[MUSIC] Yes, good morning. So the question is about lung cancer. Is it possible to envisage any early detection of lung cancer? The problem of lung cancer is it is one of the cancer which is really associated with a high level of mortality. Survival after diagnosis of lung cancer is very catastrophic. It has not evolved since after civil war. Well, one or two. Meaning that, in fact, most of the cancer have benefited from tremendous, dramatic increase of survival due to, of course, early diagnosis. But also, of course, of new chemotherapy, and radiation, and all the treatment of cancer, but not for the lung cancer. One of the reason is lung cancer is very deep inside the body and very hard to detect. And particularly hard to detect early. When you detect it, it's because sometimes you are coughing blood. And because of that, that means that the cancer is already very developed. It's not an early phase of the cancer when you detect it. So because of that and because of the prognosis of lung cancer, it was stuck with no real progress since after the World War Two. So what happened is because of the new imaging, because standard chest X-ray, the standard radiography of thorax cannot help you so much. Because when you detect an image, an anomaly on the chest X-rays, it means it is too big. You can't detect the very, very small tumors. But thanks to the CT scan it has been possible to envisage a detection of very, very small tumor and maybe at early stage. And when you see that because of the stage you may have a better survival when it is early. The small tumor, the early phase, early stage tumor may be associated with much better prognosis. And you can detect them through the low dose CT scan. It may happen that because of that, because of that new technology you may save lives. That was a question. And it takes time to demonstrate that. First of all, there was a very big study which is named ELCAP for Early Lung Cancer Action Program. It was an open study where all the patients, not the patients, smokers, in fact. They were not patients, they did not had any symptoms. And they come to the physicians for a CT scan, a low dose CT scan. And it has been recorded and their survivals have been recorded. And it has demonstrated much better survival than what was expected just because of the long time service we had and the experience of lung cancer. It was published in the New England Journal of Medicine. And the leader of this program, Claudia Henschke from New York City said « no, the game is over. You should screen all the smokers for this early diagnosis of lung cancer. And if you detect one, you have now to go to the surgery and to really extract the tumor and you can cure your patient. » But there was bruise, I would say, and there was debate, vivid debate about that. Some people say no, it's not acceptable to validate a screening program only based on an open study. An open study like ELCAP. Even if it is published in a very good journal, we cannot accept that as sufficient evidence to validate, really, the screening from this new technology. So what has been decided is in the USA but also in Europe. Several programs have been set up to validate the new device, the CT scan. So, clinical trials. So it has been randomized studies where half of the people were assigned in an arm where they were just given chest X-rays and in the other arm they were assigned to a CT scan. So when they had a CT scan we followed-up them for a couple of years. And when they had the standard chest X-ray they were also followed-up for a couple of years. And at the end of the day, we compare the survival. Of course, also we compare if they had a tumor, if they have been extracted tumor, if they are still smoker, if they have cessation of tobacco, and so on. And what happens is the National Lung Cancer Study, NLST, conducted by the NIH, National Institute of Health, a public funded institute in the USA decided to conduct this clinical trials in holding 50,000 smokers aged between 55 and 75. And they were involved in this large randomized clinical trials and followed for seven years. And after seven years there was an early stop of this clinical trial. Just because the people were enrolled in the, how those CT Scan really had a better survival, 20% less mortality than in the control arm. And also there was another old mortality which was much better in the CT scan arm in comparison with the chest X-ray. Meaning that, so this clinical trial, these very large clinical trials, a sufficient amount of evidence was now on the table to say to the smokers. Only, of course, to the heavy smokers, smokers who have smoked for all their life, up to 50 or 55 or maybe 60 years old. And now we can tell them, you can have this early screening for lung cancer. And if we detect a tumor, if it is early enough, we can detect a very small tumor and we can propose you surgery. And early, we can tremendously improve your prognosis. Of course, to say that has been hard to demonstrate, first. Soon we always have to know that there is some counterpart, some side effects of the early screening. For instance, there is a lot of false positive. Meaning that you may have an image which looks like an anomaly when, in fact, it is nothing. Just maybe something you had from the early beginning of your life. But it is a image on the CT scan. And we may, due to that, perform surgery. And, of course, surgery of the thorax is not the same as surgery of the skin. So it is very deep. It is invasive and it is risky. So when you go through these kind of procedures, you may be prone to risk and you may have a side effect which sometimes may be very severe. And we have to say that to the patient, of course. But this is today probably something which is coming on the table. Which is beginning to be reimbursed. Which is recommended in the USA for sure. We cannot expect anymore evidence even from the European studies because they are too small, really, to demonstrate a 20% decrease in mortality. Although it is very significant, it is, you need a lot of people to enroll and it is very costly. So it will probably not be performed for a long time now. And we can say now that we have something which is not completely safe. You may have some risk, to face some risk. But which may be very interesting for all the smokers who have smoked for all their life. They have some solution, that they have to quit tobacco. Because tobacco cessation is always beneficial for the patient, even for reducing the risk of further lung cancer. But also on all other disease associated with tobacco. But if they cease, they stop that tobacco consumption, and if they perform such screening program, they may be early detected for these kind of very, very dangerous risk which is the lung cancer. [MUSIC]
