 patients. We did have a dropout rate of 18% before the intervention started due to, again, COVID. Like, literally, we went into lockdown, and so two people didn't even wanna come to clinic for that initial evaluation because that sense of fear was so heightened. And then one did have a technology issue, and we did end up finding mild cognitive impairment in that patient. But then 18 started the intervention, and then 11 of them completed 70% or more of the study intervention visits, and so we actually did meet our feasibility outcome of 61% able to complete at least 70% of the visits. And we had seven withdrawals, which are listed, the reasons are listed there, and our dropout. So our dropout rate after intervention start was about 39%, but this is the, a lot of people don't know, but Temel's first study was actually trying to exercise adults with advanced lung cancer, but they couldn't accrue, they couldn't do it. So then that's when she actually pivoted into embedded palliative care approaches. But anyway, so we were able to do this, and our patients loved it. And now in the phase two, we're doing qualitative interviews to really capture the joy of the intervention, because it's also, I think, really decreasing social isolation, which we didn't measure in the pilot as well. And that's also been a huge issue post-COVID for older adults. And so the phase two's open, we've completed 25% of our enrollment, even, we've only been open for five months, so it's going great, and it's randomized to the intervention versus usual care, which is just a standard referral. And so that'll hopefully, we'll hopefully finish up accrual within the next year and a half. And so this is, again, the pilot feasibility data of those 18 participants. So we were able to really enroll a variety of treatment types, non-small cell and small cell. We also collected stool samples for the gut microbiome, and so we actually have the taxonomy of the bacteria listed there, and then we were also able to pilot using actigraphy to get some more objective movement data. So really rich data source here that we were able to do despite the pandemic. So that was just a very brief snapshot of the possibilities of things that you can do in survivorship care, and these patients were all on active treatment, and so now we're modifying it to see if we can do it for patients undergoing surgical resection, and then also patients who are done with their cancer treatment, because all of these patients were enrolled on active cancer treatment. So really, I hope I've convinced you that survivorship planning begins at diagnosis and includes much more than just cancer treatment, but we really need more novel supportive care interventions and comprehensive survivorship care plans specifically designed for an aging patient population. Thank you. trial. My experience with pulmonary rehab is kind of similar in that we know it seems to work quite well, but some people can't tolerate it in the midst of active therapy. Yet, we know doing something during active therapy is pretty crucial. Dr. Groninger. Okay. Can you all hear me in the back? Okay. My name is Hunter Groninger and I'm a palliative medicine physician in Washington, D.C. at MedStar Health and Georgetown University. And what I hope to do in a few minutes here today is give you a little bit of a vantage point on lung cancer survivorship in a way that aligns hopefully with your own sort of practice and practice patterns and at least brings into conversation some language around what I would call primary palliative care, primary palliative care skills. You've heard a little bit about that already today. That all of us practice in one way or another when we're asking people about their symptoms, when we're asking about quality of life and evaluating that and trying to intervene on that, asking about caregivers and caregiver support and sort of a holistic plan of care. And specialty palliative care, which is what I do, which are people who go through specific training and kind of devote all their times to that. I want to ask really just really quickly, wherever you practice, wherever you are, do you have palliative care readily available? Yeah? Generally? Is it in part of your oncology settings? Pulmonology? Good. Because part of the things that we'll talk about today are just kind of some of the issues that are related to access of palliative care and the impact that that has on overall quality of life in these patient populations. So we don't have enough time to spend to cover all of the things that I would love to be able to talk about with you today, but I just want to cover a couple of survivorship issues that are impacting lung cancer and the longitudinal experience and then at least an update or some considerations of recent interesting literature that you might consider in your own practices moving forward. Just as a 30,000 foot view, just to echo what my colleagues have already shared with you, thankfully the Cochrane Review has kind of hit the nail on the head finally that if you, if patients have unmet supportive care needs, it leads to poor quality of life. That's something that I think we've known anecdotally for a while. The evidence is becoming very robust to show that and that constitutes not only physical symptoms, which I think is probably what we spend most of our time thinking about when we think about quality of life and assessing palliative and supportive care needs. But I also really want to call out and emphasize psychosocial distress. Dr. Beatty talked about depression and anxiety and the impact that that has on quality of life and therefore on morbidity and mortality, but also caregivers and caregiver support. And then finally I think something that we're just beginning to think about and some of my colleagues have already brought up today, more practical issues around quality of life, like your home environment and geography and ability to make a home, to provide for your dependents, to provide for yourself, transportation and so on. And all of these things, I know as I am proud of where I practice in central Washington, D.C., but where many of our patients living with lung cancers have to take two buses and a metro to get to a palliative care follow-up visit or to engage in a cancer support group. That's something that we still haven't figured out how to address really well. And in lung cancer, I think we know now that this is a wider gap that needs to be met compared to other malignancies, for example, breast or colorectal malignancies. The American College of Chest Physicians has certainly recommended an introduction to palliative care for stage four disease. Some time ago, this last was updated in 2013 over people with a higher symptom burden. I would even advocate to go beyond just sort of a discussion of palliative care, but really more of an introduction and maybe integration earlier on. We'll talk a little bit more about specialty palliative in a bit. And health disparities, I think, need to be brought into conversation as well. And when I talk about health disparities here, and I'm no health disparities expert, but certainly issues around race and ethnicity, geography, as I mentioned, how hard is it to get to these appointments, socioeconomic issues, am I able to make my co-pays, am I able to pay for my medications? Our case conference in our hospital with our service last week was a patient who was unable to pay for her long-acting morphine for her cancer pain. So how are we able to begin to bridge these gaps? And where do these disparities really arise? Well, we've known for a long time that people in under-resourced groups have much, much less access to pain and symptom assessment and to management strategies. We also have a much better developing sense that these patients have worse access to specialty palliative care, to integrative therapies when that's of interest to them or relevant to their symptom management, and to mental health specialists. And finally, I think we're getting a better sense that even on the level of support communities, where people are being able to connect with others who are living in similar situations, certainly the pandemic, as we just noted, we've all experienced, has really brought out the importance of telehealth and telehealth access. But there are, again, under-resourced communities, I think that many of us are participating in their care, that still don't have great access even to those support mechanisms. We've talked a little bit today already about common symptoms in advanced lung cancer, lung cancer survivors. Here are some of the top three. I won't go through all of these today, but I just wanted to point out a couple of things related to fatigue. We talked earlier, we heard earlier about the importance of some non-pharmacologic interventions that could be emphasized more. Regarding dyspnea, I always like to point out that there's some really small but interesting research to me on airflow and fans improving dyspnea in this patient population. It's a cheap, easy way to help people feel better really quickly without a lot of side effect. And then finally, regarding pain, I think emphasizing not only comfort and skill with opioid therapies, but opioid therapies are certainly have come full force into the mainstream in long-term cancer care. I'll share in a couple of slides one of the consequences of that. And so I really encourage people who are continuing to hone your primary palliative care skills to continue to emphasize non-opioid therapies or whenever possible, non-pharmacologic strategies, of which there are many that are developing and certainly have a much better safety profile. So I said that I would just bring up a couple of recent studies or findings in the last few years that might be interesting for us to be thinking about and maybe some signals of where directions are we going in this intersection of palliative care and lung cancer survivorship. This was an interesting multi-site randomized control trial that was looking at patient-reported outcomes-based PRO monitoring and alerts for patients who were undergoing lung cancer surgery post-operatively in their care. And the surgeons actually, I like this, the surgeons received triggered alerts on smartphones for events that the patient would say, I'm having problems with pain or with dyspnea or with cough or with sleep or with fatigue. And in the PRO alert group compared to usual care, they had fewer threshold events. People were able to kind of get to a rising symptom a lot quicker and mitigate it a lot better. And I bring this up just as a way that technology, I think, in symptom assessment and management is really going to become more integrated with end users. And our patients will be, as they become more, as we all become more savvy with technology, we'll be able to use these PRO alert mechanisms to reach better symptom management earlier and better. But I also mentioned I would talk about opioid therapies in the long term and some interesting data on long-term cancer survivors is also showing that many, many of these patients are on opioid therapies and benzodiazepine therapies for a very, very long time, often when they're far into the survivorship phase. In this cohort, about 36% of these cancer patients were patients with lung cancer. Of those, 8% had what I would call very high doses of opioids, more than 90 oral morphine equivalents a day that they were being prescribed, and really not a lot of kind of long-term oversight into that. I don't think that's because we don't care, people don't care. I think that it's part of our, part of what we talked about a little bit earlier today, that often when patients get into the surveillance and longer-term survivorship phase, that we don't necessarily have great care mechanisms in place, certainly not with palliative care resources to be able to manage that longer-term. And that's something that we need to be thinking about more. I did say I would talk about psychosocial concerns, and this to me is where I think a lot of emphasis needs to be made and a lot of work to be done. Patients living with lung cancer often report psychosocial distress that's three times that of other cancers. And in a lot of these patient populations, measuring psychosocial distress is really overlooked. It's not part of routine care, and when it's brought up, it's not really implemented very well. Some of this, I think many of you probably are aware of this already, that just living with lung cancer, having a diagnosis of lung cancer can, for many patients, create a lot of stigma. Maybe it's related to my smoking habit, and I should have been smoking, and this was wrong for me to do, and so on. And that can lead to a lot of psychosocial distress in these patients as well. But also I think something that is really interesting, emerging, maybe over the last decade, and this is not my area of expertise, but when I learn about the new anti-cancer therapies that have been developed and have been rolled out, and survivorship models are changing over time, even thinking back to that Jennifer Temel study from 2010, how we think about living with lung cancer, and certainly from the specialty palliative care perspective, that patients have to shift more from a diagnosis and a very active treatment, and then perhaps like a relatively short prognosis into a world in which the prognosis is changing, and in many cases, really improving. And I think the patient video that we saw today speaks to that, kind of shifting from a first diagnosis, second diagnosis, and then her comment about having a 50-50 chance, that a lot of patients are living in this sort of in-between state, and that can create, it sounds good in terms of survivorship, that they're living longer and able to do that, but it also comes with a consequence of some psychosocial distress related to just not being sure what's around the corner. And many of us worry about talking about these things with our patients or with their families. A lot of my colleagues across the board I hear often are very concerned about not taking away hope, and this interesting study by Cohen in 2022 looked back at a randomized control trial of advanced care planning in cancer patients and found actually that those who engaged proactively in end-of-life discussions about treatment preferences and goals and completed advanced care planning actually had better hope, higher hope, because they felt more empowered than those who didn't engage in those conversations. So that's a plug to engage in those conversations earlier. As a palliative care provider, when I talk about nutrition, when I talk about eating and drinking, pleasures of life, with my patients I'm mostly interested in are you able to kind of do the things that you want to do and eat and drink the things that you want to eat, but there is certainly data that's worth pointing out that perhaps patients with a higher BMI, with a larger body habitus, may have a survival benefit compared to those sort of in a U-shaped curve compared to those who are with a significantly lower BMI or a higher BMI. And I wanted to point out again that as providers we often forget to ask about or we're worried to ask about sexual health and sexual function, which are significantly impacted living with cancer and cancer survivorship. It's something that our national guidelines are really bringing into the forefront now, but it's something that kind of boots on the ground we either forget to bring up or don't really want to bring up and encourage people to consider that. The last thing I wanted to mention, I mentioned I would go back to specialty palliative care, thinking about the impact of that in lung cancer survivorship. This is always really interesting to me, of course, because it impacts the work that I'm doing as well. This systematic review of concurrent palliative care in lung cancer continues to find this kind of growing body of literature that really started again back in 2010 with Dr. Temel in the lung cancer arena showing improved quality of life, better depression scores, and a better advanced care planning and communication about wishes. Results still tend to be a little bit mixed in terms of does early palliative care impact health care utilization or what some people call aggressive care or intensive care at end of life. I'm not really sure how important that needs to be. I think what's most important to sort of underline and bring to light what the patient's particular care preferences are if he or she has all the information needed to make a decision. It also continues to kind of bring out this question about what is the palliative care secret sauce? What is that palliative care intervention that's happening that's creating these results? This is something that a lot of my colleagues are trying to figure out. If you look back to those early randomized trials of early palliative care versus usual care, those really couldn't be very well replicated today because of the awareness of palliative care and primary palliative care skills that I'm sure most or all of you have as well. Really hard to create that usual care group that doesn't have any sort of palliative skills in it, but we're still trying to figure that out because there will never be enough of me to do all the work that needs to be done out there. Then as a side note, as a palliative care specialist, it is also interesting to reflect on the fact that our own language about integrating palliative care with patients living with lung cancer and doing the palliative care intervention is also having to shift as prognosis is shifting, as survival is improving, and we're still trying to figure out where should we begin and where does our role end, does it ever end, and that's something that's really sort of out in the jury right now. So in summary, health disparities certainly worsen survivorship experience and worsen health-related quality of life. Common physical symptoms are still there and there's a lot of work to be done to continue to assess, reassess, and address those. I think psychosocial distress is usually underscreened and under-addressed, something that you should put on your radar. And then finally, that palliative care specialty services in this setting continue to evolve as lung cancer care evolves as well. With that, thank you very much. Lots of references. Be sure to evaluate. Thank you, Hunter. And our last speaker is Dr. Fez, and we will save questions until the end again. Sorry, you're a little constricted. Oh, that's good. There you go. So first off, I'm going to try to give you an overview about sleep disturbances and cancer itself, as well as in lung cancer. I want to thank Dr. Boddy for inviting me for the session and especially ACCP for giving this important issue a stage. I'm going to focus on three different things, and first, like I said, sleep and cancer, lung cancer and sleep, and also touch on workup for sleep disorders. So I think this is probably one of the best diagrams to kind of highlight different areas within the continuum of cancer care where you can have issues, where you can have symptoms. So these symptoms can be fatigue, it can be sleep. Pre-diagnosis, there are studies that show that you can have sleep disturbances even before the diagnosis of your cancer. Cancer-related fatigue can also occur there. When you get the diagnosis, or you may also have fear, anxiety, you can develop insomnias with different therapies as well. There can be hospitalizations, there can be surgeries that can all precipitate insomnia, and that can perpetuate later throughout the cycle of your treatment and the disease. And even within remission, there can be anxiety, scansiety is what we call it. When you get the CT scan, you're like, what is it going to show? You worry. That can disrupt your sleep. And finally, with disease progression, with advanced cancer, we see circadian rhythm dysfunction that can affect their sleep. There's also side effects of the pain medicine, which can lead to sleep disorder breathing, and also impact just the day-to-day functioning of these patients. So sleep disturbance in cancer is well described. Patients reported in, you know, 30 to 87 percent of patients report it. And one thing about all the sleep and cancer data is there's a paucity of data for lung cancer patients. This is primarily in breast cancer patients or other cancers whose survival historically has been better. About a third of these patients may use sleep aids, and sleep issues often persist after the therapy. This graph is a nice study done by Oksana Palash and Karen Mustian, where they looked at insomnia in patients getting chemotherapy during the first and second cycle. And what they found is in cancer patients, the rate of insomnia is three times that of the general population. Factors contributing to insomnia, I kind of touched on this. You may have someone that already has insomnia or predisposing factors, but definitely precipitating factors can include therapy, surgery, hospitalization, and then these can perpetuate with maladaptive sleep behaviors or essentially beliefs or attitudes about sleep that may be wrong. And commonly we'll see patients that say that I haven't slept for three days. They've slept for three days, but they don't feel like it because they're not rested. Sleep apnea and cancer definitely has a link, and there's a lot of both population-based studies as well as animal models which link the two. Primarily the population studies look at incident cancer in those with sleep apnea. So there are two aspects to sleep apnea that can perpetuate or predispose to cancer. First would be sleep fragmentation, which leads to reactive oxygen species and also increased sympathetic activity. The sleep fragmentation can also contribute to circadian rhythm dysfunction, which has also been linked to cancer or tumor genesis. And also intermittent hypoxia where you have hypoxia inducible factor activation. In animal models specifically, they've seen with melanoma where they subject them to conditions similar to what you would get with sleep apnea, less oxygen intermittent, and they've shown cancer progression and aggressiveness. There are limitations to these in terms of, you know, not all these studies were designed to study the association and cancer behaviors may actually vary. So looking also at sleep apnea and actually those that have cancer is yet to be done as well. Well how about lung cancer and sleep? Well lung cancer and sleep, the data is limited mainly because these patients didn't survive and were basically focusing on treating their cancer. But within the cancer and sleep literature, there's a lot of data or talk about symptom clusters. So you have different clusters of symptoms that exist. So you may have pain, fatigue, and sleep disturbance. They may occur together, they may perpetuate, they may antagonize each other. With lung cancer itself, in addition to the normal psychoneurologic symptoms such as fatigue, depression, anxiety, you can also have GI. But you can also have respiratory. So if you're coughing all night or you can't breathe or you're wheezing, that can keep you up as well. The data, like I said, is limited. One earlier study shows that in patients that had polysomnography with breast cancer and lung cancer, those that had lung cancer actually had sleep difficulties and sleep patterns similar to insomniacs. Smaller studies have associated sleep disorder breathing with newly diagnosed and advanced lung cancer. There are also studies with incident sleep apnea linking to lung cancer in large population studies or review of databases. And preliminary data though does reveal that there is significant sleep disruption in these patients. We still have to define exactly what it is and likely it's a combination of factors. So when you look at someone with lung cancer, say stage four metastatic disease, one other sleep disorder that can happen is sleep-related hyperventilation. You have disease above the diaphragm, so you may have parenchymal disease, you may have chronic, acute, or chronic radiation changes. You can have pleural disease as well. You can have disease below the diaphragm, so those with metastatic disease may have organomegaly or ascites. And there are other factors such as sedating medicines, upper airway dysfunction, or CNS disease. So metastatic disease to the brain can lead to other sleep disorders, definitely to circadian rhythm dysfunction as well. And finally, in addition to cancer, you can have things that you normally have. So COPD, where we see overlap syndrome, or you can have obesity hyperventilation syndrome as well. One other important point to make is we have a lot of data when your sleep is disrupted, your pain thresholds can be lower. So it's kind of several different cycles that can kind of propagate or perpetuate itself. Finally, for workup or sleep disorders, we would follow the NCNCM guidelines, and really the main thing is to ask. So ask your patients about insomnia. Do you have, do you stop breathing? Do you feel sleepy during the day? Do you have restless leg syndrome? Within our institution, we focus primarily on using surveys when they are referred to the sleep clinic. So we work in a large institution. Not everybody is necessarily referred to sleep clinic, but when they do come, we work closely with our cancer-related fatigue clinic and our supportive care colleagues. We use survey data, and then those that are needed, we do sleep studies. We also look for other things that may highlight sleep-related hyperventilation or sleep apnea with the exam and imaging, pulmonary studies looking for obstructive or restrictive dysfunction, cardiac dysfunction, and finally, laboratory data. There are barriers, definitely, within this population. So first off, you have to recognize the symptoms. Sometimes we're all kind of in our own lane now with multidisciplinary care. We're trying to merge and open discussions. Sometimes a patient and their family is just focused on cancer. They don't have time to do a sleep study or don't want to do a home sleep test or pulse oximetry. And there are other barriers in access to care. So you have to have a sleep specialist within your center. We have to think about it. You have to be able to afford the oxygen or your insurance has to cover the positive airway pressure therapy. So I hope I've given you a good overview of the fact that sleep and cancer are definitely linked and something we need to discuss. There's a lack of data on lung cancer in sleep, but to be continued. And workup for sleep disorders include surveys, other imaging, and eventually sleep testing.

lung cancer survivorship

care models

symptom burden

sleep disturbances

personalized care plans

primary palliative care

psychosocial distress

health disparities

palliative care