Newly Diagnosed Lung Cancer: Key Tests, Questions, and Language Access

Deandre White:

So, Dr. Florez, many newly diagnosed patients with lung cancer aren’t really sure what tests are needed for them at the beginning of their care. So, for both patients who have non-small cell or small cell lung cancer, what should they be asking to ensure that they receive the appropriate tests to fully stage their cancer? And which biomarkers or molecular tests are essential to guide the most effective therapy from day one?

Dr. Narjust Florez:

I think what is very important here is to answer this in two parts, right? So we talk about stage. That’s a word. What stage is my cancer will determine what the treatment options are. So it’s very important that patients have imaging of the brain. These can be an MRI or CT scan in case that patients cannot tolerate the MRI for many reasons, and that the body, at least from the neck up to the knees, is scanned to determine if the cancer has traveled anywhere. Ideally, it will be a type of imaging called PET scan, in which there’s a contrast that has a radio-labeled sugar that kind of works as a radar. Stage is very important, because that will lead to treatment.

So, patients need to know what stage is my cancer is a question that we often don’t get asked. Patients should ask, so you understand in what group of patients you are and the prognosis.The second question related here is biomarkers. And we’re talking about small cell (SCLC) and non-small cell (NSCLC). So for staging, it applies to both. Non-small cell is the one that has biomarkers for which we have targeted therapy. And what is targeted therapy? So, targeted therapy are mutations that cause the lung cancer. Currently, for non-squamous, non-small cell lung cancer, 54 percent of patients will have a targetable mutation. So, a proper biomarker testing allows to find out the mutation that caused the cancer so the patient can get the tailored treatment. 

I use the analogy of the key and the lock. The key is biomarker testing, and the lock is the lung cancer. So we need to find the appropriate key for that lock.

And why is this so important? Biomarker testing is important, because if you have an ALK rearrangement, the survival right now with one drug after 5 years, over 60 percent of patients are still alive, 5 years with metastatic disease. If that mutation is not found, and the patient is treated with a standard chemotherapy, the survival is 12 months. We’re talking about years’ difference in how long patients can survive. 

So here, the [ACT]IVATION part that I love about this is imaging head to toe to know where the cancer is and biomarker to find out what treatment choice is the best choice for me.

Deandre White:

Thank you, Dr. Florez. So before starting any treatment for lung cancer, no matter the stage, patients often don’t know what key information they should fully understand first. So, what should every patient with lung cancer know or ask about before beginning treatment?

Dr. Narjust Florez:

I think it’s very important that patients understand all the side effects. As oncologists, sometimes we talk about the bad side effects, like the severe side effects. But the severe side effects are actually the rare ones. Myocarditis, which is inflammation of the heart. Pneumonitis, inflammation of the lung. Patients need to ask, my recommendation would be: How is my everyday life going to be affected by treatment? Let’s walk through a day. Let’s walk through the day after chemo.

Day 7 for traditional chemotherapy, day 7 to 10, are the worst days. The red cells are low, the white cells are low, the platelets are low, patients feel very tired. So, I like to walk my patients through: you wake up, you don’t want to get out of bed. Food tastes very funny. You are nauseous. You may be constipated, or you may have diarrhea. So, how is my every day going to be affected by the treatment side effects, I think it’s the right way to ask. Because otherwise, we may just focus on very rare side effects that the patient may never get. And these common side effects may affect it more often, and affect a part of your life more highly than any other rare side effects.

Deandre White:

And also with understanding treatment, for many patients, especially in Latinx and immigrant communities, language barriers make this even harder. So for patients who prefer a language other than English, what should they request to ensure they fully understand their diagnosis, their test results, and their treatment options? And are there trusted foundations or resources available in Spanish that you can recommend?

Dr. Narjust Florez:

So, this is a tip for everybody. Patients, providers, and everybody. That you took Spanish in high school is not enough to discuss a chemotherapy regimen or a lung cancer diagnosis. It is not enough. And it’s in part unethical to talk to a patient in a language they don’t understand. Right? So… [speaks in Spanish]…that’s exactly how a patient feels when a provider with broken Spanish or other language is trying to explain very high-level information. You are lost. 

So, there are currently free apps that provide live translators, interpreters on your smartphone for doctors, and for patients too. You can use, it’s called Jeenie, it was developed by doctors and it has free translators, because the cancer centers, you should have interpreters, translators, but if you don’t, there are other ways around. So you have this app called Jeenie. We also have Google Translate that can live translate if you need it. But it’s the right thing to ask for the language that you feel comfortable. And we need to eliminate the myth in all immigrant communities, that if you ask to be treated in your native language, you’re going to get suboptimal treatment. And that is a myth in the community. So, a lot of patients, they say, no, English is fine.

And when you see a patient that’s only smiling to you and it’s only saying, yes, you know they’re not getting it. So, it’s important to stop and use it. I speak Portuguese, but my Portuguese is Portuguese for the streets. It’s not a medical Portuguese where I can explain chemotherapy, so I have a Portuguese interpreter. And the interpreter’s like, why do you need me? I need you, because there are things I don’t know how to speak in the language. And it’s unfair that my patient gets half-explanation because of my language limitations.