Philippa Cheetham, MD; Leora Horn, MD, MSc; and Kim L. Sandler, MD, consider challenges in monitoring patients for disease recurrence and comment on how advances in the field will help experts better manage lung cancer in the near future.
PUBLISHED November 13, 2017
Philippa Cheetham, MD: Dr. Sandler, you’ve talked a lot about imaging patients for screening. But when a patient comes back to you who has already had treatment with surgery to remove a lung or part of a lung, a lobectomy, or who has had radiation that we know causes scarring in tissue and fibrosis, how easy it is to interpret patients for recurrence who have already been treated?
Kim L. Sandler, MD: Evan is laughing at me, because I complain about his scans. It is very complicated when patients have had surgery, particularly when they’ve had radiation therapy to their lung. It changes the architectural landscape of the chest enormously. When patients have lymph node dissections and nodes removed from their chest, there’s scar tissue that forms that can then mimic lymph nodes and other types of adenopathy, which can be an early sign of a recurrence.
What we try to do to make those imaging studies more sensitive and specific is give intravenous contrast because the contrast will go and enhance the structures in the mediastinum, where there are blood vessels and lymph nodes, and make it easier to distinguish what’s scar tissue and what might be recurrent disease. There’s no better friend to a radiologist than their prior scan, so any time we are interpreting a study, we’ll always look at the prior images that we have. When patients are treated, they tend to be imaged quite frequently, every several months, so we can look for very small changes in their chest. But there’s no question that it becomes much, much more complicated once a patient has been treated.
Philippa Cheetham, MD: We’ve heard about some of the very exciting new ways to image and treat patients. How much has this impacted on survival for patients in the last decade?
Leora Horn, MD, MSc: In terms of survival for early-stage disease, it’s hard to know if we are improving survival, because we don’t know if we’re just detecting more early-stage cancers with screening or if our treatments getting any better. In terms of therapies that we have right now, systemic therapies, we have not seen significant improvements in terms of overall survival. The last big trials that completed accrual and were presented showed that adding some of the newer generation of agents to traditional chemotherapy has not improved overall survival for lung cancer patients.
A big thing that we need to think about in patients with early-stage disease is that our goal is cure. So, when we’re seeing trials that are talking about improving their progression-free survival—the time until their cancer grows again—that’s not good enough in early-stage disease. We want to improve that overall survival curve. In early-stage disease, there are a lot of ongoing trials, and I think we’re going to get there in the next decade. But nothing to date has improved on the traditional 4 cycles of platinum-based chemotherapy.
Philippa Cheetham, MD: Which is why it’s so important to have trials to look at this, well-run trials and randomized controlled trials in centers of excellence, and to really use the data for everything from imaging to diagnosis to biopsy to treatment. Thank you to all of you for this excellent information, and hopefully the future will continue to show improved survival for all of our patients. Thank you very much.