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Lung cancer remains the leading cause of cancer-related death in both men and women in the United States. And for America’s veterans, that risk is even higher as they are 25 percent more likely to be diagnosed with lung cancer than those who did not serve in the military.

As we recognize this year’s Veterans Day, Laurie Fenton Ambrose, President and CEO of Lung Cancer Alliance, explains how early detection and the treatment of lung cancer is evolving in and benefiting the veteran community, and what still needs to be done to improve the care for the men and women who have served our country.

Why are veterans disproportionately affected by lung cancer?

“Veterans are disproportionately affected for two key reasons: their smoking history and their occupational exposures. First, veterans have a higher prevalence of smoking than the civilian population. Many use smoking as a way to cope with the stress of their occupation and cigarettes were readily available to them while in service. At the same time, veterans were also exposed to a variety of chemicals that are linked with an increased risk of lung cancer, such as asbestos, Agent Orange, burn pits and chemical weapons.”

Why is treating veterans with lung cancer challenging?

LAURIE FENTON AMBROSE

LAURIE FENTON AMBROSE, PRESIDENT AND CEO OF LUNG CANCER ALLIANCE, IS HELPING TO LEAD THE CHARGE IN IMPROVING PREVENTION, SCREENING AND TREATMENT OF LUNG CANCER IN THE VETERAN COMMUNITY.

“Research has shown that many Veterans’ Affairs facilities are not prepared to implement comprehensive lung cancer screening programs. More work needs to be done to support the investment in infrastructure and resources to offer more coordinated care to American veterans with lung cancer as quickly as possible.

We also need to address the stigma associated with having lung cancer—which affects how the disease is both resourced and advocated for — and the comorbidities that many veterans face in addition to lung cancer.”

How is Lung Cancer Alliance working to improve care for veterans with lung cancer?

“We are working with military facilities and programs to reduce tobacco use and exposure. We are also working on awareness campaigns to alert veterans to their elevated risk for lung cancer as well as directing them to responsible screening and care so that we catch and manage the disease early.”

Why is early detection so important?

“Because it can save your life. Just like other diseases with approved screenings, you see higher survival rates in those whose disease has been caught early by screening. Now lung cancer can join this fold. Simply put, if you find lung cancer in its earliest form, you improve your treatment options and your quality of life. But right now, approximately 75 percent of lung cancers in the general population are diagnosed at late stage when there are fewer effective treatment options.

We need to highlight the benefits of screening and make sure that it is made available to our veterans. Studies have shown that low-dose CT screenings can decrease lung cancer death rates if we provide adequate resources and infrastructure. It’s key that we make sure everyone at risk—including our military community—is aware that these screenings are available to them.”

We’re at a pivotal moment right now with lung cancer screening and treatment advances, and we are seeing more lung cancer survivors than ever.

How are the efforts to improve screenings going so far?

“Screening is a fairly new preventive service. The federal government gave a green light just four years ago for coverage. So, we are now working hard to “ramp-up” this service in communities across the country. This involves bringing national awareness to the issue as well as educating providers and those at risk of the benefits and risks. We are also committed to making sure screening and care is being provided in the most responsible way in medical centers and considering how we collect information to help further improve early detection and treatment options. It is not easy. It takes time. But we are focused on moving this forward as rapidly as possible.

The challenge I see is that there isn’t the same sense of urgency and focus around lung cancer screening as we have seen with other cancers such as breast and colon. That’s likely related to the stigma around this disease. We really need more national attention on this issue.”

How are new treatment options helping patients with lung cancer?

“New treatment options for patients with lung cancer are improving care and bringing hope. For example, we have more targeted therapies and immunotherapies being paired with chemotherapy to treat lung cancer today than we have had in decades.

When you combine these new therapies with the ability to detect lung cancer earlier, outcomes can be more favorable for early stage patients. This one-two punch is making a dent in the high mortality rates. We’re seeing five-year survival rates rise to 19 percent; a leap forward from where we were in the 1980s, when five-year survival was only 13 percent. We’re at a pivotal moment right now with lung cancer screening and treatment advances.”

What else should veterans know about lung cancer?

“No veteran should ever feel alone. We are ready to support them. That’s what Lung Cancer Alliance is here to do. Veterans should know that there’s a place where they can go to feel part of the community and find information. We are honoring their service by making sure our service is there for them.”

To learn more about how researchers are developing new treatments strategies for lung cancer, read “Hitting Moving Targets in Lung Cancer Subtypes.”

CHRISTINE FILLMORE BRAINSON, PHD, ASSISTANT PROFESSOR AT UNIVERSITY OF KENTUCKY MARKEY CANCER CENTER, EXPLAINS THE IMPLICATIONS OF RECENT DISCOVERIES IN NON-SMALL CELL LUNG CANCER SUBTYPES.

CHRISTINE FILLMORE BRAINSON, PHD, ASSISTANT PROFESSOR AT UNIVERSITY OF KENTUCKY MARKEY CANCER CENTER, EXPLAINS THE IMPLICATIONS OF RECENT DISCOVERIES IN NON-SMALL CELL LUNG CANCER SUBTYPES.

The two major types of non-small cell lung cancer (NSCLC), adenocarcinomas and squamous cell carcinomas, have long been considered two distinct diseases. But researchers are now discovering that these tumor types may have a much more complicated, intertwined relationship.

As researchers gather for the 2018 American Society of Clinical Oncology meeting, we reviewed the implications of these discoveries for the future of lung cancer treatment with Christine Fillmore Brainson, PhD, assistant professor at the University of Kentucky Markey Cancer Center.

What are some of the unanswered questions that continue to drive research in NSCLC?

We still don’t know which cells are the culprits — the “cells of origin” for different subtypes of lung cancer. That’s something our lab is trying to parse out in mouse models. Understanding the cells of origin may help us to develop treatments that specifically target these NSCLC subtypes.

We’re also trying to personalize treatment for lung cancer patients. At the University of Kentucky, when lung cancer patients don’t respond to chemotherapy, we sequence their tumor biopsy. This lets us understand the unique genetic combinations that contribute to their lung cancer. Then we consider the approved and investigational therapies that target those mutations.

How has our understanding of different types of lung cancer evolved recently?

We’re beginning to understand that there may be more plasticity in NSCLC subtypes than we had thought. Sometimes, a patient is originally diagnosed with adenocarcinoma. Then a second biopsy after treatment may reveal that those tumors have qualities of both adenocarcinoma and squamous cell carcinomas. Having a tumor that looks like both, which we call adenosquamous lung cancer, complicates things, and it has a poor prognosis. This transformation could be a factor in resistance to therapy in NSCLC.

Non-small Cell Lung Cancer Subtypes

Do we know what drives this change in the tumor cells?

We typically only see second biopsies after a patient has been treated with epidermal growth factor receptor (EGFR) kinase inhibitors. So that treatment might be driving the transformation in patients. Or it might also happen after chemotherapy. We don’t know because we don’t take that second biopsy then to look at it.

In a previous study, we showed that we could force this transition in mice through specific genetic changes.

How might this finding affect how doctors diagnose patients?

In the future, a diagnosis of adenosquamous lung cancer, rather than just adenocarcinomas or squamous cell carcinomas, might be common. And it might justify taking a second biopsy after chemotherapy. Right now, that’s not recommended, because often the patient isn’t doing well at that point, and you don’t want to add a lung surgery unless there will be a clear benefit.

Understanding the cells of origin may help us to develop treatments that specifically target these NSCLC subtypes.

If one NSCLC subtype can change into another, how could that affect treatment?

We’ve seen that targeted immunotherapies work well in squamous cell carcinoma. My laboratory is studying whether the transition to squamous cell carcinoma can make the patient’s cancer more susceptible to immunotherapy. We’re studying this in a mouse model right now. If we can push the transition toward squamous cell carcinoma with a targeted therapy, maybe we can boost the response to immunotherapy.

What does the future of lung cancer treatment look like?

Cytotoxic therapy, such as chemotherapy, and immunotherapy combinations are potentially going to be the future of NSCLC treatment. At ASCO, researchers will present studies that show more data on chemotherapy and immunotherapy combinations to treat adenocarcinomas. Combinations are being tested in clinical trials, and the Food and Drug Administration have approved a few combinations for specific circumstances. We see that some patients do much better when treated with immunotherapy and chemotherapy. So we should continue exploring combinations of immunotherapies with our standard therapies. Combinations seem to be one clear way to go forward.

To learn more about how immunotherapies may be a new partner for chemotherapy, read “The Evolving Role of Chemotherapy in Lung Cancer.”

While progress made in immunotherapy is bringing hope to many patients, chemotherapy remains the backbone of treatment for the majority of patients living with non-small cell lung cancer. In some ways, researchers continue to evaluate the full potential of this foundational therapeutic class.

UPAL BASU ROY, DIRECTOR OF RESEARCH AND POLICY AT THE LUNGEVITY FOUNDATION EXPLAINS THAT CHEMOTHERAPY AND IMMUNOTHERAPY MAY MAKE A POWERFUL COMBINATION IN THE FUTURE.

UPAL BASU ROY, DIRECTOR OF RESEARCH AND POLICY AT THE LUNGEVITY FOUNDATION EXPLAINS THAT CHEMOTHERAPY AND IMMUNOTHERAPY MAY MAKE A POWERFUL COMBINATION IN THE FUTURE.

“We’re still learning how best to use chemotherapy and personalize it to help lung cancer patients live longer, better lives,” Upal Basu Roy, director of research and policy at the LUNGevity Foundation, said. “The role of chemotherapy in lung cancer treatment is still evolving and improving every day. I don’t see it ever really going away anytime soon.”

Lung cancer remains one of the deadliest forms of cancer, with an approximate 18 percent five-year survival rate. While certain subtypes of non-small cell lung cancer can be treated with targeted therapies, the majority are still treated with chemotherapy.

Fortunately, the experience of chemotherapy today is considerably less challenging than it was decades ago.

“When my grandmother was treated with chemotherapy for cancer in the 1980s, she suffered just as much from the side effects as she did from the cancer,” Basu Roy said. “But when my uncle was treated in the 2000s, his doctors prescribed him anti-nausea medications to help minimize that side effect.” Other medicines used along with chemotherapy aim to battle fatigue and loss of appetite.

By making chemotherapy more tolerable, doctors have expanded its use to earlier stages, when the disease has not spread (“metastasized”) beyond the lungs, so surgeons can attempt to remove the tumor. Chemotherapy before surgery can help shrink the tumor, making it easier to be removed. Giving chemotherapy soon after surgery is meant to kill any cancer cells left behind and has increased the five-year survival rate for patients with non-small cell lung cancer by 5 percent. When the tumor cannot be removed surgically, a combination of chemotherapy and radiation, given at the same time, has helped patients live longer.

We’re figuring out not only which treatment approaches are most effective but also how to combine them and in which order

With immunotherapies, which work with your body’s immune cells to fight cancer, the potential for innovative combination treatments with chemotherapy is growing. These new therapies have significantly reduced, or in rare case even eliminated, the tumor burden of metastatic disease in patients. But they don’t work for everyone. For instance, PD1 inhibitors work for 20 to 30 percent of patients with non-small cell lung cancer, meaning the remainder needs other options. Some studies are combining immunotherapy with chemotherapy to determine whether more patients respond.

With a rapidly changing treatment landscape, community oncologists who treat many types of cancer may not be up to date on the latest advances specific to lung cancer. So patients should learn all they can, ask plenty of questions and seek out second opinions from lung cancer specialists.

To provide the lung cancer community with the information needed to ask the right questions and make the best treatment decisions with their doctors, Celgene has worked with Cancer Support Community and LUNGEVITY to publish an educational resource called “Treatments for Advanced and Metastatic Lung Cancer” as part of the Frankly Speaking About Cancer® series. This guide is designed to help patients feel empowered to take control of their cancer—and their lives – and provides a comprehensive overview of treatment options for metastatic lung cancer, as well as a tear-out discussion guide to help patients understand what questions to ask and the type of information they need to work with their doctor to decide the best treatment options.

“We’re figuring out not only which treatment approaches are most effective but also how to combine them and in which order,” Basu Roy said. “And as we continue to learn, we need to make sure this information gets to the front lines, to the community oncologists who see the majority of lung cancer patients.”

To learn more about the treatment options for metastatic lung cancer, read Treatments for Advanced and Metastatic Lung Cancer at the Cancer Support Community website.

It’s normal for cancer patients to feel helpless, not in control of their lives. But Joe Stivala was determined not to develop that mindset when he was diagnosed with non-small-cell lung cancer three years ago at the age of 58. Instead, he learned as much as possible about his disease, began asking his doctors questions about his treatment options and took control of his situation.

As part of this year’s Lung Cancer Awareness Month, Stivala wants to help others take control of their cancer treatment by sharing his story on staying positive and taking charge of his treatment when faced with this difficult-to-treat disease.

How did you learn that you had lung cancer?

I was at my favorite restaurant and couldn’t eat a single bite. Being a former chef and a person who loves food, I knew something was wrong. Ten days later, I was admitted to the hospital and put in isolation. Visitors had to wear masks; my doctors didn’t know what I had and thought I could be contagious. A pulmonologist biopsied my lungs and diagnosed me with stage IIIb non-small-cell lung cancer. People talk about being diagnosed with such an advanced stage lung cancer as a death sentence. And it’s certainly true that the survival rate is low.

LUNG CANCER SURVIVOR JOE STIVALA (FAR RIGHT) IS THANKFUL THAT HE WAS ABLE TO WATCH HIS OLDEST DAUGHTER GET MARRIED IN 2014.

LUNG CANCER SURVIVOR JOE STIVALA (FAR RIGHT) IS THANKFUL THAT HE WAS ABLE TO WATCH HIS OLDEST DAUGHTER GET MARRIED IN 2014.

How did you react to that diagnosis?

I refused to look at it as the end. I could have gone around feeling sorry for myself, but that would not have helped. I decided this wasn’t the end. So, I geared myself up to do whatever was needed, and I took full ownership. I decided to do it my way, like the Frank Sinatra song. I learned as much as possible from sources such as the American Cancer Society, the National Lung Cancer Foundation of America, Lungevity Foundation and the Bonnie J. Addario Lung Cancer Foundation. I’m not a doctor, but I can now talk intelligently about my disease.

How did that approach help you through your treatment?

It gave me the confidence to push back on my doctors when I didn’t agree. I was raised to treat doctors as if they were infallible, but now I’ve come to realize that each doctor has his own expertise and opinions. I didn’t waste time with answers that didn’t satisfy me. You have to get a second, third, and fourth opinion—as many as you need. Otherwise, you’re doing yourself a disservice. So I researched a specialist in my particular cancer. He talked with me about the options, including clinical trials, and we decided to try a new chemotherapy combination.

There’s more hope than ever before. In just the last three years, so many new treatments and trials have become available.

How effective was the treatment?

My pulmonologist still doesn’t believe that I’m alive and living normally. There’s nothing I can’t do. I used to love golfing when I was younger, and now I’m back out on the golf range almost every week. It’s nice to be on the course and in the sun, enjoying time with my friends.

How did you remain positive through your experience? What gave you optimism?

My three children kept me going. That included little signs of support—like how my oldest daughter would text me positive quotes every morning during my treatment—and big milestones that I wanted to celebrate with them. I’m thankful that I got to watch my youngest daughter graduate high school and my two older children get married. And now, we’re expecting my first granddaughter in a couple of months.

JOE STIVALA (FAR LEFT) CELEBRATES HIS YOUNGER DAUGHTER’S HIGH SCHOOL GRADUATION WITH HIS OTHER CHILDREN AND EX-WIFE.

JOE STIVALA (FAR LEFT) CELEBRATES HIS YOUNGER DAUGHTER’S HIGH SCHOOL GRADUATION WITH HIS OTHER CHILDREN AND EX-WIFE.

Did you get emotional support from any unexpected places?

I’m grateful for my spiritual advisors and some true friends who have really stepped up. I was really surprised by the number of old classmates from high school who have wished me well through Facebook. I never liked Facebook, but it gave me a forum to be very open and honest about my disease. The response was very positive, and now I’m paying it forward to support others. I connected with a high school friend the day after her 38-year-old daughter was diagnosed with colon cancer, unbeknownst to me, and now I’m supporting them. Everything happens for a reason.

Why should lung cancer patients be hopeful about their future?

There’s more hope than ever before. In just the last three years, so many new treatments and trials have become available. You have new immunotherapies and chemotherapy combinations. And it’s just the beginning. So many doctors and researchers are working hard on a cure. When I heard Siddhartha Mukherjee, the author of “The Emperor of All Maladies,” speak earlier this year, he said we could see cures for most cancers within the next 25 years. And I believe him, and lung cancer patients should too.