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Questions To Ask If You've Been Diagnosed With Lung Cancer
If you have been diagnosed with lung cancer, where you go first matters — and so does knowing what questions to ask your care team.
There have been remarkable strides in understanding and treating lung cancer over the past two decades, from better screening procedures to lifesaving new therapies, with MSK helping to lead the way on many advances.
But lung cancer remains a very serious diagnosis, resulting in more deaths than breast, colorectal, and prostates cancers combined, according to the American Cancer Society.
Thoracic oncologist, Mark Awad, MD, PhD, has successfully treated many people with lung cancer and compassionately guided them and their loved ones through the next steps after diagnosis.
He is Chief of the Thoracic Oncology Service at Memorial Sloan Kettering Cancer Center (MSK) and a prominent researcher of some of the newest and most promising treatments for lung cancer, including cellular and immunotherapies.
Dr. Awad suggests asking these questions of your care team to help you get started.
What Type of Lung Cancer Do I Have?That distinction is based on how the cancer looks under the microscope to a pathologist, who is a doctor that specializes in diagnosing disease.
Non-small cell lung cancer can be further divided into more specific subtypes, including:
It's important to understand the type of lung cancer, Dr. Awad says, "because how we treat small cell lung cancer differs from adenocarcinoma, which in turn differs from squamous cell carcinoma."
What Stage Is the Lung Cancer, and Have I Had All the Right Scans to Accurately Stage the Cancer?"The stage tells us where in the body the cancer is located," says Dr. Awad.
For non-small cell lung cancer, which is the most common type, "we assign a number — stage 1, 2, 3, or 4," says Dr. Awad, with 4 representing cancer that has spread (metastasized) to other parts of the body.
Staging the cancer typically requires comprehensive scans, Dr. Awad explains:
"To stage, we need a head-to-toe evaluation of where the cancer is in the body," says Dr. Awad.
What Genomic or Biomarker Testing Do You Offer for Lung Cancer?Genomic testing, also known as biomarker testing or genetic testing, looks to see if cancer cells have mutations in their genes. Some mutations can be targeted with therapies that can slow or stop the growth of cancer.
"We use as much information as we can about a patient and the tumor to personalize treatment and tailor it as precisely as possible, because fortunately there are many different therapies," says Dr. Awad. "Comprehensive genomic tests can help us determine which treatment to select, and in which order we should give different treatments, so they work best for the patient."
"Sometimes I'll talk to patients who have been diagnosed somewhere else," says Dr. Awad, "and the genomic testing that was done only includes three or four genes. That's not enough in this day and age."
Dr. Awad says there are FDA-approved therapies for specific mutations in genes, including:
"At MSK, we also have clinical trials investigating treatments for more mutations that are very promising," says Dr. Awad. "The list of mutations that a comprehensive test should look for will keep growing."
He also urges people to ask about another biomarker, called PD-L1.
"Testing for this biomarker gives us a signal about how a person may respond to a form of immunotherapy called an immune checkpoint inhibitor," says Dr. Awad. This treatment helps a patient's own immune system fight cancer, and for some people can be a powerful treatment for lung cancer.
Does Your Team Focus Solely on Lung Cancer?"Lung cancer is complex and quite nuanced," says Dr. Awad. "Getting care from a dedicated thoracic oncology team who really only treats lung cancer is quite vital for receiving top-notch care."
Expertise is also important for lung cancer surgery. Dr. Awad suggests asking how many operations a surgeon has performed. Surgical teams — like those at MSK — that have done a high volume of procedures generally have better outcomes. MSK lung cancer surgeons have also helped pioneer minimally invasive surgeries and other advances.
Do You Recommend Getting a Second Opinion?"For a serious diagnosis like lung cancer, I think it can only be beneficial to get a second opinion, and we do them commonly at MSK in our thoracic oncology group."
"Once a person has connected with us," says Dr. Awad, "we always consider ourselves part of their care team, even if they seek treatment elsewhere. They are always welcome to return to us, or we can coordinate care with other doctors."
When Should I Begin Treatment and Can I Do it Close to Home?"It can be a challenging time, obviously, for patients after they get a diagnosis of lung cancer and want to start treatment. But it's important that we gather as much information as possible, rather than rush."
The reality, says Dr. Awad, is that "it's uncommon that we have to treat urgently. Waiting a few more days or, in some cases, a few more weeks to get test results back to personalize a treatment plan for an individual patient is usually best."
For people treated at MSK, Dr. Awad says that much of their treatment can take place at a facility as close to their home as possible. "There are thoracic oncologists who treat lung cancer at all of MSK's locations across New Jersey, Westchester, and Long Island, in addition to the Manhattan location. That means people can be closer to home and the people they love, which can be an enormous help."
What Is My Prognosis or Outlook?Dr. Awad notes that this can be a difficult question to answer at the beginning of treatment because there are so many variables, including how each person responds individually to treatment.
He suggests framing the question as an on-going conversation between the oncologist and the patient. He recommends asking:
He also recommends being open with your oncology team about what's most important to you in terms of your priorities and wishes. "For instance, do you have a milestone coming up like the birth of a grandchild or a wedding? We have a lot of flexibility around scheduling treatment and a great deal of expertise in symptom management to help people continue to do what's most important to them during treatment."
"We have great supportive care services here at MSK," he adds. "Whether that's managing symptoms and side effects, or addressing nutrition, social work, financial issues, and much more. We're here to support your whole life, not just treat your cancer."
Here Are Some Helpful Links:Analysis Reveals Prognostic Factors For LS-SCLC
Researchers say they have identified several prognostic factors for patients with limited-stage small cell lung cancer (LS-SCLC) receiving chemoradiotherapy, including disease stage, nodal stage, patient age and sex, and treatment center volume. These findings were published in JAMA Network Open.
The researchers conducted a post hoc secondary analysis of data from the CALGB 30610-RTOG 0538 trial (NCT00632853) to assess demographic, disease-related, treatment-related, and social factors that might be associated with overall survival (OS) and progression-free survival (PFS) in patients with LS-SCLC and to determine whether certain patients might benefit from radiotherapy dose escalation.
The analysis included 507 patients with LS-SCLC. Their mean age at baseline was 62.6 years, and 51.3% were women. All patients received chemotherapy and radiotherapy. They were randomly assigned to receive radiotherapy twice daily to a dosage of 45 Gy for 3 weeks (n=257) or once daily to a dosage of 70 Gy for 7 weeks (n=250).
The median follow-up was 4.7 years. A multivariate analysis suggested that none of the treatment-related factors evaluated were significantly associated with PFS or OS. These factors included type of chemotherapy, radiotherapy dosing, timing of radiotherapy initiation, type of radiotherapy (intensity-modulated radiation vs 3D conformal radiation), and use of prophylactic cranial irradiation.
However, the researchers did find that women had better OS than men (hazard ratio [HR], 0.73; 95% CI, 0.58-0.91; P =.006), and patients aged 70 years and older had worse OS than younger patients (HR, 1.50; 95% CI, 1.14-1.98; P =.004). Neither of these factors were associated with PFS.
In an unplanned subgroup analysis, the researchers found that, among patients receiving twice-daily radiotherapy, those younger than 70 years of age had significantly better OS (HR, 0.56; 95% CI, 0.40-0.78; P <.001) and PFS (HR, 0.61; 95% CI, 0.45-0.84; P =.002) than older patients. Among older patients, those receiving once-daily radiotherapy had better PFS than those receiving twice-daily radiotherapy (HR, 0.58; 95% CI, 0.37-0.91; P =.02).
In the main analysis, the researchers found that tumor category was not associated with OS or PFS, but "nodal category and overall stage emerged as factors associated with both OS and PFS."
Patients with stage IIIA disease had worse OS than those with stage II disease (HR, 1.65; 95% CI, 1.17-2.31; P =.004). OS was also worse in patients with stage IIIB disease than in those with stage II disease (HR, 1.94; 95% CI, 1.34-2.83; P <.001).
OS was worse in patients with N2 disease (HR, 1.64; 95% CI, 1.19-2.26; P =.002) and N3 disease (HR, 2.03; 95% CI, 1.40-2.93; P <.001) than in patients with N1 disease. PFS was also worse in patients with N2 disease (HR, 1.36; 95% CI, 1.02-1.81; P =.04) and N3 disease (HR, 1.63; 95% CI, 1.17-2.26; P =.004) than in those with N1 disease. There was no significant difference in PFS or OS between patients with N2 disease and those with N3 disease.
The researchers also found that receiving treatment at a low-volume center was associated with worse OS (HR, 1.55; 95% CI, 1.03-2.32; P =.03) and PFS (HR, 1.94; 95% CI, 1.33-2.82; P <.001) than receiving treatment at a high-volume center. Treatment at a middle-volume center was also associated with worse OS (HR, 1.33; 95% CI, 1.04-1.70; P =.02) and PFS (1.44; 95% CI, 1.15-1.82; P =.002) than treatment at a high-volume center.
"Our study highlights the need for consideration of evidence-based patient and clinical factors during the design of randomized clinical trials in LS-SCLC, including overall clinical stage and nodal category, sex, and patient age," the researchers wrote.
Disclosures: This research was supported by various grants. One study author disclosed conflicts of interest. Please see the original reference for complete disclosures.
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