The right lung cancer testing can make a big difference when choosing the most effective treatment. Dr. Thomas Marron reviews the essential tests patients should ask about – including biomarker testing – and how these results help doctors decide which lung cancer treatment approach may be best for you. Dr. Marron also discusses why reviewing imaging results with your doctor and understanding your treatment approach can empower patients and care partners when making decisions about care.
Dr. Thomas Marron is Director of the Early Phase Trials Unit and Associate Director for Translational Research at the Mount Sinai Tisch Cancer Center. Dr. Marron is also Professor of Medicine and Professor of Immunology and Immunotherapy at the Icahn School of Medicine at Mount Sinai. Learn more about Dr. Marron.
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Transcript
Katherine Banwell:
Dr. Marron, what testing should patients undergo following a lung cancer diagnosis?
Dr. Thomas Marron:
So, unfortunately, most patients who are diagnosed with lung cancer are diagnosed with metastatic disease.
So, that means it started in the lung, and it has spread somewhere else in the body. Even spreading to the lining of the lung, which is called the pleura, that would represent stage IV disease. So, patients who have stage IV disease, we don’t typically do radiation or surgery because we know that’s not going to be curative. So, we really focus on systemic disease, which means oral medicines or IV medicines. When we say systemic, we basically are saying it’s a medicine that we put in you and it goes everywhere in your body, everywhere the blood goes which is everywhere in your body.
So, the most important thing to – the questions that we’re asking first and that you guys should be asking as well is what are the biomarkers that would suggest we should use one treatment or the other? The number one biomarker that we use is PDL-1, which is called Program death-ligand 1.
It’s basically a stop sign that cancer puts up on its cell surface that tells the immune system to stay away. So, patients who have lots of that stop sign on their cell surface, oftentimes we can give them immunotherapy alone, not even chemotherapy.
We can spare them chemotherapy, at least initially. But if you have lower levels of that stop sign, then we usually need a more combination approach. Patients also need to be asking what is the mutational status, what mutations are present, what changes in the DNA are present in the tumor? And those mutations or DNA changes that are in the tumor and are unique to the tumor and not anywhere else in the body really are why you have the cancer, why the cancer is growing. And depending on the mutations you have, it’s going to suggest that you might be more or less susceptible to additional therapies. Some of those are oral medicines.
This is particularly common in patients who are not smokers who haven’t been smokers in the past. We oftentimes will find these mutations in the DNA that mean that we can use oral medicines at least initially to treat those patients with cancer.
Katherine Banwell:
What questions should they be asking about their test results and treatment plan?
Dr. Thomas Marron:
Patients should be asking what is their mutational status? What mutations are in the DNA of the tumor? They should be asking about PDL-1. As far as imaging, most patients hopefully in their patient portal will have access to the imaging studies. But these are very difficult studies to read. The average doctor can’t read a PET scan and really understand what’s happening. You should really ask the doctor to go through the imaging report with you. I oftentimes will go through the pictures themselves just to give patients a good idea of where the cancer is and how much cancer there is. Because if you have lots of cancer in your body, the response to therapy is going to be definitely different than if you have just a tiny amount of cancer.
So, it’s important that you have as much information as possible. I think it’s also super important that patients be asking their doctors how the medicines that they’re taking work and what the expected side effects are going to be. I always think it’s important, my nurses say that I give a nerdy Immunology 101 lecture to all of my patients.
But if I’m trying to give somebody a medicine that uses their immune system to recognize and attack the cancer, I really want them to understand what that means. I think it’s important that people can visualize what these medicines are and not just say, “Okay, I’ll take it,” and hope things go away. I think it’s important to get as much information as possible, not only so that you can understand possible side effects, but that you can just have an idea of what’s happening in your own body.
Katherine Banwell:
Dr. Marron, would you define personalized medicine for our audience?
Dr. Thomas Marron:
So, personalized medicine is medicine that is basically selected because it would most likely benefit you versus another patient. Increasingly, we’re finding more and more personalized approaches because we are doing genetic sequencing on everyone’s tumors. And that will allow us to potentially give patients a therapy that we think is going to work better than the average Joe. We aren’t at the point yet where we can draw a blood test or do a biopsy and know exactly the medicine that you will respond to and that’s going to cure the cancer.
There are situations like in patients who have never smoked before and have lung cancer, which is increasingly a huge problem, especially here in New York City, that when we do genetic sequencing, they might have a mutation in EGFR, for instance. That will tell us that we should use a medicine called a targeted tyrosine kinase inhibitor, which is an oral medicine for them. So, that is one type of personalized medicine. But increasingly, we’re hoping that we will be moving to the point where we will be able to do blood tests and tissue tests and actually tailor a treatment regimen specifically to somebody’s own cancer, but also their own immune system.
So, I think that that’s really the work that we’re focused on in the laboratory is better understanding how these new drugs work, and most importantly who they’re going to work for. Because we don’t want to waste a patient’s time and a patient’s money and effort on a drug if it’s not actually going to do them any good.