In the final installment of our series on lung cancer, we continue our conversation with one of the nation’s leading experts.
Dr. Ross Camidge, MD, PhD is a well-known lung cancer specialist and director of the thoracic oncology clinical program at the University of Colorado.
In this article, we discuss statistics, emotional responses and exciting advancements in understanding and treating lung cancer.
dailyRx: Lung cancer is generally considered to be one of the worst forms of the disease. True?
Dr. Camidge: If you look at the absolute number of deaths, then yes. So when people are diagnosed with lung cancer, and their friends and family get on the Internet, they often get very depressed. But these numbers are misleading.
Like any other cancer, the sooner it's diagnosed, especially if it can be found before it has spread too far, the better. Even with advanced stage lung cancer, though, you have to be careful with the statistics you can find online.
Dr. Google can be both a friend and an enemy - the reason being that what you'll see are averages, and no patient is average.
Oncology, and particularly thoracic oncology, is now becoming an encyclopedia of different diseases on the molecular level.
The other reason the statistics on survival can be misleading is that if you're looking at 5-year survival rates, the data are least five years old. And in many centers, we're doing things very differently than we did five years ago.
When this comes up in the clinic what I tend to say is, ‘We don't know if that data will apply to you. We have to see how well you're going to cope with treatment, how well it's going to work and many other subtleties that will all influence whether you are going to do better or worse than the average.’
dailyRx: Is there a lot of shame around a lung cancer diagnosis?
Dr. Camidge: It’s not really shame. I think a lot of smokers are not surprised when they're diagnosed with lung cancer. The thing is they've made a conscious decision to smoke, and I don't think they necessarily feel that guilty.
However, I think these feelings of having contributed to the disease themselves sometimes keeps patients from seeking the best care available to them. Sometimes they don’t fight for themselves as much as some other cancer patients do.
If they broke their leg, they would still go out and find the best person to fix it. Sometimes, that fight has to come from others, and often that’s where the families come into their own.
On the other side of the coin, if you've never smoked and you're diagnosed with lung cancer, on top of dealing with your disease, you have to deal with everyone asking you if you were a smoker. I find many of my patients get very irritated by this.
All this boils down to, though - is you need to treat the person and you need to treat the disease. The causes of why this disease occurred are not immediately relevant for the person sitting across from you who has been diagnosed with lung cancer.
dailyRx: Should we even be treating advanced lung cancer?
Dr. Camidge: I guess you don’t want an emotional answer to that one - or a rude one. This issue was addressed in principle about 20 years ago. Then it was a valid question to ask as the treatment was toxic and usually involved some sort of chemotherapy and palliative (providing comfort only) radiation, and on average these treatments worked but didn't seem to extend life very much.
However, even then we were dealing with averages. Some people benefited enormously from the treatment, sometimes with a much better trade off compared to the side effects they experienced, and others didn't.
Back then, we didn't know how individual patients would respond until we began treatment. Today, at least for some treatments, we have much better clues as to who will benefit from a given therapy before we put them on it than we did a decade ago.
Even for unselected therapies like most chemotherapies, the treatments have become more effective and less toxic, and our supportive care has become better.
There's more and more data now that suggests even if you're old and frail - if you can tailor the treatment to the individual, then you can extend life, and it can be good quality life.
But, we warned against averages and the question every treating physician needs to ask themselves as they consider or try any treatment is: “Is the treatment worse than the disease?" And if it is, they shouldn't give it.
dailyRx: The recently approved drug Xalkori (crizotinib) seems to offer new hope for people with non-small cell lung cancer.
Dr. Camidge: Yes, specifically for those with an ALK gene rearrangement that can now be tested for on the tumor biopsy. But it is also important because if demonstrates that other subtypes are likely to exist (if you find one planet next to a new star, you don’t stop looking, you start looking harder…) and our treatment paradigms are likely to get a lot more personalized in the near future.
dailyRx: Talk about other recent breakthroughs.
Dr. Camidge: I think the two most exciting breakthroughs on the close horizon are the advent of immunotherapy in lung cancer, particularly exploiting the programmed death (PD-1) pathway – that seems to produce activity across many of the genetic divisions we are currently creating. And secondly, the idea of the brain as the next battleground for targeted therapies.
New data show that a very high percentage of patients with EGFR or ALK driven cancers progress on their targeted therapy through growth occurring in the brain. This may reflect inadequate drug exposures in this part of the body, as opposed to a change in the biology of the cancer.
If we could just figure out a way of getting drugs directed against the targets we already know are valid into the brain, we would significantly affect the lives of many patients.
Fortunately, the brain is starting to be more formally assessed within trials of new drugs, and I am optimistic the brain in lung cancer will start to get the attention it really deserves.
We’d like to thanks Dr. Camidge for taking time to offer us important insights into lung cancer – its development, treatment and research advancements.