Lung Cancer and Advances in Treatment, Surgery and Screening to Save Lives
For the past two years, however, it has been gratifying to see the overall cancer death rate in the United States decline, specifically because more lives are being saved from lung cancer than ever before. The American Lung Association 2022 State of Lung Cancer Report ranks Rhode Island number one in five-year survival rates among states with survival data.
Improved survival rates are a result of the Lifespan Cancer Institute’s efforts to reach underserved populations, aggressively promote and offer screening to high-risk populations, and provide cutting edge treatments through a team of world class experts.
Low dose computed tomography (CT) scans are detecting more early-stage lung cancers, which can be cured by surgery or radiation therapy. For patients with advanced (metastatic) non-small cell lung cancers, a new class of drugs called, immune checkpoint inhibitors, have doubled patient survival.
Our experts explain more about the impact of these lung cancer treatment advances.
Surgery for lung cancer
What are the surgical options available to patients with lung cancer?
Recent studies continue to support the fact that surgery remains the most important modality for lung cancer treatment in early and intermediate stages. Advances have happened in two main aspects of thoracic surgery; how much of the lung is removed and how that removal is done.
Firstly, we learned from recent studies that it is not always necessary to remove an entire lobe of the lung when tumors are in the early stages. Often, all that is required, is a removal of a smaller segment which contains the tumor. Although removing a segment is technically more difficult than removing an entire lobe, it does leave the patient with more residual lung function and more ability to recover from their surgery.
Secondly, major advances have happened in how surgeries are performed. Open, painful surgery that involved invasive rib-spreading has been largely replaced with minimally invasive approaches. These include video-assisted and robot-assisted approaches to surgery.
Now the patient can have the same operation that used to require a large incision by means of what is described as “keyhole surgery.” In particular, the robotic platform offers more technical advantages over video-assisted surgery, providing the surgeon with the ability to perform meticulous two-handed surgery using very fine miniaturized instruments and high-definition magnification.
Who is eligible for lung cancer surgery?
Before a patient is offered lung cancer surgery, a careful evaluation is performed to determine the stage of the cancer and the ability of the patient to undergo anesthesia. Once determined that the cancer has not spread outside the chest, the patient is referred for pulmonary function tests and cardiac testing. Because of the ability to provide less painful minimally invasive surgery and the tendency to remove smaller segments of the lung, we can offer surgery to more patients who may not have been candidates in the past.
What advantages does robotic surgery offer for patients with lung cancer?
Robotic surgery offers specific advantages to the patient.
- The ability of the surgeon to perform fine meticulous maneuvers ensures that the operation is done well and the cancer is fully removed.
- There is evidence that because it is less painful, patients who undergo robotic surgery may be able to return to work and normal activities sooner.
- Almost all studies have shown shorter hospital stay after robotic surgery compared to open surgery.
- Many studies have also shown that the ability of the surgeon to perform the removal of lymph nodes is better with robotic surgery than other minimally invasive approaches.
In short, robotic surgery may allow for a better operation, faster recovery, and hopefully, although not proven, improved long-term outcome.
Have there been other advances in surgical procedures or techniques that have impacted outcomes and survival rates for patients with lung cancer?
The use of minimally invasive approaches to lung cancer surgery, including video-assisted and robot-assisted surgery, has consistently been shown to improve short-term outcomes compared to open surgery. These outcomes include:
- less pain
- shorter length of stay in the hospital
- fewer complications
- less blood transfusion
- increased ability to undergo further therapy when needed
Robotic surgery has also been shown to be superior to video-assisted surgery in terms of the ability to evaluate undiagnosed disease in the lymph nodes.
Medications and Clinical Trials for Lung Cancer
Christopher G. Azzoli, MD, is director of thoracic oncology at the Lifespan Cancer Institute. He is currently the principal investigator at the Lifespan Cancer Institute and a co-investigator in a worldwide phase 1 clinical trial of an extremely promising drug. The Lifespan Cancer Institute hopes to be the first program anywhere to administer this drug therapy that may be the first to treat an unmet need in lung cancer patients.
What are some of the new drugs available to treat lung cancer?
Immune checkpoint inhibitors
Many lung cancers grow and spread because they actively evade the immune system. Immune checkpoint inhibitors are antibodies which block the ability of the cancer cells to evade the immune system, thus fostering an immune attack. These drugs are so powerful and effective that drug makers are using direct-to-consumer advertising to make patients aware of their potential. Many patients know about drugs such as pembrolizumab (Keytruda®), nivolumab (Opdivo®), and ipilimumab (Yervoy®) because they see them in television advertisements.
For patients with advanced disease, these drugs are so effective that we are now giving them to patients with early-stage disease to improve rates of cure. The Thoracic Multidisciplinary Clinic at the Lifespan Cancer Institute is offering a new drug trial which combines nivolumab and ipilimumab plus an immune-stimulating dose of radiation delivered to a non-small cell lung cancer prior to surgical resection.
The goal of this approach is to foster immune attack so that a patient’s own immune system protects patients from metastatic spread, which can improve rates of cure. This study is becoming popular because patients who respond to the new immune treatment do not require traditional chemotherapy.
Oncogene targeted drugs
While immune therapies bring new hope to patients with a wide variety of lung cancers, another class of drugs known as oncogene targeted drugs provide excellent disease control for patients with specific gene mutations in their cancer, so-called precision medicine.
The Lifespan Cancer Institute is one of the fastest centers in the United States to process critical gene mutation tests of lung cancer tissue, to find the mutations that match with highly effective, targeted drugs. Our lab can detect key genetic changes in the genes in biopsy tissue in under two weeks, which can lead to earlier initiation of life-saving gene targeted drug therapy.
Lung cancer screening
Hina Khan, MD, is a medical oncologist who specializes in thoracic cancers at the Lifespan Cancer Institute.
What is lung cancer screening?
Cancer screenings are aimed at detecting cancer before symptoms appear. Screening leads to earlier detection of cancer and offers a higher likelihood of curing the cancer in a less invasive way.
Lung cancer screening involves a low dose CT scan of the chest, which collects multiple images while the individual lies on a donut-shaped scanner table. It is just like a regular CT scan but uses a lower dose of radiation as compared to regular scans.
The test uses computer software to create a three-dimensional view of the lungs and organs. This gives us a better picture of the lungs than a chest X-ray.
Why is lung cancer screening important?
Lung cancer causes more deaths than the next three deadliest cancers combined. About 25 percent of all cancer deaths are attributed to lung cancer, making it the leading cause of cancer death in both men and women.
In a large national study called the National Lung Screening Trial (NLST), a compelling 20 percent reduction in lung cancer deaths was seen with the use of low-dose CT screening in high-risk patients. This prompted the approval for screening reimbursement by the U.S. Preventive Services Task Force (USPSTF) and the Centers for Medicare and Medicaid Services (CMS).
We know that survival in lung cancer patients is directly related to the stage of cancer at diagnosis. Lung cancer screening with an annual low-dose CT improves survival by detecting these cancers at an early stage.
Who is eligible for lung cancer screening?
High risk individuals who are between the ages of 50 and 80 and who have at least a 20 pack year history (a pack per day for 20 years; 2 packs per day for 10 years, etc.) of smoking; current smokers or those who have quit in the past 15 years.
Is a physician referral required or can individuals self-refer?
Yes, a referral from a physician is required for lung cancer screening. Typically, your primary care physician or pulmonologist/lung specialist will discuss the details of lung cancer screening with you and make the referral.
Is lung cancer screening covered by insurance?
In the state of Rhode Island, all insurance carriers cover lung cancer screening. You may also check with your insurance company prior to your appointment to confirm the test is covered.
Despite the proven benefit, lung cancer screening is significantly underutilized by those individuals who qualify for it. Here at Lifespan, our mission is to provide the care and access to all those eligible for lung cancer screening. We provided coordinated care in partnership with our primary care community providers.
The best lung cancer treatment for each patient
To offer the best treatment to each of our patients, our Thoracic Multidisciplinary Clinic includes doctors who specialize in lung surgery, lung radiation, drug therapy, and all required diagnostic tests, so that our patients get an accurate diagnosis as quickly as possible, and a team of doctors brings all potential treatments to bear. Experience and specialization are important because each of the treatments discussed above have unique application, risks, and side effects.
Rest assured, if you are cared for by the thoracic oncology team at the Lifespan Cancer Institute, we have the experience, know-how, and enthusiasm, to provide you with the best treatment, and the best chance for cure. Learn more about us here.
About the Author:
Abbas El-Sayed Abbas, MD, Christopher G. Azzoli, MD and Hina Khan, MD
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