In an interview with Targeted Oncology, Steven H. Kirtland, MD, FCCP, discussed the different factors that play a role in the decline of lung cancer mortality over the last few years. He highlighted how these advancements will continue to impact the survival of patients with lung cancer and his thoughts on the evolving landscape.
Steven H. Kirtland, MD
Steven H. Kirtland, MD, FCCP
The death rate from cancer dropped 2.2% between 2016 and 2017 in the United States, according to The American Cancer Society (ACS). This is the largest single-year drop ever recorded, according to ACS, who also reported a 29% decline in the cancer death rate from 1991 to 2017.
This decline is mostly due to declining death rates in patients with lung cancer, where morbidity decreased from almost 3% per year from 2008 to 2013 to 5% from 2013 to 2017 in men and 2% to almost 4% in women, respectively. The rates of new cases of lung cancer also declined by 5% in men and 4% in women annually from 2013 to 2017.
The 4 most common cancer types include lung cancer, colorectal cancer, breast cancer, and prostate cancer, but lung cancer accounts for almost one-quarter of all cancer deaths, which is more than breast, prostate, and colorectal cancers combined. However, the rate of new lung cancer cases declined by 5% annually from 2013 to 2017 in men and by 4% in women.
“I would be remised if I didn’t say smoking rates are going down, but that is preventing the development of lung cancer rather than impacting the survival of patients with lung cancer,” Steven H. Kirtland, MD, FCCP, said. He says the declines in lung cancer-related deaths can be credited by the advancements in lung cancer screening for early detection, minimally invasive surgical techniques, and targeted therapies.
With improvements in early detection of lung cancers, patients are diagnosed at earlier stages of disease that are associated with better survival than more advanced stages of disease. Minimally invasive surgical techniques are associated with less risks, while targeted therapies are generally associated with more limited toxicities than standard chemotherapy options.
In an interview withTargeted Oncology, Kirtland, chief of staff, section head of Pulmonary Medicine Department, and medical director of the Center for Lung Cancer Care at Virginia Mason Medical Center, discussed the different factors that play a role in the decline of lung cancer mortality over the last few years. He highlighted how these advancements will continue to impact the survival of patients with lung cancer and his thoughts on the evolving landscape.
TARGETED ONCOLOGY: ACS reported a significant drop in lung cancer mortality between 2016 and 2017. Could you discuss the factors that have impacted this?
Kirtland:Dealing with lung cancer, you don’t often get to talk about good news, so I am excited to talk about this. As the report said, there was an overall cancer rate drop in 2016, which is a dramatic improvement. When they subcategorized, they find its most related to the improvements in lung cancer survival and melanoma. This is something I’ve been waiting for as the multiple different therapies for both early-stage lung cancer as well as advanced-stage lung cancer have really advanced over the past decade but even within the past 5 years.
It’s interesting to note that this was the year from 2016 to 2017, and the Center for Medicare and Medicaid Services formally approved the low-dose CT scan screening for people at risk in February 2015. We would be remised if we did not mention that 1 of the aspects is we are now finding lung cancers at an earlier stage, which we all know has a much higher survival rate in the upwards of 80% to 90% for the very early stage Ia lung cancers.
Other reasons for the improvement would include advances in the surgical techniques, more folks using minimally invasive techniques and robotics, and all of the new targeted therapies that are coming out and changing bi-annually with different trials looking at combinations of chemotherapy and targeted therapies or chemotherapy and immunotherapy. We have seen cases of advanced lung cancer now that are living for even a decade, which, when I started 20 years ago, was unheard of.
I think [this decline] is due to a combination of finding cancers earlier in the disease course when they inherently have a higher survival rate, as well as improving the survival for patients with advanced stage disease.
TARGETED ONCOLOGY: Could you discuss the advancements in early detection and how this plays a role in the survival of lung cancer?
Kirtland:We still have a long way to go. We are still not screening nearly the number of folks that need it. Unfortunately, the groups that most screening centers are getting screened are also those who have a higher survival rate from cancer in general, which are higher-socioeconomic Caucasians, as well as the urban group as well. If you look at lung cancer screening in the folks who would probably benefit the most are those that are low-socioeconomic, rural, and minorities. Almost across the board, they are less apt to get screened, so there is more work to be done in developing different avenues through education and making screening convenient for folks that are not close to an urban area.
We have our challenges, and I think as we approach those challenges, we will continue to see improvement. The real benefit of lung cancer screening will be seen in not year 1, but the years thereafter down the line. In the first year, you are typically picking up more advanced tumors than you do in the subsequent years.
The other challenge, I would say, is that screening is only approved for those who were identified in the National Lung Screen Trial published in 2011. We know that there are other folks out there who are at significant risk from either genetics and family history or exposure to other carcinogens, such as asbestos, nickel, or radon, that lung cancer screening is not offered because it is not covered by Medicare and insurance companies.
TARGETED ONCOLOGY: You mentioned that surgical techniques have played a role in the increasing survival of lung cancer. Could you discuss these advancements?
Kirtland:At our institution, I can tell you our length of stay in regard to lung cancer surgery has dropped dramatically with each advancement in minimally invasive techniques. It wasn’t long ago that more people were getting open thoracotomies, which is associated with a significant amount of pain and requiring more narcotics and more disability. Now, most folks, instead of being in the hospital for 5 to 7 days with an open thoracotomy, are going home on average after around 2 days. With robotics at our institution, we have people staying, oftentimes, just overnight for a lobectomy or a segmentectomy.
I haven’t seen that data directly, but when folks are able to get up and around, using less narcotics, there is less morbidity. I would think that eventually, that will translate into reduced mortality. Those are the advancements in surgical techniques.
The next exciting avenue is going to be with these small lung cancers that are found oftentimes now via navigation-directed bronchoscopy; this is still years away, but studies are going to be starting regarding the treatment of these lung cancers with ablative techniques bronchoscopically. That’s the next [advancement]. As you go down the spectrum of minimally invasive treatment, that truly is minimally invasive when you don’t need to make an incision. How that will translate into mortality, we will see, but this is all very exciting work that is occurring over the last 10 years. It’s quite exciting.
Stereotactic radiation is another localized radiation technique, which has also expanded in use over the past years. This is a real focused what we call minimal fractions but high-intensity treatment anywhere between 3 and 5 fractions. Instead of getting radiation for 30 days, these patients are getting it for about 5 days. This will hold less morbidity, less radiation tissue damage to the surrounding tissues, and outcomes that are nearly equivalent to surgical resection. We now have a local therapy for those patients who either refuse surgery and don’t want to pursue that avenue or because of their underlining lung disease and other morbidities, they are not typical candidates but can have a therapy that is associated with excellent survival similar to surgery.
TARGETED ONCOLOGY: There have been a lot of advances in targeted therapies. How would you say this impacts the treatment of lung cancer today?
Kirtland:I interreact with medical oncologists daily and am very interested in this. This is an area of thoracic oncology that is moving at almost light speed. It is moving so fast that it is hard for patients and providers to keep up with, such that it speaks to the importance of [things likeTargeted Oncology] and of avenues for both patients and providers to come together to speak with each other and say, “I know of these trials and other trials.”
A few years ago, I had a patient who found in a trial in Denver with Ross Camidge, MD, PhD, for her ROS1 marker. With that, she has been on that [trial] and remains cancer-free over the past 5 years. It’s exciting, and these many of these lung cancers, as you know, have molecular antigens or genetic markers on the cell wall that make them sensitive to targeted therapies, which are generally oral medications that have much more limited side effects than systemic chemotherapy. The drugs are generally better tolerated, and these have led to dramatic reductions in tumor burden. I don’t think we are to the point where in advanced lung cancer we could say it’s curative, but it stabilizes and improves the cancer burden, as well as lengthens life. We generally tell these patients the treatment will be effective for a while, and at some point the cancer will mutate. As long as we keep a close eye on the patient, and when we see a change in pattern of the decrement of cancer or the growth of the mass, then we re-biopsy and see what new mutations or antigens are there to change therapy.
One of my favorite patients was diagnosed with stage IV disease over a decade ago. He lived for about 11 years, but during that time, he was put on 8 different treatments for his disease as the cancer mutated and we altered the therapies accordingly.
More and more of these targeted therapies are coming out and are being evaluated, and we are still trying to figure out when and where they should be added to the standard chemotherapy. Then along comes immunotherapy, a way to stimulate the body’s own immune system to effectively, if you will, “naturally” kill the tumor or treat the tumor. This is extremely exciting too.
Now we have the standard of care for, say, locally advanced NSCLC, which would be chemotherapy followed by immunotherapy after data from the PACIFIC trial. There are more and more of these trials coming out with combination therapies between immunotherapy and chemotherapy. We generally don’t combine immunotherapy and targeted therapy; the outcomes there are not generally as beneficial. It is hard to keep up with all the new targeted therapies because we can run next-generation sequencing on tissue or do blood testing to look for markers, and there are up to 100 or more markers. Unfortunately, we have not developed antibodies or treatments for all those markers, but it will only be a matter of time before we develop additional therapies. That will be very exciting. It will be a bit confusing, but it will be very exciting to be able to offer a larger proportion of patients who may have a different marker this type of therapy.
TARGETED ONCOLOGY: Overall, the field is moving in a positive direction based on this report. What are your final thoughts on how this will continue to advance in the future?
Kirtland:To be frank, I am in the latter third of my career, and when I entered medicine, I was trying to decide what I wanted to do. Medical oncology was not something that excited me because especially in terms of thoracic oncology, it was not a fairly optimistic, positive type of position to be in with your patients. I think if I were entering medicine today, it’s a much different landscape. Over the next 10 years, I think we will see even more improved survival rates. Our goal is to not be the number 1 cancer killer, and I think we will get there.
Lung cancer, for a long time, was the ugly stepsister that didn’t get a lot of attention compared with the other cancers, and now it is getting a lot of attention. Following that, we are finding multiple effective therapies. There is more support financially for the development of those, and I think it will follow that the survival rates will improve.
I am a bit melancholy because I wish I wasn’t in the latter third of my career. I wish I were younger because it is about to be really exciting. I would love to be able to say in a number of years we have put pulmonologists and thoracic surgeons out of business because the survival rates have gotten so much better.
Facts & Figures 2020 Reports Largest One-year Drop in Cancer Mortality [news release]. Atlanta, GA: American Cancer Society; January 8, 2020. https://bit.ly/3a6Bp5Q. Accessed January 15, 2020.