Maggie McKay (Host): When you or someone you know gets a diagnosis of lung cancer, all kinds of questions rush through your mind. So today, Dr. Kamran Darabi, Internal Medicine, Hematology-Oncology, will discuss what you need to know from screenings to treatments and everything in between.

Welcome to BayCare HealthChat. I'm your host, Maggie McKay. Dr. Darabi, thank you so much for being here. Let's start with screening for lung cancer. What does that involve?

Dr. Kamran Darabi: Hi, and thank you for having me. This is an important topic. The U.S. Preventive Services Task Force recommends screening all adults aged 50 to 80 years who have smoked at least 20-pack years and currently smoke or have quit within the last 15 years with low-dose CT scans. Basically, that's something that can be ordered by anybody's primary care provider and entails going to a CT scan center and getting some images of your lungs taken.

Host: What is a liquid biopsy, and how does that work?

Dr. Kamran Darabi: So, this is something that's been really in the news quite a lot recently. We have the ability now to detect certain mutations that cancer cells shed into the bloodstream by means of getting a blood sample from patients and looking for those specific mutations that we know about and for some, we have drugs for. So, that's an important test, especially in lung cancer. And it really came to the mainstream of oncology treatment in lung cancer first. So, it's actually recommended by the current guidelines for all patients with stage IV non-small cell lung cancer at this time and covered by insurance.

Host: So, it sounds like there are several options for chemotherapy. Let's start with neoadjuvant chemotherapy, if I am saying that correctly.

Dr. Kamran Darabi: Yes, that's actually an important subject that has been studied recently with novel treatments including immunotherapy in addition to chemotherapy. So for years people did studies with chemotherapy before someone had their lung cancer removed surgically, and that means receiving neoadjuvant chemotherapy, and neoadjuvant as in before surgery and adjuvant meaning after surgery.

The studies with chemotherapy alone were not as convincing. So, this practice didn't really become widely adopted to give neoadjuvant chemotherapy before someone went for their surgical resection. If they had an earlier stage lung cancer, that could be surgically removed. But recent studies have shown that if you actually give the chemotherapy with immunotherapy, you have a higher response rate and you have some patients, up to about 20% of people may have complete responses where the tumor actually completely disappears with neoadjuvant chemotherapy.

Host: And so then, they don't have a need for adjuvant after?

Dr. Kamran Darabi: Correct. So, the advantage of the neoadjuvant chemotherapy over doing the chemotherapy after surgery or in the adjuvant setting is that if you identify a patient who had a complete response from neoadjuvant chemotherapy, that means the surgeon did their resection and they couldn't find any viable cancer left behind, then you know that patient may need less treatment after surgery.

Host: Wow, that's amazing. What about palliative chemotherapy?

Dr. Kamran Darabi: That's for patients who are diagnosed with stage IV lung cancer, which by definition is considered incurable Now, that's been a moving target now in the last 10 years or so with the advent of immunotherapy. There are 10-20% of patients with stage IV non-small cell lung cancer, which were deemed to have incurable disease in the past, that now become long-term survivors thanks to immunotherapy.

So, the immunotherapy switches their immune system on to fight the cancer, no matter how widespread it is in their body, and they can take control of this cancer. So, 10-20% of people can become long-term responders, and some of those patients may ultimately be cured just with immunotherapy.

The mainstay of palliative treatment though still is chemotherapy, usually given together with immunotherapy. About 80% of patients with stage IV non-small cell lung cancer will have some sort of response initially. Unfortunately, the majority lose that response. About 20% don't respond to the initial chemo-immunotherapy. And for those patients, we usually transition pretty quickly to just other supportive and palliative treatments, which include anything from pain control to management of other symptoms depending on what the cancer is causing. Be it a fluid accumulation in the lung, which it can drain by means of a procedure called thoracentesis, or radiation to certain areas that may be causing pain if the tumor is growing, for example, in the chest and pushing on your heart, or if the tumor is growing in a certain bone and it's causing too much pain.

Host: And what is targeted chemotherapy?

Dr. Kamran Darabi: So, that's an important subject for a subset of patients. Some patients have certain mutations that specifically drive their lung cancer. So, there could be just one mutation that keeps this cancer going. Basically, that's called a driver mutation. And we do have specific drugs that target these genetic aberrations in the cancers. And you usually take those chemotherapy medications by mouth. Most of them come in pill form, and you can get a pretty dramatic response in patients that have a certain mutation that's specifically designed to work with the corresponding drug. Now, that happens only in like 10-20% of patients again. So, the majority get chemotherapy and immunotherapy, so old-fashioned chemotherapy given intravenously, usually with immunotherapy. But the 10-20% of stage IV non-small cell lung cancers that have a specific driver mutation can be treated with targeted treatments that are usually oral or pill chemotherapy.

Host: And Dr. Darabi, is lung cancer hereditary and what are some things we can do to prevent it besides not smoking?

Dr. Kamran Darabi: We currently don't routinely recommend genetic testing in patients who get diagnosed with lung cancer because we haven't really found a connection between hereditary cancer syndromes that are common and lung cancer. However, lung cancer does run in some families so there may be some connection that has to be yet identified. But in the majority of patients, we think lung cancer happens sporadically, which means they acquire a mutation, so by smoking or some other noxious substance, let's say radon, or exposure to potential risk factors that we don't really understand yet.

Host: Do you see people who live in big cities with more lung cancer than those who live rurally?

Dr. Kamran Darabi: Lung cancer obviously correlates with the percentage of people smoking in a community. So in parts of the South where smoking is more prevalent, I think you have a higher lung cancer rate than in other places like let's say California or New England where people may smoke less nowadays.

Host: Yeah. So, it's not necessarily environmental.

Dr. Kamran Darabi: So, there is data that has connected a higher incidence of lung cancer in certain areas of the country where there's a high concentration of radon gas in buildings, specifically basements. So, that's something else that's still being studied. And obviously, that's something that the government recommends to mitigate. So if you test for radon in your basement, and this is a problem, especially in the Midwest and parts of the Northeast. So in parts of the Midwest and the Northeast, you can test your basement for radon. And if it's above the EPA cutoff, you can, and it is recommended to, mitigate that, which means basically you try to vent out the radon through a connection from your sump pump outside your building.

Host: Are there any other things we can do to try and prevent getting lung cancer besides not smoking?

Dr. Kamran Darabi: You know, obviously, if you're in that small group of people where cancer may run in the family, and that's certainly less than 10% of all lung cancers, you do want to watch for symptoms of lung cancer because obviously you don't qualify for the lung cancer screening that we just discussed, because that's just something that can be offered to folks with the history of smoking, as I mentioned. But symptoms of lung cancer are cough, cough that won't go away, abnormalities on chest X-ray that are detected when you go in for other reasons and get evaluated by a health care provider.

The other symptoms are kind of happening at later stages. So, pain, unfortunately, or shortness of breath usually don't happen until the cancer is more advanced. And that's one of the big problems with lung cancer. And that's why most patients are still diagnosed with stage IV lung cancer, unless we make more headway in getting people screened more with CT scans who are at high risk. But unfortunately, most patients get diagnosed with stage IV lung cancer because of lack of good screening for people who don't smoke. So unfortunately, in general, there's no good screening for lung cancer, besides low-dose CT scanning, which is currently only approved for high-risk individuals, who have an extensive smoking history.

Host: Well, thank you so much for being here today and sharing your expertise. We certainly appreciate it.

Dr. Kamran Darabi: You're welcome. Thank you.

Maggie McKay (Host): Absolutely. Again, that's Dr. Kamran Darabi. To find out more, please visit BayCare.org. And that wraps up this episode of BayCare HealthChat. Head on over to our website at BayCare.org for more information and to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other BayCare podcasts. For more health tips and updates, follow us on your social channels. And if you found this podcast informative, please share it on your social media and be sure to check out all the other interesting podcasts in our library. I'm Maggie McKay, thanks for listening to BayCare HealthChat.