Lung Cancer – A Basic Understanding
This interview was originally published in www.oncofocus.com on 09th August 2019
Cancer awareness is a continuous exercise that requires a multi-dimensional approach and the proactive involvement of every stakeholder. Oncofocus, is a management consulting and research firm, will be publishing every month a short interview with leading Oncologists across the APAC region on a particular Cancer type. The main objective of these interviews is to learn the "What, Why, How" of the present state of cancer management directly from the treaters.
As August 01 is marked as the World Lung Cancer Day, our analyst Ms. Rihana Kuniyilakath connected with Dr. Vaishnavi Jeyasingam, clinical oncologist from Hospital Kuala Lumpur, a government tertiary referral hospital, that serves as a flagship hospital of the Malaysian public healthcare system
We understand that most cancers are manageable if they are identified at an early stage. So, for someone to get an early diagnosis, are there any early signs and symptoms to look for lung cancer?
Dr. Jeyasingam: I think it’s quite challenging to detect lung cancer at an early stage in the absence of screening programs. This is because patients are usually asymptomatic when the tumors are small. By the time symptoms appear, patients are usually already at an advanced stage.
In Malaysia, most patients get detected at Stage 4, and a small percentage in Stage 3. Few patients get diagnosed at Stage 1 or Stage 2, incidentally as a part of their pre-employment health check-up or routine medical check-up. Cases of early, operable lung cancers are not that common in Malaysia compared to the number of patients with Stage IV disease. In the Kuala Lumpur General Hospital, which is the biggest center in Malaysia, we see 2 – 3 cases of early lung cancer patients in a year compared to 10 - 15 patients with Stage 4 lung cancer every month.
What are your suggestions to increase the early diagnosis of lung cancer?
Dr. Jeyasingam: Early screening with X-rays and low dose CTs is practiced in the western world for the early diagnosis of lung cancer. But the cost-effectiveness of such screening tests limits their use in this part of the world. There are a lot of issues with screening modalities with regards to their sensitivity and specificity.
If you take cervical cancer, an easy-to-do, cheap test like PAP smears has also not been that successful in this part of the world due to poor compliance rates. Lung cancer screening with X-rays and CT scans is challenging with regards to its cost-effectiveness. Preventive measures like quit smoking campaigns would indeed make a big difference.
Who are at risk of developing lung cancer?
Dr. Jeyasingam: Anyone who smokes regularly is at the risk of developing lung cancer. In recent years, we have also seen a trend of female, non-smokers developing lung cancer.
Besides smoking, other sources like industrial exposure to certain chemicals like asbestos and other gases could also lead to lung cancer.
The general understanding is that smoking, and lung cancer is correlated. Could you elaborate more on this?
Dr. Jeyasingam: Association between smoking and lung cancer is well established, but it doesn’t mean that everybody who smokes will get lung cancer. Nevertheless, lung cancer is indeed more commonly seen among smokers. In recent years, we have seen an increasing number of non-smokers being diagnosed with lung cancer.
Are there different types of lung cancers? Please explain about the sub-types?
Dr. Jeyasingam: Small Cell Lung cancer (SCLC) and Non-Small Cell Lung Cancer (NSCLC) are two major types.
These days they are treated differently based on the histology and molecular profile. Previously, all Stage IV lung cancers are treated with chemotherapy, mainly platinum-based regimes. Survival rates were noted to be better with chemotherapy.
In this day and age, molecular profiling is the standard of care. EGFR, ALK, KRAS, BRAF testing, and other mutation tests are conducted routinely, even in the government setting. Treatment options have advanced to much greater levels in the last five years which is personalized to specific molecular subtypes of cancers.
Dr Vaishnavi Jeyasingam
MBBS, M. CLIN. ONCO (UM)
Clinical Oncologist, Hospital Kuala Lumpur, Malaysia
What is the prognosis? What are the common treatment options?
Dr. Jeyasingam: In the government setting, chemotherapies such as cisplatin, Alimta, all platinum-based drugs, gemcitabine, etc. are available at a minimal cost.
Iressa is already available in the government formulary for patients with EGFR mutation-positive disease. However, other anti-EGFR TKIs are not in the government formulary as of now. Such drugs are offered to patients through social welfare schemes or government pension schemes.
In terms of availability, newer drugs like osimertinib, alectinib, crizotinib, etc. are also available. The major prohibitive factor for the patients both in government and private setup is cost. Some of these molecular therapies have exorbitant prices and are beyond the reach of average citizens.
Do you foresee any interesting trends in terms of lung cancer space?
Dr. Jeyasingam: There are a lot of new drugs in the pipeline. They are entering the market more rapidly than earlier, and we see a lot of drugs that are basically mutation-specific. There is plenty of research ongoing in the molecular space, and heavy competition exists between companies targeting similar groups of patients. Competition is a good thing as it can eventually lead to a reduction in drug costs and in improvement in the quality of the drugs.
In the future, there will be more and more targeted therapies, antibodies-based therapies which are less toxic when compared to chemotherapies. Overall, I feel things are moving very fast in the field of lung cancer.
As far as assistance is concerned, we have financial support from the government, cancer societies, non-government organizations, etc which provide assistance.
Thank you for sharing your valuable thoughts!
Dr. Jeyasingam: Thank you!