Lung Cancer Archives

Lung cancer is the second most common cancer in men and women. About 14% of all new cancers are lung cancers.

The two main types of lung cancer are non-small cell lung cancer and small cell lung cancer. The types are based on the way the cells look under a microscope. Non-small cell lung cancer is much more common than small cell lung cancer

More resources for Lung Cancer from Patient Empowerment Network.

Lung Cancer and COVID-19 Vaccine Effectiveness

Lung Cancer and COVID-19 Vaccine Effectiveness from Patient Empowerment Network on Vimeo.

What do lung cancer patients need to know about COVID-19 vaccine effectiveness and safety? Expert Dr. Heather Wakelee shares information gathered about lung cancer patients early on in the pandemic and advice regarding COVID-19 vaccination.

Dr. Heather Wakelee is a thoracic medical oncologist and deputy director of the Stanford Cancer Institute where she also serves as the division chief of medical oncology. Learn more about Dr. Wakelee, here.

See More From INSIST! Lung Cancer

Related Resources:

Accessing Personalized Treatment for Lung Cancer

NCCN Guidance on Safety and Effectiveness of COVID-19 Vaccines for Cancer Patients

What Are the Goals of Lung Cancer Treatment?

What Are the Goals of Lung Cancer Treatment?


Transcript:

Katherine:

I’d be remiss if I did not bring up COVID-19, and, I’m sure a lot of patients are curious whether the vaccine is safe and effective.

Dr. Wakelee:

So, we do believe the vaccine is safe and effective for patients living with lung cancer, and really important to be protected as much as possible. I was part of a group of other physicians around the world looking at the impact of COVID-19 on patients living with lung cancer. And, we collaborated with a group of physicians, Rayna Garcina was the lead. She was living in northern Italy at the time of the first wave, and so, was really face-to-face with it early on when there was so much we didn’t know. And, she gathered a group of us to watch and see, and what we were able to figure out before the vaccine was available was that people living with lung cancer who were overall healthy still except for their cancer were perhaps on a pill, targeted therapy, or immune therapy seemed to really not have that different of an impact compared to people who didn’t have lung cancer.

Chemotherapy was a little bit harder to see that but didn’t seem to be such a big issue. It’s different than people living with, say, leukemias or lymphomas where the treatments are impacting their immune systems even more. They seem to have worse outcomes. A lot of lung cancer patients were okay, but still, it’s a higher risk. And so, we want to protect our patients as much as possible.

So, we are, now that we have the vaccines, strongly advocating vaccines for any patient who was living with cancer really for almost anybody because as a physician, we really think that makes a big impact. We have not seen any negative impacts of the vaccine on any aspect of cancer treatment. It does not have a negative impact on how well the cancer is treated by the therapies. We did notice that when someone gets the vaccine, they can get some enlargement of the lymph nodes. That’s part of having an immune response is your lymph nodes get enlarged. And so, we did get a bunch of scans that the vaccines came out showing, “Well, this person has some lymph nodes in the axilla, which is the armpit.”

And it seemed to be correlating with the side that someone had a vaccine. And then, those go away. And, this was actually an interesting medical literature thing because for people getting screened with mammograms for breast cancer, there were suddenly all these lymph nodes showing up. But that was actually a sign that the person was responding to the vaccine, and it went away over time. And, it was a fine thing. It was just – I remember the first patient I had where that happened, we’re like, “Oh, well, that makes sense. Okay.” So, it’s okay. So, it was not cancer. It was just the immune response. But, yeah, so, we are recommending vaccines. There’s no data showing it is not working for lung cancer patients. The vaccines are less effective in people getting certain types of cancer treatment that are really suppressing the immune system. But even some response is better than none, and we’re still recommending the patients really do their best to stay safe with masks and things like that. 

How Will You Know if Your Lung Cancer Treatment Is Working?

How Will You Know if Your Lung Cancer Treatment Is Working? from Patient Empowerment Network on Vimeo.

How do lung cancer experts determine if a treatment approach is working? Expert Dr. Heather Wakelee explains how treatment effectiveness is monitored and what should be analyzed when treatments stop working.

Dr. Heather Wakelee is a thoracic medical oncologist and deputy director of the Stanford Cancer Institute where she also serves as the division chief of medical oncology. Learn more about Dr. Wakelee, here.

See More From INSIST! Lung Cancer

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What Are the Goals of Lung Cancer Treatment?

What Are the Goals of Lung Cancer Treatment?

How Are Targeted Therapy and Immunotherapy Used in Lung Cancer Care?

How Are Targeted Therapy and Immunotherapy Used in Lung Cancer Care?

What Are the Advantages of Newer Lung Cancer Treatment Approaches?

What Are the Advantages of Newer Lung Cancer Treatment Approaches?

Transcript:

Katherine:

We have a question that we received from an audience member earlier. Jeff asks, “How do you know if your lung cancer treatment is working?”

Dr. Wakelee:

So, there are a lot of ways of knowing if treatment is helping. So, the one I rely on the most is, “Does the patient overall feel better?” That is difficult to say exactly how. Sometimes people are having breathing problems; they feel that that’s better. Sometimes their energy’s lower. They feel better. It can be vague. We also use scans. So, we tend to get scans, depending on the treatment we’re giving, every couple of months plus or minus, sometimes, every three months to help track what’s actually going on. But occasionally, there are discrepancies.

So, sometimes, the scan, is it better? Is it not better? Can’t really tell. And then, you’re always taking that, “How does the patient feel?” So, usually, if the scans are better, the patient feels better. It’s easy. Usually if the patient’s feeling worse and the scan looks worse, clear decision. Not a good one, but clearly, we need to do something different. But sometimes, you’re left, and especially this happens with the first scan because you get a scan, it takes a little while, you start the new treatment, then you get the next scan, how much of the changes happened before you started the new one and how much didn’t? So, these can be more challenging conversations, but generally if the patient’s feeling a little bit better, the scan’s unclear, we usually say, “You know, let’s give this treatment a little bit more time.” We also, I think your question was specifically around how do we tell if it’s working, but you also often need to be thinking about, “Well, what’s it doing that’s negative to the person and is that potential, those side effects worth the benefits we are or are not seeing?”

So, it’s kind of all of those things together. It can be a bit complex.

Katherine:

What goes into the decision to change therapies if it becomes necessary?

Dr. Wakelee:

So, when we’re thinking about making a change, the way I always look at it is, is where we are today still okay or not? And, if it’s not, that would be because clearly the cancer’s growing or clearly the side effects are just not tolerable. Then, we decide together with the patient we need to do something different. And, when we think about what do we do next, we look at what have we’ve already done, did it work or not, if not, let’s do something more different. And so, let’s think about something that might be somewhat similar. When we’re dealing with targeted therapies, we have ways to try to figure out what changed in the tumor that made it now resistant or not working with that treatment.

And so, with some of the pill drugs, there’s been a lot of research and understanding how does the tumor change that helps it evade, get away from, be resistant to whatever treatment you’re on.

And then, sometimes, we have other pill drugs that work in that particular setting, not always. With immune therapy, we’re trying to better understand why does the immune therapy stop working?

Sometimes you can add back to it, like, you can add chemotherapy back to immune therapy alone or sometimes you can do radiation with immune therapy to get that response back. Or, add other combinations to it. So, that’s another thing that we’re working on. And then, like I said, if someone hasn’t ever had chemotherapy and the tumor’s become resistant, we’re going to be thinking a lot about chemo because that can play a role against so many different reasons that the cancer might not be responding to whatever treatments someone’s on. And then also, looking at how the patient’s feeling and doing, what their overall what we call “performance status, ” their sort of overall health, and how well do we feel with them that they’re going to be able to tolerate the next treatment because, you’re always having to weigh how much is this likely to help, and how might this harm in finding the right balance. 

What Are the Advantages of Newer Lung Cancer Treatment Approaches?

What Are the Advantages of Newer Lung Cancer Treatment Approaches? from Patient Empowerment Network on Vimeo.

Lung cancer expert Dr. Heather Wakelee shares insight about how newer treatments, such as targeted therapy and immunotherapy, impact quality of life and patient outcomes.

Dr. Heather Wakelee is a thoracic medical oncologist and deputy director of the Stanford Cancer Institute where she also serves as the division chief of medical oncology. Learn more about Dr. Wakelee, here.

See More From INSIST! Lung Cancer

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How Are Targeted Therapy and Immunotherapy Used in Lung Cancer Care?

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Transcript:

Katherine:

Right. What are the advantages of these new treatment approaches compared to standard chemotherapy?

Dr. Wakelee:

Well, I think the most exciting news that we’ve seen in lung cancer over the last few years is that we’re actually helping more people live longer. And the way that we’re doing that is through these newer treatments. So, when we can personalize treatment by recognizing that a person’s cancer has a specific gene mutation and we can give them the right targeted pill drug, we can help them live longer and feel better because those often have fewer side effects. Wish I could say they were curing the disease, but they’re helping people live longer.

And, that can be measured in years for some folks, which is fantastic. And then, with immune therapy, again, they’re not working for everybody, but they were for a large number of patients with lung cancer with non-small cell to help them live longer with their cancer controlled. And so, we’ve actually improved the overall survival rates for lung cancer with these new developments. Where we can make even more of an impact is also by finding more of the cancers earlier, and that’s where cancer screening is so important also. So, by having more choices, chemotherapy can still help a lot of people. Targeted therapies can help probably close to 20, 30, 40 percent of people with non-small cell lung cancer that’s the adenocarcinoma type.

And then, the immune therapies can help other people living with lung cancer. Usually immune therapies don’t work on the same tumors the way the targeted pills work. So, you’re kind of getting at different groups of people with those different strategies. It’s not completely true, but it’s a kind of general principle about it.

Katherine:

What about side effects for some of these treatment choices?

Dr. Wakelee:

So, chemotherapy is one people fear the most, but I think it has a bit more of a bad reputation than it needs. A lot of the lung cancer therapies that are chemotherapy can be reasonably tolerated. I mean, I’m not signing up to go get chemotherapy just because. There definitely are side effects. The biggest one is people get fatigue, get really tired. Though, if they’re feeling horrible because of the cancer, a lot of times people feel dramatically better. But, tiredness, it can impact appetite a little bit, though cancer does that also. There can be nausea, vomiting, but we’re much better at controlling that with the newer drugs. Some cancer therapies cause hair loss, but a lot of our non-small cell lung cancer therapies don’t cause hair loss. So, there are a lot of options there you can talk about with your doctor. And then, when the blood counts are low, there can be risk for infection, low red blood cells with anemia.

So, there are a lot of different things. But in general, chemotherapy is better tolerated than people think it’s going to be because in the movies, they make it look horrendous.

With the pill therapies, again, lots of variability depending on the specific pill. Some of them cause rash. Some don’t. Some of them can cause some changes to the heart that we have to monitor with EKGs, electrocardiograms, some don’t. Some cause some changes to labs like for liver tests that we have to monitor. Some don’t. Some cause hair color changes. Some don’t. It’s always to gray, unfortunately.

So, there are a lot of different variations in what different treatments can do. And so, it’s just really important if your doctor is talking with you about starting one of the targeted pill drugs that you really ask what are the side effects I need to be watching for, what are the ones I need to know to call you about, and which are the ones I just know, “Okay, this is happening and it’s okay. It’s going to cause swelling in the ankles,” no, just a huge range of them. And then, with the immune therapy drugs, they tend to be mostly fatigue, just like with chemotherapy, though some people feel fine.

What we have to watch for is that they can cause what we call autoimmunity. So, it’s talking about the fact that the way they work is they help the immune system better recognize the cancer, and they do that by taking away one of the stop signals. But that stop signal, the PD-1, PD-L1, that stop signal is also used by a lot of normal cells to tell the immune system to back off.

So, when you remove it, when you block it, the immune system can get confused and start to attack normal cells. So, you can get a rash, people can end up with gut symptoms like diarrhea, they also can end up with it attacking the lungs and causing what we call a pneumonitis lung inflammation or brain symptoms, so, almost anything. Now, those are rare, and we can treat them with steroids. But, people need to be aware that if something new is happening, they need to alert their doctor. I think sometimes, there’s this false impression that immune therapy is completely safe, but, it’s not. And, all of the treatments that I’m talking about are designed to help people live better and live longer when they’re dealing with lung cancer, but they all also have risk.

And so, it’s just really important to have those discussions with the care team as you’re starting something new about what are the things I need to be watching for and to know how to reach people if you’ve got a new and concerning symptom, especially if you’re starting on something new. 

How Are Targeted Therapy and Immunotherapy Used in Lung Cancer Care?

How Are Targeted Therapy and Immunotherapy Used in Lung Cancer Care? from Patient Empowerment Network on Vimeo.

Expert Dr. Heather Wakelee explains how targeted therapy and immunotherapy work to treat lung cancer and which patient type each therapy is most appropriate for.

Dr. Heather Wakelee is a thoracic medical oncologist and deputy director of the Stanford Cancer Institute where she also serves as the division chief of medical oncology. Learn more about Dr. Wakelee, here.

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Transcript:

Katherine:

Dr. Wakelee, you mentioned targeted therapies. How do they work?

Dr. Wakelee:

Targeted therapies are something we can use when we find a specific gene mutation in the tumor. So, I mentioned before that in order for a cancer cell to become cancer, something has to happen to the DNA in the cell.

And, there’s a change or a mutation in the DNA of the cell which leads it to be a cancer. And, a lot of the time, that mutation happens in a specific kind of gene that makes a type of protein called a tyrosine kinase. And for those of you who haven’t studied a lot of science, it’s a word you might not have heard before. But basically, these tyrosine kinases are proteins in the body that make a lot of changes to what’s going on in the rest of the cell. So, they’re sort of what we call regulators. And, one way of thinking about them is like on and off switches. So, normally, their job is to sit and if the right molecule comes around, that turns it on, and then it turns on other proteins in the cell. And if that molecule isn’t there, it’s turned off. So, it’s this on and off switch that does a lot of other aspects of what’s going on in the cell. But, sometimes, a mutation happens. It turns it on all the time. So, it’s like if you leave the light on.

It’s on all the time, that’s using a lot of energy, and that’s actually what’s driving the cell to act like a cancer. And so, we can now look for some of those mutations that turn some of these tyrosine kinases on all the time. But we’ve also developed drugs that we can use to turn them off. So, if we find this specific gene mutation that’s turning, say, the EGFR protein on all the time, if we find that, we can have the patient take a pill that then turns that off.

And that helps the cancer slow down, some of it die, some of the cancer cells die, but it doesn’t completely wipe it out. It helps the patient for a long time though by shrinking the cancer, helping them feel better because the symptoms are gone, keeping the cancer from growing. But, cancer cells are clever. They continue to divide, they can continue to make new mutations, and eventually, they figure out ways around that. So, when we talk about targeted therapy, it’s a setting where we find the cancer.

In the cancer, we find the gene mutation, it’s in one of these specific types of proteins, genes that make specific protein that turn something on that we can then turn off, and with those pill drugs, we can have a big impact for people.

Katherine:

And, what exactly is immunotherapy?

Dr. Wakelee:

Immunotherapies are treatments that were used to help keep the immune system more active.

So, the immune system is a very complex mechanism. There are cells that their whole job is to figure out and find things that are not us. So, they are looking for bacteria, they’re looking for cells that have a virus in them, and when they find it, they attack. And, that attack can be in the form of antibodies, it can be cells that actually go in and attack other cells directly, and we are all familiar a little bit with the immune system because we know that if we get a cold, our body, we can get a fever, that’s part of our immune response, and we get better. And then, some people know the bad side of the immune system if they have allergies or certain autoimmune diseases where the immune system gets a little bit too revved up and starts to recognize normal things as foreign.

So, in the setting of cancer, normally, the immune system is able to recognize a cancer cell, see that it’s different from the rest, and get rid of it. But, cancer cells are clever and they figure out ways to evade the immune system. And, one of the ways they do this is they put a protein called PD-L1. So, PD-L1 is a protein that a lot of our normal cells use to say, “Just a normal cell. Ignore me.”

And so, when an immune cell comes in and sees that, it gets turned off it goes away. So, what our immune therapies do is most of them are blocking that PD-L1 protein. And, when they do that, it’s sort of like taking away the stop sign. So, you’ve got a tumor using a stop sign to say, “Go away, immune cell,” you block it so the immune cells can’t see that stop sign, and so then it kills the cancer cell better. So, that’s how these drugs work, and that’s the immune therapy.

There are some other stop signs besides PD-1 and PD-L1, but that’s the most common. So, when we’re talking about immune therapy, it’s drugs that block that. So, they increase the ability for the immune cell to recognize cancers. The risk from them is that you can get the body to recognize normal tissue as a problem sometimes. So, that’s the toxicity that we watch for. 

What Are the Goals of Lung Cancer Treatment?

What Are the Goals of Lung Cancer Treatment? from Patient Empowerment Network on Vimeo.

The goals of lung cancer treatment can vary depending on the stage. Expert Dr. Heather Wakelee explains how lung cancer stage is determined and shares insight about the goals of treatment at each stage.

Dr. Heather Wakelee is a thoracic medical oncologist and deputy director of the Stanford Cancer Institute where she also serves as the division chief of medical oncology. Learn more about Dr. Wakelee, here.

See More From INSIST! Lung Cancer

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In-Depth Testing for Lung Cancer Prognosis and Treatment


Transcript:

Katherine:

Let’s turn to treatment, Dr. Wakelee. On a basic level, what are the goals of treatment for lung cancer?

Dr. Wakelee:

So, with lung cancer, we’d love to cure everybody, that’s the ultimate goal, and do it in a way where people are able to continue living their life as they were before the cancer diagnosis. The ways that we do it, first of all, we’ve got to find the cancer, and that’s where screening is such an important aspect of things. If we can find the cancer at an earlier stage, we’re more likely to be able to cure someone.

So, what do I mean by “earlier stage?” Well, when a tumor first develops, usually, there is a single cell that develops a mutation, meaning a change in the gene, which gives that cell an advantage so it doesn’t die the way it’s supposed to. And then, it keeps growing, and dividing, and making new cells. And those over time get to a large enough size that they are the cancer. And given more time, those cancer cells start to spread into other parts of the body, usually first into what we call the lymph nodes, and from there then into other organs in the body. And this stage refers to health or how the cancer spread. So, the stage I cancer is still in that ball of cancer. Stage II means that it’s spread into some lymph nodes. Stage III is it spread into more lymph nodes, usually in the center part of the chest or mediastinum, and that’s where it starts to be much more difficult for the surgeons to be able to truly remove all of the cancer.

And then stage IV means that the cancer is not something that we’re going to be able to remove with surgery. It’s spread either within the lung to the lining of the lung or it has spread to other organs in the body. And so, when we talk about those stages that I, II, III, IV, it’s a bit more complicated than that. But, I think for most people, if they just think about it as stage I, just the cancer, stage II, lymph nodes and the lungs, stage III, lymph nodes in the center, and then stage IV, elsewhere, that’s a good way to kind of wrap your head around it.

And when we talk about stage I and II, that’s the truly early stage where we hope to be able to cure people with surgery. Surgery alone is enough for the majority of people with stage I cancer, and for maybe half, a little more than half of people with stage II. So, how can we be better than that? Well, that’s where there’s been a lot of new advances. So, adding chemotherapy after surgery can help a lot of stage II patients.

If the tumor genomic testing biomarkers shows that there’s a mutation called EGFR, we now know that there’s a pill drug that people can take that would prolong the time to when the cancer might come back. And then, just very recently, there was stated that that immune therapy drugs

IV can also prolong time to when the cancer comes back and maybe improve cure if the tumor has that biomarker called PD-L1. So, that’s that early stage. So it’s, again, getting more and more complicated and emphasizing that you’ve got to understand the biomarkers of the tumor to know how to best help someone.

When we move to stage III, some have surgery, but when you can’t have surgery, then we do the chemotherapy and the radiation. That’s the key part of the treatment there. And, we also know that immune therapy can be really helpful for a lot of patients when it’s given after the chemo and radiation’s completed. And then for stage IV, I talked about that already, which is you’ve gotta do the biomarkers to figure out the best treatments for some people starting with a targeted pill drug is the right thing if their tumor has those right gene mutations.

For other people, immune therapy alone might be an option if the PD-L1 level is very high and they don’t have one of those gene mutations in the tumor. And for a lot of people, chemotherapy or chemotherapy plus immunotherapy is the right strategy.

Katherine:

Would you help the audience understand the types of therapy for small cell lung cancer specifically?

Dr. Wakelee:

Yes. So, small cell still has the same kind of staging, but it’s a little bit more simple. We talk about extensive stage or limited stage. And what that has to do with is we rarely do surgery for small cell. It tends to have spread earlier. There are a few cases where that’s done, but normally, we divide it up into limited or extensive. And when we talk about that, limited is the radiation doctors can get all of the cancer in one radiation field, and then radiation plus chemotherapy is the standard approach to try to cure. If it’s more extensive than that, then it becomes extensive stage.

And, the best treatment are going to be chemotherapy plus those immune therapy drugs added together.

And so, the chemotherapy drugs that we use for non-small cell and small cell, the platinum drugs play a role in all of it. The drug we partner is a little bit different. There’s a drug etoposide we use a lot in small cell and a lot of other options for non-small cell. And then, the immune therapy drugs, there are a lot of options that are fairly similar for both small cell and for non-small cell. 

In-Depth Testing for Lung Cancer Prognosis and Treatment

In-Depth Testing for Lung Cancer Prognosis and Treatment from Patient Empowerment Network on Vimeo.

How is in-depth lung cancer testing used in determining lung cancer prognosis and treatment? Expert Dr. Heather Wakelee shares insight about biomarker testing, genomic testing, and how test results may impact treatment options.

Dr. Heather Wakelee is a thoracic medical oncologist and deputy director of the Stanford Cancer Institute where she also serves as the division chief of medical oncology. Learn more about Dr. Wakelee, here.

See More From INSIST! Lung Cancer

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Transcript:

Katherine:

Dr. Wakelee, but what is genomic or biomarker testing?

Dr. Wakelee:

So, we are struggling with how to have one unifying way of describing it because it’s so complicated. So, to me, biomarker testing is any aspect of the tumor that helps us choose the best treatment for that patient. And so, it’s a very broad term. And, within biomarker testing, there are several different ways that we look at it.

So, one is to look at what proteins are on the cell’s surface. And, we do that by having stains that we use to stain the tissue. So again, complicated, but when a piece of tissue is taken out of the person, part of the tumor is removed. It’s sliced into little tiny slices, which are then put on glass slides that can be looked at under the microscope. And, that’s how the pathology doctors can look and see, “Ah, this looks like cancer,” or, “It doesn’t look like cancer.” When it does look like cancer, you can then put on stains, so basically, different colored antibodies that will light up if that particular protein is there. And so, that helps us figure out for sure that this started in the lung because there are specific proteins that are only found in lung. So, that’s one way we used it, and this is an older technology. But we also can use that to look for how much of this PD-L1 protein is expressed.

And so, that’s an important biomarker, but it’s not based on genomics, which is when we’re talking about the DNA.

Then, we have the genomic testing, and that’s when we’re looking at the genome of the tumor and how that genome is different. And, that’s that DNA or RNA testing. We talk about it with the next-gen sequencing. So, “sequencing,” any of those terms are all meaning we’re looking at some aspect of what makes the tumor genes and therefore the proteins made by the tumor different than the rest of the genes in the person.

And so, that testing, that genomic testing can be done on either the tumor specimen or that’s where we can do blood tests that will be able to pull out those bits of the DNA that are from the tumor versus from the person and help us figure out what’s going on with the cancer. So, when we talk about biomarkers, the whole picture, and when I’m talking with patients who are diagnosed with lung cancer, we talk about well, there’s chemotherapy treatment, which is good for almost everybody. There is targeted therapy.

Targeted therapy is usually based on those genomic tests, and the genomic tests can be done either on the tissue or on blood. But, they’re really important to have a full understanding of the

tumors to do a comprehensive or next-gen sequencing analysis of the tumor or DNA. And then, you have the immune therapy where that PD-L1 biomarker is important. So, that’s the way I think about it, and the biomarkers are really critical for helping us figure out what’s the best path forward for any individual patient.

When I started treating lung cancer patients 20 years ago, we only had chemotherapy. And now, for metastatic disease, with using the right biomarkers, we can figure out so much more about the cancer to be able to personalize the treatment, for many patients, being able to offer pill therapies that are somewhat less toxic and highly active and give people more time. And now, we’re in the immune therapy revolution, which is helping a whole other group of patients living with lung cancer to be able to live with quality life for much longer. And the pace of discovery is just going up so quickly. And, I think that’s what I’m most hopeful about is just how much attention is being paid on lung cancer and finding better therapies that are going to help more people for a longer period of time. 

Which Tests Do You Need Following a Lung Cancer Diagnosis?

Which Tests Do You Need Following a Lung Cancer Diagnosis? from Patient Empowerment Network on Vimeo.

Which lung cancer tests do patients need after a diagnosis? Expert Dr. Heather Wakelee provides an overview of lung cancer testing, explains how the results are used, and discusses how testing differs for small cell lung cancer versus non-small cell lung cancer.

Dr. Heather Wakelee is a thoracic medical oncologist and deputy director of the Stanford Cancer Institute where she also serves as the division chief of medical oncology. Learn more about Dr. Wakelee, here.

See More From INSIST! Lung Cancer

Related Resources:

Accessing Personalized Treatment for Lung Cancer

In-Depth Testing for Lung Cancer Prognosis and Treatment

In-Depth Testing for Lung Cancer Prognosis and Treatment


Transcript:

Katherine:

Can you provide an overview of important tests following a lung cancer diagnosis?

Dr. Wakelee:

That’s a fabulous question. When we think about the tests that we need to have done, they’re mostly tests that are done on the tumor, so, either if someone has a surgery or at the time of biopsy. and, that’s where we can figure out what we call, again, the histology that’s squamous or non-squamous. That’s when they look at it under the microscope. But, they also, with the tumor specimen, you can pull the DNA out of the tumor and then test for the gene mutations in the tumor. And, I always emphasize these are not changes in the genes that are in the whole person. They are things that are unique to the tumor. They are what make the tumor different from the rest of the person.

So, we look at those gene mutations, or that’s kind of a biomarker. So, there are a lot of terms that we use, and I know it gets really confusing. So, I try to use “biomarker” to mean all of these things, but that gene mutation is what we look at in the tumor tissue to see if there are specific changes that will allow us to give a pill therapy, a targeted pill therapy. And then, there are also aspects of the tumor that help us figure out whether or not the immune therapy might work, and most commonly, that’s something called PD-L1. That’s a protein that we look at on the surface of the tumor, and so again, under the microscope.

Katherine:

And, when you talk about extracting DNA, is that via a blood test?

Dr. Wakelee:

So, we have two different ways to do that. So, what I was talking about before was from the tumor tissue, you can extract the DNA. But now, there are these liquid biopsies where we can draw blood and find the tumor DNA that is different from the rest of the person’s DNA and look for those gene mutations in the tumor.

And that is where there’s a lot of developments happening. And, that’s so fabulous because they’re often faster results for patients, and it means that you cannot have to go through another biopsy. We still need the biopsy to establish whether or not there is even cancer. But, once we know that there’s cancer for sure, then we can use the liquid biopsies to get a faster information result on those gene mutations and to follow over time to see how the tumor evolves because tumors change after they’ve been treated.

Katherine:

Do you use imaging at all?

Dr. Wakelee:

Yes. Always. So, when someone is first diagnosed with cancer, we usually find that because of imaging, so, a CT scan or an X-ray, maybe they had a screening CT scan or maybe they had a cough that led someone to go get an X-ray, an examination. So, the imaging is a part of the original diagnosis. And in addition to CT scans, we’ll often get a PET scan that helps us look for, in a different way, the rest of the body, maybe an MRI of the brain to look in that area.

And then, wherever we’ve found the tumor, we will track that area with scans over time. And, it gets a little complicated for a patient that was found with what we call early-stage disease. So, stage I or II. Many of the times, those patients can have surgery and then we don’t have any tumor we can follow anymore. But we get CT scans to look to see if it could have come back. For patients with more advanced disease, so, stage III that couldn’t have surgery or stage IV, there we have areas that we’re going to continue to follow with the scans. And which scans and how often is going to depend a lot on what treatment the patient’s on and where the tumors are located that we’re tracking.

Katherine:

Do these tests differ for small cell lung cancer and non-small cell lung cancer patients? And, I know that non-small cell lung cancer is also known as NSCLC.

Dr. Wakelee:

Yes. So, long ago, the only distinction we had with lung cancer was that small cell versus non-small cell, and that is something that is seen under the microscope when that tissue is taken out from the biopsy. The pathology doctors look at it under the microscope, and the cells look different. And, the small cell lung cancer, those cells are small. It’s not very creative naming. And then, everything else is non-small cell or NSCLC. So, it’s SCLC and NSCLC. So, that was one of the first distinctions.

And, it is still very important because the chemotherapy drugs that we use are slightly different. And, the genetic, those gene mutations, we see them in any cancer. That’s what makes a cancer different from the rest of the body. But in small cell lung cancer, the tumor mutations that we see are not things that we know how to target specifically. In non-small cell, there are targets that we can target specifically for some patients.

So, just there, it’s different in having the targeted pill drugs in non-small cell, not so much in small cell. With immune therapy, those newer immune therapy IV drugs, they can work in both small cell and non-small cell.

But for small cell, the biomarkers, that PD-L1 level is not as important for helping us figure out who’s going to benefit. For non-small cell, with many of the drugs, it is important. So, there are differences there. 

Accessing Personalized Treatment for Lung Cancer

 

Accessing Personalized Treatment for Lung Cancer from Patient Empowerment Network on Vimeo.

Lung cancer expert Dr. Heather Wakelee defines personalized medicine and explains the factors that are considered when determining a treatment approach.

Dr. Heather Wakelee is a thoracic medical oncologist and deputy director of the Stanford Cancer Institute where she also serves as the division chief of medical oncology. Learn more about Dr. Wakelee, here.

See More From INSIST! Lung Cancer

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Transcript:

Katherine:

We’ve been hearing the term “personalized medicine” a lot more often. How would you define that term?

Dr. Wakelee:

That’s a great question. So, I think back when I first started taking care of patients living with lung cancer 20 years ago, we really just had chemotherapy for those with metastatic disease. And for those with earlier stage disease, it was just surgery radiation. And since that time, we’ve learned a whole lot and brought in a lot of different types of treatment. Surgery and radiation still have important roles for many patients.

And we think about them as being targeted and personalized based on stage, but it’s a little bit different. When we talk about personalized, we’re thinking more about what are aspects about the tumor that allow us to pick the right systemic treatment. So, “systemic” meaning a pill or something that we give IV.

With chemotherapy, we don’t have much to pick between them as far as specifics for the tumor. We can look at what we call the histology, which is how it looks under the microscope, whether it’s the squamous type or the non-squamous type and some of the chemotherapy drugs matter there. But, in the last 15, 20 years, we’ve learned about the specific what we call “gene mutations” that define the tumor.

And, depending on the gene mutation in the tumor, for some patients, we can give them pill therapy drugs that will work well. So, that’s personalized. Or, immune therapy now is an option for a lot of patients. That’s usually IV therapy.

And, there are some aspects of the tumor that can help us pick that also. 

Which Lung Cancer Treatment Is Right for You? What You Need to Know Guide

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How Can You Access Personalized Lung Cancer Treatment?

How do diagnostic tests affect your lung cancer treatment plan. Dr. Tejas Patil discusses appropriate testing for lung cancer, latest targeted therapies and how emerging research is affecting patient outcomes.

See More from INSIST! Lung Cancer

About the Guest:
Dr. Tejas Patil is an academic thoracic oncologist at the University of Colorado Cancer Center focused on targeted therapies and novel biomarkers in lung cancer. Learn more about Dr. Patil, here.


Transcript:

Katherine:

Welcome to Insist! Lung Cancer, a program focused on empowering patients to insist on better care. Today, we’ll discuss the latest advances in lung cancer, including the role of genetic testing and how this may affect treatment options.

I’m Katherine Banwell, your host for today’s program. Joining me is Dr. Tejas Patil. Dr. Patil, would you introduce yourself please?

Dr. Patil:                     

Sure. Thank you for inviting me to speak on this platform. My name is Dr. Tejas Patil. I am an Assistant Professor at the University of Colorado, where I take care of patients diagnosed with thoracic cancers, which include non-small cell lung cancer, small cell lung cancer, and also include mesothelioma and thymic cancers. My main research focus is on molecular alterations in lung cancer and development of targeted therapies.

Katherine:                  

Thank you. Before we start, a reminder that this program is not a substitute for seeking medical advice. Please refer to your own healthcare team.

Dr Patil, before we get into an in-depth discussion on lung cancer, would you tell us about the types of lung cancer?

Dr. Patil:                     

Absolutely. Lung cancer has a bit of a confusing nomenclature. Historically, Lung cancer was divided into small cell lung cancer and non-small cell lung cancer, and this distinction was based on how the lung cancer appeared under a microscope, but it also has practical implications. Small cell lung cancer tends to have a very different biology than non-small cell lung cancer. It originates from neuroendocrine cells and is treated very differently than non-small cell lung cancer.

Non-small cell lung cancer is also a bit of a misleading term because it really is a catch-all term. It represents a wide group of histologies that are not small cell lung cancer. So, basically, anything that isn’t small cell lung cancer will be non-small cell lung cancer, but that group is very heterogenous and includes subtypes like adenocarcinoma, squamous cell carcinoma, adenosquamous, large cell and even sarcoma type variance.

Distinguishing between the two is important because the prognosis and treatment options are actually very different between small cell and non-small cell lung cancer.

Katherine:                  

Well, let’s talk about testing and diagnosis. Following a diagnosis, are there specific tests that patients should ask their doctor for?

Dr.  Patil:                    

Right. After a diagnosis of lung cancer has been made, the most important next step is to establish a cancer stage, and so this is typically done through the TNM staging criteria. The T typically reflects the size of the tumor. The N reflects whether there’s lymph nodes involved with cancer and the M refers to whether there’s a metastasis, and metastasis refers to whether the cancer has spread outside of the lung.

Based on a combination of scores using the TNM criteria, lung cancers are staged from one to four. Now, to establish these different scores, oncologists will typically request varieties of scans. These include CT scans, PET CT scans, MRI and in some cases, very sophisticated ultrasound techniques called endobronchial ultrasound, so that’s the staging component. I think, in addition to the staging component, once a patient has a diagnosis of lung cancer, the tissue itself can be subject to a variety of different molecular tests which we will cover in this talk.

Katherine:                  

Well, let’s get into the tests. How are each of these tests administered?

Dr. Patil:                     

Well, first let’s discuss imaging.

Staging is a very important component of lung cancer, and at minimum, a patient should have a CT scan of the chest and abdomen with extension down to the adrenal glands. The reason for this is that this type of imaging, at least the extent of the imaging, will cover most of the metastatic sites that lung cancer tends to go towards. Additionally, a PET CT scan can be obtained.

Now, a PET scan is a very unique form of imaging. Patients will receive a radio labeled form of glucose and the principle of a PET scan is that since cancers metabolize glucose, which is sugar at a higher rate than normal tissue, the scan in principle helps clinicians identify spots where cancer could be. One important point about imaging and this is something patients should be aware of, is that lung cancers are unique cancers in that there’s a very high risk of spread to the brain.

And so, as part of baseline staging, almost every patient with lung cancer should be getting an MRI of the brain to rule out brain metastases.

Then a final point I’ll make is that patients with Stage 2 or 3 lung cancer really should have their cases reviewed in a multi-disciplinary context where there’s input from surgeons, pulmonologists, medical oncologists, and radiation specialists because the treatment for Stage 2 and 3 lung cancer can be quite complicated. I think, and we’ll talk about the – so, that was the staging part. Now, we can talk a little bit more about the diagnostic testing and molecular testing specifically.                    

There’s been tremendous advances in lung cancer. One of the biggest advances has been the appreciation that there are very specific mutations that actually “drive” cancers that cause them to grow, divide and metastasize.

We call this mutation an oncogene. Over the past two decades, there have been many oncogenes in lung cancer that have been identified. Interestingly several of these oncogenes, such as the ALK mutation, or the EGFR mutation, tend to occur in patients who were never smokers.

So, while smoking is the major environmental risk factor for lung cancer, our understanding of these, through molecular testing has identified a group of patients who were never smokers yet still developed lung cancer. The reason this is important to know is that there’s a variety of targeted therapies available for patients who do have mutations such as ALK or EGFR, and these are typically associated with very favorable outcomes in lung cancer.

Katherine:                  

What are common lung cancer mutations, first of all?

Dr. Patil:                     

There are many mutations that are found in lung cancer. I should mention that the scope of what mutations we find very much depends on the type of molecular test that’s performed. This is a topic that’s beyond the scope of this discussion, but know that when you say you are getting genetic testing, a lot of that depends on the genes that are in the test, meaning if a molecular test is only looking for 10 genes, or 10 mutations, it’s only going to pick up 10 mutations versus more comprehensive molecular testing, which look at hundreds or even thousands of genes, will identify more mutations.

That being said, there are approximately 10 mutations currently for which there are targeted therapies, either that are commercially licensed through the FDA, or are being evaluated in the context of the clinical trial.

And in patients who are heavy smokers, the most common mutation that we see that’s an oncogene is a KRAS mutation, and there’s currently drugs in clinical trials that are looking to target a very specific KRAS mutation. 

Dr. Patil:                     

In never smokers, the mutation spectrum is actually quite a bit more varied, and here, we see mutations such as ALK, EGFR, ROS1, RET, MET, HER2 and BRAF.

I want to make a quick point that there’s another biomarker that we use in lung cancer that’s not technically a mutation, per se, but it’s very important for clinicians to obtain, and that’s called a PD-L1 score. This is a score that helps clinicians decide how effective immunotherapy can be in a certain patient.

Katherine:                  

Are some mutations more common than others?

Dr. Patil:                     

Yes. I mean, there are mutations that are very common. I think to answer that question a little bit more in this cleanly, I would say that there are some mutations that are very common in lung cancer such as TP53, but these are mutations where we can’t actually, we don’t have a targeted approach to manage them. So, when I refer to common mutations, I’m talking about mutations where I either have a drug that is available and able to target the mutation, and this drug is being either investigated in a clinical trial, or is commercially licensed.

In lung cancer, the most common oncogene would be KRAS, and there, there’s a couple of exciting clinical trials where there are some promising drugs in development for treating this specific mutation which has been very challenging to treat in lung cancer.

Katherine:                  

How is genetic testing for lung cancer different from hereditary genetic testing?

Dr. Patil:                     

That’s a great question. We have learned that there are several cancers, such as breast and colorectal cancer, where there’s clear evidence that there are hereditary genes that increase an individual’s risk for developing cancer. I personally prefer the term molecular testing over genetic testing as this emphasizes that we’re looking for specific mutations that are really acquired during a patient’s lifetime and typically not inherited.

Katherine:                  

How do genetic mutations in lung cancer affect treatment options for patients?

Dr. Patil:                     

Well, the finding of a molecular alteration, or an oncogene, is really important for a patient with lung cancer because it offers a unique class of therapy that the patient would not have had otherwise. Finding a mutation is important because it allows patients to have treatment options outside of traditional chemotherapy or immunotherapy.

Katherine:                  

Dr. Patil, how do targeted therapies work?

Dr. Patil:                     

Targeted therapies are interesting. They work by specifically targeting and blocking specific mutations in lung cancer, and so it’s kind of like a lock and key model. By blocking the binding site of a mutation, the treatment actually prevents that cancer cell from properly functioning, and this in turn causes the cancer cell to be unable to divide, unable to grow, and ultimately results in cancer cell death. Targeted therapies typically come in either a form of a pill.

That’s the most common way that patients take targeted therapies.

As an aside, I will note that there’s a very unique class of targeted therapies called antibody-drug conjugates. These are really fascinating molecules. They are treatments that are consistent, but very complex, bioengineered structures, so what you have is an antibody that targets some protein on the surface of a cancer cell, a mutation.

This antibody is linked to a chemotherapy payload, and so it allows for very potent chemotherapy to be delivered effectively and selectively to cancer cells, sort of like a Trojan Horse effect where the antibody finds the cancer cell, goes inside the cancer cell, and once the whole structure is inside the cell, that’s when the chemotherapy is released.

Therefore, it’s a way of giving chemotherapy in a more targeted way, and there are several of these in clinical trials right now.

Katherine:                  

Well, you mentioned patients taking pills. What other treatment regimens are there for the targeted therapies?

Dr. Patil:                     

For targeted therapies, the most common is a pill. The schedule depends on the mutation, so it can sometimes be once a day or twice a day. And then, there are IV treatments that we see, and that is the antibody drug conjugate that I’m referring to where patients will have to go to a infusion center to get those. But to my knowledge, most of those are still in the context of a clinical trial, and so I think it’ll be a while before we start seeing them commercially licensed.

Katherine:                  

How do the newer therapies differ from the more traditional chemotherapy?

Dr. Patil:                     

Chemotherapy is still an important tool in an oncologist’s arsenal.

It works by killing, or rather it works by affecting a cancer cell’s ability to divide and grow. The logic here is that since cancer cells typically grow faster than normal cells, chemotherapy is more likely to kill cancer cells. It should be noted that while that is true, there are certain cells in the human body that grow very quickly as well, such as hair follicles, the lining of the mouth, and cells within the bone marrow. And so, as a result, it’s very common that the side effects of chemotherapy typically affect these cells, so you typically see hair loss. You see mucositis, or inflammation of the mouth, diarrhea, and low blood counts, and this a general side effect of chemotherapy.

Katherine:                  

Are there common side effects for some of the newer therapies as well?

Dr.  Patil:                    

That’s a great question and the way I’m going to answer that is it depends on the mutation that the targeted therapy’s affecting. So, a mutation that I’m going to use as an example is a mutation called EGFR. Now, this is a mutation that we see in lung cancer that causes cancer cells to grow, divide, and metastasize.

But EGFR is interesting because it also is found in normal cells, and specifically it’s found in the cells of the skin and the gut lining. This is an example where you’re giving a very targeted therapy that’s trying to attack just the cancer cell, but because normal skin cells and gut cells have this EGFR receptor, the side effects there tend to be rash and diarrhea. Now, that’s unique to EGFR. There are other drugs such as the ALK mutation or the ROS1 mutation that do not have this side effect because that specific receptor is not found in the human body.

Katherine:                  

Oh, I see. Well, how is the effectiveness of treatment monitored?

Dr. Patil:                     

Typically, I have the philosophy that patients generally know their body and can tell when symptoms are getting better or worse. So, as a guiding principle, I rely on patient input very heavily. That being said, I corroborate that experience with some testing. In my practice, I frequently use what we call serum tumor markers, so these are very nonspecific-like tests that sort of let us know if there’s cancer type proteins in the blood that we can detect while they are on targeted therapy.

And then additionally I would recommend that patients get scans frequently, at the minimum every three months if they are on targeted therapy and doing otherwise well. That includes a CT scan of the chest and abdomen, and in certain cases, an MRI of the brain, if there were brain metastases before.

Katherine:                  

Is it necessary to retest at any time?

Dr. Patil:                     

This is a good question and it’s an evolving question. In general, I strongly advocate that patients who are on targeted therapies obtain additional molecular testing after they’ve progressed, and the reason is the following. Cancer cells evolve resistance mechanisms to overcome targeted therapies and understanding these resistance mechanisms can be quite helpful in designing next lines of treatments.

A very good example of this is in EGFR lung cancer. The very first type of targeted therapy for EGFR positive lung cancer was a drug called Erlotinib. What we had seen was that when patients were on this drug, Erlotinib, they would respond, and they would do really well for a period of time.

But after a period of time, patients would progress on this therapy, and a very common mutation that we would find, once they progressed was a mutation called T790M. By biopsying this patient and finding this mutation, it was very helpful because it allowed the medical community and researchers to investigate a new drug called Osimertinib, which can overcome that resistance mutation.

And we’re learning a lot about resistance pathways and resistance mutations in lung cancer, so I think it’s very important that patients who are on targeted therapies specifically get retested and re-biopsied.

Katherine:

Let’s move on then. Dr. Patil, what are you excited about in lung cancer research right now?

Dr. Patil:                     

I thought ASCO 2020 this year was a very exciting cancer conference, and I’m very excited about where lung cancer research is going. I think there are two areas to be very hopeful about.

First, is that there have been several oncogenes or mutations that we had known about for a very long time, but there was just no targeted therapy available. I think in the next several years, you’re going to start to see more and more targeted therapies available for patients who have otherwise rare mutations.

And examples of this would include KRAS G12C, RET, Met and HER2, so this is very exciting because these were mutations that we had known about for a long time, but just until more recently really haven’t had any successful therapy for.

The other area that’s very exciting is that we’re starting to see the use of targeted therapy and immunotherapy in patients who have earlier stage cancer. So, there was a lot of talk this ASCO about using targeted therapies in patients who have, for example, Stage 3 lung cancer, and is there a benefit in doing that? I think that’s going to be a very interesting development of patients who have Stage 1 to 3, which we typically treat with curative intent, how do we make sure that they improve their outcomes and really stay cured?

Katherine:                  

Right. What would you say to patients who are nervous about participating in a clinical trial?

Dr. Patil:                     

That’s a great question. I really appreciate you asking that. In general, I would highly recommend patients consider clinical trials. I think there’s a couple of things to point out. It’s very important to remember that clinical trials are evaluating novel therapies as compared to current standard best practice. So, placebos are rarely used in cancer research unless there’s no known effective therapy. It’s important to remember, it’s not ethical to have someone take placebo if there’s known treatment that work, so when a patient enrolls in a clinical trial, sometimes they don’t know which treatment they’re getting, but at least they will know that whatever treatment they’re getting is the best current standard of care.

I want to also point out that clinical trials really answer, in my mind, two important questions. The first question is, is the new treatment safe? And does the new treatment work better than current standard of care? These are really important questions for advancing the field, especially in cancer research. Clinical trials are a small part of the research. I mean, when a drug that’s getting introduced into a clinical trial, it’s sometimes helpful to think about all the investment that has gone in before them. The drug has to be discovered, created.

It has to be purified, tested in animal studies, before it ever reaches human studies. And so, there’s only the most promising agents are actually ever introduced at clinical trials, and there’s a lot of data to show that the biggest barrier for completing clinical trials, and therefore understanding which treatments are effective, is really participant enrollment.

I think there was a recent study that showed that about, I think less than five percent of patients, less than 1 in 20, with cancer will ever take part in a clinical trial, Therefore, if a patient has that opportunity, I would strongly encourage them to consider it.  

Katherine:                  

Do you think a second opinion is necessary? Would you encourage patients to consult with another specialist?

Dr. Patil:                     

In general, I’m a big advocate that patients should get all the information they need to make informed treatment decisions, and if that involves getting second opinions, I welcome that.

 I think that a knowledgeable patient is an empowered patient, and certainly a knowledgeable patient is one that I think will be able to guide themselves through a very complex medical journey. So, in general my philosophy is I’m always encouraging of second opinions if the patient feels that they need more information to make a best decision.    

Katherine:                  

What advice do you have for patients who may be hesitant to speak up and advocate for themselves when it comes to their care and treatment?

Dr. Patil:                     

Great question. In general, I’m a big believer that an empowered patient is a patient that can make really good medical decisions as they navigate their own medical journey. Ultimately, it’s important for patients to be knowledgeable and seek multiple opinions. Really get the best advice, so that they make the best decisions. Oncology is a very complicated field. The treatment options can be very nuanced.

Therefore, it’s important to know that when a decision is presented to a patient, that it is a decision that is made with the knowledge of what is the best standard of care. But if the patient doesn’t feel like they have the most informed data to guide their own medical decision making, then it’s really important for them to advocate for themselves.

To that point, especially for some of these rarer mutations, there are many social media patient advocacy groups that are very, very, very well organized, very effective, and have a list of really useful questions. Some examples of that are the ALK Positives and the EGFR Resisters.

Katherine:                  

Okay. I would be remiss if we didn’t discuss COVID-19 to some extent. What should lung cancer patients be considering at this time?

Dr. Patil:                     

This is also a very important and timely question. lung cancer patients are certainly at very high risk of complications from COVID-19. And it’s understandable, especially given the kinds of treatments that patients with lung cancer receive, that there’s a lot of them will wind up having compromised immunity which makes them at increased risk for adverse outcomes from COVID-19. That being said, I think it’s really important that this be balanced with the actual risk of untreated or inadequately treated lung cancer, which is also a major medical concern. What I tell patients is that, at least at our institution, we do everything we can to create an environment that is as safe as possible from a COVID mitigation standpoint.

But at the end of the day, untreated lung cancer can have a very aggressive course, and so making sure that patients understand that as we try to move things to a more telemedicine type approach, that there are some things where you really just have to come and see your doctor. Not everything can be done virtually.

Katherine:                  

Right, and my next question was is telemedicine the best approach right now?

Dr. Patil:                     

Well, that’s also, I’m going to answer that in a somewhat frustrating way, which is that there’s – yes and no. I think telemedicine is helpful for patients who have very stable disease and are on anti-cancer treatment, so specifically a patient on targeted therapy, for example.

A pill once a day. Their last scans show that they’re doing really well. They feel well. They’re exercising every day. That patient, probably we can do a visit virtually and just make sure and check in that there’s nothing new or concerning that’s come up.

The other patient that probably I can see a role for telemedicine is someone who had, let’s say, a Stage 1 lung cancer that was treated with surgery, and we’re just monitoring them on surveillance. That patient probably doesn’t have to come into the clinic to see us. But in general, the thing about lung cancer is that most patients are getting some kind of chemotherapy or immunotherapy and will be coming into an infusion center, and so what I would tell patients is if there’s any new or concerning symptoms, to a very low threshold for seeking an in-person evaluation.

Katherine:                  

As a researcher in this field, Dr. Patil, what do you want to leave the audience with? Are you hopeful?

Dr. Patil:                     

I’m very hopeful. I think, it’s kind of amazing when I look at the history of lung cancer and where the field was in the 2000s, now that we’re in 2020, and what remarkable advances have been made in 20 years. It’s worth reminding patients that in 2000, there was, platinum chemotherapy was the first line for metastatic lung cancer, and then there was a second line chemotherapy and that was basically it. Now we’re in an era where we have extensive molecular testing of lung cancer. We’re identifying new mutations that can be targeted with very sophisticated pill-based therapies. We have immunotherapy. We’re learning about how these combine with each other to produce the most optimal outcomes, so I think in 20 years a lot has been achieved, and I’m really excited to see where we go from here.

Katherine:                  

Dr. Patil, thank you so much for joining us today.

Dr. Patil:                     

Thank you. Thank you for inviting me. This was wonderful.

Katherine:

And thank you to all of our partners.

To learn more about lung cancer, and to access tools to help you become a more proactive patient, visit www.powerfulpatients.org. I’m Katherine Banwell.  

Lung Cancer Advocate Shares How to Optimize Your Telemedicine Visit

Lung Cancer Advocate Shares How to Optimize Your Telemedicine Visit from Patient Empowerment Network on Vimeo.

How can lung cancer patients optimize their telemedicine visits? Watch as lung cancer patient Jill shares her top tips for how to prepare for virtual visits and how to advocate for yourself when communicating for optimal care.

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Transcript:

Jill:

One thing that someone else recently mentioned to me is to be patient with the doctor who might be late, and I don’t mind actually, the doctor’s late or early. I’ve had a doctor be up to half an hour early or up to an hour late, and that doesn’t bother me, I just go on living life and doing other things while I wait for the call, but I do book a bigger chunk of time on my calendar with the expectation that doctors are really busy people and they can’t always predict how long something else will go or what would come up, so it’s good to be understanding about it for sure. 

It’s also helpful for me and a lot of people to write a list of questions, symptoms, and make sure that you get them all answered, so write them down and actually check them off, or cross them off while you’re in the appointment, because you don’t wanna walk away from there thinking, oh shoot, there was that one big question I had and some doctors are okay with getting an email or something between appointments, and some nurses are great to call, but not everyone has that opportunity. 

So, I would say, make the most of your appointment just like you would in-person. Take good care to make sure that you’re advocating for yourself, and if the doctor says words after you ask your cost your question, you don’t feel like you understood them. Don’t be embarrassed or afraid or anything… just ask again, ask for clarification. Sometimes these doctors talk in big words, and my doctor has been great, my oncologist he would like draw pictures and I ask him often to write words down for me if I don’t know how to spell them because why would I know how to spell that? I don’t have a medical and oncology degree, so there’s no shame in asking questions, asking questions is smart, and it helps make us better informed, and it’s true that a better informed and a better-informed patient is a more empowered patient, and we tend to have better outcomes, when we know what’s going on in our treatment, so take the time to ask your questions.

_____________________________________________________________________________

Lung Cancer Patient Shares Why Telemedicine Should Be a Long-Term Tool

Lung Cancer Patient Shares Why Telemedicine Should Be a Long-Term Tool from Patient Empowerment Network on Vimeo.

Can lung cancer patients look to telemedicine as a long-term tool in their care? Watch as lung cancer patient Jill explains how telehealth has been a benefit for her care and how it can serve as a benefit for other patients.

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Transcript:

Jill:

In the future, I hope that telemedicine plays a really significant role in my care and in the care of others as well, so I would really like to not have to travel to my cancer clinic for every single appointment. For some of them, I definitely want to go. There are times when we want to look our doctor or nurse in the eye and really have strong, stronger communication, but for the most part, I would rather not have to travel and I live really close to my cancer center, so I always think about people who live farther away, and there are so many people who travel hours, there are people who travel days to get to their appointments, there are people who have to leave their communities and be, away for an extended period of time, and that’s not something that I would want to do, especially when we’re in a going counter treatment, we can feel so alone and fragile, and I would rather that people had more support and other people with them could stay at home, could stay in their communities and just have a call and their people could be with them if they wanted it during the call, they can all gather around and listen to.

And I think it matters so much. It’s not just convenience, it’s better care for people to have their loved ones near them, that’s one thing we’ve learned during COVID, even more so that it’s not good to be alone. It’s good to have our loved ones near us supporting us, and so as much as possible, if we can keep telemedicine as an option to use for the times when it doesn’t really matter if we’re in person or not, let’s make that choice, let’s make second opinions available let’s work out whatever permissions need to be in place for people to get care across regional lines or state lines, let’s get those things in place so that we can provide the best care possible, and let’s always be thinking about our most vulnerable people, and those are usually the people in the rural and remote regions, the people with a really hard cancer diagnosis, the people who are feeling alone and vulnerable, let’s take it, care of them.

Lung Cancer Advocate Shares Importance of Staying Hopeful During Pandemic

Lung Cancer Advocate Shares Importance of Staying Hopeful During Pandemic from Patient Empowerment Network on Vimeo.

How can lung cancer patients stay hopeful during a pandemic? Watch as lung cancer patient Jill shares her advice on coping methods that have been helpful for her during the COVID-19 pandemic.

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Transcript:

Jill:

These are really hard times, and we need to recognize that we’re not alone, that we’re not the only ones, we’re not the only one going through the hard time, and it’s so important to reach out to others, to reach out to someone, to ask for help, and we hear some really, really sad stories of things like people being turned away from the ER or we can have a lot of fear about what might happen. And I think it’s really important to not let those fears rule our lives, that can be really challenging to do, it’s very easy to say, but it takes a lot of skills to live without letting fear take hold at times. So, reach out for help. Talk to people, ask them, how do they cope? What do they do? For me, I talked to friends and my friends help remind me of what’s real and what’s true, my friends helped me hold on to hope. I’m a person of faith, so I believe in Jesus, and I read the Bible and I pray, and that really helps me too.

But each person finds their own ways to hold on to hope and let go of fear, and fear is, fear is not our friend. Good things don’t come from fear. So the other thing is we need to be advocates for ourselves, sometimes we need to ask for what we want, and if we believe in something, we need to fight for it, we can’t just sit back and expect things to be dropped in our lap, so they’re gonna be tons, when we’re going to have to really, really work hard, and that could hurt and in my life is an advocate, I find there’s a lot of pain and a lot of hard work, but there’s also a lot of real joy, and I get to meet some of the most amazing new people, and those are people who helped me have hope, so grab a hold of the people who help you have hope and don’t let go, call them up and reach out to them, lean on them.

Understanding Telemedicine Pros and Cons for Lung Cancer Patients

Understanding Telemedicine Pros and Cons for Lung Cancer Patients from Patient Empowerment Network on Vimeo.

What can lung cancer patients expect for telemedicine opportunities and challenges? Watch as lung cancer patient Jill shares some situations telemedicine has served well and some patients who have run into care disparities.

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Transcript:

Jill:

Telemedicine offers some opportunities as well as challenges, so I’ll speak to some of the challenges at first, which are…we don’t in-person, tend to build relationships as quickly. In general, I find when we’re just talking over the phone, when we’re in-person, we can get to know each other more comfortably, for the most part, everyone is unique, so you could be different, but for me, the relationship-building aspect is something that I’ve missed out on to some degree. 

And the doctor may miss some visual cues, so for example, there might be something that he or she would pick up on, would notice some sort of symptom or side effect that we had perhaps not noticed, we’re not, thought important enough to raise. So those are challenges. How do we get past not being able to see each other, so also, what if the doctor is delivering some tough news that could be harder to do if we’re not in-person, if we’re not able to see those visual, non-verbal cues, that can help us understand how to help the doctor understand how the patient is processing, receiving the news. Another thing is that sometimes patients, and I’m not going to say that I do this, but I’ve heard quite a few patients say that they might try to hide some of their side effects because they’re concerned that they’ll get a reduced dose and they’re concerned that it won’t be as effective. 

Now, from what I’ve heard, you know I understand that’s not a really wise choice to make, but everyone makes their own choices, and so if the patient is trying to hide the side effects from their doctor and their nurse, it might be more helpful for that patient to actually be present with their healthcare team, so the healthcare providers can actually notice and pick up on things. 

The opportunities are really powerful though, because it frees up so much more time for the system and generally, we often, I’ve had an awful lot of appointments, I know my oncologist quite well because I’ve had the same one since 2013, and we don’t need to talk for a long time, so usually 10 minutes is good and it saves the travel time in. Also, it opens up possibilities for remote consults with potentially anyone anywhere in the world, which is so terrific as an opportunity for a second opinion perhaps, or for someone who doesn’t have a doctor in their community, it makes it so much easier for them to gain access to care that they need.

And we really need to focus on the disparities that occur, especially people in rural and remote regions can miss out on some of the best healthcare. And if this is a great opportunity for us to serve them better.

Lung Cancer Patient Shares Why Telemedicine Is an Important Tool

Lung Cancer Patient Shares Why Telemedicine Is an Important Tool from Patient Empowerment Network on Vimeo.

How can telemedicine serve as a vital tool in lung cancer care? Watch as stage IV lung cancer patient Jill shares how telehealth has helped her during the COVID-19 pandemic and how she views it in the future of her care.

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Transcript:

Jill:

I was diagnosed with stage IV lung cancer back in 2013, and prior to the COVID pandemic, I had never had a telemedicine appointment, but now that I’ve had quite a few.

I think they’re such an important tool in lung cancer care, especially during a pandemic, when they protect us from exposure to various potential infections, not just COVID, but it can protect us from illness, so that’s terrific. But also, they’re really convenient, I just have a quick 10-minute appointment, there is no waiting in the waiting room, there’s no traveling to the clinic, which is…I’ll be honest, that’s not a very big inconvenience for me because I live quite close to my cancer center, but especially for people in rural and remote regions, what a game changer it can be to just be able to talk on the phone or perhaps have a video chat with a health care provider. So, I think that telemedicine is a very important tool in lung cancer care, and I hope that it will continue, maybe not 100 percent of the time, but there will still be available to him after the pandemic is over.