Dr. Frank Detterbeck and Dr. Lynn Tanoue, Lung
Cancer Awareness Month 2008
November 30, 2008
Welcome to Yale Cancer Center Answers with Dr. Ed Chu and Dr. Ken Miller. I am Bruce Barber. Dr. Chu is Deputy Director and Chief of Medical Oncology at Yale Cancer Center and he is an internationally recognized expert on colorectal cancer. Dr. Miller is the Director of the Connecticut Challenge Survivorship Program and he is also the author of "Choices in Breast Cancer Treatment." If you would like to join the discussion, you can contact the doctors directly at canceranswers@yale.edu or1-888-234-4YCC. This evening, as we reach the end of lung cancer awareness month, Ed and Ken welcome the Directors of the Yale Cancer Center Thoracic Oncology Program, Dr. Frank Detterbeck and Dr. Lynn Tanoue. Dr. Detterbeck is a Professor of thoracic surgery at Yale and Dr. Tanoue is a Professor of pulmonary medicine.
Tanoue
Unfortunately, lung cancer is a very common cancer. It is the most
common cause of death from cancer, and if you add up the number of
cancer deaths from lung cancer, it exceeds the combination of
breast, prostate, colorectal, and pancreatic cancer deaths.
More women will die of lung cancer than ovarian cancer and breast
cancer, and more nonsmoking women will die of lung cancer than
ovarian cancer, so it is a very common cancer. Unfortunately,
it claims a lot of lives.
Miller
Let me ask you a little bit more about that. On one hand, it
is not as common as breast cancer, but on the other hand, there are
more women dying of it. How do you explain that?
Tanoue
We do not have a good way of early detection, and I think that is
one of the important things that lung cancer research needs to
focus, on a way to screen. We do not have that right now, and there
is relatively poor awareness of the fact that lung cancer is so
common, and breast and ovarian cancer have gotten a lot more
attention over the last several decades; although that is
changing.
Chu
When we think of lung cancer, what are the typical risk factors
that one should be aware of?
Detterbeck
Certainly the thing that comes to everyone's mind is smoking, and
there is no question that smoking is the major risk factor, but
many people stop thinking after smoking, and there clearly are
other risk factors. We certainly see lung cancer in
non-smokers; in fact over half of the people that we diagnose with
lung cancer now are people that quit smoking years and years ago. I
am not talking about quitting two weeks ago, but 20-30 years
ago. In fact, if you look at lung cancer in non-smokers, it
is equal to people with lymphoma. It is not a minor group of
people. What are other factors? Well, family history is
clearly one. If you have a first-degree relative with lung
cancer corrected for any second-hand smoke exposure or whatever,
you clearly do. There clearly is some genetic factor.
There are occupational exposures; asbestos is one of the major
ones. If you have evidence of obstructive airways disease,
emphysema, that is an independent risk factor, independent from
whatever effect smoking may have had.
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Chu
One thing that I think is commonly misunderstood, that I hear a
lot from patients, is that they have quit smoking 15-20 years ago.
Does the risk of developing lung cancer go completely to 0, or is
there still a residual risk for developing lung cancer?
Detterbeck
There clearly is solid residual risk; it does not go to 0.
Even the early studies, I think, were misinterpreted in suggesting
that the risk goes down to 0. Certainly the risk diminishes
relative to continued smoking, but it never goes down to that of a
non-smoker. Whatever risk you have built up during your years of
smoking you sort of maintain through your life. You do not
build it up any higher, but you do not really lose whatever you
have built up.
Tanoue
I just want to add something to what Dr. Detterbeck said, and that
is that the risk diminishes when you stop smoking, and that is true
no matter how old you are. So, people who stop smoking when
they are 50 and 60 and 70, have a decrease in their lung cancer
risk as well as, importantly, a decrease in their cardiovascular
and cerebrovascular risks. The chance of having a heart
attack or stroke goes down quickly, and the chance of having lung
cancer goes down steadily over time. While it never reaches the
level of a never smoker, it gets pretty low.
Chu
And what about this issue of second-hand smoke, we have heard a lot
about that issue recently and I am just curious what each of you
thinks about second-hand smoke and the risk for developing lung
cancer?
Detterbeck
It clearly is a risk factor. There is no question about it,
but I think it has been overblown. For example, the risk with
a first-degree relative who had lung cancer is about 400% higher
than that of a non-smoker without a first-degree relative.
The risk with second-hand smoke is about 40% higher. We are
talking 10 times higher with a family history, and yet we talk
about second-hand smoke 10 times more than we talk about family
history.
Miller
Let us say someone is at higher risk, and we will talk about a few
populations; one are people that smoke, the second are people that
were smokers, the third are people with a family history or some
combinations of those, what constitutes good screening, is their
any screening?
Tanoue
There is no recommendation to screen the population at large.
For people who recognize that they have risk because they have a
lot of factors such as they smoked, they have emphysema, they have
a family history, and they may have had occupational exposure, that
is different than the population; that is an individual decision.
If an individual person feels they have excessive risk because of
those factors, that is something they should speak about with their
physicians and then a very conscious decision needs to be made
about whether or not to
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pursue an imaging study like a chest x-ray or maybe even a CT scan, but those are conversations that should happen between an individual and their own physician.
Chu
There has also been a lot recently in the news about the beneficial
effects of CAT scans, as you just mentioned, and I am just curious,
where do you weigh in on the role of CAT scan for early detection
screening of lung cancer?
Detterbeck
Certainly CT has been studied a lot. There have been a lot of
efforts towards having a screening test for lung cancer, but we are
not there. One of the things we have realized with CT scan is that
we are picking up a different spectrum of disease. We pick up
things that are very slow growing, very indolent tumors that we did
not really pick up as well, and I think we are still struggling to
understand what we do about those tumors. We do not necessarily
want to approach those with the same approach as the more
aggressive lung cancer. Screening changes the spectrum of
disease, you have to understand that as well, and without
understanding it better, I do not think we can define where that
fits at this point.
Chu
In your Thoracic Oncology Program, what do you recommend in terms
of say an individual, like Ken said, that has a high risk for
developing lung cancer?
Tanoue
I think those individuals, again, have to speak with their
physicians who know their history and can appreciate all the
nuances of their risks and an individual decision needs to be made
as to whether to pursue any sort of imaging study to look in a more
directed fashion. As a population though, there is no
evidence right now that there should be screening done on a general
level the way mammogram is done for breast cancer, PSA for
prostate, and so forth.
Detterbeck
One of the issues with screening is that you really need to look at
the risk, and I think that underscores what Lynn was saying.
Patients should discuss it with their physician and put some
thought towards it. Screening a broad population, people over
50 that smoked for some period in their life, we are not there to
recommend anything on that, but if you can increase the pool of
people that are at higher risk, now that is a different group of
people to look at, that is a different situation, so I think that
is a very important piece of it.
Miller
We get a number of E-mails from people saying, "What is the very
best way to find out if I have breast cancer or prostate cancer?"
Let me pose a clinical question. A patient sits in front of
you and says, "Doctor, listen I want to be as vigilant as possible,
I have been a smoker, I wish I had not been." What is the
gold standard in terms of what you would tell that patient if he or
she was sitting in front of you?
Tanoue
Again, there is not a gold standard, that is the problem. We
certainly appreciate that mammography and PSA, even colonoscopy,
will pick up lots of findings that
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are abnormal, but not cancer, and we can deal with those, those are reasonably easy places for us to do a biopsy. The problem with CT scanning, which was supposed to help us with this, is that it is too sensitive. What I mean by that is that when you do a CT scan, particularly in a population of people who smoked even 10 packs a day for years, it is very, very likely you will find something. In fact, these studies, of which there have now been a number of, find abnormalities in one scan, just the first scan, in between 12% to over 50% of the people being screened. Of those many abnormalities, maybe 1% to 2% of them are cancerous, so you have to deal with the other 98% to 99% of them which are not cancers, but to know that confidently often requires many imaging studies over time. This requires waiting and being able to live with that, and invasive things like biopsies or even surgeries, and that is what Dr. Detterbeck was talking about with risk. These are procedures that can carry risks and complications, so at the present time the benefit of doing things like CT scanning is outweighed by the risk of those procedures and our increasing knowledge that some of these cancers that we pick up this way are probably never going to hurt people, the way that little prostate cancers that we pick up by high PSA often would not hurt somebody, but we do invasive procedures to figure that out. Weighing all those things right now it is probably more harmful to do the screening with CT studies on a population basis than not to do them.
Chu
For prostate cancer, obviously we have PSA, and now there are some
blood tests emerging to detect ovarian cancer at earlier stages. I
am just curious, where are we in terms of trying to develop simple
blood tests that might be able to identify high-risk populations
who would have lung cancer?
Detterbeck
There has been work done in that regard. There is actually a
paper that was just published a few weeks ago from Yale by Joanne
Weidhaas and Frank Slack. They looked at microRNAs, which are
relatively new. It is something that had not been recognized
for a long time, and the thing about microRNAs is that they can
influence an abnormality and the microRNA can influence a lot of
different genes so it potentially has a lot more effect.
Previously they were not very well understood. What this
study showed is that the incidence of a genetic mutation in a
particular microRNA was much higher in people who develop lung
cancer than in a baseline population. In other words, this
potentially is a way of trying to figure out who is at higher risk.
As we have talked about before, if we can figure out who is at
higher risk, we are a whole lot further along in saying, perhaps
this is an appropriate population to do CT screening on.
Miller
Let me change the topic a little bit. You see a lot of new
patients, unfortunately, with lung cancer, what symptoms do they
report?
Tanoue
Individuals should seek medical attention for things like
persistent cough, if you
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are coughing up blood, if you have chest pain that does not resolve itself, fevers that do not go away, or symptoms that persist and are unusual. Definitely always seek medical attention.
Detterbeck
I want to underscore that. We probably can detect lung cancers
earlier if people pay more attention to subtle symptoms. It
is another area of research that we want to pursue. Many
people quit smoking for reasons that I think they are not entirely
clear about, and then within a year they are diagnosed with a lung
cancer. If we study this a little bit more, we realize that there
are reasons why they quit smoking, and if we can pick up on that
and be more aware of that, I think that we stand a chance to get an
edge on those people that have a lung cancer already there.
Chu
We are going to take a break. We will be back after a medical
minute to hear more about lung cancer with Dr. Lynn Tanoue and Dr.
Frank Detterbeck from Yale Cancer Center.
Miller
Welcome back to Yale Cancer Center Answers. This is Dr. Ken
Miller and I am joined by my co-host Dr. Ed Chu and our guests, Dr.
Frank Detterbeck and Dr. Lynn Tanoue from Yale Cancer Center.
We are talking about lung cancer. So we were talking about these
subtle symptoms that people may have that can perhaps give us some
clues. When a patient has those types of symptoms, how would
you evaluate it, and how do you make the diagnosis for that
matter?
Detterbeck
First of all, I would encourage people, if they have some subtle
symptoms, that it is probably a good idea to talk with their
physician about it and not blow it off for a long period of
time.
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Chu
Who should they see, their family doctor, an internist, or should
they go and see a pulmonary specialist such as Dr. Tanoue?
Tanoue
I think their family doctor, or their internist is always the best
bet because that person usually knows the patient. Then if that
physician feels that a referral should be made to a specialist,
they can choose which appropriate specialist to make that referral
to. I would strongly encourage everybody to keep their family
doctor in the loop. You want somebody who will steer your
little boat, even if there are many oars rowing.
Chu
Just following up with that, what kind of tests would be done once
an individual goes to see their general family doctor?
Detterbeck
Certainly one of the straight forward tests is a chest x-ray, and
while there is pretty good data from a number of studies done in
the past that a screening chest x-ray just on a broad population is
not really worthwhile, I think that is a very different situation
from someone who comes in with some subtle symptoms and it is not
so clear. That is a very different situation, and one should not
say chest x-ray has proven not to be useful in that
situation. I think we have gone a little bit wrong in that
regard. We often see people who had some symptoms, they were
seen, and yet it took six months before they ever got a chest
x-ray.
Miller
After a patient is diagnosed, does everybody have surgery of some
kind?
Detterbeck
No, I think you need a biopsy of some sort, but it used to be said
that if you can't have surgery there is really nothing that can be
done, and that is certainly not true. Surgery as a
treatment for a lung cancer certainly is a major treatment, but we
have excellent radiation and excellent chemotherapy drugs. In fact,
I have backed off, and I think many in the surgical community have
backed off in a number of situations, from doing a surgery because
we get such good results with other treatments. Surgery is not
necessarily the only treatment that works. The other thing
though that we have learned is that a combination of treatments is
in many situations more effective than just one treatment
alone.
Chu
Can you tell us a little bit about what happens if a patient is
diagnosed with lung cancer as is seen by your Thoracic Oncology
Program at Yale? What goes into deciding what kind of treatment
should be initiated for an individual patient?
Tanoue
The group consists of thoracic surgeons like Dr. Detterbeck,
pulmonologists like myself, medical oncologists, radiation
oncologists, social workers, pathologists, diagnostic imagers,
nuclear medicine, and so forth. Our job at that initial
evaluation of a new patient is to decide if they have a lung
cancer, if a biopsy needs to be done, and what the stage is. Lung
cancer, like all solid organ cancers,
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is classified as different stages. For lung cancer it is I through
IV. The initial assessment of what the best treatment is will be
based on the stage, so the very important focus of the group of our
tumor board is to decide what the likely stage is, because that
guides the initial assessment about treatment.
Detterbeck
Let me add to that in a general way, I think that many diseases
have become more complex and there is a greater knowledge base.
There is not any one person that knows everything about a
disease. Everybody has sort of a different chunk of it and a
different view. The key thing is to get that collective brain power
and judgment working, so our policy is that all major decisions
about patients, whether it is how they should be evaluated or how
they should be treated, are made by the whole team. It does
not mean the patient needs to see a whole bunch of different
people, but it gets discussed so that the collective wisdom and
judgment of that whole team can be brought to bear on making that
decision.
Miller
Frank, let me ask you about minimally invasive surgery for lung
cancer, what does that mean?
Detterbeck
Things have changed dramatically. It used to be an operation
for lung cancer. It was a big incision, and often required
removal of a rib, and it was very painful and a big ordeal. Now the
majority of resections that we do for a lung cancer, or for
anything really, are done with a video camera with about a quarter
inch incision for the video camera and some other incisions that
are about a half to three quarters of an inch long. It is much less
invasive, and it is much less painful. Typically people are
in the hospital about 2-1/2 to 3 days, and usually within a week or
2 people are getting around quite well. It is a very
different experience because we have modified the incision and how
invasive the operation is.
Chu
As we were talking about earlier, many patients at risk for
developing lung cancer have underlying lung disease. Is there a
need requirement to try to assess their underlying lung function
status before they can be taken for surgery?
Tanoue
Absolutely, any patient who is going to be having thoracic surgery,
whether it is in the old style with a big incision which is less
common, or with a videoscopic approach, should have their lung
function assessed. Particularly with the minimally invasive
approach, the recovery is easier but that patient will have gone
through a big surgery nonetheless, so it is important to assess
their pulmonary function to see if there is something that can be
done preoperatively to maximize that function, or to anticipate
postoperatively if there might be any needs.
Detterbeck
We also have to be careful about what we consider to be too high
risk. There are a lot of nuances about that and certainly
some of the data that we have applies to the old style operation,
and it is pretty clear that with minimally invasive
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techniques and newer things, mortality is lower. There is also a reason to select some people that have really poor lung function because in fact their lung function is going to be better, but you have to be careful about choosing those patients; it is not a simple answer.
Chu
When surgery is done, is there any role for follow-up therapy such
as radiation therapy or chemotherapy?
Detterbeck
In many situations, as I had mentioned earlier, we do a lot more
combination treatments. Not in all situations, in some situations
we do so well with surgery alone that there is really no reason to
add anything. But, in many situations, we know that we do
fairly well with surgery, but we clearly do somewhat better by
adding some additional treatment. Most often it is additional
chemotherapy, and to a lesser extent, radiation.
Miller
There is a lot of exciting work going on throughout the country,
and at Yale also, what are some of the trials you are working on
and some of the projects that you are excited about?
Tanoue
We have clinical trials open for nearly every stage of lung cancer,
and it is very important that patients have access to new drugs and
new therapies because they take advantage of all the scientific
discoveries that have been made over the past few years. For lung
cancer, there have been some incredibly exciting advances that have
changed the way that we approach patients. Five years ago we
probably would not have given chemotherapy in addition to surgery
for some patients with early stage lung cancer, but it is clear now
that we can get improved survival and decreased death over time
when we use these multiple approaches to patients even with early
stage disease. We are really interested in the kind of
research that Dr. Detterbeck discussed earlier, how can we define
patients who are at higher risk? Can we predict whether patients
who have had cancers are going to go on to relapse? We have been
collaborating with colleagues at Yale, friends in the pathology
division, to try to identify biochemical markers that we can see in
biopsy specimens, and perhaps even in blood, to identify
populations that might benefit from other therapy, novel therapies,
and so forth.
Detterbeck
Just to add a little something about clinical trials, clinical
trials sometimes represent a very new drug, for example one that we
do not have a lot of experience with, but that is not the only
situation. There are many clinical trials that use drugs that
have been used quite a bit, but they are used in a slightly
different combination. What it really represents is a very
carefully thought out organized way of providing treatment, that
some of the best minds in the country have gotten together and
discussed, and think that this is a better way to do things.
It is very well thought out, it is very well organized. That is a
reason why, in general, people do better if they are treated on a
clinical trial than if they get the
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same treatment interventions but done off trial, it is just not as
organized and it tends not to give us as good results.
Chu
Frank, we are hearing a lot about the role of targeted therapies,
either alone or in combination with chemotherapy, to treat patients
with lung cancer. Following up on what you just said, could you
tell us a little bit about what is going on in terms of trying to
combine those new targeted molecules with traditional
chemotherapy?
Detterbeck
Clearly it has been an exciting time in lung cancer and targeted
therapies. One of the reasons for that excitement is when we
understand a particular tumor and why this tumor is growing, and
when we can flip that switch off, we have dramatic results.
Unfortunately, we do not understand quite as well how to pick those
patients, and we only know that a switch exists for a relatively
small number at this point, but we have come a long way to
understanding that better and there is a lot of research going on
in this area.
Miller
Projecting into the future, if you had a crystal ball, which none
of us have, but what do you think the big breakthroughs will be in
terms of treating lung cancer?
Tanoue
I think there will be many. We need to understand better how
to define populations at risk, and we need to focus on
understanding the biology of these tumors so that we can develop
targeted therapy and broader treatment approaches for patients who
do develop cancers.
Detterbeck
I want to add how important it is to be treated and seen in an
organized way and be appropriately staged. There is a recent study
that suggests that by just doing a better job of evaluating
patients we will increase the survival for patients with lung
cancer about five times as much as for things that we call
breakthrough new treatments.
Chu
I think that is a terrific message to end the show on. You
have been listening to Yale Cancer Center Answers and we would like
to thank our guest experts, Dr. Frank Detterbeck and Dr. Lynn
Tanoue for joining us this evening. We look forward, Lynn and
Frank, to having you back on a future show to hear more about what
is going on with the Thoracic Oncology Program. Until next
time, I am Dr. Ed Chu from the Yale Cancer Center wishing you a
safe and healthy week.
If you have questions for the doctors or would like to share your comments, go to www.yalecancercenter.org where you can also subscribe to our podcast and find written transcripts of past programs. Next week, Dr. John Colberg and Dr. Richard Peschel join Ed and Ken to talk about prostate cancer. I am Bruce Barber, and you are listening to the WNPR Health Forum from Connecticut Public Radio.