Lung Cancer is on the rise, and no matter what one can blame for it – the increasing pollution in the cities, smoking, lack of adequate antioxidants in diet, cooking fumes and so on, we need better options to treat the disease. This is not only because most lung cancers are detected in late stages, but also because a sizeable population is elderly too, who cannot withstand the brunt of chemotherapy, radiotherapy, surgery etc.
I will describe a case of an 88/F as seen in the photograph below, who came to my OPD with lung mass on the right side and an FNAC diagnosis of Adenocarcinoma. Thankfully at least an FNAC was done, as many a time such masses are subject to ATT without being mindful of the fact that they can be more sinister, only to present at a time that nothing much can be done.
I had the option of properly investigating it and doing a biopsy and staging process, but it was clear that all these may lead to only more expenditure, as patient is unlikely to tolerate most of the treatments, so I adopted a conservative approach, which went well with the expectations of the family too. Biopsy is essential to subtype the cancer and also test for mutations such as EGFR and EML4-ALK, which are targetable with simple drugs.
Conceptually, on the biological front these tumors are driven by epidermal growth factor (EGF) signaling which bind to the receptors present on the cancer cells and promote tumor growth. Drugs blocking this signaling such as “Gefitinib & Erlotinib” have shown efficacy in lung cancer patients (Figure 1). These drugs are available as a pill and need to be taken once a day, making therapy simpler and free of serious side effects. However, all did not seem to benefit still, which led scientist to study the ones in whom it worked the best. After studying the genetic make up of the EGF receptor of tumor cells it has been identified that those carrying specific mutations [exon 19-21 & L858R] are the ones who show extraordinary response rates to the tune of 70-75% and a median survival reaching 3 years, practically unheard of in lung cancer. On an average approx 30% patients with lung cancer may harbor these mutations; hence laying strong ground for their testing before initiating therapy with toxic chemotherapy and thus, extending the benefit of this relatively non-toxic and much superior therapy to our patients. We are now regularly doing these tests in eligible patients of lung cancer.
Another target lately identified in lung cancer which has attracted ardent interest in the oncology community is cancer gene EML4-ALK which if positive responds to a new research molecule Crizotinib, again in a pill form, with similar encouraging response rates.
Our patient was started on Tab Gefitinib, which was tolerated well. 3 months post treatment the Xray of the chest showed marked reduction in the lung mass, and patient continued to tolerate the drug well, with no adverse effects at all. She continued therapy for around a year. In the last, she made visits very infrequent, as she was doing well, until she developed brain metastasis, and came to us too late, to allow salvage and succumbed to her illness.
These new drugs called as targeted therapy are surely bringing a new hope for patients especially elderly when other modalities such as chemotherapy become formidable, especially in elderly population. We have had now patients who had continued on these therapies and are now in 5th year of their disease.