You are looking at early detection of lung cancer, quite an exciting area, really. Here at ESMO you’ve been giving a talk about less invasive treatment for early stage lung cancer. I presume there’s scope for that, why did you think that was an important issue to address now?

It is very important now to [align] the local treatment, in particular surgery or even radiotherapy, to what is the new entity of lung cancer we identified now in the screening era because with the screening programme we are able to detect very, very small tumours: more than 80% are stage 1 and 2 disease, the mean size of tumour is 16mm and many of them are not aggressive tumours.

Now, at 16mm and stage 1a and b you can go for just resection but there is a subgroup of stage 1 that you would go for additional therapy, isn’t there?

Yes. We are going to define and stratify tumours according to the biology of these cancers and in fact we have developed also some prognostic markers that we will find in the serum and these are microRNA signatures. Also we have a gene expression profile of tumours and that can stratify the prognosis of stage 1 disease.

Now, on the state of knowledge right now, how much could clinicians do to either add more invasive therapy or refrain from adding invasive therapy in stage 1 lung cancer?

Today we can analyse very well the type of tumours according to size, to volume doubling time, to metabolism FDG at PET scan and all these are prognostic factors. So if we are in front of the patient with a very aggressive tumour, even in stage 1a, we can do a standard treatment with lobectomy, radical lymph node dissection and what is the best for him. But if we are in the presence of very small slow-growing lesions, despite it will be a true adenocarcinoma or invasive tumour, we can adapt the treatment, reduce the invasiveness, perform minimal invasive segmentectomy or also sublobar resection, maybe without lymph node dissection because we know that we have reliable factors to predict the presence of lymph node involvement.

It sounds as if there’s scope for improving therapy, perhaps improving cure rates in the subgroup who have the negative predictive markers and perhaps for having less morbidity in the ones who don’t have them. But you have, I know, a programme of detecting, of screening for, lung cancer. First of all your standard programme using CT, how does that mesh or join in with your attitude towards making the therapy less invasive?

Of course, we have had a screening programme since the year 2000 and now we have recently started to study a new cohort of high risk individuals with low dose CT plus molecular markers in the serum. We want to validate a signature in the blood that can make early detection very easy and not invasive, avoiding even the CT scan.

So you’ve got the CT scan which can give you some false positives or false negatives but you can add now a molecular signature?

Yes.

How near is that to prime time?

We are validating the signature in a prospective multi-centre cohort. The signature is highly specific and highly sensitive so we think it is very promising for the future for a more diffuse screening in the population reducing the side effects of screening which are nowadays related with the high number of false positives at CT scan, maybe the indeterminate nodules that require sometimes invasive procedures for diagnosis.

Now, it is really exciting to see your enthusiasm for detecting cancer at a stage when it can be cured. What should clinicians take home from your findings so far on this, on the efficacy of finding a subgroup to reduce the treatment on and also on these new molecular signatures? What should clinicians make of this now?

The message of this presentation is that we are now faced with very early stages for which the standard approach and lobectomy is an over-treatment. We are going to analyse the role of sublobar resection in a randomised trial and our future aim will be to evaluate the role of stereotactic radiotherapy instead of surgery in stage 1a disease with good prognostic features.

So in ten or fifteen seconds, what would you say to clinicians about the future for early stage lung cancer?

The future is to detect very early stage with screening procedures to treat patients in a non-invasive way and improve the survival of lung cancer in the next twenty years probably.