In general, there are two types of lung cancer: small cell and non-small cell. Non-small cell lung cancer (NSCLC) is the most common type, accounting for about 85% of lung cancers. When NSCLC is in its early stages, doctors will typically remove the tumors via surgery and then may recommend chemotherapy and radiation therapy. However, when the cancer spreads to both lungs, to the area around the lungs, or to other organs, treatment options like surgery, chemo, and radiation may not be enough. This means the cancer is considered advanced, and it’s time for something different.
Until recently, these patients had few options. But in the last decade, we’ve seen the introduction of two important types of cancer treatment: targeted therapies and immunotherapies. Targeted therapies came onto the scene in the 2000s, and for certain patients, can give great results. Whereas chemotherapy kills many cells in your body, not just cancer cells, targeted therapy can identify cancer cells specifically and interfere with key elements that make these cells divide and grow. Instead of trying to kill cancer cells with a shotgun, like with chemo, we now have a sniper rifle, with targeted therapy.
However, targeted therapies don’t work for all patients—they only help patients who have specific gene mutations. When patients don’t qualify for targeted therapy, immunotherapies may come into play.
The Impact of Immunotherapy
The goal of immunotherapy is to wake up the immune system so it identifies cancer cells as foreign enemies; we’re boosting the ability of your body to fight the cancer. This is necessary because our immune system does not respond the right way to cancer cells. When you have a cold, your immune system recognizes cold cells as invaders, and jumps into action to destroy them. But cancer cells use strategies to hide from immune cells. One set of immunotherapy drugs, called checkpoint inhibitors, step in to prevent cancer cells from running the show. They block the ability of the cancer to hide itself.
Immunotherapies offer an effective treatment option for patients who haven’t seen success from other treatments. So far, three of these drugs have been approved by the U.S. Food and Drug Administration (FDA): nivolumab (Opdivo), pembrolizumab (Keytruda), and atezolizumab (Tecentriq). These treatments don’t work for every patient: only about 30 to 40% of patients respond to the therapy. But when it works, it works incredibly well with lasting results. Plus, side effects are, for the most part, manageable—most commonly, patients experience nausea and fatigue. However, I’ve found that having patients do physical therapy while receiving this treatment helps them stave off fatigue quite well.
Choosing the Right Treatment Plan
Along with the development of targeted therapies and immunotherapies, we’ve also found ways to test patients to see what treatments would most benefit them. By analyzing patients’ tumors at a molecular level, we’re able to determine if they should start with chemotherapy, targeted therapy, or immunotherapy. In some cases, patients might be better off skipping chemotherapy altogether and going right to immunotherapy. Right now, only one checkpoint inhibitor, pembrolizumab (Keytruda), has been approved as a first-line treatment for advanced lung cancer, but more are being studied for this purpose.
Scientists are researching better ways to predict treatment success, and I believe we will see some major advances in the next few years. For now, I tell patients that I can’t guarantee that immunotherapies (or any treatment, for that matter) will work. It works for some and doesn’t work for others, but it’s hard to know exactly why. I think with time, we will know more and get better at understanding what treatments are best for individual patients. Until then, it’s still wonderful when a patient has success with immunotherapy. One of my patients tried everything for her lung cancer and basically exhausted all her options. But then she started immunotherapy and now she’s been cancer-free for three and a half years.
Twenty years ago, researchers believed immunotherapies wouldn’t work well for lung cancer, but look where we are now. We’ve come quite a ways in the past two decades, but we still have quite a ways to go. I think we are going to see many changes in the next few years regarding how these therapies are best used—we’ll continue learning more and more about how they work and how to get the best outcome for the most patients.
For now, though, it’s important for patients to avoid lung cancer altogether. I always say this type of cancer should be rare. The number one cause of lung cancer is smoking, followed by radon gas exposure. If we tested for radon more, and if everyone stopped smoking, we’d have 200,000 fewer patients diagnosed with lung cancer every year.