Lung cancer is the leading cause of cancer death in the country, according to the American Cancer Society.
The cancer movement in the U.S. has grown in recent years. Each October, people, businesses and even sports teams are awash in pink for Breast Cancer Awareness month, but not as many people may be aware that the following month is devoted to lung cancer awareness.
November is Lung Cancer Awareness Month. We have a long way to go, but we’ve made significant strides in treatment and research that should be celebrated, while also maintaining a focus on how to save more lives.
Evolution in Lung Cancer Treatment
We’ve made two large gains with lung cancer: first in understanding the biology of lung cancer and finding targeted therapies that address genetic mutations, and secondly in the field of immuno-oncology.
Twelve years ago, we didn’t have a means to molecularly characterize lung cancer. Now we know of dozens of driver mutations. Though most of these mutations still lack a targeted therapy, the ability to refine therapy and personalize therapy to the molecular signature of lung cancer has been a huge game-changer. We have targeted therapies now for epidermal growth factor receptor- (EGFR) driven tumors, with at least four therapies currently approved. For a subset of patients who have EGFR mutations, these drugs are potentially life-changing. Still, we’re trying to catch up. We now know of more than 200 different genetic mutations, but we still have a lot of work to do to find targeted drugs for these mutations.
Immunotherapy drugs also have transformed lung cancer treatment. Nivolumab is the first immunotherapy drug to be approved for non-small cell lung cancer. The approved indication is for patients who have had traditional chemotherapy that didn’t work. There are also two other immunotherapy drugs approved: pembrolizumab, which was just approved for first line treatment along with second line treatment, and atezolizumab, approved for second line treatment.
Molecular Drivers of Lung Cancer
The majority of lung cancer patients we treat at Orlando Health have late-stage disease. For patients with late-stage disease, we must rely on systemic treatment such as chemotherapy, immunotherapy or targeted agents. What we’re fighting for is to help our patients live longer and preserve their quality of life.
The survival gains are changing each year, and a lot of this has to do with advances in our molecular understanding of the disease. All tumor cells have a complex makeup of different genes, with their own fingerprint. Some tumors will have a dominant gene, or what we call a driver mutation, such as EGFR, which is present in about 10-15 percent of patients, particularly in the non-squamous type of non-small cell lung cancer. This represents a very important type of non-small cell lung cancer tumor for which we have multiple targeted agents. Another example is the ALK gene. We now have three FDA-approved targeted treatments for this specific gene as well.
We’re still pinpointing what leads to these genetic mutations, but very often these driver mutations occur in patients that don’t have a smoking history — about 15 percent of patients with non-small lung cancers aren’t smokers. In certain areas of the world, about 30-50 percent of patients with lung cancer are EGFR-driven, so it’s a very different epidemiology today than what we saw 25 years ago.
Making Strides in Lung Cancer Research
There are still certain areas of research that need improvement, including lowering recurrence rates for early stage patients.
In patients who have had surgery, the recurrence rate is significant and we don’t have as many adjuvant treatment options. We’ve reached a therapeutic plateau with chemotherapy where the gains are about a 20-percent decrease in relapse. Obviously, there’s room for greater gains in this area, and it’s part of the reason researchers are examining whether immunotherapy drugs can lower the recurrence rate. Orlando Health’s partner institution, Shands Hospital in Gainesville, currently has an open immunotherapy study to assess whether this treatment will improve outcomes for patients who have had surgery.
However, we still can make more gains for patients with locally advanced lung cancer. One of the areas where we hope to see improvement is radiation therapy. The Proton Therapy Center at UF Health Cancer Center — Orlando Health recently opened, which will give some patients the option for targeted proton radiation treatment which may improve tolerability.
We also need to emphasize early detection. For patients with stage IV disease, the average survival is about 15-18 months. For some stage IV patients with EGFR or ALK mutations, survival may be up to five years or longer, depending on the tumor’s molecular profile. Furthermore, we can increase survivorship if we focus on early detection and work with our partners in the primary care and pulmonary communities to promote screening, especially now that the Centers for Medicare and Medicaid Services has approved low-dose screening CT. With these changes, we hope to diagnose more patients at an earlier stage, thereby improving their long-term prognosis.
I’d also encourage patients to be their own advocates. If you’ve smoked for decades, ask your primary care doctor for a screening CT. Primary care physicians also should be aware that if their patient has a 30-year smoking history, these patients may be candidates for a screening CT. Many lung cancer patients are referred to us because their primary care doctor did exactly that.
For years, there’s been a stigma around lung cancer, which has slowed some of the strides we could have made with awareness, treatment and research. But every day we make progress. From clinical trials to combination therapies and early detection, we can save more lives if the international community comes together and focuses on research and funding.
We need the same level of public outcry for this disease as we have for other forms of cancer. This November, during Lung Cancer Awareness Month, is the perfect time to reinvigorate this effort.
By Jennifer Tseng, MD
Jennifer Tseng, MD, hematologist/medical oncologist, is the Thoracic/Head and Neck Specialty Section leader for Medical Oncology and the associate director of Clinical Research for Medical Oncology at UF Health Cancer Center — Orlando Health.
Dr. Tseng received her medical degree from Duke University School of Medicine. She completed her residency and served as assistant chief resident in internal medicine at Duke University Medical Center. She completed a fellowship in medical oncology and hematology at The University of Texas MD Anderson Cancer Center in Houston. She is board-certified in internal medicine and medical oncology and board-eligible in hematology. Dr. Tseng has received several honors and awards, including the C.D. Howe Award for clinical excellence in medical oncology and a Clinical Research Award from MD Anderson, the American Medical Women’s Award, Hewlett Packard Award, the Alpha Omega Alpha Research Symposium Award from Duke University and a Beneficial-Hodgson scholarship from The Johns Hopkins University. She was also awarded Attending of the Year from the Internal Medicine Residency Program from Orlando Regional Medical Center and received the Exemplary Physician Colleague Award from Orlando Health in 2009.
In addition to her clinical studies, Dr. Tseng has published research on various topics including molecular alterations in lung cancer and novel agents in the treatment of head and neck cancer. She has recently presented at the Annual Thoracic Oncology Symposium of the Puerto Rican Society of Hematology Oncology and spoke on neoadjuvant and adjuvant treatment strategies in lung cancer.