Attacking Lung Cancer on All Fronts
Some cancers are called "silent cancers" because there are no symptoms until the cancer has advanced and spread. Lung cancer is one of those cancers.
Marge Combe was lucky, her lung cancer was found by chance. Marge, 59, an executive coach, and her husband, Michel, live in Fox Point, Wisconsin.
“In 1999, I had a chest X-ray for a heart arrhythmia, and the radiologist saw something on my right upper lung,” Marge said. “He suggested having it checked out.”
Marge saw a pulmonologist (a lung specialist) who ordered a CT scan. “He thought the spot could be a scar from a previous case of pneumonia, and suggested monitoring me for two years,” she said. “Toward the end of the two years, he said the spot had changed, and there was a 50-50 chance that it was cancer.”
Marge, who had never smoked, was stunned. “The terror of the ‘C’ word is huge,” she said. “You don’t know where to start, what questions to ask.”
She learned that the growth needed to be biopsied (and possibly removed) in a surgical procedure. She met with two surgeons at two different hospitals before a friend put her in touch with Medical College of Wisconsin radiation oncologist Elizabeth Gore, MD, in November 2001. After reviewing Marge’s CT scan, Dr. Gore referred Marge to Medical College of Wisconsin cardiothoracic surgeon George Haasler, MD, FACS, FACCP.
“I wanted to get a range of opinions and feel comfortable that the person doing the surgery knew his stuff,” Marge said. “I knew this was complicated and wanted someone with a reputation who knew what he was doing.”
“It’s not uncommon to discover lung cancer during a chest X-ray or CT scan for another reason,” Dr. Haasler said. “For example, imaging may be done for an injury or an unrelated problem, and a spot may be seen on a lung. Most spots found this way tend to be small — less than 2-3 mm, and are almost always considered benign. If a spot is more than 7-8 mm when it’s found, there’s a higher chance that it’s cancer. But when it’s caught early, these are some of the most curable cases of lung cancer, before there are symptoms.”
“Dr. Haasler was straight with me,” Marge said. “He said it’s likely to be cancer. I liked his no-nonsense style. He was very open and caring and put me at ease.”
Just after Thanksgiving in 2001, Marge underwent surgery. Dr. Haasler made an incision on her right side and removed a rib to gain access to the right lung. (Today, a less invasive approach is used.) He then removed a sample of lung tissue from the right upper lobe for testing. A short time later, the test confirmed that the cells were cancerous. Dr. Haasler then removed the entire upper lobe of the right lung along with nearby lymph nodes. The lymph node report one week later showed that the cancer had not spread beyond the tumor.
After surgery, Marge spent a few days in the hospital and completed her recovery at home with the help of her husband and daughter. She did not need radiation therapy or chemotherapy as part of her treatment. But because this type of lung cancer can recur, and because it grows slowly, she continues to have regular follow-up visits and CT scans.
“The staff at Froedtert & The Medical College is amazing, and the nurses are tremendous,” she said. “I have tremendous respect for and had an excellent experience with the physicians and staff. If I have a choice about being admitted to a hospital, it will be at Froedtert.”
Types of Lung CancerThere are two major types of lung cancer — non-small cell lung cancer (85 percent) and small cell lung cancer (15 percent). In general, small cell lung cancer tends to be more aggressive and spreads sooner to other sites in the body. Each type of lung cancer grows and spreads in different ways, and each is treated differently. While smoking is the major cause of lung cancer, other causes include exposure to cancer-causing agents (asbestos, certain chemicals) or exposure to radiation or radon gas (occurs naturally in soil in certain areas). Some causes are unknown.
Marge was diagnosed with bronchioloalveolar carcinoma (BAC), a rare type of lung cancer that disproportionately affects women, people who have never smoked and Asians. BAC, a type of non-small cell lung cancer, grows slowly. For this type of lung cancer, surgery can provide a potentially curative treatment.
The Lung Cancer TeamThe Thoracic Cancer Program is one of 13 disease-specific teams within the Clinical Cancer Center at Froedtert & The Medical College. A team of specialists focuses on cancers of the lung, esophagus and other cancers of the chest cavity. In weekly tumor board meetings, team members collaborate to provide patients with the most effective treatment plan. Patients receive the expert advice of many specialists, without having to see each one individually.
The team includes board-certified thoracic surgeons, radiation oncologists, medical oncologists, radiologists, interventional radiologists, pulmonologists, pathologists, nurse practitioners, physician assistants and nurses. A new patient coordinator and a nurse coordinator in the Clinical Cancer Center guide patients and make sure they receive all the services and support they need.
People with lung cancer usually need different types of treatment. The Thoracic Cancer Program’s team of specialists has expertise in every treatment option, no matter the stage (extent) of the lung cancer. Despite the serious prognosis of lung cancer, some people are cured.
Physicians from throughout southeast Wisconsin and beyond refer patients with suspected lung disease to Medical College of Wisconsin pulmonologists. “In the Clinical Cancer Center, our pulmonologists work collaboratively to diagnose lung cancers — the first and one of the most vital steps in lung cancer care,” said Medical College of Wisconsin pulmonologist Ahmed Khan, MD, one of several pulmonologists in the Thoracic Cancer Program. Team pulmonologists are highly skilled in performing advanced bronchoscopy techniques, such as endobrachial ultrasound and navigation-guided bronchoscopy with the Super Dimension inReach™ System, to locate masses in the lungs.
“We also manage the care of patients referred to the clinic who are found not to have lung cancer, work with other team members to monitor patients’ lung health during and after lung cancer treatment, and provide follow-up care as needed,” Dr. Khan said.
To ensure the most comprehensive care for lung cancer patients, the Clinical Cancer Center also offers a smoking cessation program under the supervision of Dr. Khan, a nurse practitioner and a pharmacist who prescribes smoking-cessation medications. In addition, a respiratory therapist sees patients in the Center to assist with treatments for many other lung conditions.
Detecting and Diagnosing Lung CancerWhen a person’s symptoms indicate lung disease, imaging — CT, X-ray, positron emission tomography (PET) and brain MRI — is done to evaluate and stage lung cancer. Radiologists at Froedtert & The Medical College specialize in interpreting images of the chest area. CT is also used to help physicians guide needles through the chest wall to perform lung biopsies.
A variety of minimally invasive procedures can be used to obtain a tissue sample to diagnose lung cancer and to see if cancer has spread to lymph nodes. These procedures, which prevent the need to open the chest, involve placing a scope into the lungs via the mouth, nose or through a small incision in the neck or chest. In some cases, a scope can be placed through the esophagus to biopsy lymph nodes.
A newer approach, the Super Dimension in Reach™ System, is used to reach peripheral lung lesions and lymph nodes in the area between the lungs. These areas are difficult to reach with traditional bronchoscopy (a scope placed in the airway). The system is used to diagnose, potentially treat and stage lung cancer. This minimally invasive approach is also invaluable in diagnosing lung cancer in patients who are considered poor surgical candidates.
The Treatment ArsenalThe highly skilled and experienced Thoracic Cancer team uses the most advanced treatments — surgery, radiation therapy, chemotherapy and interventional radiology — to treat lung cancer. All treatments provided have been proven effective in research conducted throughout the country. The team is committed to providing the latest treatments and offers participation in clinical trials when available.
Surgery. Surgery to remove the cancer may be done if it’s determined that all the cancer can be removed and the patient is able to tolerate the surgery. Surgery may involve the removal of the tumor, sections of the lung that contain the tumor, and nearby lymph nodes. Surgery is the most effective treatment for early stage non-small cell lung cancers. For advanced stages, surgery is often combined with radiation and/or chemotherapy.
“We do a lot of lung surgery here, which is important for patients who need this type of surgery,” Dr. Haasler said. “We have four thoracic surgeons who specialize in different areas of these surgeries.We work with referring physicians and oncologists in the area to coordinate care for their patients with lung cancer.”
When possible, a minimally invasive approach is used. Video-assisted thorascopic surgery (VATS) is used to diagnose and treat lung cancer. A small video camera and surgical instruments are placed in the chest through small incisions. VATS enables a surgeon to view, biopsy and operate on the lungs, such as removing small to very large sections of a single lung.
Another method, a thoracotomy, involves making a somewhat larger incision on the side, between the ribs, if a tumor is not accessible with the VATS procedure.
“Cancers that are closer to the center of the lung often require open-chest surgery,” Dr. Haasler said. “But even open-chest surgery is so much better tolerated today than in the past. We’re able to make a smaller incision and provide better pain control. At times, we can combine the VATS approach with a smaller, open-chest incision.
“During surgery, we try to do the most complete removal of the tumor and lymph nodes we can to achieve a cure and to obtain information on the potential for the cancer to spread. This guides us in how we follow the patient’s progress. Survival depends on the stage of the cancer, where it is located and other factors.”
Chemotherapy. The use of drugs to destroy cancer cells is a part of treatment for most patients with lung cancer. After surgery, patients are recommended to receive chemotherapy if cancer is found in the lymph nodes or the tumor is larger than 4 cm (1.6 inches).
“Almost all patients who have lung cancer surgery are offered chemotherapy, either because we know the cancer has spread or there’s a chance that it may have spread,” said Nicholas Choong, MD, Medical College of Wisconsin medical oncologist. “There are different forms of lung cancer and many forms of chemotherapy. Once we know the stage of the cancer, we determine the most appropriate chemotherapy drugs.
“If lung cancer is confined to the lung (stage I) and surgically removed, chemotherapy is given to prevent recurrence. This is considered curative chemotherapy. Chemotherapy is also used for stages II and III, for lung cancer that is confined to the chest. For lung cancer that has spread in the body (stage IV), chemotherapy is given to relieve symptoms and prolong life. Today, the side effects of chemotherapy — nausea and vomiting — are greatly reduced.
“In addition to our expert team, what sets our Thoracic Cancer Program apart is the opportunity for patients to receive new chemotherapy drugs as part of clinical studies for almost every stage of lung cancer. These drugs of the future are not otherwise available in the community. We’re doing clinical studies for all stages of non-small cell lung cancer. People come from all over Wisconsin and beyond to take part in these studies. Over the years, the survival of lung cancer has increased as a result of new drugs that come out of clinical studies.”
Radiation Therapy. In the treatment of lung cancer, radiation may be used in many ways — as a primary treatment for cure, to shrink a tumor before surgery, to eliminate remaining cancer cells after surgery, and to control symptoms caused by lung cancer that has spread to other areas of the body. Radiation therapy may be given alone or combined with chemotherapy.
“The majority of radiation therapy for lung cancer is external beam therapy,” said Medical College of Wisconsin radiation oncologist Elizabeth Gore, MD.
While small lung cancer tumors are usually removed surgically, some patients are unable to have surgery because of the location of the tumor or other health conditions. For these patients, stereotactic body radio therapy (SBRT) is used.
SBRT accounts for tumor movement as a patient breathes. It uses special equipment to place the patient in the exact same position for each radiation treatment. During each treatment, 12 to 15 small radiation beams converge on the tumor with pinpoint accuracy, delivering high doses of radiation to a tumor while sparing healthy tissue. SBRT reduces radiation treatment time from several weeks to just three treatments over one to two weeks. “With SBRT in carefully selected patients, 96 percent of lung tumors are controlled,” Dr. Gore said.
Interventional Radiology. A newer treatment for lung cancer involves the use of radiofrequency ablation, a high-frequency electrical current used to heat a specific area of tissue to destroy cancer cells while minimizing damage to surrounding cells.
“Radiofrequency ablation is most appropriate for patients with small, early stage primary lung cancer (cancer that starts in the lung) who, because of reduced lung function or other conditions, are unable to have surgery, or patients with metastatic tumors who had previous surgery,” said William Rilling, MD, FSIR, director of Vascular and Interventional Radiology. “We’re performing this procedure as part of a multi-center national trial with the American College of Surgeons Oncology Group.”
To perform the procedure, a tiny incision is made in the chest wall. Using CT guidance, the needle electrode is placed into the chest and moved to the site of the tumor. Once the electrode is in place, radiofrequency energy is applied to destroy the cancer cells. The electrode is then removed.
“Some patients can return home the same day, and some are observed overnight in the hospital,” Dr. Rilling said. “Patients generally recover quickly.”
Second Opinions“With lung cancer, everyone has time to get a second opinion,” Dr. Haasler said. “The best patient is one who is informed and comfortable with his or her treatment decision. It’s important to talk to a team with knowledge of the entire lung cancer process. We have a broad base of knowledge to share with patients about their many options and treatment approaches. Many newer treatment options are offered here that may not be available elsewhere.”
To learn more about the Thoracic Cancer Program and physicians or to make an appointment, call 414-805-0505 or 866-680-0505.
Source: Froedtert Today
Date: January 2010 Issue