Philippa Cheetham, MD: Nance mentioned earlier on that one of the biggest issues for her was fatigue. For somebody who’s very active, you live alone, Nance?
Nance Neshanian: No, my son and I share an apartment.
Philippa Cheetham, MD: Does he help you with cooking, shopping?
Nance Neshanian: Oh, he’s a good cook.
Philippa Cheetham, MD: How can we address this issue of fatigue, which seems to be related to both the cancer and the treatments? Are there any recommendations that you have for managing something that’s obviously very impactful on somebody like Nance who’s active and busy?
Sara F. Martin, MD: Well, so I think fatigue is probably the most common symptom that cancer patients report, just because, as you mentioned, you can have it from cancer itself. And then I always tell patients that most cancer treatments will also give you fatigue. The thing with the most data behind it is what Nance did, actually, which is exercise. So, if you can make yourself do some amount of exercise, and light exercise—I’m not talking running a mile but walking daily or playing golf—that helps you more than anything to combat to the fatigue associated with the diagnosis and the treatment. There are medications we can use. None of them tend to work as well as if you can make yourself stay a little active, but there are medications we can try.
Philippa Cheetham, MD: And Dr. Horn, just bringing Nance’s situation into the discussion, she has had chemotherapy, she has had radiation treatment to the spine. You’ve talked about further radiation treatment. It’s quite a lot of treatment, particularly with the radiation and visits to the hospital. What’s the plan now other than radiation treatment? Is it just a finite course of treatment that she needs on this lung lesion or do you have other cocktails of chemotherapy planned to follow?
Leora Horn, MD, MSc: So, we always have other cocktails available. The last treatment left her feeling pretty tired, and so sometimes we’ll take what we call a chemotherapy holiday. And that doesn’t mean that we’re not doing any treatment, we’re just taking a break for a while. And so, the plan right now was to radiate the one area that was growing and then she’ll just have CT scans every two to three months. The key is surveillance. So, if patients are not interested in therapy, then obviously we shouldn’t do CT scans and all these additional tests. But for patients who want to continue with therapy, I think continue to do scans, blood work, and clinic visits to make sure that if something starts to grow, we can catch it and treat it before it starts causing symptoms again. I think that is very important. So, she’ll get a break over the holidays, and her next CT scan will be sometime in the new year.
Philippa Cheetham, MD: Just going back to the original diagnosis of the lung biopsy, obviously that tells you about the tissue type, the cells that the lung cancer is made of. And we know for many diseases, there’s a huge spectrum. Lung cancer isn’t just one disease but there’s many different cell types. How different is the management of a patient who has a lung cancer subtype A, for example, from a lung cancer subtype B? Is the management hugely different or are all these tumors amenable to some form of radiation, some form of chemotherapy?
Leora Horn, MD, MSc: Treatment is very different and prognosis is. So, when we have a patient with lung cancer, we want to know is it small-cell lung cancer or non–small cell, with small-cell being thought of as being a more aggressive tumor type where surgery is not necessarily indicated and now treatment options are really just chemotherapy and radiation therapy. With a non–small cell, we want to know what type of non–small cell. Is it a squamous or is it a nonsquamous? And then based on that, we want to do further subtyping with what we call molecular testing, where we’re looking at the DNA of the tumor to figure out should we treat this with a pill or should we treat this with IV therapy. And if it’s IV, do we do chemotherapy or do we do immunotherapy? Non–small cell is also a tumor type that patients with earlier stages of disease—so stage 1, 2, or sometimes 3a—may have surgery, whereas for all patients with stage 4 disease, surgery is generally not indicated.
Philippa Cheetham, MD: So, there are many factors that come into this: the age of the patient, the fitness of the patient, the tumor type. You’ve already talked about other medical conditions that patients may have. Is it fair to say that we’ve come a long way in the last 20 or so years? If you look at patients who we’re treating now in 2017 versus say 20 years ago, are we making big improvements in outcomes and survival with these newer treatments?
Leora Horn, MD, MSc: Absolutely. I would say it’s even just in the past 10 years. There have been more drugs approved for lung cancer in the past 10 years than 30 years before that, and just treatments that are so much better tolerated and so many more options that we had for patients that we never had a decade ago when I started practicing.