Cancer Research, Statistics, and Treatment

: 2021  |  Volume : 4  |  Issue : 3  |  Page : 599--600

Advanced lung cancer: The scope(s) of the pulmonologist!

Jayamol Revendran1, Sujith Kumar Mullapally2,  
1 Department of Pulmonary Medicine, Chettinad Hospital and Research Institute, Kelambakkam, Chennai, Tamil Nadu, India
2 Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India

Correspondence Address:
Sujith Kumar Mullapally
4/661, Dr. Vikram Sarabai Instronic Estate 7th Street, Dr. Vasi Estate, Phase II, Tharamani, Chennai - 600 096, Tamil Nadu

How to cite this article:
Revendran J, Mullapally SK. Advanced lung cancer: The scope(s) of the pulmonologist!.Cancer Res Stat Treat 2021;4:599-600

How to cite this URL:
Revendran J, Mullapally SK. Advanced lung cancer: The scope(s) of the pulmonologist!. Cancer Res Stat Treat [serial online] 2021 [cited 2022 Jan 16 ];4:599-600
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Full Text

It was with great interest that we read the lung cancer consensus guidelines update 2021 by Prabhash et al.[1] It was a commendable effort by all the authors in compiling an excellent set of guidelines which will be useful not only for the oncology community but also for pulmonologists. There have been tremendous advancements in lung cancer management which have led to improvement in both survival and quality of life.[2] Indeed, as patients do well, it is a heartening experience for chest physicians involved in the initial patient evaluation and diagnosis. We would like to reflect on these guidelines in the context of low- and middle-income countries (LMICs) like India.

The article mentions the option of performing a diagnostic liquid rather than a tissue biopsy.[1] The bronchoscopic biopsy is an invasive but safe procedure and is routinely done by pulmonologists across the country. Bronchoscopic procedures including endobronchial ultrasound (EBUS) have a high yield of obtaining tissue for histologic diagnosis and molecular tests.[3],[4] In India, squamous cell carcinoma still constitutes a significant proportion of newly diagnosed lung cancers.[5] Except in non-smokers who may have epidermal growth factor receptor mutations or ALK rearrangements, PD-L1 tests may suffice in those patients and the cost of comprehensive molecular analysis with liquid biopsy can be avoided. The most important constraint we face in smaller towns is the unavailability of validated molecular laboratories to process the tissue and to analyze for targetable alterations. Often bronchoscopic alveolar lavage and biopsies detect co-existing tuberculosis and other infections in our patients.[6]

Liquid biopsy is an important emerging molecular tool in advanced lung cancers[7],[8] However, as mentioned earlier, it is not yet the initial diagnostic test of choice due to a severe lack of access to validated molecular laboratories, the easily available option of bronchoscopy that can be performed by trained pulmonologists (including EBUS at many places), and the co-existing burden of tuberculosis and community-acquired infection in our population; in case the pathology is noted to be squamous cell carcinoma, comprehensive molecular testing may not be as useful as in adenocarcinoma.[9] Thus, the recommendation that a baseline liquid biopsy for molecular testing should be done only if tissue is inadequate and not accessible is very appropriate.[1] Tissue biopsy remains the initial diagnostic test of choice in patients with advanced lung cancers.

The other perspective which needs to be discussed in the context of the management of advanced lung cancers is the scope of a pulmonologist as part of the treating team. Mostly, patients are referred to oncologists by pulmonologists from peripheral towns and even villages. In the era of chemotherapy-only options, there was a need for patients to stay in first- or second-tier cities with oncology facilities for their treatment. The resulting socioeconomic burden was huge for patients and families. As more patients may now be treated with oral tyrosine kinase inhibitors (TKIs) like gefitinib, there exists the option of referring them back to pulmonologists in their locality for the continuation of drugs.[10] In case of clinical progression, they can be seen again by oncologists for re-evaluation, as necessary. This decentralization of oncology care will create better drug compliance and lesser chances of patients being lost-to-follow-up and drifting to alternative medications. It is now essential that training for pulmonologists in follow-up and managing the side-effects of TKIs be taken up jointly by respective oncology and pulmonology national organizations.

To conclude, the guidelines article was an extremely useful summary of current practices in advanced lung cancer for the pulmonology community and will help in creating better awareness. The “scope” of the pulmonologist does exist in both the diagnostic space by bronchoscopy and also as an integral part of the treatment team, especially in LMICs.

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Conflicts of interest

There are no conflicts of interest.


1Prabhash K, Vora A, Limaye S, Sahoo TP, Batra U, Patil S, et al. Treatment of advanced non-small-cell lung cancer: First line, maintenance, and second line – Indian consensus statement update (Under the aegis of Lung Cancer Consortium Asia, Indian Cooperative Oncology Network, Indian Society of Medical and Pediatric Oncology, Molecular Oncology Society, and Association of Physicians of India). Cancer Res Stat Treat 2021;4:279-314.
2Majeed U, Manochakian R, Zhao Y, Lou Y. Targeted therapy in advanced non-small cell lung cancer: Current advances and future trends. J Hematol Oncol 2021;14:108.
3Gaga M, Powell CA, Schraufnagel DE, Schönfeld N, Rabe K, Hill NS, et al. An official American Thoracic Society/European Respiratory Society statement: The role of the pulmonologist in the diagnosis and management of lung cancer. Am J Respir Crit Care Med 2013;188:503-7.
4Krishnamurthy A. Bridging the gap between guidelines and practice for invasive mediastinal staging in non-small-cell lung cancers. Cancer Res Stat Treat 2021;4:360-2.
5Noronha V, Pinninti R, Patil VM, Joshi A, Prabhash K. Lung cancer in the Indian subcontinent. South Asian J Cancer 2016;5:95-103.
6Kaur A, Kajal N, Goyal A. Lung cancer coexisting with pulmonary tuberculosis: A rare case report. Indian J Respir Care 2021;10:126-8.
7Choughule A, D'Souza H. Liquid biopsy in lung cancer-hope or hype? Cancer Res Stat Treat 2019;2:221-3.
8Durrett S, Bowling MR, Oliver AL. The liquid biopsy, what is it, how is it provided, and what is the role of the pulmonologist. Clin Pulm Med 2018;25:33-8.
9Joshi A, Mishra R, Desai S, Chandrani P, Kore H, Sunder R, et al. Molecular characterization of lung squamous cell carcinoma tumors reveals therapeutically relevant alterations. Oncotarget 2021;12:578-88.
10Mohapatra PR. Optimizing the management of lung cancer: Role of the pulmonologist in India. Lung India 2013;30:173-4.