Lung Cancer- A dangerous repercussion of smoking- QnA Session with an Expert
Dr. Azura Rozila Ahmad, a leading Malaysian oncologist, has extended her hand to support the initiative taken by decodeMR, a unit of Oncofocus, to spread health awareness, and provide our readers with comprehensive and relevant information regarding Lung Cancer.
Dr. Azura Rozila Ahmad is designated as a Medical Oncologist and currently serving in Beacon Hospital, Malaysia.
The targeted therapy started back in the 1990s, the first major one was EGFR mutation tyrosine kinase inhibitors (TKI) was proven to be better than chemotherapy
Doctor, Thank You for joining us, kindly let us know what are the early signs and symptoms of lung cancer that one should be aware of?
Dr. Azura: A persistent cough or one that is changing in nature can be an early sign of lung cancer. Cough can be especially confusing symptoms as many non-cancerous conditions including infections can cause this. Some symptoms can be alarming for example coughing blood, although you can also cough blood if you have an infection. Of course, if coughing is persistent and worsening or if cancer has spread to other parts like the covering of the lung (pleura), bones, or brain, the patient may have shortness of breath, pain, or headaches as well.
Overall, however, lung cancer can be challenging to diagnose because its symptoms are similar to any other lung infection, especially now in the COVID era. Many of the lung cancer patients are smokers, who would have chronic coughs which makes the diagnosis a little more complicated.
So, there is no great way to detect it early, but for high-risk people who are smokers and are above 50 years of age, we can do a low-dose CT scan of the chest as a way to screen for lung cancer.
Doctor, you mentioned that smokers are more prone to get lung cancer. So, which other groups are at a high risk of developing lung cancer?
Dr. Azura: Non-smoking lung cancers are on the rise, and we see that particularly in women. Environmental factors like pollution, environmental radiation called radon have also been implicated. Those are the common things that we talk about. But, in general, smoking is definitely the leading risk factor for the majority of lung cancers.
So, doctor, talking about the types of lung cancer, could you briefly comment on the different types of lung cancer?
Dr. Azura: There are two types of lung cancer in broad terms - small cell lung cancer and non-small cell lung cancer. Lung cancer treatment is a highly dynamic area now with its therapy whether driven by genomic alterations or not.
In non-small cell cancer, there is a type of cancer called adenocarcinoma, which consists of varying molecular subtypes that need to be “profiled” to understand the mechanisms that may be driving its growth. The number of these alterations is increasing, and importantly they can be associated with important druggable and actionable targets that we can use to recommend targeted treatment for the patient. We also look at other things such as protein expressions, for example, PDL-1 status, which may have implications for the use as immunotherapy in lung cancer treatment.
Immunotherapy has taken the field of lung cancer treatment beyond what we have achieved through chemotherapy and is used for cancers that do not have any targeted treatment options available.
Doctor, you talked about many molecular subtypes of lung cancer. Could you explain how you treat these patients?
Dr. Azura: In general, when we are talking about treatment options, we look if it is a genomically-driven disease or not. Genomic means that we have found druggable targets based on the changes in the cancer DNA, RNA, and so on. This is a growing and exciting area in oncology. So, the genomically-driven tumor should be treated by targeted therapy because these sorts of therapy work best for those groups.
The targeted therapy started back in the 1990s when the major one was EGFR mutation tyrosine kinase inhibitors (TKI) and was proven to be better than chemotherapy. This alteration is more common in the Asia Pacific region and we now have got 3rd generation EGFR TKIs for that and the 4th generation is under evaluation.
So, it has become standard practice now, and all lung cancer specialists have widely accepted that if there is a target for lung cancer, the patient should receive targeted therapy rather than chemotherapy.
What are the other treatment options available for the treatment of lung cancer?
Dr. Azura: So, conventionally, we have been using chemotherapy before discovering the differences based on their molecular subtypes for advanced lung cancer. Beyond the targeted therapies, defined by the molecular profiling results, we have immunotherapy as well. Immunotherapy has taken the field of lung cancer treatment beyond what we have achieved through chemotherapy and is used for cancers that do not have any targeted treatment options available. Combination immunotherapies are also being used. Other non-drug treatment methods such as radiotherapy and surgery also have a role in lung cancer treatment depending on the scenario.
Talking about the current pandemic scenario, how has the COVID-19 pandemic impacted Malaysia's lung cancer treatment and management?
Dr. Azura: Yeah, this is a very tricky situation and, hopefully, we are now coming to the tail of the COVID-19 pandemic. As both COVID-19 and lung cancer affect the lungs, they have similar presentations. During the height of COVID-19, we were often in dilemma whether symptoms of a patient are because of COVID-19 or lung cancer.
Despite the challenges of the COVID-19, lung cancer treatment cannot be delayed. We need to understand that as a disease, lung cancer is a rapidly progressing disease. So, we need to quickly rule out COVID-19 infection and continue with the lung cancer treatment. And, it is quite challenging.
For the patients on targeted therapies, many of them have pill treatment as an option. This, in general, makes things manageable as these therapies do not suppress the immune system. Also, the patients do not have to spend too much time in the hospital to get the treatment administered.
We have to adjust according to the patient's needs. If the patient is symptomatic, we need to get on with the treatment. But, if they are stable and on the maintenance treatment, we can prolong the intervals of the hospital visits.
Doctor, what changes were implemented by the healthcare stakeholders in your hospital to ward off the negative impact of the pandemic on lung cancer care?
Dr. Azura: We had to ensure that the safety of patients, healthcare providers, and the public is being looked at despite the pandemic. So, at the hospital level, we have taken extra steps, such as limiting people traffic within our hospital and testing for COVID-19 adequately and judiciously prior to hospital admissions and procedures.
At the beginning of the pandemic, when the covid PCR test results took 1-2 days, it caused quite a fair bit of anxiety to manage ill lung cancer patients. However, now we have quick and reliable covid testing methods and are able to adjust and ease some of our process flows and procedures. Malaysia has a reasonably high C19 vaccination uptake, which helps us to relax our SOP while remaining vigilant to current trends of Covid-19 infections.
General practices such as adequate physical distancing and good hygiene practices such as washing hands are being enforced. We also keep close contact with our local health authority to ensure that we get advice on the best standard operating procedures, which is invaluable, ensuring we can continue delivering lung cancer care for our patients.
While I was preparing for this interview, Doctor, I came across an article of yours in the 'STAR' titled "These doctors favorite prescription is cycling," wherein you have mentioned that exercise can help cancer patients deal with their treatment better. Could you tell me more about this?
Dr. Azura: Sure. So, you know, there are a few things that are being actively researched like drugs and so on. However, for exercise, there is no financial drive for research. As a result, we do not have a lot of studies specific to the benefits to exercise for cancer patients.
For many cancers, especially breast and colorectal cancer, prescribing exercises can help to improve the outcome for patients. There is no specific scientific answer to why that is the case. But, of course, it improves the immune system, mood, appetite, and maintains fitness.
So, exercise is something we do not necessarily restrict our patients from doing. As it is an expensive intervention as long as their condition permits this, they should be encouraged to remain active. At the end of the day, it is all about treating the cancer patient holistically. If somebody wants to exercise, they should certainly do those exercises that they can manage along with the treatment.
We learned that due to COVID-19, the clinical trials were either suspended or terminated. Could you let us know about the status of lung cancer trials in Malaysia?
Dr. Azura: We continued to run lung cancer clinical trials, and some of them were slow in starting up due to the pandemic. And there were also some difficulties in the recruitment of patients because people were understandably scared about turning up in the hospital due to the infection risks. Yes, the recruitment was a bit slower during that time. Now, the lung cancer trial is recruiting quite well, and some trials are fully recruited now.
So, how do these new clinical trials impact your hospital in providing lung cancer care?
Dr. Azura: These trials are certainly invaluable for the patients and health providers. They give us the experience and gain expertise in using these advanced treatments and more importantly, for patients, access to these innovative, latest forms of treatments, which are really expensive and beyond the affordability range of most people. We see this innovative treatment breaking barriers of previous standard therapies and contributing our data to the global cancer community is certainly rewarding. These new drugs are making a difference and patients are grateful for them. So, it is an area that will continue to be of interest to us which we hope will improve how we treat lung cancer in the future.
Doctor, how do you think the lung cancer trial ecosystem differs in Malaysia compared to other neighboring countries?
Dr. Azura: Every country will have a different ecosystem. Malaysia is an evolving one. As a country, due to our multi-ethnic population & size, we certainly have a good potential to recruit lung cancer patients of different ethnicity into trials. Malaysia has a good health tourism industry, and the government has set up an organization called Cancer Research Malaysia to support clinical trials coming into Malaysia. Many are industry-sponsored trials with contract research organizations, however investigator-led and early phase trials will be happening more now. Most of these trials are in Kuala Lumpur, however, there are strategic trial centers for lung cancer in some parts of Malaysia which can include patients from different geographical locations. I think our lung cancer trial ecosystem will continue to expand its capabilities in the near future including collaborating as a region of the Asia Pacific community.
Thank you so much doctor for providing your valuable inputs on Lung Cancer.