It’s interesting to see how cancer treatments evolve over time, like putting pieces of a puzzle together to see how they fit—the hopeful beneficiaries being the patients with the illness, who frequently over time have better options resulting in better outlooks after treatment for their cancers.
Lung cancer, fortunately, has not been an exception over the past couple of years. Advances in screening and early detection and better treatments for localized and advanced disease have made a real difference, resulting in rapidly declining death rates and longer survival for many folks who in the past almost uniformly would have been diagnosed with late-stage disease and sadly very short survival after diagnosis. Treatments just weren’t that effective.
Now we have a sea-change in the diagnosis and treatment of lung cancer, if only we could apply the benefit of that research to more people:
- Screening for early detection has improved over the past decade;
- Targeted therapies have emerged where specific abnormalities in the cancer genes lead to medications that have resulted (for some folks who have those mutations in their cancers) in dramatic improvements in the course of their disease, sometimes lasting several years;
- Immunotherapy has made a huge difference in outcomes for people with late-stage disease when combined with chemotherapy;
- Newer preventive treatments used after primary therapies for localized lung cancer have meant long term survival for people with specific genetic markers in their cancers.
The list goes on—and with it the fact that so many more people are living longer, more fulfilling lives after a diagnosis of lung cancer than was the case just a few years ago. Of course, it is not enough: not everyone benefits from these advances, however many do, and I have no doubt many more would benefit, especially if we did a better job of getting the benefits of those new screening tests and treatments to more people.
However, there is an even more tantalizing possibility: what if we could diagnose, treat and monitor patients with localized lung cancer without even using surgery and radiation therapy as primary treatment? Now, that would be amazing. And yet as I gaze into my crystal ball, I really do think that may just be a possibility sometime in the future. And that may not be so far away.
This possibility isn’t just for lung cancer: as new research produces new opportunities, I suspect for other”solid” cancers where new approaches are proving successful in reducing the disease burden before traditional primary treatment (such as surgery) there may be the opportunity to move to a much different world when it comes to how we treat and perhaps even cure those who are diagnosed with certain cancers—without resorting to surgery and/or radiation treatment at all.
Not everyone will benefit from this brave new world, at least not in the foreseeable future. But some things are coming together that may just make it possible to reconsider some long-ingrained approaches that we use for cancer treatment and turn them on their head, much as was done in the past with radical, disfiguring surgery for breast cancer– which now is fortunately very much a thing of the past for almost all women.
What would it take to get to this brave new world of lung cancer treatment? Let me share my thinking (and for you clinicians out there please understand these are “blue sky” thoughts for the future, not today) since Parts of the picture are already in place:
If we could get more people screened for lung cancer we would find more of these tumors earlier when they are more treatable. Although there has been considerable debate about the value of such screening, newer approaches have improved the value of lung cancer screening making it more accurate with less risk of the screening itself causing a serious problem or major inconvenience (such as with false positive results when a cancer is not present).
We know if we find lung cancers at an earlier stage, the long-term outlook is much better than if we wait until the cancer spreads outside the chest. We know that surgery and radiation can treat these cancers. We also know that for certain folks who have a specific mutation that using a newer drug after primary treatment with surgery or radiation can make a huge difference in outcome over the longer term. And, I suspect other so-called targeted therapies could be effective in those with different genetic mutations. Time will tell us whether that in fact is possible.
But here is the newest addition to the treatment options: using chemotherapy and immunotherapy before surgery/radiation—a treatment approach that has recently been approved by the Food and Drug Administration. That has been proven successful in reducing the tumor burden in lung cancer patients when used as neoadjuvant therapy—meaning medical treatment prior to any surgery or radiation is done. In about 1 out of 4 cases the tumors disappeared completely, and for others the tumors shrank significantly.
So as one thinks about how this could work, there is still another question: how can you be sure all the tumor is gone? And how can you continue to be sure over time? That’s the other piece of the puzzle that remains to be worked out.
We are clearly moving forward with another revolution in our abilities to detect cancer, namely the use of circulating bits of a cancer’s genetic material, or DNA. We are seeing the advent of blood-based tests which are going to be used to find cancers earlier in their course than is possible today for most folks.
Meanwhile, those same tests are being evaluated to follow patients after their primary treatment in the hope that measurement of the circulating tumor DNA will give an early signal that a cancer is recurring. So far much of this is research based, but the advances over the past decade which are continuing with considerable speed will undoubtedly reward our curiosity and ability to find even smaller and smaller amounts of circulating cancer-specific genetic material in our bodies.
So, imagine this:
- A person at risk is found through screening to have a primary lung cancer which after evaluation is confined to the lung.
- They have a needle biopsy to get a piece of the tumor which is then sent for analysis. That analysis finds they have no genetic marker for a specific treatable mutation.
- They can then receive a regimen of chemotherapy and immunotherapy (recently approved by the Food and Drug Administration) before they have their surgery and possibly radiation. Studies show that for about 1 out of 4 patients the tumor disappears completely pre-operatively.
- Surgery is postponed, and potentially the patient continues on additional medical treatment for a period of time.
- At the same time, blood tests are drawn before and during the period of medical treatment and afterwards. The blood tests show no evidence of recurrence, and no further treatment is needed.
- Or, the blood tests pick up an early change, resulting in a re-evaluation of the treatment approach, perhaps this time including surgery and radiation.
That is the possibility of where we are headed in lung cancer treatment, and perhaps in other cancers as well. We are still a very long way from this happening but thinking about the future is tantalizing: curative cancer treatment without the use of surgery and radiation. Yes, it may well be possible for solid tumors such as lung cancer, just as it has been for some leukemias and lymphomas.
In the past, we held that vision out as a pipedream. The recent research showing that lung cancers can disappear completely in some patients who are pretreated before surgery certainly makes that pipedream seem a lot closer to reality.
Thinking about the future is always interesting, however we then must come back down to earth and deal with the reality of where we are today, which is nowhere near the scenario laid out above. We still could do much, much better making sure everyone gets access to the best available care for those with lung cancer. Sadly, we are not there. And although it may not be fancy to talk about doing what we already know, if we did that it would substantially improve the outlook for many patients.
Lung cancer was once such a terrible disease: filled with stigma because of the tobacco connection, finding the diagnosis so late in the course for so many folks, having little to offer in the way of effective treatments to extend both the length and quality of patients’ lives.
Today we can celebrate our progress, but we should not celebrate too much until everyone at risk has the best opportunity to get their lung cancer discovered early, and access to the best and most appropriate treatment for their illness if it is diagnosed. And maybe—just maybe—we will see the day when lung cancer becomes not the deadliest cancer, but the most effectively treated cancer with early diagnosis and revolutionary approaches to treatment.
Promise: stranger things have happened in the annals of cancer care. There is a good chance we will see this one happen too.