Lung Cancer Awareness Month 2020

November 09, 2020

Information

November 8, 2020

Yale Cancer Center

visit: http://www.yalecancercenter.org

email: canceranswers@yale.edu

call: 203-785-4095

ID5856

To CiteDCA Citation Guide

00:00Support for Yale Cancer Answers
00:02comes from AstraZeneca, committed to
00:06pioneering the next generation of
00:08innovative lung cancer treatments.
00:10Learn more at astrazeneca-us.com.
00:14Welcome to Yale Cancer Answers with
00:16your host doctor Anees Chagpar.
00:19Yale Cancer Answers features the
00:21latest information on cancer care by
00:23welcoming oncologists and specialists
00:24who are on the forefront of the
00:27battle to fight cancer. This week,
00:28it's a conversation about lung
00:30cancer with Doctor Sarah Goldberg.
00:32Doctor Goldberg is an associate
00:34professor of internal medicine and
00:36medical oncology at the Yale School
00:38of Medicine where Doctor Chagpar
00:40is a professor of surgical oncology.
00:43Sarah, maybe we can start off
00:46by talking about lung cancer.
00:48I mean when many people think
00:51about lung cancer, they think of it
00:53as kind of a devastating disease.
00:56Tell us a little bit more
00:58about how many people get it,
01:00who gets it, and historically,
01:02what has been the prognosis?
01:05So lung cancer is
01:06a very common cancer.
01:07It's the second most common cancer
01:10in the US among both men and women.
01:12But you're right, it absolutely can be a
01:15devastating illness and because of that,
01:16it's the number one cause of cancer deaths
01:19among both men and women.
01:21So it's common, and it's a common
01:23cause of death from cancer.
01:25But I think a lot has changed
01:27in recent years.
01:28I know we'll talk about a lot of that,
01:31but some of the things that we've
01:34known for a long time now is that
01:36people tend to be older when
01:38they get lung cancer,
01:39although some people are quite young.
01:41Smoking is a risk factor for lung cancer,
01:44but again,
01:44some people have never smoked
01:46a day in their life and they
01:48can still get the disease.
01:53Does genetics play into it?
01:54I mean on this show we talk a
01:56lot about genetics as well,
01:58but when it comes to lung cancer,
02:00most of us think that this
02:02is really a smoking related cancer.
02:04Although as you say there are
02:06people who never smoked a day in
02:08their life who get lung cancer.
02:09So for them, is it really genetics?
02:12What's an underlying
02:12cause for that?
02:13There's a lot about lung cancer
02:15that we still don't know.
02:16And your question is a great one,
02:18and it's something that we still don't
02:20fully understand about lung cancer
02:22because smoking is such a common risk
02:25factor for lung cancer.
02:29When we see someone who's smoked,
02:31who gets lung cancer, we think that it's
02:33probably related in some way.
02:35But again, when people have never smoked,
02:37we really don't understand the cause
02:39for the vast majority of those cancers.
02:41When you think of
02:42genetics in terms of
02:44inheriting a gene from your parents
02:46or passing it along to kids,
02:48that's not really common at all
02:49in lung cancer like it is in
02:51other cancers like breast cancer,
02:53which tends to be more common.
02:55We just don't see that very
02:56much in lung cancer,
02:57so why some people who have never
02:59smoked get it is still really
03:01an outstanding question in the field.
03:03There are some other environmental risks,
03:06but much,
03:06much lower than the risk of smoking.
03:09So secondhand smoke is also a risk,
03:12but again, much lower.
03:14Radon is always a question.
03:16There probably is some risk there,
03:19but how to quantify that?
03:20It is very difficult,
03:22so for many people who haven't
03:25smoked or haven't smoked much,
03:27it's still very unclear
03:29why they get this disease.
03:31You know the other thing
03:33that we talked about in a lot
03:35of different cancers is that any
03:38particular cancer lung cancer,
03:39breast cancer, colon cancer,
03:41whatever, it is rarely one disease, is
03:43lung cancer like that as well?
03:45Or are all lung
03:47cancers essentially the same?
03:50So this is one of the things that
03:53I think is the most interesting and
03:55probably exciting about lung cancer.
03:56Up until a couple years ago we really
03:59thought there were two types of lung cancer,
04:02small cell and non small cell lung cancer.
04:05But over the last really 10 or 15 years
04:07it's become clear that it's multiple
04:09diseases that are all labeled as lung
04:11cancer because of where it started,
04:13where the cancer started in the lung.
04:16And this is one of the biggest advances
04:18in the field over the last several years
04:20is the understanding of the different
04:23types of lung cancer and it's not just so
04:25that we can define things in a different way.
04:28It's really because it impacts treatment
04:30and how well different cancers
04:32respond to different treatments.
04:33How well someone is going to
04:35do with various treatments,
04:36and so differentiating these
04:37different types of lung cancers is
04:39absolutely critical so that we can
04:41get the best treatments for patients.
04:43We still do think about small
04:45cell and non small cell,
04:46but mostly within the realm of non
04:48small cell lung cancer is where
04:50we've been able to divide things
04:52up even more and understand
04:54mostly the molecular basis of lung cancer.
04:58Meaning that the cancer has different
05:00mutations and that is really
05:02part of what defines it.
05:04Now you just asked me about mutations and I
05:06said it's not very common in lung cancer,
05:09but I'm talking about a different
05:11type of mutation here,
05:13so it's not very common that people have
05:16a genetic predisposition to lung cancer.
05:18But finding mutations in the cancer
05:20itself is actually quite common.
05:22Yeah, we've had
05:25other guests on the show here as well who
05:28talk about this concept where
05:30a biopsy is taken and the tumor is
05:33profiled for a number of mutations,
05:36genetic mutations that it could
05:38have that could tailor
05:41therapy and it sounds like lung cancer
05:44is in that realm as well.
05:46Tell us more about the mutations
05:49that you look for and the sub
05:52classifications that you think about
05:54when you're treating a lung cancer
05:57patient.
05:58Lung cancer is a great example
06:00of a disease where the molecular
06:02classifications are so important,
06:04and so whenever we see a patient
06:07with a non small cell lung cancer,
06:09that's advanced
06:10meaning at stage four, it's critical
06:12to get molecular or mutation testing.
06:15People will call it different things.
06:17Molecular testing, mutation testing.
06:19Tumor profiling is sometimes used,
06:20and so that is now entirely a standard
06:23part of treatment and what's really
06:25changed over the years is what we
06:28need to test and
06:31when I first started in this field
06:33now 10 years ago there was really
06:35just one mutation that we can target
06:37and that was the EGFR mutation and
06:39that was so exciting at the time
06:41because it was really the first
06:43time in lung cancer that we could
06:45get a biopsy as you say and do the
06:47mutation testing and if we found this
06:49mutation we had a great treatment
06:51which is a targeted therapy pill,
06:53EGFR inhibitor and that is still the
06:55case today where we're looking for
06:57EGFR mutations and we will target
06:59those cancers with pills that treat
07:01that specific abnormality in the cancer.
07:03Some people will call it targeted therapy
07:05or precision or personalized medicine,
07:07but now instead of just one
07:09mutation that we can target,
07:10we have several that have been
07:12discovered in lung cancer that have
07:14associated targeted therapies.
07:15So we've really come a
07:17long way in just a couple of years
07:20where now we don't test one,
07:22but we test many genes because we
07:24may be able to find a mutation
07:26that is important in that
07:28cancer.
07:29Tell us the other mutations that you
07:31look for.
07:33Thinking about a timeline, so ALK was probably
07:36the next one that was discovered.
07:38Alk is a mutation in a gene that
07:41again can be part of a lung cancer,
07:44especially lung adenocarcinomas.
07:45Most of these mutations really all
07:47these mutations are mostly found in
07:49adenocarcinomas, which is a type
07:51of non small cell lung cancer.
07:53And so ALK is another mutation like the
07:57EGFR mutation where if we find it
08:00I get very excited for patients because
08:02we have fantastic therapies for Alk.
08:04So that's another one.
08:06It's rare, ALK rearrangements are found
08:08in just a couple percent of lung cancers.
08:10But again,
08:11absolutely critical to look for because
08:13of the great options for treatment,
08:15we have another another gene that
08:16we always test is called RAS one,
08:19and that also can have a mutation
08:20in it and the list keeps going on.
08:23So that was really all we had
08:25for a couple of years.
08:26But really,
08:27in the last I would say year or two,
08:30there's been even more of
08:31discovery of alterations,
08:32so now we always will need to
08:34assess for BRAF mutations.
08:35BRAF is a gene that
08:38commonly has mutations in Melanoma,
08:40but more recently was also found
08:41to have mutations in lung cancers.
08:43Again just a couple of percent of
08:45lung cancers have BNRAF mutations,
08:47but now we have targeted therapies
08:49that we can use for that and then
08:51really recently within just the last
08:53couple of months or year we look at
08:55MET mutations and ntrk mutations,
08:57RET I might have forgotten a couple
09:00there's getting to be so many.
09:03We have now several new FDA
09:04approvals for these
09:05targeted therapies,
09:06but if you don't know the mutation is there,
09:09you're not going to use the drug,
09:12so it's really become very
09:13important to test even
09:15more than ever before.
09:16And you mentioned
09:18that this is standard,
09:20but you've mentioned now
09:21at least half a
09:24dozen mutations that you look for.
09:26So is that something that
09:28is standard of care?
09:29So any of our listeners,
09:31no matter where they go,
09:33whether they go to
09:35a large academic Cancer
09:36Center or whether they go to
09:38a local private practice oncologist,
09:41is that something that is going
09:43to be tested for them for
09:46their lung cancer across the
09:48board and across the country?
09:51Or is this still something that really
09:54hasn't found its way out of academe
09:57yet?
09:59It absolutely should be standard of care
10:01because we have FDA approved therapies
10:03when you find one of these targets
10:05that aren't useful unless the
10:07target is there and you don't know
10:09to use it unless you find it so,
10:11this should be part of standard
10:13of care for every patient,
10:14no matter where they are.
10:16The testing is available anywhere.
10:18We do the testing in house,
10:20so our pathology Department is fantastic.
10:22They do the testing here, but there's
10:24companies that do this testing now,
10:26so it is available anywhere in the US.
10:28It's a matter of whether it's done,
10:31and I think that's the bigger question,
10:33so I think now,
10:35because EGFR mutations have been
10:36part of the standard testing,
10:38you really have to test for EGFR mutations,
10:41and that's been for 2004 was
10:44when the mutation was first discovered,
10:46so we've
10:47known about EGFR mutations
10:49for well over a decade.
10:51I think that's become very standard to
10:53test and then the other ones I mentioned,
10:56initially, Alk and RAS,
10:57those have become more common because
11:00they've been around for awhile too.
11:02But the other ones that I
11:04mentioned are equally important.
11:05The issue is that there are more
11:07recent so that sometimes
11:09things take longer to catch on,
11:11and they're also really rare,
11:12so each one of the other ones I mentioned,
11:16are no more than 2% of lung adenocarcinomas,
11:19so they are rare but really
11:21important to test for,
11:22so I would hope and expect that they
11:24are being tested in every patient with
11:26an advanced form of adenocarcinoma,
11:28but I suspect that that's not always
11:30happening because of the rarity of them,
11:32and because it's
11:33a relatively
11:35recent advance in lung cancer,
11:36but they should be tested.
11:39Now we actually test for a whole
11:40lot of other genes at Yale,
11:42and I think that a lot of
11:44other academic centers,
11:45so that part is maybe not as necessary.
11:47You know, we test for
11:50at least 50 genes at Yale and some of
11:52that is trying to think about clinical
11:55trials for patients and other things,
11:57but those,
11:58as you said,
11:59more than half a
12:00dozen genes are standard care.
12:02Obviously, important to test for
12:03and is that covered by insurance?
12:05I mean, is that expensive?
12:07I'm kind of trying
12:10to think of this from the standpoint of
12:12our listeners who may have lung cancer,
12:15may have family members or friends
12:17who have been recently diagnosed
12:19and who may not have known to ask.
12:22You know what is my ALK status, you know?
12:25Do I have a RAS
12:27mutation and so you know,
12:29in broaching that subject, one of the
12:32issues that always comes up is number one,
12:35what is the cost and #2,
12:37is it covered by my insurance?
12:40And then of course #3,
12:42can I really avail myself of the therapies?
12:45But we'll get to the
12:47therapies part in a moment.
12:49What about the testing?
12:51Is it covered or not covered?
12:53Is it expensive?
12:54If people haven't been tested,
12:56can they get their own specimens and
12:58send them off to some lab that can do
13:00a commercial test if they so wanted?
13:02How does that all work?
13:04Right, so because the testing
13:06and the treatment is standard of
13:09care and approved by the FDA,
13:10it's covered by insurance,
13:12so these tests are expensive.
13:14It's all genetic testing DNA
13:16sequencing things like that
13:17but it's covered it's standard,
13:19so it's covered by insurance.
13:21So in terms of if someone could just go,
13:25you know, do their own testing,
13:27the nice thing is
13:29that once you've had a biopsy,
13:31it goes to the lab and it stays there
13:34for as far as I understand, decades.
13:37So if someone
13:38asked their oncologist,
13:39have I had this test and the answer is no.
13:42Actually we didn't test for all these.
13:44It's not like all is lost.
13:46You can still test it.
13:47So I think that has to be
13:49done from the doctor's office
13:50and the pathology Department,
13:51but it absolutely could be done
13:54even years after
13:54a diagnosis is made.
13:56Well, we're going to dig more into
13:58what happens after you have that
13:59information in terms of treatment,
14:01right after we take a short
14:02break for medical minute.
14:03Please stay tuned to learn
14:05more about lung cancer with my
14:06guest doctor Sarah Goldberg.
14:08Support for Yale Cancer Answers
14:10comes from AstraZeneca,
14:12an industry leader in the development of
14:16breakthrough immunooncology therapies across
14:18multiple tumor types and stages of cancer.
14:21Learn more at astrazeneca-us.com.
14:25This is a medical minute about Melanoma.
14:27While Melanoma accounts for only
14:29about 4% of skin cancer cases,
14:32it causes the most skin cancer
14:34deaths. When detected early,
14:36however, Melanoma is easily treated
14:38and highly curable. Clinical
14:39trials are currently underway to test
14:42innovative new treatments for Melanoma.
14:44The goal of the specialized programs
14:46of research excellence in skin cancer
14:49or SPORE grant is to better understand
14:51the biology of skin cancer with a focus
14:54on discovering targets that will lead
14:57to improved diagnosis and treatment.
14:59More information is available
15:01at yalecancercenter.org.
15:02You're listening to Connecticut Public Radio.
15:07Welcome
15:08back to Yale Cancer Answers.
15:09This is doctor Anees Chagpar and I'm
15:12joined tonight by my guest doctor
15:15Sarah Goldberg and we're talking about
15:17lung cancer and right before the break
15:19Sarah was telling us about how lung
15:22cancer is actually a much more complex
15:24disease than we thought previously.
15:26No longer do we think about it just as
15:30small cell and non small cell but really,
15:33lung cancer has burgeoned into
15:35a whole plethora of of diseases
15:37based on genetic mutations
15:39of the cancer itself that can be profiled
15:42and potentially targeted for therapies,
15:45and this testing, while expensive,
15:47is covered by insurance.
15:49Sarah the one question I wanted
15:53to pick up on just before we
15:56move on to the treatments,
15:59which I think is going to be super
16:02interesting, is what about for our
16:05non insured uninsured patients?
16:07It's great that the testing
16:10is covered by insurance,
16:12but if somebody doesn't have
16:15insurance as many,
16:17many American patients don't,
16:20what are their
16:21alternatives?
16:22Yeah, lack of insurance is
16:24difficult in a lot of different ways,
16:27not just with testing.
16:29It also comes down to doctors
16:30visits and treatment too,
16:32so I think that's something
16:35that we sometimes see and
16:37we work
16:40very closely with
16:41multiple people to try
16:43to to work on these issues,
16:45especially our social workers
16:46and try to make every effort to
16:49get people the care that they
16:50need in whatever way possible,
16:52whether that's helping them
16:53find insurance or figure out
16:55other resources
16:57because it's such an important part
16:59of care to get this testing done.
17:01I think that kind of is wrapped
17:03up in the whole
17:05issue with diagnosis and
17:07then finding the right treatment.
17:09It's all part of that.
17:10So typically were able to find
17:12a way to cover this in some
17:15capacity for patients.
17:16We could do a whole show on all
17:19of the implications of having so many
17:21millions of Americans being uninsured,
17:24and what that does for
17:25the health of our nation,
17:28but that's another show.
17:29Let's turn to a happier topic,
17:33which is now that we have an
17:37understanding of all of these mutations
17:39that every cancer can exhibit,
17:43we now can figure out what
17:46makes one cancer different from another.
17:50And once we can figure out
17:53what makes a cancer tick,
17:55we can potentially
17:56stop it from ticking through personalized
17:59therapies and targeted agents that
18:02can really address these pathways.
18:04So can you talk a little bit about
18:07what we know and what are some of
18:10the exciting drugs that
18:13address each of these mutations?
18:16Sure, so as you mentioned,
18:18there's many different exciting
18:19drugs for the various mutations,
18:21and each one generally
18:23does the same thing.
18:24It tries to block the activity of
18:26the abnormal mutation that's
18:30causing the cancer
18:32cell to grow and be abnormal.
18:34And if you could block that,
18:36it could be extremely effective,
18:38and so that's true regardless of which of
18:41these mutations are found in the cancer.
18:43EGFR is a great example,
18:47because we've known about it
18:48for the most amount of time,
18:50there was an EGFR inhibitor
18:52that we used initially called erlotinib
18:55and if that was really effective.
18:57But over the years we've realized
18:59that other EGFR inhibitors that have
19:01been developed since then are even
19:03more effective and seemed to work in
19:06more people and work for longer,
19:08because one thing that I haven't
19:10mentioned is that these drugs,
19:11while they can be extremely effective and
19:14help people,
19:15and shrink the cancer and work for a long,
19:18long time when the cancer is at
19:20an advanced stage,
19:21it's not curable so the drugs can work
19:24and again they can work for years.
19:26But at some point the cancer gets smarter
19:28and grows despite these targeted therapies.
19:31So as we've developed newer and better drugs,
19:33they tend to work for longer,
19:35and so that's really what we're
19:37trying to do is find drugs that work
19:39for a really long time and make this
19:42cancer a chronic disease that people
19:44may not be able to cure or get
19:46rid of entirely,
19:47but they can live
19:49with it for a long time,
19:50and so in each of the different
19:52targeted therapy realms for each
19:54mutation we have great examples
19:56of drugs that can give people
19:57many more years of life than they
19:59otherwise would have had.
20:01And with each of these drugs, though
20:04there's presumably side effects,
20:06what does that look
20:08like?
20:10Any drug can have its share of
20:12side effects and it's variable
20:14depending on the drug, but overall,
20:16the targeted therapies tend to
20:18have less side effects than kind
20:20of our classic cancer drugs,
20:21mainly chemotherapy because
20:22they're targeted and aimed
20:24specifically at the mutation.
20:25That's the abnormality in the
20:27cancer cells which doesn't exist
20:28in other cells,
20:30in the normal cells in the body.
20:32The non cancer cells.
20:34The mutation is not there,
20:35so the drugs don't tend to bother
20:37the normal cells quite as much
20:39as with chemotherapy.
20:40So again, every drug is different.
20:42Some of the more common ones
20:44that we sometimes see is rash,
20:46sometimes people are more
20:47tired than they usually are,
20:48but generally they are much better tolerated.
20:50So it's almost like a win win.
20:52They work better than other cancer therapies,
20:54and they have less side effects,
20:56so again,
20:57we find one of these mutations
20:59that we can target in a patient.
21:01I am very excited and I think
21:03hopefully my enthusiasm catches
21:04on to the page with the patient
21:06and they get very excited too,
21:08especially once they see how well
21:10it works. Now you know when people
21:12are talking about therapies,
21:14I mean on the one hand,
21:16clearly they're really excited about
21:18these really effective therapies
21:19that last a really along time,
21:21but the other thing is that they don't
21:24really want to come to the hospital
21:27and have an IV infusion of a therapy.
21:29And when people think about chemotherapy,
21:32that's what they think about they think
21:34about being in the infusion suite,
21:36hooked up to an IV
21:38losing their hair and getting nauseous,
21:40and repeating that cycle
21:42multiple times, so are these therapies
21:45IV, or are they oral?
21:47How well do they fit into peoples lives?
21:51Especially if we're talking about
21:53taking them for a long time
21:56and making what was previously
21:58thought of as a fatal disease,
22:01more of a chronic one that you can live
22:05with rather than die from.
22:12The IV treatments are challenging because
22:13people usually have to
22:16come in fairly frequently for them,
22:17and you spend time here instead
22:19of where you want to be.
22:21These drugs are all pills,
22:22so that does make it a really nice
22:24part of it is that you take your
22:26daily pill or twice a day pill like you
22:29would take your blood pressure pills
22:31and you don't need to come into the
22:33hospital nearly as often as an IV medicine.
22:35I will say that
22:38as exciting as all of this is,
22:40and hopefully you can
22:42sense my enthusiasm for it,
22:43it still is only
22:45maybe about 20 or 25% of patients
22:48with lung cancer that we can find one
22:51of these mutations that we can target.
22:53So the numbers are
22:56going up as we find more mutations,
22:58but it's still unfortunately
23:00not everyone and so
23:02there's been a huge amount of work in
23:04other areas of lung cancer where
23:06we can't find a targetable mutation,
23:08and then the other end
23:11that's mainly with immune therapies.
23:14What about the other 75% of people?
23:16What's in their cancer
23:18if they don't have targetable mutations,
23:19and what can we do about that?
23:22So I think those two areas are so
23:24critical as well because we
23:27haven't come far enough to
23:28figure out a targeted therapy
23:30strategy for every patient yet.
23:31And I think that both of those
23:34issues are are so critical.
23:36Let's dig into those.
23:38But before we get there,
23:40these targeted therapies are,
23:42for example, in breast cancer we
23:45have targeted therapies as well,
23:46which often are given in
23:48combination with chemotherapy.
23:49But it sounds like these targeted
23:52therapies can be used as sole agents.
23:54Is that right?
23:55That's right. Yes.
23:57There is some research going
24:00on trying to combine them with chemotherapy,
24:02but you're right at this point,
24:04the way we use them is
24:07the targeted therapy alone.
24:08They've been really in almost
24:10every case
24:11there's been trials comparing the targeted
24:13therapy compared to chemotherapy,
24:14and it's superior in all the cases.
24:16Again, when you have the target
24:18and use the targeted therapy,
24:20it's better than using chemotherapy,
24:22and we haven't found a reason to combine it,
24:25although there again,
24:26is some research looking at
24:27if combining it is beneficial.
24:29The standard is to use the
24:31targeted therapy alone.
24:33It's really nice for a logistic point of
24:36view and side effect point of view as well.
24:39Yeah, I mean that's so exciting,
24:42it does kind of sound like if
24:45you've got one of these mutations, you can
24:48take a pill and
24:51have fewer side effects and a better
24:53outcome than being hooked up to chemo.
24:56And you can take your pills on
24:58vacation with you to wherever you're
25:00going to go and live your life.
25:02And it sounds like that is just so
25:05exciting in terms of an advance,
25:07but it does bring us to the
25:10question of what if you're not
25:12in one of those lucky groups that
25:15has a known targetable mutation,
25:17you mentioned immunotherapy.
25:18You know we've talked on this show
25:21about immunotherapy a little bit,
25:23and I'd like to dig into
25:26immunotherapy for lung cancer.
25:28But the one thing that some have
25:31found is that for some cancers,
25:34they actually still will look for
25:36a checkpoint in order to use a
25:39checkpoint inhibitor just to
25:41see what people's PDL1 status is.
25:44But in other cancers,
25:46that isn't necessarily something
25:49that necessarily plays into whether
25:51or not you can use immune therapy.
25:54So how does it work in
25:56lung cancer?
25:59This has been a huge area of research over the last few years
26:01in lung cancer and other cancers.
26:03As you mentioned, in lung cancer,
26:05we have now started using immune therapy,
26:07for I would say almost every
26:09patient with advanced cancer.
26:10Again stage four cancer who does
26:12not have one of those mutations
26:14that we were talking about before.
26:16Again, if you have one of the mutations
26:18targeted therapies are great options,
26:20but otherwise typically immune therapy
26:22is going to be some part of the
26:24treatment because of how effective
26:26it can be and your question about
26:28the PD L1 status in lung cancer
26:30is really important.
26:31So just like we get those mutation tests
26:34and it's so important for patients
26:36to find the best treatment for them.
26:38It's the same with PD L1 status.
26:40So PD L1 is not a mutation or gene
26:43like we were talking about with the
26:45other area in lung cancer treatments.
26:48But it's a protein on the surface
26:50of cells of cancer cells or of
26:52immune system cells.
26:53But in lung cancer,
26:54we look at the cancer cells and
26:56that protein PDL1
26:58can tell us if immune therapy
27:00is more or less likely to work.
27:02So it's not a perfect test by any means.
27:05I've had patients where the
27:07PD L1 status is zero,
27:08which tells you it has a
27:10low chance of working.
27:11However,
27:11they've done incredibly well
27:12with immune therapy,
27:14and sometimes it's high and the
27:16drugs doesn't seem to work,
27:18so it's not a perfect biomarker.
27:19But we do use it as part of
27:21standard treatment in lung cancer,
27:23and so when I meet a new patient
27:25with lung cancer again at Stage 4,
27:27advanced form of lung cancer,
27:28we always will check mutations in PDL1
27:30and the reason really is if someone
27:32has a high level of that PDL1
27:34marker we think we might be able
27:35to get away with just giving immune
27:37therapy just like we were
27:39talking about with targeted therapy,
27:40how it's nice to avoid the
27:42chemotherapy if you can.
27:43It's the same thing with immune
27:44therapy with a high level of PDL1
27:47there's a high chance of the immune
27:48therapy working even on its
27:50own, so we will try that
27:52instead of giving chemotherapy
27:54or other medicines.
27:57And so if you are PDL1 low and
28:00you don't have another targeted
28:02over another targetable mutation,
28:04those patients are more likely to
28:07get chemotherapy, but they'll still
28:09get the immunotherapy as well.
28:15Therapy can work so well we will
28:18typically give it no matter what,
28:21unless there's a contraindication.
28:23If someone has an underlying
28:25autoimmune disorder
28:27but yes, if someone has that low PDL1
28:29status or we don't know PDL1 status
28:31then we don't think and this is based
28:33on several different clinical trials.
28:35We don't think we can get away with
28:37just immune therapy on its own and
28:39it seems to be much more effective
28:41if you combine it with something else
28:43and that something else is a
28:45bit of a question mark in lung cancer.
28:47Until recently it used to be we
28:48would combine it with chemotherapy
28:50so people would get a combination
28:51of chemo and immune therapy.
28:53But more recently now based on
28:55several recent clinical trials,
28:56we're actually combining two
28:57different immune therapies together.
28:58So avoiding chemotherapy,
28:59but combining the immune therapies.
29:01And that's an area of future research
29:03that is currently ongoing.
29:06We have several different
29:07clinical trials at Yale
29:09looking at these different
29:11combinations of immune therapy.
29:12Really trying to get away from the
29:14chemotherapy if we can and using
29:17combinations of immune therapy to
29:18really try to beat the cancer and
29:21really try to improve patients
29:22quality of life and how long they
29:25are able to live.
29:28Doctor Sarah Goldberg is an associate professor of internal
29:30medicine in medical oncology at
29:31the Yale School of Medicine.
29:33If you have questions,
29:35the address is canceranswers@yale.edu
29:36and past editions of the program
29:38are available in audio and written
29:40form at yalecancercenter.org.
29:42We hope you'll join us next week to
29:44learn more about the fight against
29:47cancer here on Connecticut Public Radio.