body • mind • spirit Fighting Lung Cancer by Gabriel Carabulea, M.D.
Lung Cancer Statistics Did you know that lung cancer is the lead-
ing cause of cancer death for both men and women in the US? Lung cancer affects mainly older people, but there are more deaths from lung cancer than from colon, breast, and prostate cancers combined. Both smokers and non-smokers can get lung cancer. There are cer- tain risk factors that can predispose a person to lung cancer, including smoking tobacco, sec- ondhand smoke, exposure to radon, asbestos, or air pollution, radiation therapy from treating cancers in the chest and arsenic from drinking water. There is also at higher risk for developing lung cancer if a person has had another type of cancer or if a family member has had lung can- cer previously.
Risk and Screening
for Lung Cancer Individuals who are at higher risk for lung
cancer, such as current or former smokers, may want to discuss lung cancer screening guide- lines with their doctor to determine if they are eligible. One of the advantages to the cancer screening test is to find cancer in people who do not have any symptoms of disease. Recently, results from the National Lung Screening Trial (NLST) showed that in some people who were at high risk for developing lung cancer, a screening test called a low-dose CT (LDCT) scan could lessen the chance of dying from lung cancer. These results prompted the American Cancer Society to develop screening guidelines
Dr. Carabulea, M.D. practices local here in San Clemente.
for your doctor to follow. Although screening by LDCT may catch cancer earlier, it also has a few disadvantages. The LDCT exposes a per- son to a small amount of radiation with each test. Also, the test finds things, like scarring, that may not be cancer, but that still may need to be checked out to be certain. If lung cancer is found early, the cancer may be able to be re- moved or treated so that it does not come back. Sometimes the cancer can return, or in some
patients, the cancer is not found until it has ad- vanced, meaning that it has moved to more than one spot in the body or spread to different places in the body. Once a cancer has advanced, the doctor needs more information about the tumor in order to find the right therapy for the patient
Biomarker Testing Once a person is diagnosed with advanced lung cancer,
a
biopsy of the tumor will be taken and genetic
“bio-
marker” testing will be performed on the tumor sample to test for changes in the genes EGFR and ALK. Patients with tumors that are positive for changes in EGFR (around 10% of Caucasian patients and up to 50% of Asian patients with non-small cell lung cancer [NSCLC]) or ALK (around 2- 7% of all patients with NSCLC) have been able to benefit from drugs that tar- get the specific ge- netic change in the tumor. However, the majority of pa-
tients don’t test positive for one of these changes, but may still be able to benefit from targeted drugs. Interestingly, a blood-based protein test (VeriStrat®) is in standard of care guidelines, and can help quickly determine which of these patients might (and might not) be able to benefit from a targeted drug as test results are provided within 72 hours of the blood draw. Precision or personalized medi- cine, using new gene and protein blood tests, are great news for patients as they can help in- form treatment options and help guide patient and doctor discussions on the specifics of the individual patient’s disease. The protein (proteomics) test in treatment
guidelines, VeriStrat, can help patients in sev- eral ways. This test can identify whether a pa- tient with advanced NSCLC who doesn’t have a change in the EGFR gene (or whose EGFR status is unknown) will benefit from a FDA- approved targeted drug after they have pro- gressed on chemotherapy. Some patients can’t tolerate chemotherapy because of the nature of their disease. Targeted therapies may offer fewer side effects, a break from what some patients find to be hard to tolerate chemotherapy treat- ments, and greater convenience over standard chemotherapy because they can be taken by mouth (chemotherapy is taken intravenously [IV], which may require long visits to the in- fusion clinic). Importantly, the test provides an evidence-based approach for doctors and pa- tients to have a discussion on the various treat- ment options, as VeriStrat also identifies patient survival outcomes and disease aggressiveness.
Treatments Patients with tumors that are positive for
changes in EGFR or ALK genes are typically treated with an agent that targets those changes, while patients without changes are typically given chemotherapy. For a therapy choice in 2nd line, options are restricted to treatments that have not already been given previously. As of now, gefitinib, erlotinib, gem- citabine, docetaxel, docetaxel plus ramu- cirumab, pemetrexed (in a specific type of lung cancer- non-squamous cell carcinoma), or nivolumab (Opdivo) are FDA-approved ther- apies in this treatment setting. Nivolumab is a new type of treatment option, an immunother- apy, and cancer immunotherapy is changing the face of lung cancer by allowing some pa- tients to live longer and, in some cases, result- ing in patients’ cancer disappearing. However, scientists are still trying to figure out which pa- tients benefit
from immunotherapies.
Nivolumab, a specific immunotherapy that works as a PD-1 inhibitor, is the most exciting new therapy option available because it is a new kind of treatment that stimulates the body’s own immune system to fight cancer. Targeted agents still have the edge over immunotherapy in terms of response rates, but when patients do respond to immunotherapy, their benefits can be durable.
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