answered by Dr. Vanesa Gregorc

1. Lung cancer has always been talked about as dominant in males, but is it true that women are the most affected today?

This is unfortunately true. Lung cancer has become the first cause of cancer death in women, surpassing breast cancer. This represents both a major health and social problem. The increase in lung cancer is observed even in relatively young women, which may be explained by the fact that women, like men, start smoking at an increasingly early age (15-18 years old). It is not surprising to diagnose a tumor 25-30 years after exposure to tobacco. Unfortunately, considering that women today conceive at a later age compared to previous generations, this diagnosis ends up becoming a serious family issue as well, involving also young children.

2. Is smoking the main cause of lung cancer?

Yes, smoking is the main cause! Pollution and some toxins found in the environment and some workplaces definitely play a role as well. There are laws and regulations that protect the health of citizens and workers by reducing this risk through monitoring the presence of dust or other harmful particles in the environment. As for smoking, the law protects exposure to passive smoking in closed public places.

I recommend NOT to smoke!

3. Is there a hereditary predisposition in the case of lung cancer?

Unlike other cancers, we cannot say there is a true hereditary predisposition for lung cancer. It is perhaps better to say that for unknown reasons, though probably genetic and of which we know very little, in some families, we are witnessing a greater number of cases of neoplasia, but there is no evidence of inheritance of lung cancer.

4. How is lung cancer diagnosed?

Lung cancer is usually diagnosed with a chest radiograph (X-ray), followed by a chest-abdomen CT, which would show the presence of a suspicious mass. Diagnosis takes place by a biopsy sample of the mass itself. There are two ways to obtain this sample: either through a needle, entering from the outside, puncturing the mass to obtain a fragment of lung tissue, or through a bronchoscopy exam. Bronchoscopy uses a small tube, which passes through our airways (trachea and bronchi), to reach the site of disease and obtain fluid or material to be analyzed under a microscope.

If neoplasm is indeed diagnosed, further investigations must be done in order to assess the possible extension of the disease out of the chest. Based on the symptoms presented by the patient; a scintigraphy may be required to study the bones, a CT scan with contrast to study the brain and an abdominal CT (normally done in conjunction with chest CT) or an abdominal ultrasound to study abdominal structures. A total body PET is another test that is required if the patient should be evaluated for surgery.

5. What are the symptoms of lung cancer?

Unfortunately, lung cancer itself is a sign that the disease is at a generally advanced stage. The main symptoms of lung cancer are cough (not improved with drugs), breathing difficulty (wheezing), weight loss, or pain that lasts a while, often located in the chest but also other body areas. Sometimes, fever or neurological changes may be observed.

6. When lung cancer is at an advanced stage, what organs are most frequently affected?

The organs most frequently affected reflect the patient’s symptoms and are represented by the lung, lymph nodes (glands found in the space between the 2 lungs called the mediastinum), bones, liver, brain and adrenal glands (glands located just above the kidneys).

7. We often hear about biological agents or drugs. What are these and who can use them?

Biological drugs have been one of the greatest successes achieved in lung cancer research in the last 10 years. In addition to histological classification, there is also a molecular classification, which is taking on an increasingly important role in the choice of therapy. The discovery of two genetic alterations: mutations of the epidermal growth factor receptor (EGFR) gene and the chromosomal rearrangement between the EML4 and ALK genes, and the specific drugs built to target them, have changed radically the therapeutic strategy in the subgroup of patients carrying these alterations, significantly prolonging their survival.

EGFR mutations are found in about 10% of patients with non-small cell lung cancer, more frequently in the following categories: females with adenocarcinoma, non-smokers, and Asians. Gefitinib, Erlotinib and Afatinib are three oral drugs that inhibit the aforementioned mutated gene, turning off the switch that is responsible for tumor growth in these patients. Results of several studies comparing the use of these drugs compared to standard chemotherapy showed a clear advantage of the former. All three drugs today represent a valid therapeutic choice and the gold standard for the treatment of lung cancer patients with an EGFR gene mutation. New (and very effective) molecules designed to overcome the tumor’s resistance mechanisms against gefitinib, erlotinib and afatinib are also currently being tested (also in Italy).

The EML4-ALK rearrangement is found in 5-7% of patients with non-small cell lung cancer, especially in non-smokers under the age of 50 with adenocarcinoma. For these patients, the gold standard is Crizotinib, an oral drug and the only ALK inhibitor currently approved in Italy. Research involving this type of disease has also achieved many advances and at least four other drugs are being tested (also in Italian centers). These drugs are all very effective and promising, as they can function when the effectiveness of crizotinib is decreased.

8. What are the side effects of the treatment?

The side effects (drug-induced disorders) mainly depend on the therapy regimen used. Fortunately, today, we have some choices when it comes to which treatment to use, and so the decision regarding the choice of drug should be taken with the patient, considering the effects each drug can cause. Concerning the drugs used in the treatment of lung cancer, the most frequent side effects can be: fatigue, nausea (for 3-4 days), and less frequently vomiting, constipation or slight diarrhea, and blood value alterations. Throughout the treatment, based on the doctor’s advice, blood tests will be required to monitor these values. One of the most difficult side effects to accept is the reversible hair loss (alopecia) caused by some drugs. Side effects do not always happen, and they are almost all reversible, of short duration and can often be prevented pharmacologically.

9. After the end of treatment, how often are checkups?

Frequency of follow-up visits depend on the treatments performed and the extent of the illness. The frequency of these visits varies from a minimum of 3 months to longer periods which can become annual.

10. Is it possible to recover from lung cancer?

Depending on the extent of disease, some cases may be cured, and others may be treated when they are not curable by definition. Each person will respond differently to treatment and achieve different results. Sometimes, the disease is so aggressive that our efforts are not enough. In other cases, the patient is not able to withstand the treatment due to other health problems. I trust the research a lot and can testify that it has made great progress. In 1993-1994 we did not have the certainty that our treatments would help our patients. Today, we are talking about very advanced, increasingly targeted and less toxic treatments. A European census was recently carried out, which I was part of, ranked Italy, specifically with regards to lung tumors, among the world leaders. This recognition was achieved thanks to great efforts, few resources but a lot of strong will.

11. Is it possible that the therapy can ‘wake’ the tumor up?

While I understand your concern, this is just not possible. Therapy cannot facilitate cancer.