In an interview with Targeted Oncology, Zangmeister Cancer Center Medical Oncologist Jorge A. Rios, MD, discusses recent advances in non-small cell lung cancer and the role targeted and immune checkpoint inhibitor therapy has played in this progress. Read the article.
On August 1, Messino Cancer Centers (MCC) and American Oncology Network (AON) join the Lung Cancer Foundation of America for World Lung Cancer Day, celebrating the researchers, clinicians, and patient advocates who exemplify what “Living with Lung Cancer” looks like. We’re also raising awareness of the need for ongoing and expanded lung cancer research to continue building upon the advances that have given greater hope to patients who receive this devastating diagnosis.
Lung cancer is the third most common cancer in the U.S. It also claims more lives – both men and women – than any other type of cancer. Yet there is room for optimism, thanks to the significant advances in early diagnosis and treatment.
It was not that long ago when chemotherapy was the only real option when it came to treating metastatic lung cancer. Now, we have a broader selection of treatment tools at our disposal, which has helped improve life expectancy for non-small cell lung cancer and small cell lung cancer.
At MCC, my practice centers around systemic therapy, where medications are given intravenously or orally and disseminate throughout the body to target cancer wherever it lurks. While chemotherapy – which attacks rapidly dividing cells – is still used in frontline treatment, we now have additional types of treatment including targeted therapy and immunotherapy.
With targeted therapies, we leverage the knowledge that certain types of lung cancer can have specific gene mutations, so-called driver mutations, that create hyper-activated protein products. As their name implies, these mutations drive the formation, growth, and dissemination of these cancers. Targeted therapies are designed to inhibit the production of these driver mutations. Doing so creates a catastrophic response that kills the cancer cells and shrinks the tumor.
Immunotherapies are another advancement that have completely reshaped how oncologists treat lung cancer. The idea of immunotherapy is decades-old, the premise being that our immune systems recognize cancers as foreign, but cancer cells evade attack by immune cells. Early attempts at overcoming so-called immune evasion involved deploying high dose cytokines to hyperactivate immune cells, but these are fairly toxic and have a very narrow scope of activity.
More recently, the molecular mechanisms of so-called checkpoints between tumor cells and immune cells that mediate immune evasion have been delineated by immunologists. This has directly led to the development of antibodies that block these checkpoints, allowing a patient’s immune system to bypass these checkpoints and proceed to attack and kill the cancer cells. Immunotherapies are now ubiquitously deployed in metastatic lung cancer with or without chemotherapy and tend to be more durable and less toxic than chemotherapy.
When it comes to lung cancer therapies, MCC plays an active role in their advancement by participating in clinical trials to uncover the next cutting-edge treatment. In addition to an affiliation with the Southeast Clinical Oncology Research (SCOR) Consortium, our partnership with AON paved the way for us to become a strategic research site for Sarah Cannon Research Institute. These relationships help us bring clinical trial opportunities to more of our patients than would otherwise be possible as an independent community-based practice.
For example, researchers are looking at combining standard of care immunotherapies with a new investigational drug that could potentially boost their effectiveness. Participating in these kinds of clinical trials help evaluate effectiveness of drugs or treatment routines – and give our patients the opportunity to participate in approved and exploratory therapies without need for travel to an academic center.
It’s also important to point out that, in addition to novel therapies, palliative care is now established as fundamental to frontline care of lung cancer patients. The so-called Temel study – published in the New England Journal of Medicine in 2010 – found that early palliative care not only led to significant improvements in both quality of life and mood among patients with metastatic non-small-cell lung cancer, but actually prolonged survival compared to usual care. Early palliative care is now a standard of care in non-small cell lung cancer and a motivation for MCC’s recent addition of Dr. Joshua Baru, a consummate palliative physician, to our clinical team.
There is no question that, when it comes to the diagnosis and treatment of lung cancer, research has allowed us to move the needle on both survival and quality of life. A cure has yet to be found, but the dedication of oncologists, clinical researchers, patient advocates and patients themselves has resulted in life-altering advancements that mean a lung cancer diagnosis comes with a level of hope that exceeds what we’ve seen in the past.
Though lung cancer may not be the most common type worldwide, it nonetheless kills more men and women in the United States each year than any other type of cancer. Thankfully, the number of people dying from non-small cell lung cancer—the most common type of lung cancer—has sharply declined in recent years, according to a study published in the New England Journal of Medicine by Howlader et al. This is a result of both the decline in tobacco use (particularly among men) as well as the increased effectiveness of new lung cancer treatments.
At Zangmeister Cancer Center, we offer all the cutting-edge, Food & Drug Administration (FDA) approved treatments available, as well as investigational treatments being studied through the National Cancer Institute Community Oncology Research Program (NCORP).
Precision medicine is an approach for disease treatment and prevention that takes into account individual variability in the genes, environment and lifestyle for each person. It has significantly impacted how cancer care providers help patients with lung cancer. Currently, physicians select the best treatment based on an in-depth analysis of the patient’s tumor. This analysis allows for the search for genetic alterations that could be treated with therapies that target that specific alteration (targeted therapies) and helps sort out patients more likely to benefit from other treatments such as immunotherapy. These targeted therapies and immunotherapies have helped drive down lung cancer mortality rates at an accelerated rate over the last seven years.
Targeted therapies have a high success in controlling disease growth, with shrinkage of tumors that can be seen in roughly 80% of patients using this treatment. This is significant in comparison to a 30%-40% rate of response with chemotherapy treatments — and can add 10-12 months and in some case more than 20 months to a patient’s survival compared to chemotherapy.
Currently, immunotherapy, through drugs called immune checkpoint inhibitors, have firmly established a role in the treatment of advanced non-small cell lung cancer. In this type of treatment, medicines are used to help a person’s own immune system identify and attack cancer cells. One out of every four patients with advanced non-small cell lung cancer receiving these treatments are alive at five years. Since not every patient receiving these treatments obtains the same benefit, the scientific community is actively looking for different strategies to identify those that would benefit the most, as well as how to increase the number of patients that have good outcomes.
Both immunotherapy and targeted therapies are making inroads in the treatment of patients with locally advanced and early stages of lung cancer, which had previously been treated only with surgery or radiation and/or chemotherapy. The use of these therapies in early-stage lung cancer seems imminent in the near future.
While lung cancer CT screens have a significant impact in the reduction of lung cancer mortality rates, the strategy is underutilized due to a variety of reasons such as logistics and cost. Consequently, liquid biopsies are currently being tested as a potential strategy to overcome the limitations of low-dose lung CT screening.
Liquid biopsies could help doctors screen for cancer long before a patient has any symptoms and could also be administered after surgery to check for the presence of any residual cancer. Other screening strategies, such as the analysis of exhaled volatile organic compounds and quantification of lipids in the blood of patients, are currently being tested as well.
Prior to the development of targeted therapies and immunotherapy, a patient with advanced lung cancer had a less than 5% chance of being alive after two years. Currently, approximately one in four patients with advanced lung cancer can be alive at five years. Newer technologies such as liquid biopsies, artificial intelligence and “omics” approaches are exciting opportunities that could have the potential of further improving the outcomes in patients with lung cancer at all stages.
14543 Global Parkway
Suite 110
Fort Myers, FL 33913