In the second of our series on lung cancer, we continue our conversation with one of the nation's experts on the subject. D. Ross Camidge, MD, PhD, is a well-known lung cancer specialist and director of the thoracic oncology clinical program at the University of Colorado.
In this ongoing conversation, we discuss what someone diagnosed with lung cancer can do to get the best care.
dailyRx: What's the best thing someone diagnosed with lung cancer can do?
Dr. Camidge: I think without a doubt that every person diagnosed with lung cancer should get their primary opinion, or at least a second opinion, from a lung cancer specialist - a thoracic oncologist. I whole-heartedly believe that.
I know many amazing, brilliant general oncologists who I would happily have treat any member of my family. But through the many second opinions I have given, I have also seen examples of gross mismanagement as well. Fortunately, the latter are rare, but even one is too many in my opinion.
One of the reasons lung cancer survival rates have been so appalling is that some clinicians see a diagnosis of lung cancer and they don't push hard enough to treat the patient optimally.
And also, even for a great doctor, there have been so many recent breakthroughs in the treatment of lung cancer, you really need to go to an expert who's staying up to speed with the cutting edge.
You don't need to be treated by this expert. Once the diagnosis is made and treatment plan is in place, if this is something that can be delivered by a general oncologist who is closer or who you have a good relationship with, you can be treated by whoever is treating you now.
That's what we often do here at the University of Colorado - we'll give a second opinion, and then we'll work as a team with the local treating oncologist.
But the worst scenario is to just assume that someone is going to be able to keep up with every single development in an increasingly diverse setting. So you want to see someone who focuses only on lung cancer or breast cancer and so forth.
dailyRx: What are the next steps after the diagnosis?
Dr. Camidge: Some things haven't changed in decades. So a patient needs to find out:
- What subtype of lung cancer do you have, i.e., is it small cell, or non-small cell (NSCLC)?
- How far has the cancer spread throughout your body?
This process of determining the degree of spread is called ‘staging’ of the cancer.
dailyRx: What tests are used for staging lung cancer?
Dr. Camidge: In most centers in the U.S. the usual staging investigations include using either CT [computerized tomography] scans of the chest and abdomen or, more and more, a combined PET/CT scan.
PET stands for Positron Emission Tomography and this technology is very sensitive for finding cancer. When this ability is combined with the anatomic detail given by a CT scan, these imaging studies are effective at picking up even small deposits of cancer throughout the body.
About 20 percent of lung cancer patients will have deposits in their brain at the time of diagnosis, so expert centers will also usually perform a baseline MRI (Magnetic Resonance Imaging) brain scan before treatment.
dailyRx: What else should patients be considering?
Dr. Camidge: After establishing the basic diagnosis and stage of the cancer, two other things are also important at this point. Patients need to find out:
1. If it is non-small cell cancer and it is anything other than very early stage, is there enough tissue in the initial biopsy to have some molecular testing done? There needs to be more than a few suspicious cells to work with.
I say more than very early stage because at present this information is only of immediate use in patients with incurable cancers looking to establish optimal control of the disease. For cancers that are potentially cured, this molecular information may never be needed. That's why some have argued that this testing is a waste of money. However, this information could simply be kept in reserve for those who see the cancer return.
2. Secondly, as discussed earlier, I recommend that patients at least ask for an expert opinion to help with decision making as early as possible, ideally before starting any specific treatment.
dailyRx: Why is molecular testing important?
Dr. Camidge: The technology for doing molecular testing is looking for key gene mutations or gene rearrangements that occur in the DNA of cancer cells.
We want to find these mutations so that we can come up with a treatment plan that treats the exact type of lung cancer each individual has. That's what people often don't understand. Lung cancer isn't one disease, and everyone has a unique form of the disease.
Knowing what molecules are involved lets us better determine the best drugs to use to fight the cancer. This is known as personalized care.
dailyRx: What mutations are seen in lung cancer?
Dr. Camidge: In 2004, mutations in a gene called EGFR were described in about 10 percent of NSCLC cases in the West. EGFR stands for epidermal growth factor receptor. The gene codes for a molecule present on the surface of many cancer cells and when it is mutated, it helps the cancer grow and spread.
Cancers that have EGFR mutations are now known to predict who will significantly benefit from drugs that work against this protein - like erlotinib - brand name Tarceva, or gefitinib – brand name Iressa.
For a while, some people felt the EGFR mutations were the exception that proved the rule - that the rest of lung cancer was just one big awful disease and that very modest benefit from therapy was the norm.
Then in 2009, we got the first demonstration that there was at least another subgroup hidden under the umbrella term of NSCLC. These are called ALK (anaplastic lymphoma kinase) gene rearrangements.
This is where in some people's cancers the cancer is activated not by a single change in the DNA - a mutation - but by a large rearrangement of the cancer’s chromosomes. Literally two genes break, intermingle and join back together again in a different sequence.
ALK-rearranged lung cancer we now know responds well to a different drug called crizotinib, or Xalkori, that blocks or inhibits ALK.
Now the race is on to find all the other different molecular subtypes of lung cancer, some of them only occurring in 1-2 percent of people, and match them with specific treatments.
I don’t think we’ll find these kind of examples in every case, but we may be able to make relevant molecular distinctions that alter therapy choices in about half of cases in a few years.
In the final of this series, Dr. Camidge will talk about the emotional impact of living with a lung cancer diagnosis, the statistics and the breakthroughs in treating the disease.