Transcription:
Lung Cancer Treatment

Maggie McKay (Host): Welcome to the Live Greater Podcast series, information for a healthier you from the University of Maryland Medical System. When diagnosed with lung cancer, a lot of questions come to mind, like what caused it? What are my options? What type do I have? And more in this episode, Dr. Eric Krause, thoracic surgeon at university of Maryland Capital Region Health and Dr. Heather Lee radiation oncologist at University of Maryland Capital Region Health. We'll discuss lung cancer, treatment options, survival rates symptoms, and more. Thank you for joining us today. It's a pleasure to have you both here.

Dr Heather Lee: Hello. It's a pleasure to be here.

Maggie McKay (Host): Dr. Krause. If you could start off by telling us how lung cancer develops?

Dr Eric Krause: Well, the most common way that someone develops lung cancer is having a history of smoking cigarettes. And over time, the inflammation in your lungs from smoking cigarettes causes your cells and the DNA within your cells to have mutations within them. Those mutations lead to eventually causing the cells to divide and multiply in an unregulated way. And that essentially is the essence of cancer. And over time, the cancer grows and it starts spreading throughout your body. And that's eventually what leads to people having symptoms or even dying from cancer.

Maggie McKay (Host): And Dr. Lee, what are the most common symptoms of lung cancer?

Dr Heather Lee: So one of the most common symptoms is a persistent cough. one that lasts for several weeks. it can be dry or it could be wet or mild or severe, It can be continuous or come and go. But if something is getting worse and not going away, you should see your doctor. a lot of smokers may have a smoker's cough, so that might be part of their normal, but, if there's a change in your normal cough, that may be an important sign. Another possible symptom could be coughing up blood that's not as common, known as Hemoptysis.

So if you ever see any blood streaks, we're just a little pink tinge in your cough then that's something that you should definitely go see a doctor about. Some more rare symptoms, could be shoulder or chest pain, but that's usually associated with, more advanced cancer, weight loss, shortness of breath or wheezing. Those are something that if you're starting to get symptoms that are getting worse or new, just see your doctor about.

Dr Eric Krause: Unfortunately the most common symptom is actually no symptoms, maybe some weight loss and that might just be it or might not even be that. Unfortunately, a lot of patients, it comes as a real surprise to them cuz they didn't have anything that they knew about.

Maggie McKay (Host): And Dr. Krause, are there certain conditions or factors that would make someone more susceptible to developing lung cancer?

Dr Eric Krause: So again, the most common one is cigarette smoking or any type of inhalation either. the data is not there yet to say that vaping is gonna have the same effect of cigarette smoking, has on the incidence of lung cancer. The pathway sort of seems the same. People are inhaling toxin into their lungs and it's sitting there causing inflammation and sort of starting that pathway again for what causes lung cancer. We just haven't seen it yet. It generally will take 10, 20 years for people to develop lung cancer from these inhalation injuries. but anything else that causes that.

So people who work around chemicals a long time, they work around small particulates minors, factory workers, sawdust, all of these things can sort of increase your risk of lung cancer. Anyone who's heard of mesothelioma knows that. Asbestos causes that, but asbestos plus smoking increases your chance of having lung cancer, almost 50 fold over the general public. So there's a myriad of things that cause lung cancer and the most important thing that anyone who's worried about it should do is either never smoke or if they are smoking, stop smoking.

Dr Heather Lee: And then non-smokers, have a 20 to 30% greater risk of developing lung cancer ex is exposed to secondhand smoke at home or work. So, not just smoking, but the secondhand smoke as well.

Dr Eric Krause: Right, and that's why all those laws that came out recently making it, that we can't smoke in bars and you can't smoke in restaurants are really so important for all the people who are workers there that don't have a choice or patrons that wanted to go to those places. And now can go there without feeling that they're putting their health at risk.

Maggie McKay (Host): And Dr. Lee, what treatment options are available for someone who has lung cancer?

Dr Heather Lee: So it really depends on the stage and type of disease. There are two major types of cancer. non small cell lung cancer and small cell lung cancer. 85% of lung cancers will be non small cell lung cancers. And so for that type of cancer, it is largely determined by the stage of disease. So if you find it early, then surgical resection offers the best opportunity for cure. But if it's more advanced, then we may be treating with chemotherapy and radiation therapy together, or maybe even a combination of chemotherapy, radiation therapy followed by surgery, depending on the size location of the cancer, has it gone to the lymph nodes in the lung or within the chest. And, if it's more advanced, then we are treating with more with chemotherapy and using radiation therapy for palliation to help with symptoms of pain.

Maggie McKay (Host): And Dr. Krause, one question that I'm sure a lot of patients have right off of bat is what is a survival rate for individuals with lung cancer?

Dr Eric Krause: So, I tell this to every patient. I see that percentages, are a great tool to look at a population, but unfortunately for a person it's kind of binary. Either you fall into the survival group or you fall into the, non survival group I start talking with people about it, if you have an early stage lung cancer to give the percentage and that's a stage one cancer, and what that means in terms of someone who's diagnosed is that they have a biopsy proven cancer within their lung. It's confined within a single lobe of the lung.

Every person has five lobes that they're born with three on the right and two on the left. And so that cancer's just within one lobe, maybe even just one little small part of that lung and it hasn't gone to any of the lymph nodes and it hasn't gone to any other structures around in the chest. That person who gets definitive surgery has about a little over a 90% in that range five year survival. So it's very good. If you get all the way down to where someone who has had cancer and it's been there for a while and it's stage three.

And in that case, that would mean that the cancer is either very large or it's spread to the lymph nodes or it's spread to somewhere else in the chest, that five year survival is gonna be closer to 20, 30%. But everyone's different and the field's evolving all the time. So what you hear today on this podcast might not be true in two to five years. New drugs come out, new surgical techniques come out. So it's never a death sentence. Even people with metastatic disease can live for a while with the new therapies that are coming out.

Getting seen by a doctor, especially if you're a smoker and having that early cancer screening really changes the chances for survival. Because If we catch it early, even though I don't love percentages, ninety's a hell of a lot better than 20.

Maggie McKay (Host): Right. When you say five years, is that the best scenario?

Dr Eric Krause: Well, that's the way we talk about cancer survival. in five years after your diagnosis of cancer and treat ment. We then do surveillance on you for, in my world, for the surgery world. Once you have a cancer surgery for lung cancer, you have your surgery and that marks time, zero six months later, we get a CT scan to make sure that you're still, cancer free. And we do that every six months for the first two years. After that it's once a year for the next three years. And that gets you to five years. After five years, we call quote unquote, cure.

But you still have all the underlying risk factors they gave you cancer in the first place. So we still keep on watching you, but it could be a new cancer that creeps up. So that's why we talk about a five year survival. but the reality is that someone, after five years they get pretty close back to their regular survival curve that they would have as just any person that didn't have cancer, but the cancer's always in the background and they always have those risk factors that cause the cancer in the first.

Maggie McKay (Host): Dr. Lee, are there any recent developments for lung cancer treatment?

Dr Heather Lee: Yes. So there's always research going on. And, recently there's been a lot of targeted therapies for patients with advanced disease with specific molecular features. So you'll see when a patient's just diagnosed with lung cancer, they'll meet several doctors. They'll meet the thoracic surgeon if that's appropriate, the radiation oncologist, and also a medical oncologist. And the medical oncologist will, ask the pathologist to run certain tests on the cancer to see if there's certain mutations in the cancer that can be targeted with targeted therapies. And some of these targeted therapies can be very effective.

And not all cancers have them, but when a patient is a candidate for this, it can be very effective in treatment, just like Dr. Krause mentioned, when somebody has stage four disease, meaning it's metastatic. These new treatments can definitely benefit in their overall survival. And we have seen improvement in overall survivals in these patients. there's also been, advancement in and Dr. Krause can talk about advancements in surgical procedures, but also in radiation procedures where we can treat much smaller areas and limit the dose of radiation to normal structures to decrease the, possible side effects and long term toxicities to normal structures and really focus on the tumor themselves.

Maggie McKay (Host): Dr. Krause, you wanna add anything to that about the recent developments for treatment?

Dr Eric Krause: In the surgery realm, the newest things that are coming out, and the data is. still being presented, but the early data for the shows that traditionally, what we used to think was is that we had to do bigger resections. So take out more lung because we thought that the cancer would spread more slowly throughout the lung. And that was the way to make sure that people got the best cure possible. Two new, big trials, one out of Japan that's already reported its data. And one out of the us that is yet to report with the early results correlate with what's out of Japan, are that we actually can do. The surgery and take much less lung.

And the advantage of that is that means that people who weren't surgical candidates before, because they didn't have good enough. Lung function now are surgical candidates and people that were surgical candidates before now will probably have a slightly better quality of life after the surgery. Most people can tolerate having a lobe removed, but some people feel a little short of breath or they complain afterwards. I can't run as fast as I wanted to, or, I can't do as many activities in the heat without feeling like I get tired.

And sort of with these new techniques that, fewer people will probably experience those sequel of the surgery afterwards. Furthermore, in the past 10 years to 15 years or so, the field has really shifted from having to do these surgeries with big incisions about the size of a hand on the back of someone's chest that someone might have seen in an older parent or a grandparent where they had a lung cancer surgery, and we took out a big chunk of their lung. And they have this big scar on them. Not an hour ago, I did, cancer surgery on a patient and the argest incision is about two centimeters, two and a half centimeters. And there's only three of them and the other two are about a centimeter each. And she'll go home tomorrow or the day after. And she had a lung cancer.

Maggie McKay (Host): Wow. Isn't that amazing? How different is that from say 10 years?

Dr Eric Krause: 10 years ago, the average length of stay would be about six days in the hospital. they would have something called the thoracotomy, which is an incision that's about, 11 to 15 centimeters in size. People would have two chest tubes. They'd have an epidural, which is the pain catheter that most women have when they give birth. And they don't feel right for about a month. most of my patients are back driving and at work within a week or two.

Dr Heather Lee: So looking at early stage cancers for some of these patients who may not be a candidate for surgery for stage one cancer, you would then use radiation therapy. In the past, radiation therapy is daily treatment Monday through Friday, five days a week. And for even early stage lung cancers, you would have to do, six to seven weeks of treatment. However, now we have this technology where we can do stereotypical ablative, radiation therapy and treatment to these small cancers can be done in one to five treatments.

Just a high dose, very focused. So the treatment is much better tolerated and the survival for these patients are much better with these short radiation therapy treatment courses than the six to seven weeks. And getting near to the surgical survival rates, which is surgery is still gold standard. However, that's one of the new technologies that can be offered for these early stage. Lung cancers, who aren't candidates for surgery.

Dr Eric Krause: And Heather, correct me if I'm wrong. My father was a radiation oncologist and I would listen to him talk about how these people would have, skin burns and a lot of bad side effects from the radiation, which my understanding is in this day and age, those are, few and far between.

Dr Heather Lee: Yes. So depending on what area we're treating, if it's the smaller lung cancers that are more peripheral, and especially if you do this, stereotypical ablative radiation therapy, you're not going to see the same amount of fatigue, the skin reaction. The problem swallowing or weight loss with treatment now for more advanced cancers where you need to do longer course radiation therapy with chemotherapy yes, you are going to see some more of those symptoms, because you were treating in the middle of the chest where your esophagus is running, because you have a lot of lymph nodes around the esophagus.

Then you're going to have more problems with possible problems with nausea, vomiting, swallowing issues, and they have a higher risk. Especially the older patients may have a higher risk of having skin reaction, but the technology is much better. So we're seeing less and less of that compared to what we saw 20, 30 years ago.

Maggie McKay (Host): And are there any other takeaways either of you would like to share with our audience?

Dr Eric Krause: one of the earliest questions that you talked about with, prognosis, early diagnosis, as in almost everything is really king. If you have a smoking history, even if it's a short one, talk to your primary care doctor about whether you fall into the new categories, the expanded categories for lung cancer screening. Lung cancer screening is actually in terms of the absolute risk reduction, the most effective of the cancer screening tools that we have now. Relatively fewer people have to be screened for lung cancer to save a life than either for mammography or even colonoscopies.

It is just that a lot of people don't know about it and a lot of people don't get it. And there's probably somewhat of a stigma to it too, in the reality, because it is so often caused by smoking that people feel a stigma about it, and they might not seek treatment for it. But we're here to say that treat all comers and getting treated early and getting diagnosed early, really could save your life.

Maggie McKay (Host): What does screening entail?

Dr Eric Krause: So it's actually rather simple, it's a CT scan, that's it. And it's a low dose CT scan. So it's not even as much. radiation is normally is given during a CT. If we find anything suspicious on that CT scan, it doesn't necessarily mean that a person has cancer just means that we've seen something on the CT that needs further investigation. And depending on what that looks like, it could either be another CT in three months, six months, maybe a year, or if it's rather suspicious, we might send someone for a pet scan or maybe some kind of invasive biopsy. But it all depends on, what's seen on the CT, but the initial screening test, it's easier than getting a colonoscopy. You walk to a radiology center and you do a CT, takes about 10 minutes and that's it.

Maggie McKay (Host): So that's good to know. Get screened.

Dr Heather Lee: Yeah, the current guidelines for the screening is, people who are 50 to 77 years who have what we calculate to be a 20 pack year smoking history. So that's the number of years you've smoked, multiplied by the number of packs you smoke per. So let's say you've smoked for 20 years and one pack per day, that would be 20 pack your smoking history. Or if you smoked two packs per day for 10 years, that would also be a 20 pack year smoking history.

And, for people who are current smokers or have quit within the past 15 years, they would fall within the guidelines for the low dose CT scans for screening, for lung cancer. And the biggest thing is to quit smoking. The longer you quit and if it's over 15 years, then you've really done yourself a huge favor, not only for lung cancer, but for all these other diseases that can be associated with smoking.

Maggie McKay (Host): And you touched on vaping earlier. Are the statistics not in yet? Is that not conclusive whether that causes lung cancer?

Dr Eric Krause: The statistics aren't in yet. Part of it is they just haven't been out long enough for the data to accrue. And also a lot of the people who are doing it are younger. So as your cancer risk increases with age and just, time of smoking, but I've seen people get lung transplants from vaping. So I can't imagine that we're not gonna see cancers.

Maggie McKay (Host): Lung transplants from vaping. That's dramatic.

Dr Eric Krause: People who make their own, Vape oil or however you want to call it at home sometimes can have contaminants in it. And if any, vitamin E gets into that contaminant, it will destroy the lungs. It's happened, seen it, and, it's tragic and their life expectancy will go down from that, with having a lung transplant. So it'd be hard to imagine that there isn't gonna be some kind of cancer effect that happens from vaping.

Maggie McKay (Host): Right. Dr. Krause and Dr. Lee, thank you so much for joining us today. I know you're so busy. We appreciate you making the time and sharing your expertise.

Dr Eric Krause: Thank you.

Dr Heather Lee: Thank you.

Maggie McKay (Host): Thank you so much. Find more shows just like this one at umms.org/podcast. Thank you for listening to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We look forward to you joining us again. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you.