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What are the Goals of Treating Advanced NSCLC?

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GCVL_LU-F01_Goals_Treating_Advanced_NSCLC

 

Dr. Benjamin Levy, Mount Sinai Health Systems, lists the goals of treating advanced NSCLC and the methods used to achieve those goals.

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I think there are several goals when treating a patient with advanced non-small cell lung cancer. For one I think we want to extend life, two is I think we want to palliate symptoms, and three is I think we want to improve quality of life. So all three of those goals are achievable, I think, with the therapies that we have right now.

Now, some of these therapies are targeted drugs, so for patients that have genetic alterations or a genetic makeup that makes them eligible for targeted drugs, then clearly we can offer these drugs and I think we can achieve all three of those goals. But even for patients without genetic alterations, and patients who will not be receiving targeted drugs, I think we can extend life, improve quality of life and palliate symptoms by delivering chemotherapy. I think we know now that chemotherapy is not the chemotherapy of the days of old — these drugs are given in combination, are tolerable and can improve outcomes. We also have now immunotherapy, and so all three types of systemic approaches can help achieve these three goals.

In addition to these three goals, I think it’s important that we also have goals of care discussions with patients from the being of treatment. I think what that means is that we really come up with what the shared expectations are for treatment. Patients may ask specific questions like “how many months will additional chemotherapy give me versus no chemotherapy?” I think these questions are fair game. I think we can certainly talk about averages but also tell patients that they’re not an average and I would sway doctors or patients receiving information not to stick to exact numbers, but I do think that a goals of care discussion upfront is very important.

That brings into the realm the role of palliative approaches or palliative care. Many patients feel that palliative care is hospice or end of life care, but this is not the case. I think what we know now is that patients who have early palliative care referrals to palliative care specialists in conjunction with their treatment, specifically for lung cancer patients, these patients actually live longer.

So I bring up this whole concept of discussing goals of care very early on so we can make sure that our patients are referred to palliative care specialists who can treat patents alongside us and work in conjunction to help improve outcomes for our patients.


GRACE Video

The Basics of a Lung Cancer Workup

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Dr. Gerard Silvestri, Medical University of South Carolina, describes the steps necessary to work up a lung cancer diagnosis, from initial scan to choice of treatment.

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What are the basics of working up a lung cancer? When I see a patient in my clinic, usually they haven’t had anything done yet. They’ve been referred to me with a “spot” or lesion, or a mass on their lungs, and again, the first thing I need to do is take a good history and physical. How long have you had your symptoms, have you had weight loss, do you have bone pain, have you had headaches, what are some of the things going on — what diagnostic workup have you had? Sometimes they’ll already have had a biopsy. My job though is to do these three steps, absolutely simultaneously and sometimes in order — what is it, where is it, what I can do about it — diagnosis, stage and treatment.

The first visit is almost always trying to review the imaging and decide whether you need more imaging, do a good physical exam, do a good smoking history, find out what other health issues the person may have like heart disease, that can give us a challenge in terms of how we’re going to treat the cancer. So that’s the first part.

Sometimes I have to say that some patients are — it’s thought they may have a lung cancer, and in fact it’s something else. It could be a fungal infection or something else going on in the lungs. So usually what happens over sort of the course of the next ten working days is, either some more imaging, or a biopsy, and then perhaps a PET scan to help us with the staging portion of this. So sometimes we get a PET scan that will help us both direct the biopsy, but also help us with the stage. Over the next ten days or so we’ll try to get those tests done.

In addition, we always present our new cases at a multidisciplinary tumor board. What’s that? A multidisciplinary tumor board is where all the different specialties get together to look over the imaging, the biopsy results, the pathologic results, and come up with a better treatment plan. So who’s in the room during the tumor board? A pulmonologist usually, a chest surgeon or a thoracic surgeon, a medical oncologist, a radiation therapist, a pathologist, sometimes you’ll have a dedicated chest radiologist who will help review the films, and then also people from other ancillary services that are extremely helpful like clinical trials staff, like palliative care nursing. So we have all those people in the room at the same time, and they’re either reviewing brand new cases, or difficult and challenging cases that are coming back to the tumor board for consideration.

So that kind of happens in that first ten days and for us, we know how anxious patients can get during that time period that they just want to get something started, but I would urge anyone listening to this to consider is, if you don’t get it right, if you don’t give the person the correct stage and the correct treatment options, you won’t get the best care. Yes, speed is important, but you’ve got to get it right — what is it, the diagnosis, where is it, the appropriate stage, and then what are your treatment options, which really differ depending on stage. For stage I it’s usually surgery, for stage II, surgery followed by chemotherapy, for stage III, chemotherapy and radiation, and for stage IV, chemotherapy alone or some of the targeted agents. So if you don’t get that right, you’re going to get the wrong treatment, so be patient with that and if your doctors need to biopsy in a different area, as long as they’re explaining it appropriately to you, you should try to stay with that program.

So that’s the general workup of a patient. I will say, every patient gives a little bit of a nuance and so sometimes a patient seemingly needs something that’s a bit unusual in terms of a biopsy or the location of a biopsy or how to best go about getting that biopsy, and I can also say that sometimes the tumor board is split. Sometimes there’s no right answer about whether we should do it via a needle biopsy through the chest wall, or a bronchoscopy, and sometimes talking that through with a patient, they can help us – you can help us as patients make a decision about which way we would go next. That’s the general workup of a lung cancer.


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