Naman Julka-Anderson (00:00.717)
This is episode number two of our ALK Positive Charity short series. So we'll be hearing from our guest Dr. Shobhit Baijal talking about his career as a medical oncologist and ALK Positive lung cancer. Hi Shobhit, how are you?

Shobhit Baijal (00:13.989)
Hi, morning. Good, thank you.

Naman Julka-Anderson (00:18.959)
Great to have you here. Would you mind just starting and telling us a bit about your background and your career as well, please?

Shobhit Baijal (00:25.522)
Yeah, it's nothing too exciting I'm afraid. So grew up in the Midlands, went to medical school in London, Barts in the London, trained there, did my junior house jobs, bit of A &E and then came back to the Midlands. That was always the long-term plan. Did my junior medical training and knew I wanted to stay in hospital medicine but really hadn't found a specialty that

really grabbed me and then actually ended up doing a standalone junior doctor job, SHO job in oncology at the Queen Elizabeth Hospital and that was my first taste of oncology. I fell in love with it and hence pursued that as my career and became a medical oncology consultant now in 2011. And yeah, here I am specialising in lung as well as colorectal cancer.

Jo McNamara Rad Chat Host (01:22.008)
So Shobhit, tell us a little bit about what a day in your life looks like because I'm sure, even from a patient's perspective, they see you in clinics constantly but don't necessarily realise everything else you maybe do.

Shobhit Baijal (01:35.615)
Yeah, I mean, I think, you know, from a career perspective, I've probably got my fingers in many pies. So in a fun way, you know, I like to be busy. So yes, I mean, I think obviously the crux and the core of my work is my patients, my cancer patients, treating them, as you say, seeing them in clinic, beyond the clinic, which, you know, goes with the reviews of patients on treatment, on follow-up.

goes kind of the acute side of things, i.e. the bits where patients may not be as well. So kind of coordinating that care, whether it's inpatient, on our day units, seeing patients in that setting as well. Frustratingly, but understandably, there goes a lot, probably a huge amount of admin that is not seen behind the scenes with every patient we see. I think they probably wonder what we're doing in the clinic room after we've seen them for 10, 15 minutes.

We're not having a chit chat or scrolling our emails. You'd be surprised how much administrative work goes into each patient. Outside of that, I have a very heavy clinical trial portfolio, which I'm very passionate about bringing clinical trials, breaking treatments or new treatments to patients. So again, that is quite intensive. Each patient takes a lot of time, but again,

There is a lot of administrative work that goes with clinical trials. So that's another aspect of that. We have to stay up to date as well. So there's a lot of online stuff. I also attend a lot of congresses where I'm nationally, locally, nationally, internationally, which is great learning, great networking, and a little bit of fun as well. I'll confess, we do enjoy those.

few of the evenings at these congresses. I'm also in a privileged place where I get to educate as well in terms of speaking at these events. I'm also involved in national bodies. part of BETA, which is the British Thoracic Oncology Group. I'm one of the steering committee members there and we do lot of advocacy work, educational work for our UK long oncology healthcare professionals.

Shobhit Baijal (04:00.8)
Charity work, as obviously today's talk is, I work with Out Positive as well as other charities such as EGFR Positive, Roy Castle, Lung Foundation. I'm working with a nice committee in terms of trying to get drugs through approval, so I'm invited medical experts in that, which is very important because, we can get all the clinical trials and the excitement of that, but we also need our reimbursers to approve these drugs so we can access them for our patients.

So kind of that's my nine to nine, I And then there's my dog, and family, they keep me busy as well.

Jo McNamara Rad Chat Host (04:33.237)
You're so lazy, so lazy.

Naman Julka-Anderson (04:40.003)
What made you wanna...

Naman Julka-Anderson (04:44.429)
Sounds like it. What made you want to get involved with all the charities and especially ALK positive?

Shobhit Baijal (04:52.064)
I think, I mean was more a case of the charities initially approached us. I mean it was a brilliant thing. mean something, obviously we were aware of some of the charities which I've done a little bit of work for but as the lung cancer world has evolved and we're finding groups of patients with certain changes in the cancer that require very specialist or very, or different treatment pathways to what would be our

our normal pathway for patients. think the charity leads themselves, I think, hats off to them to actually create these charities and patient advocacy groups because their needs are very different. some of these groups, the alterations are very rare. So there'll be oncologists there that may never have seen a patient with this mutation or may see one a year and hence no fault of their own, but they may not know what.

or be up to speed with how to manage the best way to treat these patients. And then having been invited and speaking at some of the events, I think it's very humbling to see patients, their carers, really taking control of their condition, taking a lead, wanting to understand it on a level that I'd say goes beyond what just a patient would understand, but really on a...

healthcare professional level wanting to know and help guide and I think that's, I think it's very admirable that patients want to take control of their condition and lead the care beyond just what the consultant or their doctor or their oncologist is saying to them in clinic. And I think probably the most valuable bit which we don't see is that patient to patient interaction, that shared experience. I can empathise with my patients but I can't put myself in their shoes.

and go on that journey with them or feel that journey hands on, whereas definitely when they meet up and whether it's via remote or in person, think those interactions or I imagine those interactions are invaluable for them to know that they're not alone and there are other people going through that same experience.

Jo McNamara Rad Chat Host (07:11.917)
So tell us, Shobhit what is ALK positive?

Shobhit Baijal (07:16.458)
So, positive, so maybe taking it step back. We used to kind of group lung cancer all as one, maybe about 20 years ago. And the treatments we used to, we played a little bit with the chemotherapy, but it wasn't very sophisticated. But it was really just, you had lung cancer, you were treated in almost a similar manner. Probably over the last 15 years has become this, or this evolution in what we call personalized.

care. So we're starting to understand that for certain patients there's certain changes in their gene and in their cancer genes that are driving the cancer. An ALK is exactly one of those. it's an alteration in the gene that is then driving that cancer. So they're rare. They probably make maybe around one to two percent of our lung cancer population.

but their treatments are very, different to how we would treat a patient without a OK or ALK altered lung cancer. So it's crucial, should I say, or imperative that every patient with a certain makeup is tested for that.

Naman Julka-Anderson (08:31.262)
How do you test for it? I presume there's lots of specialist testing that happens and how long does it take?

Shobhit Baijal (08:37.908)
Yeah, again, testing in lung cancer and probably in cancer in general is a very rapidly evolving field, probably as rapidly evolving as our therapies have. So historically, we used to do what we call, I call them the traditional methods and I'm not a pathologist, I hope I'm not insulting any pathologists out there, but these would be kind of one test to look for a specific alteration. So it started off by something called FISH.

which then moved forward onto immunohistochemistry, which is a quicker turnaround test. But this is really just looking at one, or to put it in perspective at the moment in the current landscape, there's probably about seven or eight alterations that we look for in lung cancer. So looking for each one requires a specific amount of tissue. And if you're looking at one at a time, there's also a time implication on that.

The field of testing has evolved to what we call next generation sequencing where potentially by newer techniques you can look for all of these alterations in a one stop shop test. It sounds great, it sounds fancy, there are still huge challenges that we are facing with this in the UK, in particular with turnaround time, as well as not every sample that goes to the lab.

is able to be read out successfully. So we have what we call a failure rate on that that can sometimes then obviously require further time if further biopsies are required. And to say although the newer tests or this next generation sequencing are really probably evolving as a standard of care, the historic tests are still very important. They're much quicker to do. We do sometimes default to those if we feel it's appropriate for a patient.

There are also what we call a salvage test. If the sequencing has failed, then sometimes we can salvage it with another historic test. Another exciting area is blood biopsies, where we can actually pick up these mutations on blood samples. It is as simple for the patient. It is as simple as taking a blood test. And then this can give us all the readings that we want. And that is very recently something that's been commissioned.

Shobhit Baijal (10:55.946)
for our patients in England where any patient with a lung cancer diagnosis can have a blood biopsy to try and speed up the diagnostic pathway.

Naman Julka-Anderson (11:07.122)
Does everyone who has a potential lung cancer get all of this testing?

Shobhit Baijal (11:14.154)
So again, if we take it a step back, lung cancer split between two broad subtypes. One is squamous and the other we call non-squamous, which is predominantly made from adenocarcinoma. What we call the driving mutations, which ALK is one of them, is predominantly seen in the non-squamous adeno, almost 99%. You can see them in squamous, but it's very rare. As a minimum, ideally,

every non-scuema should be being tested for all of these driver mutations. Where I work, I'm quite fortunate, I work in a lab where we test the squamous as well, but that's, you know, it's a lower yield to find them in there. But definitely if you have a non-scuema, and this is probably something that I haven't mentioned it, but especially a young patient where there's minimal smoking history should be somebody that should be going for these tests. And that's because these alterations, especially ALK,

seem to be more prevalent in those patients who have a minimal or never smoking history. But again, the flip still stands in that we do find them in smokers, so smokers shouldn't be excluded from this testing.

Jo McNamara Rad Chat Host (12:24.567)
So what treatments are available for these patients and do they differ to other patients who have lung cancer?

Shobhit Baijal (12:34.354)
Yes, so treatments have evolved for ALK probably around the time I became a consultant, a couple of years after that, where we first realized that targeted ALK drugs are better than chemotherapy.

and significantly better. we started and the drugs have evolved from first generation to we're now into third generation drugs. So we first had a drug called Crozotinib that initially proved itself to be better than chemotherapy. In all honesty not a huge gain but it was definitely better. A tablet drug, a cleaner drug and also and beyond that then came what we call the second generation drugs. So a drug called Electonib and a drug called Brigatinib.

and they really dominated the field. We saw survival outcomes for patients treated with these drugs that, in all honesty, solid lung cancer we'd never seen before. They're tablet drugs, they're reasonably well tolerated, but another important facet for them is that they have good activity in the brain, and the reason that's important is

Sadly, patients with ALK lung cancer do have a high propensity to develop brain or spread to the brain. So having drugs that are very potent in the brain has been crucial in terms of the development of these drugs. And only a couple of weeks ago, at one of our major congresses, we had a survival outcome read out for one of our big studies using these second generation drugs. So this was the ALIX trial and the median overall survival.

was eight years for patients treated with lectinib, which from a lung cancer perspective, where when I started as a consultant, the average survival for patients was maybe 12 to 18 months. These are huge gains. I'm not saying that patients don't want more and understandably they do, but this is data that we thought we'd never see in terms of solid tumors like lung cancer.

Shobhit Baijal (14:38.738)
It's now evolved, we've also now got a third generation drug which, hot off the press, only about a month ago got approved by NICE. It's a drug called Lorlatanib, which definitely seems more effective than the second generation drugs. The second generation drugs are still very good, but the third generation drugs, especially across the the brain activity is very active. So again, I think this is a drug that we will see being used now for our patients.

Naman Julka-Anderson (15:08.814)
So compared to the chemotherapy kind of equivalence, are there different side effects for these targeted like immunotherapy type drugs and stuff? Is there something that people should be looking out for more or less compared to chemo?

Shobhit Baijal (15:22.986)
They're very different to chemotherapy. They're more convenient in that they're tablet drugs. The different drugs do carry different side effects. They have their own unique profile. Yeah, so as I said, I the key players in this modern era are electinib, rugatinib, and lorlatinib.

The vast majority of patients get on with them pretty well, but they do have unique facets which I'm sure whatever the oncologist will be choosing will go through in detail. I think the key thing also is that if patients do have side effects, there's a lot we can do as their healthcare professionals to make things better, either with supportive medications or dose reductions that can be very effective.

And there is now emerging data that actually reducing the dose doesn't impact on efficacy, which is obviously always a concern, understandably, for patients and sometimes even for us. So having that kind of data is also very reassuring.

Jo McNamara Rad Chat Host (16:27.893)
Is there any role for radiotherapy to play in treatment for these patients? I'm thinking maybe if patients did present with brain metastatic disease.

Shobhit Baijal (16:38.25)
So, Roger therapy, without a doubt, does play a big role in how I manage, and I'm sure many of my colleagues manage, our positive patients. Probably not at diagnosis unless we really are up against it. And the rationale for that is that the drugs, that the potency across the blood-brain barrier, even with patients presented with a spread to the brain, the potency of the drugs is so high that we actually would go drug first.

But really where radiotherapy is really coming to its own is in what we call when patients progress. So if they're to develop resistance to their treatment, often what we'll try and do, what can often happen is what we call oligo progression. So that means there might be just a solitary site where the cancer's growing or it's growing at a very indolent rate. So that's where if we've got a solitary site that's misbehaving, that's where I'll reach out to my

clinical oncology colleague and explore radiotherapy options, whether that's conventional radiotherapy or more sophisticated forms such as stereotactic radiotherapy. And definitely that's, again, a field that's really evolved and we work very closely with our colleagues because it means, especially with the newer techniques, that we can deliver exceptionally potent doses but at a relatively well tolerated, in a relatively well tolerated manner that we're not compromising the patient's drug treatment at the same time.

So yeah, I think hand in hand both areas have evolved. mean, not in the outfield, but in a similarish mutation called EGFR. We again just had quite a big study read out at that same Congress looking at this very question about with patients with kind of low volume disease, if we treat them first with their drug.

if we kind of give local therapy, which radiotherapy was probably the predominant modality to the residual areas that can be seen, can that improve outcomes? It's an early study, so a lot more work needs to be done, but there was quite an interesting signal in terms of the benefit of that. So for the right patient, should we be considering what we call consolidated therapy if they're responding well to treatment rather than waiting for the cancer to grow and then considering treatment.

Naman Julka-Anderson (19:33.733)
So thinking about the late effects of cancer treatments for targeted therapies, what are the differences for late effects that you might see with your patients?

Shobhit Baijal (19:51.681)
In all honesty, I would say for targeted therapies, because of the half-life of the drugs, usually when patients or we stop treatment, we don't tend to see late effects. I think there are general, no matter what cancer treatment patients are, whether it's targeted, chemo, immunotherapy, things like cancer fatigue, are probably elements that we don't understand too well, but I think any treatment can cause that. But the actual specific side effects, usually when patients stop treatment,

within a period of time. And again, that can be sometimes if somebody's really having a difficult time with the side effects, we try and avoid it, but if we have to give a break off treatment, that can often be very effective in terms of resolving the treatments. I think the difference, the other aspect is usually in terms of the ALCS space, we're talking about patients with advanced disease, so it really is a case of if we're stopping a treatment, we're often moving on to another one. So there isn't this kind of reprieve.

But often we would obviously want the patient to be well enough to move on to the next treatment. But we don't often have to worry about any legacy side effects. But interestingly, the field of treating ALK has also moved to early stage cancer. So we now have data as well as approved treatment for patients who have their lung cancer taken out. And we give them what we call adjuvant treatment, which is kind of a mop up treatment after they've had their surgery to try and reduce the risk of the cancer coming back. And again, we saw really

effective or really powerful data for reducing the risk of the cancer coming back by using the drug I mentioned, Lectinib, in that post-surgery setting, and that's now a drug that is approved. But you're right, I think for these patients, the long-term impact is definitely going to be more important because they're going to have their treatment and then stop, and then the aspects of survivorship clearly are very important then.

Jo McNamara Rad Chat Host (21:47.01)
So tell us a bit about your work with ALK. What is it that you do for the charity and what do you think you bring to that kind of element of the charity supporting patients?

Shobhit Baijal (21:59.147)
The hard work is done by the charity themselves. I mean, they do a lot of activities, events behind the scenes that myself and a few of my other colleagues are heavily involved without that we don't see. As an oncologist, where we come into it is,

We support with advice whether it's with guidance, any work or audits that they may want to be doing. We try to avoid too much but where we can if there is some clinical advice on a specific patient that's been put to the charity, sometimes our opinion is asked but obviously we do have to give that with a pinch of salt because we are not fully aware of the full context of the clinical scenario.

But I think the biggest highlight is the conference. they, Alck and Deborah Montague, who's obviously been pivotal for that study, they run a yearly patient conference, patient and carer conference, which it's a two or three day event now. Attendance is phenomenal. They pack out the room and they have myself and my colleagues. There's normally a group of us and we are

championed with different talks to give. And as I said, these are high level talks. are, you know, but it's that whole remit. There's the holistic aspect, but there is also a very heavy clinical aspect, really, I think, empowering the patients with the knowledge base about the condition, what's happening now, what should be happening now, and more importantly, what's coming around the corner.

Naman Julka-Anderson (23:50.253)
Is there something you'd want people to know about ALK-positive cancers that maybe is a myth or the misconceptions?

Shobhit Baijal (24:01.089)
I don't know about myths or misconceptions. it's a challenge. The kind of non-smoker lung cancer is a challenge. Challenge for us in the UK. It's a challenge globally because these patients are not on the radar for screening. They're not. They're often the ones that are going to the GP with recurrent infections. But understandably without that smoking history, you know, the GP, it's not going to be on the front of their mind that this could be a lung cancer patient. So sadly,

lots of these patients end up presenting with advanced disease. And I think that's, I'd say probably not a myth or from that, I think the point, the big myth is, you know, that emphasis and it's not just for out, there are these other alterations where the, you know, the lung cancer doesn't just affect smokers. I think that's probably the big message we really need to emphasise.

Naman Julka-Anderson (24:52.325)
Just for anyone listening who doesn't understand that you can get lung cancer without smoking, what are the other risk factors that could lead to it?

Shobhit Baijal (25:01.184)
So we don't fully understand, although there has been some big work done by a study called Darwin, which has been looking at how cancers evolve. This is Charlie Swanson's work. And he's done also some quite interesting work in cancers that develop in never smokers. And the thought of the hypothesis is that there probably is an altered gene.

single gene and it probably is environmental exposure to certain elements or carcinogenic elements that then sends that second trigger that then ultimately causes cancers in these patients. But I think we're not in a world where we understand it enough to know how to prevent this or to educate people how to avoid this.

Naman Julka-Anderson (25:56.902)
So Shobhit bit, we always like to ask our guests what's next for them but I feel like you have your plate very full at the moment. Is there anything else we should expect from you for the rest of the year and onwards?

Shobhit Baijal (26:07.424)
For me or for outpatients? There's not much left of 2025. think conferences and conferences are tailing down but the work is still going on. No, it's still a busy couple of months. yeah, a bit more of the same.

Naman Julka-Anderson (26:09.925)
For you

Naman Julka-Anderson (26:27.919)
And then We always end our episode show with top tips for anyone listening. Is there any final points you want to give to our listeners before we end?

Shobhit Baijal (26:37.251)
I think, well, first of all, thank you for listening because, yeah, think, know, lung cancer, lung cancer in general, it's a field, it's what, it was a Cinderella cancer. And when I started as a consultant, sorry, it was kind of the neglected cancer, I say, and it's kind of evolved to be the Cinderella of oncology in terms of, really driven the field of personalized oncology.

It's really driven, I think, the field of diagnostics and how we test for cancers. So, you know, I think if there are anybody out there thinking about a career in oncology, you know, for me, it's got everything from the interaction with patients, the relationship you develop with them, the research, the trials, the opportunities are great.

again, whatever field you're in or as an HCP. I know you guys are passionate about your radiotherapy. Again, it's a field that's rapidly evolving. Go out and if you're a student, and send some emails out and go get some taste of days. We're all very, we have open doors and we're very passionate about sharing what's going on in our clinics and in our clinical work. But yeah, just thank you for listening.

Naman Julka-Anderson (27:58.171)
Thanks everyone for listening to Rad Chat with me, Naman Julka-Anderson and Jo McNamara. Thank you.