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Bill Klaproth: The American Cancer Society estimates for lung cancer in the United States for 2020 that there are about 228,000 new cases of lung cancer and 135,000 deaths from lung cancer. These are very sobering statistics. So we are here today with Dr. Neha Bhooshan, our radiation oncologist at UPMC Hillman Cancer Center to discuss the role of radiation therapy in the treatment of lung cancer.

This is Healthier You, a podcast from UPMC Pinnacle. I'm Bill Klaproth. Dr. Bhooshan, thank you so much for your time and it's always great to talk with you. So let's start with this, what is the general approach to treating lung cancer once it has been diagnosed?

Dr. Neha Bhooshan: Thank you again for having me. I'm always happy to come and talk about cancer treatment with our patients. And you know, I think lung cancer is a really important topic because it is unfortunately one of the most common cancers we have and the American Cancer Society actually estimated there were about 228,000 new cases of lung cancer in 2020 alone, of which there were 135,000 deaths. So very sobering statistics. And so I'm just very pleased to be here to talk about the role of radiation therapy in the treatment of lung cancer.

So, as I had talked about in my previous podcast on radiation therapy for cancer treatment, cancer treatment typically involves three pillars of treatment. We have surgery, systemic therapy, which includes chemotherapy or immunotherapy, and then last is radiation therapy. Once all the necessary workup, including imaging and biopsies have been done and we know the staging of the patient's lung cancer, we can then determine what is the optimal treatment.

In general, we classify lung cancers as either early stage with small nodule seen on a CT scan or locally advanced cancers, which are larger tumors with or without positive lymph nodes. Or the third stage is typically then metastatic lung cancer, which is cancer that has spread outside of the lung.

For early-stage lung cancers, the typical treatment options are surgery or radiation therapy. Sometimes after surgery, the tissue from the surgery may indicate further treatment. For locally advanced lung cancers, typical treatment options may be surgery with additional treatment or radiation and chemotherapy at the same time. And then, finally for metastatic lung cancer, typical treatment is chemotherapy alone with additional treatment as needed.

Bill Klaproth: So when it comes to the different types of lung radiation therapy, what are the different types that we should know about?

Dr. Neha Bhooshan: Great question. So when a patient meets with the radiation oncologist, they will of course review the patient's entire oncologic history to determine what is the optimal treatment or treatments for that specific patient. We deliver radiation therapy with a machine called a linear accelerator. It's basically like getting an x-ray.

If the patient has an early-stage lung cancer, then one treatment option is what we call stereotactic body radiotherapy or SBRT. This is a form of delivery of highly focused and guided radiotherapy in large doses per fraction over typically four to five fractions delivered over one to two weeks. The data show 80 to 90% control rates. And whilst lots of cases are using this technique, the regional lymphatics are not part of the treatment volume, so therefore that's why it's used only in the very early stages of lung cancer. And we typically use this approach when surgery is not medically feasible.

Now if the patient has a locally advanced lung cancer, then we typically consider radiation and chemotherapy at the same time. Because this is typically a larger target and the patient is receiving chemotherapy at the same time, we deliver the radiation more gently compared to the SBRT technique with smaller doses delivered daily over six to seven weeks.

Finally, for a metastatic lung cancer patients, again they are typically getting systemic therapy like chemotherapy or immunotherapy. But if there is a lesion that is causing symptoms to the patient, then we can give a short course of radiation, what we call palliative radiation to provide symptom relief or if they have brain metastases, which is when the lung cancer spreads to the brain, we can also give radiation to treat those brain metastases.

Bill Klaproth: That is really informative and a great explanation. So then when it comes to radiation therapy, what is the process by which patients receive lung radiation therapy?

Dr. Neha Bhooshan: So first they will meet with the radiation oncologist to discuss the rationale, the logistics and obviously the side effects of the radiation treatment. Once the patient agrees to proceed radiation, they will then be scheduled for a CT simulation scan. We do customize radiation. Everyone's tumor and body anatomy is different. So we fit the radiation beams to the patient's specific tumor and anatomy in order to reduce radiation dose to the nearby normal tissues.

The other issue is that if the patient is laying on the treatment table and then starts moving, the radiation machine or linear accelerator cannot track a patient's body in real time. So we want to make sure that the patient is in the same position every time for radiation treatment, so we can be confident that the radiation is going where it's supposed to go.

To address those two issues, we have patients undergo what is called a CT simulation scan or a planning CT scan. Every radiation oncology clinic in the UPMC Pinnacle network has its own CT scanner for this purpose. The patient will come in. We will place them in the treatment position, either using a mold or a mask sometimes. The patient is then scanned in that treatment position.

For the lung cancer patients, we also take a movie with the CT scanner so we can assess the respiratory motion of the tumor so that we can make sure that we are including that in our target volume for the radiation. Then, our radiation therapists will place very small permanent skin tattoos, the size of a freckle, on the patient, since we have lasers in the treatment room to make sure that we have accurate setup every day,

So after the scan is done, the patient goes home. And on our end, we contour where the tumor is on that CT scan. We also contour out normal organs or structures that are nearby. The radiation beams are then placed to give the prescribed dose to the target, which is the tumor, while minimizing the dose to those nearby organs in order to minimize potential side effects of the radiation treatment.

We have physicists on staff here who do a QA or a safety check on the radiation plan to make sure everything is safe before the patient starts the treatment. Once the radiation plan is ready, the patient will turn to our treatment and then start radiation. This entire planning process typically takes us with one to two weeks to generate that customized radiation plan for that patient.

The patients will then come in and we'll start the radiation. A typical long radiation treatment is about 10 to 20 minutes while an SBRT treatment can be a little bit longer, maybe around 30 minutes. Patients will not feel anything during the treatment. It's just like getting an x-ray or a CT scan. The patient will not feel, hear, smell anything. And, patients are not radioactive while getting radiation or afterwards. And so they are safe to be around family and pets during the radiation treatment.

Bill Klaproth: Wow. That is really interesting. So you did mention side effects in that answer. What are the side effects of lung radiation?

Dr. Neha Bhooshan: That's a very important question because obviously, you know, patients are concerned about potential side effects with any cancer treatment. I always emphasize to my patients that radiation is a local treatment. Wherever the beams go is where the radiation goes. And so then that dictates the potential side effects of the treatment.

For the early-stage lung cancers, where I talked about the stereotactic body radiation therapy or SBRT technique. SBRT is typically very well tolerated. During SBRT, patients may develop fatigue, cough, new or worsening shortness of breath or pain or difficulty with swallowing. If these occur, they typically resolve once the radiation is done.

After the radiation is completed, there is a low risk of scar tissue developing where the radiation was delivered in the lung, which we call lung fibrosis or lung scarring. Sometimes that scar tissue can get inflamed causing a pneumonia-like condition that we call radiation pneumonitis, inflammation of the lung secondary to radiation. If that occurs, we treat with high dose steroids and that typically resolves the issue. There's low risk of any serious damage to any of the nearby organs, such as the heart ribs, esophagus, chest wall, heart, or major vessels.

For locally advanced lung cancers, patients can develop similar symptoms during radiation, including again fatigue, cough, new or worsening shortness of breath, pain or difficulty with swallowing or heartburn or indigestion. Again, if these occur, they typically resolve once the radiation is done.

And after the radiation is done, there was a similar risk of lung fibrosis and radiation pneumonitis as well as low risk of any serious damage to the nearby organs. The radiation oncologist will obviously go into a detailed discussion of potential side effects during and after treatment as part of the initial consultation with the patient.

Bill Klaproth: So earlier, you said with metastatic lung cancer, the type of cancer that can spread outside of the lungs, it sounded like you said that typically it can travel to the brain. So if I can ask you that question, if it does travel to the brain, what kinds of brain radiation is there?  

Dr. Neha Bhooshan: Excellent question. So, as you said, you know, if the patient has metastatic lung cancer and unfortunately if the cancer spreads to the brain, we can offer radiation to treat those brain metastases. If the patient has very limited disease in the brain, then we can offer something called stereotactic radiosurgery or SRS.

SRS is very similar to SBRT in that it is delivery of, again, very focused high dose of radiation to the lesion or lesions in the brain. We can typically deliver the radiation in one treatment, but sometimes up to five treatments. It is generally very well tolerated with very low risk of side effects, such as headache, nausea or vomiting.

If the patient has more extensive disease in the brain, either in terms of the number lesions or the size of the lesions, then we typically offer a radiation treatment called whole brain radiation. So this is radiation therapy that is delivered to the entire brain. A whole brain radiation therapy is given daily, typically over 10 treatments or two weeks. It is also overall very well tolerated. but it has additional side effects of neurocognitive dysfunction. Again, the radiation oncologists will go into the detailed discussion of the rationale, logistics and potential side effects during and after treatment of brain radiation as part of the initial consultation.

Bill Klaproth: Well, this has really been informative and insightful. Dr. Bhooshan, as always, thank you so much for your time.

Dr. Neha Bhooshan: Thank you so much for having me. I always enjoy being on here. So thank you so much.

Bill Klaproth: That's Dr. Neha Bhooshan. And for more information, please visit UPMCPinnacle.com/cancer. 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. This is Healthier You, a podcast from UPMC Pinnacle. I'm Bill Klaproth. Thanks for listening.