Radiotherapy for Lung Cancer

Transcript

00:00 --> 00:02Funding for Yale Cancer Answers
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00:05 --> 00:07Hospital and AstraZeneca.
00:07 --> 00:08Welcome to Yale Cancer Answers,
00:08 --> 00:10with your host,
00:10 --> 00:12Doctor Anees Chagpar.
00:12 --> 00:13Yale Cancer Answers features the latest
00:13 --> 00:15information on cancer care by
00:15 --> 00:17welcoming oncologists and specialists
00:17 --> 00:19who are on the forefront of the
00:19 --> 00:21battle to fight cancer. This week,
00:21 --> 00:23it's a conversation about radiotherapy
00:23 --> 00:25for lung cancer with Doctor Henry Park.
00:25 --> 00:28Dr. Park is an assistant professor
00:28 --> 00:29of therapeutic radiology at
00:29 --> 00:31the Yale School of Medicine,
00:31 --> 00:33where Doctor Chagpar is a
00:33 --> 00:34professor of surgical oncology.
00:36 --> 00:38Henry, maybe we can start off by
00:38 --> 00:40you telling us a little bit more
00:40 --> 00:42about yourself and what you do.
00:42 --> 00:44I'd be happy to, so I grew up in Jersey
00:44 --> 00:47and first came to Yale as a college
00:47 --> 00:49student about 18 years ago.
00:49 --> 00:51I stayed at Yale for medical
00:51 --> 00:54school and moved to Boston for two years.
00:54 --> 00:55And then I focused on public
00:55 --> 00:57health and I received an MPH
00:57 --> 00:59in public health at Harvard.
00:59 --> 01:01I then stayed there for
01:01 --> 01:02my medical internship and
01:02 --> 01:04returned to Yale about eight years ago
01:05 --> 01:07and after my radiation oncology residency
01:07 --> 01:10I joined the faculty about four years ago.
01:10 --> 01:11So as a radiation oncologist,
01:11 --> 01:13I specialize in helping patients
01:13 --> 01:15who have a cancer diagnosis to
01:15 --> 01:16figure out if radiation therapy
01:16 --> 01:18is the right choice for them.
01:18 --> 01:20I focus primarily on treating
01:20 --> 01:22patients with lung cancer as well
01:22 --> 01:24as those with head and neck cancer,
01:24 --> 01:26and I see patients in New Haven and
01:26 --> 01:28in Waterford and help to manage
01:28 --> 01:29their care throughout the course
01:29 --> 01:31of their radiation therapy and
01:31 --> 01:33really work with the surgeons and
01:33 --> 01:34the medical oncologists together as a team
01:35 --> 01:38to try to figure out what are the
01:38 --> 01:39best recommendations that we can
01:39 --> 01:40give for each individual patient.
01:41 --> 01:44Henry, let's talk a little bit more
01:44 --> 01:47about lung cancer and how it's treated.
01:47 --> 01:50I mean, for many of our listeners
01:50 --> 01:52there may be questions about
01:52 --> 01:55how exactly we decide
01:55 --> 01:57whether a patient should be
01:57 --> 02:00treated with surgery or with chemotherapy,
02:00 --> 02:01or with radiotherapy,
02:01 --> 02:04or with a combination of all
02:04 --> 02:07three or two of the three.
02:07 --> 02:09Tell us more about how those decisions are made.
02:10 --> 02:12It's a very complex discussion
02:12 --> 02:14we have often with the patients
02:14 --> 02:16as well as each of us from the
02:16 --> 02:18surgeons and the medical oncologists,
02:18 --> 02:20as well as the radiation oncologists.
02:20 --> 02:23We meet once a week at a lung
02:23 --> 02:25tumor board which is every Monday and
02:25 --> 02:27we get together and discuss any
02:27 --> 02:29situations that might be challenging
02:29 --> 02:31for us to to decide what the right
02:31 --> 02:33combination or treatment is.
02:33 --> 02:35The overarching goal though is to
02:35 --> 02:37be individualized with with how
02:37 --> 02:39we make recommendations and
02:39 --> 02:41to make sure that we're meeting
02:41 --> 02:44the goals of the patient as well.
02:44 --> 02:47So we want to really focus on that.
02:47 --> 02:47Primarily,
02:47 --> 02:49radiation is specifically a non
02:49 --> 02:52invasive and invisible as well as
02:52 --> 02:54very precise way of treating many
02:54 --> 02:56kinds of cancers and for lung
02:56 --> 02:58cancer specifically it is very useful in
02:58 --> 03:00multiple different kinds of contexts.
03:00 --> 03:02And it really depends a lot on
03:02 --> 03:04the stage of disease as well
03:04 --> 03:06as the patients status,
03:06 --> 03:08health status and goals.
03:08 --> 03:09So for example,
03:09 --> 03:12for stage one lung cancer,
03:12 --> 03:14when the disease is very localized,
03:16 --> 03:19we really often choose between
03:19 --> 03:21surgery and radiation therapy for
03:21 --> 03:23a patient to try to figure out
03:23 --> 03:26how best to cure their cancer.
03:26 --> 03:28So we've found overtime that
03:28 --> 03:29this technique called SBRT or
03:30 --> 03:31stereotactic body radiation therapy
03:31 --> 03:34serves as an excellent alternative
03:34 --> 03:36to surgery in certain patients.
03:36 --> 03:40We use a high dose of radiation per session.
03:40 --> 03:42Over just three to five treatments
03:42 --> 03:45using this very precise technique
03:45 --> 03:47in order to target these small
03:47 --> 03:50localized lung tumors and then to
03:50 --> 03:52try to eliminate them completely.
03:52 --> 03:54But for more locally advanced disease,
03:54 --> 03:56we had to make the decision about
03:56 --> 04:00whether or not we need to use
04:00 --> 04:02chemotherapy with radiation together.
04:02 --> 04:05Often we will need lower doses of
04:05 --> 04:08radiation each day and spread out over
04:08 --> 04:10multiple weeks of daily treatment
04:10 --> 04:13in order to to be able to treat
04:13 --> 04:15larger volumes of disease,
04:15 --> 04:16especially when the disease
04:16 --> 04:19has spread to the lymph nodes,
04:19 --> 04:21we still do this with
04:21 --> 04:22a curative intent most of the time
04:24 --> 04:26but sometimes we decide that there's
04:26 --> 04:28some situations where
04:28 --> 04:29chemotherapy first is helpful,
04:29 --> 04:31followed by surgery.
04:31 --> 04:33Other times we do chemo-radiation,
04:33 --> 04:35meaning chemotherapy and radiation
04:35 --> 04:36therapy together, and
04:36 --> 04:36other times,
04:36 --> 04:39chemo and radiation followed by surgery,
04:39 --> 04:40so there really are
04:40 --> 04:42multiple options that depending
04:42 --> 04:45on exactly where the tumor is and
04:45 --> 04:47how it's spread and what we think
04:47 --> 04:49each patient can tolerate in terms
04:49 --> 04:50of the treatment,
04:50 --> 04:53we often have to make
04:53 --> 04:54those recommendations and discuss
04:54 --> 04:56those options with each patient.
04:58 --> 05:01Getting back to where you started with early
05:01 --> 05:03stage lung cancer, stage one,
05:03 --> 05:06when you said well,
05:06 --> 05:09we need to make the decision
05:09 --> 05:11about using SBRT versus surgery,
05:11 --> 05:14it sounds to me
05:14 --> 05:16like many patients may opt for
05:16 --> 05:19SBRT if these two are equivalent.
05:19 --> 05:21Here you have radiation therapy
05:21 --> 05:23which is non invasive, painless.
05:23 --> 05:25Three to five days I believe
05:25 --> 05:27you said versus surgery,
05:27 --> 05:29which is clearly invasive.
05:29 --> 05:32Often will result in a hospital
05:32 --> 05:34stay and so are these
05:34 --> 05:35really equivalent or is one superior?
05:42 --> 05:44It's hard to say for sure.
05:44 --> 05:46We have not yet been successful as a specialty,
05:48 --> 05:50either surgery or radiation oncology,
05:50 --> 05:52at comparing head-to-head in a
05:52 --> 05:55randomized trial to be sure of
05:55 --> 05:56that answer about exactly which
05:56 --> 05:58patients are best for surgery
05:58 --> 06:00and which are best for radiation.
06:00 --> 06:03We do know that when you compare them
06:03 --> 06:05in terms of patients who receive
06:05 --> 06:07surgery and receive radiation therapy,
06:07 --> 06:10that those who have received
06:10 --> 06:11surgery often have
06:11 --> 06:12better outcomes than those
06:12 --> 06:14who had radiation therapy,
06:14 --> 06:16but we don't know if that's because
06:16 --> 06:18of the fact that patients who
06:18 --> 06:20get radiation therapy may not
06:20 --> 06:22always be candidates for surgery,
06:22 --> 06:25or may not be the best suited
06:25 --> 06:26for surgery either.
06:26 --> 06:28So that's why we don't
06:28 --> 06:31know for sure about that.
06:31 --> 06:33Typically, if patients can get surgery,
06:33 --> 06:36and if the surgeons believe that they can
06:36 --> 06:38take the tumor out
06:38 --> 06:41without causing too much of a
06:41 --> 06:42functional deficit,
06:42 --> 06:44meaning that your lung
06:44 --> 06:47function can handle our surgery and
06:47 --> 06:49that you as a patient can handle the
06:49 --> 06:52surgery and recover well from it
06:52 --> 06:54if it is expected that can happen,
06:54 --> 06:57then our gold standard still is surgery.
06:57 --> 06:58At this point, however,
06:58 --> 07:00we believe that radiation,
07:00 --> 07:02especially for those who are not
07:02 --> 07:04good surgical candidates, meaning
07:04 --> 07:07that surgery would likely lead to
07:07 --> 07:09a major issue with their quality
07:09 --> 07:11of life going forward
07:11 --> 07:13and that recovery may be too
07:13 --> 07:15much for a patient,
07:15 --> 07:17then we believe that radiation,
07:17 --> 07:18especially this SBRT technique,
07:18 --> 07:20does achieve very good outcomes.
07:20 --> 07:23We're still working on trying to
07:23 --> 07:25complete a clinical trial to try to
07:25 --> 07:27compare surgery and radiation therapy
07:27 --> 07:30for those who are eligible for either one,
07:30 --> 07:33but it is has been hard to get enough patients
07:35 --> 07:38on this clinical trial to answer
07:38 --> 07:40the question fully so far.
07:40 --> 07:42The clinical trial is
07:42 --> 07:44currently open and enrolling at the VA.
07:49 --> 07:51There have been other clinical trials
07:54 --> 07:56that did not have enough
07:56 --> 07:59patients to answer the question fully,
07:59 --> 08:01but when they combine the results
08:01 --> 08:03of those studies they found among
08:03 --> 08:05the patients that did
08:05 --> 08:08receive SBRT who were
08:08 --> 08:10also eligible for surgery otherwise
08:10 --> 08:12but did receive SBRT,
08:12 --> 08:15did have very good outcomes and
08:15 --> 08:18seemed to be just as good as surgery
08:18 --> 08:20in those small number of patients,
08:20 --> 08:23but we don't have enough patients yet on
08:23 --> 08:26one of these randomized trials to know
08:26 --> 08:29for sure if radiation is truly
08:29 --> 08:32a fully adequate alternative to surgery,
08:32 --> 08:35for those who can get surgery.
08:38 --> 08:41I know on this show I'm often standing on
08:41 --> 08:44a soapbox talking about clinical trials.
08:44 --> 08:46But if these two modalities truly are
08:46 --> 08:49equivalent, the only way that
08:49 --> 08:51we're going to in practice offer SBRT to
08:51 --> 08:55all patients is if we have the clinical
08:55 --> 08:58trial data that compares head-to-head and
08:58 --> 08:59demonstrates that they're equivalent.
09:02 --> 09:05And the signal so far is that based on
09:05 --> 09:07combining results of trials that
09:07 --> 09:10didn't meet their accrual target,
09:10 --> 09:12it looks like these two are equivalent.
09:12 --> 09:15But it would really be a tremendous
09:15 --> 09:18advance to avoid surgery in patients
09:18 --> 09:22we could offering them SBRT.
09:22 --> 09:25Am I correct in assuming that SBRT has fewer
09:25 --> 09:28side effects than surgery long term?
09:28 --> 09:31Are there side effects to the SBRT
09:31 --> 09:33as well that cause patients
09:33 --> 09:36difficulties in breathing
09:36 --> 09:38or reduced lung capacity and so on
09:38 --> 09:41and so forth that they should be
09:41 --> 09:41concerned about?
09:41 --> 09:44There are in the short term,
09:44 --> 09:46we believe that SBRT has
09:46 --> 09:48fewer side effects,
09:48 --> 09:50so often for patients who may be
09:50 --> 09:52older or have more other medical
09:52 --> 09:55issues or who may not be able to
09:55 --> 09:57withstand the recovery very well
09:57 --> 09:59from surgery in the short term,
10:02 --> 10:04we feel confident that SBRT has fewer
10:04 --> 10:06side effects in that short term.
10:06 --> 10:08However, as time goes by,
10:08 --> 10:10I think the other issue here is
10:10 --> 10:13long term follow up and long term
10:13 --> 10:15survival as well as side effects.
10:15 --> 10:17The side effects do accumulate
10:17 --> 10:20overtime and the more we learn about
10:20 --> 10:22SBRT which has been in widespread
10:22 --> 10:25practice for only about 15 years or so,
10:25 --> 10:28not as long as surgery has been around,
10:28 --> 10:30so we don't have as much long
10:30 --> 10:32term data as a surgery does.
10:32 --> 10:34But we know in that three
10:34 --> 10:36to five year period that
10:36 --> 10:39as you go further along in that period,
10:39 --> 10:42close follow up is really required because we
10:42 --> 10:45need to see how the side effects accumulate.
10:46 --> 10:48And sometimes they don't present
10:48 --> 10:50themselves for a couple of years
10:50 --> 10:51or a few years afterwards.
10:51 --> 10:54So we do want to watch closely for that,
10:54 --> 10:57because there can be side effects,
10:57 --> 10:58especially with lung function.
10:58 --> 10:58Overall in the lung function,
11:00 --> 11:02as inflammation occurs and
11:02 --> 11:04eventually scarring as part of
11:04 --> 11:06the healing process is that
11:06 --> 11:07ultimately,
11:07 --> 11:09we may see that the pulmonary
11:09 --> 11:11function may decline more gradually
11:11 --> 11:12overtime compared to surgery,
11:12 --> 11:14where the decline tends to be
11:14 --> 11:17a little on the sooner side,
11:17 --> 11:21so that's why it's really nuanced and subtle.
11:21 --> 11:23So there are some
11:23 --> 11:24differences there,
11:24 --> 11:25but both of them have their
11:25 --> 11:27risks and side effects,
11:27 --> 11:28and that's why we encourage our
11:28 --> 11:30patients to meet both the surgeons
11:30 --> 11:32and the radiation oncologists who
11:32 --> 11:34have stage one disease to really
11:34 --> 11:35determine what exactly is expected
11:35 --> 11:37for each individual patient.
11:37 --> 11:39The other thing about radiation, just as it is NOTE Confidence: 0.93686986
11:39 --> 11:42for surgery, is it depends
11:42 --> 11:44on where exactly within the lung
11:44 --> 11:46the tumor is arising from.
11:46 --> 11:49So if it's right in the middle
11:49 --> 11:51of the lung, far away from other
11:51 --> 11:52organs, then
11:52 --> 11:55the side effects may be less, however, if
11:55 --> 11:58the tumor is closer to the
11:58 --> 12:00esophagus or the airways,
12:00 --> 12:01or to the ribs,
12:01 --> 12:03you might see other side effects
12:03 --> 12:05that are beyond the lung themselves.
12:05 --> 12:06So for example,
12:06 --> 12:08if we get treatment very close
12:08 --> 12:09to the esophagus,
12:09 --> 12:11we might expect that we'll see some
12:11 --> 12:13more difficulty with swallowing
12:13 --> 12:14or painful swallowing, heartburn,
12:14 --> 12:15things like that,
12:15 --> 12:19and then if it's too close to the airways,
12:19 --> 12:21we might see some bleeding, more cough.
12:23 --> 12:25If it's too close to the ribs
12:25 --> 12:27or the chest wall or the back,
12:27 --> 12:29sometimes we'll see some pain that can
12:29 --> 12:32arise even a couple of years afterwards,
12:32 --> 12:34so it's not a benign treatment completely,
12:34 --> 12:36but the side effects generally
12:36 --> 12:37are well tolerated for
12:37 --> 12:38most patients.
12:39 --> 12:42And what about long term side effects?
12:42 --> 12:45I realized that you said that SBRT is
12:45 --> 12:48relatively new in the past 15 years or so,
12:48 --> 12:50but with other
12:50 --> 12:51cancers treated with radiation,
12:51 --> 12:53people are often told about
12:53 --> 12:55the possibility of secondary
12:55 --> 12:56malignancies and worry about that,
12:56 --> 12:57especially with scarring
12:57 --> 13:00that takes place and so on.
13:00 --> 13:01Is that something that patients
13:01 --> 13:04should be worried about in lung
13:04 --> 13:05cancer treated with SBRT as well?
13:09 --> 13:11It is something we counsel our patients
13:11 --> 13:13about and we don't know for sure if
13:13 --> 13:15radiation really leads to, in the lung
13:15 --> 13:17at least, if it really leads to
13:17 --> 13:19significantly increased risk of
13:19 --> 13:20other lung cancers down the road.
13:20 --> 13:22Because often when patients get one
13:22 --> 13:24lung cancer, it doesn't matter
13:24 --> 13:26what kind of treatment they get,
13:26 --> 13:29they are often more prone to other lung
13:29 --> 13:31cancers that we watch very closely for.
13:31 --> 13:33So if something comes back in an
13:33 --> 13:35area that was previously radiated,
13:35 --> 13:37we may not know if that was because
13:37 --> 13:39of the radiation, or because it
13:39 --> 13:41would have happened anyway,
13:41 --> 13:43but we do see that sometimes
13:43 --> 13:44where lung tumors do come up,
13:44 --> 13:47both in the areas where there was a
13:47 --> 13:49previous radiation as well as other
13:49 --> 13:51areas of the lung or in the body,
13:51 --> 13:53that really had nothing
13:53 --> 13:55to do with the radiation
13:55 --> 13:57so it is hard to know for sure.
13:57 --> 13:58But it's something that we
13:58 --> 14:00counsel our patients about,
14:00 --> 14:01that theoretical risk that
14:01 --> 14:04radiation can lead to a second
14:04 --> 14:05malignancy many years down the road,
14:05 --> 14:08but it seems to be less of
14:08 --> 14:09a problem for lung cancer
14:09 --> 14:11then it is for other kinds of
14:11 --> 14:12cancers like breast cancer.
14:15 --> 14:17We're going to take a short
14:17 --> 14:19break for a medical minute and
14:19 --> 14:22then come back and talk more
14:22 --> 14:24about radiotherapy for lung cancer
14:24 --> 14:26with my guest doctor Henry Park.
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15:43 --> 15:45Welcome back to Yale Cancer Answers.
15:45 --> 15:48This is doctor Anees Chagpar
15:48 --> 15:50and I'm joined tonight by
15:50 --> 15:52my guest Doctor Henry Park.
15:52 --> 15:54We're talking about radiotherapy for
15:54 --> 15:56lung cancer and right before the
15:56 --> 15:59break we were talking about the use
15:59 --> 16:01of radiation therapy and specifically
16:01 --> 16:03SBRT for the management of stage
16:03 --> 16:05one or early stage lung cancer.
16:05 --> 16:08So Henry, you were mentioning that
16:08 --> 16:11radiation also may play a role in more
16:11 --> 16:13advanced cancers that are locally advanced
16:13 --> 16:14and not metastatic.
16:14 --> 16:17But one of the questions
16:17 --> 16:19that often comes up is,
16:19 --> 16:21sometimes we use
16:21 --> 16:22chemotherapy alone and sometimes
16:22 --> 16:24we use chemotherapy plus radiation
16:24 --> 16:26combined at the same time.
16:26 --> 16:28How do we make those decisions?
16:29 --> 16:31So that's a very good question.
16:31 --> 16:33We do that based on seeing
16:33 --> 16:35exactly where the disease has spread.
16:35 --> 16:38So if it has gone to the lymph
16:38 --> 16:40nodes that are still in the chest,
16:40 --> 16:43or if it's a very advanced tumor in the lung
16:43 --> 16:45that seems to be invading
16:45 --> 16:46other structures in the chest,
16:46 --> 16:48then that's often where we consider this
16:48 --> 16:51to be locally advanced but not metastatic,
16:51 --> 16:54meaning that it has not spread to other
16:54 --> 16:56organs throughout the body like the
16:56 --> 16:58brain or the liver or other areas.
16:58 --> 17:00So in that case
17:00 --> 17:02we still do approach this with
17:02 --> 17:04the intent to cure,
17:04 --> 17:07so we use some kind of combination,
17:07 --> 17:10typically of chemotherapy with radiation.
17:10 --> 17:12Or some kind of combination
17:12 --> 17:14of chemo with surgery,
17:14 --> 17:17with or without radiation, so for those patients
17:17 --> 17:18it really depends on
17:20 --> 17:22the similar features that
17:22 --> 17:25we look for in early stage lung cancer.
17:25 --> 17:28Given how much the patient can tolerate and what
17:28 --> 17:31they're willing to tolerate,
17:31 --> 17:34as well as the amount of
17:34 --> 17:37disease that needs to be treated.
17:37 --> 17:40The surgeons will weigh in about how much
17:40 --> 17:43lung would have to be removed in
17:43 --> 17:45order to do the adequate surgery
17:45 --> 17:48and we will weigh in about how much
17:48 --> 17:51the normal organs nearby will receive
17:51 --> 17:53radiation therapy and how much
17:53 --> 17:55we think the patient can take and
17:55 --> 17:57ultimately will be able to come up
17:57 --> 17:59with a recommendation about what the
17:59 --> 18:01best approach is to usually combine
18:01 --> 18:04at least two types of therapy and
18:04 --> 18:07sometimes three in order to achieve the
18:07 --> 18:09best outcomes.
18:09 --> 18:11In early stage lung cancer,
18:11 --> 18:13you talked a little bit about
18:13 --> 18:15deciding between surgery and radiation,
18:15 --> 18:19and I think we get the concept that
18:19 --> 18:21both surgery and radiation therapy
18:21 --> 18:24are local modalities designed to
18:24 --> 18:26treat lung cancer in the lung itself.
18:26 --> 18:29So one question that comes up is,
18:29 --> 18:32if my cancer is resectable,
18:32 --> 18:36say I've got
18:36 --> 18:37locally advanced lung cancer,
18:37 --> 18:40I'm going to get chemotherapy.
18:40 --> 18:42The surgeons say it's resectable.
18:42 --> 18:44Having you decide then whether
18:44 --> 18:47to add more radiation therapy or
18:47 --> 18:49whether to leave it with
18:49 --> 18:50the surgery alone.
18:50 --> 18:53Often we decide that we don't add
18:53 --> 18:54more radiation therapy afterwards or
18:54 --> 18:57we don't add radiation therapy at all.
18:57 --> 18:59It's a conversation
18:59 --> 19:01with the surgeon about whether or
19:03 --> 19:05not they think they can resect this
19:05 --> 19:06tumor after the chemotherapy.
19:06 --> 19:09Sometimes they may prefer to have chemo
19:09 --> 19:11and radiation together before surgery,
19:11 --> 19:13or they may prefer to have the
19:13 --> 19:15chemotherapy alone before surgery.
19:15 --> 19:17We used to do more
19:17 --> 19:19radiation therapy after surgery.
19:19 --> 19:21But like you mentioned before,
19:21 --> 19:23clinical trials being so important,
19:23 --> 19:25there's been a recent clinical trial
19:25 --> 19:27this past year that showed that
19:27 --> 19:29for those patients who had certain
19:29 --> 19:32types of lymph nodes or in certain
19:32 --> 19:33locations, that adding radiation
19:33 --> 19:35therapy after surgery may not be
19:35 --> 19:38as necessary as we once thought.
19:38 --> 19:40And so far the five year survival
19:40 --> 19:42numbers have just been released as well
19:42 --> 19:45for stage three disease and are at
19:45 --> 19:47least 10% higher than we've ever seen
19:47 --> 19:51in really any clinical trial.
19:51 --> 19:53Either involving surgery or not involving surgery.
19:57 --> 19:59I can't emphasize enough how
19:59 --> 20:02important these clinical trials are
20:02 --> 20:04to really moving the field forward.
20:04 --> 20:07Are all patients eligible for immunotherapy given that data?
20:08 --> 20:11Or do we look for certain biomarkers
20:11 --> 20:14to decide whether or not they
20:14 --> 20:16would be candidates for that?
20:16 --> 20:19Most patients are eligible for it
20:19 --> 20:21after chemotherapy and radiation
20:21 --> 20:23if they have stage three disease,
20:23 --> 20:26we may not always give it afterwards.
20:26 --> 20:28Depending on their response to
20:28 --> 20:29the chemotherapy and radiation,
20:29 --> 20:31so we'd require before receiving
20:31 --> 20:33that that we have another scan
20:33 --> 20:36that shows that there's not new
20:36 --> 20:37disease elsewhere already starting.
20:37 --> 20:40We'd also want to be sure that
20:40 --> 20:42patients have tolerated
20:42 --> 20:44the chemotherapy and radiation well
20:44 --> 20:46enough to start the immune therapy,
20:46 --> 20:48and there's other biomarkers like
20:48 --> 20:51PDL1 that are very helpful
20:51 --> 20:53in determining how likely the patient
20:53 --> 20:56is to respond to immunotherapy as well.
20:57 --> 21:00Right now we still do offer it even for those
21:00 --> 21:03who do not have the PDL1 marker.
21:04 --> 21:06But it may not be as helpful
21:06 --> 21:09in those patients as it is for
21:09 --> 21:12those who have a high PD L1 expression.
21:12 --> 21:13Given those data
21:13 --> 21:15than the fact that we offer
21:15 --> 21:17immunotherapy regardless of PDL1
21:17 --> 21:19status and the fact
21:19 --> 21:21that the clinical trials
21:21 --> 21:23have demonstrated that chemo,
21:23 --> 21:25radiation therapy followed by immune
21:25 --> 21:26therapy without surgery offers
21:26 --> 21:28tremendous survival benefits,
21:28 --> 21:31do we ever offer surgery to
21:31 --> 21:32stage three patients anymore?
21:32 --> 21:34We still do.
21:34 --> 21:36I think there's certain circumstances
21:36 --> 21:40still where we don't know what the role
21:40 --> 21:42is yet of surgery with immunotherapy
21:42 --> 21:46and if we still get good outcomes from
21:46 --> 21:48let's say, chemo with surgery afterwards,
21:48 --> 21:51or chemo and radiation, then surgery
21:51 --> 21:54and we'd save the immunotherapy,
21:54 --> 21:55which didn't really exist during
21:55 --> 21:58the time of the surgical trials,
21:58 --> 22:00then you know, could we still
22:00 --> 22:02get good outcomes from that?
22:02 --> 22:04We believe we may be able to.
22:04 --> 22:06We still don't have that clinical
22:06 --> 22:09trial data yet to prove that yet.
22:09 --> 22:11But as we move forward,
22:11 --> 22:13there's other trials that are
22:13 --> 22:15currently being considered right now about
22:15 --> 22:17combining immunotherapy with surgery as well.
22:17 --> 22:20And even in the earlier stage setting that's
22:20 --> 22:23I think becoming more and more
22:23 --> 22:25studied seeing
22:25 --> 22:28if that is going to be helpful and
22:28 --> 22:31and as the months and even
22:31 --> 22:33as the days and weeks go by,
22:33 --> 22:36new data comes out all the time
22:36 --> 22:37from clinical trials that changed
22:37 --> 22:40the way we think about the best
22:40 --> 22:42way of treating stage three lung cancer.
22:42 --> 22:44And so when we were talking about
22:44 --> 22:47stage one and even locally advanced
22:47 --> 22:49up to stage three lung cancer,
22:49 --> 22:51you used the term curative intent
22:51 --> 22:53and can you explain to our listeners
22:53 --> 22:55what you mean by curative intent and
22:57 --> 23:00what the alternative is?
23:00 --> 23:02The concept there is that we are
23:02 --> 23:04hoping to eliminate the tumor so
23:04 --> 23:07that it does not grow and come back
23:07 --> 23:10at any point in the patients life.
23:10 --> 23:12Are we always successful at that?
23:12 --> 23:14No, but we would approach it
23:14 --> 23:16with the intention of doing that,
23:16 --> 23:18and that's supposed to palliative
23:18 --> 23:21intent where the goal is to help with
23:21 --> 23:23alleviate symptoms that may come up.
23:23 --> 23:26For example, if the disease has
23:26 --> 23:29already spread outside of the chest,
23:29 --> 23:31we may be approaching the disease
23:31 --> 23:34more in that capacity in terms of
23:34 --> 23:36the treatments that we may offer.
23:36 --> 23:39However, in the past five to 10 years,
23:39 --> 23:41there's a lot of wiggle room in between
23:41 --> 23:44where we may not necessarily believe
23:44 --> 23:46we will completely eradicate the tumor
23:46 --> 23:49with any combination of therapies,
23:49 --> 23:51but that we believe we can extend
23:51 --> 23:54survival and extend Disease Control
23:54 --> 23:55for years afterwards,
23:55 --> 23:58and we're often successful at doing that and
23:58 --> 24:00that's often an important goal
24:00 --> 24:03for a lot of patients is to live as
24:03 --> 24:06long as possible and to turn their
24:06 --> 24:09cancer into more of a chronic disease.
24:09 --> 24:11And I think we're seeing that more and
24:11 --> 24:14more with the advent of immunotherapy.
24:14 --> 24:16Better combinations with surgery and
24:16 --> 24:17chemotherapy and radiation therapy,
24:17 --> 24:20as well as targeted therapy that
24:20 --> 24:21specifically targets certain mutations,
24:21 --> 24:24especially in lung cancer, that can often,
24:24 --> 24:27even if they are not specifically curative,
24:27 --> 24:29they may give patients multiple years
24:29 --> 24:31of extra life and time before they
24:31 --> 24:34require other kinds of therapies.
24:34 --> 24:36So when you say that,
24:36 --> 24:39I mean you're referring to stage
24:39 --> 24:41four or metastatic patients in whom
24:43 --> 24:46can still have many years of good quality of life.
24:46 --> 24:49Tell us more about the use of radiation
24:49 --> 24:51therapy in those circumstances?
24:51 --> 24:53More and more we're using it
24:53 --> 24:55because we're seeing such
24:55 --> 24:56improved outcomes from our
24:56 --> 24:57excellent systemic therapies,
24:57 --> 24:59meaning the chemotherapies and immune
24:59 --> 25:01therapies and also targeted therapies.
25:01 --> 25:04Radiation has an increasing role as well.
25:04 --> 25:06In stage four patients, we used to
25:06 --> 25:09be limited to alleviating symptoms,
25:09 --> 25:11which radiation is very effective
25:11 --> 25:13in doing over a very low dose
25:13 --> 25:16and a short period of time.
25:16 --> 25:18However, with this SBRT technique that
25:18 --> 25:21we've been using for stage one lung cancer,
25:21 --> 25:24we often use this in the metastatic setting especially
25:25 --> 25:27for those who have disease called
25:27 --> 25:29oligometastatic disease and what
25:29 --> 25:32this means is that only a few spots,
25:32 --> 25:35maybe one or three or even five spots,
25:35 --> 25:37may be present
25:37 --> 25:40outside of the lung and if we can
25:40 --> 25:42use either surgery or radiation,
25:42 --> 25:44some kind of local therapy to address
25:44 --> 25:46those areas after systemic therapy
25:46 --> 25:48has worked well for a patient,
25:48 --> 25:51then we may be able to really extend
25:51 --> 25:53their time without needing systemic
25:53 --> 25:56therapy and having good disease
25:56 --> 25:57control so it's something that
25:57 --> 25:59we're seeing improved survival
25:59 --> 26:01from clinical trials recently.
26:01 --> 26:03When you add radiation or surgery
26:03 --> 26:05in very selected populations,
26:05 --> 26:07meaning those who responded well
26:07 --> 26:09to their systemic therapy and
26:09 --> 26:11who have a limited number and
26:11 --> 26:13treatable areas where we
26:13 --> 26:15can use surgery or radiation,
26:15 --> 26:18these patients have
26:21 --> 26:23been able to live longer
26:23 --> 26:25than they would have otherwise.
26:26 --> 26:28We talked a lot in
26:28 --> 26:31this show so far about clinical trials
26:31 --> 26:34and historically people have always
26:34 --> 26:36thought that clinical trials were only
26:36 --> 26:39for patients who had no other option.
26:39 --> 26:41Patients who had stage four disease.
26:41 --> 26:44But it sounds like that clearly is
26:44 --> 26:47not the case and that
26:47 --> 26:51there are clinical trials that are offered
26:51 --> 26:53across various different stages to allow
26:53 --> 26:56patients to get the best therapies.
26:56 --> 26:57What clinical trials are currently
26:57 --> 27:00ongoing that you're most excited about?
27:00 --> 27:03We have a lot of clinical trials ongoing
27:03 --> 27:05right now at yield in lung cancer,
27:05 --> 27:08but specific to radiation we actually have
27:08 --> 27:10three right now for stage one disease,
27:10 --> 27:12so exactly the opposite of what we had
27:12 --> 27:15been used to seeing for clinical trials,
27:15 --> 27:17and that they're really often used
27:17 --> 27:19like you're saying for patients
27:19 --> 27:21as a sort of a last resort.
27:21 --> 27:23It's really the opposite for us,
27:23 --> 27:25where we're trying to approach this
27:25 --> 27:28to improve the standard of care
27:28 --> 27:31even more at all stages of disease.
27:31 --> 27:33So for example, stage one lung cancer,
27:34 --> 27:35we do have a two clinical trials
27:36 --> 27:38one that's currently active and one
27:38 --> 27:41that is about to open fairly
27:41 --> 27:44soon that look at the idea of SBRT with
27:44 --> 27:46immune therapy for stage one disease.
27:46 --> 27:48So half the patients will get the
27:48 --> 27:50standard of care, radiation therapy,
27:50 --> 27:52and half the patients will also
27:52 --> 27:53get immune therapy as well.
27:53 --> 27:56And that's our way of studying to see if
27:56 --> 27:59will get even better outcomes with SBRT
27:59 --> 28:02and with immune therapy and try to prevent
28:02 --> 28:03recurrences that happened
28:03 --> 28:04elsewhere in the body,
28:04 --> 28:06in the lymph nodes or elsewhere,
28:06 --> 28:07so I'm very,
28:07 --> 28:08very excited about those studies,
28:08 --> 28:10and I also have a study of my own
28:10 --> 28:13as well that looks at a clinical
28:13 --> 28:15trial that's looking at a fewer
28:15 --> 28:17number of sessions of SBRT for those
28:17 --> 28:19tumors that are a little closer to
28:19 --> 28:21the middle of the chest and trying
28:21 --> 28:23to make it more convenient and
28:23 --> 28:25for patients they only come in
28:25 --> 28:27three times instead
28:27 --> 28:29of five times for tumors that are
28:29 --> 28:31closer to the middle of the chest.
28:32 --> 28:34Henry Park is an assistant
28:34 --> 28:36professor of therapeutic radiology
28:36 --> 28:37at the Yale School of Medicine.
28:37 --> 28:39If you have questions,
28:39 --> 28:41the address is canceranswers@yale.edu
28:41 --> 28:43and past editions of the program
28:43 --> 28:45are available in audio and written
28:45 --> 28:47form at YaleCancerCenter.org
28:47 --> 28:49We hope you'll join us next week to
28:49 --> 28:51learn more about the fight against
28:51 --> 28:53cancer here on Connecticut Public Radio.
28:53 --> 28:55Funding for Yale Cancer
28:55 --> 28:57Answers is provided by Smilow
28:57 --> 29:00Cancer Hospital and AstraZeneca.

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July 18, 2021

Yale Cancer Center

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