At the Forefront Live: Lung Cancer

Welcome to University of Chicago Medicine At the Forefront Live. Physicians Jyoti Patel and Kyle Hogarth join us for a conversation about common lung cancer myths, exciting innovations in lung cancer, and how those innovations are changing care and cure rates. Now remember, we're taking your questions live, so start typing in the comments section and we'll get to as many as possible. 

As always, we want to remind our viewers that our program today is not designed to take the place of a medical consultation with your physician. Let's dive right into the questions. There's a lot of misconceptions surrounding lung cancer. And one of the big ones that I'm sure you've probably heard many times is that only smokers get lung cancer. How true is that or not true is that? 

So certainly, though smoking is the biggest risk factor for lung cancer, there are about 30,000 Americans in the United States who are diagnosed with lung cancer every year who've never smoked a cigarette. Moreover, many people smoked years ago and had completely stopped smoking. And they still remain at elevated risk and are surprised when they're given a diagnosis of lung cancer. 

Often, symptoms go unnoticed for a long time, because they feel that they're not at risk. And so, I think this is really where the education comes in, that if there are symptoms that are concerning like cough or pain or shortness of breath, even people who don't feel they have elevated risk, really, find medical attention for timely diagnosis. 

I want to ask a follow up question. And Dr. Hogarth, you can jump in on this one as well. I've heard often that if you quit smoking, that your lungs get back to normal and healthy very quickly. Is that not the case? 

Well, it depends on how one is defining that, I suppose. I think, without a doubt, anyone who's watching, if you are indeed a smoker, then you absolutely have to quit. And we're obviously focusing on cancer and lung health, but there is a ridiculously long list of all the other health benefits of quitting smoking. 

You do get some immediate improvements upon quitting smoking, in the sense of how someone feels. Actually, within a couple of days, the sense of taste starts to come back and the various sense of smell starts to also return. But in regards to normal-- so if you've already developed COPD or emphysema related to smoking, that won't reverse. That will remain. 

Now, there are great ways to manage those diseases. And so, I think as Dr. Patel just said, if you're having symptoms, sure. Lung cancer is in the thought process, but so is just COPD. And at a minimum, the thoughtful evaluation by your physician in the sense of what might be causing my symptoms would lead to things. Now, as also stated, people who quit smoking, the risk for lung cancer is always still slightly higher than the general population, even many years out. 

And so, I think that comes as a surprise for a lot of people. They say, well, look. I did quit. And though that is fantastic-- because the risk of cancer as a continued smoker is exponentially higher than the person who has quit-- that's where things like lung cancer screening start to come into play, precisely because lung cancer can be so insidious and essentially be sneaking up on you. 

We've taken a more proactive approach, based off of great studies that showed that in certain type of patient, there is a huge benefit in outcomes by looking for this disease at the early stages. 
You know, we just got finished with Breast Cancer Awareness Month. In fact, we did one of these for breast cancer awareness, an At the Forefront Live. And I think a lot of women are aware of the risk of breast cancer. Now we're talking about lung cancer. Is that as dangerous for women or not? 

Unfortunately, absolutely. So since the late 1980s, more women have died from lung cancer than from breast cancer every year. And it exerts an enormous toll on American health. Again, rates, we hope, are going down as more people are stopping to smoke and never picking up the habit. 

But if someone has risk factors-- so smoking history, strong family history-- discussion needs to take place about whether or not those women who are so good about getting annual mammograms and looking for early stage breast cancer do the same for their lungs. 

I think there's the other perception -- this is important. You know, I'm very glad that we're doing Lung Cancer Awareness Month. Because though we diagnose a significant amount of breast cancer-- and prostate cancer, obviously, in men -- we're going to lose more people to lung cancer this year, that will die from lung cancer, than we're going to lose from breast, prostate, and colon combined. 

If you think about those numbers, it's staggering. Because some of that represents, of course, that we're better at diagnosing those other cancers at earlier stages, and so, therefore, at higher cure rates. But it also represents the sort of bias almost, if you will, in society against lung cancer. It's this sort of stigma-associated disease. 

And I think the first question you asked about the smoking, non-smoking, regardless of your smoking status, lung cancer is not something you deserve. So this proactive approach is precisely to kill off that stigma of the, you know, you earned this. You got this. That's ridiculous. 

Yeah, I think that's an excellent, excellent point. What are some of the early signs of lung cancer? 

So unfortunately, when people have very early lung cancer, people have few symptoms. When the cancer progresses and can either occupy space in the center of the chest or when it metastasizes and goes to another place, that's really when we meet patients who haven't undergone screening. So generally, symptoms are shortness of breath, cough, unexpected weight loss, perhaps chest pain, even if it's intermittent. 

Any of those things can herald disease in your chest. But sometimes if the cancer's already spread, you could have pain in your back or pain in your head that doesn't go away over a couple of days. And so, awareness and advocacy for yourself for symptoms that you can't explain, really seeking medical opinions is, I think, absolutely necessary. 

One of the things we're trying to change so desperately is lung cancer screening is similar to-- you just said you did breast cancer awareness. The average, of course, symptom of breast cancer is none. That's why we screen. So the majority of lung cancer is asymptomatic. And in fact, until lung cancer screening came along, a lot of the early stage lung cancer that we found was accidental. 

The CAT scan was obtained for a different reason. And, you know, whatever reason it was done, so be it. But oh, by the way, there's this nodule in your lung. And the person, of course, had no symptoms. It was an accidental discovery. 

Absolutely. And one of the things I think that has changed so profoundly in our approach is that we now have great evidence that really shows that screening for lung cancer saves lives. There is an absolute reduction in mortality. That's huge. And if a patient is at high risk-- again, based upon their age and perhaps their smoking history-- they should absolutely do screening exams to reduce that risk, because we can cure cancer when it's small. 

And correct me if I'm wrong on this, but lung cancer screening is relatively new. Is that right? I mean, you've been doing it for a few years. But it doesn't-- 
Correct. Outside of a clinical trial, where there have been obviously studies going on to prove this, it's a relatively new phenomenon. Which is one of things that, for people who work in the field of lung cancer, makes us even more excited. I think we always knew in our heart that looking for lung cancer with something as excellent as a CT scan of the chest, we were going to see an improvement. 

But you obviously need to prove this if you're going to ask people to obtain CT scans, if you're going to ask Medicare and payers to cover this. And so, no surprise, of course, the study did prove this. And recently, actually just published this week and presented at the recent World Lung Conference, the Europeans have similar data. So it's not just an American phenomenon. It's a worldwide phenomenon, or at least a European and North American phenomenon. 

I don't think we can underestimate, really, the magnitude of benefits. There are a lot of screening exams that we do that have marginal benefit. But a CT scan reduces mortality by almost 30%. That's a home run in the cancer world. 

Yeah. That's fantastic. And that's why it's so important to get the word out and let people know that this does exist. And speaking of the fact that it does exist, how do you qualify for lung cancer screening? Who comes in for that and who should do that? 

Well, so first of all, it's a beginning discussion with your physician, your primary care doctor and/or your pulmonary care specialist. Broadly speaking, it's someone who has smoked at least a pack a day of cigarettes for roughly 30 years. Now, there's some fudging in there. And if it was more than a pack a day for less amount of time. 

And age range between 55 and then-- depending on whose guidelines you want to follow-- somewhere between the ages of 73 to 80, but generally, typically 75. This is a shifting target. And I think this comes up frequently. These are guidelines. So they're our starting point. 

And then there are, of course, exceptions. You may be someone who's a never smoker, who is younger, but has a profound family history of lung cancer. Multiple members of your family. Well, though you won't fit into a guideline, I can guarantee you if you're coming to see me in clinic, we're going to have a discussion. We're going to find a way to obtain a screening CT scan on you. 

Because even though I don't necessarily have the science behind it, you have such a profound family history. If nothing else, I'm going to want to do it to give you that extra piece of mind. And then, the other scenario, of course, that excludes you from lung cancer screening is if you have other comorbid diseases, other disorders that are so severe that the discussion of lung cancer is not relevant. 

If you have such advanced heart disease that you wouldn't even be able to undergo any form of an intervention or therapeutic. But again, that's-- those are kind of subtle points. And that's part of the big picture discussion you would have with your physician. But broadly speaking, that's the group. And that actually comes, obviously, from the data. And the idea behind this is, let's find the most people to benefit here. Right? Let's use the ability of this scan to help the most people. 

Can I jump in here a little bit and say that lung cancer screening is very much a team sport. And so one, it's about your patient and the physician having the discussion. But then, even after the scan, it really takes a team of experts to help this patient decide what the scan means. 

And so, often-- particularly those of us that have lived in the Midwest for most of our lives-- have a lot of scars on our lungs from having old infections or being outside or taking a walk in the woods. There are things that happen as we age. And many of those scars can be benign, but some of them can be troublesome and need follow up. 

And so, it's really a question working with your pulmonologist, working with the radiologist. And a system that incorporates sort of scanning over time, not just one a one-and-done procedure that really brings the best outcome. And that's also what Medicare requires, frankly. 

Can I add it's an important thing for anyone who's watching who, let's say, they just recently had a CT scan. And for whatever reason-- it might have been for a different cause or for lung cancer screening-- and a nodule has been found, but a relatively small one, something smaller than a centimeter. It's obviously concerning. 

And one of the reasons that I obviously agree with Jyoti that the whole idea of having this sort of team approach is thankfully a majority of these small nodules are actually going to be benign. And that is kind of the first, let's reassure people. It doesn't mean you don't need to follow it. It doesn't mean it's not going to be a discussion with people that there may be something that needs to be done. 

There's individual characteristics of a nodule. But part of this proactive approach is to actually have an intelligent discussion about whether this nodule needs to be pursued from a biopsy perspective, surgery, et cetera, et cetera, or just simply watched and re-examined with a follow up image at some point. 

Now, we're starting to get some questions in from our viewers. And I want to remind our viewers that if you do have any questions for our experts here today, please type them in the comments section. We'll try to get to as many as possible as we can over the next 20 minutes or so. 

So one of the questions we just received, what differences have you seen in lung cancer for women versus men? Are more women diagnosed than men and how does it-- how does that work? 
So there's actually, now, almost equity in the number of women and men that are diagnosed with lung cancer. But there has been some interesting data that's even, I think, surprised many of us in the past year, showing that we are seeing higher numbers of never smoking women who are diagnosed with lung cancer. And we're still trying to understand the risk factors that are involved. 

Certainly, we know that there's an epidemiologic shift. We've talked about smoking behaviors have changed over time. What people smoke has changed over time. When you go from a filtered or an unfiltered cigarette to a cigarette. And so, carcinogen exposure is different, as well as environmental exposures are different. And so, we're tracking that. But certainly we think that many lung cancers and never-smokers are unique, because they're driven by particular genetic mutations that cause the cancer to grow in the first place. 

Sure. What are some of the preventive measures that people can take? 

Well, several things. I mean, one, obviously if you're not a smoker, don't start. And if you are a smoker, quit. Quit immediately. And I will say I'm under no illusion that quitting smoking is the simplest thing in the world. If it was, people would quit and do it without any difficulty. But there are a lot of resources to help people. There's a lot of medicines that can help make things easier. There are support groups. There is counseling. There's clinics devoted to this. 

It's an under-recognized cause. But in various parts of the country, there's a significant amount of radon, which is a natural occurring radio isotope. But it's in the ground. And if you spend a lot of time in your basement, a significant amount of time, you are potentially being exposed. There's a simple evaluation that could be obtained to determine if you have radon in your basement. 

And then, lastly, if you have the requirements for smoking-- or excuse me, for lung cancer screening-- get screened. You know, you asked how new is this? It is new. And it's being ramped up because, of course, it requires a lot of systems in place. It required an upswing in radiology. You can't just suddenly need to do thousands of scans. It will overwhelm the system if they're not prepared for it. We've been ramping up. Others have, obviously, as well. 

Lung cancer screening is still relatively new, but we are working hard and love events like this. Because this does need to be right up there with getting your mammogram, pap smears, prostates, colonoscopies. All the things that we do to help find diseases in their earliest stage, when they're going to least impact the quality of your life and definitely quantity of your life. 
Lung cancer is a difficult enough problem. And we've made unbelievable advances in more advanced disease. But it's always easier to deal with this disease when it's early stage, right? 
What kind of programs does U Chicago Medicine offer to help reduce risk of lung cancer? We can talk about clinical trials, as well, I think, if you'd like. 

So certainly I think we offer a broad program in smoking cessation. There are multiple, I think, trials, even that Dr. Hogarth is leading in terms of reducing risk. 
Yes. And so, Andrea King runs multiple different trials within our hospital that help people quit smoking, as well as support groups. The pulmonary clinic does the same thing. There are trials that are about to start for people that are definitely at high risk, that are so-called chemo prevention trials. So taking a medication that looks like it actually helps to prevent a growth of potential-- of a cancer, long before we could even find it. 

These are exciting areas to explore. They are trials. They are sort of research, nothing yet that's clinical. And at a minimum, all of our physicians-- you know, you don't have to see a specialist to help you quit smoking if you're a smoker. These drugs are available for any physician to prescribe. 

Another question from a viewer. And this one may be a difficult one to answer, but I'll throw it out just in case. Are schools in Illinois required to be checked for radon? Lots of times, offices and even classrooms or in the basement. I'm not sure about public buildings like that. 

I don't know, but I think so. 

That's a good question. And, you know, one of the things I will say to our viewers, since you are leaving the questions and the comments, we'll try to do a little research and get back to those, maybe after the program. But good question. It's very interesting. So what are some of the current innovations that are taking place in the marketplace for lung cancer sufferers, and even people who maybe aren't quite there yet? 

I think in terms of early diagnosis, you should. 

Sure. So the reason-- you know, lung cancer is a spectrum of disease. The spectrum of how it presents in each individual patient's journey, I would argue, is unbelievably different than the next. And that right there is actually one of the most exciting things going on in lung cancer. 

This historically was a disease that kind of was a one-size-fits-all approach, in the sense that, sadly, we frequently found it late stage. And sadly, our therapies weren't as good as they are now. And so, you know, we offered to help. We definitely helped some people. But our surgical approaches weren't as excellent they are now. Our biopsy techniques and our chemotherapies and so forth. 
So I love being able to look back at actually the beginning part of my career and see where we are now. And honestly, kind of make fun of myself for where we used to be. And realize, just in a very short period of time, the unbelievable advances. So let's start with some of the easy things to really highlight kind of what's different. 

So we already talked about lung cancer screening. The fact that this even exists and has data behind it is unbelievably exciting. The more we can find this disease at earlier stages, the better. The other exciting thing of course, you do have early stage lung cancer. You need it removed. 

The number of patients who can undergo now a surgical resection based on the expertise of our thoracic surgeons, and the type of patients they can operate on, as well as the technique they use. So the definitive approach is minimally invasive, tiny incisions. Gone are the large incisions that used to leave patients very debilitated. 

Smaller incisions, shorter recovery, quicker recovery, better recovery. And also the ability to do these surgeries on sicker patients. So if someone says, oh, my lung function is so bad. My doctor said there's no way they can do surgery on me. Well, before you go and say that, make sure you come see the thoracic surgeons here. Because I will tell you between Dr. Donington and Dr. Ferguson, the list of people that can't be operated on keeps shrinking. 

And, of course, if there isn't that option, if surgery truly is not an option-- or the patient doesn't want it, or there may be other factors-- the massive improvements in radiation oncology and the ability to have much more targeted, higher doses of radiation that you can truly have an excellent rate of killing that tumor while minimizing the damage to the surrounding tissue is unbelievable. 

You know, I think you go back some time ago, radiation oncology wasn't even close to being as good as surgery. There's a debate as to whether or not it's almost a tie. I would still argue for surgery.

But radiation oncology, the ability to radiate your tumor, has gotten exponentially better. 

Dr. Patel, quality of life for patients who are going through treatment now has changed substantially. 

Absolutely. So I think about these past 20 years, in terms of cancer therapeutics. And what an evolution we've made. So certainly in patients who have-- who are getting chemotherapy, certainly we've made huge advancements in supportive care. Patients often, despite having advanced disease or stage 4 disease or metastatic disease, are able to do simple things such as chemotherapy as outpatients-- or working or traveling, or caring for their families-- with very controlled and chronic cancer. 

The therapies, again, become more and more effective all the time. But the real advancements we've made, I think, are in our foundational understanding of what drives cancer growth. So the huge investment in sequencing cancers and understanding differences between individual cancers has led to this world in which patients either get targeted therapies-- which can often be pills that are taken at home every day, that cause reductions in tumors that are greater than 80% or 90% for a long period of time. 

Very effective therapy options. So targeted therapies for some patients. We have a multitude of targets, genetic aberrations, that we now are able to design drugs for. Many of these drugs are FDA approved. And many more are in the pipeline and are the subject of multiple clinical trials. 

So that's been fantastic and so fun to watch. Some of my patients with stage four metastatic disease are having their lives every day, taking care of their families, doing the things that are important to them, and seeing me maybe once every three months with scans to make sure the cancer is being treated adequately. 

The other huge advancement has been integration of immunotherapy. So we now know that we can harness your body's immune system to fight cancer effectively. And in some instances, it's far more effective than chemotherapy. We've seen improvements in survival, long durable responses, and very good quality of life. Better than chemotherapy. 

So integration of targeted therapy, chemotherapy, and immunotherapy in all spectrums of disease is really what we're trying to do. So in patients with early stage disease, we have immunotherapy trials that are seeing if we can shrink the cancer prior to surgery. In patients with locally advanced disease, we're integrating immunotherapy with radiation and chemotherapy to cure more people. 
In patients with stage 4 disease, we're personalizing therapy based on genetic characteristics of the patient, as well as the tumor, to get the best paradigm with a combination of immunotherapies, local therapies-- because people are doing so well, even with stage 4 disease, where we might do radiation and come back to surgery-- and really design treatment paradigms. 

Again, even in patients with advanced disease, we recognize that there's a full spectrum. And we require a full team. And so, much of this is based upon the pathology that we get. From that first biopsy, when I ask Dr. Hogarth to diagnose a lung cancer. But not only diagnose a lung cancer, to give me enough information at that first needle that I can start devising a roadmap for a patient, and really help them understand not only what treatment one looks like, but also the entire continuum of their cancer while science continues to grow. 

You're helping segue into my next question, which is great. We'll talk about biopsies. And I was fortunate enough, I got to see this new piece of technology that we have here now at University of Chicago Medicine called The Monarch. Is that correct? 

That's correct. 

Describe what that is and what it does. 

Sure. Sure. 

I know you're kind of proud of this. 

was fortunate enough to be involved early with the company that has manufactured this device as a consultant. So I was able to watch something go from early design, very sort of rough, to an elegant device that's FDA approved of being used in people. And it's changing what we're able to do. 

You know, as Dr. Patel just said, the need for the tissue, to be able to get pieces of that tumor and then personalize your care based off of the factors inside that tumor, that make it your tumor versus someone else's. So that you get the appropriate therapies with chemo and targeted therapies, immunotherapies, et cetera. That does require adequate pieces. 

And so, for myself as a bronchoscopist, a person who takes biopsies inside the lung, we go through your mouth. This used to actually be very straightforward. We just simply needed to get a small little piece, prove it was cancer, and we were done. Now we have to definitely make sure we're getting plenty of material, so that we can run all of these tests on the tumor. 

And, depending on your cancer journey, if things change and we need more, we need to be able to do that in a way that's simple and easy for our patients, so that we can see if the tumor has changed. Maybe there's a new target. Maybe the reason the tumor has advanced is that the old drug isn't working anymore, because the tumor is now resistant to that. We can tell you these things.

But we've got to have pieces of the tumor. 

So the development in bronchoscopy, I think, has been right in parallel with all the exciting things going on in the whole field of lung cancer. You know, if you need to know what's happening inside the middle of the chest in the lymph nodes, we can now do that through a simple procedure going through your mouth. Takes about half an hour to 45 minutes. And we can sample all those lymph nodes and prove if the tumor has spread or not and get the material. 

But for many people, there's been nodules inside the lungs. We talk about lung cancer screening. We find a nodule. And it's a certain size, it's concerning, it could be cancer. But, of course, it doesn't have to be cancer. And we would like to obviously know. You would like to know as a patient. 

There were parts of the lung that we just couldn't get to from going through the mouth. And it required a much more invasive procedure. It required you to get what's called a needle biopsy, where a needle gets put through between the ribs into this thing to biopsy it. It had-- it was a safe procedure, but it had a higher complication rate than we would like. 

It also didn't stage you, because it might prove it's a cancer, but didn't sample any of your lymph nodes. But bronchoscopy, the scope going into the lungs, was limited on where it can go. So this robotic device has opened up an entire new world for us. It's allowed us to essentially get to every region of the lung from the inside, following the natural path. 

We go where the air goes-- that's probably the easiest way to explain it-- with a level of precision and stability that's unprecedented. And so, that lets us get out to where this thing is. Because we've built a road map of your lungs based off of your CAT scan. Your CAT scan gives me a three dimensional tree. And it's essentially GPS following a road map. Go left, go right, head right to this thing, and then pass our instruments through. And then get the biopsies. 

Prove if it's not cancer. Wonderful. You had an outpatient procedure. You're going to go home that afternoon. You're going to play golf the next day. And you didn't have cancer. You didn't have to be cut. And then if it is cancer, then during that same procedure, we'll get all the material we need so that whatever therapies may need to be done. And then we're going to sample all of your lymph nodes. 

So we're going to prove that we thought you were early stage cancer, and actually you are early stage cancer. Let's get you in the hands of our thoracic surgeons to go cure you of cancer. And if the lymph nodes, unfortunately, do show that the cancer has spread, well, we're going to make sure we have enough material and Dr. Patel's going to help you out. And that's that whole team approach again. 

I think it is important-- just one last thing-- because sampling of the lymph nodes to prove that the tumor hasn't spread is the most important thing before anyone undergoes a resection. Because you say-- you meet people all the time who said, I had a PET scan. And it's a type of a specialized scan that looks to determine if tumors have spread and things like that. 
It's not a perfect test. And when a scan says no tumor has spread to your lymph nodes, sadly, up to about 10% to 15% of the time, the scan's wrong and the tumor has spread to your lymph nodes.

And then, you're not stage one. And if we treat you as a stage one, you won't do as well, obviously. 

And so, we want to sample your lymph nodes, prove you're stage one, so that our surgeons can cure you of this. And if you're not stage one, then I want to be able to get you that targeted therapy, that immunotherapy. Get you what you need. 

It's a fascinating piece of equipment. Looks like something out of a movie. 

Yes. Robots are neat, though, aren't they? 

They are. Now, we want to get to as many viewer questions as we can. We may go a few minutes over if that's OK. Well try to keep it fairly tight. But I want to answer a couple of these, because this is an important topic. One that we just got. Do you ever use immunotherapy on patients with the oncogenes such as EGFR after targeted agents stop working? An explain in English what that means, because a lot of viewers won't know what that is. 

Absolutely. So we talked a little bit about those genetic changes that cause a target to form at what we call sort of an oncogene, which, if you'd imagine, is sort of a protein that doesn't shut off and causes a cancer to grow. So we are able to measure those in tumor tissue. And there are a number of targets that we have wonderful drugs for. And one of the most common is EGFR. And that's about 15% or 20% of patients with lung cancer. 

So for those patients, targeted therapy-- so treatments that shut that protein off-- are the most effective. We know that they're superior to chemotherapy. And patients, often they'll start on these oral treatments with great response for some time. Unfortunately, cancer can become resistant. And it develops a way to grow, despite having a drug that is on target and initially causes a great response. Eventually the tumor finds a way around it. 

And so, certainly, this is when I ask for another biopsy to further inform my treatment decisions. And we usually do another targeted therapy or sometimes chemotherapy. Immunotherapy is becoming more and more part of the mix. And we're learning how to add immunotherapy with chemotherapy, to see some nice responses. 

Generally, we don't recommend that immunotherapy by itself as a single agent is used. But that's why we do a lot of clinical trials. And we combine immunotherapies, we combine immunotherapies with radiation and immunotherapies with other agents that kill cancers to improve outcome. 

What is molecular profiling? And why is that important? 

So molecular profiling is a process by which we take a piece of your tumor. And we do a technique in which, essentially, we read the alphabet soup of the tumor to determine if there are any changes in your genes. And this is kind of crazy, if you think about. It we all have very complex chromosomes, millions of genes. 

And a cancer can be caused by one sort of cellular mismatch, like one letter, essentially, is transposed. A single problem can flip a gene switch on and cause that cancer to grow. So it's absolutely essential that we do full molecular profiling, because that list continues to grow. 

Yes, we know a couple of targets that are sort of easy-- like EGFR and ALK and Ros1, those are robust markers. But there's so many emerging targets. And the more we look, the more we're finding. So uncommon targets that the technology for depth of penetration for the genes is just evolving is absolutely essential. So again, we can target therapies that are appropriate. 

Other things that those targets do is also tell us when targeted therapies aren't appropriate, or when immunotherapy may not be as effective. So we don't want to waste time, either. We want to get you to the right drug. But we also don't want to over-treat you with chemotherapy or immunotherapy that may not be as effective. So in many ways, that gives us that sort of bigger picture of really what your cancer will do. And helps us with prognosis, as well as prediction, for right therapies. 

It's so we don't take a one-size-fits-all approach. So that, the term molecular profiling, is what makes your tumor your tumor, versus the other person's. And it's why the therapies that you might receive are going to be completely different to the person in the waiting room next to you. 

Interesting. So one more viewer question, then I've got a wrap-up that I'm going to ask you both. But the last viewer question is, there have been a lot of advancements in non-small cell lung cancer. What advancements have there been in small cell lung cancer? 

So certainly, small cell lung cancer is about 15% of all lung cancers. And it's a cancer that traditionally has been thought of as very aggressive. It's one that often metastasizes early and has been tough, admittedly very tough. We've had the same treatment options for small cell cancer for almost three decades, the same chemotherapy. 

ust recently, however-- again at the World Conference on Lung Cancer-- we learned that integrating immunotherapy with chemotherapy improves outcome at one year and at two years. So we're really excited about that. We're also understanding, again, some of the molecular profile of those targets that we can find in a tumor to develop therapies that can find that tumor, deposit drugs into the tumor with fewer side effects and cause cellular death. 

So certainly advancements are being made. We've also, in addition to systemic therapies, made progress in radiation. So we know that changing radiation can improve survival in small cell. So although the progress has not been as much as we might have seen in some non-small cell lung cancer, I feel like this past year has been one of tremendous hope. That we're really investing, again, in the science and the clinical trials to make a significant difference in the outcome of patients with small cell lung cancer. 

One of the other things that's also going on in this field that's exciting is now that we have the ability to get to any region of the lung, what other therapeutic options do we have up our sleeves? Other options to give locally directed drugs, inject something that may be too powerful to be given through the vein, but would be perfect if you could put it right in the middle of the tumor. 

Now, that obviously would be a trial. It's under investigation. But now that we can get to that, it's not a crazy idea to even think about looking at it. There are microwave ablation catheters that are being studied in trials right now across the US. And we are going to be a center for that shortly, where we will be putting a catheter in the middle of the tumor using our robotic scope. And then, essentially, turning on the microwave and killing this thing from the inside. 

It's being obviously investigated. We obviously have high hopes for it. I think what this really comes down to is that all of the advances that we're seeing with the molecular profiling, better surgical techniques, better bronchoscopy techniques, it's so exciting to just think about all the things that are available. 

And at a minimum, you know, I think one of the best things about being able to be at a center like this is being able to work with people this brilliant, and the other folks that are on our team that aren't here. And see what we've been able to do for our patients. 

It is so exciting to see the advances that are happening here at U Chicago Medicine. 


It's fantastic. Final question for both of you. You know, for cancer patients, there's a real feeling of fear of cancer coming back. So what's the single biggest thing that you would like people to know? 
So I think it's absolutely understandable that if you have had cancer and you've had curative intent that you worry about scans. Certainly, we have a big program in terms of supporting people in learning how to manage anxiety, or scanxiety, we call it. But I think the biggest thing is to know that if your cancer comes back, this is a time in which we have so many more treatment options. 
There is not a single patient with advanced disease that I see in clinic now that I treated like I did five years ago. The number of tools that I have in my tool box has exploded, is exponentially higher. So if your lung cancer comes back, it's absolutely treatable. And what we know in 2018 is going to be vastly different from what we know in 2021. And that idea, that continued investment and continued optimism in controlling through the things we can. If patients are healthy, we have lots of options to treat them. 

I'd echo that completely. And to be honest with you, depending on how much time has passed, if there is a new nodule that presents and its biopsy has proven to be cancer, it's very likely that it's actually not the first tumor. It's the start of a new tumor. And so, you know what? You're going to get treated like a person with brand new lung cancer. 
And if you're early stage, you're going to go for curative resection or curative radiation. And if you need various immuno or chemotherapies, et cetera. What I guess I always tell people, too, who say, I went through cancer therapy three years ago. And I'm cured. I'm free of disease. 

What I think is amazing is what Dr. Patel just said. What we cured you with three years ago? We got a whole bunch of new things to try if something comes back. And because we'll be able to get tissue easily and do molecular profiling, we'll find out if we've got these other drugs and immunotherapies to try for you. 

You know, it was so much fantastic information that you both gave us today. I really, really thank you. And I do want to remind people that if you want to come back and check this out later on, we'll have it on our YouTube page. It'll, of course, live on Facebook as well. And we will have it indexed on the YouTube page eventually, so you can skip from question to question that might be of particular interest to you. And you can tell your friends about it, too, so have them check it out. Thanks very much for being on the show. 

You bet. 

Thank you. 

That's all the time we have today. We want to thank Dr. Patel and Dr. Hogarth for the help with the program. Of course, if you want more information, you can visit our website at, or you can call 888-824-0200. 

And make sure you watch later this month to learn the ABCs of diabetes. We'll take your questions about diabetes and have our experts on to answer as many of those as possible on that one.

Watch or your Facebook page for more information on that important program. Thanks again for watching At the Forefront Live. We hope you have a wonderful week. 

Thank you.

UChicago Medicine lung cancer experts Jyoti Patel, MD, and D. Kyle Hogarth, MD, answer questions about lung cancer and discuss the latest advances in lung cancer prevention, screening, diagnosis and treatment, including targeted therapies, advanced brochoscopy and immunotherapy.

Radiologist Christopher Straus, MD, reviews radiology images

Lung Cancer Care

At UChicago Medicine, we offer a wide range of lung cancer care options, including minimally invasive surgery and innovative targeted therapies, as well as clinical trials of promising treatments not widely available.

Learn more about our lung cancer care.
dr hogarth profile

D. Kyle Hogarth, MD

D. Kyle Hogarth, MD, is an expert in pulmonary diseases — including lung cancer and alpha-1 antitrypsin (AAT) deficiency. He is an expert in the minimally invasive diagnosis, management and staging of lung cancer through bronchoscopy. He is a leader in advanced bronchoscopy using electromagnetic navigation systems that employ 3D imaging technology to detect and biopsy lung nodules and masses.

Read Dr. Hogarth's physician profile.
Jyoti D. Patel, MD

Jyoti D. Patel, MD

Jyoti D. Patel, MD, specializes in the treatment of patients with lung cancer and other thoracic cancers. She uses targeted approaches, immunotherapy, and cytotoxic chemotherapy to tailor treatment to each patient with the goal of improving outcomes.

Read Dr. Patel's physician profile.