Welcome to the ISLC webinar. We are going to talk about the highlights of Latin American Lung Cancer Conference that we had recently in Bogota, Colombia. My name is Luis Reyes. I'm the Medical Director of Memorial Cancer Institute in Miami, Florida. I'm a medical oncologist, thoracic oncologist. And Dr. Clarissa Valdoto, who is co-chairing with me, and I will be your webinar moderators today. We will start this activity with some brief housekeeping items. After the presentation has concluded, you may ask questions using the Q&A button feature located in your video screen. We will be addressing questions after the, we have three speaker presentations as the time permits. The accreditation, this activity has been planned and implemented in accordance to the accreditation requirements and policies of the Accreditation Council for Continued Medical Education, ACCME. The International Association for the Study of Lung Cancer is accredited by the ACCME to provide continuing medical education for physicians. The International Association for the Study of Cancer, ISLC, designates the live format for this educational activity for a maximum of one AMA PRA Category 1 credits. Physicians should only claim credit commensurate to the extent of their participation in the activity. All faculty, planners, and reviewers for the webinar today have disclosed their conflict of interest. This information is provided on the slide. Clarissa. Hi, hi, everyone. I'm Clarissa Baldotto. I'm a Medical Oncologist at Instituto Dori in Rio de Janeiro, Brazil. I want to thank you for being with us today. I'll start the webinar introducing Dr. Lucia Viola. She was one of the chairs of the LAUCA meeting this year. She's a Pneumologist, Head of the Oncology Service and Institutional Lung Cancer Screening Program at the Fundacion Pneumologica Colombiana in Bogota, Colombia. Welcome and thank you, Dr. Viola. Thank you, Dr. Baldotto for the introduction. Many thanks to the public here today. Let's start with the best of LAUCA 2024. As Dr. Baldotto mentioned, I'm an Interventional Pneumologist and I will share with you the lung cancer screening situation in Latin America and something also related to lung cancer diagnosis here in Latin America. You know, Latin American heterogeneity in the population is important for the clinical presentation of lung cancer. And this is the first abstract selected for this best of LAUCA 2024. This is an abstract presented by Dr. Oscar Arrieta. We know about Dr. Oscar Arrieta previous publications about lung cancer screening in people who have never smoked. And this is one also in this topic. They presented here the genomic and clinical profiles associated to wood smoke exposure among patients with diagnosis of lung cancer. This is a cohort, a retrospective cross-sectional single center study between 2022 and 2023. And the background is that wood smoke exposure is a risk factor for lung cancer in the low and middle income countries. And what they did here was try to identify understand the genomic and clinical characteristics of Latin American patients with non-smoke cell lung cancer. And they did a retrospective cohort and they selected these patients to have the characteristics, genomic characteristic of the tumors. What they found was interesting, very interesting. We know here in Latin America that we have a high proportion of AGFR mutated lung cancer cases. And as they use this diagnostic tool to characterize this population, they found a concurrence with TB 53 between these patients. What is not usual because the panels we use here in Latin America are not this wide and we don't have access to these kind of information which is relevant and important for the future of research in lung cancer here in our countries. There is also an inverse proportional correlation between PD-L1 expression and the WSE index. They selected the population based on the exposure to wood smoke. They tried to do it very systematically, selected the population based on the index cooking score. And I think it's important for our region to have this kind of information. The next, well, the discussion was focused in the biology of the lung cancer in people without a history of tobacco exposure. And we know that this is a different heterogeneous disease and access to genomic profiling here for lung cancer in Latin America is a big concern. There's also concerns about the good quality of the tissue to have these kind of diagnostic tools. The next abstract selected is a lung cancer screening pilot study here in Latin America. What do we know from the previous lung cancer screening clinical trials is that almost a big proportion of them were positive in LST, the Nelson trial. And there were also negative studies. For example, the Danish lung cancer screening trial was a negative trial. And what we know is that the mortality reduction from any cause is very important in the positive studies. And the mortality reduction from lung cancer is also important in these studies. What they did, this is an abstract submitted from a Colombian group in the middle region of the country. They selected a population based on the lung cancer screening trials, you know, traditional risk factors. They choose people between 50 and 75 years old with high risk for lung cancer, with tobacco exposure. And what they did for this population was screening for lung cancer using low-dose CT. The methodology was a retrospective multi-center screening study. They had the database for medical records from an insurance company here, from one of the biggest insurance company here in Colombia. And they applied a model between 2022 and 2024. The results, the screen population was almost 2,000 people. The cases detected were 14 number needed to be screened to detect a case. This was 140. The proportion of early stage diagnosis for the patients was 27. 71.4 versus 5.2 for the patients detected by screening and by clinical diagnosis. This is what they presented, the cases detected by screening versus clinical presentation. The big proportion of the screening detected cancer cases were earlier stages, stage one and stage two, more than 70%. The clinical detected cancer cases was about 5%. The cost for every patient expressed in USD, was 20% of the global cost of the clinical detected cancer cases in the screening cohort. They were obviously more frequent in the clinical detected cancer cases. And the follow-up was short, which is one of the limitations of this study. What we discussed about this ASTRAD was we need to continue applying for lung cancer screening, at least here in Latin America, with the information that we have from the big clinical trials and from the regional clinical trials. For example, the BREL-2 trial is to continue applying the traditional lung cancer screening selection of the population. The granulomatous disease was not a problem for them as it wasn't in the BREL-2 trial. In the low-income countries, lung cancer screening could reduce the cost for the healthcare. These findings are very promising. And this must be integrated into a national policy framework. Well, what we know, trying to put these two ASTRADs together, is that, for example, in the Thailand, which was a lung cancer screening trial in never a small population, is that they selected the population based on the wood smoke exposure. And they also are having very good data about the genomic profiling of this population. We are still waiting for these publications. But I think it's not, in Latin America, maybe having access to lung cancer screening in selecting the high-risk population based on tobacco exposure would not be feasible for every region. And we need to go further and try to have interesting information about the never smokers and the trials that could be applicable to Latin America. And many thanks for your time. This is all from me today. Our next presenter is Dr. Estela Martinez. We are going to do questions and answers at the end. So please, if you have questions, I already mentioned to put it out. Dr. Estela Martinez is a thoracic surgeon from the Luis Carlos Armiento Angulo Cancer Treatment Research Center in Bogota. She was one of our chairs of the LALCA meeting and she's going to do the next presentation. Thank you. Regarding surgery, I want to highlight that surgery is an important tool in the treatment of non-small cell lung cancer, still in advanced stages. In locally advanced resectable non-small cell lung cancer, recently neoadjuvant therapies have changed the outcomes. The N-staging is essential, but difficult. Adequate staging is necessary to be able to offer appropriate treatments. And in LATAM, we have limitations in access to genomic profiling and new therapies that maybe produce some problem with access in immunotherapies and target therapies. Inadequate staging prevents patients from benefiting from appropriate therapies. And this is the abstract that I will comment. The authors trying to see how risk factors are associated with nodal upstaging in stage 1A lung adenocarcinoma. This is very interesting because I think many of us are interested to have a good N-stage that usually is discordant. They based his work in these results of the 9th edition when the pathological nodal status is a strong predictor of long-term outcomes. In all the T's, even if it's T1 or it's T4, and in this course, we can see that stage N0, pathological N0 has a five-year survival over 80%. They present also that the patients who had nodal upstaging had many opportunities with adjuvant therapies that every day are evolving. And they mentioned also that recent studies as this Japanese and this American study that are very well known for us, defining that sublobular resections are not inferior to lobular resection, especially in T1A and T1B. And this is the reason because sublobular resections have become popular and is very important to have in mind that the nodal staging, even in these small cancers is important because sometimes they can have N1 or N2 positive. The aims of the study are trying to identify rates and trends in nodal upstaging and identify risk factors and evaluate the predictive model and evaluate also the impact of sublobular resection in nodal evaluation. These are the methods and the outcomes are rate of nodal upstaging and factor associated with nodal upstaging. They collected 626 patients and in 35 of them, they get nodal upstaging. It was 5.6% and the results were that nodal upstaging had differences statistically significant when they saw PET-SUV max and if the nodal was GGO or not in intraoperative factors, all of them have significant differences. Even the surgical approach, the type of lung resection, the number of lymph nodes resected, the number of stations that they assess and in pathological aspects, they found important differences, especially in visceral pleural invasion and in lymphovascular invasion, but also in the subtype of adenocarcinoma that we expect the micropapular and solid adenocarcinomas have more possibility to have upstaging. But when they performed a multivariate logistic regression, they found that only the pathological aspects have a real difference, significant differences. It was in visceral pleural invasion and lymphovascular invasion. The problem is that it has a little impact on surgical decisions, because we know these factors after surgery. Of course, we can re-operate the patients, but I think we don't have enough evidence to decide that, especially because we have other treatments. They tried then to build a predictive model using the pathological factors and the PET-SUV-MAX, and it was positive. But anyway, it is not a predictive model because these factors, we know them after surgery. The conclusions for them were nodal upstaging remains a concern in clinical stage 1 adenocarcinoma, despite modern clinical staging modalities. Visceral pleural invasion and lymphovascular invasion are strongly associated with nodal upstaging. Sublovar resections are associated with lower rates of upstaging. The use of sublovar pulmonary resections in the presence of identified risk factors deserves continued evaluation. All of these conclusions are true, but again, more studies are needed to know better predictors of upstaging, I think. Thank you very much. Thank you, Dr. Martinez. Well, our next presenter will be Dr. Raiz. Unfortunately, Dr. Cardona had some technical issues and he will not be able to join us today. So, Dr. Raiz had the kindness to substitute him in this presentation today. Thank you. Well, I tried to do my best. Let's see. Okay. So, basically, Dr. Cardona, unfortunately, as Clarissa said, couldn't come. But he had a presentation that we are going to try to follow. During the meeting, during the LALCA, he reviewed three abstracts that I think are very important and interesting. And we are going to briefly review them and then we will have time for questions. The first abstract is about the challenges and opportunities to do lung cancer research in Latin America. This is a very relevant topic for us Latin Americans, you know, I'm Peruvian, because we need to increase the research in Latin America. And the ASNC has this as an important mission for us, for our continent. You can see in the right, in the pie chart, that the clinical trials are not homogeneous in Latin America. Most of the research has been done in Brazil, as you can see in blue, or Argentina, and probably following by Mexico. And it's very centralized compared with other countries. Latin America has more than 25 countries, if you consider. And you see in this pie chart, five or six. So, that's why there is a lot of needs that need to be made. And if you look at the bottom in that map, Dr. Cardona chose this slide, because you can see the amount of money invested for the pharmaceutical industry. Because in Latin America, due to lack of resources, most of the research is driven by the pharmaceutical industry. We're very lucky to have the industry as partners. But you can see the amount of money invested is very disproportionate. Same thing in Brazil and Argentina, and a little bit less in Mexico. But then all of our other countries are far, far below. And that is why, I guess, there is a need to, I guess, increase the research, because a lot of this funding, for example, from industry comes from outside the continent. So, in other words, it comes probably to Brazil, because there's more trials, some more researchers, but that doesn't mean that it cannot come to another country. So, that's why these are things that we can solve, you know. This is, for example, the number of trials. And these trials by country, you see, are divided by their clinical trials. They are early phase ones. As you can see, pretty much, most of the trials are phase three. And that is not bad, because in Latin America, the industry gives the control. So, if you are matching a chemo against a new immunotherapy, the good thing is that the industry will provide also the chemo. So, all the patients have access to either something when we do a phase three trial. But ideally, we would prefer to do early phase studies, like early phase ones, because as we know, that's where most of the benefit comes with the new agents, new drugs, especially now that we're doing target therapy. Sometimes, you know, I participate, for example, in the approval of larotrectinib. And, you know, we only had 100 patients in the phase one, and that was enough to get the approval. So, we don't have to wait for the phase three. That is why also I call our friends in Latin America, our colleagues, we need to try to ask the industry to allow us to do more phase twos, if it's possible, phase ones, because, as you can see, that makes a big difference. And our patients have faster access than only doing phase threes. And as you can see, again, it's the same trend. Most of the research is done in Brazil. You see the large number of trials, 1349, compared with other countries. And that is something that we're going to keep working on this. Regarding institutional studies, this is very important, because we have to generate our own research, because industry may not be covering all the areas that are important for us, especially when we have regional differences. To give you an example, in the Andean region, in Colombia, in Peru, in Bolivia, lung cancer is associated with cooking inside the house. That type of lung cancer may not be the same type of lung cancers that we get anywhere in the world. So, that's why we cannot expect the pharmaceutical company to give us all the funding for research, because this is something that happens only in this country. So, that's why maybe it's important that we get support from the different institutions at the local level, or we request support also, to do our own research. The other important thing is to collaborate among ourselves, because you can say, okay, we don't have a lot of resources, but you can collaborate. For example, we have the LACOG, the Latin American Cooperative Group, that Dr. Carlos Barrios has in South Brazil. But the LACOG runs Latin American studies in several countries. So, if you don't have access to generate a clinical trial, at least you can join. You can try to see if you have the logistics to join this Latin American Cooperative Group. In another level, for example, we have the CLICAP that Dr. Cardona and Dr. Arrieta are founders, that basically we publish together, you know, including people like me from the United States. Sometimes we join together. We try to do chart reviews, gather our data for our patients, and we have a lot of publications every year. You can join us and participate with, you know, providing your data. In that way, these inter-institutional projects are very important, because that gives us an idea about what's happening in the whole Latin America. Because if each of us publishes, oh, my EFR from Peru, my EFR from Bolivia, my EFR from Colombia, it's not the same. And also, you know, these genetic aberrations, especially, are not very common, some of them. That's why, for example, with the CLICAP, we publish our red data. We want to publish our red data soon. We already published our ELK entry in Latin America and things like that. So, it's all of these. If you want to try to start a cancer research in Latin America, don't forget about this. Try to look for outcome research. That's the most basic one. You can do the assigned population-based studies. You can do the networking. Use mentorship. You know, a lot of us live in the United States, but we're Latins. We love to mentor people in Latin America. A lot of people in Latin America come to the United States to rotate. We'll be happy to host you here and help you and collaborate with you and improve the research with all of this. The other abstract that Dr. Cardona wanted to review, it was the association between air pollution and lung cancer. You know, this is very important because if, I don't know if you are aware, but Dr. Charlie Swarton from the Crick Institute, already from London, already showed us, if you remember, it was last year in World Lung, that the PM25 particle is associated with the developing of EFR in tumors. So, that's why more and more we are getting, we're closing to prove that lung cancer is associated with pollution. So, I know that sounds obvious, no? That more pollution, more lung cancer, but we need really to prove it. It's the same as the tobacco. It was not easy to prove and accept that tobacco causes cancer. This is now we're in the process to prove that the pollution causes lung cancer, but we need a lot of studies. That's why I think Dr. Cardona considered this abstract important because this was done in Colombia. You know, there is a lot of environmental and occupational agents that are carcinogenics. It's not only the PM25. Like, for example, here in Colombia, they check the nitrogen dioxide, the sulfur dioxide, the PM10, and other pollutants. And basically, the investigators here were associating the measurement of this in 12 air stations in Bogota and getting a group of 200 lung cancer patients and trying to find if there is an association. This is only epidemiological association. Of course, it's not cost effective because this is impossible to prove this in the lab with humans. But there was an association. Of course, if you are EFR positive, you live longer. If you are a non-smoker, you live longer. It was hard to prove that every individual pollutant that was listed here, the PM2.5, the PM10, and SO2, are associated with lung cancer, mainly EFR. However, there is a tendency in the univariate analysis, as you can see here, that there is a potential association if you are EFR positive with some of the pollutants like PM10, PM2.5. And this is like a pilot that can give us opportunities to do much larger studies. The sample here was small. 200 patients is nothing to do an epidemiological study of this magnitude. We need to analyze thousands of patients. But this is very challenging. As more data we gathered around the world, I mentioned before, the PM2.5 is probably the suspect number one among all of the pollutants here. But that's why I think Dr. Cardona found this presentation very interesting. We are working to prove that pollution causes lung cancer so we can ask our governments to take care of this problem. Because if it gets worse, lung cancer will not disappear only telling people to stop smoking tobacco or using tobacco products. Finally, the last abstract that was chosen is among the disparities. In the United States, we have this NCBD database that you can interrogate freely because it's free, and then you can do studies. The database has minimum data. They have age, sex, descriptives. Maybe in this case, for example, they are interrogating the database to see if there is any correlation between access to immunotherapy and ethnicity and race. But you cannot expect to have a lot of data because what we report to this database is the minimum. But anyway, these are interesting studies. This is basically here. In the NCBD, it had data in 96,000 patients. As you can see, 10,000 got immunotherapy, 85,000 no. And to make the story short, basically, patients that have senior patients, more than 65, and patients that have comorbidities have less access to immunotherapy. And there were other interesting factors like insurance, education, facility type, household income. This study also found something that we already know, that there are disparities in the survival in lung cancer comparing Black population, Hispanics, and Whites. We already knew all that. But the important thing is regarding immunotherapy, lower education and income were associated with lower odds of immunotherapy therapy treatment. These associations persisted for non-Hispanic White patients. However, among non-Hispanic Black patients, there was only association with lower education. As I said, this is very interesting because we know that there are disparities in lung cancer outcomes. But I encourage people that have never worked with this NCBD database to do studies. You can interrogate the database and try to find. I know this is limited information that we get, but you will never find the opportunity to work with so many samples so large as the ones that we have access here. I am going to stop here because we are going to have an opportunity to ask questions to our panelists today. Thank you, Dr. Reyes. You did a terrific job in the last minute. Well, now you're open for questions. If the audience, if anyone has any questions, you can put on Q&A and they're going to read it out loud here. In the meantime, we also are going to put up some questions for the speakers. I want to start with Dr. Viola. We are hearing a lot about this difference in Latin American ancestrality, maybe environment exposure. We are also trying to do screening trials or screening implementation in Latin America following the U.S. guidelines, the European guidelines. Do you foresee any opportunity for us to try to create our own lung cancer screening guideline or at least try to look at these specificities in Latin America while we are trying to implement this screening, a lung cancer screening in Latin America? How do you see them? Well, thank you, Dr. Pallotto, for the question. I think it's an interesting point of view in lung cancer screening. I think Latin America, it's a heterogeneous region. We have countries with high prevalence of tobacco exposure like Uruguay, Argentina, and the behavior of the disease in these countries is quite different from the countries where the population exposed to tobacco has lower rates of tobacco exposure. As we can see here, for example, in Peru, Colombia, Mexico, where wood smoke, the exposure to wood smoke trends a different kind of disease. I think that we must have our lung cancer screening guidelines. We do have guidelines here in Latin America. The Brazilian guideline is pretty good for selecting high-risk population based on tobacco exposure, for example, but we don't have any guidelines, for example, for people exposed to other risk factors as wood smoke or, for example, for people with historic clinical records with respiratory disease as COPD or interstitial disease, but I think we need more data here in Latin America. My suggestion for the working group in the IASLC has been to have at least a registry here in Latin America, and we are trying to make that possible because we need to have data, you know, to make a pilot study for each country that is going to be high cost for the countries. Governments have a low interest in conducting lung cancer screening trials and to have a healthcare policy or mandatory lung cancer screening for each country. That's not a priority for healthcare in Latin America. And I think we need to be more organized in our countries and to know our epidemiology, for example, and then to know if it is correct to make a lung cancer screening for each region. I think that that could be a mistake, but for example, we can try also to uptake the Asian strategy of selecting people without tobacco exposure for selecting high-risk population based on other risk factors. I have a question for both of you. You know, it's so hard even in the United States to do lung screening, because we depend for the primary care doctors to send the patients, you know, because we are cancer doctors, we don't screen really. So we need to wait for the primary care patients to identify the patients, send the patients, the patient has to come. A lot of times patients only come one time and they never come next year. How about the implementation of the incidental pulmonary nodal program? You know, for the people in the audience, if you don't know is, so what we do is we go to the radiology department in the hospital and we check all the CAT scans on the chest zone for any reason. And in these CAT scans, we identify suspicious nodules. So we call the patients, we enroll them in the screening and we follow them. For example, in my institution doing that, we found eight or nine times more cancers checking the pulmonary nodules than waiting for the patient to come. Does it, how about, and the advantage of that also is that for people that don't qualify for screening, for example, people that doesn't smoke, we can diagnose some lung cancers with incidental pulmonary nodules, you know, so. Well, I think that's a great strategy to catch earlier stages of lung cancer. And I think that's the, maybe that's the answer to this question here in Latin America. Because as you just mentioned, Dr. Rice, selecting high-risk population based on tobacco exposure could not be a good strategy for the entire population in Latin America. So selecting the population from incidental pulmonary nodule clinics is a good idea, is less expensive than lung cancer screening. And we do have some previews data about this. You know, the publications from the Mississippi Delta in the United States that could be, represent more close to the reality of our population, because, you know, the access there, the population has some characteristics that could be similar to the characteristics here in Latin America. So I think that the incidental pulmonary nodule is a good way to start. And then you can also build your lung cancer screening program from this initial strategy, or for example, from the multidisciplinary tumor board. Actually, we have here in our institution an incidental nodule tumor program using AI. I had the chance to present it at the WCLC meeting, and we had a high detection of lung nodules with diagnosis of lung cancer, actually. I agree, I think we should move in different fronts. We need to have a structured lung cancer screening programs, but I also believe that incidental lung nodule programs, they are also an opportunity to try to look at this non-high risk population, as we are mentioning here, the non-smokers, people exposed to other risk factors. At least in Brazil, CT scan is becoming the new X-ray. So almost everybody that has a chance to go someday in the hospital, they get a lung CT scan. And we are trying to move in all these different fronts in order to screen our patients here. Yes, I think that furthermore, the patients will be more determined to assist to the controls, because when you don't have any nodule or any disease for the screening patients, it's not very useful that the patients continue assisting to their controls. Maybe in these cases, when you have one nodule, you are worried about that, and I think it's better. I have another question also, that is very common. You know, Lucia, you mentioned the talent study. You know, this is a study done in Taiwan for people that are non-smokers. So are we ready to start to screen people that are non-smokers? Well, I think in some regions in Latin America, where the tobacco exposure is not that high as the one we can see in Europe, for example, in some regions of Europe and in some regions of North America, it could be a good way to select the high-risk population, because it's not like selecting people from nothing. No, that's an incorrect view of the situation, because they did select the population based on some other risk, not the tobacco exposure, or they included people with low tobacco exposure, but they did select the population. They make an initial screening with X-rays, and they didn't include the people with some abnormalities in the X-ray, like having, you know, lateral effusion, or a big mask, or a pulmonary nodule. Those patients were not included, and I think it's a good thing from this lung cancer screening study. They also selected the population based on other risk factors, like smoke exposure, and also people with a family history of lung cancer. And in Latin America, this could represent a high resource of patients, or, you know, that could be selected for lung cancer screening. And they also selected patients with history, you know, medical history of pulmonary disease, like the history of tuberculosis, COPD, and ILD. And I think it could be a good way to have a lung cancer screening for people who have never smoked, but I think we need more information from these clinical trials. We are still waiting for the complete data about these cohorts in Asia, and I think that when we have this wide, or big resource of information, we can make better decisions. You know, the study from Taiwan, I think it's a very serious study. Dr. D.C. White, which is the first author of this study, he's very involved in the lung cancer screening initiatives in the entire world. He's always supporting people in places where the tobacco exposure is not that high as in Europe or North America. And I think getting the support from these groups is also important to have better information and to have better clinical trials in the future. Well, let's change gears a little bit. Dr. Martinez, I found very interesting this study trying to look at high-risk features for nodal upstaging, especially now where we are moving from new adjuvant treatment indications for some patients to segmentectomy and less invasive surgery. But it's very disappointing when you see the only pathological features can influence the decision or influence the prognosis, having an upstaging nodal disease. But as for today, which characteristics do you take into account when you're considering submitting a patient to a segmentectomy? Do you always require biopsy? How do you think this study could help us in our decision on a daily basis? Yes, I was amazed about the results of this study. I expect that other preoperative factors will be exploring the model as GGO, for example, that in the first analysis had differences, but they don't. Maybe the statistical note were better. And about your answer, your question, your indication, your answer, your question, your indications for sublobary sections, I think we prefer to perform sublobary sections in GGO nodules or in solid nodules less than two centimeters, as the studies shown that is benefit. But we prefer when we are doing a sublobary section to have a process section for the N1 nodules, because we know that if you have N positive nodules, maybe the sublobary section is not the best surgery. And we have any concerns about these decisions because the stats is another factor that is not so good for sublobary sections, but we don't know how to have, how to get the diagnosis of the stats previous to the surgery. And it will used to be a postoperative diagnosis. And the people always is worried about to, if they must to complete the lobectomy, but anyway, the evidence don't show that you need to complete the lobectomy, but the prognosis is not so good with a sublobary section in patients with the stats, maybe because it's a bad prognosis factor. I do, I think I have a lot to understand about the biology of the tumors in order to have this decision in the future too. I also have a question. That we have a very aggressive subtype as micropopular or solid, but the problem is that usually we don't know the total histology of the tumor previous to the surgery. Yes. I have a question Estela for you is, you know, sometimes in Latin America, we think that it's because lack of resources that we cannot do things well, but I think the Da Vinci robot, for example, is a good example, no? So everybody, every patient with lung cancer wants to be operated by the robot, but you as a surgeon, do you really think that the robot is necessary because it's a very expensive tool and maybe it's not necessary, you know? Because for example, in my healthcare system, we have 15 Da Vinci robots, but we don't use them for all the lung cancer patients because our surgeons are faster and the surgeons are shorter with laparoscopic surgery. We use, for example, Da Vinci robots for prostate cancer or ovarian cancer, but for lung cancer specifically. So what do you think is the importance of the robot? I think that the technologies proportionate comfortability and maybe security. The nice thing for the robot is that the surgeon have the camera that it doesn't occur in a box. The assistant manage the camera and this is not so comfortable. The other side, you can operate in a seat way that is comfortable. But if you are a good thoracoscopist, I think you can do the same surgeons with the robot. But if you have the possibility to get a robot, I think in the future, the most of the people will operate by robot because it's a little easier and very comfortable. And I think this precision in the movements will give security to the patients, I think. Dr. Reis, I think I have time for a final question. It's more like a philosophical question, I guess I have to. But we are urging for diversity in clinical trials, diversity in the oncology scenario. But as you show it in the studies presented at LAUCA, we still have a lot of disparities in clinical trials distribution all over the world and also in access. Do you foresee any chance to put up with this disparities based on this claim for diversity that is coming from US and Europe in clinical trials? Do you think you can have more like phase one trials in Latin America? What do we need to move on? I think that's a very important question because for example, one of the best studies, Pacific trial, the standard of care for stage three non-small cell lung cancer that you give chemo radiation followed by immunotherapy for one year. That study, for example, is a landmark study. Only 2% were black patients. Nobody knows how many were Hispanics because it was not asked during the study. And then you can say, how do you extrapolate that to these populations that they were not being participated? You can say, oh yeah, it's the same thing, but it's not the same thing because even the biology and the genetics of some of our ethnicities or races are different. That's why I think it's a need to do more studies in many parts of the world. Latin America actually is a benefit because I can predict that studies in Latin America are probably cheaper than studies in the United States. The other thing is, I was mentioning for our people, for our patients, in the United States, when you have a phase three, the control arm, the insurance needs to pay for that. In Latin America or overseas, when we do a study, the sponsor pays for the control arm to be sure that the patient gets at least the control drug. So that is why it's important because if for countries like my country, for example, like National Cancer Institute in Peru, we have very few drugs, but every time that we do a study, you guarantee that all the patients get all the research drug or the control drug, but they get therapy. So that's why I think Dr. Cardona was pushing, presenting that abstract because I think it's necessary that we, as Latin Americans, request the industry wider participation in the studies and offer to participate in the studies and that people that we live in United States or Europe can help. Oh, you need some of your people needs training for to do a phase one, but they can come and spend time with us and more than happy, we'll help you train so the industry feels comfortable doing more studies in Latin America, no? Yeah, I agree. I'm hopeful for the future here in the region. Well, I want to thank you again for being with us today and congratulate you for the LAWCA meeting organization. We are waiting for you here in Brazil for the next LAWCA meeting in 2026. And I also want to thank ISOC for the opportunity to have this highlight webinar here. It's very important for us in the region. And with that, I want to tell you that to claim credit for this webinar, you can complete and submit the evaluation form linked from the thank you email you received after the webinar, or you can scan the QR code on this slide to complete and submit the evaluation immediately. To discover more education activities being offered by ISOC, please visit their website at ISOC.org. We have the long 360 panel website that is new and I really encourage you to access. And thank you again for joining us today.

Latin American Lung Cancer Conference

lung cancer screening

EGFR mutations

wood smoke exposure

non-small cell lung cancer

low-dose CT screens

nodal upstaging

clinical trials disparities

localized healthcare guidelines