New screening guidelines and improvements in diagnostics and treatment have improved outcomes in lung cancer. Though lung cancer remains the leading cause of cancer death in the nation, physicians at the O’Neal Comprehensive Cancer Center at the University of Alabama at Birmingham want patients to know about the advancements in diagnostic technologies and therapies, as well as new screening guidelines, which provide more hope for lung cancer patients than ever before.

“We’ve come a really long way,” said Maya Khalil, M.D., associate scientist in the O’Neal Comprehensive Cancer Center and assistant professor of medicine in the UAB Marnix E. Heersink School of Medicine Division of Hematology and Oncology. “Our options are not one-size-fits-all anymore. We now learn a lot about the biology of the cancer of the specific patient in front of us to know how to treat it best. There really aren’t two patients who are alike.”

Lung cancer is a particularly deadly form of cancer. There are two main types: non-small cell lung cancer, which makes up the majority of all lung cancers, and small cell lung cancer, which is the more aggressive form. Risk factors can include smoking, having a family history of lung cancer or exposure to cancer-causing agents. In some less common cases, people may develop lung cancer without any of the known risk factors.

In 2022, the American Cancer Society estimates there will be approximately 236,740 new cases of lung cancer. The five-year survival rate depends on the stage of the disease. Early detection and treatment is critical.

The latest therapies

“Fifteen years ago, everybody got chemotherapy,” Khalil said. “But over the past five to seven years, immune therapy has come to the forefront.”

Immune therapy involves infusions of antibodies that are designed to activate a patient’s own immune system to kill cancer cells. This is now one of the backbones of lung cancer treatment, particularly in the metastatic setting. This type of therapy may also happen before or after surgical removal of the cancer, usually in combination with or after chemotherapy. Immune therapies are generally more tolerable and less toxic to the patient.

For certain patients who do not respond to immune therapy, physicians may now be able to tweak the biology of their cancer cells to make them more likely to respond, usually using novel therapies on clinical trials.

Equally important, there are targeted therapies that seek out and block certain pathways that drive cancer growth caused by genetic mutations in the cancer cells. This involves precision medicine, or highly specialized pills, that work on specific proteins in the cancer cells and inhibit their otherwise uncontrolled division and growth. There are many new generations of these drugs with multiple different targets. Khalil says, because of these targeted therapies, she has treated patients who have been living with metastatic cancer for five, six and seven years.

“The options we have available today have changed the prognosis for lung cancer,” she said. “What is crucial is to perform molecular or genetic testing on cancer tissue from patients presenting with metastatic lung cancer to identify these drivers early on.”

The role of clinical trials

“This is how UAB is moving the needle on cancer. It’s very dear to my heart,” Khalil. Together with her colleague Aparna Hegde, M.D., an associate scientist at the O’Neal Comprehensive Cancer Center, she has sought to expand the trial portfolio to allow for trial options for nearly every patient who comes to their clinic.

“Clinical trials are how we got these therapeutic advancements – the advancements that are now standard of care,” Khalil said. “They did not come out of a vacuum. We test new therapies with clinical trials, and besides moving the needle, they allow us to have these therapies available earlier for our patients.”

If patients are apprehensive about taking part in clinical research, Khalil reassures them that their care is thorough.

“We follow these patients rigorously,” she said. “There’s a team of coordinators, nurses and others who take any symptoms seriously. It’s very close monitoring — we want to catch side effects early to reverse them and minimize any complications from a new medication and to maximize safety for our patients on these trials.”

Patients from across the state or in surrounding states may be referred to the O’Neal Comprehensive Cancer Center to participate in clinical trials. In many of these cases, the patient’s trial is managed at UAB with regular communication and collaboration with their community oncologist back home. When they come off the trial, patients usually continue their treatment path with standard-of-care therapies with their primary oncologist.

Screening recommendations

As a result of the findings of the past decade’s National Lung Screening Trial, in which UAB physicians participated, doctors may recommend screening for patients who are asymptomatic but meet certain criteria.

“There’s not a blood test or a swab to check for lung cancer,” said Nina Terry, M.D., professor in the Department of Radiology. “It’s along the lines of breast cancer. You have to get the imaging. If you wait until you have symptoms, the likelihood that you have something incurable is high.”

Screening recommendations include a low-dose computerized tomography scan for patients who are 50 to 80 years of age (or 50 to 77 years if the patient is covered by Medicare), have a history of smoking 20 packs a year, and are current smokers or quit less than 15 years ago. Because the CT scan is a low-dose scan, it can be performed annually. If a lung nodule is identified that needs closer monitoring, more frequent scans may be warranted, as well as a biopsy if it is suspicious enough.

The national study’s researchers reported a 20 percent mortality reduction with screening, which led to today’s standards.

Effective screening requires a degree of nuance that UAB radiologists specialize in.

“Our radiologists are full-time chest radiologists. That’s all we do,” said Terry of the specialists at UAB Medicine. “And we know, if we catch it when it’s localized, our patients have better outcomes.”

Evaluating biopsies

When an abnormality is found on a CT scan, an interventional pulmonologist will perform a biopsy of the suspicious nodule. Aline Zouk, M.D., an assistant professor specializing in interventional pulmonology in the Department of Medicine Division of Pulmonary, Allergy and Critical Care Medicine, says there are different types of biopsy techniques; but new robotic bronchoscopy allows UAB physicians to get answers in a less invasive way — a way that allows patients to go home in little more than an hour after surgery. A state-of-the-art portable cone beam CT is used during the procedure, providing a high degree of accuracy during the biopsy. In many cases, it allows for high yield from biopsies on tiny nodules, which was not possible a few years ago.

UAB Medicine physicians also participate in a weekly tumor board, a group of specialists — including medical and radiation oncologists, chest surgeons, interventional pulmonologists, radiologists, and pathologists — who confer about the treatment plan and nuances specific to patient scenarios that are brought up.

“We all work very closely together as colleagues,” Zouk said. “It’s a good working relationship that benefits the patients as we evaluate their path forward.”

The importance of early detection — or better yet, prevention

Lung cancer is the leading cause of cancer death in Alabama, with more deaths occurring each year than deaths from breast, colorectal and prostate cancer combined. Alabama has a particularly low survival rate — something the clinicians and researchers at the O’Neal Comprehensive Cancer Center are hoping to improve.

“Prevention — that’s the most important piece of this puzzle,” Zouk said. “That and screening. What we are trying to do is to shift the timeline, to diagnose this cancer at an early stage. We know that, when it’s local, patients have a much higher survival rate.”

--Julie Cole Miller