GRACE :: Lung Cancer

resection

Denise Brock

Lung Cancer Video Library 2017-What is the Optimal Follow-up for Patients After Resection of an Early Stage Non-Small Cell Lung Cancer (NSCLC)

Share

 

GRACE Cancer Video Library - Lung

 

H. Jack West, MD
President & CEO, GRACE

 

We are pleased to have GRACE’s Jack West, MD, Medical Director, Thoracic Oncology Program, Swedish Cancer Institute in Seattle, Washington, and President and CEO of GRACE bring 2017 updates to our Lung Cancer Video Library.  

In this latest video, Dr. West discusses the optimal follow up for patients after resection of an early-stage non-small cell lung cancer (NSCLC), and IFCT0302.


 

 

 

 

How Did You Like This Video?

Please feel free to offer comments and raise questions in our Discussion Forums.


 We would like to thank the following companies for their support of this program

 

                

 

 

                        

 

 
 

 

 


  


GRACE Video

The Role of Targeted Therapy Post-Resection

Share
GRACE Cancer Video Library - Lung

GCVL_LU-D21_Targeted_Therapy_Post-Resection

 

Dr. Heather Wakelee, Stanford University Medical Center, evaluates the lack of evidence for the use of targeted therapies after surgery, and describes ongoing trials attempting to resolve that issue.

[]

Download Transcript

How Did You Like This Video?

Please feel free to offer comments and raise questions in our Discussion Forums.

 

Transcript

Since the mid-2000s we’ve known that many patients who have non-small cell lung cancer, particularly the adenocarcinoma type, have particular gene mutations that we can identify and when we find them, treat with specific new drugs. We know this data from patients with metastatic lung cancer — the first to be discovered was EGFR or epidermal growth factor receptor, then ALK or anaplastic lymphoma kinase. Now there’s a very long list of gene mutations that we can identify when we look in patients with advanced stage lung cancer, and when we find them, offer specific targeted therapy that can have a very high likelihood of shrinking the tumor. This has really changed the way we think about and treat advanced stage lung cancer. However we haven’t figured out how to best use those treatments for patients who have earlier stages of lung cancer.

So in the setting of an early stage lung cancer that’s been removed with surgery, patients are theoretically cured at that point. Chemotherapy has been proven to lower the chance of the cancer coming back, but when you find one of these mutations in the tumor, the temptation is to give one of these targeted drugs. That strategy has been looked at in multiple clinical trials and we still don’t have a straightforward answer.

The largest trial to look at this so far was called the RADIANT trial and in that trial, after getting chemotherapy if that was the right thing for them, patients either received the EGFR drug called erlotinib, or a placebo. Now most of those patients in that trial actually did not have a specific mutation in EGFR because the study was designed before we knew about how important those mutations were. In the subset of patients who did have the EGFR mutation, those getting erlotinib seemed to have more time before the cancer came back, but if you looked at their overall survival, it wasn’t any different than the patients who had been on the placebo arm. The theory is that those who were on the placebo arm who had the cancer come back, when it came back they were then able to get erlotinib or a similar drug and have the same benefit. So it’s not clear that starting the erlotinib right at the time of surgery actually helps people live longer, though it might slow down the time to recurrence.

That’s obviously not a complete answer so there are more studies happening now trying to get a better sense of what we should do in that setting. There are a couple of trials in China, actually several trials in China, a study in Japan, and now a big study in the United States, all with the same general idea that a patient who has a tumor resected or removed by surgery, who is shown to have an EGFR mutation in that tumor, is randomized to either get an EGFR drug or to get placebo. Some of the studies have chemotherapy before or after, some compare it to chemotherapy, so there are some differences, but the general idea is whether or not giving the EGFR targeted drug will actually help people be cured or live longer versus waiting, and then for those who do have recurrence, giving it at that time. So those are really important trials that are ongoing and we’ll hope to know the answers in the next few years.

For the patients with the ALK translocation in the United States, the big trial called ALCHEMIST is open not just to EGFR but also to ALK patients. What that trial is about is asking that any patient who has a surgery at a site that’s participating in ALCHEMIST have part of their tissue from the tumor sent in to a central laboratory to be tested for EGFR or ALK. Those patients who have EGFR are then randomized to either get the EGFR drug erlotinib, or to get a placebo pill, and those who have ALK to get the ALK drug crizotinib versus a placebo pill. Over time people will be followed to see — does this change when the cancer comes back, and does it ultimately change overall survival for the patients where the cancer does come back?

So this is a really critical trial and it’s going to help us know what the best way is to use these targeted drugs for patients in this setting. Until we have those trial results back, I do not recommend that patients get the EGFR or ALK targeted drugs after surgery because we just don’t know if that’s going to help them live longer.


GRACE Video

Potential Advantages, Disadvantages and Limitations of Lung Cancer Screening

Share
GRACE Cancer Video Library - Lung

GCVL_LU-A06_Potential_Advantages_Disadvantages_Limitations_Lung_Cancer_Screening

 

Dr. Gerard Silvestri, Medical University of South Carolina, discusses the benefits and drawbacks of lung cancer screenings.

Download Transcript

How Did You Like This Video?

Please feel free to offer comments and raise questions in our Discussion Forums.

 

Transcript

Lung cancer screening is something that’s quite new in the United States. In 2010, the data was published on a 50,000 person trial where patients were either randomly allocated to get a CT (CAT) scan of their chest, a low dose radiation CT scan, or a chest x-ray, and the study showed a 20% reduction in lung cancer mortality in the patients who got screened for lung cancer with a CT.

There are a few things that you need to understand about that trial. One, it only included patients between the ages of 55 and 74; two, you had to have smoked at least 30 pack-years — that’s 30 years at a pack a day, or for example, 15 years at two packs a day. So you need to have a certain smoking history and be of a certain age to enter into that trial, and now patients in that age range with that smoking history are eligible to be screened for lung cancer with a yearly CT.

The advantage is that you hope to get the cancer when it’s quite small, and so it can be resected with a surgery, taken out, and that patient will have a better chance of being cured of their cancer because as we get to more advanced stages like when the cancer has spread outside of the chest, the hope for a complete cure is lessened. Early stage cancer, screen-detected cancer, has a better chance for cure.

There are some disadvantages to screening though that people need to be aware of. About one quarter of the time, patients who have a scan will have a spot on their lung, or a nodule, or a lesion it’s sometimes called — a quarter of the time those spots are there, and 96% of the time they’re benign spots, but they still need to be evaluated. Sometimes they’re evaluated just with following up with a CT scan, sometimes they’re evaluated with a biopsy, and even sometimes it requires surgery to get those out. That can cause a lot of anxiety in patients and certainly put them at risk for unnecessary procedures, particularly if you’re taking out something that was going to be benign all along. So that’s some of the disadvantage of being screened for lung cancer.

Also, as folks get older, so when you get up into that 75-77 age range, you also have other comorbidities, other things, other health issues that make it difficult for you to undergo surgery, and so some patients may not want to be screened if they have other health problems that may preclude a long life expectancy.

Overall, screening is being implemented in the United States the same way breast cancer screening was implemented years ago in the United States, and we’re doing it very carefully to make sure the patients are of the appropriate setting. The other thing we’re doing is making sure that if patients are smoking, that they get some smoking cessation as part of their screening endeavor.


Dr West

Limited Resection vs. Radiation for Marginal Patients with Early Stage NSCLC

Share

The standard of care for at least stage I and II NSCLC is surgery, sometimes followed by chemotherapy. We know, however, that not every patient who presents with early stage NSCLC is healthy enough to pursue surgery, whether due to general age-related or other illnesses, or due specifically to a low pulmonary reserves, usually from years of smoking. As our population ages and the median age of newly diagnosed lung cancer patients crosses 70, this is likely to become a bigger issue, but unfortunately we haven’t got a lot of information on the best way to treat sicker patients who are on the border of safety and feasibility for standard surgery for lung cancer. I’ve described in a prior post that there is some evidence that older patients may do as well with a limited, smaller resection (the different types of surgery described in another prior post). Otherwise, we know that many patients who are marginal for surgery are recommended to receive radiation instead. Perhaps not surprisingly, the survival results of patients with early stage NSCLC who receive radiation are not as favorable as the results with surgery, stage for stage.

While one explanation for this may be that surgery is just more effective in curing early stage lung cancer than radiation, there are some confounding issues. One is that it’s not uncommon for the patients who undergo surgery to be found to have involved lymph nodes or other findings at surgery that increase their stage. In contrast, patients who never undergo surgery may have those same lymph nodes or other findings but never be properly staged pathologically, so they would potentially be considered a stage I patient but really be a stage II or III if surgery had been done and could detect occult cancer involvement. Probably more important, though, is the fact that the vast majority of patients who receive radiation have been recommended to not receive surgery, presumably because they were felt to have too many competing risks and to not be healthy enough to pursue the rigors of surgery. Therefore, we’re really talking about two different populations of patients, one likely appreciably healthier than the other, so it shouldn’t be surprising that the excluded group does less well.

There are some novel radiation approaches that have been developed over the past several years that may serve as alternatives to surgery for some patients with early stage NSCLC, so it would be great to really know how advantageous surgery is vs. a non-surgical approach in marginal resection candidates. What would really answer the question is a randomized trial of borderline patients to receive either surgery or radiation. Well, dream on, because that’s not happening. At least in the US, it’s nearly impossible to imagine doctors and patients accepting a randomization to either surgery or non-surgery — it’s very difficult to do such randomizations in a system where people are used to having much more control. Continue reading


Ask Us, Q&A
Lung/Thoracic Cancer Expert Content

Archives

Share

GRACE Cancer Video Library - Lung Cancer Videos

 

2015_Immunotherapy_Forum_Videos

 

2015 Acquired Resistance in Lung Cancer Patient Forum Videos

Share

Join the GRACE Faculty

Breast Cancer Blog
Pancreatic Cancer Blog
Kidney Cancer Blog
Bladder Cancer Blog
Head/Neck Cancer Blog
Share

Subscribe to the GRACEcast Podcast on iTunes

Share

Email Newsletter icon, E-mail Newsletter icon, Email List icon, E-mail List icon

Subscribe to
GRACE Notes
   (Free Newsletter)

Other Resources

Share

ClinicalTrials.gov


Biomedical Learning Institute

peerview_institute_logo_243