New cancer drug approval: a tipping point for lung cancer
L Ung’s cancer has long held the infamous distinction as the deadliest cancer in America. This disease kills approximately 160,000 American men and women each year and causes one in four cancer deaths, and it kills more than colon cancer, breast cancer, and prostate cancer combined. But many experts believe they are seeing a turning point in the battle against lung cancer, for two reasons: More new drugs are being approved to treat advanced cases, and oncologists now know more than ever about the disease they’re fighting. “The future of lung cancer treatment looks very bright,” said Ashish Sangal, MD, medical director of the CTCA® Lung Cancer Center, Phoenix and an oncologist at Phoenix Hospital. This optimism stems, in large part, from the shift in treatment paradigms, from a one-size-fits-all approach to more individualized care.
Oncologists classify lung cancer into two categories: non-small cell, which makes up nine out of 10 lung cancers, and small cell, which makes up less than 20 percent of lung cancers. A decade ago, treatment decisions required little additional information. Each type was treated with the same techniques, usually surgery for lung cancers in its early stages and chemotherapy for those in advanced stages. Today, lung cancer treatments are determined by more than one type and stage of the disease. If the cancer is non-small cell lung cancer, for example, oncologists determine whether it’s squamous cell or adenocarcinoma, the two main subtypes of non-small cell lung cancer. They also perform genomic tests on some patients to look for mutations that may be driving the tumor’s behavior. Patricia Rich, MD, director of medical oncology at the CTCA Lung Cancer Institute and a medical oncologist at The Hospital of Atlanta says:
Treatments for early-stage non-small cell lung cancer have changed quite a bit over the years; First-line treatment remains surgery, with radiotherapy and chemotherapy among the common alternatives. But recently, oncologists and drug developers have begun to expand treatment options for patients whose cancer has spread to other areas of the body. The vast majority of these efforts have been directed at non-small cell lung cancer, which accounts for 85 percent of lung cancer.
New drug approvals
In recent years, the US Food and Drug Administration (FDA) has approved new drugs developed to target specific genetic changes that help non-small-cell lung cancer cells to grow. Some of these targeted therapies work to prevent cancer cells from forming new blood vessels; Others are designed to neutralize DNA mutations in certain protein receptors, such as EGFR, ALK and BRAF, to prevent cancer cells from growing and dividing. “It’s a very small subset of people that these targeted medications can help, unfortunately,” says Dr. Sangal. “Only about 15 percent of non-small cell lung cancer patients have an EGFR mutation, and only about 5 percent have an ALK mutation, for example. But you get such a good response from these patients with these drugs that you don’t need to think about it.”
Oncologists also know that they have more to learn about how to use targeted therapies as a patient’s cancer changes and progresses. “Even if targeted therapy works and a person’s cancer is gone for a year or two, it can come back because the cancer is a second or even a third mutation,” says Dr. Sangal.
“It’s almost like a graceful punch. Cancer is forming new mutations and we have to find new drugs to prevent these new mutations.” – Ashish Sangal, MD
The Food and Drug Administration also recently approved several immunotherapy drugs called checkpoint inhibitors to treat non-small cell lung cancer: pembrolizumab (Keytruda ® ), nivolumab (Opdivo ® ) and atezolizumab (Tecentriq ® ). These drugs target PD-1 and PD-L1 cell receptors, which help regulate the immune response. The treatments are approved only for patients with certain types of non-small cell lung cancer who haven’t responded to chemotherapy or other treatments. Pembrolizumab has also been approved as a first-line treatment in some patients, either in combination with chemotherapy or on its own.
In addition to treating cancer, immunotherapies can also mean a better quality of life for some patients, because their side effects, such as fatigue and nausea, are often less serious than those associated with chemotherapy and other conventional treatments. But for a small number of patients, immunotherapy can cause serious, life-threatening reactions. Says Daniel Nader, DO, FCCP, FACP, chief of lung services at Cancer Treatment Centers of America® (CTCA). In such cases, the liver or colon may become inflamed and treatment may need to be delayed or stopped altogether.
Explore combination therapies
However, despite the drug’s limitations, oncologists are optimistic about the future of immunotherapy for lung cancer patients. “I see more trials of checkpoint inhibitor drugs coming and a better choice for patients,” says Dr. Rich. “As we learn more about checkpoints and how to work with them to treat patients, we will see more and more drugs that can treat more and more mutations.” For example, a study was published in September in the New England Journal of MedicineIt was found that patients with stage III non-small cell lung cancer who were treated with chemotherapy and radiotherapy, followed by the checkpoint inhibitor drug durvalumab (IMFINZI™), lived longer than those treated with only chemotherapy and radiotherapy. Dr. says. Rich: “I think the request will be approved.” “And maybe this is it: sequential immunotherapy for non-small cell lung cancers that have spread and cannot be removed surgically.”
Dr. Sangal says other formulations that show promising results are on the horizon. “Treats have become very individualized based on the type of cancer a patient has,” he says. “It’s not just about getting the treatment out of the bag. It’s about determining where the patient belongs in a wide range of factors.”
Learn more about how the immune system works, both in diet and in the fight against cancer.