Physician stories: Lung cancer - five reasons for hope

Lung cancer remains the deadliest of all cancers, taking more lives than breast, colon, prostate and bladder cancers combined. But for the 219,000 Americans diagnosed last year - 2,610 of them in Oregon - there are reasons to be optimistic.

Diagnosis and treatment for lung cancer have advanced dramatically in the past two decades, improving long-term survival for many patients. Providence Cancer Center specialists explain the latest gains in lung cancer care, and tell us what they hope the future will bring.

1. Better detection

Lung cancer is up to 70 percent curable if caught early. Unfortunately, symptoms often appear only after the cancer has spread to other places. There are new devices, however, that can spot and test small tumors that X-ray images can't detect, and without the need for invasive surgery.

A new kind of technique - electromagnetic navigation bronchoscopy - gives doctors access to distant areas of the lungs that used to be accessible mainly through open surgery.

CT images provide a three-dimensional roadmap of the lung, while a flexible catheter is inserted down the windpipe and guided along the delicate branches of the "bronchial tree" to reach the tumor, where it can collect a sample for biopsy.

"The idea is to be able to get at smaller spots on the lung," says Michael Skokan, M.D., a pulmonologist with Providence Thoracic Oncology Program and The Oregon Clinic. "This is less invasive than having a surgeon take out that piece."

Another device, an endobronchial ultrasound, is a breakthrough for learning the stage of a chest cancer, which determines what kind of treatment will be needed. Also inserted down the windpipe, the imaging probe can spot a tumor or an enlarged lymph node, which may indicate the cancer has spread beyond the lung. The device includes a tiny needle that is inserted into the lymph nodes to collect a specimen for biopsy.

"Before we had this kind of scope we used to take a regular bronchoscope and poke needles into things based on our knowledge of the anatomy," Dr. Skokan says. "We didn't do any harm but a lot of times we weren't successful in hitting the lymph nodes. Now, 80 percent of the time we're getting an answer on these lymph nodes."

2. Less invasive treatments

When surgery is the best option - either for a cure or to relieve symptoms, such as difficulty breathing - more patients are benefitting from minimally invasive techniques that bring less pain and faster recovery.

Video-assisted thorascopic surgery requires just a few small incisions in the torso through which a fiber optic camera can be inserted to guide instruments. John R. Handy Jr., M.D., a thoracic surgeon with The Oregon Clinic and co-medical director of Providence Thoracic Oncology Program, can remove large sections of lung through these small openings.

"It's operating with little cuts," he says. "We don't cut muscles and we don't cut nerves."

In some cases, doctors can stop a tumor from bleeding by using a noninvasive catheter that can blast an electrified dose of ionized argon gas, a technique called "argon plasma coagulation." The heated gas cauterizes the blood vessels, easing the symptom.

Photodynamic therapy is another method to relieve symptoms. It combines a chemical with a particular kind of light from a laser to produce oxygen molecules that kill cancer cells. The method can sometimes cure early lung cancer or shrink a tumor that may be blocking a patient's airway.

Steven Seung, M.D., Ph.D., uses stereotactic body radiation therapy to deliver high doses of radiation to lung tumors.

3. Smarter chemotherapy and radiation

"Fifteen years ago we asked if we should even give chemotherapy to patients who had lung cancer," says oncologist Rachel Sanborn, M.D., co-medical director of Providence Thoracic Oncology Program. "Ten years ago we said, yes, there are the couple of chemotherapy drugs we can use, and that's it. And now the chemotherapy field has changed dramatically."

There are now first-line drugs to combat the cancer, followed by second- and even third-line therapies used to keep the cancer at bay. There are drugs that ease the side effects of chemotherapy, and drugs that work in combination with other therapies. Perhaps even more promising are targeted therapies. Unlike conventional chemotherapy that affects all cells in the body, these drugs focus more on the abnormal cancer cells, resulting in fewer side effects than chemotherapy.

Thanks to research funded in part by Providence Medical Foundations donors, some Providence lung cancer patients are benefitting from targeted therapies by participating in clinical trials.

Some of the drugs being studied aim to starve a tumor by closing off its blood supply; others are designed as boosters to help the body's immune system fight cancer. (For more about research being done at Robert W. Franz Cancer Research Center in the Earle A. Chiles Research Institute at Providence Cancer Center, including groundbreaking work in immunology, see "Research stories: When radiotherapy marries immunology.")

Likewise, radiation therapy for lung cancer has advanced by leaps. Stereotactic body radiation therapy, an emerging technology secured in part through donor contributions, can blast tumors with far more concentrated cancer-killing radiation than traditional methods without damaging healthy surrounding tissue.

Until 2009, such high-dose treatment for lung cancer was difficult because breathing creates a moving target. Stereotactic body radiation therapy uses a computer model to choreograph the patient's breathing with radiation doses, allowing for high-dose treatments with pinpoint accuracy.

4. Improved outcomes

Cancer patients at Providence benefit from multidisciplinary, collaborative care, a treatment strategy that calls upon the expertise of a variety of specialists.

Providence Thoracic Oncology Program holds weekly multidisciplinary "chest conferences" where top specialists review patient cases and consult on treatment. In 2009, the program launched Providence Lung Cancer Clinic. There, people with confirmed or suspected lung cancer can get a treatment plan crafted in one day by experts in oncology, pulmonology, thoracic surgery, radiation oncology and more.

"One of the benefits of multidisciplinary care is shortening the time to get to your appropriate treatment," Dr. Handy says.

Specialization brings volume, and volume produces even greater expertise. This is especially true within Providence Thoracic Surgery Program. More life-saving lung surgeries are performed at Providence Portland and Providence St. Vincent medical centers - 614 cases in 2009 - than typical metropolitan hospitals.

"Our death rate is half the national average," Dr. Handy says. "And our complication rate is half."

5. Raising awareness for more dollars

Breast cancer has a pink ribbon, prostate cancer a blue one. Lung cancer's ribbon is clear, a double metaphor for a disease that remains largely invisible despite its prevalence.

"We don't have a giant march on Washington," says Dr. Sanborn. "We don't have large runs in every city in the United States. The clear ribbon represents the people who are not represented."

Because smoking causes up to 80 to 90 percent of lung cancer cases, it carries the unfortunate stigma of a self-inflicted disease.

This may contribute to the fact that lung cancer research draws a fraction of the funding granted to other cancers, according to the American Cancer Society. Advocates are out to improve those numbers with a new emphasis on public awareness.

"We all know that nobody deserves lung cancer," says Beverly Stewart of the American Lung Association's Oregon chapter. "We need to break past that [stigma] so we can fund research to improve survival rates."