JCO PO author Dr. Mary Redman shares insights into her JCO PO article, “Representativeness of Patients Enrolled in the Lung Cancer Master Protocol (Lung-MAP)” Host Dr. Rafeh Naqash and Dr. Redman discuss the background of LungMAP and how it was developed to accelerate drug development and biomarker-driven therapies in lung cancer. Dr. Redman shares the initiatives undertaken to increase participant diversity in LungMAP and invites junior investigators to get involved in the project.

TRANSCRIPT 

Dr. Rafeh Naqash: Hello and welcome to JCO Precision Oncology conversations, where we bring you engaging conversations with authors of clinically relevant and highly significant JCO PO articles. I'm your host, Dr. Rafeh Naqash, Social Media Editor for JCO Precision Oncology and Assistant Professor at the OU Stevenson Cancer Center. Today I'm delighted to be joined by Dr. Mary Redman, Professor of the Clinical Research Division at the Fred Hutch Cancer Center and also Senior Author of the JCO Precision Oncology article, “Representativeness of Patients Enrolled in the Lung Cancer Master Protocol” or the Lung-MAP.

Our guest disclosures will be linked in the transcript.

Dr. Rafeh Naqash: Dr. Redman, welcome to the podcast, and thank you for joining us today.

Dr. Mary Redman: Thank you very much for the invitation.

Dr. Rafeh Naqash: And for the sake of this podcast, we'll just use each other's first names. If that's okay with you.

Dr. Mary Redman: Please.

Dr. Rafeh Naqash: And since you and I know each other through the lung working group, we've worked on some things, or planning to work on some things, this article was something that I came across recently that you published with some very well-known folks in the field of lung cancer. And I wanted to utilize the first few minutes of this discussion to understand what was the background behind Lung-MAP because I think it's very important for people to understand why this kind of an approach was started in the first place and how it has successfully created a mechanism for master protocol. So, if you could dive a little deeper into that for us, since you've been there, you've done that, and it would help our listeners understand the genesis or the origination of this whole process of Lung-MAP.

Dr. Mary Redman: Happy to do so. So, Lung-MAP, the original concept goes back to February of 2012. And in February of 2012, the Thoracic Malignancy Steering Committee, the FDA and the NCI had a workshop. And the focus of the workshop was how we could accelerate drug development in lung cancer, and in particular, how we could accelerate biomarker driven therapies within lung cancer. And the outcome of that meeting was that master protocols or studies that set up infrastructures to evaluate multiple therapies, all within one infrastructure, were the way to go. And so born out of that, there were three master protocols. The Lung-MAP trial, the ALCHEMIST trials to evaluate studies in adjuvant therapy setting, and then the MATCH trial, which, of course, isn't just in lung cancer, it looks across different cancer types and looks on biomarker targets that transcend across. 

So, when the Lung-MAP trial was being thought of, the idea was that while in non-squamous, non-small cell lung cancer, we had seen some advances with targeted therapies, that squamous cell lung cancer had essentially no targeted therapies that had been successfully evaluated. And therefore, there was an unmet need that squamous cell lung cancer being a more aggressive form of lung cancer than non-squamous lung cancers, and in particular in the second line setting, after patients had received platinum-based therapy, there was pretty much nothing other than docetaxel. 

And so, the study was initially conceived of by Vassiliki Papadimitrakopoulou, who was at MD Anderson at the time and Roy Herbst who we had at Yale. And so therefore, we thought second line squamous cell lung cancer was an unmet need and that we could potentially have targeted therapies, given now that we had the genome atlas, the TCGA understanding of what all the potential biomarkers or targets that exist in squamous cell cancer. Concurrently, we also had the developments and improvements in next-gen sequencing. So, the technology improved for us to be able to detect these different genomic alterations that were present in these cancers.

So, all of that together - an unmet need of an aggressive cancer, a better understanding of the biology and the potential to have these targeted therapies - led to the development of Lung-MAP. But in addition, what we had seen and I think most of you who have studied cancers across the country know, patients who live in urban areas or are financially more well off are more able to access therapies, whereas patients who are less well off, more rural areas, and then just in general, different race ethnicities, didn't have the access that other patients from other settings had. And so, when we conceived of Lung-MAP, it wasn't just about meeting the unmet need in terms of treatment, it was also about an unmet need in terms of accessibility of these types of studies for all types of patients who get lung cancer. And so, utilizing the National Clinical Trials Network system that has sites all over the country, I think there's something like 2500 sites around the country, which include community oncology sites and of course academic sites. 

Dr. Rafeh Naqash: Excellent. Thank you so much Mary, for explaining that. Now, as you highlighted, this dates back to 2011-2012, when things were just picking up from a broad sequencing platform standpoint, rather than limited gene testing, which has been more and more, there's been more and more uptick of NGS, especially in the space of lung cancer. So, you and several others came up with this idea and eventually implemented it. And there's a significant process of thinking about something and implementing something. So, what were some of the challenges that you encountered in this process and successfully circumvented or dealt with appropriately over these years, some of the lessons or some of the processes that you were able to understand and navigate around.

Dr. Mary Redman: We could spend the next hour probably talking on that topic. Anytime that you're setting up a big infrastructure, and I really do think the best way to describe Lung-MAP and a master protocol is that it's an infrastructure because the goal is to set up something where we can bring in new studies and so that everything is modular. And you complete one study, you add a new one. Things can be added while things are ongoing. And by things, I mean studies evaluating investigational therapies.  

And so, anytime you're setting up an infrastructure that's never been done before, well, first of all, the complexities of different partners that had never worked together, so just understanding how best to work together, the infrastructure in terms of how to build it within our systems, the statistical and data management center had many complexities. The infrastructure in terms of how our systems at the statistical and data management center spoke to the NCI had challenges. How the NCI evaluated this protocol that had all these different studies that were coming and going.  The studies oftentimes involved therapies that were very new in their development. And so oftentimes you'd have some new safety signal that came up which required a rapid amendment. And how do you do that when you have this infrastructure, and you don't want to stop one thing for other studies to be moving forward. And that because it's a public-private partnership and the pharmaceutical partners that are partially supporting financially and scientifically, some of these studies, learning to work with them, they have a little bit more say because they are more financially involved with the studies than a study that's typically funded by the NCI. And maybe the company is only supplying drug. So, contracting had its challenges, budgets, how do we actually budget things appropriately in this new infrastructure? I talked about all of that. And then a challenge about running such a study is how do you educate the sites so that when they're approaching patients, how can they talk to a patient about, “You're going to have your tissues submitted to be tested, and then on the basis of that tumor testing you're going to be assigned to get to an investigational treatment study.” And how do you describe all of that?

Dr. Rafeh Naqash: So definitely lots of lessons and experiences that you and your team have had. And the way I describe or look at Lung-MAP is one of those success stories that has redefined the way to run clinical trials from an NCTN and a SWOG cognitive group network standpoint. And going to this paper that you have published in this, your Precision Oncology, there's one aspect of clinical trials where we are always very focused on responses and survival and other clinical outcomes data. And then there is this important component that you and your team have looked at is, what is the distribution of the different kind of clinical trial participants? What kind of people are we getting in? What kind of people are we trying to cater to, and what is the unmet need gap that we still have not completely met? Could you tell us how this project started, the idea behind this project, and then some of the results that you can highlight for us today?

Dr. Mary Redman: So, Lung-MAP also has a company advisory board, and we meet with them either quarterly or biannually. And one of the conversations that we were having with our industry partners or collaborators was especially after the FDA came out with some of their work saying, we think it's really important that industry does better that they enroll a more representative patient population in their studies. You see some of these studies in lung cancer with 1% or a very small percentage of Black participants, for example, whereas the US population has significantly higher levels. And so, one of the major objectives, as I said about Lung-MAP, was to enroll a more representative patient population to provide access. And as part of these conversations, we kept saying, “Well, we've done a better job.” And I was thinking, well, we actually could evaluate how we have done.

And so, in thinking about that, I proposed within some of the researchers that are part of the SWOG Statistical and Data Management Center that we look at this question in particular, I approached Dr. Riha Vaidya, who is here at Fred Hutch with me, and she's a Health Economist with this idea. And she was very excited to look at this. And my initial thought was just to look at race, ethnicity, gender. And she took it one step further where she wanted to look at not only that, but also area deprivation index and then rural versus urban. So, getting at some of those other very important aspects of representativeness when we think about patient populations. And so that was how it came about. 

Dr. Rafeh Naqash: Going back to some of the interesting things that you and the authors have done, is not only looked at the gender, age, but also looked at the socio-demographic representativeness. Now, there's definitely some things that you guys looked at and that Lung-MAP study did better on, and some things where maybe there's more room for improvement. Could you highlight some of those results for us today?

Dr. Mary Redman: Happily. And one thing I think that it's important if one goes and looks at this paper, and as I talk through the results, so Lung-MAP opened to enrolling patients in June of 2014. And from June of 2014 to January of 2019, we exclusively enrolled patients with squamous cell histology. And then in 2019, we expanded the study to enroll all histologic types of non-small cell lung cancer. And so, in this paper that's published here in JCO Precision Oncology, we compare our patient population and Lung Map to other patients enrolled within advanced non-small cell lung cancer trials. So that's all-histologic types. And then we compared it to the SEER population, the US population evaluated by SEER. And that also is all histologic types of non-small cell lung cancer.

 And so, one of the major results, as you pointed out, is that while we did well in certain areas, for example, we did not enroll as many females as the other SWOG trials and then the US population. And I think that is probably, I would attribute all of that to being the case that squamous cell lung cancer patients tend to be more male than female. So therefore, those results, I don't know that if we looked at only the data since 2019, we might actually see that we were comparable. Going through the results, as you were just asking about, compared to previous SWOG trials, we did better in terms of enrolling older patients, not as well as the SEER data. Some of the challenge is I'm not 100% clear that we'll ever be able to get perfectly there, in part because Lung-MAP, for the majority of the time, only enrolled patients who had performance status 0 or 1, and older patients tend to have higher performance status, and so they might just not have been eligible. And I do think, especially with these investigational treatments, particularly with immunotherapies, for safety reasons, we do need to enroll patients with performance status 0 or 1.

We talked about the female sex versus male sex percentages and that our numbers were smaller. But if you look at SWOG trials versus SEER trials, they're pretty much identical numbers. So, I think that if we just looked at the later part of Lung-MAP, you'd see that they match. In terms of race ethnicity, the earlier part of Lung-MAP, we enrolled close to 15% of patients of nonwhite race or ethnicity. Historically, SWOG trials were slightly higher, but in the US population, it's around 21.5%, based on this year's data. And so, we did better than industry sponsored trials. So, if you look at those data, but there's definitely room for improvement. And that just in part, has to do with getting more sites, better outreach, more education, and better access. 

And so, I think we have an accrual enhancement committee that does include patient advocacy groups. And I think that that is just going to be an area that we need to continue to work on. And then, as you mentioned, that we did better in terms of enrolling more patients from rural areas. We enrolled more patients from socioeconomically deprived neighborhoods, and more patients that were using Medicaid or no insurance for those who are under 65.

Dr. Rafeh Naqash: Absolutely. I think those are very important results. Me, as somebody who sees people on clinical trials, both phase I and late phase, of the questions that I get commonly asked if somebody refers a patient from the community is, “Am I going to be treated on a placebo?” It's one of those common things. And the second question ends up being like, “Is my insurance going to cover some of the costs associated?” And I think understanding those concepts, whether it's from an educational standpoint or a financial barrier standpoint, is extremely important in clinical trials because at the end of the day, these are things that people use as metrics for enrolling or not enrolling themselves on a clinical trial. There are certain aspects or sensitivities associated with enrolling people, let's say, of Native American ethnicity or American Indian ethnicity, where outreach is extremely important. From a Lung-MAP standpoint, could you talk about some of the outreach initiatives that are being implemented or have already been implemented to potentially help decrease this gap of representation? 

Dr. Mary Redman: I think that one of the major- and this isn't exactly outreach, but to start out with one of the things that we have, in addition, I mentioned that we had an accrual enhancement committee. We also have a site coordinators committee. And when we set up the site coordinators committee, we make certain that we have representation from the geographic regions within the country and different types of sites. And the major goal for our site coordinators committee is to give us input about how it is to implement Lung-MAP within their own institutions. And so, we want to be able to overcome any type of barriers or perceived barriers that are out there, and we want to hear it directly from those people who are working closely to enroll the patients. And so that's been a key part of everything that we've done. And so, part of that is that we've just developed educational materials. We have modified the protocol based on input that we've received from them. So that's, I think, been a major approach that we have used to try to reach more patients. 

We do have a newsletter that we put out. The accrual enhancement committee has also contacted different sites to really have more conversations, one on one, just more, I guess, almost like focus type groups where you try to understand, really understanding what's coming on, what are the challenges from their perspectives. And then we've had webinars where we try, and we've had hundreds of attendees for these webinars, where we let the sites have direct access to those of us who are running the study to ask their questions. So those have been our major approaches. And I think that we're always trying to figure out how we can do better. 

Dr. Rafeh Naqash: I agree with you, and I think as both physicians, providers, and the clinical trial staff as such become more and more cognizant of increasing diversity, these conversations end up happening earlier and earlier in an individual's patient's journey, where trying to see feasibility, trying to see financial aspects, getting a patient enrolled on a clinical trial gets evaluated earlier and earlier. And hopefully, with some of the measures that the SWOG or the Lung-MAP group is implementing, these percentages will see more spike in the long run for better clinical trial enrollment approach.

So, Mary, now going to the science part of Lung-MAP for maybe some of the fellows or the investigators, early career investigators, who might be listening to this podcast, could you briefly explain what is the process of getting involved in Lung-MAP? Because for me, as a junior faculty a few years back, I was a fellow, and I remember at that point I hardly had any knowledge of corporate groups. SWOG, for example, was one of those that I'd heard about, but didn't necessarily know how to get involved. So, for trainees, for junior faculty, could you briefly say, what's the process? What does it involve? How would somebody propose something to Lung-MAP? 

Dr. Mary Redman: Yeah, thank you for that question. And I really do hope that this actually is a way to get people to understand, and we'd love to have more engagement from more junior faculty and that's a major objective for the study. Because this infrastructure is in place, we are actually well suited to be able to mentor and bring junior faculty in. And so, the process is basically, you contact any of us that are in leadership within Lung-MAP and talk to us and we'll see if we can figure out a way. If you have an idea of a new study, wonderful. Our drug selection committee chair is Saima Waqar. She's a member of ASCO as well. I mean, one could find her and send her a note. The study chairs for Lung-MAP are Hoss Borghaei and Karen Reckamp. You can send them a note. You can send me an email, maryredman@fredhutch, and we will make certain that you are engaged and brought into the direct conversations that would lead to something. 

So, it would be wonderful to have more junior faculty proposing ideas and leading sub studies, being a sub study chair. Each of our sub studies, as I mentioned before, are conducted independently, and then you are responsible for the development, conduct of the trial and writing of the paper and presenting. And so, we want all of that to happen. But we also would love to have ideas. If you think of this infrastructure as just being an amazing resource of data, we are happy to and would love to receive proposals for data analysis that could result in publication and presentation as well. So, if there's something that somebody sees as a question that they think we could answer, again, contact any of us and we will happily figure out a way how to work with you. We have a great team and a lot of capacity to be able to work with new people.

 

Dr. Rafeh Naqash: Thanks, Mary. And for all those listeners, trainees listening, you did get Mary's email, so try to send her an email, and hopefully she won't be complaining that there was a lot of requests. But I think all things considered, the Lung-MAP is a great data resource. As you mentioned, it's a great resource for junior investigators who are trying to build a career around clinical trials, precision medicine, and it's also a great resource, as you've shown, regarding diversity equity research from a clinical trial standpoint. So, I think it has all the components that are needed to run and create some interesting questions and answer those questions using the data set. 

So now, Mary, going to the last part of the discussion here, one of the key components, we try to ask a few questions of the investigator, which in this case is yourself. Could you tell us briefly about your career trajectory, how you ended up doing what you're doing now, and what are some of the things that you've learned from and maybe advice to all the junior people listening to this podcast? 

Dr. Mary Redman: Wow. Okay. Well, so if you hadn't already guessed, I'm a biostatistician. I started out in mathematics as an undergrad and then learned about biostatistics and thought that it sounded perfect for me. After I finished my doctorate, I did a year of postdoc and was starting to look for faculty positions. And if you haven't already inferred, I am a Seattle native. And so, when a position became available at the Fred Hutchinson Cancer Center here in Seattle, I applied for it, and the job happened to be with the SWOG Statistical Center. And so, you probably already guessed as well that I got the job. And so, I have been here at Fred Hutch since 2005. And when I joined Fred Hutch and the SWOG Statistical Center, which is co-located here and at Cancer Research and Biostatistics, just a mile west across Lake Union here in Seattle, the person who had been the lead statistician for the Lung Cancer Committee in SWOG, John Crowley, he was also the director of the SWOG Statistical Center and had been doing that for over 20 years, and he was ready to take some things off of his plate. And so, when I joined, they thought that I would be a great fit for the lung committee, in part because I had shown an ability to work with vibrant personalities, let's just say, which the lung community has in spades. 

And so, when I started in the lung committee, David Gandara was the chair of the lung committee. And so, I worked for many, many years very closely with David, and we established a very close and really wonderful working relationship. And I learned a lot from him. I learned a lot from a lot of the other lung cancer researchers in the country and around the world. I pretty quickly became involved with the International Association for the Study of Lung Cancer and have attended most of the World Congress on Lung Cancer meetings and have gotten to know people around there. So as a biostatistician, obviously, I enjoy my mathematical and statistical skills, but I also just really enjoy learning and thinking about what I can bring to the problem where I come from a certain point of view and I love collaborating with the other people doing clinical research, in particular in lung cancer. And basically, my focus has always been on doing the best to answer our questions the most efficiently and effectively so that we can move the field forward and help people live longer.

Dr. Rafeh Naqash: Thank you so much, Mary, for your time and giving us insights into your professional and personal journey.

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