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Tag: NSCLC
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Having ‘The Talk’ with Your Doctor About Your Late-Stage NSCLC Treatment and Outlook
Late-stage, NSCLC, treatment, outcome, palliative care, hospice care, and outlook.
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NSCLC: Advances in Treatment
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Doctors once thought non-small-cell lung cancer (NSCLC) was one disease. Most people got the same treatment — chemotherapy (chemo) — especially if their cancer had spread to other parts of the body.
Now, doctors know there are many different types of NSCLC, with “more coming down the pike,” says Nathan Pennell, MD, a medical oncologist specializing in thoracic cancer at the Cleveland Clinic’s Taussig Cancer Institute.
That means treatment plans are no longer once-size-fits-all. Instead, treatments like targeted therapies and immunotherapy are tailored to each person’s tumor.
Targeted Therapies
Some cancer cells have gene changes (also called mutations) that help them grow and spread. The goal of several targeted therapies is to block those changes. The FDA has approved medicines to treat eleven different gene mutations that can drive NSCLC:
- EGFR
- ALK
- BRAF
- ROS1
- RET
- MET
- KRAS
- PIK3CA
- HER2
- NTRK
- MEK1
One drug targets the growth of tumors on blood vessels:
Epidermal growth factor receptor — or EGFR — is the most common. It’s a protein on the surface of cells that helps them grow and divide. If you have too much EGFR, your cells grow faster than normal. Medicines called EGFR inhibitors stop this growth.
Karen Reckamp, MD, co-directs the lung cancer and thoracic oncology program at City of Hope in Duarte, CA. She says targeted therapy has completely changed the way doctors manage lung cancer. Now, before you start treatment for advanced NSCLC, you’re likely to have genetic testing to see if you have a mutation that might help guide your treatment.
Reckamp says this new way of doing things has changed the game for many people with advanced NSCLC.
“We don’t talk about a cure,” Reckamp says. “But the tumor shrinks, people feel better, go back to work, and have a better quality of life.”
Targeted therapies also have drawbacks. Some only work for the small number of people who have gene mutations that respond to a certain targeted therapy. About 15% of people with lung cancer have EGFR-positive lung cancer. The numbers are much smaller for other gene changes.
The medicines also have side effects, like:
- Skin rash
- Diarrhea
- Liver damage
- Bone marrow problems
Reckamp says these usually aren’t as severe as side effects from chemotherapy.
“For most people, the side effects are pretty tolerable, and they do pretty well.”
Another problem is that targeted medicines often stop working, eventually.
“Cancer cells find ways to survive and overcome the toxic treatments we’re giving them,” Reckamp says. “When that happens, you have to try a different treatment.”
Still, she says targeted therapies have greatly improved the odds for people with NSCLC.
“With chemotherapy alone, [extending life] by 1 year was as good as we could get. Now, with these therapies in addition to chemo, it’s not uncommon for patients to live 2, or even 5 years.”
Immunotherapy
Your immune system normally destroys cancer cells. But tumor cells are sneaky and can find ways to evade your body’s best defenses. If you have NSCLC, some cancer cells may churn out a protein called PD-L1. It attaches to another protein, PD-1, on important immune T cells. This is called an immune checkpoint, and it tells your T cells to leave the tumor alone.
One way to get around this is with medicines called checkpoint inhibitors. They prevent PD-L1 and PD-1 from getting together. This unleashes your immune system, so it’ll be at full power against cancer cells. But healthy cells get caught in the crossfire.
“Immunotherapy can cause inflammation anywhere in your body from head to toe,” Reckamp says. “When your immune system never turns off, you can get something resembling an autoimmune disease like rheumatoid arthritis. Or you can have problems with your thyroid, liver, bladder, kidneys, and heart.
“And this can happen anytime — even after you’ve stopped treatment. But most symptoms can be well-controlled with high-dose steroids.”
Your doctor won’t suggest immunotherapy unless your tumor tests positive for high levels of PD-L1. The test isn’t always correct, though, and some tumors that test positive for PD-L1 may not respond to immunotherapy.
Still, Reckamp says immunotherapy is a better choice than chemo for most people who have it, despite the severe side effects and hefty price tag. It may even keep working after you stop taking it.
In the Pipeline
Reckamp says to look for improvements in targeted medicines and smarter drugs that can outwit and outlast cancer cells.
“There are lots of clinical trials focused on overcoming resistance to targeted medicines and immunotherapy, and combining these with chemotherapy to improve not just the length of a [person’s] life, but also the quality,” she says.
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NSCLC: Advances in Treatment
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NSCLC: Advances in Treatment
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NSCLC: When You Need More Than One Treatment
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NSCLC: When You Need More Than One Treatment
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NSCLC: When You Need More Than One Treatment
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Standard chemotherapy (chemo) was once the only treatment for advanced non-small-cell lung cancer (NSCLC). Now, you’re likely to get chemo plus a targeted medicine or immunotherapy, says Karen Reckamp, MD, co-director of the lung cancer and thoracic oncology program at City of Hope in Duarte, CA.
She says most people need more than one therapy, and often, they get all three at some time during their treatment. Combined treatments may work better because they attack cancer in different ways. And while they aren’t likely to cure advanced NSCLC, they may help you live longer with fewer symptoms.
Targeted Therapies
These block gene changes that cause tumors to grow and spread. The meds are more precise in targeting tumors than chemo, so side effects may not be as tough to deal with.
The problem is they often work for a while and then stop. This may be because the gene changes again, so it’s no longer a good target. Or, cancer might find a way around the therapy. Either way, you’ll probably need to add another medicine — usually chemo or a different targeted drug.
Immunotherapy
This treatment works in a different way. It triggers your immune system to attack your cancer. If your tumor has a high level of the protein PD-L1, immunotherapy medicines called checkpoint inhibitors may be your best treatment. These often work better when combined with chemo.
You May Still Need Chemo
If you don’t have the PD-L1 protein or a gene target, immunotherapy plus chemo is likely to be your main treatment. Reckamp says that fact disappoints some people.
“But we’re not at the point where we can do without [chemo],” she says. “In an era where we have all these new therapies, chemo is still helpful and will be part of most people’s treatment.”
That’s because chemotherapy can mop up cancer cells that other treatments leave behind.
“Metastatic cancer has spread through the lymph and blood to other places in the body,” Reckamp says. “That’s billions of cells. There’s always some cancer left, no matter what the treatment.”
Dealing With Side Effects
Cancer medicines can have serious side effects. What happens when you get two at the same time, or one right after the other? It can be tough, Reckamp says, especially since therapies can cause so many different problems.
For example, platinum-based chemo — the kind used for advanced NSCLC — damages all your fast-growing cells, even the healthy ones. Common side effects are:
- Nausea
- Diarrhea
- Hair loss
- Anemia
- Bleeding
Chemo also can cause liver and kidney damage. If your side effects are severe, you may need a lower dose, or to stop treatment completely. Reckamp says many people can predict how they’re going to feel on certain days and plan around it. And since chemo is given in cycles, you have a chance to rest during the breaks.
You may not get a break from certain targeted medicine, though. Many targeted medicines are taken every day. That makes you more likely to have constant, but manageable symptoms, like rashes and diarrhea.
“You might have one really bad day of diarrhea with chemo and mild diarrhea every day with a targeted therapy,” Reckamp says.
Targeted medicines usually won’t make you as tired as chemo. Other side effects are usually easier on your body, too, but they still need to be dealt with.
“All these drugs are attacking cancer, so there is a level of not feeling like yourself,” Reckamp says. “Most people get used to that feeling. When they stop treatment, they remember what they’re supposed to feel like.”
What about side effects from immunotherapy, which can be pretty unpredictable?
“That’s anyone’s guess,” Reckamp says. “It can cause inflammation anywhere in your body at any time, even after you stop treatment. You can get inflammation in the brain, colon, thyroid gland, liver, bladder, kidneys, or heart.
“We can predict when you’ll feel bad with chemotherapy, but with immunotherapy, we can’t.”
She says people who get both immunotherapy and chemo need to be on high alert. The number of possible side effects is high, and some can come without warning.
“If you’re not feeling like yourself, call your doctor, and they can help guide you what to do next,” she advises. “Also, [very serious] problems like colitis and pneumonitis [lung inflammation] can happen quickly and suddenly. We need to hear about that right away.”
Scott Gettinger, MD, an expert in immunotherapy and targeted therapy at Yale Cancer Center in New Haven, CT, also warns about pneumonitis. It’s inflammation of lung tissue that can cause cough and shortness of breath. For people with NSCLC, it can be deadly.
“When you suspect pneumonitis, you need to start steroids right away,” he says.
High-dose steroids can bring down life-threatening inflammation. Lower doses may help treat less serious symptoms.
Despite the intense side effects, Reckamp says most people do pretty well with combined treatments.
“You can work, travel, and live a fairly normal life, but you need to adjust for days when you don’t feel well,” she explains. “Hospitals and treatment centers have social workers and many other resources to help you get back into life.”
But, Reckamp says, you’ll also need help you can’t get from a hospital.
“You also need strong social support from your family,” she says. “And it can be helpful to join a group of like-minded people or talk to a therapist or counselor.
“Patients are living longer, so it’s important to help them figure out how to frame what they want for their lives and how to do what they want to do.”
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