Approaching Stage IV Lung Cancer - Episode 1
Philippa Cheetham, MD: Hello, and welcome to Cure Connections®. I am your host, Dr. Philippa Cheetham. November is lung cancer awareness month, and here at CURE Connections®, we thought it was the perfect time to highlight many of the exciting advances in lung cancer and also to discuss important issues in education and advocacy. Today, we are fortunate to have several members of the lung cancer healthcare team from Vanderbilt University Medical Center and Vanderbilt-Ingram Cancer Center. Together, we will provide you with a behind-the-scenes look at how they help patients with lung cancer all day, every day.
The Vanderbilt team brought one of their patients with them to share her story, 93-year-old Nance Neshanian. Nance was diagnosed several years ago with stage IV lung cancer. We also have Nance’s oncologist, Dr. Leora Horn, and palliative care specialist, Dr. Sara Martin, here with us in the studio today. Welcome to CURE Connections®. Welcome, Nance. We look forward to hearing you tell your story shortly. Welcome, Dr. Martin and Dr. Horn. Thank you for joining us here on CURE Connections® today. Nance, you were diagnosed with lung cancer. How long ago now has it been?
Nance Neshanian: Approximately three years ago.
Philippa Cheetham, MD: How did that diagnosis come about?
Nance Neshanian: I had a torn rotator cuff and I was part of Dr. John Kuhn’s study there at Vanderbilt. And in doing a follow-up, they noticed that the mass in my lung, that had been previously checked, had grown. And so, they were kind enough to notify my primary care doctor, who got in touch with the cancer doctors. We did another biopsy and found it was cancerous.
Philippa Cheetham, MD: So, you initially had a shoulder injury and had you had a chest X-ray before, that already alerted you to a problem with the lung or no?
Nance Neshanian: No, not necessarily. It all happened from this rotator cuff and Dr. Kuhn’s study there at Vanderbilt. And they read the X-rays that noticed that the mass had grown.
Philippa Cheetham, MD: As part of the study to evaluate your shoulder, you had a chest X-ray, and that’s when they saw that there was an area of concern on the lung.
Nance Neshanian: It had grown.
Philippa Cheetham, MD: When you say it had grown, you already knew that it was there?
Nance Neshanian: Yes, I knew that it was there, I knew that it was benign. But this time when they biopsied it, they found it was cancerous.
Philippa Cheetham, MD: So, this area had grown, but did you have any symptoms at all?
Nance Neshanian: No.
Philippa Cheetham, MD: You didn’t have a cough or anything like that?
Nance Neshanian: No.
Philippa Cheetham, MD: So, it was a big shock to hear that.
Nance Neshanian: Yes. The funny thing about it was in the beginning, when the doctor told me that the mass was benign, he said it’s a good thing that it is because of your age, we would not give you chemotherapy or radiation. So, in these last few years, things have progressed enough that someone my age can have treatment and here I am.
Philippa Cheetham, MD: For 93, you’re in fantastic health. For 73, you would be in fantastic health.
Nance Neshanian: Yes, 94 next month.
Philippa Cheetham, MD: You learned that this chest X-ray showed that the lung area had grown.
Nance Neshanian: Right.
Philippa Cheetham, MD: You were being evaluated at the time because of your shoulder. Tell us how much it must have affected you to be trying to sort out your shoulder and then to hear that this lung lesion had gotten much bigger.
Nance Neshanian: I have to tell you, and perhaps it’s just my way of coping, I don’t think about it. I don’t think about having lung cancer every day of my life at all. Maybe that’s a self-defense mechanism, I don’t know, but it seems to work for me.
Philippa Cheetham, MD: And when you learned that this lung lesion had got bigger, what was the management of this lung lesion after that? What happened?
Nance Neshanian: Well, enter Dr. Horn and we did chemotherapy, then she thought that I was a candidate for a study that I was doing, and we did infusions. The reason we stopped those, I believe, was primarily because in doing those, I was becoming not just tired but a weary tired.
Philippa Cheetham, MD: So, you did actually have a biopsy that confirmed that this was a cancer.
Nance Neshanian: Oh yes, oh yes.
Philippa Cheetham, MD: And how soon after the biopsy did you start treatments?
Nance Neshanian: Immediately.
Philippa Cheetham, MD: You went from having no symptoms at all before treatment. And how much did the treatment knock you about?
Nance Neshanian: Not that much, just being tired. I do my errands and then all of a sudden, I’d say, “Uh-oh, I can’t go any further,” and that was it.
Philippa Cheetham, MD: Did you ever consider not having treatment at all, considering you were so well?
Nance Neshanian: No, no. These doctors are remarkable. No, I wouldn’t stop treatment for anything.
Philippa Cheetham, MD: We’ve heard about Nance’s diagnosis with lung cancer. She said that initially it was thought to be a benign lesion, but obviously, it was subsequently biopsied and shown to be lung cancer. How typical is this kind of presentation where a patient feels completely well and has imaging that shows that the situation is very different?
Leora Horn, MD, MSc: There are two situations where people can feel well but we find something. Sometimes when patients have lung cancer screening—and I know that we’re going to talk about that today—the common patient who will have a CT scan or a chest X-ray, who’s asymptomatic as a patient, and who’s getting a scan for something else, the majority of patients will have some sort of symptom being cough, shortness of breath, weight loss, or pain. And the symptom is often dictated by where the cancer is. So, if something is in the middle of the chest, you might have cough. If something is touching a bone or in an area near the rib, you might have pain, or if it spread to somewhere else, you might have pain.
Philippa Cheetham, MD: So, lots of different presentations.
Leora Horn, MD, MSc: Exactly.
Philippa Cheetham, MD: And we know that in medicine these days, we do so many scans for so many reasons. And imaging has gotten so much better that sometimes we think we’re detecting more cancers, but we may just actually be better at diagnosing those that were always there. If Nance had not gone for this screening, this imaging as part of her workup for the shoulder study that she was in, how do you think she may have presented had it not been picked up as an incidental finding?
Leora Horn, MD, MSc: The tumor in her lung was picked up as an incidental finding, but when we originally did her staging, which included a PET scan, we also found a spot in her bone. And so, I think that with time, she probably would have experienced some back pain related to where the tumor had spread to.
Transcript Edited for Clarity