You Have Advanced Lung Cancer, Now What?

So, you were just diagnosed with advanced non-small cell lung cancer (NSCLC), and your head is full of thoughts and concerns about the future of your loved ones and yours. It is difficult to take a lung cancer crash course with Dr. Google in preparation for a consult with your oncologist when your brain is so busy, so I have prepared a list of questions you should ask. This review is aimed at patients with stage IV lung cancer. If you have earlier stages, this information may not be fully applicable to you.

A Proper Diagnosis

The process of establishing a firm diagnosis is crucial to start you out with the best treatment.

The first element is a good tissue biopsy, which will confirm the diagnosis of lung cancer and provide information about the subtype. The most common subtypes of NSCLC are adenocarcinoma and squamous cell carcinoma.

In order to get a complete staging of your cancer you should have imaging studies including a PET-CT (or CT scans of the chest, abdomen, pelvis and a bone scan if PET is not available) plus an MRI of your head. 

Complete laboratory work should be done to look at your blood, kidney and liver functional status. If your tumor is an adenocarcinoma, you could also have a tumor marker called carcinoembryonic antigen or CEA measured. If elevated, that marker could be a surrogate of tumor activity down the road.

The most important testing in 2017 however, is molecular testing of the tumor. That will give your cancer doctor information about potential targets that if present, could dramatically change your treatment and prognosis.

Testing by Tumor Type

When the tumor type is adenocarcinoma, the biopsy sample should be sent for testing for several targets including EGFR, ALK, ROS-1 and BRAF as there are specific smart drugs that can be used against them. Clinical trials comparing those drugs against standard chemotherapy show that targeted treatments are associated with better response rates (about three times better), lower risk of progression and significantly less toxicity, in turn, all that translates into longer survival for patients with targetable mutations. For squamous cell lung cancers, we do not run those tests unless your doctor thinks that there is a special circumstance, such as a negative history of cigarette use.

Another important test to run in the biopsy sample is PDL-1 status. This is applicable to all types of non-small cell lung cancer, adenocarcinoma and squamous cell cancer. PDL-1 is a marker to identify patients who will do better with immunotherapy than with chemotherapy for upfront treatment of lung cancer. If PDL-1 is expressed in 50% of tumor cells or greater, you would be a candidate for treatment with a drug called pembrolizumab. The response rates and time it takes for the tumor to grow back are significantly better compared to our best available chemotherapy combination, with less toxicity as well.

Of course, not everything runs always smoothly, many times the pathologist will inform your doctor that the biopsy sample was not sufficient to perform those important tests, and in that case your doctor could either ask you to repeat a biopsy or run a “liquid biopsy”. This is a neat test that is done in a regular blood sample. Through special techniques, they can detect tumor DNA in the circulation and sometimes circulating tumor cells. The molecular tests (except PDL-1) can be done in that sample.

Questions to Ask Your Doctor

In summary, on your first or second encounter with your oncologist, you should get answers to the following questions.

• Does he have a firm diagnosis regarding your lung cancer type?
• Does he have all the radiologic tests necessary to stage your lung cancer? Remember that even though PET-CT scans look at the brain, an MRI of the head is the most sensitive test and many times detect brain lesions missed by PET-CT.
• Has he sent the tumor (adenocarcinoma) for molecular testing for the following markers: EGFR, ALK, ROS-1 and BRAF?
• Has he tested the tumor for PDL-1?
• Is there a clinical trial here or at a near university cancer center that can be good for me?

Closing Thoughts

As you can see, in lung cancer treatment, the one size fits all approach is not appropriate anymore. We are personalizing the treatments of each patient and it is important to know your options.

If you do not have severe symptoms, it is fine to wait a couple of weeks to gather all the information before deciding to embark on any specific treatment. However, if you do have symptoms and your doctor feels that it is not safe to wait that long, it is perfectly fine to start treatment with standard chemotherapy and then modify your treatment accordingly.

I hope this review is helpful. These are exciting times in oncology, and keep in mind that the information regarding cancer treatment is dynamic and many changes will continue to occur in the near future. I wish you the best of luck!