Imagine receiving a late-stage cancer diagnosis but never being told about a treatment option that could be effective. That’s the situation for far too many lung cancer patients across the country. Elizabeth David, MD, associate professor of clinical surgery at the Keck School of Medicine of USC who joined the division of thoracic surgery in June, studies the biases that can discourage doctors from recommending surgery for advanced-stage lung cancer patients.
According to the American Cancer Society, lung cancer is the leading cause of death by cancer in both men and women. More people are expected to die of lung cancer in 2018 than are expected to die of breast, colon and prostate cancer combined. Studies indicate that the most effective treatment for advanced non-small cell lung cancer is some combination of chemotherapy, radiation and surgery, but many referring physicians are reluctant to include surgery as an option.
“Sometimes a doctor will see that it’s late-stage lung cancer and tell the patient to take a vacation instead of undergoing treatment options, including surgery,” David said. “It happens less frequently now, but it definitely does happen.”
Part of the problem, she said, is that outdated clinical trials on lung cancer surgery form the basis for treatment guidelines. In the older studies, a lot of patients had an entire lung removed rather than a lobectomy, the more likely procedure today. The removal of an entire lung could be very hard on a patient in the short run, while in the long term it could make a simple cold a real health hazard. Similarly, the old clinical trials involved patients who had traditional open surgeries, a much bigger shock to the system than modern minimally invasive procedures.
“The retrospective data we have for patients who have undergone lung cancer surgery with modern techniques shows a real survival benefit,” David said. “Unfortunately, people tend not to value that data as much as a prospective clinical trial.”
Part of David’s mission is to generate enough interest in retrospective data to conduct new randomized clinical trials.
“It’s an uphill battle,” she admitted. “Stage 3 and 4 lung cancer patients can vary a great deal. One patient might have a heavy disease burden and still be a stage 3 or 4, while another might have an isolated tumor in the lung and a single tumor somewhere else and be a stage 4 because of that. It makes it challenging to study and difficult to design a trial that patients want to be on and doctors support.”
Another barrier is simply the way referring physicians may think about surgery. “If they haven’t had much exposure to a surgeon who uses minimally invasive techniques and has good outcomes, they may still think of lung cancer surgery as painful and hard on the patient. They’re going to be reluctant to recommend it.”
David noted that social stigmas around lung cancer affect attitudes toward research and treatment as well.
“People think of lung cancer as a smoker’s disease — you did this to yourself, so why should you get treatment?” she asked.
People who have lung cancer can be reluctant to get treatment because of the fear of being judged. But in fact, according to the American Cancer Society, 20 percent of the patients who die from lung cancer have never used any kind of tobacco. “And regardless of whether someone smoked, everyone deserves a chance at treatment,” David said.
David says that talking openly about lung cancer is the best thing people can do to change the attitudes of patients, referring physicians, and researchers. She pointed out that breast cancer advocates have worked hard over the years to make the disease a subject of open conversation and popular national campaigns, with positive results. In 2017, the American Cancer Society estimated 41,070 deaths from breast cancer and the National Institutes of Health spent $689 million on breast cancer research. That works out to about $16,776 per death. In contrast, there were 155,870 deaths due to lung cancer in 2017, but the NIH spent $352 million on lung cancer research — a drastically lower $2,258 per death, less than one-sixth of what was spent for breast cancer.
In all this, there is good news that David feels is important to keep in mind: “Lung cancer is still the No. 1 cancer killer, but the annual number of deaths from lung cancer is going down. Surgery is easier for people to tolerate, and so are radiation, chemotherapy and other systemic treatments. People can still choose to forgo treatment — we just need to make sure they have the best data before they do.”
— Lex Davis