Lung Cancer

Is your treatment what more than 1,100 Oncologists recommend?

The information provided below is meant to help you understand the role of your lung cancer biology treatment decisions, as well as the role of other tools used in determining your ability to receive chemotherapy or targeted therapy (precision medicine)

In 2016, an estimated 224,390 new cases of lung cancer will be diagnoses in the United States (117,920 in men and 106,470 in women) (CA Cancer J Clin 2016; 66(1):7-30). Globally, 1.2 million new cases of lung cancer will be diagnosed every year. Lung cancer is the leading cause of death in the United States and worldwide, mainly due to its advanced stage at diagnosis.

Risk Factor

Smoking is the leading risk factor for lung cancer. However, other risk factors such as, family history, exposure to radon, asbestos, radioactive ores, arsenic, beryllium, cadmium, silica, vinyl chloride, nickel compounds, chromium compounds, coal products, mustard gas, chloromethyl ethers, diesel exhaust, and pollution may increase the risk of developing lung cancer.

Treatment

Three different approaches to treating lung cancer are available. Treatment recommendations will vary based on the type of cancer you have and could include a combination of all three options listed below:

• Lung cancer resection surgery
• Radiation
• Chemotherapy with or without targeted therapy (precision medicine)

This application is designed to outline in detail your chemotherapy and/or targeted therapy options and offer you personalized information about the best options to yield optimal survival and quality of life. Multiple factors affect your treatment options including:

1. Cancer is recurring (you have had lung cancer before) or your cancer is a first time diagnosis: The treatment for recurrence is determined by what type of treatment you received for your first diagnosis. Certain chemotherapies can only be given once in your lifetime, so if you have already received one type of chemotherapy with your first cancer, then that chemotherapy will not be recommended for you again.
2. The molecular characteristics of the tumor (tumor biology) will greatly affect treatment decisions.  Lung cancer divides into two major types: non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC).
3. Cancer stage at the time of the diagnosis. Your treating physicians will do imaging tests (CT, bone scan or PET/CT) to determine your stage. Early stage lung cancer (tumor only in the lung) is mainly treated with surgery. If the cancer has spread outside the chest, it is considered advanced lung cancer and treatment is mainly with chemotherapy and targeted therapy.

Advances in lung cancer treatment in medical oncology that affect treatment choices as following:

Non-small cell lung cancer (NSCLC): accounts for 85% of all lung cancers. This is further classified into three different subtypes:

• squamous type – develops in the cells that line the airways, this accounts for 20-25% of NSCLC
• adenocarcinoma type – develops from the cells which produce mucus (phlegm) in the lining of the airways, it represents 50% of all NSCLC
• large cell type – grows at an accelerated rate near the surface of the lung

Recent technological advances have identified multiple molecular markers (the characteristics) of your lung cancer that will help your treating physician predicts your response to targeted therapy. These targeted therapies are more effective and less toxic compared to chemotherapy. Your tumor is used to test for these markers.  These include:

• Epidermal growth factor receptor (EGFR) mutation (exon 19 and exon 21) – this mutation is seen in about 10-15% patients with adenocarcinoma lung cancer. These mutations are found in 10% of Caucasian and as high as 50% in Asian patients. Although this mutation causes uncontrolled tumor growth, it renders the tumor susceptible to a drugs called to EGFR tyrosine kinase inhibitors, such as erlotinib (Tarceva), afatinib, or gefitinib (Iressa). The drugs can have response in about 55% in patients. If these drugs no longer work (due to the devlopemnt of T790M mutation) then osimertinib (Tagrisso) can be used to fight cancer
• Anaplastic lymphoma kinase (ALK) gene rearrangement – this presents in 2-7% of adenocarcinoma lung cancer. If your tumor has this feature then a drug called crizotinib can be used, as it has a 60% response rate. If you are unable to tolerate this drug or your cancer continues to grow then another drug called ceritinib can be used to fight cancer
• ROS1 gene fusion – this is present in 2% of lung cancer. In this case crizotinib is the recommended treatment

Immunotherapy drugs is used to unleash your own immune system to fight cancer, such as nivolumab and pembrolizumab. This is accomplished via the programmed death (PD-1) receptor (the PD-1 protein helps tumors escape the immune system). Blocking PD-1 /PD-L1 path leads to increase T-cells (cells that play an essential role in immunity) to kill tumors.

Chemotherapy can also be used if the above treatment options fail to kill or control the cancer. These includes carboplatin, paclitaxel, docetaxel, pemetrexed, gemcitabine, vinorelbine, etc.

The stages for NSCLC:

Stage I: tumor is less than or equal to 5 cm and no lymph node has cancer cells
Stage II: primary tumor of any size and peribronchial, hilar and intrapulmonary lymph nodes within the same lung involved with cancer
Stage III: tumor has grown into mediastinum, heart, trachea and mediastinal or hilar nodes involved with cancer
Stage IV: tumor spreading to other parts of body

Small cell lung cancer (SCLC): accounts for 15% of all lung cancers

Most SCLC comes from smoking. SCLC grows fast and has early spread to advanced or metastatic disease. Thus, it is very sensitive to initial chemotherapy and radiation therapy.

The stages for SCLC:

• Limited stage: where tumor is confined within one lung
• Extensive or advanced stage: where tumor is spreading to other parts of the body

The major treatment for SCLCA is mostly radiation and chemotherapy (cisplatin, etoposide, topotecan). Lung cancer resection surgery in SCLCA is not commonly used.

This website gives you 85% of straight forward lung cancer treatment plans. All cancer treatment is recommended based on expertise’s opinion from multiple national guidelines (NCCN, ASCO, ESMO, ASTRO). If your cancer is atypical with different histology like neuroendocrine carcinoma, the treatment plan is more involved and complicated thus it is not included in the website at the moment.

Even though the standard of treatment is outlined, your individual tolerability to each treatment will depend on your overall health, i.e. whether you have other illness (diabetes, heart disease, liver disease, arthritis, or kidney disease). Another assessment tool that your treating physicians may use to determine your ability to receive chemotherapy is called ECOG performance status.

ECOG PERFORMANCE STATUS

Grade 0: Fully active, able to carry on all activity
Grade 1: Restricted in physically strenuous activity but ambulatory and able to carry out light house work, office work
Grade 2: Ambulatory and capable of all self-care but unable to carry out any work activities
Grade 3: Capable of only limited self-care, confined to bed or chair more than 50% of waking hours
Grade 4: Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair

(Am J Clin Oncol 1982: 5: 649-655)

Finally, chemotherapy and targeted therapies can result in unpleasant side effects such as hair loss, numbness of fingers or toes, cardiac toxicity, nausea, vomiting, diarrhea, abnormal liver function or low white blood cell count that could cause infection, and fatigue. However, advances in the oncology field have led to numerous supportive measures, such as white blood cell growth support (i.e. Neulasta) or anti-nausea medications (such as Zofran), that help to control most side effects when used as prescribed.

The best time to use this service (based on more than 1,100 cancer experts) is after you have learned the details of your cancer and treatment plan from your treating physicians, and would like to clarify and confirm that your treatment is the best option for your cancer. This questionnaire is used mainly for drug treatment in medical oncology.