At first, I was glad to see Saturday’s story in the Chicago Tribune, “Women who don’t smoke can still get lung cancer.”

Then the dread crept in: This was news!

In this digital age, newspaper editors have to work harder than ever to ensure the stories they run are exciting and unexpected. The best stories always have an element of surprise. The stories should be so unexpected that readers will share it on Facebook and tell their friends, “I had no idea… Did you?”

The Chicago Tribune has an audience of approximately 1.2 million people daily.  That’s a lot of people! And you can bet this metropolitan publication employs the best editors with their fingers firmly on the pulse of their city. Good editors know their readers’ interests and cater to their tastes and background.

So, perhaps I should be glad. Glad that the editor at the Chicago Tribune thought that the readers of the greater Chicago area would be interested in learning more about lung cancer. And maybe I should be grateful that this editor learned the statistics that so many LUNGevity supporters already know and decided to share them with others.

But I can’t help but worry that this story, which we all know so well, is still a surprising headline to so many people. T

Perhaps this article, which is an eye-opening piece for so many people, can open our eyes in a different way. While this article teaches others about the rates of lung cancer in nonsmokers, it also teaches us that our work is far from finished.

Right in our own backyard, people still think this is news!

I certainly appreciate that this article is helping to raise lung cancer awareness. But I also think it is powerful motivation to continue expanding our events and becoming LinkUp advocates.

Let’s work together to make this story old news!

The basic principle is this: we know that people who undergo surgery for lung cancer remain at some risk for the cancer recurring.  The stage of the cancer provides a pretty good approximation of the prognosis, which is really primarily the likelihood of the cancer recurring and the patient dying from the cancer.  The lower the stage (from Ia on the low end to IVb on the high end), the better the prognosis.  In the world of resectable, curable NSCLC, patients who have stage II or IIIa NSCLC are the group of surgery patients who have the strongest evidence to support additional therapy after surgery, and the results are much more equivocal for patients with stage Ib NSCLC (in the slightly outdated staging system that was used in these trials, these were primarily people with a cancer larger than 3 cm or with a smaller one but pleural lining involved by tumor, and no lymph nodes involved).

Chemotherapy, typically 3-4 cycles of a platinum-based doublet combination, has been shown to reduce the risk of the cancer recurring, thereby improving survival, in higher risk patients.  How much of a benefit it provides depends on how great the risk is that the cancer will recur: it is relative to the risk of recurrence.  What this means is that for people with a very high risk of recurrence, like 50-75% with surgery alone, that reduction in absolute terms may be pretty substantial, in the range of a 20% reduction.  In contrast, if a person has a very low risk of recurrence, such as 10% for a very small and well-behaved cancer, the absolute reduction might be more like 1-2%.  In contrast, the detrimental effect of chemotherapy, in terms of both acute challenges and potential long-term risks, are the same whether someone has a more threatening or a less threatening cancer.  The detrimental effects are more related to the health of the patient.

What all of this means is that whether the benefits of treatment exceed the risk for an individual patient depends on the threat of the cancer along with the fitness of the patient to tolerate chemotherapy safely.  While stage captures a fair amount of the threat posed by the resected cancer, there are actually several others that are not captured.  The National Comprehensive Cancer Network (NCCN), which produces the most widely used guidelines for clinical oncology practice, has noted that chemotherapy is a consideration for patients with node-negative NSCLC that is identified as higher risk not only based on size of the cancer, where a cut-off of 4 cm or greater has been the primary consideration as a threshold marking higher risk that would justify chemotherapy, but several other factors that are also correlated with higher risk of recurrence, including each of the following:

• visceral pleural invasion
• tumor grade (particularly poorly differentiated cancers)
• vascular invasion
• wedge resection
• absence of lymph nodes removed during surgery

All of these have been studied and shown to be correlated with survival, even if they don’t have a clear rule for a cut-off to follow. Over the next few weeks, I’ll provided a discussion of each of these variables in more detail.

What we come away with is a sense that there are several important factors that might lead us to modify our level of concern about an individual patient, aside from surgical stage alone.  The decision of whether to recommend chemotherapy ultimately emerges as a very personal discussion that includes not only a focus on the stage of the cancer, but also integration of factors such as the bulleted list noted above, the patient’s health and ability to tolerate rigorous chemotherapy safely, and their own preferences and motivation.

This was just the top level view, but I’ll cover these issues more thoroughly in upcoming posts.

I was listening to a segment on NPR (National Public Radio) recently, where the guest was being interviewed about her life and journey as a long-time (15+ year) warrior of a rare, slow growing and incurable type of breast cancer.

What touched me most was how the guest discussed the reaction of others to her cancer and current status. She talked about how some people responded to her by talking about their own illness or disease in the same context as her cancer. At the most basic level, there are illnesses that are of the same magnitude as, for example, a late stage lung cancer diagnosis but not many.

In the years since my husband’s diagnosis, I have heard several people compare his cancer to a cold, the flu and other short – term and curable illnesses.  This is difficult given that you can overcome the flu, but lung cancer is different because the prognosis is not the same, the treatment path is not the same, the life impact is not the same, and the fifteen (15) percent five-year survival rate is definitely not the same.  It is sometimes hard to get people to understand the distinctions and it is difficult to understand that in some cases people are just not going to get it.

I believe that this reaction or focus on someone else’s illness or disease is a coping mechanism. While this response is frustrating, I have (slowly) learned to pick my battles. When I am faced with this dilemma I do my best to remember that not everyone is going to understand the reality of our situation and not everyone is going to respond in the way I would like them to or think that they should.

I have found it helpful to listen to them with empathy and compassion, but my real feeling is that we have bigger battles to fight.

What are some of the things you’ve found helpful?

Here are a couple of additional installments from our special two hour webinar on molecular markers in advanced NSCLC, broadcast from the Santa Monica Targeted Therapies in Lung Cancer conference and featuring four great panelists who joined me that day:

• Drs. Charlie Rudin, Johns Hopkins University
• Dr. Alice Shaw, Massachusetts General Hospital
• Dr. David Spigel, Sarah Cannon Cancer Center
• Dr. Glen Goss, University of Ottawa, and head of NCI-Canada’s Lung Cancer Committee

Part three of our program includes some debate on the merits of uniform vs. more selective testing of “druggable” targets, as well as a discussion of whether to favor simultaneous testing for molecular targets vs. a sequential, stepwise approach (because the key relevant targets are mutually exclusive).  We also review the challenge of delays in treatment that can emerge as a byproduct of weeks of up front testing.

Below you’ll find the audio and video versions of the podcast, along with the transcript and figures for this activity.

Molecular Targets PD Pt 3 Video Podcast

Molecular Targets PD Pt 3 Audio Podcast

Molecular Targets PD Pt 3 Transcript

Molecular Targets PD Pt 3 Figures

The fourth part continued with an animated discussion of the pros and cons of incorporating more widespread molecular testing into broad clinical practice.

Here are the audio and video versions of the 4th podcast, as well as the transcript (there aren’t any particularly relevant figures to go with this one):

Molecular Targets PD Pt 4 Video Podcast

Molecular Targets PD Pt 4 Audio Podcast

Molecular Targets PD Pt 4 Transcript

The upcoming segment (cleverly titled “Part 5″) will feature a presentation by Dr. Spigel on the process of incorporating molecular testing into new models for conducting clinical trials in lung cancer.

I hope these podcasts are interesting and helpful!