Radiotherapy for Lung Cancer

July 19, 2021

Information

July 18, 2021

Yale Cancer Center

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00:00Funding for Yale Cancer Answers
00:03is provided by Smilow Cancer
00:05Hospital and AstraZeneca.
00:08Welcome to Yale Cancer Answers,
00:09with your host,
00:10Doctor Anees Chagpar.
00:12Yale Cancer Answers features the latest
00:14information on cancer care by
00:16welcoming oncologists and specialists
00:18who are on the forefront of the
00:20battle to fight cancer. This week,
00:22it's a conversation about radiotherapy
00:23for lung cancer with Doctor Henry Park.
00:26Dr. Park is an assistant professor
00:28of therapeutic radiology at
00:29the Yale School of Medicine,
00:31where Doctor Chagpar is a
00:33professor of surgical oncology.
00:36Henry, maybe we can start off by
00:38you telling us a little bit more
00:40about yourself and what you do.
00:42I'd be happy to, so I grew up in Jersey
00:45and first came to Yale as a college
00:47student about 18 years ago.
00:50I stayed at Yale for medical
00:52school and moved to Boston for two years.
00:54And then I focused on public
00:56health and I received an MPH
00:57in public health at Harvard.
00:59I then stayed there for
01:01my medical internship and
01:02returned to Yale about eight years ago
01:06and after my radiation oncology residency
01:08I joined the faculty about four years ago.
01:10So as a radiation oncologist,
01:12I specialize in helping patients
01:13who have a cancer diagnosis to
01:15figure out if radiation therapy
01:17is the right choice for them.
01:19I focus primarily on treating
01:20patients with lung cancer as well
01:22as those with head and neck cancer,
01:24and I see patients in New Haven and
01:26in Waterford and help to manage
01:28their care throughout the course
01:30of their radiation therapy and
01:31really work with the surgeons and
01:33the medical oncologists together as a team
01:36to try to figure out what are the
01:38best recommendations that we can
01:40give for each individual patient.
01:42Henry, let's talk a little bit more
01:45about lung cancer and how it's treated.
01:48I mean, for many of our listeners
01:51there may be questions about
01:53how exactly we decide
01:55whether a patient should be
01:58treated with surgery or with chemotherapy,
02:00or with radiotherapy,
02:02or with a combination of all
02:05three or two of the three.
02:07Tell us more about how those decisions are made.
02:11It's a very complex discussion
02:12we have often with the patients
02:14as well as each of us from the
02:17surgeons and the medical oncologists,
02:19as well as the radiation oncologists.
02:21We meet once a week at a lung
02:23tumor board which is every Monday and
02:25we get together and discuss any
02:27situations that might be challenging
02:29for us to to decide what the right
02:32combination or treatment is.
02:33The overarching goal though is to
02:36be individualized with with how
02:38we make recommendations and
02:40to make sure that we're meeting
02:42the goals of the patient as well.
02:44So we want to really focus on that.
02:47Primarily,
02:47radiation is specifically a non
02:50invasive and invisible as well as
02:52very precise way of treating many
02:54kinds of cancers and for lung
02:56cancer specifically it is very useful in
02:59multiple different kinds of contexts.
03:00And it really depends a lot on
03:03the stage of disease as well
03:05as the patients status,
03:06health status and goals.
03:08So for example,
03:10for stage one lung cancer,
03:12when the disease is very localized,
03:17we really often choose between
03:19surgery and radiation therapy for
03:22a patient to try to figure out
03:24how best to cure their cancer.
03:26So we've found overtime that
03:28this technique called SBRT or
03:30stereotactic body radiation therapy
03:32serves as an excellent alternative
03:34to surgery in certain patients.
03:36We use a high dose of radiation per session.
03:41Over just three to five treatments
03:43using this very precise technique
03:45in order to target these small
03:48localized lung tumors and then to
03:50try to eliminate them completely.
03:52But for more locally advanced disease,
03:54we had to make the decision about
03:57whether or not we need to use
04:01chemotherapy with radiation together.
04:03Often we will need lower doses of
04:05radiation each day and spread out over
04:08multiple weeks of daily treatment
04:11in order to to be able to treat
04:14larger volumes of disease,
04:15especially when the disease
04:17has spread to the lymph nodes,
04:19we still do this with
04:22a curative intent most of the time
04:24but sometimes we decide that there's
04:26some situations where
04:28chemotherapy first is helpful,
04:30followed by surgery.
04:31Other times we do chemo-radiation,
04:34meaning chemotherapy and radiation
04:35therapy together, and
04:36other times,
04:37chemo and radiation followed by surgery,
04:39so there really are
04:41multiple options that depending
04:43on exactly where the tumor is and
04:45how it's spread and what we think
04:48each patient can tolerate in terms
04:50of the treatment,
04:51we often have to make
04:53those recommendations and discuss
04:55those options with each patient.
04:59Getting back to where you started with early
05:01stage lung cancer, stage one,
05:04when you said well,
05:07we need to make the decision
05:09about using SBRT versus surgery,
05:11it sounds to me
05:14like many patients may opt for
05:17SBRT if these two are equivalent.
05:19Here you have radiation therapy
05:21which is non invasive, painless.
05:23Three to five days I believe
05:26you said versus surgery,
05:28which is clearly invasive.
05:29Often will result in a hospital
05:32stay and so are these
05:34really equivalent or is one superior?
05:42It's hard to say for sure.
05:44We have not yet been successful as a specialty,
05:49either surgery or radiation oncology,
05:51at comparing head-to-head in a
05:53randomized trial to be sure of
05:55that answer about exactly which
05:57patients are best for surgery
05:59and which are best for radiation.
06:01We do know that when you compare them
06:03in terms of patients who receive
06:06surgery and receive radiation therapy,
06:08that those who have received
06:10surgery often have
06:11better outcomes than those
06:13who had radiation therapy,
06:14but we don't know if that's because
06:17of the fact that patients who
06:19get radiation therapy may not
06:20always be candidates for surgery,
06:23or may not be the best suited
06:25for surgery either.
06:26So that's why we don't
06:29know for sure about that.
06:31Typically, if patients can get surgery,
06:33and if the surgeons believe that they can
06:36take the tumor out
06:39without causing too much of a
06:41functional deficit,
06:42meaning that your lung
06:45function can handle our surgery and
06:47that you as a patient can handle the
06:50surgery and recover well from it
06:52if it is expected that can happen,
06:55then our gold standard still is surgery.
06:57At this point, however,
06:59we believe that radiation,
07:00especially for those who are not
07:03good surgical candidates, meaning
07:05that surgery would likely lead to
07:07a major issue with their quality
07:10of life going forward
07:11and that recovery may be too
07:14much for a patient,
07:15then we believe that radiation,
07:17especially this SBRT technique,
07:19does achieve very good outcomes.
07:21We're still working on trying to
07:23complete a clinical trial to try to
07:26compare surgery and radiation therapy
07:28for those who are eligible for either one,
07:31but it is has been hard to get enough patients
07:36on this clinical trial to answer
07:38the question fully so far.
07:41The clinical trial is
07:43currently open and enrolling at the VA.
07:49There have been other clinical trials
07:54that did not have enough
07:57patients to answer the question fully,
07:59but when they combine the results
08:01of those studies they found among
08:04the patients that did
08:06receive SBRT who were
08:08also eligible for surgery otherwise
08:10but did receive SBRT,
08:13did have very good outcomes and
08:15seemed to be just as good as surgery
08:18in those small number of patients,
08:21but we don't have enough patients yet on
08:23one of these randomized trials to know
08:26for sure if radiation is truly
08:29a fully adequate alternative to surgery,
08:32for those who can get surgery.
08:38I know on this show I'm often standing on
08:41a soapbox talking about clinical trials.
08:44But if these two modalities truly are
08:47equivalent, the only way that
08:49we're going to in practice offer SBRT to
08:52all patients is if we have the clinical
08:55trial data that compares head-to-head and
08:58demonstrates that they're equivalent.
09:02And the signal so far is that based on
09:05combining results of trials that
09:08didn't meet their accrual target,
09:10it looks like these two are equivalent.
09:13But it would really be a tremendous
09:16advance to avoid surgery in patients
09:19we could offering them SBRT.
09:23Am I correct in assuming that SBRT has fewer
09:25side effects than surgery long term?
09:29Are there side effects to the SBRT
09:31as well that cause patients
09:34difficulties in breathing
09:36or reduced lung capacity and so on
09:39and so forth that they should be
09:41concerned about?
09:42There are in the short term,
09:45we believe that SBRT has
09:47fewer side effects,
09:48so often for patients who may be
09:50older or have more other medical
09:53issues or who may not be able to
09:55withstand the recovery very well
09:57from surgery in the short term,
10:02we feel confident that SBRT has fewer
10:05side effects in that short term.
10:07However, as time goes by,
10:09I think the other issue here is
10:11long term follow up and long term
10:13survival as well as side effects.
10:15The side effects do accumulate
10:18overtime and the more we learn about
10:20SBRT which has been in widespread
10:22practice for only about 15 years or so,
10:26not as long as surgery has been around,
10:28so we don't have as much long
10:31term data as a surgery does.
10:33But we know in that three
10:35to five year period that
10:37as you go further along in that period,
10:40close follow up is really required because we
10:42need to see how the side effects accumulate.
10:46And sometimes they don't present
10:48themselves for a couple of years
10:50or a few years afterwards.
10:52So we do want to watch closely for that,
10:55because there can be side effects,
10:57especially with lung function.
10:59Overall in the lung function,
11:01as inflammation occurs and
11:02eventually scarring as part of
11:05the healing process is that
11:07ultimately,
11:07we may see that the pulmonary
11:09function may decline more gradually
11:11overtime compared to surgery,
11:13where the decline tends to be
11:15a little on the sooner side,
11:17so that's why it's really nuanced and subtle.
11:22So there are some
11:23differences there,
11:24but both of them have their
11:26risks and side effects,
11:27and that's why we encourage our
11:29patients to meet both the surgeons
11:31and the radiation oncologists who
11:32have stage one disease to really
11:34determine what exactly is expected
11:36for each individual patient.
11:37The other thing about radiation, just as it is NOTE Confidence: 0.93686986
11:40for surgery, is it depends
11:42on where exactly within the lung
11:44the tumor is arising from.
11:47So if it's right in the middle
11:49of the lung, far away from other
11:52organs, then
11:53the side effects may be less, however, if
11:56the tumor is closer to the
11:58esophagus or the airways,
12:00or to the ribs,
12:01you might see other side effects
12:03that are beyond the lung themselves.
12:06So for example,
12:07if we get treatment very close
12:08to the esophagus,
12:10we might expect that we'll see some
12:12more difficulty with swallowing
12:13or painful swallowing, heartburn,
12:15things like that,
12:16and then if it's too close to the airways,
12:19we might see some bleeding, more cough.
12:23If it's too close to the ribs
12:25or the chest wall or the back,
12:28sometimes we'll see some pain that can
12:30arise even a couple of years afterwards,
12:32so it's not a benign treatment completely,
12:34but the side effects generally
12:36are well tolerated for
12:38most patients.
12:40And what about long term side effects?
12:42I realized that you said that SBRT is
12:45relatively new in the past 15 years or so,
12:48but with other
12:50cancers treated with radiation,
12:52people are often told about
12:54the possibility of secondary
12:55malignancies and worry about that,
12:57especially with scarring
12:58that takes place and so on.
13:00Is that something that patients
13:02should be worried about in lung
13:04cancer treated with SBRT as well?
13:09It is something we counsel our patients
13:11about and we don't know for sure if
13:14radiation really leads to, in the lung
13:16at least, if it really leads to
13:18significantly increased risk of
13:19other lung cancers down the road.
13:21Because often when patients get one
13:23lung cancer, it doesn't matter
13:25what kind of treatment they get,
13:27they are often more prone to other lung
13:29cancers that we watch very closely for.
13:32So if something comes back in an
13:33area that was previously radiated,
13:35we may not know if that was because
13:38of the radiation, or because it
13:40would have happened anyway,
13:41but we do see that sometimes
13:43where lung tumors do come up,
13:45both in the areas where there was a
13:48previous radiation as well as other
13:50areas of the lung or in the body,
13:52that really had nothing
13:53to do with the radiation
13:55so it is hard to know for sure.
13:57But it's something that we
13:59counsel our patients about,
14:00that theoretical risk that
14:02radiation can lead to a second
14:04malignancy many years down the road,
14:06but it seems to be less of
14:08a problem for lung cancer
14:10then it is for other kinds of
14:11cancers like breast cancer.
14:15We're going to take a short
14:18break for a medical minute and
14:20then come back and talk more
14:22about radiotherapy for lung cancer
14:25with my guest doctor Henry Park.
14:26Funding for Yale Cancer Answers
14:28comes from Smilow Cancer Hospital,
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15:37More information is available at
15:40yalecancercenter.org. You're listening
15:41to Connecticut Public Radio.
15:44Welcome back to Yale Cancer Answers.
15:46This is doctor Anees Chagpar
15:48and I'm joined tonight by
15:50my guest Doctor Henry Park.
15:53We're talking about radiotherapy for
15:55lung cancer and right before the
15:57break we were talking about the use
15:59of radiation therapy and specifically
16:01SBRT for the management of stage
16:04one or early stage lung cancer.
16:06So Henry, you were mentioning that
16:08radiation also may play a role in more
16:11advanced cancers that are locally advanced
16:13and not metastatic.
16:15But one of the questions
16:17that often comes up is,
16:19sometimes we use
16:21chemotherapy alone and sometimes
16:23we use chemotherapy plus radiation
16:24combined at the same time.
16:26How do we make those decisions?
16:30So that's a very good question.
16:32We do that based on seeing
16:34exactly where the disease has spread.
16:36So if it has gone to the lymph
16:38nodes that are still in the chest,
16:41or if it's a very advanced tumor in the lung
16:44that seems to be invading
16:45other structures in the chest,
16:47then that's often where we consider this
16:49to be locally advanced but not metastatic,
16:51meaning that it has not spread to other
16:54organs throughout the body like the
16:56brain or the liver or other areas.
16:59So in that case
17:00we still do approach this with
17:03the intent to cure,
17:05so we use some kind of combination,
17:08typically of chemotherapy with radiation.
17:10Or some kind of combination
17:12of chemo with surgery,
17:14with or without radiation, so for those patients
17:17it really depends on
17:20the similar features that
17:23we look for in early stage lung cancer.
17:26Given how much the patient can tolerate and what
17:29they're willing to tolerate,
17:31as well as the amount of
17:34disease that needs to be treated.
17:37The surgeons will weigh in about how much
17:41lung would have to be removed in
17:43order to do the adequate surgery
17:46and we will weigh in about how much
17:49the normal organs nearby will receive
17:51radiation therapy and how much
17:53we think the patient can take and
17:56ultimately will be able to come up
17:58with a recommendation about what the
18:00best approach is to usually combine
18:02at least two types of therapy and
18:05sometimes three in order to achieve the
18:07best outcomes.
18:09In early stage lung cancer,
18:11you talked a little bit about
18:14deciding between surgery and radiation,
18:16and I think we get the concept that
18:19both surgery and radiation therapy
18:22are local modalities designed to
18:24treat lung cancer in the lung itself.
18:27So one question that comes up is,
18:30if my cancer is resectable,
18:33say I've got
18:36locally advanced lung cancer,
18:38I'm going to get chemotherapy.
18:40The surgeons say it's resectable.
18:42Having you decide then whether
18:45to add more radiation therapy or
18:47whether to leave it with
18:49the surgery alone.
18:51Often we decide that we don't add
18:53more radiation therapy afterwards or
18:55we don't add radiation therapy at all.
18:58It's a conversation
18:59with the surgeon about whether or
19:03not they think they can resect this
19:06tumor after the chemotherapy.
19:07Sometimes they may prefer to have chemo
19:09and radiation together before surgery,
19:11or they may prefer to have the
19:14chemotherapy alone before surgery.
19:15We used to do more
19:18radiation therapy after surgery.
19:20But like you mentioned before,
19:22clinical trials being so important,
19:24there's been a recent clinical trial
19:26this past year that showed that
19:28for those patients who had certain
19:30types of lymph nodes or in certain
19:32locations, that adding radiation
19:34therapy after surgery may not be
19:36as necessary as we once thought.
19:38And so far the five year survival
19:40numbers have just been released as well
19:43for stage three disease and are at
19:45least 10% higher than we've ever seen
19:48in really any clinical trial.
19:51Either involving surgery or not involving surgery.
19:58I can't emphasize enough how
20:00important these clinical trials are
20:02to really moving the field forward.
20:04Are all patients eligible for immunotherapy given that data?
20:08Or do we look for certain biomarkers
20:11to decide whether or not they
20:14would be candidates for that?
20:17Most patients are eligible for it
20:19after chemotherapy and radiation
20:21if they have stage three disease,
20:24we may not always give it afterwards.
20:26Depending on their response to
20:28the chemotherapy and radiation,
20:30so we'd require before receiving
20:32that that we have another scan
20:34that shows that there's not new
20:36disease elsewhere already starting.
20:38We'd also want to be sure that
20:40patients have tolerated
20:42the chemotherapy and radiation well
20:44enough to start the immune therapy,
20:47and there's other biomarkers like
20:49PDL1 that are very helpful
20:51in determining how likely the patient
20:54is to respond to immunotherapy as well.
20:57Right now we still do offer it even for those
21:00who do not have the PDL1 marker.
21:04But it may not be as helpful
21:07in those patients as it is for
21:10those who have a high PD L1 expression.
21:12Given those data
21:14than the fact that we offer
21:16immunotherapy regardless of PDL1
21:18status and the fact
21:20that the clinical trials
21:21have demonstrated that chemo,
21:23radiation therapy followed by immune
21:25therapy without surgery offers
21:27tremendous survival benefits,
21:28do we ever offer surgery to
21:31stage three patients anymore?
21:33We still do.
21:35I think there's certain circumstances
21:36still where we don't know what the role
21:40is yet of surgery with immunotherapy
21:43and if we still get good outcomes from
21:46let's say, chemo with surgery afterwards,
21:49or chemo and radiation, then surgery
21:52and we'd save the immunotherapy,
21:54which didn't really exist during
21:56the time of the surgical trials,
21:58then you know, could we still
22:00get good outcomes from that?
22:02We believe we may be able to.
22:05We still don't have that clinical
22:07trial data yet to prove that yet.
22:09But as we move forward,
22:11there's other trials that are
22:13currently being considered right now about
22:16combining immunotherapy with surgery as well.
22:18And even in the earlier stage setting that's
22:21I think becoming more and more
22:23studied seeing
22:26if that is going to be helpful and
22:29and as the months and even
22:31as the days and weeks go by,
22:34new data comes out all the time
22:36from clinical trials that changed
22:38the way we think about the best
22:40way of treating stage three lung cancer.
22:43And so when we were talking about
22:45stage one and even locally advanced
22:47up to stage three lung cancer,
22:49you used the term curative intent
22:51and can you explain to our listeners
22:54what you mean by curative intent and
22:58what the alternative is?
23:00The concept there is that we are
23:03hoping to eliminate the tumor so
23:05that it does not grow and come back
23:08at any point in the patients life.
23:10Are we always successful at that?
23:12No, but we would approach it
23:14with the intention of doing that,
23:17and that's supposed to palliative
23:19intent where the goal is to help with
23:22alleviate symptoms that may come up.
23:24For example, if the disease has
23:27already spread outside of the chest,
23:29we may be approaching the disease
23:31more in that capacity in terms of
23:34the treatments that we may offer.
23:36However, in the past five to 10 years,
23:39there's a lot of wiggle room in between
23:42where we may not necessarily believe
23:44we will completely eradicate the tumor
23:47with any combination of therapies,
23:49but that we believe we can extend
23:52survival and extend Disease Control
23:54for years afterwards,
23:55and we're often successful at doing that and
23:58that's often an important goal
24:01for a lot of patients is to live as
24:04long as possible and to turn their
24:06cancer into more of a chronic disease.
24:09And I think we're seeing that more and
24:12more with the advent of immunotherapy.
24:15Better combinations with surgery and
24:16chemotherapy and radiation therapy,
24:18as well as targeted therapy that
24:20specifically targets certain mutations,
24:22especially in lung cancer, that can often,
24:24even if they are not specifically curative,
24:27they may give patients multiple years
24:29of extra life and time before they
24:32require other kinds of therapies.
24:34So when you say that,
24:36I mean you're referring to stage
24:39four or metastatic patients in whom
24:44can still have many years of good quality of life.
24:46Tell us more about the use of radiation
24:49therapy in those circumstances?
24:51More and more we're using it
24:54because we're seeing such
24:55improved outcomes from our
24:57excellent systemic therapies,
24:58meaning the chemotherapies and immune
25:00therapies and also targeted therapies.
25:02Radiation has an increasing role as well.
25:05In stage four patients, we used to
25:07be limited to alleviating symptoms,
25:09which radiation is very effective
25:11in doing over a very low dose
25:14and a short period of time.
25:16However, with this SBRT technique that
25:18we've been using for stage one lung cancer,
25:21we often use this in the metastatic setting especially
25:25for those who have disease called
25:28oligometastatic disease and what
25:30this means is that only a few spots,
25:32maybe one or three or even five spots,
25:35may be present
25:37outside of the lung and if we can
25:40use either surgery or radiation,
25:42some kind of local therapy to address
25:45those areas after systemic therapy
25:47has worked well for a patient,
25:49then we may be able to really extend
25:51their time without needing systemic
25:54therapy and having good disease
25:56control so it's something that
25:58we're seeing improved survival
25:59from clinical trials recently.
26:01When you add radiation or surgery
26:03in very selected populations,
26:05meaning those who responded well
26:07to their systemic therapy and
26:09who have a limited number and
26:12treatable areas where we
26:14can use surgery or radiation,
26:16these patients have
26:21been able to live longer
26:23than they would have otherwise.
26:26We talked a lot in
26:29this show so far about clinical trials
26:32and historically people have always
26:34thought that clinical trials were only
26:37for patients who had no other option.
26:40Patients who had stage four disease.
26:42But it sounds like that clearly is
26:45not the case and that
26:48there are clinical trials that are offered
26:51across various different stages to allow
26:54patients to get the best therapies.
26:56What clinical trials are currently
26:58ongoing that you're most excited about?
27:01We have a lot of clinical trials ongoing
27:04right now at yield in lung cancer,
27:06but specific to radiation we actually have
27:08three right now for stage one disease,
27:10so exactly the opposite of what we had
27:13been used to seeing for clinical trials,
27:15and that they're really often used
27:18like you're saying for patients
27:19as a sort of a last resort.
27:21It's really the opposite for us,
27:23where we're trying to approach this
27:25to improve the standard of care
27:28even more at all stages of disease.
27:32So for example, stage one lung cancer,
27:34we do have a two clinical trials
27:37one that's currently active and one
27:39that is about to open fairly
27:41soon that look at the idea of SBRT with
27:44immune therapy for stage one disease.
27:46So half the patients will get the
27:49standard of care, radiation therapy,
27:50and half the patients will also
27:52get immune therapy as well.
27:54And that's our way of studying to see if
27:57will get even better outcomes with SBRT
27:59and with immune therapy and try to prevent
28:02recurrences that happened
28:03elsewhere in the body,
28:05in the lymph nodes or elsewhere,
28:06so I'm very,
28:07very excited about those studies,
28:09and I also have a study of my own
28:11as well that looks at a clinical
28:13trial that's looking at a fewer
28:15number of sessions of SBRT for those
28:17tumors that are a little closer to
28:19the middle of the chest and trying
28:21to make it more convenient and
28:23for patients they only come in
28:25three times instead
28:27of five times for tumors that are
28:29closer to the middle of the chest.
28:32Henry Park is an assistant
28:35professor of therapeutic radiology
28:36at the Yale School of Medicine.
28:38If you have questions,
28:40the address is canceranswers@yale.edu
28:41and past editions of the program
28:43are available in audio and written
28:45form at YaleCancerCenter.org
28:47We hope you'll join us next week to
28:49learn more about the fight against
28:52cancer here on Connecticut Public Radio.
28:53Funding for Yale Cancer
28:55Answers is provided by Smilow
28:57Cancer Hospital and AstraZeneca.