A diagnosis of lung cancer is one of the most devastating anyone can receive. Some 44,500 people are given the bad news each year*, and around 35,000 lose their lives. ‘That’s one person every ten minutes – most aged over 60,’ says Professor Tariq Sethi, head of respiratory medicine at King’s College London.
But for the first time there is a real buzz of optimism surrounding the disease.
‘Lung cancer was under-researched and underfunded but we’re on the brink of an exciting era,’ says Professor Sethi. ‘We’re understanding more about its biological mechanisms, and refined surgical techniques and new treatments are starting to improve quality of life and long-term outlook. The next five to ten years will bring even more progress.’
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Better diagnosis for lung cancer
A key reason the disease has lagged behind in the cancer survival stakes is that it eludes early diagnosis. Most sufferers don’t know they have it until it’s incurable. That’s partly because, while later symptoms such as coughing up blood and chest pain are unmistakably serious, earlier ones can be vague.
It’s easy to ignore, for instance, a persistent niggling cough, hoarseness or fatigue – they could, after all, easily be caused by a minor infection or just getting older. ‘But it’s vital to see the doctor if you experience any of these symptoms for more than three weeks,’ advises Lorraine Dallas, director of information and support at the Roy Castle Lung Cancer Foundation - www.roycastle.org.
The positive news is diagnosis is getting faster. In May 2015, more than 4,000 GP practices using the EMIS Web (a system for internet bookings and other uses) were issued with an online symptom checker that helps doctors assess the likelihood a patient has the disease based on physical signs and other factors such as age, and family and personal medical history.
Hot on its heels, NICE issued a new guideline allowing GPs to fast-track anyone with suspect symptoms for further tests, bypassing the traditional, usually slower specialist referral route.
A full computerised risk-calculation tool, the EMIS Web QCancer® tool, which covers 12 cancers, including lung cancer, with a ‘prompt alert’ that pops up on your GP’s computer screen, will follow. Other software is in the pipeline.
Surgical solutions for lung cancer
Surgery offers the best hope of a cure for tumours confined to the lung. Until recently, however, age, other medical problems and/or lack of fitness have ruled this out for some – withstanding open chest surgery isn’t easy. But VATS (video-assisted thoracoscopic surgery), an innovative keyhole technique, is extending the number who are suitable.
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How video-assisted thoracoscopic surgery works
The surgeon inserts a tiny telescope and surgical instruments through one to three incisions in the chest, through which he or she operates under video guidance to remove the tumour.
‘I’m now operating on people I could never have previously treated, including some with heart and other medical problems,’ explains VATS pioneer and Papworth Hospital consultant thoracic surgeon Mr Marco Scarci. ‘My oldest patient is 93.’
Mr Scarci is working on a technique that removes the need for stressful artificial ventilation, hopefully reducing the impact of surgery still further. VATS is not widely available on the NHS, but under its Patient Choice scheme you can ask to be referred to a hospital or consultant that offers the treatment.
Advances in radiotherapy for lung cancer
Radiotherapy, an alternative to surgery for people who don’t want an operation or have inoperable or hard-to-reach tumours, has also taken a stride forward. New techniques known as SABR (stereotactic ablative radiotherapy) blast tumours with small amounts of highly focused, high-energy radiation. There is no pain and no long hospital stay.
‘Because it’s so precise,’ says Dr Qamar Ghafoor, consultant in clinical oncology at Queen Elizabeth Hospital Birmingham, ‘we can deliver high doses of radiation that spare surrounding tissues. Patients need fewer visits – typically just five compared with 20 for conventional radiotherapy – and there are fewer side effects.’
In a study published in The Lancet in June 2015, people with early stage lung cancer treated with the most state-of-the-art SABR technique, CyberKnife, had a 95% chance of surviving for three years, compared with 79% for open-chest surgery. The technique uses a computer-controlled robot to deliver multiple beams of high-dose radiation from different angles to tumours with extreme accuracy. Other SABR platforms include VMAT (volumetric modulated arc therapy).
Until summer 2015, SABR was routinely offered by the NHS only as a treatment for non-small cell lung cancer. However, after a high-profile campaign backed by former England Rugby Union captain Lawrence Dallaglio, the next three years will see it more widely available to treat cancers (including lung cancer) that have spread to other parts of the body, under a new £15 million Government scheme.
Personalised drugs for lung cancer
Personalised drugs that target genes, proteins or the environment that fuels cancer growth have emerged, made possible by greater understanding of lung cancer’s complex mechanisms. As Professor Sethi explains, ‘Lung cancer has some 20,000 to 50,000 different genetic mutations compared with around 20 for breast cancer.’
These new focused drugs – unlike traditional chemotherapy that hits both cancer cells and healthy cells – slow or stop cancers by exploiting their weaknesses. Some of the most promising available to date inhibit mutated EGFR (epidermal growth factor receptor), a protein found in 10-15% of non-small cell lung cancers, and anaplastic lymphoma kinase (ALK) proteins. Others are being trialled.
Of course, chemotherapy and/or radiotherapy are still a go-to non-surgical solution. However, says Dr Martin Forster, consultant in medical oncology at University College London, and the Cancer Research UK Lung Cancer Centre of Excellence, ‘Increasingly, at diagnosis people will have their tumours analysed for genetic mutations to see if targeted drugs are suitable for them.’
Harnessing the immune system to help fight lung cancer
‘The advance that has cancer specialists most excited, however, is the emergence of agents that harness the body’s own immune system to attack lung cancer,’ comments Dr Forster. The first such drug, nivolumab (Opdivo), was licensed earlier this year, and will be considered by NICE for NHS prescription for some people with recurrent advanced lung cancer.
The new agents could revolutionise the outlook for people with the condition, according to Dr Mick Peake, consultant in respiratory medicine at Leicester’s Glenfield Hospital and clinical lead for the National Cancer Intelligence Network.
‘Like all cancers, lung cancer is a clever disease that, as it advances, protects itself with an invisible cloak to evade detection by the immune system,’ he explains. ‘These drugs, known as PD-1 inhibitors, PD-L1 inhibitors or checkpoint inhibitors, of which there are three or four others now in the pipeline, uncloak the cancer so the immune system can attack it.’ Around one in five people taking the drugs are still alive a year or two later. Previously, they’d have had only months left.
‘It’s the biggest advance I’ve seen in the 40-odd years of my working life,’ says Dr Peake, although his optimism is tempered with a note of caution. The drugs are likely to cost tens of thousands of pounds a year and, although currently only licensed for people with late-stage disease, it’s thought they could work at earlier stages and for other types of cancer, something that could stretch hard-pressed NHS budgets to breaking point.
But for now, after years on the offensive, lung cancer appears to be on the back foot and it looks certain that we will soon be seeing a significant rise in the number of people surviving.
One patient's experience of poineering lung cancer surgery
Cheryl Leigh Saville, 66, a former film and TV script supervisor from Buckinghamshire, has had pioneering surgery.
‘While being investigated for an unrelated heart condition in April, a chest X-ray revealed an early non-small cell lung cancer in my right lung. I was shell-shocked as I’d become a vegan and hadn’t felt so well for years. Although I used to smoke, I gave up in 1996 and was told it hadn’t anything to do with that. But my father died of lung cancer in the Eighties, aged 54.
‘I ended up having a double bypass for my heart problem and couldn’t face more major invasive surgery.
‘Scouring the internet, I discovered that Mr Scarci at Papworth Hospital was offering a new technique, involving just one incision. We made an appointment and I had the op on July 27. I couldn’t be more pleased. I spent just four days in hospital and could walk, have a shower and lift my arms almost immediately. I have just a small 2-inch scar beneath my armpit.
‘Luckily my cancer was small and hadn’t spread, so in a strange way my heart condition probably saved my life.’
The two main types of lung cancer
1 Non-small cell lung cancer (NSCLC) accounts for 85-90% of cases.
2 The more aggressive, but less common, small cell lung cancer (SCLC) affects 10-15% of patients.
Know the symptoms of lung cancer
If you experience any of these symptoms for more than three weeks, consult your doctor.
- A persistent or deteriorating cough
- Chest pain, often worse with deep breathing, coughing or laughing
- Unexpected weight loss
- Loss of appetite
- Coughing up blood or rust-coloured spit or phlegm
- Shortness of breath
- Fatigue and weakness
- Infections such as bronchitis and pneumonia that don’t go away or keep returning
- New wheezing