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Lung cancer diagnosis should be quick, complete and comprehensive. Then it actually allows individual selection and optimization of cancer treatment. Thanks to innovative therapies, some patients have a chance to extend their lives not by a few, but by several dozen months. Lung cancer becomes a chronic disease.
Lung cancer – diagnosis
– Lung cancer diagnosis requires the involvement of many specialists, unlike some organ cancers, such as breast cancer or melanoma, which are diagnosed and treated mainly by oncologists. Lung cancer differs significantly here – says Prof. dr hab. n. med. Joanna Chorostowska-Wynimko, head of the Department of Genetics and Clinical Immunology of the Institute of Tuberculosis and Lung Diseases in Warsaw.
The cooperation of many specialists is of great importance, the time devoted to diagnostics and then qualification for treatment is invaluable. – The sooner the cancer is diagnosed, the sooner the imaging and endoscopic diagnostics are performed, the sooner the pathomorphological assessment and the necessary molecular tests are performed, the sooner we can offer the patient the optimal treatment. Not suboptimal, just optimal. Depending on the stage of the cancer, we may seek a cure, as in the case of stage I-IIIA, or in generalized lung cancer. In the case of local advancement, we can use local treatment combined with systemic treatment, such as radiochemotherapy, optimally supplemented with immunotherapy, or finally systemic treatment dedicated to patients with generalized lung cancer, here the hope is innovative methods of treatment, i.e. molecularly targeted or immunocompetent drugs. Clinical oncologist, radiotherapist, surgeon should absolutely participate in an interdisciplinary team of specialists – in thoracic tumors it is a thoracic surgeon – in many cases also a pulmonologist and a specialist in imaging diagnostics, i.e. a radiologist – explains Prof. dr hab. n. med. Dariusz M. Kowalski from the Department of Lung and Thoracic Cancer of the National Institute of Oncology-National Research Institute in Warsaw, president of the Polish Lung Cancer Group.
Prof. Chorostowska-Wynimko reminds that many lung cancer patients have coexisting respiratory diseases. – I cannot imagine a situation where the decision about the optimal oncological treatment of such a patient is made without taking into account concomitant lung diseases. This is because we will qualify for surgical treatment a patient with generally healthy lungs except for cancer, and a patient with a chronic respiratory disease, such as pulmonary fibrosis or chronic obstructive pulmonary disease (COPD). Please remember that both conditions are strong risk factors for lung cancer. Now, in the age of a pandemic, we will have many patients with COVID-19 pulmonary complications – says Prof. Chorostowska-Wynimko.
Experts emphasize the importance of good, comprehensive and complete diagnostics. – Since time is extremely important, diagnostics should be performed efficiently and effectively, i.e. in good centers that can effectively perform minimally and invasive diagnostics, including collecting the right amount of good biopsy material for further tests, regardless of the technique used. Such a center should be functionally connected with a good pathomorphological and molecular diagnostics center. The material for research should be properly secured and forwarded immediately, which allows for a good assessment in terms of pathomorphological diagnosis, and then genetic characteristics. Ideally, the diagnostic center should ensure the simultaneous performance of biomarker determinations – believes Prof. Chorostowska-Wynimko.
What is the role of the pathologist
Without a pathomorphological or cytological examination, i.e. diagnosing the presence of cancer cells, the patient cannot qualify for any treatment. – The pathomorphologist must differentiate whether we are dealing with non-small cell lung cancer (NSCLC) or small cell cancer (DRP), because the management of patients depends on it. If it is already known that this is NSCLC, the pathologist must determine what the subtype is – glandular, large cell, squamous or any of the other, because it is absolutely necessary to order a series of molecular tests, especially in the type of non-squamous cancer, in order to qualify for targeted treatment molecular – reminds prof. Kowalski.
At the same time, the referral of the material to a pathologist should be referred to complete molecular diagnostics covering all biomarkers indicated by the drug program, the results of which are needed to decide on the optimal treatment of the patient. – It happens that the patient is referred only to certain molecular tests. This behavior is unjustified. Diagnostics performed in this way rarely make it possible to decide how to treat the patient well. There are situations where individual stages of molecular diagnostics are contracted in different centers. As a result, tissue or cytological material is circulating around Poland, and time is running out. Patients do not have time, they should not wait – alarms prof. Chorostowska-Wynimko.
– Meanwhile, an innovative treatment, appropriately selected, allows a patient with lung cancer to become a chronic disease and to dedicate him not a few months of life, but even several years – adds Prof. Kowalski.
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Should all patients be fully diagnosed?
Not every patient needs to undergo a full panel of molecular tests. It is determined by the type of cancer. – In non-squamous carcinoma, mainly adenocarcinoma, all patients qualified for palliative treatment should undergo a complete molecular diagnosis, because in this patient population molecular disorders (EGFR mutations, ROS1 and ALK gene rearrangements) occur significantly more often than in other lung cancer subtypes. On the other hand, the evaluation of the ligand for the type 1 programmed death receptor, i.e. PD-L1, should be performed in all cases of NSCLC – says Prof. Kowalski.
Chemoimmunotherapy is better than chemotherapy alone
At the beginning of 2021, patients with all NSCLC subtypes were given the opportunity to receive immunocompetent treatment, regardless of the level of PD-L1 protein expression. Pembrolizumab can be used even when PD-L1 expression is <50%. - in such a situation, in combination with chemotherapy with the use of platinum compounds and third-generation cytostatic compounds selected according to the cancer subtype.
– Such a procedure is definitely better than independent chemotherapy – the differences in the length of survival reach even 12 months in favor of chemoimmunotherapy – says prof. Kowalski. This means that patients treated with combination therapy live an average of 22 months, and patients who receive chemotherapy alone only a little over 10 months. There are patients who, thanks to chemoimmunotherapy, live even several years from its use.
Such therapy is available in the first line of treatment when surgery and chemoradiotherapy cannot be used in patients with advanced disease, i.e. distant metastases. The detailed conditions are laid down in the Drug Program of the Ministry of Health for the treatment of lung cancer (program B.6). According to estimates, 25-35 percent are candidates for chemoimmunotherapy. patients with stage IV NSCLC.
Thanks to the addition of an immunocompetent drug to chemotherapy, patients respond much better to anticancer treatment than people receiving only chemotherapy. Importantly, after the end of chemotherapy, immunotherapy as a continuation of combination therapy is used on an outpatient basis. This means that the patient does not need to be hospitalized each time they receive it. It definitely improves his quality of life.
The article was created as part of the campaign “Longer Life with Cancer”, implemented by the portal www.pacjentilekarz.pl.
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