At the Forefront Live: Understanding Lung Cancer
May 19, 2019
And joining us today on At the Forefront Live, we have Dr. Jessica Donington, Dr. Christine Bestvina, and patient, Kathy Tentinger. Welcome to the program. And remember, type in your questions, and we'll get to as many as possible over the next half hour. We expect quite a few questions from viewers. Also, today's program is not designed to take place of a visit with your physician. Let's just start off kind of with the basics and talk about the benefits of lung cancer screening, what exactly is it, and why should people look into that, Doctor.
So lung cancer screening is relatively new. And the cancer prevention world. But it was first accepted by the US Preventive Services Task Force about five years ago. And it's a way to detect lung cancer earlier in patients who have a high risk for developing lung cancer, which is traditionally people with a smoking history over the age of 50 to 55.
It's painless, it doesn't take very long. It's really just a CAT scan of the chest and a yearly follow up visit. And what we know from two large trials is that it can decrease the risk of dying from lung cancer somewhere between 20% and 25% in patients at high risk. What's really important for women to know is that that the benefit is even higher in women. A recent trial in the Netherlands showed a 60% decrease in the risk of dying from lung cancer in women who were screened with a yearly CAT scan.
So just a tremendous benefit if you are in that high risk category to get this done.
Dr. Bestvina, if you could talk to us a little bit about you who's an ideal patient for this type of screening.
So I think of this screening as a great way for patients to be able to take some ownership of their health care. So I think it's lot of times, patients will come into our clinic and ask, well, what can I do. And if you meet those requirements, as Jessica was just pointing out based off of the number of years that you've smoked, how heavily smoked, and your age, I think it's a great way to become a participant in your health care.
And Kathy, I wanted to get with you. You actually had treatment here at University of Chicago Medicine-- successful treatment, which we're happy about. Tell us a little bit about your story. You came here after you got a referral, is that correct?
I did. I had been in with another doctor. And it had been kind of a long drawn out process. I felt a little hinky about it. It was kind of not exactly-- we weren't moving forward, let's put it that way. And my gut was telling me, this is not where I need to be. And let's go to the professionals. So I went straight to University of Chicago Medicine. And the minute I walked in, the doctors, Dr. Donington here and MP Livia were in there with some other doctors. They had already met with a tumor board, they'd studied my scans. And they had a plan of action for me.
I immediately just felt at ease, and put myself in their very capable hands. And I'm grateful.
That's fantastic. And we're glad it worked out well for you. One of the things that you mentioned, which I've heard from a lot of patients and a lot of physicians, is communication, and how important it is to have that complete line of communication between patient and physician and family members. And apparently, that went quite well for you, is that correct?
It was absolutely wonderful. I am one that researches, and Googles everything. And this time, I just felt so ill at ease. And obviously, I was a little over my skis. I was also very upset, as you might imagine. But I felt comfortable with them, and I just put myself in their very capable hands, as I said. And they assured me every step of the way they were not only compassionate, but obviously, the best choice. They are my miracle workers.
Dr. Donington, my surgeon, I could not have been luckier. I could not have been more fortunate. She is an incredible thoracic surgeon. And again, I urge everyone to go straight to the source. This is a teaching hospital. And they only employ the best.
We love to hear that.
And just a comment on the importance of communication. So I can tell you that Kathy's family also played an integral role in how we were able to communicate both with Kathy as well as her family. The first time I met Kathy, she brought with her her husband Bob, both of her beautiful children. And whenever you bring family members like that, it leads to such a more productive discussion, because the rest of your family members can think of questions when your mind goes blank. And they can really challenge your doctors about, is this the right thing to do. Why are you making this decision.
So that's just something I would encourage patients to do when coming for a second opinion, a first opinion. To bring at least a second set of ears to be able to participate in that conversation.
You know, I think that's an excellent point, because oftentimes, patients are completely overwhelmed when they're at this stage. And so it is nice to have some other folks there to listen, to pay attention, and bring a little bit of a different viewpoint. I think that's a great, great point.
Dr. Donington, if you can talk to us a little bit about how the screening is done. You said it's relatively simple. Is it a quick procedure?
So lung cancer screening is done through what we call a low dose CT scan of the chest. Low dose means that we've kept the radiation dose as minimal as possible so there's no increased risk of other cancers and such. But part of it also, with lung cancer screening, which is a little unique compared to mammography or prostate screening, is that there's always a visit with a professional, too. To talk about the pluses and minuses of lung cancer screening, to talk about smoking sensations, and to talk about a follow up plan.
And I think that's a really important part of lung cancer screening, because anybody who's smoking should stop smoking. And screening has been a good way to do that. But I think all patients deserve to fully understand the implications of screening is as they take it on.
So Dr. Bestvina, if you can talk to us a little bit about some of the clinical trials that are offered here at U Chicago Medicine, because that's another area-- and Kathy, I think, alluded to this a moment ago-- where I think we're a little bit unique. Because we are teaching hospital, we're a research institution as well. And again, I think that is very important for patients, because oftentimes, patients here will see the first of a new treatment.
Absolutely. So one of the things that we're always focused on for our patients when they first walk in the door is what clinical trial do we have available here that they may be an option for. And what we really try to do with our clinical trial portfolio, or all of the clinical trials taken as a sum, is to have trials available for every patient no matter what stage they may be.
So we have clinical trials for patients who have early stage disease prior to surgery, just as Kathy participated in. We have patients who are treated with a combination of chemotherapy and radiation with the addition of immunotherapy. And then we have several clinical trials for patients who have stage 4 or metastatic disease. The clinical trial that we're particularly enthusiastic about right now is a combination of two immunotherapy agents plus radiation. So essentially, using these agents to try to boost the body's own immune system to fight off the cancer, which is quite appealing for many reasons.
But we have other clinical trials that are for targeted agent. So depending on what a patient's genomic profile looks like, how their tumor looks, we may have a clinical trial that specifically for them and for their tumor type. So if anyone is interested we absolutely encourage them, even if it's just a one time visit, to see if they may be eligible to make that step.
We are accepting questions from our viewers, as we always do. And we want encourage people to start typing in those questions. We have our first one already. And that is, what's the care team makeup for someone that is a cancer patient? It's a big team, it's not just one or two physicians. This runs the entire kind of range of care.
Right, so as we have moved lung cancer into what we call personalized care, the team that cares for each patient is bigger, and each member has a more important role. It's so rare that any one of our patients will just see one lung cancer doctor. The reality is they see the whole team.
I think the core of the lung cancer team is made up of medical oncologists, radiation oncologist, thoracic surgeons, radiologists, pathologists, palliative care, and pulmonologists.
I think we got them all.
It's a really good team. So here at the University of Chicago, that team meets once a week. We talk about all the patients we have in common. We have a multidisciplinary clinic, where we kind of move people from one of us to the next to us as needed. And I think that's a really important way to deliver efficient care. And I think it really is a better way to look at lung cancer care, because again, no one sees just one doctor anymore.
And exactly as Jessica just alluded to, all eight different subspecialty is that may be involved, even within each individual team, there are still several care members that a patient may interact with. So my personal team composed of two completely dedicated thoracic nurses. We have two physicians assistants, who also only see lung cancer. And then the physicians on the group.
And so that also allows a patient multiple levels of access to the team. It allows them to be able to call a nurse in the middle of the day and say, you know, I'm having some nausea, what do you think about this, what should I do. And again, just that in volume of team allows easier access for patients.
Well, it certainly is a wonderful team. And we have a story here of a woman named Ivy Elkins, who is not a smoker, but had lung cancer. And it was overwhelming for her when she got the news, but it turned out to be good news. Here's her story.
About six months before my diagnosis, I had started having problems with my right elbow and the left side of my neck. It wasn't anything horribly major.
One of the orthopedists that I had visited did an MRI of my elbow, and found that there was a mass in there that had eaten away part of the bone by the joint.
It wasn't benign. It ended up being an adenocarcinoma. And then I needed to have the PET scan to trace it back to where it had originated in my body. And it was traced back to my lungs. So by the time I had all my testing, it turned out that I had a mass in my lungs with several nodules kind of floating around as well. It had spread to my bones. It was in my elbow within my neck and a few other areas. And I had eight very small lesions in my brain, also.
So I was completely devastated. And I didn't know how I had gotten from just a pain in my elbow and a little bit of trouble with my neck to this stage 4 diagnosis, because otherwise, I felt fine. I didn't have any breathing issues. I didn't have a cough. I didn't have wheezing. I didn't have anything that you would traditionally associate with lung cancer.
Ivy Elkins was one of those 30,000 people a year who's never smoked who's developed lung cancer. When she first presented, her cancer it already spread from her lungs to her bones, and she was experiencing a fair bit of pain in her arms and neck, and unable to do her activities of daily living. She was unable to drive, unable to cook for her family, and care for her young sons.
We were able to do genetic testing to find that she harbored a particular mutation in her tumor that made targeted therapy a reality for her. Soon after matching the right medicine for her particular type of tumor, her symptoms dissipated. She had full range of motion in her arm within weeks. She was able to get back to her life. And I really think that's been the most satisfying piece of it.
Here I am, I'm coming up on my five year cancerversary will be in December. And I live a completely normal life. I'm active, I do things with my kids, I travel, I exercise. I really, really have a completely normal life.
Cancer can't compete with the rest of my life. I mean, yes, I have cancer, but cancer doesn't have me.
I like that it gets a nice ending. And I like how she puts that, because she's a fighter, and obviously-- Kathy, as are you. I mean, you're you are and it worked out.
Talk to us a little bit, Kathy, if you will, just kind of as you went through your diagnosis and then your treatment, how long was that, first of all?
When I came to University of Chicago, it was an immediate plan for me. So they laid out everything and I just complied. I started with chemotherapy, and then moved straight to Dr. Donington, who has incredible knife skills. And woke up and recovery. All along, by the way, I must say, everyone was not only superbly professional, but very compassionate. Always concerned. Even thinking of things that I hadn't thought of.
After surgery, the recovery, Dr. Donington was very clear that it was not an easy recovery, but it would be a good recovery. And in fact, it was. Everything that happened was no mystery to me. She had laid it out perfectly. And she saw me within two weeks, and so did Dr. Bestvina. And I was on the way and. I had a very, very smooth recovery. I was back at work three weeks before I even anticipated that I would be and I feel wonderful again thanks to these wonderful people.
That's fantastic. You clearly had a lot of confidence in these doctors. And they must have just inspired confidence in you from the very start.
Yes. And when you've seen doctors that maybe have a second thought about it, or you're not really sure, that should tell you something. Listen to yourself, and go to where you need to be. And that is at this hospital. They are always on the edge of everything that's happening. They always have new ideas. In fact, Dr. Bestvina told me, there's always another path. Don't worry. If this isn't it, there'll be another path. This isn't the end.
And it wasn't. And I talked them up all the time, and I wear the bracelet. And I want to be an advocate.
That's fantastic. We're getting some more questions from viewers-- several more. Let's go back here a couple. There's a percentage of young women nonsmokers that get diagnosed. What is the approach compared to smokers or elderly or high risk patients who get diagnosed? How does the care differ?
So I'll take it. For this question, I'm going to focus on patients who have stage 4 disease or metastatic disease. So for all patients who have a particular type of lung cancer called adenocarcinoma, which is just a designation for how the cells look under the microscope, it's now recommended and in fact, required by the NCCN guidelines that these patients receive genetic testing on their tumor. And that's because in approximately 20% to 30% of these patients, they'll have a genetic alteration. Some of the most common ones include EGFR, which Ivy, the wonderful story that we just saw, has. ALK, RAS1, BRAF, and a few other targeted mutations.
And this is so important that patients receive this type of testing, because for them, their treatment course is so incredibly different. It's actually an oral targeted pill that attacks that type of cancer that they have as opposed to a combination of chemotherapy and immunotherapy, as would be often the recommended first line therapy for other patients. And so that's something that we're really aggressive here about-- is making sure that all patients, as they need to, have this required genetic testing. And that is if the tissue is sufficient, because to us, this is just an integral part of making sure that patients have that right treatment course laid out for them.
Another question from a viewer. I've heard that low dose CT scans have a high false positive rate. Are there other screening tools which are more definitive?
So the high false positive-- it's not ridiculously high. But right, when we talk about for every 100 scans, we do we do think that about 25%, maybe even 40% of people, there will be something we see on that scan that makes it positive. There will be a nodule, a scar, a something. And that will trigger something beyond just another scan in a year.
Most typically, that trigger is just another CAT scan in three to six months to relook at this. But of all of those, if we do 100 scans, we really don't expect one of those to be a lung cancer. So we are working with ways, things like biomarkers, be that the blood, the breath, things like that, to try and tell us what those nodules is a cancer versus those that aren't.
But when we look at most of the screening trials, the number of nodules that actually went onto a biopsy be that a surgical biopsy, a needle biopsy, or a bronchoscopy, is actually fairly small. So again, a positive doesn't necessarily mean an intervention. And we are all working on ways to better refine what's positive and to decrease the amount of interventions needed that won't result in a cancer diagnosis.
Now here's kind of a basic one that I probably should have asked right off the bat. How would one schedule screening or an evaluation for the cancer or other issues? That's kind of a basic one. I should have asked you that. I'm sorry about that.
So lung cancer screening can be ordered in several ways. Your primary care doctor, you should probably speak to them first and foremost, because we all should be seeing them and speaking with them. They should know about the screening programs available to them and the screening program here at University of Chicago Medicine. If you're not getting that information you want, then you should reach out to our Cancer Center here at the University of Chicago, and we will immediately plug you into our screening program, review whether you are an appropriate candidate, and go over all the decision making required.
And John just put the information up on the bottom of the screen a minute ago, so people can call that phone number or go to our website as well. We're happy to help you out.
Now this is a long question, so be ready for this one. So they're asking about clinical trials availability for 3B stage pulmonary adenocarcinoma. Mother had a biopsy to drain for her pulmonary effusion. Result came back positive for malignancy. Left lung full of nodules. 80-year-old mother. So that's pretty specific. And again, I realize you can't give a medical opinion on something that's specific, but maybe some advice.
Absolutely. This is a case where if somebody is even asking the question and wondering whether your mom may be a candidate for clinical trials, this is certainly a great time to bring them in just for a second opinion. And even if we don't have any clinical trials, we're certainly happy to work with your local oncologist and provider in whatever way we can best support you. I think just having that peace of mind is really important to know that you're on the right pathway.
I think this case example also just brings up an interesting point. I know that age was pointed out at 80. And one of the big things that we focus on for clinical trials is just making sure that patients are essentially strong enough and in a position where they can undergo treatment with an investigational agent. But certainly, we have put octogenarians on trials. There are patients who walk into our clinic who have an age of 82 when we look in their record, and I've walked in the door before, and said, I think I'm in the wrong room, because the patient looks like they're 65.
So there's a big difference between an age on paper and actual physical age. So absolutely, we'd love to talk more with you and your family member about this case.
I think that's very encouraging too, because you know, each person is different, obviously. And it's case by case basis, which I think is very positive.
One of the things that I've always been kind of curious about particularly when we talk about screening for something like lung cancer-- and I think it's very unfair, but oftentimes, people will say, well, they're smokers, that's what you get. And that's not right. And in this case, this allows people kind of the ability to not only spot it in advance before it gets to a real significant stage. And that's something that's interesting with lung cancer-- I think you've mentioned this before, Dr. Donington, that oftentimes, when you see lung cancer, it's stage 4, because that's when people notice it.
Right. So in general, lung cancer doesn't have a lot of symptoms until it's very advanced. You heard ivy Elkins, it was in her elbows, it started in her lung. That's a long ways away before it causes symptoms. And that's one reason why screening is so important-- is that we see a real what we call stage shift. Meaning that in the general population here in the United States, most people diagnosed with lung cancer have stage 4 disease.
In the screening trials, that really shifted so that more than half of the patients were diagnosed with stage 1 disease. That's when it's curable. We all want to catch it in stage 1. I think that's a really important concept.
You also talked a lot about the stigma of lung cancer. There is a terrible stigma associated with lung cancer that is, in our opinion, completely unjustified. Tobacco is a contributor to lung cancer incidents, we know that. But there's a huge number of lung cancer patients who either never smoked or smoked very briefly in their lives. So I think it's really important as we work on curing this disease, that we separate tobacco and lung cancer care. They're not the same thing. They both play an important role, but they're not the same.
And even if you are a tobacco user, you don't deserve that.
No one deserves it.
Absolute not. And Kathy, I want to be fair to you too, because you had not been a smoker for-- we talked a little bit before the show, I thought this was interesting-- for decades. So oftentimes, people can have various cancers, lung cancer included, as you mentioned, Dr. Donington. And they're not smokers.
Oh Yeah. Kathy actually represents what most lung cancer patients in the United States look like. Someone who maybe smoked briefly formally in their lives, but most lung cancer patients are not people who are currently smoking at all.
And there is, like you said, such a stigma. I realized, of course, recently, that more women have lung cancer than breast cancer and heart disease combined. And it is stigmatized. The first question someone asks you or a loved one of yours-- well, was she a smoker? And somehow, it's deserving at that point. And like the doctors said, most often, not the case.
So I think we need much more awareness of lung cancer. And that will lead to more research. More money leads to better options.
And I do think that the patient advocacy realm of lung cancer has changed dramatically over the past five to 10 years. I think we've been very lucky to have a lot more vocal patient advocates similar to Kathy, similar to ivy. Women, men, young, But smokers, nonsmokers. People who are really trying to change what the perception of lung cancer is, and remove that guilt from the patient. Because nothing is worse than a patient who's just been told that they have lung cancer and now all of a sudden, they feel like it's their fault. That's certainly something that I try to address with my patients, and try to remove that out of this situation.
Absolutely. And it is-- you know, if you get the screening, if you are a smoker, and you want the screening, you should do that. Because we want you to stick around and enjoy your grandchildren or family members. It's very important. And we are putting the number and the address up on the bottom of the screen again, because we want people to reach out, certainly, if they have any questions.
Guys, we're out of time. That was really fantastic. And Kathy, I really thank you for bringing your input and your angle to this, because I think it's nice to hear from patients.
I'm the grateful one.
Well, we're grateful to you. Doctors, you were both fantastic.
Thanks for having us.
That's all the time we have for our program today. If you need more information or want to make an appointment, just look at the bottom of the screen. You can check out our website at UChicagoMedicine.org or call 888-824-0200. And also, be sure to keep checking up on our Facebook page for updates on future At the Forefront Live programs. Thanks again for watching. Hope you have a great weekend.
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Medical oncologist Christine Bestvina, MD, thoracic surgeon Jessica Donington, MD, and patient Kathy Tentinger joined us for a candid conversation on lung cancer screening, novel lung cancer treatment options, and the latest clinical trials offered at UChicago Medicine.
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.
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