On opposing ideas

As the year 2020 draws to a close, we cogitate on the massive impact of the COVID-19 pandemic amidst widespread geopolitical tensions, populist and civic uprisings, and amidst the troubling aftermath as well of the rapid network effect of misinformation that certifiably make this year, without a doubt, annus horribilis. The reported fatalities related to SARS-COV-2 in the USA to date, in less than 12 months, has far exceeded the annual expected mortality from lung cancer alone. No individual living in the current civilization has escaped from the far-reaching effects of this pandemic, with cancer patients facing unique vulnerabilities for various reasons. Yet, we cannot overlook the fact that 2020 marks an annus mirabilis in the history of vaccine development given the lightning speed at which, not just one, but several viable COVID-19 vaccines have received emergency use authorization—a testament to all the possibilities that can arise from the close cooperation and dedication of countless individuals in the global scientific and medical community to share data and information rapidly, as the pharmaceutical and drug manufacturing industry joined ranks and deployed resources available, backed by governmental support.

And on this theme of dueling realities, F. Scott Fitzgerald famously remarked that “The test of a first-rate intelligence is the ability to hold two opposing ideas in mind at the same time and still retain the ability to function.” And thus, as we celebrate the resilience of cancer patients and as we conclude this year’s celebration of Lung Cancer Awareness, it is my honor to feature contrasting commentaries from a diverse group of thoracic medical oncology experts on hot-topic au courant issues on targeted therapy and immune checkpoint inhibitor therapy relevant to the management of metastatic NSCLC that our dear readers of PCM will frequently encounter, COVID-19 pandemic notwithstanding. Controversies covered in this series include the perceived value of osimertinib as adjuvant therapy in resected EGFR-mutated NSCLC, the extent of diagnostic work-up entailed in the management of acquired resistance to ALK inhibitors, preferred first-line treatment of BRAF V600E NSCLC with high PD-L1 expression, the role of ipilimumab-based regimens as first-line therapy for metastatic NSCLC, the role of anti-PD1/PD-L1 monotherapy in the management of EGFR/ALK wildtype NSCLC with PD-L1 TPS 1–49%. These opposing positions largely arise from lack of solid or mature category A-type of evidence as well as from issues related to trial design and/or population enrolled. Clinicians thus extrapolate from collective empirical observations and contextually arrive at shared decision-making in such ambiguous situations. Despite apparent differences at the outset, recurrent themes of agreement emerge—the art in the heart of medicine when faced with uncertainty.

A common goal should unite us all. Endeavors to increase diversity and representation of voices can only work if all stakeholders participate. I am thus very grateful to the wonderful colleagues who contributed their precious time and expertise and for engaging us in this debate series- Salut to first-rate minds everywhere!

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Precision Cancer Medicine for the series “Evidence and Controversies in the treatment of metastatic NSCLC”. The article did not undergo external peer review.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/pcm-2020-01). The series “Evidence and Controversies in the treatment of metastatic NSCLC” was commissioned by the editorial office without any funding or sponsorship. GKD served as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of Precision Cancer Medicine from July 2020 to June 2022. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

Grace K. Dy, MD