Non-small Cell Lung Cancer (NSCLC)-An understated affliction- QnA Session with an Expert
Dr. Kananathan Ratnavelu, a dynamic Malaysian medical oncologist, joined us in a short interview to share his thoughts and insights based on his experience in the diagnosis and treatment of Non-small-cell lung carcinoma, which will help our readers in understanding this belligerent cancer better.
Dr. Kananathan Ratnavelu has been working as a Consultant Medical Oncologist, serving currently in Columbia Asia Bukit Rimau and Aurelius Hospital Nilai.
Five pillars of cancer treatment are immunotherapy, surgery, radiotherapy, chemotherapy, and targeted therapy.
Doctor, let's start the interview with a discussion on the emergence of immune-checkpoint inhibitors and how has it revolutionized the treatment landscape of NSCLC?
Dr. Kananathan: You see, I think it's important for us to understand that there is no single solution for lung cancer. In the Malaysian context, not everyone can afford checkpoint inhibitors. So, the most important thing we can see today is that lung cancer is evolving, and immunotherapy has become the fifth pillar in cancer treatment. The other four pillars are surgery, radiotherapy, chemotherapy, and targeted therapy. Checkpoint inhibitors are one of the key elements in immunotherapy.
Doctor, you mentioned that cost is one of the challenges regarding immune checkpoint inhibitors. Could you help us in understanding other challenges of using immunotherapy?
Dr. Kananathan: First of all, to use checkpoint immunotherapy patients will need to do many tests, which is pretty costly. Then, we need to counsel the patient about checkpoint inhibitors, which have a wide array of side effects that arise from the brain to the lower limbs. Furthermore, the manipulation of the immune system may trigger autoimmune disorders.
So, doctor, as you mentioned that affordability is an important factor in considering immune checkpoint inhibitors. Would you please discuss this in detail?
Dr. Kananathan: I follow the indications as suggested by guidelines in NCCN or ESMO. The guidelines recommend that we first need to check whether it is adenocarcinoma, squamous cell carcinoma, or a small cell carcinoma. Next, we have to look for the presence of mutation and act accordingly.
If the targets are not available and the patient can afford checkpoint inhibitors, we will go ahead with them. Checkpoint inhibitors have to be used carefully. There are selection criteria that need to be full filled. One has to remember once the patient responds, then there is no end date for this, which also means a large number of funds are involved.
During the heights of the Covid pandemic, the production of the investigational product was affected. We had to suspend the study and once things improved the trial has resumed. So, the patients coming to the hospital was not a problem. It was the drug supply that was affected.
Doctor, coming to CAR-T cell therapy, which is another type of immunotherapy, we can see a lot of excitement around them in general. What are your thoughts on CAR-T therapies and its use in non-small cell lung cancer?
Dr. Kananathan: CAR-T cell therapy is well established in hematological malignancies but not yet established in solid malignancies. I am not aware of any CAR-T cell therapy regarding lung cancer.
Doctor, as we have learned that due to the COVID-19 situation, clinical trials were either suspended or terminated. So, kindly let us know the status of lung cancer trials in Malaysia?
Dr. Kananathan: In Malaysia, patients' access to the hospitals during the COVID-19 was not interrupted. Even during the lockdown, patients used to get approval letters from the relevant authorities, like from the hospital saying that they needed to come to the hospital, and they were allowed to travel. So, in general, if a patient is moving to a site to get the treatment, then that was not affected.
I am involved in a lung cancer study. During the heights of the Covid pandemic, the production of the investigational product was affected. We had to suspend the study and once things improved the trial has resumed. So, the patients coming to the hospital was not a problem. It was the drug supply that was affected.
How do you think the ongoing clinical trials on lung cancer will impact in bringing the new treatment options?
Dr. Kananathan: When we look at the landscape of the last 20 years, we find that, initially, it was chemotherapy with single-agent, then there was doublet, triplet, then they went to targeted, and now we have multiple levels. Actually, today, a lung cancer patient can be considered going into a chronic illness condition, as long as the patient is kept motivated. And another thing is, in my part of the country, people need access to this kind of treatment, which means they need money as these treatments are very costly. Thus, these trials are quite helpful.
Doctor, how do you think lung cancer care in Malaysia differs from other countries?
Dr. Kananathan: In Malaysia, healthcare is free when you go to government hospitals, unlike any other country. You can get a bypass and a transplant done in the public sector with minimal cost. This applies to cancer care. Standard chemotherapy, radiotherapy, and targeted therapy are available for the general public. We can say that the Malaysian healthcare system provides for the masses, the drawback is the waiting time. The scenario is different in the private sector, Access to medication that is available in America, Australia, or any other country is available in Malaysia as well, maybe with a few months' difference. The important thing is that these medications are pretty expensive. For example, checkpoint inhibitors can range between 6000 USD to 10000 USD a month. You can imagine the cost for 12 months. I have a patient with Malignant Melanoma who is on the Checkpoint Inhibitor for the last 3 years.
Thank you so much doctor for providing insights on lung cancer in Malaysia and providing your time.