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"New Treatments for Lung Cancer-" with Roman Perez-Soler.

Event_Moderator Welcome to WebMD Live. Today we will be discussing "New Treatments for Lung Cancer-" with Roman Perez-Soler.

Dr. Roman Perez-Soler is an extensively published and highly regarded academic and medical professional with specialties in internal medicine and medical oncology. Dr. Perez-Soler, welcome to the show.

Dr. Perez-Soler Thank you.

Event_Moderator How would you define "malignant lung cancer,' and isn't malignant lung cancer the only kind (as opposed to benign)?

Dr. Perez-Soler There's really no benign lung cancer. That doesn't really exist. When we use the word 'cancer," by definition that means a malignant tumor, That's what cancer means. Therefore, anything that grows in the lungs that's a tumor but it's benign, it's not a cancer, That's rare, but it's possible to see a fatty collection of tissue, for instance, that would never cause a problem.

Event_Moderator When a patient first receives a lung cancer diagnosis, what are their treatment options? What new treatments are available, and what kinds of costs are involved?

Dr. Perez-Soler It all depends on how expensive your tumor is. It's what we call the 'staging' procedure. So if you're diagnosed with cancer or your X-rays suggest it, basically you need to confirm that first. That requires us to be able to access the area of abnormality, takes piece of tissue, and send it to the pathologist. The pathologist cuts and stains it in a special way, and looks under the microscope, at which time he can tell whether this is an infection, malignant tumor, or cancer. At that point, the doctor will tell you what the news is. The next step before treatment can be recommended is to find out how extensive the tumor is. It may be very advanced or not so advanced, so at this point, we do the staging workup, which basically consists of doing x-rays. So we do a CAT scan of the chest. Basically we only look at the lungs. There is also a PET Scan, which is a new tool - still experimental. We also look at the bones, and do a CAT scan of the abdomen. Also, I always look at the brain. Maybe in 5 percent of people with a newly diagnosed lung cancer, you may already find they have a spot in the brain, and I think it's important that in the time the diagnosis is made, you look at all of the body, as much as you can, so you have more information. The more you get, the more effective treatment will be, and the least amount of surprises you'll have. It's worth it. Then, we classify the tumors from 1-4, and the reason for this is, by classifying them, it provides prognostic information. A "1" is a small thing that can be taken out by surgery and cured in relatively all, or most of the cases. Stage "2" means cells have gone to the lymph nodes of the chest, and in stage '3' it's more extensive. The nodes are on other sides of the chest. Stage "4" is the worst. Disease isn't only in the lungs and chest, but outside of the chest. It's the worst, and most difficult to treat. There are standard treatments for each stage, meaning, what's been proven to be the best way to help patients with treatments. Even if it's the best available, standard treatment isn't always very good, so that means patients may not want to do that. They may want to do something that may not be proven but can possibly help them. Those are non-standard (experimental) approaches, and when to use that is decided between the patient and the doctor. So, the decision making of what to do with each patient is really the result of a discussion between the doctor and patient once the staging and type of cancer is known. The doctor needs to say 'the standard options are 'this,' and the results are 'this," or, 'there may be newer options, but we don't yet know the consequences yet." If the newer options are better than the standard ones, the patient may be the first to benefit. So in almost every type or stage of lung cancer, there are standard and experimental options. Each patient reacts differently to them. Some don't like to take risks, some are more willing to do something newer than what most patients do.

Event_Moderator Who gets lung cancer, primarily'? Is smoking usually the culprit, or do hereditary factors play a big role in this?

Dr. Perez-Soler That's a very good question, and it's interesting to discuss this. There's no question that if you're a chronic smoker, you have a higher risk of getting lung cancer, and other diseases. Your risk depends on many things: the amount of cigarettes you smoke each day, and the number of years you've smoked. That number is proportional to the damage caused by tobacco inside your lungs. The other factor is how good you are at repairing the damage caused by tobacco. Some people are very good about it, some aren't. Some who smoke 1 pack a day have a risk that may be smaller than other's. They're all exposed to the same amount of poison, but genetically, some people are more capable of cleaning the lungs of poison. Unfortunately, we can't yet recognize you can repair the damage slowly, or who repairs it more fast, so we can't caution people not to smoke, because of the way they are. Peter or Paul may smoke the same amounts as you do. But we can generally say, DON'T SMOKE. Another part of the story is how many people who get lung cancer never smoke. Tobacco is a poison, but we all breathe many other things that are difficult to distinguish .... it's easy with tobacco to determine exposure (the answer is yes, or no, to the question of smoking), but we are all exposed to other agents in the same amounts, which is why some who never smoke can get lung cancer. I'd tell you about 20 percent of the patients we see have never smoked. About 80 percent are current or past smokers, and of them, I'd say the majority are past smokers. So what happens is when people are young and they don't see it as a major risk, they'll think they'll quit in a few years. Even it that occurs only for a few years, you carry an increased risk. It you quit, it diminishes with time (the risk), but you still carry the potential. Twenty percent (20%) of the 170,000 people in the US who get this disease each year have never smoked or been involved in the family, for example, with smoking. So it's more complicated than just smoking. You're better off not smoking, in general, we'll tell people. At the same time, you may smoke all of your life, die at 80 and your lungs are clean. It's a genetic thing. Some people are smart, some aren't, some are good at music, some aren't, it's the same principle when some people can't clean their lungs of tobacco smoking.

Event_Moderator So passive smoking does play a part?

Dr. Perez-Soler Yes, it does play a role, but as you can imagine, the exposure of passive smokers is much lower than active ones. It would take many more years of being in an environment where people smoke a lot to get that exposure. If the people exposed are passive smokers, that's not good. Again, we can't predict this beforehand, but in a few years, we'll be able to, once we learn more about tobacco's chemicals, what they do, and what the body does to get rid of that. We'll be able to sort out those people, assuming tobacco still exists. If you look at the numbers, approximately 25 percent of adults in this country are active smokers, and the numbers haven't decreased much in the last few years. Since the sixties, the numbers have decreased, and in the last few years the numbers are actually rising with younger people. Tobacco cessation hasn't worked the way we've wanted it to. About a quarter of the population are active smokers, which tells us, this will still be the first cause of cancer related deaths. About 1/3 of all cancer deaths come from lung cancer.

Event_Moderator What is mesothelioma, and are there different types, or degrees of this cancer?

Dr. Perez-Soler Mesothelioma is a rare form of lung cancer, that originates not from the lung itself but from the surface (rnesothelium) like an internal, very thin skin that covers the lung. This is a rare disease, about 3,000 people get in the US each year. So the classic lung cancer is about 170,000, numbers-wise, and mesothelioma is about 3,000. This originates from the lung surface and looks different during biopsy than the classical lung cancer. It tends to grow locally so It doesn't spread outside of the chest like the other lung cancers, Eventually it kills the patient, by local growth. So it becomes a very big local problem, not from going outside. One of the characteristics of this disease it is effects people that have been exposed. Not always, but often, it affects those who have been exposed to asbestos. And again there's a component of both active and passive asbestos exposures. Wives of men who work in shipyards, for instance, can also get it. Anij the exposure to asbestos is found in about 80 percent of the cases, I'd think it's a lower number, about 50 pement. So again you may have never had exposure to asbestos, or your husband may not have, and you could still get it. It affects people in their 50s and 60s but we've also seen people in 30s who get it. It's rare, but it's a disease that's been publicized because of its clear risk factor. Asbestos exposure incidences should go down, as asbestos In the workplace has decreased, but the numbers haven't gone down dramatically, We don't think they'll lower much in the future, and obviously in N. Europe and S. Africa (due to mineworkers) it's very common over in those countries.

Event_Moderator How is the European medical community equipped to deal with that?

Dr. Perez-Soler There has been a rather nihilistic approach to the disease because of the fact that most patients who contract the disease die within 6 to 18 months. So there has been a defeatist approach because of the very aggressive and recalcitrant nature of this tumor, so many in Europe and Britain have more or less resigned that the patients will not survive, and therapy, many times, is only supportive.

Event_Moderator How many people are LIVING with lung cancer? What kinds of survival and remission data are currently available?

Dr. Perez-Soler The numbers are the following. Each year in the US there are 170,000 or more people diagnosed with lung cancer. The latest figures are about 20 percent, So there should be about 20,000 people who are cured of it, however this doesn't mean they'll live forever. Being cured means they'll be alive 5 years after diagnosis. After that, because these people are generally in their 60s or 70s you'll see deaths for other reasons, so it's hard to come up with a number of how many people today in this country are considered cured of lung cancer (thinking of cured as being alive 5 years later). So those who are cured have been diagnosed before 1999. It's hard to calculate but they should be in the numbers of at least 100,000. Also you have to know people that are cured of 1 lung cancer are at risk of getting a 2nd lung cancer (2-3 percent risk per year) So over time some develop a 2nd tumor. But I think there should be at least 100,000 people cured of cancer in the US, and I'd like to know who they are, because they can be a strong group of advocates to spread Information available about this disease. People hear about less lethal cancers, and one of the reasons is patients die pretty quickly. Those that are actually cured are healthy.

Event_Moderator Which drugs are must prevalent in their use in cases of lung cancer, and are there any herbs or vitamins that might substitute or complicate prescription medications?

Dr. Perez-Soler About 10 years ago, many cases of advanced lung cancer were not treated with treatments oncologists recommend (chemo) because treatments were hard to take and were ineffective. So it debilitated patients who went to unfriendly treatments causing tiredness, weight loss, nausea, etc.; very little benefits. In the last seven to eight years, we've had advances in 2 areas. First, new drugs have been developed, and second we've learned to use chemo in a way that's better tolerated. As a result, all patients with advanced lung cancer are offered chemo and the chemo that most oncologists recommend is as follows. If you really want to know what you should doctor, ask 'what would you do if you were me?' So medical oncologists that see lung cancer need to be asked, 'what would you take?" In general, they'd take a combination of two drugs: Taxol, and Carboplatinum. If it's not exactly these 2, it's going to be drugs that are very similar. So instead of Carboplatinurn it would be cisplatinum, or Taxotere rather than Taxol. Fortunately, these aren't the only drugs we have. There are other good drugs that are good but aren't used as often. Gemcitabine is one of them, and this is a good drug for what we call the non-small cell lung cancer. There are 2 major types of lung cancer, one is 'non-small cell' and the other is 'small cell.' Basically they're treated differently, or are at least perceived to be. In non-small cell, it responds less frequently than small cell in most patients. Gemcitabine is for non-small cell. Another new drug is called Topotecan, and this one is basically good for small cell. So, these are the drugs that one way or the other in combination people are offered today and response rates depend on the type of lung cancer. If it's non-small cell, you have to count on about a 30 to 40 percent real tumor shrinkage, meaning you won't see shrinkage in 60 percent. It's 80 percent in other instances, and the shrinkage is temporary, sometimes it's 3 months or it may be 1 or 2 years. There's no way to predict who will be responding and for how long, so this is one of the problems we have. We have to offer non-friendly therapies to people, and many times these don't work. So more research in finding out which would be the best drugs for each patient is the type of effort that needs to be encouraged About vitamins and nutrition, many patients have the question, what should I eat, what about vitamins and herbs? From a scientific point of view, whether these things work or not, we don't yet know. We don't have the study results. Supplements, etc, are non-toxic so they don't cause damage, either. So my position and the position of most professionals is to be tolerant and say there's nothing to lose by using this as an additional thing, but there's no data to support that It helps. There's nothing to lose. One thing people should know is vitamins and nutrients are probably much more important in the progression of the damage of the lungs to lung cancer. Most likely vitamins like Vitamin A have some protective effect of those at risk for lung cancer, especially if they smoke. Epidemiological studies have observed this for years, and have shown people whi died that were rich in these types of vitamins had lower results of lung cancer. Eighty percent (80%) of patients in Japan had that occur, nad the incidence is lower in the US. It may be Japanese tobacco, or it may be that their bodies or constitution of weather are different, it's hard to tell. It may be genetic disposition, thought that's hard to believe. When Japanese people come to the US, they develop lung cancer as much as us, which may imply something that is a protectant in the Japanese diet. Perhaps Green Tea or other herbs may protect. If you talk to scientists they'll say it's much more likely vitamins/nutrition are important more so before the cancer than after. To make the tumors disappear, you need much more aggressive intervention like surgery, chemo, or radiation. Doctors should be very tolerant and let patients know there's nothing to lose when asked about the risks or benefits of vitamin therapy, There will be no side effects and it will be very rare that they'll affect chemo negatively.

Event_Moderator {question presented} How long would you have to be exposed to asbestos to be threatened?

Dr. Perez-Soler There is no clear answer to that question because patients have reported extremely brief one day exposures, as well as multiple everyday exposures in an occupation such as ship building, and yet both develop mesothelioma. It appears, however, that the greater the exposure over the course of time, and the amount of asbestos, the greater the chance of contracting mesothelioma.

Event_Moderator {question presented} Do you recommend that your patients consider clinical trials?

Dr. Perez-Soler Definitely, yes. For several reasons. First because many times clinical trials allow access to something potentially better. So, if you don't get in a clinical trial, you know what you're getting. If you shop around, you may find one that suits your risk of taking medications that would be better. There are some trials that are better than others, and it also depends on what stage you have and what's been tried on you. Certainly if you have standard chemo and the disease comes back you'll probably want to try something new and will have to enter a clinical trial, otherwise it won't be made available to you. It depends. You have to look at what's involved, what you get, and the potential. In general, you may not want to be involved in randomized trials. Those trials are the perfect study from a scientific point of view because it involves 2 groups of patients, 1 that gets 1 type of standard therapy and the other that gets the potentially better therapy (new drug combination, etc.). Obviously the patient wants new treatment--to be in the 2nd group--but he has no control over that. He may only be assigned to standard treatment. Many times standard treatment is a waste of time for some stages. When it's good it can be very good, but if it doesn't work it can be bad. So to take three or four months out of your life for something that doesn't work, it's not a good deal. The FDA and regulatory people find it's a definitive demonstration, but for patients themselves it may not be the best trial. The best are the ones in which you get the new drug and know that it works. You get the advantage of the standard and the new drug. People recognize that by doing the trial they have nothing to lose and maybe something to gain. If they're in one that wastes their time with therapies that are defective, that's something to consider. In general, you're more intensively taken care of in trials, You're looked at more closely by research nurses, for example. Everything is recorded and in the end you may even receive better care: you come more often, tests are scheduled, you can contact the research nurse at any time, and at the end this may translate into better clinical care. So most of the time it's a good deal. All of us have had people that have died in experimental protocols, obviously, so the question arises, would they have died if they were not in the trial? So unfortunately it doesn't always work.

Event_Moderator How has gene therapy assisted in the treatment of lung cancer? Also, what is "phototherapy," and how is that utilized in cancer treatment?

Dr. Perez-Soler Gene therapy is a new form of experiment. It's more a dream to invent a reality. But in my mind, it's one of these possible dreams. Some dreams are impossible, and the reason they may be so is we don't yet have the tools. In 1999, gene cell therapy is still a dream. The idea is to be able to repair some damage that tobacco and other poisons produce in the genes. The idea is to get the gene (piece of DNA, a chemical) and examine it. To produce that gene from the call isn't easy. Genes are large and don't cross the cell membranes, so a technology has been developed for that, we're working on that. Hopefully the gene can repair damage and replace missing genes. So it's a very appealing strategy, as it goes to the essence of the problem, genetic damage. It's one thing to have it in concept on paper, and to have it work. It's like with airplanes, You can decide you'll make it fly, and there are things to make it fly. That's where it is at this point. There has been progress, and I think there's enough evidence to believe there will be a way to do it, once it can be done effectively, we'll find some diseases that can (and can't be) treated with this. It's more complicated than just repairing genes.

Event_Moderator What's been the impact of this therapy on lung cancer?

Dr. Perez-Soler There are several ideas and therapy approaches being pursued in early experimental stages. Most imply putting a needle in the tumor and injecting genes to destroy the tumors. We don't yet have something definitive to tell patients, but we are making progress. One of the things that's also being thought about is to use these genes in other therapies in some type of inhaled device so that the poison comes from the cigarette. There may be the drug or gene to repair that damage, it may also be inhaled (a nebulizer type of machine) so the damage can he repaired. We are exploring these concepts of gene therapy. It's an early idea, and it will take time and effort to sort out the technical problems. It's a dream that can be achieved in a few years.

Event_Moderator What is "tumor immunogenicity?"

Dr. Perez-Soler This is the ability of tumor cells to trigger an immune response, and therefore by doing that, that immune response can actually kill tumors. In a way it would be like showing your cards to your enemy. Tumors are very smart. If you inject tumor cells in a patient, even his own tumor cells, and you put them in blood, very few survive, So the body's very good at ridding itself of suspect cells that don't follow rules and create tumors. Some cells outsmart the system. The immune system is like a police system that doesn't detect things that become tumors. There's no police system in the body that can get rid of tumors after a certain point. The ability of not being recognized as 'bad boys' is something that immunogenicity does .... It's like the police recognizing 'bad boys' on the street. If it's 3 am, they may suspect those people as the biggest criminals of all, which tumors are. Tumors try to 'avoid suspicion,' and by the time the immune system is aware, it's too late. So immunogenicity can recognize this, when the call is made to the "police" and they arrive, these tumors will secrete substances that antagonize the body's ability to get rid of cells. Unfortunately, most tumors are not immunogenetic. And they can't handle them because they can't neutralize an immune response. The vaccine approaches haven't been successful so far. In 50 years we'll have to look back to see how we can deal with lung cancers. As of today we're pretty lost in terms of finding ways for the immune system to help us eradicate lung tumors.

Event_Moderator {question presented} Would you say the resources and treatment options are more cutting-edge in the United States?

Dr. Perez-Soler Definitly, yes. Some people feel that because of so much regulation in this country there are many options available elsewhere. This has some validity. The rules here are pretty stringent but at the same time the profit involved in having good cancer medicines are so high, no one shies away in investing things that help people, which in turn makes money. So for those reasons, the US has many more options available, however it's true that many of these options and protocols don't help the patient, so it's still harder to get access because you may be in a clinical trial that is randomized. Again this is dictated by the regulatory authorities. Many activists are involved and many of them haven't been involved in the approval process of drugs. The FDA has advocates who have had, say, breast cancer 15 years ago. It's more "cosmetic," for the public to feel represented. The reality is, if the FDA were infiltrated by people who have truly suffered from disease, things would change. Drugs need to be offered by people who are willing to take risks with different cocktails, etc. Some money needs to be put aside for treatment of patients, at their own risk. People are desperate. That makes the oncologists job hard - the patient realizes not only he's in trouble and may die, but also the system is very difficult. Sometimes this has more to do with psychology: comforting the patient that the doctor has done everything they could do, and the patient may be taking the best drugs, and that person would at least feel comfort. Politics and administrators really don't care about the lives of people and follow the rules, that's the type of message they get. That's why there's so much emotional anger against the system, so that's why many advocates should fight harder, for these reasons. Again, if something goes wrong, it's absolutely at their own risk, and somee patients would really go for that. They're desperate. Life is short. It's all we have.

Event_Moderator {question presented} Could you tell the WebMD audience a little bit about the FDA Orphan Drug Act, and the FDA Orphan Drug Program?

Dr. Perez-Soler We've said "bad things" about the FDA, and it's really very respectable. They want to protect people against the inherent desire drug companies have to make money. It drug companies could make money by lying, they would do so also. The FDA provides protection from that. If it would give access to drugs that are really good, that would be the next step. As far as the drug act goes, that's been good. Cancer is very profitable, in a sense, and all types of these diseases have funding. So they have pooled money aside to give to researchers and doctors who have ideas about this disease for research incentives. They budget money each year and provide money to institutions who have "orphan (more than 50,000 people who have the disease) indications." This has allowed new things: treatment of an array of diseases. It's been several million dollars, for sure that has been granted, and one of our studies for mesothelioma was given some funding. It's not restricted to cancer, it's for all array of diseases which are rate or for which there's not given much funding for finding now cures or therapy.

Event_Moderator Where can I find resources on the Web about the latest findings about treating lung cancer?

Dr. Perez-Soler There's a web site one of the patients from NYU, where we are, has created called I think it's the best site now for lung cancer. This is a good site Karen Parles did on her own and the reason for it is, as a patient she realized there was a need for consumer information on the internet so they could look at different doctors, theories, and approaches. She had a rare form of lung cancer and needed help from different doctors and opinions. She realized there wasn't enough information she could really access. So that's very helpful. She improves it all the time and it's a significant effort. Eventually it could be "the place to go.'' So I recommend that, as one of the best in terms of web sites for lung cancer.

Event_Moderator Thank you for joining us, Dr. Perez-Soler.

Dr. Perez-Soler Thank you, my pleasure.