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Dr. Jack West is a medical oncologist and thoracic oncology specialist, and Executive Director of Employer Services at the City of Hope Comprehensive Cancer Center in Duarte, CA.

A Non-Scientific Assessment of Better Lung Cancer Outcomes
Sat, 05/02/2009 - 08:37
Please Note: While this is Still Excellent Background Info, New Treatments and Procedures Have Emerged Since this Original Post
Howard (Jack) West, MD, Associate Clinical Professor, Medical Oncology, Executive Director, Employer Services, Founder, President and CEO of GRACE

This week I happened to see a man in my clinic who I had first met at the time of his diagnosis with metastatic lung cancer more than five years ago. He's from another part of Washington state, and this was his first time back with me to revisit treatment options. For me it was a time to take a step back and reflect on how well he's done, with the real question being whether this represented a real change in what we can expect from lung cancer or whether he represents an outlier and that our so-called progress is really modest (as suggested by some of the sobering statistics described in a recent New York Times article). But from the standpoint of an oncologist with a particular interest and expertise in lung cancer, I feel like I'm seeing more lung cancer patients doing better and better than the numbers would indicate. The gentleman I saw this week is now in his late 50s and is lifelong never-smoker who presented with brain mets (immediately treated with whole brain radiation) and a good amount of disease in his chest. Since meeting me during his initial workup, he's been managed by a very good community-based general oncologist in a small town in eastern Washington. He was treated with initial platinum-based doublet chemo (old school cisplatin/gemcitabine, actually), then taxotere (docetaxel), and both of these approaches were associated with mild benefit, though nothing spectacular. He started tarceva (erlotinib in early 2005 and had a great response that lasted about three and a half years, then had some new areas of bony metastatic disease. His oncologist actually added alimta (pemetrexed) to his tarceva, an approach I don't really favor (my take on the evidence is that there may well be an antagonistic effect between EGFR inhibitors and at least some if not most standard chemo approaches used for NSCLC). Though he's showing evidence of mild progression again, what's limiting his activity is degenerative joint pain in his hip and a need for a hip transplant (he had one last year that helped a lot). Otherwise, he's a genuine cowboy and is planning to literally get back in the saddle after surgery, which I strongly encouraged. And we talked about a bunch of options, but what impressed me most is the thought that we could be revisiting treatment options for him over many years to come. And this from a man who presented with multiple brain metastases over five years ago.

The stats for advanced NSCLC show that the median survivals we're achieving on clinical trials are gradually shifting up by a month or two every few years. We're reporting endpoints like two year survival for advanced NSCLC, which was not routinely reported before, but now we're seeing more and more patients achieving new milestones. These are hugely meaningful, because these general numbers apply to the broader population of patients with metastatic NSCLC. But what's also powerful is what I believe is a real shift toward a growing subgroup of patients with advanced lung cancer who are achieving longer term outcomes than we ever envisioned. For us and for patients, it can give a real sense of hope for what's possible. Though the stats from 20,000 may not show anything striking yet, we'd expect a lag time of years before stats reflect what we're seeing on the ground. I truly believe that while the stats show a modest benefit, part of the story is not yet being captured by the stats: those of us on the ground are seeing more longer-term survivors.

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