How Can We Improve Lung Cancer Survivial
-
Upload
kue-lee -
Category
Healthcare
-
view
1.182 -
download
0
Transcript of How Can We Improve Lung Cancer Survivial
![Page 1: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/1.jpg)
Daya Upadhyay, MDAssociate Professor of Clinical Medicine, UCSF
Medical Director, Lung Nodule ProgramDirector, Translational Research in MedicinePulmonary, Critical Care & Sleep Medicine
University of California San Francisco, Fresno
UCSF
University of CaliforniaSan Francisco
School of MedicineFresno Medical Education Program
How Can We Improve
Lung Cancer Survival UCSFCRMCCCC
![Page 2: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/2.jpg)
Future Directions
1. How to Beat the Survival Time Clock
Stage 5-Yr Survival
I A 75%I B 55%II A 50%II B 40%III A 10-35%III B 5%IV 2%
2. Decoding The Cancer Gene
![Page 3: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/3.jpg)
5-Year Survival in Lung Cancer is 17%
Lung Cancer Kills More People Than Breast Cancer, Colon Cancer and Prostate Cancer Combined
These data have not changed in the past 15 years
Lung
Can
cer
ColonBreast
Prostate
158,040
SEER Cancer Statistics Review, NCI.
![Page 4: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/4.jpg)
Lung Cancer is the Leading Cause of Cancer Deaths
SEER Cancer Statistics Review, NCI,
Lung Cancer for 2014
NCI, Cancer Statistics
Prevalence and mortality continue to remain high in Lung Cancer 215,000 are newly diagnosed and 158,000 die of lung cancer
each year
![Page 5: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/5.jpg)
Smoking and Gender Variability In Prevalence of Lung Cancer
From 1974-1994: Prevalence of Lung Cancer in women Increased by 150%;
Death Rates Increased by 600%.
Cigarette Ad 1968 Target women to smokeYou've come a long way, baby
Women
Men
Lung Cancer Prevalence
Tobacco Control Cancer in Men and in cancer in Women
Women are 1.5 times more likely to develop lung cancer than men with same amount of smoking
![Page 6: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/6.jpg)
Early Stage Lung Cancer is Asymptomatic. Therefore Diagnosis is delayed When symptoms occur, its too late
Why is Survival Poor in Lung Cancer
![Page 7: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/7.jpg)
Continued Smoking increases the Risk for Cancer Continued Smoking Decreases response to Therapy “EARLY DIAGNOSIS” improves Lung Cancer survival; however, Early Diagnosis is difficult.
Why is Survival Poor in Lung Cancer
Nicotine Enhances Tumor
Angiogenesis,Tumor Growth
![Page 8: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/8.jpg)
Despite multimillion dollar research on therapy, survival in lung cancer is 17%
“EARLY DIAGNOSIS” is the ONLY factor that improves survival in Lung Cancer. However, the progress is slow.
Why is Survival Poor in Lung CancerSEER Cancer Statistics, NCI
NCI, Office Budget Portfolio
Breast Prostate Colon Lung0
30000
60000
90000
120000
150000
180000 Death RateResearch Funding
![Page 9: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/9.jpg)
Goals
Improving Lung Cancer
Survival
Prevention Early Diagnosis
Early Treatment
Prevention
![Page 10: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/10.jpg)
Lung Cancer is a Preventable Disease
Federal Tax
Nearly 85% Of Cancer Occur Secondary To Smoking
![Page 11: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/11.jpg)
Smoking Cessation Reduces Lung Cancer Risk
Smoking CessationRisk
![Page 12: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/12.jpg)
Prevention: Smoking Cessation: Start Early
90% of Smokers Begin Before Age 1810% of high school kids & 3% of middle school kids smoke Educate Adults and Kids about bad effects of smokingEvery day over 700 kids become regular daily smokers.
We Run a Anti-Smoking Education Program for Schools
![Page 13: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/13.jpg)
![Page 14: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/14.jpg)
Other Smoke
Cigars, Smokeless Tobacco, Chew Tobacco: Are equally harmful
Electronic Cigarettes: Contain Nicotine, which is a carcinogen & Addicting substance
Studies show that E-Cigarettes DO NOT help in Quitting
Electronic Cigarettes Change Gene Expression In Lung Epithelium Similar to Tobacco Smoke
S. J. Park et al. Clin. Cancer Res. 20, B16; 2014).
Nature 508:159;2014
![Page 15: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/15.jpg)
Do Electronic Cigarettes Cause Cancer?
E-Cigarettes First moved into American market in 2007
Became popular in 2010
Target Year2027
-2030
![Page 16: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/16.jpg)
Smoking Cessation Program
Dedicated Smoking Cessation Program At CRMC – UCSF Fresno
We Run a Anti-Smoking Education Program for Schools American College of Chest Physicians
![Page 17: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/17.jpg)
Combination of Risk Factor
![Page 18: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/18.jpg)
Lung Cancer in Non-Smokers
Accounts to <10% CancerWomen > Men Asian > non-AsianEGFR Mutations seenAny Age
![Page 19: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/19.jpg)
Goals
Improving Lung Cancer
Survival
Prevention Early Diagnosis
Early Treatment
Early Diagnosis
![Page 20: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/20.jpg)
CT Screening may be the First Step In Early Diagnosis
Identify High Risk Population
2011 National Lung Cancer Screening Trial
SEER Cancer Statistics, NCI.
Target Population at risk1. Smoker who are at high risk2. Target Age Group: 50-79yrs
![Page 21: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/21.jpg)
Stage / Survival%IA:75% IIIA: 10% 65%IA:75% IB: 55% 20%IIB:40% IIIB: 5% 35%
Stage / Survival %
Why should we Speed up the Diagnosis?
Survival Time Clock
Stage TNM Rx 5-Yr Survival
I A T1N0M0 Surgical Resection
orSBRT
+/- Chemoprevention
75%I B T2N0M0 55%II A T1N1M0 50%
II B T2N1M0T3N0M0 40%
III A T1-3N2M0T3N1M0
Surgery + Chemo-XRT 10-35%
III B T1-4N3M0 Chemo-XRT 5%IV Any M1 Chemo 2% Our Goal
![Page 22: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/22.jpg)
Symptoms / SyndromesSymptoms due to Metastases
NO SYMPTOMS
Fatigue, Cough, Dyspnea, Anorexia, Weight lossHemoptysis Chest pain Recurrent infections
![Page 23: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/23.jpg)
Do not offer a Chest X-ray as an option for Lung Cancer Screening
Chest Radiographs are not very useful
![Page 24: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/24.jpg)
75y man smoker incidentalSk
![Page 25: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/25.jpg)
72y man >30 pack year smoking, admitted for CHFGI
![Page 26: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/26.jpg)
66y woman active heavy smoker
![Page 27: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/27.jpg)
DMC31y old woman non-smoker, asymptomatic
![Page 28: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/28.jpg)
![Page 29: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/29.jpg)
Three subtypes: mucinous, non-mucinous, and a mixed mucinous and non-mucinous or indeterminate form.
AdenocarcinomaBronchioloalveolar Carcinoma (BAC)
![Page 30: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/30.jpg)
Radiology (2013) 266(1):304-17.Semisolid Lung Nodule
![Page 31: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/31.jpg)
Most Critical Question is –
It’s Abnormal, What do I do Now?????
Any MD can identify High Risk Patients and can order Chest CTs
Diagnosis is particularly challenging in Endemic Cocci Area
![Page 32: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/32.jpg)
Lung Nodule ProgramUCSFCRMCCCC
Multi-disciplinary Team Approach
![Page 33: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/33.jpg)
Imaging, CT scanTissue Diagnosis- Cytology, Histology
Molecular marker –Mutational studiesIR or CT guided Fine-Needle AspirationBronchoscopic Biopsies Transbronchial Needle Aspiration (TBNA) Endobronchial Ultrasound Biopsy (EBUS) Electro-magnetic Navigation guided Biopsy Esophageal Ultrasound Needle Aspiration Trans-thoracic Needle Aspiration (TTNA)Mediastinoscopy, VATS, Surgical Biopsy
SNapShot Mutation Analysis: EGFR, ALK etc Brain MRIPFTBone Scan
Diagnostic Interventions
![Page 34: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/34.jpg)
Histology of Lung Cancer
NSCLC SCL
Histology: Adenocarcinoma: 50% , Squamous: 20%, Large cell: 3%, Small Cell: 25%, Other: 2%
Non-small Cell Lung Cancer (NSCLC): 75% of Lung Cancers
![Page 35: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/35.jpg)
Early Diagnosis & Early Surgery Offer Best Survival in Lung Cancer
ELC
AP,
NEJ
M 2
006;
355:
1763
-71
![Page 36: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/36.jpg)
Barriers to Surgical Resection of Lung Cancer
Staging in PracticePhysiological Anatomic
Barriers to Surgical Resection
![Page 37: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/37.jpg)
Multi-disciplinary Team Conference
![Page 38: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/38.jpg)
Goals
Improving Lung Cancer
Survival
Prevention Early Diagnosis
Early TreatmentEarly Treatment
![Page 39: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/39.jpg)
Early Treatment
Minimally Invasive Surgery
ChemotherapyInfusion Center
![Page 40: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/40.jpg)
Early Diagnosis of Lung Cancer
Stage / Survival%IA:75% IIIA:10% 65%IA:75% IB: 55% 20%IIB:40% IIIB:5% 35%
Stage / Survival %
Why should we Speed up the Diagnosis? Survival Time Clock
Survival in women is slightly better than men
![Page 41: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/41.jpg)
Early Diagnosis & Early Surgery Offer Best Survival in Lung Cancer
ELC
AP,
NEJ
M 2
006;
355:
1763
-71
![Page 42: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/42.jpg)
Che
st. 2
013;
144(
4):1
238-
1244
.
Early Stage & Early Surgery show Better Outcome in Lung Cancer
![Page 43: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/43.jpg)
Stereotactic Body Radiation Therapy (SBRT)
Surgery vs SBRT
Radiotherapy & Oncology, 2011;101(2):240-244
Stereotactic Radiotherapy Versus Surgery In Stage I NSCLC
Stage I NSCLC Surgery Vs SBRT
No Difference In Survival
Outcomes of Stereotactic Body Radiotherapy In Potentially Operable Stage I NSCLS
Int J Radiat Oncol Biol Phys. 2012;83(1):348-53.
Disease control 98%:1y ; 93%:3y Median survival in potentially operable NSCLC Rxed with SBRT was >5 years.
![Page 44: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/44.jpg)
Personalized Treatment Approach
Has been shown to be very effective
![Page 45: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/45.jpg)
The Digital Future of Molecular Medicine
It is based on decoding of the human gene Use molecular biology technology to
advanced therapy in cancer and diabetes. Diseases are not homogenous
Drugs, Surgery, Radiation, Vaccines, HormonesAdd Targeted Personalized Rx Approach
![Page 46: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/46.jpg)
PD1PDL1
Molecular Targets for Therapy(FDA-approved therapies & Clinical Trials)
NewerPD-1 PD-L1
![Page 47: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/47.jpg)
Personalized Treatment Approach
Use of Tumor Tissue and Blood to detect Cancer Mutation
SNaPshot analysis
EGFR, KRAS, PIK3, ALK, ROS1, PDL1, PD1 CytoGenetic Analysis By qPCR, Allelespecific qPCR, Sequencing
Mutation Targeted Treatment
EGFR
![Page 48: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/48.jpg)
Personalized Treatment ApproachEGFR Targeted Therapy
Lancet Oncol. 2011 Aug;12(8):735-42.
![Page 49: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/49.jpg)
![Page 50: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/50.jpg)
Personalized Treatment ApproachALK Targeted Therapy
N Engl J Med 2013; 368:2385-2394
![Page 51: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/51.jpg)
Personalized Treatment ApproachPD1 and PDL1 Targeted Therapy
![Page 52: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/52.jpg)
Molecular Targets for Therapy(FDA-approved therapies for solid tumors)
Extracellular targetsEGFR/HER (cetuximab, panitumumab, trastuzumab)VEGF (bevacizumab)HER2 (trastuzumab)Intracellular targetsEGFR (erlotinib)VEGFR (sorafenib, sunitinib)mTOR (temsirolimus)PDGFR (sorafenib, sunitinib)RAF/MAP kinase (sorafenib)HER2/EGFR1 (lapatinib)C-kit (sunitinib)
EGFR and KRAS mutations in NSCLC are mutually exclusive
NSCLC patients with EGFR mutations respond well to EGFR-Tyrosin Kinase Inhibitors (EGFR-TKIs)
NSCLC patients with KRAS mutations may be less likely to respond to EGFR-TKIs
EML4-ALK NSCLC: A unique subset of NSCLC who respond effectively to ALK inhibitors
![Page 53: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/53.jpg)
Immunotherapy for Lung CancerTherapeutic Vaccines for Lung Cancer
Monoclonal Antibodies Bavituximab, (SUNRISE; NCT01999673). Rilotumumab, (NCT02154490)
Immune Checkpoint Inhibitors: CTLA-4 antibodies Ipilimumab (Yervoy™), targets the CTLA-4 a Tremelimumab (NCT01655888 and NCT01649024)
PD-1 antibodies Nivolumab (BMS-936558) (NCT01673867) MK-3475 phase III (NCT01905657).
PD-L1 antibodies MPDL3280A (NCT01846416) MEDI4736 (NCT01693562), (NCT02154490)
http://www.cancerresearch.org/cancer-immunotherapy/impacting-all-cancers/lung-cancer#sthash.d5N3xlk8.dpuf
Therapeutic Vaccines: MAGE-3 and NY-ESO-1 Antigen-based immunotherapies Belagenpumatucel-L (NCT00676507) Tergenpumatucel-L (NCT01774578). GV1001 targets hTERT (telomerase ) TG4010 (NCT01383148) INGN, vaccine targets p53 (NCT01383148) A vaccine targeting the WT1 (NCT01265433) CV9202 RNActive®-derived cancer vaccine
Adoptive T Cell Transfer
Genetically Engineered T cells – target CEA (in 30% of NSCLC).Genetically Engineered T cells – target NY-ESO-1 (NCT00670748)
![Page 54: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/54.jpg)
Poor Prognostic Factors
Presence of pulmonary symptoms Large tumor size (>3 cm) Non-squamous histology Poorly Differentiated Metastases to multiple lymph nodes within a
TNM-defined nodal stations Vascular invasion.
![Page 55: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/55.jpg)
![Page 56: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/56.jpg)
![Page 57: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/57.jpg)
![Page 58: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/58.jpg)
The Digital Future of Molecular MedicineIs a Bright Ray of Hope
Our goal is to examine mutations by molecular studies in all patients to direct personalized treatment.
Very Expensive Mutation Genetic Tests, Not frequently Covered by Insurances
Limitations
![Page 59: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/59.jpg)
Early Diagnosis improves survival in Lung CancerCT Screening can saves lives in very selected patients It is expensive; Health care cost is very high Smoking cessation is important in reducing cancer riskPET Scan are False Positive in our Cocci areaAccess to Organized Multidisciplinary Lung Nodule
Program is essential for early diagnosis & managementMolecular marker Targeted Therapy is the futurePrevention, Early Diagnosis and Early Treatment can
help improve survival in lung cancer.
Summary and Conclusion
![Page 60: How Can We Improve Lung Cancer Survivial](https://reader035.fdocuments.us/reader035/viewer/2022062822/587c74241a28abd04e8b651d/html5/thumbnails/60.jpg)
Thank You