Lung Cancer Awareness Month 2022

Transcript

00:00 --> 00:02Funding for Yale Cancer Answers is
00:02 --> 00:04provided by Smilow Cancer Hospital.
00:06 --> 00:08Welcome to Yale Cancer answers
00:08 --> 00:10with Doctor Anish Chappar.
00:10 --> 00:11Yale Cancer answers features
00:11 --> 00:13the latest information on cancer
00:13 --> 00:15care by welcoming oncologists and
00:15 --> 00:17specialists who are on the forefront
00:17 --> 00:19of the battle to fight cancer.
00:19 --> 00:21This week, it's a conversation about
00:21 --> 00:23lung cancer with Doctor Gavitt Woodard.
00:23 --> 00:25Dr Woodard is an assistant professor of
00:25 --> 00:27surgery at the Yale School of Medicine,
00:27 --> 00:30where Doctor Chappar is a professor
00:30 --> 00:31of surgical oncology.
00:32 --> 00:34Maybe we can start off by you
00:34 --> 00:36telling us a little bit more about
00:36 --> 00:38yourself and what it is you do.
00:38 --> 00:41Yeah, so I am a thoracic surgeon at Yale.
00:41 --> 00:44That means that I deal with all
00:44 --> 00:46thoracic diseases in the chest.
00:46 --> 00:48But the majority of our practice
00:48 --> 00:51tends to be focused on lung cancer
00:51 --> 00:53and patients with lung cancer. You
00:53 --> 00:56know, we often hear about lung
00:56 --> 01:00cancer and as one of the most
01:00 --> 01:02common cancers there is and.
01:02 --> 01:04And likely one of the leading
01:04 --> 01:07killers of people as well in
01:07 --> 01:09terms of cancer related death.
01:09 --> 01:10Can you tell us a little
01:10 --> 01:11bit more about lung cancer,
01:11 --> 01:14what what are the statistics now in
01:14 --> 01:17terms of incidence and mortality and
01:17 --> 01:20and what kind of goes into that? Yes,
01:20 --> 01:23definitely. So as you mentioned,
01:23 --> 01:26lung cancer is the leading cause of cancer
01:26 --> 01:29mortality in the US and worldwide, it's
01:29 --> 01:31the number one cause of cancer mortality.
01:31 --> 01:36In men and women, it is the #2 most common
01:36 --> 01:40cancer in terms of who actually is diagnosed.
01:40 --> 01:43So in women, it's #2 second to breast
01:43 --> 01:46and in men it's #2 second to prostate.
01:46 --> 01:49But those cancers aren't as deadly as lung
01:49 --> 01:52cancer and so even though more patients.
01:52 --> 01:54Diagnosed with them, more patients end
01:54 --> 01:58up ultimately dying of lung cancer.
01:58 --> 02:01So if you think about your lifetime rate
02:01 --> 02:04of developing lung cancer, it's about 6%.
02:04 --> 02:07That's one in 16 US adults will end
02:07 --> 02:10up with a lung cancer diagnosis.
02:10 --> 02:13Men get it slightly more frequently
02:13 --> 02:17than women and we have seen these
02:17 --> 02:20rates slowly decline in recent years,
02:20 --> 02:22but it still accounts for.
02:22 --> 02:24The majority of lung cancer deaths.
02:25 --> 02:29And so tobacco use is still the most
02:29 --> 02:32common cause for lung cancer, right?
02:32 --> 02:36But is that just cigarette smoking?
02:36 --> 02:39How common is it to get lung cancer
02:39 --> 02:41after other forms of smoking,
02:41 --> 02:44like pipe smoking, cigar smoking or
02:44 --> 02:47perhaps more commonly these days, vaping?
02:47 --> 02:49Do we have numbers on that?
02:50 --> 02:52So all of those things do put you
02:52 --> 02:55at risk for developing lung cancer.
02:55 --> 02:58Tobacco products in general still account
02:58 --> 03:02for the vast majority of lung cancer cases.
03:02 --> 03:05Other things that we think of as
03:05 --> 03:07exposure risks besides tobacco tend to
03:07 --> 03:10be things like radon exposure, asbestos,
03:10 --> 03:13secondhand smoke and air pollution is
03:13 --> 03:16also recognized as a possible cause.
03:16 --> 03:18But the other thing that's worth mentioning
03:18 --> 03:21is that even among never smokers.
03:21 --> 03:23We are seeing a rise in the incidence
03:23 --> 03:24of lung cancer,
03:24 --> 03:27meaning that more and more people who
03:27 --> 03:29have never smoked cigarettes at all
03:29 --> 03:32are being diagnosed with lung cancer.
03:32 --> 03:35About one in five new lung cancer diagnosis
03:35 --> 03:39is in a person who has never smoked at all.
03:39 --> 03:41And if you were to think of
03:41 --> 03:43lung cancer among never smokers,
03:43 --> 03:47it would account for the #7 global
03:47 --> 03:49cause of cancer mortality just
03:49 --> 03:51among people who never smoked.
03:51 --> 03:53Wow, that's really interesting.
03:53 --> 03:56Why? Why is it that people who
03:56 --> 03:58have never smoked get lung cancer?
03:58 --> 03:59And why is that rate rising?
04:00 --> 04:04We don't have great answers for that yet.
04:04 --> 04:08Some of it is probably because we are.
04:08 --> 04:10Doing a good job of screening patients
04:10 --> 04:12whether they've been smokers or not.
04:12 --> 04:15People are getting more CT scans and we
04:15 --> 04:18are catching lesions at an earlier stage
04:18 --> 04:21or perhaps someone is found to have a
04:21 --> 04:23small slow growing adenocarcinoma who
04:23 --> 04:26was a never smoker just because we are
04:26 --> 04:29using a lot of cross-sectional imaging,
04:29 --> 04:32meaning CT scans on a patient who rolls
04:32 --> 04:35into the emergency room for some reason
04:35 --> 04:38or who is having a CT scan to screen for.
04:38 --> 04:40Coronary artery calcifications.
04:42 --> 04:46So you know then that raises the question,
04:46 --> 04:49right now we have lung cancer screening
04:49 --> 04:51for people who are heavy smokers, right?
04:51 --> 04:54And maybe you can tell us a little bit
04:54 --> 04:56more about the guidelines as to who
04:56 --> 04:59qualifies for lung cancer screening with
04:59 --> 05:04low dose CT scans but with the rate of of
05:04 --> 05:07lung cancer increasing in never smokers?
05:07 --> 05:08Should that be expanded?
05:08 --> 05:11I mean, should we be thinking about
05:11 --> 05:13screening more people for lung
05:13 --> 05:15cancer if people who have smoked
05:15 --> 05:17less or who have never smoked are
05:17 --> 05:20actually increasing in terms of their
05:20 --> 05:21rate of developing lung cancer?
05:22 --> 05:25Yes, that's a great question and probably
05:25 --> 05:28something that is coming on the horizon.
05:28 --> 05:30When the first trials were done
05:30 --> 05:32to look at lung cancer screening
05:32 --> 05:35as a way of detecting lung cancer,
05:35 --> 05:37earlier we had that the Nelson
05:37 --> 05:39trial and the in the United States,
05:39 --> 05:41the national lung cancer screening trial.
05:41 --> 05:43The original criteria for these
05:43 --> 05:45were a little bit more stringent.
05:45 --> 05:48They had a tighter age range and a
05:48 --> 05:50greater pack year smoking history,
05:50 --> 05:52meaning that they were really
05:52 --> 05:53targeting people.
05:53 --> 05:55Who were felt to be the most at risk
05:55 --> 05:57for lung cancer and these trials showed
05:57 --> 05:59that if you did lung cancer screening,
05:59 --> 06:02which means it's an annual low dose
06:02 --> 06:04CT scan done in someone who we
06:04 --> 06:06think is at risk for lung cancer,
06:06 --> 06:10you can reduce lung cancer mortality by 20%.
06:10 --> 06:12And these were really remarkable
06:12 --> 06:14results and this is widely approved
06:14 --> 06:16annual lung cancer screening.
06:16 --> 06:19CT scans are covered by Medicare
06:19 --> 06:22and most private insurance and as
06:22 --> 06:25we have had more data and more.
06:25 --> 06:28Experience with lung cancer screening CTS,
06:28 --> 06:31we've actually started to widen the criteria,
06:31 --> 06:33meaning we're screening more and more people.
06:33 --> 06:36So we've dropped the age now to 50 years,
06:36 --> 06:38so anyone over 50 would qualify.
06:38 --> 06:40And we've dropped the smoking
06:40 --> 06:42requirement down to 20 pack years.
06:42 --> 06:46So anyone over 50 who has a
06:46 --> 06:47relevant smoking history,
06:47 --> 06:49who's a current smoker,
06:49 --> 06:51or who's quit within the last
06:51 --> 06:5415 years would qualify for lung
06:54 --> 06:55cancer screening CT scans.
06:56 --> 06:59Right. And so more to come on
06:59 --> 07:01whether that expands to people
07:01 --> 07:05who have never smoked, so.
07:05 --> 07:08So with low dose CT screening,
07:08 --> 07:12you had mentioned that the mortality of
07:12 --> 07:16lung cancer is actually coming down.
07:16 --> 07:18What? What's the proportion do you
07:18 --> 07:21think of people who are diagnosed
07:21 --> 07:24with lung cancer because they're
07:24 --> 07:26caught through screening versus
07:26 --> 07:28because they are symptomatic and
07:28 --> 07:31are are diagnosed at a later stage?
07:31 --> 07:33Right. So if you're having
07:33 --> 07:35symptoms of lung cancer,
07:35 --> 07:38chances are it's a more advanced
07:38 --> 07:40tumor centrally located or that you
07:40 --> 07:43may have metastatic disease already.
07:43 --> 07:45We know that right now about half of
07:45 --> 07:48patients who are diagnosed with lung cancer,
07:48 --> 07:50the disease has already
07:50 --> 07:52spread to distant sites.
07:52 --> 07:54And so the five year survival if
07:54 --> 07:57your lung cancer is caught late
07:57 --> 07:59with distant spread is only 7%,
07:59 --> 08:02but if you can catch lung cancer.
08:02 --> 08:03When it's localized,
08:03 --> 08:05meaning just within the lungs and maybe
08:05 --> 08:08even not in any regional lymph nodes,
08:08 --> 08:09but just localized.
08:09 --> 08:11Lung cancer has a 5 year
08:11 --> 08:13overall survival of 61%.
08:13 --> 08:15So the goal of screening is to shift
08:15 --> 08:18our population of patients for those
08:18 --> 08:20with advanced disease to those with
08:20 --> 08:22localized disease where we're much
08:22 --> 08:25more likely to cure them with the
08:25 --> 08:27therapies that we have available.
08:27 --> 08:29You talked about how we are actually
08:29 --> 08:31doing a great job in moving the needle.
08:32 --> 08:34If you want to talk about where you can
08:34 --> 08:37make a difference in terms of spending
08:37 --> 08:39cancer money and Cancer Research,
08:39 --> 08:42there is a lot of work to do in lung cancer.
08:42 --> 08:45So back in the 70s when they first
08:45 --> 08:47started tracking these numbers,
08:47 --> 08:49the five year overall survival
08:49 --> 08:51of lung cancer was about 12%.
08:51 --> 08:53It didn't change much between
08:53 --> 08:56then and 2000 and back in 2000,
08:56 --> 08:57the five year.
08:57 --> 08:59Survival of kind of all patients
08:59 --> 09:02diagnosed with lung cancer was 15%.
09:02 --> 09:04But in recent years we have really started
09:04 --> 09:06to make a difference here and that's
09:06 --> 09:09for a few reasons that we can touch on.
09:09 --> 09:11But so the most recent set of data that
09:11 --> 09:13we have that the five year survival
09:13 --> 09:15on lung cancer is now up at 23%.
09:15 --> 09:18And I expect that this will continue
09:18 --> 09:21to improve for a variety of reasons.
09:21 --> 09:23One of these is lung cancer screening.
09:23 --> 09:26So even though we have a lot of room to go
09:26 --> 09:29in terms of getting this widely adopted.
09:29 --> 09:31By patients and providers having lung
09:31 --> 09:33cancer screening more available to
09:33 --> 09:36patients and having good uptake of that,
09:36 --> 09:39we'll catch cancers at an earlier stage
09:39 --> 09:41where we're more likely to cure them.
09:41 --> 09:43And then we also have some
09:43 --> 09:45really exciting other therapies
09:45 --> 09:46now available for lung cancer.
09:46 --> 09:49And these include both targeted
09:49 --> 09:51therapies and immunotherapy.
09:51 --> 09:53And those are making a big difference
09:53 --> 09:56in terms of extending life expectancy
09:56 --> 09:59and in some cases even curing patients.
09:59 --> 10:01With advanced or metastatic disease,
10:01 --> 10:04whereas in the past we would not have had
10:04 --> 10:06great treatment options for those patients.
10:07 --> 10:09And so and I would imagine that the
10:09 --> 10:11other place where you've really
10:11 --> 10:13moved the needle is in terms
10:13 --> 10:16of smoking cessation programs.
10:16 --> 10:17Is that right? Is the number of
10:17 --> 10:19smokers in the country going down?
10:19 --> 10:21It certainly seems like that
10:21 --> 10:23when you walk on the streets,
10:23 --> 10:25you see fewer people smoking,
10:25 --> 10:27you see more airplanes for
10:27 --> 10:29example or are smoke free,
10:29 --> 10:32many more restaurants are smoke free.
10:32 --> 10:35Are we making a difference there too?
10:35 --> 10:37Yes that that is an area where it's.
10:37 --> 10:40And a great kind of public health
10:40 --> 10:41education and we are having
10:41 --> 10:44lower and lower rates of smokers.
10:44 --> 10:46We are still diagnosing quite a
10:46 --> 10:49few smoking related cancers though.
10:49 --> 10:51There's about a 20 year lag between
10:51 --> 10:55when someone is smoking and when we see
10:55 --> 10:56those changes in lung cancer rates.
10:56 --> 10:59And so you can see that they are
10:59 --> 11:00falling probably primarily because
11:00 --> 11:03of all the smoking cessation efforts.
11:03 --> 11:06There are a lot of programs available
11:06 --> 11:08at our hospital and elsewhere.
11:08 --> 11:10Where patients can enroll in a
11:10 --> 11:12smoking cessation clinic and they
11:12 --> 11:14have additional resources to help
11:14 --> 11:16people who are interested in quitting.
11:17 --> 11:22And so you know, between the
11:22 --> 11:25smoking prevention and screening,
11:25 --> 11:26we're we're trying to pick these
11:26 --> 11:29cancers up earlier and earlier and then
11:29 --> 11:31we've got these great new treatments.
11:31 --> 11:35So let's kind of take it. Bit by bit.
11:35 --> 11:37So for patients who are picked
11:37 --> 11:39up with screening where they
11:39 --> 11:42have a relatively small tumor,
11:42 --> 11:43they've been asymptomatic,
11:43 --> 11:46tell us a little bit more about how
11:46 --> 11:48the diagnosis is made and what they
11:48 --> 11:51might expect in terms of treatment.
11:52 --> 11:54Yes. So for an asymptomatic patient,
11:54 --> 11:56typically their tumors tend to be found
11:56 --> 11:59either on a lung cancer screening,
11:59 --> 12:02CT scan or just incidentally,
12:02 --> 12:05meaning it was a CT scan done for another
12:05 --> 12:07reason that happened to see a lung nodule.
12:07 --> 12:10Sometimes we catch them on X-ray,
12:10 --> 12:12but most often on CT scan.
12:12 --> 12:15And so for those patients,
12:15 --> 12:16the treatment options,
12:16 --> 12:19if it's a tumor localized just to the
12:19 --> 12:21lung without lymph node involvement,
12:21 --> 12:24they'll either get treated with surgery.
12:24 --> 12:25Or radiation and the
12:25 --> 12:27radiation that they get there.
12:27 --> 12:30SBRT is targeted, it's very strong
12:30 --> 12:33and so it really fries the area.
12:33 --> 12:34When we're counseling patients one
12:34 --> 12:36way or the other, I'm a surgeon,
12:36 --> 12:38I have my bias.
12:38 --> 12:40But I would say everyone tends to agree
12:40 --> 12:42that if you can have surgery that
12:42 --> 12:44that is a better treatment option.
12:44 --> 12:46We're able to fully remove the tumor.
12:46 --> 12:48We would sample all the lymph nodes
12:48 --> 12:51and get someone a very accurate stage
12:51 --> 12:53as well as tissue on the tumor.
12:53 --> 12:56And this can typically be done
12:56 --> 12:57with small incisions,
12:57 --> 13:00a short hospital stay across the country.
13:00 --> 13:01And at Yale,
13:01 --> 13:03we do the vast majority of these
13:03 --> 13:05operations minimally, invasively.
13:05 --> 13:08And so the recovery time is quite quick
13:08 --> 13:11and patients get back to their normal life.
13:11 --> 13:13Radiation is the other treatment
13:13 --> 13:15option for these patients.
13:15 --> 13:17And so that's typically used for
13:17 --> 13:18patients who may not have enough
13:18 --> 13:20lung reserve to have a portion of
13:20 --> 13:22their lung removed with surgery.
13:22 --> 13:24And so those patients can have radiation
13:24 --> 13:26therapy and that's quite successful.
13:26 --> 13:28For patients who can't have surgery,
13:29 --> 13:31fantastic. Well, we are going to
13:31 --> 13:34take a short break for a medical
13:34 --> 13:36minute and when we come back.
13:36 --> 13:38You'll learn more about the advances
13:38 --> 13:40in treatment of lung cancer with
13:40 --> 13:42my guest, doctor Gavitt Woodard.
13:43 --> 13:45Funding for Yale Cancer answers
13:45 --> 13:47comes from Smilo Cancer Hospital,
13:47 --> 13:49where their Center for Gastrointestinal
13:49 --> 13:51Cancers provides patients with
13:51 --> 13:53gastric cancers a comprehensive,
13:53 --> 13:54multidisciplinary approach to
13:54 --> 13:56the treatment of their cancer,
13:56 --> 13:58including clinical trials.
13:58 --> 14:02Smilow cancerhospital.org.
14:02 --> 14:03It's estimated that over 240,000
14:03 --> 14:06men in the US will be diagnosed
14:06 --> 14:08with prostate cancer this year,
14:08 --> 14:11with over 3000 new cases being identified.
14:11 --> 14:12Here in Connecticut,
14:12 --> 14:14one in eight American men
14:14 --> 14:16will develop prostate cancer.
14:16 --> 14:18In the course of his lifetime,
14:18 --> 14:20major advances in the detection and
14:20 --> 14:21treatment of prostate cancer have
14:21 --> 14:23dramatically decreased the number
14:23 --> 14:25of men who die from the disease.
14:25 --> 14:27Screening can be performed quickly
14:27 --> 14:28and easily in a physician's
14:28 --> 14:30office using two simple tests.
14:30 --> 14:33A physical exam and a blood test.
14:33 --> 14:35Clinical trials are currently underway
14:35 --> 14:37at federally designated Comprehensive
14:37 --> 14:39cancer centers such as Yale Cancer
14:39 --> 14:41Center and its Milo Cancer Hospital,
14:41 --> 14:43where doctors are also
14:43 --> 14:45using the Artemis machine,
14:45 --> 14:47which enables targeted biopsies
14:47 --> 14:48to be performed.
14:48 --> 14:50More information is available
14:50 --> 14:51at yalecancercenter.org.
14:51 --> 14:54You're listening to Connecticut public radio.
14:55 --> 14:57Welcome back to Yale Cancer answers.
14:57 --> 14:59This is doctor Anish Chappar and
14:59 --> 15:01I'm joined tonight by my guest,
15:01 --> 15:02Doctor Gavitt Woodard.
15:02 --> 15:05We're talking about the care of
15:05 --> 15:07patients with lung cancer in honor
15:07 --> 15:09of lung Cancer Awareness Month.
15:09 --> 15:10So before the break,
15:10 --> 15:12we were talking about a number
15:12 --> 15:14of advances that have been made,
15:14 --> 15:17everything from smoking cessation to
15:17 --> 15:20advances in lung cancer screening.
15:20 --> 15:23And we started talking a little bit about
15:23 --> 15:26how patients with early lung cancer.
15:26 --> 15:28Can get treated with minimally
15:28 --> 15:32invasive surgery and often have really
15:32 --> 15:35excellent five year survival rates.
15:35 --> 15:37Now before the break, Gavin,
15:37 --> 15:39you were telling us that another
15:39 --> 15:41major advance has been for
15:41 --> 15:43patients with advanced disease.
15:43 --> 15:46So for those patients who may
15:46 --> 15:48present symptomatically who may
15:48 --> 15:51have distant metastatic disease,
15:51 --> 15:53we have something for them too and that's
15:53 --> 15:56advances in targeted and immunotherapy.
15:56 --> 15:59So can you tell us a little bit more,
15:59 --> 16:00maybe paint a picture for US,
16:00 --> 16:02patients with advanced cancer,
16:02 --> 16:04First off,
16:04 --> 16:06what are the symptoms that they might
16:06 --> 16:08present with that people should be aware
16:08 --> 16:10of so that they can see their doctor?
16:11 --> 16:13So patients with advanced cancer can
16:13 --> 16:16with advanced lung cancer can present
16:16 --> 16:19with a variety of different symptoms.
16:19 --> 16:22We think of cough sometimes coughing up
16:22 --> 16:25blood often it could be something like
16:25 --> 16:28pain or back pain, chest wall pain.
16:28 --> 16:30Those are things that typically
16:30 --> 16:32bring people to medical attention.
16:33 --> 16:37And so after that presumably a chest
16:37 --> 16:41X-ray plus or minus CT scan is done and.
16:41 --> 16:44Let's say lung cancer is found.
16:44 --> 16:47Tell us about the most common
16:47 --> 16:49places where lung cancer spreads to.
16:49 --> 16:51You had mentioned that patients
16:51 --> 16:53with advanced disease often present
16:53 --> 16:55with distant metastatic disease
16:55 --> 16:57at the time that they present
16:57 --> 16:59initially to their doctor.
16:59 --> 17:01So if a lung cancer was going to spread,
17:01 --> 17:03where does it go? It
17:03 --> 17:05can go to a variety of places
17:05 --> 17:07it has a preference for.
17:07 --> 17:10Sometimes we get solitary brain meds,
17:10 --> 17:11the adrenal glands.
17:11 --> 17:13Bones or even local
17:13 --> 17:15spread within lymph nodes.
17:15 --> 17:17But sometimes if those lymph nodes are
17:17 --> 17:20outside of the field that we think of
17:20 --> 17:22as typically being treated with surgery,
17:22 --> 17:24even just spread within certain
17:24 --> 17:26lymph nodes can be distant
17:26 --> 17:28enough that we think of them
17:28 --> 17:29as more advanced lung cancer.
17:29 --> 17:32How are these patients treated? Sure.
17:32 --> 17:35So the three main lines of
17:35 --> 17:37systemic therapy that we have for
17:37 --> 17:39patients are classic cytotoxic
17:39 --> 17:42chemotherapy and that's been around.
17:42 --> 17:43For many years.
17:43 --> 17:45But then the newer therapies that
17:45 --> 17:48we have which are typically better
17:48 --> 17:50tolerated with fewer side effects
17:50 --> 17:53are things like targeted therapy and
17:53 --> 17:54immunotherapy like you mentioned.
17:54 --> 17:58So targeted therapy means that
17:58 --> 18:00the patient's tumor has a mutation
18:00 --> 18:04where we have a drug that is matched
18:04 --> 18:07specifically to address that mutation
18:07 --> 18:10or that pathway and about 40% of lung
18:10 --> 18:13cancers have a targetable mutation.
18:13 --> 18:16The issue with targeted therapy is
18:16 --> 18:19that it's seen as a way of delaying
18:19 --> 18:22progression or maybe getting a good response.
18:22 --> 18:25But eventually the vast majority of
18:25 --> 18:28these patients get a mutation that
18:28 --> 18:31allows them to overcome the drug.
18:31 --> 18:33And so we will get a good response
18:33 --> 18:35for a number of years.
18:35 --> 18:37Until then they have a mutation that
18:37 --> 18:40then makes the drug stop working.
18:40 --> 18:42And so we have to look for other
18:42 --> 18:43lines of treatment.
18:43 --> 18:44To them at that point,
18:44 --> 18:47but it's been a great way to prolong the
18:47 --> 18:49life and stop disease progression in
18:49 --> 18:52patients where there is that sort of match.
18:52 --> 18:56The number one match that we have is EGFR.
18:56 --> 18:58That's the most common targetable
18:58 --> 18:59mutation that we have.
18:59 --> 19:01And then now there's recently been
19:01 --> 19:04a drug approved for patients who
19:04 --> 19:06have OK rash G12C mutation and that
19:06 --> 19:09accounts for about 13% of all cancers.
19:10 --> 19:13So 13% have a K Ras mutation or.
19:13 --> 19:18Is it 13% who have any targetable mutation,
19:18 --> 19:21so 40% have any targetable mutation. So
19:21 --> 19:23that's pretty good. So what
19:23 --> 19:25do we do for the other 60%,
19:25 --> 19:27right? Well, that's the question.
19:27 --> 19:31And so immunotherapy has been a
19:31 --> 19:34great breakthrough in this area.
19:34 --> 19:38So basically tumors have a way of avoiding
19:38 --> 19:41a patient's own immune system and often
19:41 --> 19:44that's done through expression of PDL.
19:44 --> 19:47One which kind of cloaks the tumor and
19:47 --> 19:49allows it to hide from immune cells,
19:49 --> 19:52new lines of immunotherapy work by
19:52 --> 19:55uncloaking the tumors and allowing
19:55 --> 19:57the patient's own immune system
19:57 --> 20:00to see these cancers there,
20:00 --> 20:01which they recognize as oh,
20:01 --> 20:04this is not a normal cell and attack.
20:04 --> 20:06And that immunotherapy is where we
20:06 --> 20:09have really seen a lot of these kind
20:09 --> 20:12of miracle cancer cures where someone
20:12 --> 20:14with widespread advanced disease.
20:14 --> 20:17Responds to the drug and you know,
20:17 --> 20:19the disease melts away and there are some
20:19 --> 20:21patients who are living now for going
20:21 --> 20:24on 10 years on some of these treatments.
20:25 --> 20:28And so tell us more about these treatments.
20:28 --> 20:31I mean, do you have to take this
20:31 --> 20:33drug kind of for the rest of
20:33 --> 20:36your life until you develop a
20:36 --> 20:38mutation where it stops working?
20:38 --> 20:40What are the side effects of these drugs?
20:40 --> 20:43Does this mean that you're in the hospital
20:43 --> 20:44getting an IV infusion every day?
20:44 --> 20:47Are these oral therapies that you take?
20:47 --> 20:49Do you lose your hair?
20:49 --> 20:52Tell us more. Great
20:52 --> 20:56question. These tend to be oral therapies.
20:56 --> 20:59They can be taken for shorter or
20:59 --> 21:01longer periods of time and that has
21:01 --> 21:03been something that is actively
21:03 --> 21:06being studied is how much treatment
21:06 --> 21:08do you really need specifically
21:08 --> 21:10for the immunotherapy drugs,
21:10 --> 21:12there is data that in patients who
21:12 --> 21:15even just get a short amount of these,
21:15 --> 21:17it's enough to train the immune
21:17 --> 21:20system to go after tumor even when
21:20 --> 21:22the patient is no longer on therapy.
21:22 --> 21:25There have been two major immunotherapy
21:25 --> 21:28trials that have come out in the
21:28 --> 21:30last year that relate to our surgical
21:30 --> 21:31patient population.
21:31 --> 21:34This is one of them's empower O1O
21:34 --> 21:37and the other one is Checkmate 816.
21:37 --> 21:39And what they boil down to are in
21:39 --> 21:41patients who can have surgery.
21:41 --> 21:44When should we be giving immunotherapy
21:44 --> 21:47both at one trial and power gave it
21:47 --> 21:49after surgery and the other trial
21:49 --> 21:51checkmate gave it before surgery,
21:51 --> 21:53but they both had really dramatic.
21:53 --> 21:56Results in terms of extending disease
21:56 --> 21:58free survival for these patients.
21:58 --> 22:00And so now we have all of these
22:00 --> 22:03new treatment options that weren't
22:03 --> 22:03available before,
22:03 --> 22:06but now are changing the way that we
22:06 --> 22:08think about lung cancer treatments.
22:08 --> 22:11So it remains to be seen you know
22:11 --> 22:13whether patients should be getting
22:13 --> 22:16immunotherapy before surgery or after,
22:16 --> 22:18but in patients who have stage
22:18 --> 22:19two and stage three disease,
22:19 --> 22:21this is definitely now part of the
22:21 --> 22:23treatment regimen for some of these patients.
22:24 --> 22:27And so for the patients who present
22:27 --> 22:29with distant metastatic disease
22:29 --> 22:31where we're using more and more
22:31 --> 22:33of these targeted therapies,
22:33 --> 22:35immunotherapy and seeing
22:35 --> 22:37really good response,
22:37 --> 22:41is there a role then for surgery if
22:41 --> 22:43you've gotten a really good response?
22:43 --> 22:45Normally we always used to think
22:45 --> 22:48that surgery was reserved only for
22:48 --> 22:51patients who had localized disease,
22:51 --> 22:54but is it beginning to have a role after?
22:54 --> 22:57Neoadjuvant therapy for people who
22:57 --> 23:00have distant metastatic disease.
23:01 --> 23:04You should come to some of our tumor
23:04 --> 23:05board discussions because these are
23:05 --> 23:07exactly some of the scenarios that we
23:07 --> 23:09talk about all the time. Right now.
23:09 --> 23:12We are not considering that some sort
23:12 --> 23:15of great response to immunotherapy or
23:15 --> 23:17targeted therapy would make someone
23:17 --> 23:20who wasn't a surgical candidate
23:20 --> 23:23suddenly become a surgical candidate.
23:23 --> 23:25But there are certainly exceptions to
23:25 --> 23:27this when someone has maybe gone many
23:27 --> 23:29years without disease progression in
23:29 --> 23:31other places and there's a single site.
23:31 --> 23:33A disease that starts to grow,
23:33 --> 23:35we will go in and resect.
23:35 --> 23:36These kind of oligo recurrences
23:36 --> 23:38is what we call them.
23:38 --> 23:40But so a single site or one or
23:40 --> 23:42two sites that may be enlarging
23:42 --> 23:44whenever all the other sites of
23:44 --> 23:46disease seem to be well controlled.
23:47 --> 23:51And then you know as we think
23:51 --> 23:53about these patients living longer,
23:53 --> 23:55talk to us a little bit more
23:55 --> 23:56about their quality of life.
23:56 --> 24:00I mean clearly they would have gone
24:00 --> 24:02through perhaps multiple rounds of
24:02 --> 24:05systemic therapy and perhaps radiation
24:05 --> 24:07if there was a metastases that
24:07 --> 24:10were painful or so on and so forth.
24:10 --> 24:13But ultimately do they have
24:13 --> 24:15a good quality of life,
24:15 --> 24:17what what are we doing in terms of improving?
24:17 --> 24:19Quality of life long term,
24:19 --> 24:21because it sounds like these patients,
24:21 --> 24:23nowadays more than ever before,
24:23 --> 24:25are living longer.
24:25 --> 24:27But are they living better?
24:27 --> 24:27Yeah,
24:27 --> 24:28that's a good question.
24:28 --> 24:31And it's nice to finally be at a
24:31 --> 24:33place in lung cancer when we can
24:33 --> 24:35start to think about survivorship
24:35 --> 24:37and what that means for patients,
24:37 --> 24:38because in the past,
24:38 --> 24:41this wasn't a major problem that
24:41 --> 24:43people were focused on knowing.
24:43 --> 24:46You know, a lot of these newer
24:46 --> 24:47therapies are expensive.
24:47 --> 24:49And so the financial toxicity of
24:49 --> 24:52cancer is 1 new area of research that
24:52 --> 24:55is coming up and people are studying.
24:55 --> 24:57Certainly we want to ensure that.
24:57 --> 24:59Patients are living with the best
24:59 --> 25:01quality of life possible though typically
25:01 --> 25:03you know some of these newer drugs,
25:03 --> 25:05immunotherapy and targeted therapy,
25:05 --> 25:08the side effect profile is
25:08 --> 25:10you know fairly minimal,
25:10 --> 25:13sometimes some pulmonary toxicity,
25:13 --> 25:14diarrhea,
25:14 --> 25:17those tend to be frequent common
25:17 --> 25:20complications of these other therapies.
25:20 --> 25:22But patients in general are living
25:22 --> 25:24pretty well and it's certainly
25:24 --> 25:26better than the alternative
25:26 --> 25:28and what. About people's family,
25:28 --> 25:30I'm sure that you know,
25:30 --> 25:32especially as we see more and
25:32 --> 25:34more lung cancer in never smokers,
25:34 --> 25:36people are starting to ask
25:36 --> 25:38themselves, well, why me?
25:38 --> 25:40Why did I get lung cancer?
25:40 --> 25:41Is there a genetic link?
25:41 --> 25:44And what is the implication of having
25:44 --> 25:47lung cancer on future generations?
25:47 --> 25:50Does it increase the risk for your children,
25:50 --> 25:52particularly if you were never smoker?
25:53 --> 25:56Yeah, I think that this is something
25:56 --> 25:58we don't have an answer to right now.
25:58 --> 26:01So the the quick answer is that right
26:01 --> 26:04now there are no genes like a bracca,
26:04 --> 26:06you know breast cancer equivalent for
26:06 --> 26:08lung cancer that have been identified.
26:08 --> 26:11However, there is probably some familial
26:11 --> 26:14component especially in patients who are
26:14 --> 26:17never smokers to developing lung cancer.
26:17 --> 26:19We see this in particular
26:19 --> 26:21among Asian patients,
26:21 --> 26:24so within it and never smoking Asian.
26:24 --> 26:25Patient population,
26:25 --> 26:27they have a very high predominance
26:27 --> 26:30of EGFR mutations and there are
26:30 --> 26:32some families where everyone in
26:32 --> 26:35the family is developing these
26:35 --> 26:37kind of slow growing EGFR mutated
26:37 --> 26:39lung adenocarcinomas and that is
26:39 --> 26:42something that people are studying.
26:42 --> 26:44But the exact genetic link
26:44 --> 26:46has not yet been identified.
26:46 --> 26:48Yeah, that certainly sounds like
26:48 --> 26:50it's going to be a very interesting
26:50 --> 26:52area of investigation and Speaking
26:52 --> 26:55of which in our last minute.
26:55 --> 26:57Or So what are the most exciting
26:57 --> 26:59clinical trials on the horizon
26:59 --> 27:02that you're watching? So for me as
27:02 --> 27:03a surgeon, the things that impact
27:03 --> 27:05us the most are these trials
27:05 --> 27:07of when we're giving therapy,
27:07 --> 27:10whether we're giving it before surgery
27:10 --> 27:13or after surgery and what is the best
27:13 --> 27:16approach for patients that can result
27:16 --> 27:18in the most prolonged, you know,
27:18 --> 27:21disease free survival and overall survival.
27:21 --> 27:23And so though there are currently not
27:23 --> 27:25studies that are putting these head-to-head,
27:25 --> 27:27there's a study coming out soon,
27:27 --> 27:29then Adeem 2 trial looking at
27:29 --> 27:31giving immunotherapy both.
27:31 --> 27:32Before and after surgery and
27:32 --> 27:34those will be helpful in guiding
27:34 --> 27:36our treatments for patients
27:36 --> 27:40and do we anticipate more
27:40 --> 27:42targeted therapies for
27:42 --> 27:46mutations once cancers kind of.
27:46 --> 27:47Overcome the therapies that
27:47 --> 27:49we've already given them,
27:49 --> 27:51what progress is being made there?
27:52 --> 27:55Yes, there's a lot of research into this.
27:55 --> 27:57You know, it impacts a lot of patients.
27:57 --> 27:59People are very excited for
27:59 --> 28:00these targeted therapies.
28:00 --> 28:02And so there are, you know,
28:02 --> 28:04dozens of drugs currently in development.
28:04 --> 28:06The other thing that we're probably
28:06 --> 28:09going to see is the movement of these
28:09 --> 28:11targeted therapies and immunotherapy,
28:11 --> 28:13which have first been shown to be
28:13 --> 28:15very effective in stage four patients.
28:15 --> 28:16They're now being studied.
28:16 --> 28:18In stage two and stage three
28:18 --> 28:20patients and eventually I think we
28:20 --> 28:22can expect that these therapies
28:22 --> 28:24will eventually trickle into the
28:24 --> 28:26even earlier stage one patient
28:26 --> 28:28population where there probably is
28:28 --> 28:31a benefit to some of those patients
28:31 --> 28:33to receiving an additional therapy.
28:33 --> 28:35Doctor Gavitt Woodard is an
28:35 --> 28:36assistant professor of surgery
28:36 --> 28:38at the Yale School of Medicine.
28:38 --> 28:40If you have questions,
28:40 --> 28:42the address is canceranswers@yale.edu,
28:42 --> 28:45and past editions of the program
28:45 --> 28:48are available in audio and written
28:48 --> 28:48form at yalecancercenter.org.
28:48 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:55cancer here on Connecticut Public Radio.
28:55 --> 28:57Funding for Yale Cancer Answers is
28:57 --> 29:00provided by Smilow Cancer Hospital.

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