Anatomy of a Killer – Some Hard Truths, and Advice, About Lung Cancer

Lung cancer is a leading cause of cancer death in men and women in the United States and kills more people than colon, breast, and prostate cancer combined.

The American Cancer Society’s estimates for lung cancer in the U.S. for 2016 are that about 224,390 new cases will be diagnosed and 158,080 people will die. A deadly disease that affects both smokers and non-smokers, lung-cancer patients have a 15{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} five-year survival rate. But there are other risks, too, such as high levels of pollution, radiation, and asbestos exposure. Early detection could save your life if you are at risk.

Q. My sister was just diagnosed with small-cell lung cancer, and her doctor told her she has the aggressive type. Are there different kinds of lung cancer?

A. There are two main types of lung cancer, small-cell lung cancer and non-small-cell lung cancer. Both types are considered to be aggressive cancers, as demonstrated by the high number of people who die from the disease each year. However, small-cell, like your sister has, tends to be the more aggressive of the two, spreading to other sites of the body earlier in the disease process. The most important determination of prognosis is the stage, or how early or late in the disease process the cancer is found.

Q. Why is lung cancer so deadly among the many cancers?

A. In addition to being aggressive, 85{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of lung cancers are found at an advanced stage since they do not usually cause symptoms until late in their development, when they have had time to grow and spread. This makes the cancer more difficult to treat. The most important factor is early detection, but unlike other cancers, tests and recommendations for early detection were not useful until just recently.

Lung cancer is also considered the deadliest of cancers because it is very common. I don’t know if your sister smokes, but I can tell you that most lung cancers are related to smoking, which is a habit that is practiced throughout the world, leading to the high number of people developing the disease.

Smoking is responsible for the development of approximately 80{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of lung cancers and is by far the most common cause of the disease. What this says is that the disease is highly preventable by not smoking. Quitting smoking now will decrease the risk of developing lung cancer. Exposure to second-hand smoke from being around others who smoke is also a significant factor in developing lung cancer. With prolonged exposure, if you live with someone who smokes, particularly if someone has been exposed in childhood, the risks are similar to those who are smokers.

There are other risk factors that play a role, particularly exposure to asbestos, as well as radon and other chemicals. A family history of cancer, particularly lung cancer, can also predispose you to developing lung cancer, especially if there is an exposure to smoking.

Q. I never hear about screening for lung cancer. Since my sister has it, I would like to be screened. Is there screening?

A. Until recently, no test had been shown to detect lung cancer early enough in a low-risk, cost-effective way to help improve the outcomes of this deadly disease. A large study released in 2011, however, showed that the use of a low-radiation-dose CT scan could detect cancers early in their development and improved the overall survival by 20{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of the group of patients who received this test on a yearly basis.

We now recommend that this group of high-risk individuals undergo lung-cancer screening with this low-dose CT scan. The important part of any screening study is interpretation and decisions around what to do with findings on the tests, which are not always cancer. Lung-cancer screening programs have been developed and are available in the region that employ a team of experts who perform and interpret these studies to determine if cancer is present and how to deal with each finding. Baystate Medical Center is the only hospital in Western Mass. to be named a Lung Cancer Screening Center of Excellence by the Lung Cancer Alliance, a designation that means it has agreed to follow specific guidelines and best practices to ensure the highest quality of screening and follow-up care.

Q. Are there new therapies that I should tell my sister to be sure to ask about?

A. Lung-cancer treatment is determined by the stage, or how advanced the cancer is at the time it is detected. There are three main types of treatment that can be used, often in combination. For early lung cancer, surgery to remove the tumor is the main treatment. As the cancer becomes more advanced, surgery may be combined with chemotherapy, radiation, or both. Sometimes, chemotherapy and radiation are undertaken before surgery is performed — for example, to shrink the tumor. In the most advanced cases, chemotherapy and radiation or chemotherapy alone are used.

Targeted immunotherapy has become more common in the treatment of many types of cancers today, including lung cancer. This type of treatment is based on the genetic makeup of the tumor, where the genes determine what type of receptors the cell has. These can now be detected by various methods, and have become ‘targets’ for the use of certain chemotherapy medications that will specifically act on these receptors, focusing the treatment on the tumor itself.

In this way, specific medications can now be used to target the tumor for an individual patient. This is an area of lung-cancer treatment that has advanced rapidly in the last few years. New medications or drugs are being developed to target specific types of cancer cells to help treat them. In the future, each tumor will be able to be evaluated genetically, and a regimen of medications will be chosen based on this tumor ‘profile’ that is specific to that individual tumor. Some of these medications are currently being used, and this area of cancer treatment will continue to be an active area of development.

The standard of care for patients with locally advanced (stage III) lung cancer is a combination of chemotherapy and radiation therapy, either 3-D CRT (3-dimensional conformal radiation therapy) or intensity-modulated radiation therapy (IMRT). The benefit of IMRT is that, in some cases, unlike standard 3-D radiation therapy, it may allow radiation oncologists to deliver a higher dose of radiation more precisely to the tumor, while at the same time sparing any damage to surrounding healthy tissue.

Although IMRT is still being studied in its use for lung-cancer patients, research has shown that those who received IMRT had less severe lung toxicity and were able to better tolerate their chemotherapy. At Baystate Medical Center, we use IMRT for lung cancer selectively, because it can also spread low-dose radiation to the normal lung, and there have not been enough studies on its effects. Right now IMRT is just another useful tool available to us, and it would be a misconception for patients to feel they are not getting optimal treatment if 3-D CRT is used instead of IMRT in their particular case.

Q. My sister is having chemotherapy first to shrink her tumor before surgery. Has lung cancer surgery changed over the years?

A. Surgery is still the main treatment for early-stage lung cancer. Like many surgical procedures, lung surgery has advanced with the goal of less pain and disability for the patient. This is achieved by minimizing the size of the incisions and avoiding putting pressure on the ribs with retractors to open the incisions. These less-invasive techniques are made possible by the development of cameras or ‘scopes’ that can be placed through a small incision and used to see inside of the chest. This technique decreases the discomfort from the procedure, resulting in faster recovery and fewer complications. These procedures can be performed with standard video-assisted techniques — called VATS or video-assisted thoracic surgery — as well as with new robotic systems. While not all cancers can be removed with minimally invasive techniques, the majority of them are amenable to these techniques used regularly to treat patients in Western Mass.