Tailored Lung Cancer Treatment

Lung cancer remains a formidable disease, but the outlook for improved therapies is far from grim at the University of Maryland Marlene and Stewart  Greenebaum Cancer Center (UMGCC), where a multidisciplinary approach  by specialists in radiation oncology, medical oncology and thoracic surgery combines a can-do attitude with a wide variety of innovative treatments and ongoing research designed to target the needs of specific groups of patients.

Recognized and supported by the National Cancer Institute (NCI) as one of the country’s leading cancer treatment centers, UMGCC and its physicians are immersed in numerous investigator-initiated and nationwide clinical trials — along with prominent industry collaborations — achieving advances in the care and outcomes of those with non-small cell lung cancer, elderly patients, those with locally advanced cases, never-smokers and a host of others, resulting in steadily improving prognoses and quality of life.
“There’s little question that thoracic oncology has become an area where we have a lot more to offer,” says Martin Edelman, M.D., director of solid tumor oncology at UMGCC and professor of medicine at the University of Maryland School of Medicine. “That’s gratifying, but there’s also the feeling that there’s a lot of other potential things we can do. Clearly it’s an area in which we’ve seen enormous progress in a relatively short period of time.”

Cure rates rise with multi-modality approach

In the past five to 10 years, UMGCC physicians have progressed from treating all cases of non-small cell lung cancer as a single disease to recognizing that this most common form is actually many different diseases based on a variety of biological factors, Dr. Edelman says. Several compelling gene mutations have been identified predominantly in never-smokers, who account for as many cases of lung cancer in the United States as all cases of ovarian cancer. Collaborating with the Dana-Farber Cancer Institute in Boston, UMGCC has been investigating ways of overcoming drug resistance in epidermal growth factor receptor (EGFR) translocation mutations, which is common in this patient group and for which erlotinib is being extensively tested, Dr. Edelman explains. 

In addition, the center has a number of innovative studies for patients with more typical lung cancer. One study, an NCI-sponsored randomized study evaluating the use of COX-2 inhibitors in addition to chemotherapy, is based upon work that began a decade ago at UMGCC by Dr. Edelman, who is the lead investigator nationally. Another of UMGCC’s major advances has been treating patients with locally advanced lung cancer — found in lymph nodes in the chest and/or mediastinum region as well as in the lung — with a multi-modality approach. Adding chemotherapy to radiation has resulted in improved cure rates of 20% to 30% of these patients, and some patients with localized disease undergoing adjuvant chemotherapy after surgery have seen cure rates of up to 65%. An area of particular expertise for UMGCC has been the use of chemotherapy and radiation followed by surgery, which has led to two consecutive national studies led by members of our thoracic team. “This center has been a national leader in treatments and paradigms for that,” he says.

Radiation pinpoints moving tumors

Improvements in radiation therapy have centered on deciphering how lung tumors move as patients breathe during treatment or even as tumors shrink during treatment. Tumor-specific motion technology used by UMGCC, which employs 4-D imaging, ensures that radiation targets diseased cells instead of healthy tissue nearby, decreasing treatment toxicity. Ongoing research involves developing better models to accurately predict tumor motion during daily treatments and how motion changes during a prolonged therapy. This is performed by studying surrogates of tumor movement such as the diaphragm, carina or abdominal surface, which often correlates with the dynamics of the tumor.

“Priority goal No. 1 is to hit the tumor with radiation, but these improvements can lead to less radiation to normal tissue,” says Steven Feigenberg, M.D., associate professor of radiation oncology at the University of Maryland School of Medicine and director of UMGCC’s Stereotactic Body Radiotherapy Program. “Tumors move differently from day to day, and can change rather dramatically during a prolonged treatment.” Knowing exact tumor position especially aids in the administration of stereotactic body radiotherapy (SBRT), which delivers three to five treatments of high dose radiation over the course of one week rather than daily treatments for seven weeks, the typical protocol. While SBRT is usually used on patients who are not surgical candidates, UMGCC physicians have been involved in a national study to test this technique on operable patients.

“We’ve found out, along with others, that SBRT produces not just the same results, but significantly better results with fewer side effects as compared to a prolonged course of therapy,” Dr. Feigenberg says. “The longer treatment has a 65% chance of working, but this has a 90% chance. With this newer technique, we’re curing a lot of the small tumors. In addition, these advances in techniques have also changed how we treat advanced tumors by reducing radiation to surrounding critical structures.”

International trial compared surgical techniques

Much the same as in radiation oncology, surgical advances at UMGCC have concentrated on preserving healthy lung tissue while excising primarily diseased cells. For earlier-stage tumors, physicians are using minimally invasive approaches that include video-assisted thoracic surgery (VATS) lobectomy. For tumors less than 2 cm in size with no evidence of metastasis, UMGCC is currently participating in an international phase III randomized trial sponsored by the NCI comparing wedge resection to lobectomy for non-small cell cases. Available surgical techniques span a wide range, including a sleeve upper lobectomy, which excises a portion of the bronchus with the upper lobe and reattaches the remaining lower lobe bronchus to the proximal main bronchus to avoid removing the entire lung. 

This procedure, like other lung-sparing modalities, is used more often at UMGCC than at other cancer centers, according to Richard Battafarano, M.D., Ph.D., associate professor of surgery and chief of the Division of Thoracic Surgery. The international research trial will answer an important question, Dr. Battafarano notes. “If you try to save lung by staying close to the tumor, you’re always worried about recurrence,” he explains. “If we focus on lung preservation and recurrence rates are high, that’s not an ideal endpoint. If the patient has limited pulmonary reserve and we perform lobectomy, the resulting shortness of breath may not be an appropriate balance. We have to find where that important balance point is.”

Treating the whole patient and all possible patients

Finding the right balance in patient care has also meant discerning how to help each individual patient, regardless of age. While many elderly patients have historically been passed over for lung cancer treatment because of comorbidities and increased risks, UMGCC physicians are committed to pinpointing the therapy — whether minimal or aggressive — that may improve these older patients’ outcomes without stripping them of comfort. For elderly patients with lung cancer, the UMGCC group has demonstrated that aggressive multi-modality care can be safely performed with results that are comparable to the younger population, according to Dr. Edelman.

This page was last updated: November 7, 2013

         
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