Oncology: The disease, dynamics & challenges of market research
Inoperable Lung Cancer
Inoperable lung cancer is a tumor that surgery can't treat. This might be because the cancer is in a hard-to-reach spot or for other reasons, like if it's spread outside your lungs. It's also called unresectable lung cancer.
Just because you can't have surgery doesn't mean you can't do anything about the cancer. Treatments like radiation, chemotherapy, targeted therapy, and immunotherapy can fight it, even when an operation isn't an option.
There are two main types of lung cancer, based on the size and other factors of the affected cells:
Some reasons why surgery might not be right for you:
Your cancer has spread. The goal of lung cancer surgery is to take out the whole tumor. Doctors can't do that if it's spread outside your lung.
Removing the main tumor in the lungs won't stop cancer in other organs or distant lymph nodes. Treatments like radiation, chemotherapy, or immunotherapy work better than surgery.
You have small-cell lung cancer. Surgery is one of the main treatments for early NSCLC. Doctors rarely treat SCLC with surgery because the cancer has often spread by the time it's diagnosed.
The cancer is in a tricky spot. A tumor that is very close to other organs or to blood vessels may be hard to remove without causing a lot of damage. This can make the surgery too risky.
Your lungs aren't healthy enough. Lung cancer surgery removes part or all of the diseased lung. You need enough healthy tissue left behind to be able to breathe well after the surgery.
You'll get lung function tests like spirometry before your procedure. These tests measure the force of your breath to make sure your lungs are in good enough shape for surgery.
You have heart disease. In that case, there's a small chance your lung surgery could cause complications like a heart attack or another serious heart problem. Your doctor will do tests to check your ticker's health before surgery.
You have other serious health conditions.Lung surgery and the anesthesia used to put you to sleep can cause complications. The operation may be too risky for you if you're in poor health.
Symptoms like a nagging cough, chest pain, and shortness of breath often don't start until lung cancer has spread. The lack of early symptoms is why many people aren't diagnosed until their cancer is inoperable.
Lung cancer is usually first suspected on imaging, an xray or lung ct. To make a certain diagnosis your doctor will need small sample of the mass. Depending on where in the lung it is located it may be collected by bronchoscopy or Video-assisted thoracoscopic surgery (VATS) if it is located closer to the chest wall rather than inside or close to a large airway which is more accessible by bronchoscopy.
A bronchoscopy involves using a thin tube with a light on the end that lets your doctor see inside your lungs and remove a small piece of tissue. A lab then examines the tissue sample to see if it's cancer.
Other tests can show where in your body the cancer has spread and help your doctor decide whether surgery is an option for you:
The tests will tell your doctor where the cancer is, whether it's spread, and whether it's affecting other parts of your body. The doctor will use this information to assign a stage.
The stages of non-small-cell lung cancerare:
The stages of small-cell lung cancer are:
Your doctor may consider surgery for SCLC if you're diagnosed at a very early stage.
A lung cancer diagnosis can be stressful and scary. But it's important to remember that "inoperable" doesn't always mean there's nothing to be done. If you can't have surgery, your doctor will help you choose another treatment, based on your stage and overall health.
Your outlook will depend on several things, including the cancer type and the stage at diagnosis. About 20.5% of people who have any kind of lung cancer live at least 5 years after diagnosis. This 5-year survival rate is 28% overall for non-small-cell lung cancer and 7% overall for small-cell lung cancer.
Five-year survival rates for people who have NSCLC are:
Five-year survival rates for people who have SCLC are:
Is 'Inoperable' Really The Best Term?
More than 230,000 people in the United States will be diagnosed with lung cancer this year. About 40% of those patients will also find out that their cancer is inoperable. While a diagnosis of inoperable lung cancer is alarming, doesn't mean that it can't be treated.Various forms of treatment can shrink the cancer, treat symptoms, slow its growth, and extend the patient's life. Joining me is Dr. Joseph Murray. He's the co-director of the lung Cancer Precision Medicine Center of Excellence at Johns Hopkins Medicine. And Dr. Melinda Hsu, she's a thoracic medical oncologist and assistant professor of Hematology and Oncology at the Case Comprehensive Cancer Center at University Hospital's Seidman Cancer Center. Doctors, thanks for joining me.
JOSEPH MURRAY
Thank you.JOHN WHYTE
Well, let's start off with what types of cancer are inoperable. All types of lung cancer aren't inoperable. So which ones are we talking about?JOSEPH MURRAY
I'll first start off by talking about two main categories of lung cancer that are relevant. One is called small-cell lung cancer and the other is called non-small-cell lung cancer. These two types of cancers are treated in similar, but different ways depending on how advanced they are in the inoperable setting. Small-cell lung cancer and non-small-cell lung cancer can be in the inoperable setting, locally advanced, or metastatic, and this can define what best first treatment is offered to a patient.JOHN WHYTE
Dr. Hsu, how much does location of the tumor matter? Often when we talk about surgery, surgeons have to be able to get at it. Does that matter?And what about stage? Patients are often used to hearing about the stage of cancer. Does that have relevance as well when we're talking about whether lung cancer is inoperable or not?
MELINDA HSU
Absolutely. Both of those things matter when it comes to whether or not a surgeon can get at the cancer or whether the cancer is operable. The staging system is different for non-small-cell and small-cell lung cancer. But based on the stage, most typically that's how physicians decide whether or not the cancer is operable. So things like the size of the tumor go into the staging, whether or not there are lymph nodes that are involved, and the location of the lymph nodes, as well as whether there's any other sites of cancer in the body, whether that's in the lungs, the other lung, or outside of the lungs. So those three things together help make up the stage and then that usually determines whether or not the cancer is operable or not as well as specific things about the patient.JOHN WHYTE
So taking all that into consideration, Dr. Murray, who's the ideal candidate?JOSEPH MURRAY
So it depends on what the ideal therapy might be for that patient. In patients who have stage 3 cancers, there's often the opportunity to treat them definitively with things like chemotherapy and radiation together. And when we use a definitive treatment in these settings even when a patient is inoperable, we often have the opportunity to go for a cure if you will. We follow that chemoradiation therapy with immunotherapy to consolidate and offer the best opportunity for that cure for that patient. And this would be for these locally-advanced non-small-cell lung cancers.JOHN WHYTE
How much does a patient's underlying health come into play, Dr. Hsu? Because you could say, well, look, the patient has cancer to begin with. So let's be realistic.There's always going to be challenges already with lung function, cardiovascular, health. Do we place too much emphasis on that? Or does that really matter when we're talking about inoperable lung cancer?
MELINDA HSU
I think that it does matter. And the reason that I think it matters is when we decide to operate to cure somebody's lung cancer, we're not just trying to cure their cancer, we're also trying to help them live out the rest of their lives without their cancer. And most patients don't want to be tethered to a nasal cannula for oxygen or something like that.The question that I get from my patients very often who are going to undergo surgery is, am I going to live a normal life? And I think that in our role as oncologists, while we are trying to shepherd our patients through their cancer journey, for a lot of patients, they want to be as normal as possible. And for the patients whose lung cancer is inoperable, we still try to be mindful of the types of treatments that we give them. While, of course, within the confines of standard of care or clinical trials, we still want to personalize their treatment for the patient as much as possible.
JOHN WHYTE
Dr. Murray, is inoperable the best word? Because for some people, does that mean terminal in their mind? And is it the right way of thinking about what we call inoperable lung cancer?JOSEPH MURRAY
It's a great question. Our words have strong meanings, and patients hang their hats on that. I think the use of the term inoperable can be very confusing for patients. And what I focus on is what is the treatment at hand that best fits the characteristics of the stage of their cancer and their personal comorbidities and other health issues that could be a barrier to get the best treatment we can afford them. And the terms I like to use are locally advanced or metastatic cancer and describing to patients how those could be operable, inoperable, or so advanced that systemic therapies are our only options.JOHN WHYTE
Well, Dr. Murray, this brings up the point that we don't want cancer to present when it's advanced. So what do we need to do to diagnose lung cancer earlier?JOSEPH MURRAY
We have a lot of work to improve how we screen for cancers, and particularly lung cancer in our country. We have guideline-based evidence that supports using low-dose, high-resolution CT scans to scan patients who have a smoking history in specific age groups who are at high risk for lung cancer. But I'll be mindful of the fact that there are many patients who are never smokers who also develop lung cancer, and we are lacking screening strategies for these types of patients.What I tend to tell patients who show up is that any patient with lungs can get lung cancer. And I do focus, even though screening and risk factors like smoking are quite relevant, on the fact that this is the case and looking retrospectively back in the past with hindsight always makes you want to know why this happened. But I focus on what we should do about it next.
JOHN WHYTE
So Dr. Hsu, Dr. Murray mentions the guidelines for smokers or past smokers for low-dose CT. But recent data suggests that less than 10% of people who qualify for that screening receive it. So what do we need to be doing because we want to talk about how do we address inoperable lung cancer? But what we really want to do is prevent it from getting to that stage, and we can do some of that with screening.MELINDA HSU
Absolutely. And actually those guidelines were expanded recently in 2021 to try to catch more of the population that has a previous history of smoking as well as catch patients at a younger age to try to improve that. And obviously, the data will show us whether or not that's effective. But I think that the conversation actually starts before a patient ever meets an oncologist in terms of screening. And so I think that making sure that the primary care providers are aware of these things in this era of electronic health records maybe even making things like screening orders automatic if patient's smoking history is in the chart.JOHN WHYTE
So it's important to get people screened, get people diagnosed early. And then, Dr. Murray, should a patient get a second opinion if they're told they have inoperable lung cancer? Is that important to do?JOSEPH MURRAY
I see a lot of second opinion patients myself. So I know that this is frequently happening. And I will say that not all patients can have the means and ability to get a second opinion. I do strongly recommend, even my patients, who I see, to consider second opinion evaluations, particularly if there's questions or concerns about aspects of their own health that might be affecting our recommendations for an operation or not and various therapies or not. And I do have strong advocacy for patients in this regard as I see many patients in second opinion in my own clinic.JOHN WHYTE
How often do you give a different opinion than the physician that originally saw the patient? I know people are thinking that right now when you say a second opinion. But how often do you think it changes the decision making?JOSEPH MURRAY
So first is standard of care. How might my recommendation differ based on the standard of care recommendations that a local oncologist might be providing and offering? And sometimes it boils down to the individual steps to get the patient to the best and first standard of care option available.So I may be pushing to do more genomic testing earlier and using things like liquid biopsy to advance that for a patient. And that may be an additional recommendation on top of a great plan from their local team. The other side to look at is what can we afford at a place like Johns Hopkins or in the Cleveland Clinic Hospitals as well beyond the standard of care.
And for clinical trials, this is an option we can afford our patients that a local oncologist may not have access to. And so a big important part of my job is to screen patients before their visit, at their visit, and later to assess whether they would be best served by a clinical trial versus a standard of care. And so if I had to boil down to a number, I'd say that the majority of the time I agree, more than 50% of the time. But I might be adding additional features to guide and personalize the care, just as Dr. Hsu described, to really make that care as best for the patient as possible.
JOHN WHYTE
Because getting that diagnosis right of inoperable lung cancer is critically important as one thinks about the next steps. Doctors, I want to thank you for taking time today.MELINDA HSU
Thank you.JOSEPH MURRAY
Thanks so much for having us.[MUSIC PLAYING]
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[MUSIC PLAYING]JOHN WHYTE
More than 230,000 people in the United States will be diagnosed with lung cancer this year. About 40% of those patients will also find out that their cancer is inoperable. While a diagnosis of inoperable lung cancer is alarming, doesn't mean that it can't be treated.Various forms of treatment can shrink the cancer, treat symptoms, slow its growth, and extend the patient's life. Joining me is Dr. Joseph Murray. He's the co-director of the lung Cancer Precision Medicine Center of Excellence at Johns Hopkins Medicine. And Dr. Melinda Hsu, she's a thoracic medical oncologist and assistant professor of Hematology and Oncology at the Case Comprehensive Cancer Center at University Hospital's Seidman Cancer Center. Doctors, thanks for joining me.
JOSEPH MURRAY
Thank you.JOHN WHYTE
Well, let's start off with what types of cancer are inoperable. All types of lung cancer aren't inoperable. So which ones are we talking about?JOSEPH MURRAY
I'll first start off by talking about two main categories of lung cancer that are relevant. One is called small-cell lung cancer and the other is called non-small-cell lung cancer. These two types of cancers are treated in similar, but different ways depending on how advanced they are in the inoperable setting. Small-cell lung cancer and non-small-cell lung cancer can be in the inoperable setting, locally advanced, or metastatic, and this can define what best first treatment is offered to a patient.JOHN WHYTE
Dr. Hsu, how much does location of the tumor matter? Often when we talk about surgery, surgeons have to be able to get at it. Does that matter?And what about stage? Patients are often used to hearing about the stage of cancer. Does that have relevance as well when we're talking about whether lung cancer is inoperable or not?
MELINDA HSU
Absolutely. Both of those things matter when it comes to whether or not a surgeon can get at the cancer or whether the cancer is operable. The staging system is different for non-small-cell and small-cell lung cancer. But based on the stage, most typically that's how physicians decide whether or not the cancer is operable. So things like the size of the tumor go into the staging, whether or not there are lymph nodes that are involved, and the location of the lymph nodes, as well as whether there's any other sites of cancer in the body, whether that's in the lungs, the other lung, or outside of the lungs. So those three things together help make up the stage and then that usually determines whether or not the cancer is operable or not as well as specific things about the patient.JOHN WHYTE
So taking all that into consideration, Dr. Murray, who's the ideal candidate?JOSEPH MURRAY
So it depends on what the ideal therapy might be for that patient. In patients who have stage 3 cancers, there's often the opportunity to treat them definitively with things like chemotherapy and radiation together. And when we use a definitive treatment in these settings even when a patient is inoperable, we often have the opportunity to go for a cure if you will. We follow that chemoradiation therapy with immunotherapy to consolidate and offer the best opportunity for that cure for that patient. And this would be for these locally-advanced non-small-cell lung cancers.JOHN WHYTE
How much does a patient's underlying health come into play, Dr. Hsu? Because you could say, well, look, the patient has cancer to begin with. So let's be realistic.There's always going to be challenges already with lung function, cardiovascular, health. Do we place too much emphasis on that? Or does that really matter when we're talking about inoperable lung cancer?
MELINDA HSU
I think that it does matter. And the reason that I think it matters is when we decide to operate to cure somebody's lung cancer, we're not just trying to cure their cancer, we're also trying to help them live out the rest of their lives without their cancer. And most patients don't want to be tethered to a nasal cannula for oxygen or something like that.The question that I get from my patients very often who are going to undergo surgery is, am I going to live a normal life? And I think that in our role as oncologists, while we are trying to shepherd our patients through their cancer journey, for a lot of patients, they want to be as normal as possible. And for the patients whose lung cancer is inoperable, we still try to be mindful of the types of treatments that we give them. While, of course, within the confines of standard of care or clinical trials, we still want to personalize their treatment for the patient as much as possible.
JOHN WHYTE
Dr. Murray, is inoperable the best word? Because for some people, does that mean terminal in their mind? And is it the right way of thinking about what we call inoperable lung cancer?JOSEPH MURRAY
It's a great question. Our words have strong meanings, and patients hang their hats on that. I think the use of the term inoperable can be very confusing for patients. And what I focus on is what is the treatment at hand that best fits the characteristics of the stage of their cancer and their personal comorbidities and other health issues that could be a barrier to get the best treatment we can afford them. And the terms I like to use are locally advanced or metastatic cancer and describing to patients how those could be operable, inoperable, or so advanced that systemic therapies are our only options.JOHN WHYTE
Well, Dr. Murray, this brings up the point that we don't want cancer to present when it's advanced. So what do we need to do to diagnose lung cancer earlier?JOSEPH MURRAY
We have a lot of work to improve how we screen for cancers, and particularly lung cancer in our country. We have guideline-based evidence that supports using low-dose, high-resolution CT scans to scan patients who have a smoking history in specific age groups who are at high risk for lung cancer. But I'll be mindful of the fact that there are many patients who are never smokers who also develop lung cancer, and we are lacking screening strategies for these types of patients.What I tend to tell patients who show up is that any patient with lungs can get lung cancer. And I do focus, even though screening and risk factors like smoking are quite relevant, on the fact that this is the case and looking retrospectively back in the past with hindsight always makes you want to know why this happened. But I focus on what we should do about it next.
JOHN WHYTE
So Dr. Hsu, Dr. Murray mentions the guidelines for smokers or past smokers for low-dose CT. But recent data suggests that less than 10% of people who qualify for that screening receive it. So what do we need to be doing because we want to talk about how do we address inoperable lung cancer? But what we really want to do is prevent it from getting to that stage, and we can do some of that with screening.MELINDA HSU
Absolutely. And actually those guidelines were expanded recently in 2021 to try to catch more of the population that has a previous history of smoking as well as catch patients at a younger age to try to improve that. And obviously, the data will show us whether or not that's effective. But I think that the conversation actually starts before a patient ever meets an oncologist in terms of screening. And so I think that making sure that the primary care providers are aware of these things in this era of electronic health records maybe even making things like screening orders automatic if patient's smoking history is in the chart.JOHN WHYTE
So it's important to get people screened, get people diagnosed early. And then, Dr. Murray, should a patient get a second opinion if they're told they have inoperable lung cancer? Is that important to do?JOSEPH MURRAY
I see a lot of second opinion patients myself. So I know that this is frequently happening. And I will say that not all patients can have the means and ability to get a second opinion. I do strongly recommend, even my patients, who I see, to consider second opinion evaluations, particularly if there's questions or concerns about aspects of their own health that might be affecting our recommendations for an operation or not and various therapies or not. And I do have strong advocacy for patients in this regard as I see many patients in second opinion in my own clinic.JOHN WHYTE
How often do you give a different opinion than the physician that originally saw the patient? I know people are thinking that right now when you say a second opinion. But how often do you think it changes the decision making?JOSEPH MURRAY
So first is standard of care. How might my recommendation differ based on the standard of care recommendations that a local oncologist might be providing and offering? And sometimes it boils down to the individual steps to get the patient to the best and first standard of care option available.So I may be pushing to do more genomic testing earlier and using things like liquid biopsy to advance that for a patient. And that may be an additional recommendation on top of a great plan from their local team. The other side to look at is what can we afford at a place like Johns Hopkins or in the Cleveland Clinic Hospitals as well beyond the standard of care.
And for clinical trials, this is an option we can afford our patients that a local oncologist may not have access to. And so a big important part of my job is to screen patients before their visit, at their visit, and later to assess whether they would be best served by a clinical trial versus a standard of care. And so if I had to boil down to a number, I'd say that the majority of the time I agree, more than 50% of the time. But I might be adding additional features to guide and personalize the care, just as Dr. Hsu described, to really make that care as best for the patient as possible.
JOHN WHYTE
Because getting that diagnosis right of inoperable lung cancer is critically important as one thinks about the next steps. Doctors, I want to thank you for taking time today.MELINDA HSU
Thank you.JOSEPH MURRAY
Thanks so much for having us.[MUSIC PLAYING]
Merck, Daiichi Sankyo Pull Lung Cancer Filing For ADC, Citing Underwhelming Survival Findings
Merck and Daiichi Sankyo withdrew their regulatory application Thursday for the investigational antibody-drug conjugate patritumab deruxtecan, which the partners were proposing as a treatment for locally advanced or metastatic non-small cell lung cancer.
In explaining the unusual move, the partners said patritumab deruxtecan, also called HER3-DXd, failed to significantly improve overall survival in the Phase III HERTHENA-Lung02 trial, as per a topline readout. Discussions with the FDA also played a role in Merck and Daiichi Sankyo's decision to pull their application, according to Thursday's release, though the companies did not reveal what exactly the regulator told them.
They also did not say when or if they plan to refile the application.
Patritumab deruxtecan is an antibody-drug conjugate (ADC) designed to target the HER3 protein, which is highly expressed in many different types of solid tumors. It also carries an exatecan derivative payload, which when released inside a cancer cell can trigger its death.
Merck and Daiichi Sankyo had previously sought a non-small cell lung cancer (NSCLC) approval for patritumab deruxtecan, which the FDA met with a Complete Response Letter in June 2024. At the time, the regulator cited issues with a third-party manufacturer, but did not flag problems with the ADC's efficacy and safety package. The companies on Thursday emphasized that the voluntary withdrawal of patritumab deruxtecan's application is unrelated to this prior rejection.
The study used to back patritumab deruxtecan's application, HERTHENA-Lung02, compared the ADC against doublet chemotherapy and enrolled nearly 280 patients with locally advanced or metastatic NSCLC carrying mutations in the EGFR gene.
In September last year, just a few months after the regulatory rejection, Merck and Daiichi Sankyo announced that patritsumab deruxtecan hit the trial's primary efficacy endpoint, eliciting a significant improvement in progression-free survival. Overall survival data were immature then, but the companies nevertheless signaled their regulatory intent. Ken Takeshita, global head of R&D at Daiichi Sankyo, said at the time that the companies were planning to share the findings with health authorities "to discuss next steps."
With Thursday's news, patritumab deruxtecan follows in the footsteps of datopotamab deruxtecan—likewise a Daiichi Sankyo-partnered ADC, this time with AstraZeneca—for which the regulatory application was withdrawn in November 2024. Speaking to investors last December, Dale Shuster, head of global precision medicine at Daiichi Sankyo, said datopotamab deruxtecan's Phase III lung cancer trial "was not reviewed favorably by the FDA," pushing the companies to pull their filing.
The day of the withdrawal, AstraZeneca and Daiichi Sankyo also resubmitted an application targeting a subpopulation of NSCLC patients with EGFR mutations—just as patritumab deruxtecan was attempting to do. The FDA granted this application priority review in January and a decision is expected in the third quarter.
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