How to live well with lung cancer: A treatment option guide

Lung cancer is one of the leading causes of cancer cases and deaths in Ohio and nationally, and it’s responsible for more cancer-related deaths than breast, colon and prostate cancers combined.

If you smoke, vape or use tobacco products, you are at higher risk for lung cancer, but smoking isn’t the only risk factor — lung cancer does appear in non-smokers.

“You don't have to smoke to get lung cancer. You just have to have lungs to get lung cancer,” says Regan Memmott, MD, PhD, an oncologist at The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute (OSUCCC – James).

For those who smoke or have a history of smoking (30 pack years), low dose CT scan screening is available. But less than 10% of those who are eligible for lung cancer screening are being screened, says Robert Merritt, MD, a thoracic surgeon at the OSUCCC – James and director of the Division of Thoracic Surgery at The Ohio State University College of Medicine. You can get screened if you’re age 50-80, have a history of smoking one pack per day for 30 years and currently smoke or have quit within the past 15 years. 

Drs. Memmott and Merritt were among several specialists from the OSUCCC – James and The Ohio State University Wexner Medical Center who recently spoke at the first “Living Well with Lung Cancer” patient symposium hosted in Columbus by the nonprofit Breath of Hope Ohio.

“It can be scary to hear that you have lung cancer. However, I think that if you or a loved one has been diagnosed with lung cancer, there's great reason to be hopeful. Just in the past 10 years, we've made some major advancements.” — Regan Memmott, MD, PhD

Dr. Memmott and others at the symposium shared their expertise on a wide range of topics, from biopsy and surgery to treatment options, genetic testing and pain control. Synopses of their presentations are below.

Lung cancer biopsy and staging

— Jasleen Pannu, MBBS, pulmonologist, Director of Interventional Pulmonology Translational Research, clinical assistant professor

Pulmonologists, or lung specialists, are usually the gatekeepers of patients who learn they have lung cancer. These patients may have multiple symptoms, from fatigue to coughing up blood, wheezing, shortness of breath, infections or weight loss, but often they have no symptoms.

Pulmonologists take patients toward the next step of diagnosis by determining “staging,” or how much the cancer has spread, and whether it’s blocking the airway that needs to be reopened. Many patients may get a PET (positron emission tomography) scan, usually the next step after a CT (computerized tomography) scan, to highlight suspicious areas.

The pulmonologist may then perform a biopsy at the site of the cancer, removing a small piece of tissue for testing. We choose a safely accessible area and progress further if we don’t get the answers we need. The goal is to use efficient, safe techniques to minimize the number of procedures and risk. We have multiple conferences with other specialists to discuss cases and determine the most appropriate approach.

A bronchoscopy involves looking at the airways from the inside using a thin scope, about 6 millimeters in size, with a camera and a light at the end. We use ultrasound, 3D CT imaging and computer software to guide us to our intended targets, and have different tools, including forceps, that we can send into the airways to retrieve tissue for testing. We also examine lymph nodes, which are outside the airways and targeted with the help of a thin needle.

The airways are like hollow branches of a tree that we sometimes have to follow to get to a suspicious spot. We have several tools, including some robotic instruments with thin catheters, that can travel deep into those airways toward the edge of the lungs.

Another way of performing biopsy is to insert a needle into the chest from the outside to retrieve a tissue sample.

Biopsy is used to determine diagnosis, next steps and treatment options, but it cannot treat the cancer itself. However, pulmonologists may be able to help relieve symptoms through procedures by removing fluid around the lungs, inserting catheters to manage fluid or removing, freezing or burning tumors that block the airway and make it difficult for the patient to breathe.

Lung cancer surgery

— Robert Merritt, MD, thoracic surgeon, director of the Division of Thoracic Surgery, clinical professor

I perform operations on patients with early-stage non-small cell lung cancer who usually have a solitary lesion in the lung, without any spread. The goals of surgery are to completely remove the cancer and lymph nodes, restore function and minimize pain.

Surgical options for early-stage lung cancer include:

• Lobectomy — removal of a lobe of the lung
• Bilobectomy — removal of two lobes
• Sublobar resection — also referred to as a lesser resection, sometimes used for people with emphysema or chronic obstructive pulmonary disease (COPD).
• Pneumonectomy — removal of an entire lung, used rarely, when a tumor involves central structures of the lung

For lobectomy in patients with tumors less than 6 centimeters, we can use a minimally invasive robotic approach that limits pain and complications, decreases the hospital stay to two or three days and allows patients to return to a normal function a lot faster.

Usually, four incisions are made, and a surgeon sits about 5-6 feet away at a console with complete control of the high-tech instrumentation and an excellent view of the patient’s anatomy. We’re able to detect the internal structures very safely and use special instruments to dissect and cauterize without any bleeding.

This robotic surgery offers similar survival rates to other forms of surgeries. When it comes to removing lymph nodes, it performs similarly to traditional surgery and better than video-assisted surgery.

Genetic testing, liquid biopsy and lung cancer

— Heather Mikesell, MS, LCGC, genetic counselor, Guardant Health

When a person has cancer, little pieces of DNA from the tumor are found floating in the bloodstream. These bits of DNA are referred to as “circulating tumor DNA.”  We can analyze them through liquid biopsy, which is really a fancy name for getting your blood drawn. Traditionally, genetic testing on a cancerous tumor had to be done through a tissue biopsy, but now liquid biopsy can be used to either complement a tissue biopsy or in some cases, can be used instead of a tissue biopsy.

It’s important to look at the DNA in a tumor and see what mistakes, or mutations, are present in that DNA, because we now know what kinds of mutations can drive a cancer to progress. Researchers have been able develop medicines to target specific mutations and kill cancer cells.

Genetic testing through tissue and/or liquid biopsy helps doctors find the best, most individualized treatment for each person. If someone can get on the right treatment the first time, their lifetime can be lengthened and quality of life can be significantly improved. Sometimes they can live years longer and have more time with loved ones than if they’d been treated with a general treatment like chemotherapy.

It’s important to note that, when we talk about circulating tumor DNA, we're talking about mutations that are present in the tumor itself, but not present in the rest of the body. These mutations generally aren’t the types of mutations that can be passed down to children or be present in other family members.  The purpose of genetic testing on a cancer is provide doctors another tool in their toolbox to determine the best treatment for their patients.

Radiation treatments for lung cancer

— Jeremy Brownstein, MD, radiation oncologist, clinical assistant professor

Radiation is one of the three main ways that we treat cancer, alongside surgery and chemotherapy or systemic therap. About a third of lung cancer patients undergo radiation treatment.

While surgery can target a specific cancer tumor or mass, chemotherapy or systemic therapy works throughout the whole body. Radiation is kind of a cross between the two. It can target larger tumors as well as smaller areas. But it only works where we point it.

Radiation is delivered while you're lying flat on a table, and a big machine called a linear accelerator rotates around you, shooting beams of X-rays from all different directions. Each one of those beams goes all the way through you and deposits a little bit of radiation along the way. But a high dose is delivered only where those beams overlap, like a magnifying glass focusing sunlight onto a point.

A big part of my job is to make sure we're putting all these beams in the right place. We do this by having you come in ahead of time for a CT simulation scan to determine where to focus those beams. The scan takes a 3D movie to account for your breathing, and we work with radiation physicists and analysts, who use computer software to consider millions of possible beam angle shapes and combinations to find the perfect plan. This all gets delivered to a 3D detector for review.

We also make a custom cushion molded to the shape your back to ensure you’re in the same position when you receive treatment, and we draw some marks on your body to help radiation therapists position the table in the correct space. Once you’re on the table, we take another CT scan and place it on top of the planning scan. If you’re not lined up perfectly, the computer will automatically move the table to be perfectly aligned. Treatment takes three to seven minutes, and you shouldn’t feel it.

Radiation can be used to treat all stages of lung cancer. For early-stage lung cancer, we can do a very simple treatment, with three to five high-dose treatments, that kills the tumor 85% to 90% of the time.

For cancer that’s moved into nearby lymph nodes, we give radiation for six weeks alongside chemotherapy, often followed by immunotherapy. For metastatic cancer that’s spread further, we may be able to target a spot that continues to grow while everything else is controlled by other therapies. We can also use radiation to treat symptoms of metastatic cancer that can’t be cured, to control pain and improve quality of life.

Chemotherapy and other systemic therapies for lung cancer

— Regan Memmott, MD, PhD, medical oncologist and assistant professor

As medical oncologists, we don't just have chemotherapy in our arsenal to treat lung cancer. We now have two new types of drug treatments: targeted therapy and immunotherapy. And whether chemotherapy, targeted therapy or immunotherapy is the best treatment to help someone fight their lung cancer depends on features, or biomarkers, that are particular to the specific person.

Targeted therapies: While mutations drive cancer to grow and spread, I also like to think of them as the cancer’s Achilles’ heel. And that's where genetic testing or biomarker testing comes into play.

The National Comprehensive Cancer Network (NCCN) guidelines strongly recommend that we test for mutations in nine different genes because, in recent years, we’ve developed drugs that can target these mutations and kill cancer cells. Many of these drugs can be given as a pill that can be taken at home, have fewer side effects than chemotherapy and are helping patients live years longer.

They’ve been developed for the treatment of non-small cell lung cancer, but doctors and scientists are working very hard to try to determine the driver mutations that are in small cell lung cancer and develop therapies for them as well.

Immunotherapy: Unlike targeted therapy, immunotherapy is helpful for both non-small cell lung cancer and small cell lung cancer. Drugs that we refer to as immune checkpoint inhibitors reprogram a person's own natural immune system to better identify, attack and kill their lung cancer.

The likelihood that an immune checkpoint inhibitor can reprogram a person's immune system is related to a molecule on the cancer cell surface known as PD-L1. If a person's lung cancer has particularly high levels of PD-L1, their cancer could be effectively treated using immunotherapy alone.

NCCN guidelines strongly recommend that oncologists test a patient's cancer for PD-L1.

It's important to note that some patients whose tumors have certain driver mutations don't respond well to immunotherapy. So, if you're a patient whose lung cancer has one of those driver mutations, you want to make sure that your treating oncologist is giving you targeted therapy and not immunotherapy.

Immunotherapy’s big promise for changing how we treat lung cancer

Supportive care for lung cancer

— Julia Agne, MD, palliative medicine specialist, clinical assistant professor

Palliative care is a medical specialty that really wears two hats.

One of our hats is really aggressive symptom management for patients with serious illness. And when we think about symptoms related to lung cancer, that could be anything from pain to shortness of breath, anxiety or low mood, nausea, vomiting, difficulty sleeping or difficulty coping. We get involved early, screen for symptoms, help patients learn to manage and treat them and follow the patient throughout their treatment and cancer journey.

The other hat that we often wear is communication between doctors and patients. We ask patients what they’re hearing about their cancer diagnosis and treatment and next steps.

I hear from a lot of patients that, when they meet with their doctors, they may think they understand everything perfectly crystal clear. And then five minutes after the doctor leaves the room, they think, “Oh, but wait, I forgot something.” Sometimes palliative care specialists can be that link that can help you navigate those questions.

With lung cancer, it's really important to involve palliative care because studies have shown that patients who get their symptoms managed, who see a palliative care specialist earlier in the disease course, have a higher quality of life and live longer than patients who don't have access to palliative care.

I’ll also mention that a lot of people have a misperception that palliative care is the same thing as hospice care. It’s actually a spectrum. Palliative care is a specialty that follows you along that pathway when you're getting treated for cancer, for however long that could be. We even help patients who are cancer survivors. We’re a link along the pathway when you're being treated and living with your cancer diagnosis.