Roy S. Herbst, MD, PhD, recalls that his mother always wanted him to be a doctor and he was well on his way when she was diagnosed with breast cancer.

“I was very interested in science…so when I got to Yale, as an undergraduate, I studied molecular biophysics and biochemistry in the lab and in the clinic and knew I wanted to go for a career in medicine,” Herbst says. “But my career in oncology began when I was an MD/PhD student…and my mother developed breast cancer. It was the late 80s. I sought opinions at my hospitals and others. And I read her pathology. And I became fascinated. So, I knew I wanted to be an oncologist.”

Lung cancer became his specialty because “there was a job open. The reason that job was available was because there really wasn’t much we could offer in lung cancer...it was a tough time,” he recalls. But that was about to change in the 1990s.

Herbst recently reflected on the dramatic advances made in lung cancer research and treatments—which included his own work—during a recent conversation with the director of Yale Cancer Center, Eric P. Winer, MD. Following is a synopsis of some of the high points of the conversation led by Dr. Winer.

Let’s talk about how the outlook for lung cancer has evolved

It’s really changed in my 30 years career. When I started seeing patients with lung cancer…they’d bring a packet of X-ray films [of their lungs] and you’d often be able to smell smoke on those films. It was a disease of smokers. But in the past 25 years, there are patients who never smoke or have smoked very little – there also are very different lung cancers with causes that have been linked to exposure to radon, asbestos, and pollution. And, of course, there are many more treatments—due to significant advancements including gene therapy, targeted therapy, and immunotherapy—greatly improving outcomes.

What if someone smoked in the past and they stopped smoking, does their risk go down or persist?

If you stop smoking, your risk does go back down. That’s the best way to beat lung cancer—to never get it—or to quit. Smoking cessation significantly reduces the risk over time.

How is early lung cancer detected and treated?

Early lung cancer can be treated with surgery. That means you have to find it early. More than 50% of the time, at diagnosis, it’s already spread to the liver, the bone, or the brain. Screening is a major force in addressing that. When it’s early you can surgically remove it. It happens that it’s found when a patient is in for a different procedure and the tests before it reveal something with the lungs. Early detection is the key as it is with all cancers after tissue from the tumor(s) is profiled, or sequenced.

What role does tumor profiling play in lung cancer treatment?

Remember, it’s not lung cancer, it’s lung cancers, plural. Everyone’s cancer is different. We didn’t know this in the 1990s. Now, we can take the tumor, get a biopsy, and send it off to the lab and we actually look at genetic alterations that cause the cancer and then we personalize the treatment to the patient and the tumor. Identifying specific mutations like EGFR (epidermal growth factor receptor) or ALK (anaplastic lymphoma kinase) can lead to targeted therapies that significantly improve patient outcomes.

What percentage of patients have the EGFR mutation?

It’s about 10-15% in the U.S. There are nine other similar alterations that if we know about it, we can pair a patient with a specific drug. The second most common mutation is ALK, which accounts for 3-4% of lung cancers, but that’s still many, many people. In all, the known alterations account for about 20% of cases. Identification of the alterations are critical to pairing patients with the best therapy.

Targeted therapies, which significantly improve outcomes, depend on tumor profiling, correct?

Science drives the best care. As good as these targeted therapies are, very rarely does someone go forever on these drugs. Tumors often find a way around the treatment, making clinical trials of new therapies critical to continuing to outsmart cancer by introducing a new therapy that contains it. We are constantly trying to do better, to find a way to regulate it.

To what extent have lung cancer deaths gone down?

Statistics tend to lag key a few years behind what we know to be true. The last big data showed incidences of lung cancer going down 2-3% each year and mortality going down about 3-5% a year. The immunotherapy numbers we’ll probably start seeing soon. It only recently became standard of care in this country. It’s barely 10 years. It’s really changed how we think of this disease. It’s amazing when surgeons tell us what they’ve seen. The tumors are gone or if you look at it in the pathology lab, the cancer cells are dead. The right treatment at the right time makes a difference. And we’re not done. This is why the clinical trials that we ran starting in 2011 are standard of care now and why the new trials are so critical to maintain that pipeline of new treatments.

Fairly few people get lung cancer screening. Why don’t more people get screening and who should?

Screening can detect lung cancer early, making it easier to treat. Despite its importance, only a small percentage of eligible people get screened due to complexities in lung biopsy procedures and previous issues with insurance coverage. Increasing awareness and accessibility is crucial.