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The Risk of Overtreating Indolent Bronchioloalveolar Carcinoma
Bronchioloalveolar carcinoma, or BAC, is a subtype of lung adenocarcinoma that has a tendency to progress more slowly, stage for stage, than other types of lung cancer. There are many patients who experience symptomatic and significant progression over months, and rarely patients have a very aggressive and fulminant form of the disease. However, many patients with BAC experience slow growth that raises the risk of potentially overtreating it, with the possibility of detrimental effects from that.
As someone with a particular interest and expertise in BAC, I see the situation with BAC as being similar to the issues we face with prostate cancer. Once a blood test for detecting prostate cancer emerged (prostatic serum antigen, or PSA), it became possible to identify 200,000 men in the US per year who had prostate cancer. The problem is while a huge proportion of men will develop prostate cancer as they get older, many will have an indolent cancer that will not really threaten their survival, and for which treatment with surgery or radiation can have significant long-term side effects. A low grade prostate cancer is well known for being a cancer men can “die with, but not of”. In other words, men can have a prostate cancer that would never directly threaten them, and they can go on to a ripe old age before succumbing to heart disease or another non-cancerous condition. Continue reading
Prophylactic Cranial Irradiation for SCLC
Prophylactic cranial irradiation, or PCI, for SCLC, usually limited disease (LD-SCLC), remains a controversial issue, although this is generally recommended for patients with LD-SCLC who have a complete response to treatment (no evidence of disease). However, the idea of radiating the brain of someone who has no evidence of cancer there and may never get it is something that many patients and also some oncologists (radiation oncologists and medical oncologists) may not embrace. So how did we get to a point where we standardly recommend radiation to prevent brain metastases from developing?
Well, as I mentioned in previous posts, the brain is remarkably fertile soil for brain metastases for SCLC, which has a consistent propensity to spread there. In some studies, up to two thirds of patients with SCLC who don’t receive PCI develop brain metastases within two years. Several small trials in the 1970s and 1980s consistently showed a reduced risk of developing brain metastases but no clear improvement in survival from PCI, although these trials were really too small to show any significant benefits. Continue reading
Current Standards of Care for Limited Disease SCLC
While SCLC accounts for only about 13% of lung cancer, and only approximately one third of patients with SCLC have limited disease SCLC (LD-SCLC), this remains a high stakes area with the potential for being cured, so it needs to be treated as optimally as possible. I’m going to give a brief history and highlight some of the current principles of what has developed as the current standard of care.
As mentioned in my prior posts that included general information about SCLC and extensive disease, limited disease is defined as SCLC in which full staging shows that all visible disease is confined to what can be reached in a single radiation port, so generally localized to one half of the chest. Whether patients who have SCLC cells in fluid outside of the lung (a malignant pleural effusion) or the neck/upper chest on the side opposite the main cancer mass is controversial. Only 5-10% of patients with SCLC have their cancer detected before it is at least involving the mediastinal (or middle of the chest) lymph nodes, so SCLC is usually either locally advanced or metastatic. It is quite uncommon to find a single lung nodule of SCLC without significant lymph node involvement, unlike NSCLC, where a larger minority of fortunate patients can have stage I or II disease detected. Continue reading
Management Approaches for EGFR Inhibitor-Induced Rash
After describing the association of a rash on EGFR inhibitors with overall better outcomes on this class of agents, we can now take a step back and recognize that the rash can be an annoyance at the very least and sometimes a real problem. While there are no established guidelines, both treating physicians and patients have developed experience with the rash over the past few years that we should be able to use to minimize the impact for the majority of patients and reduce the proportion of people who need stop a potentially helpful agent due to this toxicity. Continue reading
Old and New Approaches to Initial Treatment of Extensive SCLC
While progress in small cell lung cancer (SCLC) has been slow, over the past few years there have been leads in management of extensive disease that have introduced a potential change in the standard of care based on better results. Extensive disease SCLC, or ED-SCLC, is defined by having cancer that has spread outside of the region that can safely be covered by a radiation port (more details and relevant figure in SCLC 101 post), and this accounts for approximately two thirds of SCLC cases. Patients can often show very rapid cancer progression and clinical deterioration, but fortunately initial treatment very often leads to rapid and dramatic improvement, although we are not able to cure ED-SCLC.
Is Rash a Good Thing with EGFR Inhibitors?
An acne-like rash or dry skin is a very common side effect of the drugs that target the epidermal growth factor receptor, with approximately 3/4 of patients who receive the EGFR tyrosine kinase inhbitor tarceva/erlotinib experiencing skin toxicity. Similar skin toxicities are also seen, but a bit less commonly, with the very similar drug iressa/gefitinib, and also frequently with erbitux/cetuximab, a monoclonal antibody that is less well studied in lung cancer. But since the earliest clinical trials of these agents, there have been questions of whether the rash is something more than just a potentially problematic side effect, but rather a marker of someone likely to do well with these agents.
Small Cell Lung Cancer 101: An Introduction
After several weeks of posts on other aspects of lung cancer, I am long overdue to write on small cell lung cancer (SCLC). Although it is good to see the number of SCLC cases decreasing over time, and becoming a smaller and smaller percentage of lung cancer cases overall (only about 13% in the US and steadily falling), this has translated into fewer clinical trials and less of a focus on SCLC in the lung cancer community. However, there are some promising developments that may lead to some long overdue progress in the field.
First, this post will start with some general concepts and an introduction to SCLC, and this will be followed in the next few weeks by posts describing current and emerging ideas for the basic stages of small cell lung cancer, and also a discussion of prophylactic cranial irradiation for small cell, where it has been most extensively studied. Continue reading
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