The Picture Brightens for Lung Cancer

According to the Lung Cancer Research Foundation, one in 16 people will be diagnosed with lung cancer in their lifetime. It is the third most commonly diagnosed cancer, comprising around 12% of new cases. And despite its relatively lower incidence, it remains the deadliest cancer, the number one cause of cancer deaths for both men and women.

While these facts appear to paint a bleak picture, things are much brighter for patients with lung cancer than they have ever been. It is far from the untreatable disease it was once considered, but that fact is often overlooked when it comes to discussing treatment advances for various cancers.

In fact, over the last 15 years, nearly three dozen new drugs have been approved for lung cancer, including more refined approaches like targeted therapy and immunotherapy, which has emerged over the last several years. These drugs, coupled with new screening methods that can detect lung cancer earlier than ever, have resulted in it becoming a highly treatable disease with substantially better survival rates.

“I’ve been doing this for about 35 years now. For the first time, I am now able to realistically talk to a patient who comes in with advanced lung cancer about a five-year survival. Not that many years ago, I’d say one-year survival was a 50/50 proposition,” said Martin Edelman, Chair of the Department of Hematology/Oncology and Associate Cancer Center Director for Clinical Research Integration at Fox Chase Cancer Center.

However, despite the push toward early detection and the development of more personalized and effective treatments, screening numbers remain stubbornly low nationally among those who are eligible. The reasons for this disconnect include problems with lack of referrals and the potential stigma that still surrounds a lung cancer diagnosis, which is often solely associated with cigarette smoking.

“What’s important to remember is that anyone can get lung cancer regardless of smoking history. It’s not necessarily just related to tobacco or asbestos exposure, although those certainly are major risk factors,” said Edelman.

Despite this complex picture, Fox Chase and Temple Health have developed an exemplary lung cancer treatment program, one that utilizes top-of-the-line diagnostic tools, ongoing clinical trials, and large multidisciplinary tumor boards that assist in the development of nuanced treatment for each individual cancer case.

The Statistics

Nationally, lung cancer survival rates have begun to rise, but according to the report, only 26.6% of cases are diagnosed at an early stage when the five-year survival rate is much higher — approximately 63%. Unfortunately, 44% of cases are not caught until later stages when the five-year survival rate is only 8%. 

These statistics can be puzzling, particularly given the ease of lung cancer screening. “These appointments take approximately 10 to 15 minutes. I would say it’s no bigger a time commitment than it would be for something like a mammogram, for example,” said Edelman. A low-dose computed tomography (LDCT) scan is currently the only recommended screening tool for detection of lung cancer.

“The lungs don’t have pain fibers in them, so the reason lung cancer is so deadly is because unless it’s picked up with screening, which is very important, symptoms may not appear until much later,” said Joseph Friedberg, Thoracic Surgeon-in-Chief at Temple Health and a Professor in the Department of Surgical Oncology at Fox Chase.

To encourage these early screenings and prevent late-stage diagnoses, the American Cancer Society updated their screening recommendations to include a wider age range and a lower pack-year smoking history. “Pack year” refers to someone who smokes a pack a day for one year.

While the new guidelines provide an opportunity for more at-risk individuals to be screened, the numbers of those doing so continues to lag.

One program designed to make lung cancer screenings more accessible in the Philadelphia area is the Temple Healthy Chest Initiative (THCI), which uses LDCT scans that can also detect COPD, emphysema, and other conditions. An intensive communications effort to get the word out about this program has been wildly successful.

From 2017 through 2020, Temple Health facilities performed an average of 39.7 LDCT screenings per month, but between April 2022 and January 2023, that increased to an average of 187.5 per month. The effort has also resulted in higher percentages of Black (39.94% versus 4.5%), Hispanic (17.79% versus 1.8%), and female (53% versus 41%) patients receiving LDCTs in comparison to the National Lung Screening Trial. Several abstracts have been published on THCI, and other hospitals have looked to it as a model for similar programs at their own institutions. Temple Health also offers other options to support patients being treated for lung cancer. (See “Temple Lung Center Manages Comorbidities in Lung Cancer Treatment,” below.)

But even if the screening hurdle is cleared, the possibility of stigma that still surrounds a lung cancer diagnosis due to its association with smoking may also be a deterrent to testing for many patients.

“It’s not infrequent that you’ll hear stories from patients diagnosed with lung cancer where one of the first questions they hear from someone is ‘Did you smoke?’ That’s very different from when a patient is diagnosed with any other cancer type, including those that are also known to be linked to smoking. It almost insinuates blame,” said Sukhmani Padda, Vice Chair of Medical Oncology at Fox Chase Cancer Center at Temple University Hospital. And if the patient does make it to screening, that process can reinforce preconceptions.

“While smoking is linked to lung cancer, many people who never smoke get lung cancer and those who do smoke may never get lung cancer,” said Padda. “We know that stigma is impacting people undergoing lung cancer screening and that may be one of the factors of why the uptake is so low in the United States.”

Edelman noted that even if all smoking-related lung cancer cases were eliminated, it would still be the seventh most common cancer. “Ten percent of lung cancer patients are people who never smoked. That doesn’t sound like a lot of patients, but it actually would make it one of the most important cancers. I see at least one patient every month who never touched a cigarette who has lung cancer.”

For these patients, Temple Health and Fox Chase offer the services of the Never Smoker Lung Cancer Clinic, which opened in 2019. It offers standard-of-care treatments and clinical trials for lung cancer patients who have never smoked or have a light smoking history. 

Improvements in Treatment

While screening numbers are not quite where they should be nationally, the incidence rate of new lung cancer cases being diagnosed in Pennsylvania has improved by 20% and the overall survival rate in the state has improved by 27%. In Pennsylvania, the rate of cases caught at an early stage improved by 10% over the past five years.

These improvements are likely a direct result of the increased diagnostic and treatment options that have become available over the past few decades. A variety of newer tools, including imaging technology and biopsy procedures, are used to detect and diagnose lung cancer and create a personalized plan for treatment.

Refined diagnostic tools like robotic bronchoscopy, which has been used at Fox Chase since the technology first emerged several years ago, allow physicians to reach formerly inaccessible areas of the lung with greater control. With this technology, physicians have a 3-D visualization of the patient’s lung anatomy throughout the procedure and are able to obtain tissue samples for biopsy. But identifying a tumor is only the first step in determining care.

“I think another thing about lung cancer, and it’s a bit shocking, is that it has become the most complex cancer to treat in some ways because it requires an extensive evaluation of the tumor for immunologic and genetic markers to determine the right therapy,” said Edelman.

ED CUNICELLI

Even lung cancers that result from some of the most commonly mutated genes require precision oncology tailored to the gene’s specific subtype. The KRAS gene, for example, is the most common oncogene-driven form of non-small cell lung cancer. According to Padda, it became one of the earliest known potential targets for lung cancer in the 1980s, but it has been very difficult to target and was often considered “undruggable.” As proof of that, the first KRAS inhibitor was not approved until 2021.

“To give an example of precision oncology, we now have 10 genomic targets in lung cancer with associated targeted therapies approved by the Food and Drug Administration,” said Padda. “So it’s not enough to just say it’s a mutation in the KRAS gene, you have to say exactly what the specific mutation is. For example, we now have two drug approvals just for the KRAS^G12C mutation subtype of lung cancer. We also have to understand the treatment landscape to make sure the patient is getting access to all of the approved options.”

Part of understanding that landscape and making treatments more effective is a continued effort to under-stand how individual biology affects the development and growth of cancer, as well as disparities among lung cancer patients. (See “Lung Cancer Progression and Racial Disparities,” above.)

“This is not a single issue that we’re dealing with. It’s everything from making sure people get screened, the navigation of that initial diagnostic process, and then assuring that all these treatment options are available in an equitable manner,” said Edelman. “The therapeutic options for lung cancer may be far more complicated, but they are also far more promising than they were in the past. And development is continuing at a remarkably rapid pace.”

The Fox Chase and Temple Difference

Despite these advancements, a lung cancer diagnosis at any stage can be an unwelcome experience. Physicians at Fox Chase and Temple Health know that this multifaceted disease requires specialization that spans the cancer care continuum.

“What really sets the Fox Chase and Temple Health team apart when it comes to lung cancer and disease is our exceptional level of expertise. Our physicians, surgeons, medical oncologists, and radiation oncologists treat nothing but lung cancer. So we stand out from some of the other areas where an oncologist might see a variety of different cancers,” said Hossein Borghaei, a medical oncologist and Chief of the Division of Thoracic Medical Oncology at Fox Chase.

JOE HURLEY

This expertise is demonstrated from the moment of diagnosis. Fox Chase’s molecular pathology lab offers reflexive testing, in which a series of initial molecular tests are performed and subsequent tests follow depending on the original results. This process helps determine which specific mutations may be present in a tumor. “The benefit of this is that patients don’t have to wait a long time to get the results of the testing, and the doctors don’t have to wait, so we can make a treatment decision a little bit earlier,” said Borghaei.

In addition to streamlined testing, Fox Chase and Temple patients have access to breakthrough drugs that may not be available elsewhere through Fox Chase’s Early Clinical Drug Development Phase 1 Program, which facilitates the testing of early-stage cancer treatments.

“We have a very active and well-run phase 1 program. Many of my patients have participated in a phase 1 clinical trial and have been able to have access to drugs that could become the standard of care 7 to 10 years later,” said Borghaei.

Perhaps the most direct, comprehensive way physicians at Fox Chase and Temple are able to provide nuanced lung care is through tumor boards. “The Thoracic Tumor Board is one of the best I have ever been part of, mainly because of the valuable feedback of so many specialists across Fox Chase and Temple,” said Friedberg. Drawing on the vast experience of this group, physicians develop the most effective and uniform approach to treating some of the most complex lung cancer cases.

“The tumor board and our excellent phase 1 program are just a few of the ways Fox Chase and Temple are working to improve the lives of patients with lung cancer. We still have a long way to go, but there are infinitely more options and hope for lung cancer patients than there used to be. I think that in itself is remarkable progress,” said Friedberg.