Premonitions About Lung Cancer for the Next Decade 

Daniel Kahneman, PhD, was awarded the Nobel Prize in 2002 for proving, among other things, that intuitions—even expert ones—fail and that formulas based on data fare better. Intuitions are more reliable for short-term predictions if they are based on stable environments.¹ 

For decades, we have had a relatively stable environment in the prevention, diagnosis, and treatment of lung cancer: the indications and contraindications of surgical resection are well established; there do not seem to be more chemotherapeutic agents besides the ones available today; radiotherapy has improved instruments and ways of delivering radiation that were unthinkable a few years ago; screening, although not generalized, is established as an effective way to diagnose lung cancer in early stages, leading to early treatment and prolonged survival; and anti-tobacco policies to reduce lung cancer incidence have been approved and enforced in Western countries of the Northern Hemisphere. Then, in the past few years, two therapeutic innovations came to alter this environment: targeted therapies and immunotherapy. Both have modified the prognosis of advanced lung cancer—mainly NSCLC, but also SCLC. 

However, in the midst of these promising therapeutic advances, we have been struck by the COVID-19 pandemic. At its peak, the pandemic has exhausted material and human resources in many hospitals in all geographic areas, relegating routine medical care, especially the treatment of patients with cancer. We now know that patients with lung cancer being treated during the pandemic or who contracted COVID-19 while in treatment are faring much worse than they should in normal times, and that surgery is associated with higher morbidity and mortality rates.^2,3 Therapy for those who could not be treated was either postponed for weeks or changed to an alternative that did not require hospitalization. The pandemic is likely to get under control at different times in different countries, in a similar way to that of its spread. However, if the expert predictions are correct, we may have to deal with the pandemic for 2 to 3 years before the virus reduces its infectivity and its fatality rate or there is an effective vaccine available to the world population.  

For at least one-third of this decade, the COVID-19 pandemic will interfere in some degree in medical practice. The incidence of lung cancer is likely to continue decreasing in North America, Europe, Australia, and New Zealand, mainly because it is decreasing in men in whom smoking prevalence is lower than in women. However, it will still increase in the rest of the world—especially in South America, China, India, and South East Asia—where, in addition to the lack of anti-tobacco policies, pollution is affecting millions of people living in the largest cities.^4,5 Moreover, targeted therapies and immunotherapy will not be available to patients with lung cancer in these areas due to their high cost. For example, the cost of 1 month of immunotherapy in India is more than Euro 1,100.00,⁶ which is only slightly below the per capita national income estimated for 2020, which is Euro 1,543.00.⁷ Most patients with lung cancer will not have access to these drugs unless they are subsidized. 

In the next decade, the benefits of health policies and new therapeutic strategies available in the Western countries of the Northern Hemisphere will be minimized by the persistent smoking, lack of screening programs, and the unavailability of new drugs in other regions. My premonition is that in the next decade, lung cancer will still be leading the cancer incidence and mortality lists in the world.  

References:

1. Kahneman D. Thinking, Fast and Slow. Penguin Random House UK; 2011. 
2. Lei S, Jiang F, Su W, et al. Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection. EClinical Medicine. 2020;21:100331.
3. Garassino MC, Whisenant JG, Huang LC, et al. COVID-19 in patients with thoracic malignancies (TERAVOLT): first results of an international, registry-based, cohort study. Lancet Oncol. 2020;21(7):914-922. 
4. Youlden DR, Cramb SM, Baade PD. The international epidemiology of lung cancer. Geographical distribution and secular trends. J Thorac Oncol. 2008;3(8):819-831. 
5. Barta JA, Powell CA, Wisnivesky JP. Global epidemiology of lung cancer. Ann Global Health. 2019;85(1):8.
6. Cancer doctors try shorter treatment to cut cost. The Times of India. https://timesofindia.indiatimes.com/city/mumbai/cancer-doctors-try-shor…. Published March 17, 2019. Accessed October 11, 2020.
7. Keelery S. Per capita national income across India in financial years 2015 and 2016 with estimates until 2020. Statista. https://www.statista.com/statistics/802122/india-net-national-income-pe…. Published May 13, 2020. Accessed October 11, 2020.