Professor Dr Anand Sachithanandan, founding president of LCNMA localised clinical practice guidelines (CPG) for the peri-operative management of early-stage resectable non-small cell lung cancer (NSCLC) was recently launched by Lung Cancer Network Malaysia (LCNM). MIMS Doctor speaks to Professor Dr Anand Sachithanandan, founding president of LCNM on the pertinence of the CPG and how it fits into the Ministry of Health’s Lung Health Initiative (LHI), which is a framework for the integration of preventive efforts; AI-assisted screening; and diagnosis, treatment, and rehabilitation for major respiratory diseases like tuberculosis, chronic obstructive pulmonary disorder (COPD), asthma, and lung cancer.
Q. LCNM recently launched its first national CPG for the peri-operative management of early-stage resectable NSCLC. Why was it important to develop Malaysian guidelines at this point, and what gaps in current practice is it intended to address?
A. Although several international guidelines for lung cancer (e.g., NCCN, ESMO, ACCP and NICE) exist, there are subtle but important nuanced differences from the West. It was imperative that we developed our own national guidelines for several reasons. First, our patient demographics and tumour biology are quite different. For example, we have more oncogene-driven lung cancer here in Malaysia and proportionately more non-smokers affected compared to the West although overall, smokers still make up the largest cohort here. Second, there is considerable geographical discordance with the provision of lung cancer services in terms of access to relevant specialists and facilities for diagnostic and staging tests, and timeliness of intervention across our dichotomous healthcare landscape as some people may seek therapy at a MOH facility, university hospital or in a private center. Third, services and expertise may differ across different regions of the country. Surgery for lung cancer may be performed by cardiothoracic surgeons and some general thoracic surgeons in Malaysia. Access to a staging PET scan is quite limited and varied. Finally, the treatment paradigm for early-stage lung cancer has evolved considerably in recent years hence, the need for a contemporary evidence-based approach. The aim of our guidelines is to harmonise and elevate the standard of care. Put simply, it should not matter where one seeks therapy and by whom. Any Malaysian diagnosed with lung cancer should rightly expect to receive high-quality care in a timely manner, based on the latest available ‘best-practice’ evidence.
Q. What do you consider the most important recommendations within the guidelines that could change how clinicians manage patients with early-stage lung cancer, particularly in terms of multidisciplinary care and surgical decision-making?
A: In total, the guidelines comprise 21 key recommendation statements across five domains: screening, diagnosis and staging, neoadjuvant and peri-operative treatment, adjuvant treatment, and operative procedure and post-resection surveillance. Four key recommendations that warrant special mention are: first, the need to screen the high-risk non-smoker, given the rising phenomenon of lung cancer in the never smoker especially Asians, now overall, the fifth most common cause of cancer death globally. Our guidelines emphasise the importance of screening never-smokers with a salient family history i.e., siblings or first-degree relatives with the disease.
Second, we highlight the importance of reflex biomarker (genomic) testing at the start of the patient journey upon initial diagnosis of lung cancer to guide the treatment strategy. In this era of precision diagnostics and personalised therapies, tumour biology is as important as the disease stage to guide treatment.
A third key recommendation is the need for timely intervention. Time-to-treatment initiation is especially important for early-stage lung cancer and impacts on outcomes in terms of prognosis for survival and cancer-free survival. We have stipulated ambitious but highly achievable timeliness even for the public sector, if prioritised.
Finally, the guidelines reiterate the value and need for a truly multidisciplinary approach particularly for all stage III tumours and many stage II cancers as well. The best outcomes require a cross-disciplinary approach and often multi-modal therapies along with curative surgery. We must move away from a siloed and fragmented approach towards more comprehensive and holistic care.
Q. One of the recurring themes in lung cancer care is delayed diagnosis and treatment. Beyond screening, what changes are needed to ensure patients with suspected early-stage lung cancer move efficiently from diagnosis to potentially curative surgery?
A: For patients with suspected early-stage disease to move swiftly towards definitive potentially curative surgery requires a whole-of-healthcare and whole-of-society approach. First, greater awareness is required from both the public and primary care doctors beyond the traditional risk factor of smoking and a recognition of subtle ‘red-flag’ symptoms (recurrent chest infections, persistent cough) to be quickly investigated.
Second, suspected cases must be prioritised to ensure patients are diagnosed and staged quickly. Leveraging on the vast resources and specialist expertise available in the private sector through a meaningful public-private partnership can circumvent the long waiting times at the government hospitals due to limited resources and overwhelming caseload. Our guidelines, developed by a group of surgeons from public, university and private hospitals across the country, have been endorsed by all the relevant professional medical specialist societies and reflect real-world practice. It can and should serve as a national key performance index to deliver better care and outcomes.
Q. How do the new guidelines fit into the broader LHI, and what are the key priorities for improving lung cancer outcomes in Malaysia over the next few years?
A: Our Health Minister (Dr. Dzulkefly Ahmad) and the MOH have been visionary in developing the LHI. The endgame is to create stage-shift through impactful screening and detect more cases of lung cancer in Malaysia, at an early-stage. This will translate to better clinical outcomes for patients and their families and is more cost-effective for society-at-large. Hence, the guidelines are perfectly poised to complement the LHI, as ‘actionable roadmap’ on how best to manage newly detected early-stage lung cancer.
Q. What do you see as the biggest barriers to implementing these recommendations nationwide, particularly across different healthcare settings in Malaysia, and how can these challenges be overcome?
A: We need a more integrated, less siloed and less fragmented health system. Given the limited facilities, resources and even medical specialists in the often-overburdened public system, it seems only sensible to leverage the facilities and vast expertise of the private sector to ensure timely intervention, which positively impacts patient outcomes.
For lung cancer screening to be impactful, it must be targeted, large-scale and cost-effective. Given the high disease burden and preponderance of late-stage diagnosis here, Malaysia needs a national screening programme; however, this may be hampered by cost. Screening is rarely an isolated investigation, but rather a process and downstream costs of surveillance scans and biopsies have to be factored in. Similarly, biomarker testing and game-changing bespoke therapies (e.g., oral targeted therapy and systemic immunotherapy) are no longer a luxury, but constitute essential standard-of-care. However, therapy access and equity are often limited by financial toxicity as many such drugs are prohibitively expensive. A ring-fenced health budget for lung cancer and other tobacco-related diseases from tobacco taxation ‘sin’ tax revenue can help offset such expenditure in tandem with perhaps a means-tested co-payment model. Switching to generic or biosimilar drugs and local production are other reasonable options to explore, provided safety and efficacy are not compromised. Finally, we must ensure an adequate supply of trained specialists, skilled technicians and allied health professionals for timely and quality service provision. This requires diligent workforce planning and staff retention through appropriate remuneration, incentives and opportunities for genuine career progression.
Q. What would you like GPs and other frontline clinicians to take away from both the new guidelines and the LHI? How can they contribute to improving the early detection and management of lung cancer?
I hope colleagues in primary care will remember that lung cancer afflicts nonsmokers too, and anyone with a salient family history, irrespective of smoking status, should be offered screening. Additionally, there must be a low threshold to investigate any red flag symptoms, and any suspected case should be referred early to a relevant lung specialist. Lung cancer is no longer a death sentence and early-stage disease is curable.
Once a patient enters the hospital system, clinicians must prioritise the diagnostic and staging work-up of any suspected or confirmed case to ensure timely intervention. Collectively, we can eliminate lung cancer as a cause of death and gradually transform even advanced-stage disease into a manageable chronic condition providing those affected with many years of a decent quality of life.
Professor Dr Anand Sachithanandan is a senior consultant cardiothoracic surgeon, founding president of Lung Cancer Network Malaysia (LCNM), Clinical Professor in Cardiothoracic Surgery at Jeffrey Cheah Sunway Medical School, and recently elected to the global advisory council of the International Association for the Study of Lung Cancer (IASLC). He is Chair of the Expert Working Group that developed the first clinical practice guidelines for lung cancer in Malaysia.
The full guidelines are available as a free download at www.lungcancer.net.my
NCCN: National Comprehensive Cancer Network
ESMO: European Society for Medical Oncology
ACCP: American College of Chest Physicians
NICE: National Institute for Health and Care Excellence