People with a hepatitis C cure still face substantial risk of death | BMJ

What Causes Lung Cancer? Scientists Are Working To Connect The Dots.

For Sharon Fisher, the lung cancer diagnosis came as a gut punch.

A simple cold had turned into a lingering feeling of congestion, with a dry cough. Eventually diagnosed with pneumonia, a closer look revealed a lesion in the left lobe of her lung. But, how?

After all, she'd never been a smoker, was an avid hiker, was still the same weight she'd been since high school, had no history of illnesses, and was a foodie who ate no processed foods and cooked healthy meals for herself, in spite of her hectic work schedule.

What most people do not realize is that in approximately 15% of lung cancer diagnoses, the patient has never smoked. And, they had no exposure to known carcinogens.

While this fact has baffled the medical community, further exploration revealed that there were many more female never-smokers (as they are referred to) who were contracting this cancer, and at an earlier age, than smokers.

Analyzing the tumors of these never-smokers, a study by the National Cancer Institute revealed that there was an accumulation of genetic mutations within this group. Scientists are still trying to connect the dots to figure out what exposures may have added to the risk. 

For patient Fisher, the lung cancer was already Stage 2 at diagnosis, and required a surgical lobectomy, wherein one of the five lobes of her lungs was removed.

After chemotherapy there was no further evidence of disease. But, the five-year survival rate for stage 2 lung cancer, after treatment, is only 35%.

Over the next few years, Fisher's tumors would return in other areas of her lungs, and despite being a part of clinical trials for her specific cancer mutations and receiving various forms of immunotherapy and targeted treatments, she died of the disease four years later. She was 70 when she passed away, in 2019.

"This is why it is so important to catch lung cancer in its earliest stages," said Ramsy Abdelghani, M.D., Tulane's Director of Interventional Pulmonology. "At stage 1, your 5-year survival rate is 95%. But, in Louisiana, 80% of those diagnosed are either stage 3 or 4. At these advanced stages, survival rates drop precipitously. At stage 4, you're looking at a five-year survival rate of 5%. We're not doing well here with lung cancer screening."

Detecting lung cancer early is easier said than done, and in fact, most people are unaware there is any screening at all for lung cancer.

To receive the low-dose CT scan (10% of the normal radiation) that can detect the earliest of lung cancers, one must meet certain criteria. Patients must be between the ages of 50 and 80, either be a current smoker, or someone who has quit in the last 15 years.

And, the smoking history must be significant — that equates to 20 years of smoking a pack a day, or 10 years of smoking two packs a day. If these criteria are met, patients are entitled to one scan a year, covered by insurance. But, those who have family histories of lung cancer should certainly be in that mix, as they are twice as likely to contract the disease.

Sadly, there are no signs or symptoms in the earliest of stages, so screening is vital. Finding these cancers at stage 2 means there can still be microscopic areas of disease that are present even after surgery, but are not always detectable.

The key is to know your family history, honestly discuss your smoking history with your primary care physician, and take advantage of the ability to screen for this deadly disease. Abdelghany is meeting with primary care physicians to ensure that patients' histories are triggering notifications that will lead to early screening.

Even if you're not a smoker, exposure to radon is the second leading cause of lung cancer. It is a colorless, odorless, radioactive gas that is often found in soil and water.

Although radon decays quickly, it gives off tiny radioactive particles which can leach into buildings and homes and be inhaled. When that happens, it damages the cells that line the lungs. Long-term exposure can lead to lung cancer. According to the National Cancer Institute, it is the only cancer proven to be associated with inhaling radon.

Diagnosis for lung cancer has become far more sophisticated of late. Biopsies are less invasive and pinpointing the exact location of a tumor has become far more accurate.

"I do robotic bronchoscopies by navigating an endoscope through the intricate branches of the bronchi, then do intraoperative imaging to confirm my location," Abdelghany said. "This is a quick, minimally invasive technique to isolate the lesion, and get it analyzed, so treatment can begin."

Major strides are being made in treating all types of lung cancer

Although not technically lung cancer, mesothelioma is a type of cancer that starts in the membranes that cover the lungs. If you didn't know much about this disease prior to the barrage of television ads now asking those with the disease to join class-action lawsuits, you have now probably learned that 80% of these cases are caused by exposure to asbestos — much of it from factories.

Tiny bundles of asbestos fibers which fly through the air can be inhaled. This causes cell turnover, which leads to cancer.

There is a high mortality rate associated with this cancer, as there are no early signs or symptoms that would lead someone to treatment. It is critical that anyone working with asbestos wear a proper mask that filters out all particulate matter.

Major strides have been made over the last decade, relative to all types of lung cancer.

Before these new treatments, the only recourse for treating lung cancer was surgery, chemotherapy or radiation.

Now, by knowing the exact type of cancer you have and determining what stage it is, along with knowing what factors within the tumor can be targeted, precision medicine can go after specific markers within the tumor. As researchers like to say — it is important to know the enemy, so you can find the right tools to fight it.

WTOP's Neal Augenstein: My First Year With Stage 4 Lung Cancer

WTOP's Neal Augenstein relives his cancer diagnosis one year later.

Listen to Neal Augenstein reflect on his year with cancer – all this week on WTOP-FM.

By now, you likely know that after a couple months of coughing, I was surprised to learn in November 2022 that I had cancerous tumors and lymph nodes in both lungs, at age 63, with no history of smoking.

Fast forward, after five months of one-pill-a-day targeted therapy, and a robot-assisted lobectomy, my oncologist said I had no evidence of disease — or NED.

I'll be the first to acknowledge I've had good doctors, good medicine, good insurance and good luck on my side — not to mention countless warm wishes and prayers from folks who know my work at WTOP.

My hope is sharing my journey may make the experience a little less scary for others diagnosed with the leading cause of cancer death in the U.S., according to the American Cancer Society.

So, one year in, I decided to interview three key members of my treatment team at Inova Schar Cancer Institute. I'll introduce you to the doctor who first told me and my wife that I had cancer, the surgeon who removed the upper lobe of my left lung and the oncologist who has overseen the process of stopping the spread of my cancer, shrinking it, removing any remnants and minimizing the likelihood of recurrence.

And, just as importantly, he provides information and support, as I live life with stage 4 cancer.

Fear and diagnosis

I first met interventional pulmonologist Bobby Mahajan, the medical director of interventional pulmonology for Inova Health System, in the minutes before he performed my bronchoscopy and biopsy at Inova Fairfax Hospital. The goal was to figure out why I had been coughing, and why chest X-rays and CT scans showed a mass in my left lung.

"There's a ton of things it could be, but my job is to always think of the worst case scenarios," said Mahajan. "When we saw your scans we said, 'look, there's something up.' We worry about cancer because we know 20% of cancers that are lung origin are from nonsmokers."

Young and confident, Mahajan patted my shoulder before the anesthesiologist started my Propofol, assuring, "We'll take good care of you," before I started the backward counting into deep sedation.

I didn't know it at the time, but while I was asleep, and even before he took a biopsy, Mahajan was pretty sure I had cancer.

"I could see your lymph nodes and that mass under ultrasound," he said. "There's certain characteristics that make it more concerning — something that's a really dense lesion on ultrasound, usually means there are cells that are really packed together, and that's more indicative of cancer."

Within a few hours, while I was resting comfortably in my hospital room, Mahajan broke the news to me and my wife. He expected the biopsy would show I had adenocarcinoma, a slow-growing form of non-small cell lung cancer.

Before I became weighed down with what I previously assumed would be life-changing news, Mahajan provided hope.

"When we met that night, I could give you good information, and my anticipation, based on your history, was 'look, this is going to be turned into a chronic disease, we want to make this something that can make you disease-free,'" he said.

By the time he talked with my wife and I, Mahajan had already sent my biopsy for biomarker testing.

"We're able to now look at biopsies, to test if someone has a certain mutation," he said. If they do, that allows us to target your treatment.""

'A difficult conversation — and an important one'

Before I went to sleep that night, my oncologist, Amin Benyounes, visited me.

"When I walk into someone's room, when they have just been newly-diagnosed with cancer, I realize it must be very challenging, and sometimes devastating news for someone to hear," he said.

Soft-spoken and measured, Benyounes, a thoracic medical oncologist, who still usually calls me Mr. Augenstein, said in the next few days I would have a brain MRI and PET scan, to determine whether my cancer had spread beyond my left lung and a lymph node in the center of my chest. And, he was already arranging for my wife and I to meet with him, a radiologist and a surgeon, the following Monday.

When we met on that Monday, some of the test results were still pending. With a black Sharpie, he drew a chart of the possibilities that lay ahead.

Most important, biomarker testing showed my cancer had the epidermal growth factor receptor mutation — EGFR 19 Deletion — which has a targeted therapy available.

If my cancer was limited to one lung and the lymph node in the center of my chest, Benyounes said it would be considered Stage 3, and was curable, with radiation and chemotherapy. If it spread, it would be stage 4, treated with targeted therapy, "and the prognosis would be years."

During our recent interview, I told Benyounes that was the first time someone had suggested my life might be cut short. I had done enough reporting to know that people often die with stage 4 lung cancer.

"Yes, Neal, it is a difficult conversation to have and an important one as well," he said. "Sometimes, if you don't call things by their names and tiptoe around concepts and notions, there can be a misunderstanding."

If you Google stage 4 lung cancer — and I certainly had, before I was diagnosed — you'll see the statistic that patients have a 1 in 4 chance of living another five years. I've never asked Benyounes how long he expects I'll live.

"Those numbers and percentages are just a rough estimate. The person who is sitting in front of me is not a number. Each person's journey is unique. Each person's outcome is different than anybody else," he said.

When my PET scan showed cancer in both lungs, that meant stage 4. I knew my treatment would be one pill of Osimertinib — with the brand name of Tagrisso — daily. The side effects of Tagrisso are generally quite tolerable, and far fewer than chemotherapy.

My cough was gone within weeks. Amazingly, after four months, Osimertinib had killed all but the tiniest remnants of cancer in both lungs, and surgery was back on the table.

Surgery, then home the next day

When I first met surgeon Michael Weyant in November, surgery wasn't an option.

"The day you walked in the door there was no way your body would survive the surgery necessary to extract all the tumor cells from you. If you had surgery on both lungs, in multiple lobes of your lungs, you would almost envision a lung transplant being needed to remove all the tumors, which really wasn't feasible," said Weyant, the director of thoracic surgery at Inova, during our recent interview.

By early April, "the drug you got remarkably reduced the overall number of tumor sites in your body and narrowed it down to one single area," said Weyant, who said he could now do a lobectomy, with minimally-invasive robot-assisted surgery.

Advances in lung surgeries have been monumental in recent decades, said Weyant. "In the 1960s and '70s the only option of entry into the chest was a very large incision that curved around your shoulder blade. The large incisions and the spreading of the ribs induced a fair amount of pain for patients after surgery."

These days, Weyant sits in a console, operating the robot. Four tiny robot arms — a left hand, a right hand, a retraction device and a camera, went through tiny incisions on my side and back.

After spending the night sleeping sitting up, with a chest tube inserted, Weyant visited me early the next day, verified my lung wasn't leaking, and sent me home.

"I'd be more than happy to be put out of business because a medicine was developed that would obviate the need for surgery," Weyant said. "It wouldn't bother me one bit — that would be an incredible advance in science and medicine."

'We work our way out of that hole'

Even though I'm now cancer-free, since I was diagnosed with stage 4, I probably will never hear the phrase "you're cured."

"Unfortunately, a tumor at any stage has the ability to resurrect itself and return," said Weyant. "That's why we think that surveillance after treatment of any tumor is really important, and that's not unique to lung cancer, per se."

With CT scans every three months, and less-frequent brain MRIs and PET scans, I still take my Tagrisso, to try to stem cancer's recurrence.

Benyounes said until recently, "the stage that the person is diagnosed with is, so to speak, the stage that person stays in."

"This has clearly been challenged," said Benyounes. "We are thankful and grateful that we have patients that beat the preconceived notion that someone with stage 4 cannot be cured from their disease."

With recent improvements in treatments, "All of us in the lung cancer community have patients who were diagnosed with stage 4, who are no longer even on any cancer treatment, because there was no evidence of disease for a long time."

Benyounes said being forthcoming with patients is important for building trust.

"This is going to be a long-term relationship, and setting realistic expectations goes a long way," he said. "I think most people appreciate a healthy balance of optimism and realism."

And while he doesn't want to provide false hope, Benyounes says equipping newly-diagnosed patients with accurate information is empowering: "This gives us back a sense of control, which initially we completely lack. Gradually, we work our way out of that hole we initially found ourselves in, after just being given devastating, life-altering news."

New developments in biopharmaceuticals and operating room technology are in the works.

"We live in a very dynamic time, when it comes to cancer treatment. We have so many world-class institutions within driving distance that offer the most promising cutting-edge clinical trials," citing facilities in Maryland, D.C., and Northern Virginia.

Benyounes says these days, when he walks into the room of newly-diagnosed lung cancer patient, "more often than not, I can promise there are many good days and years ahead of them."

After one year with lung cancer, I feel healthy, hopeful and empowered.

"I think time also plays a role. As one continues one's life, things, for the most part, don't turn out as bad as they thought they would," said Benyounes.

"They find themselves in a better spot, hopefully well taken care of, and that they're able to continue their life, despite cancer."

I intend to follow doctor's orders.

Dame Esther Rantzen Says Her Lung Cancer Is In Stage Four

Image caption,

Dame Esther Rantzen presented BBC consumer show That's Life! For 21 years

By Steven McIntosh

Entertainment reporter

Dame Esther Rantzen has revealed her lung cancer, which she was diagnosed with in January, is in stage four.

The 82-year-old, who founded Childline and the Silver Line, also told the Daily Mirror she was on a new form of medication.

In a wide-ranging interview about her health, Dame Esther told the newspaper: "I'm on one of the new medications, and nobody knows if it's working or not."

"But I will have a scan fairly soon which will reveal one way or another."

She explained she had gone public with her lung cancer diagnosis "because I find it difficult to skulk around various hospitals wearing an unconvincing disguise".

Stage four is the most advanced stage of lung cancer, and means the cancer has spread beyond the lungs or from one lung to the other.

Dame Esther enjoyed a successful TV presenting career which included hosting BBC consumer show That's Life! For 21 years.

Image caption,

Rantzen and That's Life! Co-presenters Howard Leader, Kevin Devine and Gavin Campbell pictured in 1993

She is also known for launching of ChildLine in 1986, the first national helpline for children in danger or distress.

In 2013, she launched the Silver Line, a charity to help elderly people suffering from isolation and loneliness.

She told the Mirror: "My diagnosis of stage four lung cancer made me realise how very lucky I've been in my life, working with Childline and the Silver Line, and meeting so many fascinating and inspiring people, and especially lucky to have spent 21 years working as producer/presenter of That's Life!"

"I'm not good at regrets," she continued. "What I treasure most are the fantastic friendships I have made thanks to That's Life! During the last 50 years, the people I met, and the team who worked so hard, and laughed so hard, together for so long."

Lung cancer: Signs and symptoms

Lung cancer is one of the most common and serious types of cancer. More than 43,000 people are diagnosed with the condition every year in the UK

There are usually no signs or symptoms in the early stages of lung cancer, but many people with the condition eventually develop symptoms including a persistent cough, coughing up blood, persistent breathlessness, unexplained tiredness and weight loss, and an ache or pain when breathing or coughing

Lung cancer mainly affects older people. It's rare in people younger than 40. More than four out of 10 people diagnosed with lung cancer in the UK are aged 75 and older

Lung cancer does not usually cause noticeable symptoms until it's spread through the lungs or into other parts of the body. This means the outlook for the condition is not as good as many other types of cancer

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