Lung Cancer Treatment Update

LUNG CANCER
Lung Cancer
Treatment Update
Presented by
Richard J. Gralla, MD
New York Lung Cancer Alliance
Winfield A. Boerckel, MSW, MBA
CancerCare
Find out about:
• Lung cancer basics
• Diagnostic tools
• Treatment options
• Your support team
Help and Hope

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LUNG CANCER
Lung Cancer
Treatment Update
Presented by
Richard J. Gralla, MD
President
New York Lung Cancer Alliance
New York, NY
Winfield A. Boerckel, MSW, MBA
Lung Cancer Program Coordinator
CancerCare
The information in this booklet is based on the CancerCare Connect®
Telephone Education Workshop “Living with Lung Cancer,” which took
place in February 2006. The workshop was conducted by CancerCare
in partnership with the American Society of Clinical Oncology,
Association of Clinicians for the Underserved, Association of Oncology
Social Work, Intercultural Cancer Council, the Lung Cancer Al iance,
Multinational Association of Supportive Care in Cancer, and Women
Against Lung Cancer.
INTRODUCTION
page 2
■ TYPES OF LUNG CANCER, page 3
■ DIAGNOSTIC TOOLS, page 4
■ STAGES OF LUNG CANCER, page 5
■ TREATMENT OPTIONS, page 6
■ TARGETED TREATMENTS, page 7
■ YOUR SUPPORT TEAM, page 9
FREQUENTLY ASKED QUESTIONS
page 11
GLOSSARY (definitions of blue boldfaced words in the text)
page 13
RESOURCES
page 16
This patient booklet was made possible by an
educational grant from sanofi-aventis US Inc.
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New targeted treatments
are benefiting people
with lung cancer.
Each year, nearly 175,000 Americans are diagnosed with lung
cancer—the number one cause of cancer death in the United
States among both men and women. Nearly twice as many
women die of lung cancer than of breast cancer.
About 85 percent of people who develop lung cancer either
are or have been smokers. Yet, some people who have never
smoked still get the disease. Scientists are not sure whether this
is due to secondhand smoke, naturally occurring radon gas, or
other carcinogens. Some studies show that nearly seven of
ten smokers would like to quit.
But tobacco is highly addicting,
and that makes it very difficult
to stop a habit that many
people began as teenagers.
However, it is never too late to
stop smoking. Even at age 60,
a person can cut his or her risk
of lung cancer nearly in half. Of
course, the earlier smokers quit,
the better.
Because the lungs are large,
Colored chest x-ray showing a tumor
tumors can grow in them for
(orange, yellow) in the left lung
a long time before they are
detected. In fact, lung cancer can easily spread outside the
lungs without causing any symptoms. Many people who have
the more common symptoms, such as cough and fatigue,
often assume these problems are due to smoking itself or to a
minor illness such as a cold.
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LUNG CANCER
Types of Lung Cancer
Doctors determine the type of lung cancer by looking at a
biopsy of individual tumor cells under the microscope. It’s
important to make the distinction because it helps doctors
design the best treatment. There are two major types of lung
cancer:
Non-small cell lung cancer accounts for about 85 percent
of lung cancers. Among them are these types of tumors:
■ Epidermoid carcinoma (also called squamous cell
carcinoma) forms in the lining of the bronchial tubes. This
is the most prevalent type of lung cancer in men.
■ Adenocarcinoma is the most common form of lung cancer
in the United States among both men and women.
Bronchioalveolar carcinoma, or BAC, is a less common
type of adenocarcinoma. It forms near the lungs’ air sacs.
Recently, research has shown that some people with BAC
Signs and Symptoms
Signs (things you or others can see or experience) and symptoms
(things you feel) are often not specific to lung cancer. Every time
someone coughs, for instance, it doesn’t mean that their lungs
are diseased. And not every person with lung cancer experiences
the same signs or symptoms. In fact, some people may not notice
any change in their health. But at some point, most people with
lung cancer do notice the following:
■ Fatigue
■ Cough
■ Hoarseness
■ Shortness of breath
■ Pain
■ Loss of appetite
■ Coughing up blood
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may have an abnormal gene in their tumor cells. A new
targeted treatment appears to be effective in treating BAC
and other types of non-small cell lung cancer in which this
gene mutation occurs.
■ Large-cell undifferentiated carcinomas This name
refers to non-smal cel lung cancers that are neither
adenocarcinomas nor epidermoid cancers.
Small cell lung cancer accounts for about 15 percent of lung
cancers in the United States. As a rule, small cell lung cancer
has spread — at least microscopically — by the time doctors find
it. So surgery is usually not recommended because it would be
ineffective.
Diagnostic Tools
Unlike mammography for breast cancer or colonoscopy for
colon cancer, there is no widely accepted screening tool for
early-stage lung cancer. Unfortunately, regular chest x-rays
are not reliable enough to find lung tumors in their earliest
stages, at their smallest. But recent studies have suggested
that another imaging technique can detect tumors as small as
5 millimeters — less than a ¼ inch — in size. Called computed
tomography (or CT scan), the technique is being tested in
several studies around the world to see if it can detect lung
cancer early enough to improve survival. These results should
be available in the next few years.
If lung cancer is suspected, a smal piece of tissue from the lung
must be examined under a microscope to look for cancer cel s.
Cal ed a biopsy, this procedure can be performed in different
ways. In some cases, the doctor passes a needle through the
skin into the lung to remove a smal piece of tissue. In other
cases, a bronchoscopy is done. For this procedure, the doctor
threads a smal tube through the mouth or nose and into the
lungs. The tube, which has a light on the end, al ows the doctor
to see inside the lungs and to remove a smal tissue sample.
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LUNG CANCER
These procedures can be performed without a hospital stay.
Occasional y, a smal surgery, requiring anesthesia, is needed.
Stages of Lung Cancer
When lung cancer is diagnosed, it’s important to know what
stage it is. The stage helps determine treatment, taking into
account the size of the tumor and whether the cancer has
spread. Because early-stage lung cancer (stages I and II) is so
hard to detect, most people are diagnosed at stages III and IV.
The four stages of non-small cell lung cancer are:
Stage I The cancer is located only in the lungs and has not
spread. This is the least advanced stage.
Stage II The cancer is in the lung and lymph nodes or
between the lobes. Lymph nodes are small, bean-shaped
structures that act as filtering stations to remove waste and
fluids and to help fight infection. When invaded by cancer
cells, lymph nodes are a point from which tumors can spread
throughout the body.
Stage III Cancer is found in the lung and in the lymph nodes
in the middle of the chest, or there is a tumor in the lung plus
fluid in the chest cavity. Stage III cancer has two subtypes:
■ If the cancer has spread to the lymph nodes on the same
side of the chest as where the cancer started, it is called
stage III-A.
■ If the cancer has spread to the lymph nodes on the opposite
side of the chest, it is called stage III-B.
Stage IV Stage IV is the most advanced stage of lung cancer.
This is when the cancer has spread to another part of the body
such as the liver or other organs.
STAGES OF SMALL CELL LUNG CANCER
Small cell lung cancer is divided into two stages:
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■ Limited stage In this form, cancer is found on one side
of the chest, involving just one part of the lung and nearby
lymph nodes.
■ Extensive stage Here, cancer has spread to other regions
of the chest or other parts of the body.
Treatment Options
Surgery, radiation, chemotherapy, and targeted therapies —
alone or in combination — are used to treat lung cancer.
SURGERY
Most stage I and II non-small cell lung cancers are treated with
surgery to remove the tumor. Even if a tumor is quite small,
a lobectomy is performed. For this procedure, a surgeon
removes the lobe, or section, of
the lung containing the tumor.
Some surgeons use video-
assisted thoracoscopic
surgery (VATS). For this
procedure, the surgeon makes
a relatively small incision (cut)
in the chest and inserts a tiny
camera attached to a tube called
a thoracoscope. The camera is
connected to a video monitor
that enables the surgeon to see inside the chest. A lung lobe
can then be removed through the scope, without making a
large incision.
CHEMOTHERAPY AND RADIATION
For people with non-small cell lung tumors that can be
surgically removed, evidence suggests that chemotherapy
after surgery, known as adjuvant chemotherapy, will help
prevent the cancer from returning. Still, questions remain
about whether adjuvant chemotherapy is best for all patients
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LUNG CANCER
and how much people with different stages of lung cancer will
benefit. Research continue on this much-debated topic.
For people with stage III lung cancer, doctors may recommend
a combination of anti-cancer drugs, possibly followed by
radiation treatments to shrink the
tumor or surgery to remove what
remains of the tumor.
In stage IV lung cancer,
chemotherapy is typically the
cornerstone of treatment. It is
often combined with radiation.
The chemotherapy treatment
protocol for lung cancer often
consists of a combination of drugs:
among the ones most commonly
used are cisplatin (available under the trade name Platinol,
as well as generically) or carboplatin (Paraplatin and generic
carboplatin) plus one other drug such as docetaxel (Taxotere),
gemcitabine (Gemzar), paclitaxel (Taxol and others), or
vinorelbine (Navelbine and others).
If, after treatment with these drugs, lung cancer comes back or
if the first round of chemotherapy is not effective, then doctors
often prescribe a second course of drug treatment referred to
as second-line chemotherapy. For example, docetaxel is
often used in second-line treatment if it was not used initially.
A new drug called pemetrexed (Alimta) is also used in second-
line treatment of lung cancer.
For people with small cell lung cancer, chemotherapy, rather
than surgery, is usually the treatment of choice right from the
start. Radiation treatment is used as well.
Targeted Treatments
Recently, scientists have been developing new drugs that
appear to be effective treatments for lung cancer. They’re cal ed
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targeted treatments because they zero in on the mechanisms
that supply blood to tumors and promote their growth and
division. Rather than kil ing both healthy cel s and cancer cel s,
as chemotherapy does, targeted treatments attack cancer cel s
primarily. This spares healthy tissues and causes fewer side effects.
For example, a targeted treatment called erlotinib (Tarceva) has
been shown to benefit people with non-small cell lung cancer.
Erlotinib puts the brakes on proteins known as epidermal
growth factor receptors (EGFRs). These receptors reside
on the surface of cells and take in messages ordering the
cells to grow and divide. Although many normal cells contain
EGFRs, some kinds of cancer cells contain excess amounts
of them. The more receptors on a cell, the more signals the
cell receives to grow and multiply. In lung tumors with many
EGFRs, erlotinib can sometimes slow the cancer’s growth.
Ongoing clinical trials are helping doctors determine which
people are likely to benefit from treatments that target EGFRs.
For example, research has shown that:
■ Erlotinib and gefitinib (Iressa) appear to work best in people
who have never smoked or smoked very lightly in the past.
■ Some people with a rare type of non-smal lung cancer cal ed
BAC seem to benefit more from treatment with erlotinib and
gefitinib. The key difference appears to be a smal change, or
mutation, in one of the EGFR genes. People with BAC who
have the mutation respond better than BAC patients without
the mutation.
Another form of targeted treatment takes advantage of one
of the things we know about how lung tumors grow. Tumors
need to have a blood supply, the same as normal tissues. A
drug called bevacizumab (Avastin) works by stopping this
growth. When combined with chemotherapy, bevacizumab
has been shown to improve survival in people with certain
types of non-small lung cancer such as adenocarcinoma. The
main concern with this treatment is the side effect of increased
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