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Q&A on lung cancer - Questions answered by Dr. Gary Hochheiser, chief of Thoracic Surgery

November 03, 2015

By Dr. Gary Hochheiser for the Gazette

(Published in print: Tuesday, November 3, 2015)

Lung cancer is a leading cause of cancer deaths in men and women in the United States and kills more people than colon, breast and prostate cancer combined. The American Cancer Society’s estimates that in 2015 in the United States, about 221,200 new cases will be diagnosed and 158,040 people will die.

Lung cancer patients, both smokers and non smokers, have a 15 percent five-year survival rate. Beside smoking, other risks include high levels of pollution, radiation and asbestos exposure. Early detection could be life-saving.

Following is a look at the risks, types and treatments presented in a question and answer format.

Q. What are the different types of lung cancer?

A. There are two main types of lung cancer, small cell lung cancer and non-small cell lung cancer. Both types are considered to be aggressive cancers as demonstrated by the high number of people who die from the disease each year. However, small cell tends to be the more aggressive of the two, spreading to other sites of the body earlier in the disease process.

The most important determination of the outcome is how early it is diagnosed and its progression.

Q. Why is lung cancer so deadly?

A. In addition to being aggressive, 85 percent of lung cancers are found at an advanced stage since they do not usually cause symptoms until they have had time to grow and spread. This makes the cancer more difficult to treat.

While early detection is critical, tests were not useful until just recently.

Lung cancer is considered the deadliest of cancers because it is very common. Most lung cancers are related to smoking, which is a habit that is practiced throughout the world.

Q. What screening has been found to be useful?

A. While over the years no test had been found to detect lung cancer early enough in a low-risk, cost-effective way to improve survival rates, a large study reported in 2011 showed promise. It indicated that the use of a low radiation dose Cat scan could detect cancers early in their development and improved the overall survival by 20 percent of the group of patients who received the test annually.

We now recommend that high-risk individuals undergo lung cancer screening with this low dose Cat scan.

The important part of any screening study is interpretation and decisions around what to do with findings which are not always cancer. Screening programs have been developed and are available in the region, including at the Baystate Regional Cancer Program, that employ teams of experts who perform and interpret these studies to determine if cancer is present and how to deal with each finding.

Q. How is lung cancer usually treated?

A. Lung cancer treatment is determined by the stage, or how advanced the cancer is at the time it is detected.

There are three main types of treatment used, often in combination. At an early stage, surgery is done to remove the tumor. If the cancer is more advanced, surgery may be combined with chemotherapy, radiation or both. Sometimes, chemotherapy and radiation are done before surgery to shrink the tumor. In the most advanced cases, chemotherapy and radiation or chemotherapy alone are used.

Q. What is targeted or immunotherapy?

This treatment is based on the genetic makeup of the tumor. Genes determine what type of receptors a cell has and various methods now exist to detect them. These receptors become targets for certain chemotherapy medications, focusing the treatment on the tumor itself.

Immunotherapy has advanced rapidly in the last few years. Ways to evaluate tumors and new medications or drugs are being developed to target specific types of cancer cells.

Q. What role does a newer, more advanced technique called IMRT (intensity modulated radiation therapy) play?

A. The standard of care for patients with locally advanced (stage III) lung cancer is a combination of chemotherapy and radiation therapy, either 3-D CRT (3-dimensional conformal radiation therapy) or intensity modulated radiation therapy (IMRT).

The benefit of IMRT is that, in some cases, unlike standard 3-D radiation therapy, it may allow doctors to deliver a higher dose of radiation more precisely to the tumor, while at the same time sparing any damage to surrounding healthy tissue.

At Baystate Medical Center we use IMRT for lung cancer selectively because it can also spread low dose radiation to the normal lung and there have not been enough studies on its effects. Right now IMRT is just another useful tool and it would be a misconception for patients to think they are not getting optimal treatment if 3-D CRT is used instead of it in their particular cases.

Q. How has lung cancer surgery changed over the years?

A. Like many surgical procedures, lung surgery has advanced with the goal of less pain and disability for the patient. This is achieved by minimizing the size of the incisions and avoiding putting pressure on the ribs with retractors to open the incisions. These less invasive techniques are made possible by the development of cameras or “scopes” that can be placed through a small incision and used to see inside of the chest.

These procedures can be performed with standard video techniques — called VATS or video assisted thoracic surgery — as well as with new robotic systems. While not all cancers are able to be removed with minimally invasive techniques, the majority of them are.

Q. How greatly does smoking contribute to lung cancer and what are some of the other risk factors?

A. Smoking is responsible for approximately 80 percent of lung cancers. What this says is that the disease is highly preventable by not smoking. Quitting smoking will decrease the risk.

Exposure to secondhand smoke is also a significant factor in developing lung cancer. With prolonged exposure — if you live with someone who smokes, particularly during childhood — the risks are similar to those who are smokers.

There are other risk factors that play a role, particularly exposure to asbestos, as well as radon and other chemicals.

A family history of cancer, particularly lung cancer, can also predispose you, especially if there is also exposure to smoking.

Cancer Q&A, which appears monthly, is written by doctors from Baystate Regional Cancer Program based in Springfield. Dr. Gary Hochheiser is chief of Thoracic Surgery there.