Navigating the New Landscape of Lung Cancer Care: Insights from Christine Bestvina, MD

Lung cancer treatment has undergone a remarkable transformation over the past decade, and for community oncologists tasked with keeping pace, the challenge has never been greater. Christine Bestvina, MD, a thoracic oncologist at the University of Chicago, sat down to discuss the evolving complexities of lung cancer management, emerging treatment paradigms, and what community clinicians need to know to stay ahead.

From 1 Disease to 12

Ask Dr Bestvina what the biggest challenge in lung cancer is today, and her answer cuts to the heart of the field's rapid evolution.

"As we get better at targeted therapies, lung cancer has gone from 1 disease to really 12 different diseases," she explained. "What's very difficult is trying to keep up with understanding all of the molecular information, understanding which therapies are available in which lines and also for which stages."

For community oncologists who may not have the same institutional resources as large academic centers, that complexity can feel overwhelming. The sheer number of molecular subgroups, each with its own therapeutic landscape and evolving data, demands a level of ongoing education that is difficult to sustain in a busy practice. Yet staying current is not optional—it is essential to delivering optimal care.

A Paradigm Shift in EGFR-Mutated Lung Cancer

One of the most significant developments that Dr Bestvina believes deserves greater attention is the shift in how EGFR-mutated lung cancer is being treated in the frontline setting.

"The way that we treat EGFR-mutated lung cancer has changed now, where most patients should be offered escalated therapy—chemotherapy plus osimertinib [Tagrisso] as frontline," she said. "It's always hard to let go of just a single-agent oral targeted therapy, but the outcomes that we're seeing with combination therapy do warrant the additional toxicity of an escalated regimen."

This is a meaningful departure from the long-standing approach of relying solely on osimertinib as initial treatment. For community oncologists, understanding this shift and feeling confident in offering combination therapy is critical, even when it means navigating a more complex toxicity profile.

Bringing Clinical Trials Into the Community

Another area where Dr Bestvina sees both progress and opportunity is clinical trial access. Historically, trial eligibility criteria were so restrictive that many real-world patients—those with comorbidities, less-than-ideal performance status, or brain metastases—were effectively excluded. That is beginning to change, and Dr Bestvina is encouraged by the direction things are heading.

"I think it's wonderful that clinical trials are moving more towards the community," she said. "It's going to allow for more equitable distribution of trial participation."

At the University of Chicago, which operates a large network of community centers, Dr Bestvina noted that first-line patients are generally seen in the community setting. "If we're going to capture those patients for trials, it's going to be in the community."

She is also quick to address a common misconception that may discourage community oncologists from enrolling patients. "A lot of randomized phase three trials are pretty easy. Patients don't have to be perfect to go on these trials. Sometimes there's this perception that patients have to be an ECOG of 0 and have 0 comorbidities." In reality, the field wants to enroll real-world patients, including those who are symptomatic from their lung cancer. The administrative effort of trial enrollment, she argues, is well worth it given how rapidly new therapies are advancing.

Looking Ahead: Data to Watch

When asked what upcoming data she is most anticipating, Dr Bestvina pointed to 2 areas with real potential to reshape practice.

First, she is following a head-to-head trial comparing two KRAS inhibitors, divarasib vs adagrasib, in second- and third-line treatment for patients with KRAS G12C mutations. "This is the first time that we're seeing a randomized trial in this space, and I'm hopeful that the next generation of KRAS inhibitors is going to really advance care for these patients," she said.

Second, she is eager to see longer-term data from patients who received neoadjuvant osimertinib plus chemotherapy vs osimertinib alone. "I think this really is going to be a paradigm shift for us about how we treat patients who are found to have molecular alterations in the neoadjuvant setting." The implications could extend beyond osimertinib, potentially opening the door to combinations of other targeted therapies with chemotherapy before surgery as a strategy to maximize outcomes.

The Bottom Line for Community Oncologists

Dr Bestvina's message to community oncologists is one of empowerment rather than overwhelm. The tools exist, the trials are increasingly accessible, and the data are moving quickly in patients' favor. Staying informed on molecular subgroups, embracing combination strategies where evidence supports them, and actively engaging with clinical trial enrollment are the pillars of high-quality lung cancer care, regardless of practice setting.