Basic Cancer Info

It has become a common topic of conversation on this site (and in the lung cancer community at large) to discuss mutations in the epidermal growth factor receptor (EGFR). However, since we frequently throw out the terms “deletion 19 mutation”, “L858R”, and “T790M”, I thought would be worthwhile to explain a little bit about the different EGFR mutations and what we know about their clinical significance.

Here's a video slide presentation that provides a basic introduction to bronchioloalveolar carcinoma (BAC), including the demographics, natural history, imaging appearance, and patterns of response that make it a unique subpopulation within lung cancer. The audio only version is below the video.

With all this recent talk about never-smokers with lung cancer, and the interest in stories of patients with so-called “oligometastatic” cancer (minimal metastatic burden to perhaps a single site), I thought I would describe a recent case in my clinic as an illustration of how I use this information in everyday decision making. Mrs. D, a very fit 36 year-old woman with a young child at home, presented to her family doctor last year with back pain. It didn’t seem to be getting better, so her doctor ordered an x-ray of the back which showed a very nasty-looking spot in the lower spine.

One of the general rules in oncologist is that we typically use our most effective treatments first, and often early, though there are certainly exceptions. Women with metastatic breast cancer may have a higher response rate by receiving combination chemotherapy than single agent chemo, but when a gentle single drug chemotherapy or hormone therapy option will do very well and provide fewer side effects, that’s usually the approach we recommend until bigger guns are needed.

Tarceva and Iressa (some of you may remember this drugs from a few years ago) have certainly become popular drugs for treating lung cancer, specially in the adenocarcinoma type of lung cancer. Drs. Pennell and West have discussed tarceva in other posts on this website – how it works, who benefits the most, what is the impact of certain mutations on the effect of the drug. Unfortunately, we are also too well familiar with the fact that these drugs don’t work forever and the cancer relapses even after having initially responded well.

Back when I first started doing this, one of my earliest posts (see here) was on the question of whether EGFR tyrosine kinase inhibitors (TKIs) (see introduction to this work in prior post).

I'm very happy to present an audio interview with Dr. Eric Vallières, an excellent thoracic surgeon and Surgical Director of the Lung Cancer Program at Swedish Cancer Institute. Within the lung cancer community, he actually happens to be among the most well known thoracic surgeons in the country and even world, and he has a major expertise in the integration of chemotherapy and other systemic therapies for early stage lung cancer.

One of the most pressing issues in lung cancer research is in identifying patients who could benefit from a particular drug, both to increase their chances of having a good outcome and to spare everyone else from an ineffective drug with unnecessary toxicity. There have been some exciting advances in this field, but before I elaborate I want to give some (simplified) background on how drugs are traditionally developed. Classically, potential cancer drugs are tested on cancer cell lines in a Petri dish, and if the drug appears to kill the cells, it is then tested in animals.

Several years ago, we learned that EGFR tyrosine kinase inhibitors (TKIs) were not a very helpful strategy for an unselected population of frail patients in the US, clearly inferior to standard chemotherapy (see prior posts here and here).

About 18 months ago, I wrote a post about a new technique being developed that looks at the pattern of proteins in the blood of a patient in order to determine whether a patient is likely to do well or poorly after receiving an EGFR tyrosine kinase inhibitor like tarceva (erlotinib) or iressa (gefitinib) for advanced NSCLC.