Lung Cancer Awareness Month: Q&A with Dr. Rolfo

Dr. Christian Rolfo is Director of Thoracic Medical Oncology and Early Clinical Trials at the University of Maryland Greenebaum Comprehensive Cancer Center (UMGCCC). He specializes in thoracic oncology, drug development and translational oncology. He is also a Professor of Medicine in the Division of Hematology/Oncology at University of Maryland School of Medicine.

What are the signs and symptoms of lung cancer?

The symptoms depend on the location and stage of the disease. Symptoms are not common in the early stages of disease, but when they are present, they include coughing, coughing up blood, shortness of breath, loss of appetite, weakness or being excessively tired. It's important to consult your physician or visit our center for a complete evaluation to exclude this or other diseases.

What are the risk factors for lung cancer, and what steps can people take to reduce their risk?

Tobacco smoking is the No.1 risk factor and is associated with about 80 percent of lung cancers. Current and former smokers both are at increased risk. We need to remind people that tobacco smoke is a mix of a number of toxic substances with the power to cause cancer by themselves. Cigarette smoking is not only responsible for lung cancer, but is an important cause of other tumors, such as bladder and head and neck cancer, among others.

Secondhand smoke is also a risk factor. It is important to note that a large proportion of those exposed to this secondary smoke are children. Unfortunately, 18-25 percent of patients diagnosed with lung cancer have never smoked.

Exposure to radon also increases the risk of lung cancer. The U.S. Environmental Protection Agency estimates about 20,000 cases of lung cancer are related to radon, which is a naturally occurring radioactive gas that can be found in homes, schools and other buildings. Other substances such as asbestos, arsenic and diesel exhaust also present potential risk.

What are the tests and procedures used to diagnose lung cancer?

In order to determine the most effective therapy, we need to diagnose the disease through the analysis of cancer cells and imaging with CT scans or PET/CT scans. We can also analyze a person's sputum (mucus) or take biopsies of the tumor. We can perform a bronchoscopy in which a thin tube is inserted into the air pipes to examine the airways, an image-guided needle biopsy of the tumor, or a mediastinoscopy in which an incision is made at the base of neck to access to the space between the lungs. In addition, your doctor could request additional tests, such as magnetic resonance imaging, or MRI, of the brain to exclude the spread of the disease. In some cases, we can also use liquid biopsies to analyze tumor information in your blood with a simple blood draw, complementing other tests.

Are there different types of lung cancer?

There are two main categories of lung cancer: non-small cell lung cancer and small cell lung cancer. These two categories have different prognoses and therapeutic options.

Is lung cancer difficult to diagnose?

Lung cancer is not difficult to diagnose, but it is important to get the diagnosis quickly in order to determine the best treatment options. Nowadays, we have an important number of techniques, and the multidisciplinary expertise of a center like UMGCCC is crucial. Prevention is key, and it's important that heavy smokers or people with other risk factors have regular low-dose CT scans of the chest to screen for lung cancer.

How do you typically treat lung cancer? What are some of the new treatments?

Treatment depends on the type of lung cancer, the stage of the cancer and the health condition of individual patients. Surgery plays an important role, mainly when the disease is confined to the chest. Other techniques, such as radiation therapy or chemotherapy drugs, given intravenously or taken by mouth, are commonly used to treat this disease, often in combination. We now have new targeted therapies and immunotherapies, such as pembrolizumab (Keytruda) and nivolumab (Opdivo), among others, which have been shown to be effective in treating types of non-small cell lung cancer. With the current treatments, we are able to obtain impressive results, including curing a significant proportion of early-stage cancers and better controlling more advanced disease.

What percentage of patients diagnosed with lung cancer have never smoked?

An estimated 18-25 percent of our patients are never smokers. For this reason, it's very important to avoid the stigma of lung cancer, which is often viewed as a self-inflicted disease caused by smoking.

Do non-smokers develop a different type of lung cancer than smokers?

There are differences in the epidemiological, clinical and molecular characteristics of lung cancers arising in never smokers compared with the one in smokers, suggesting that they are separate entities.

What are some of the exciting new areas of research in regard to lung cancer?

There are several new areas of research. The lung cancer treatment landscape has changed dramatically in the last few years, with new techniques in surgery and radiotherapy (including proton therapy), the inclusion of targeted therapies against different genetic aberrations in the tumor and the use of immunotherapy compounds as first-line treatment for certain lung cancers. These new therapeutic options are increasing the opportunities to control this disease. At UMGCCC, we have an active research program, from studies in the lab to clinical trials for patients, with our experts from multiple disciplines working together to come up with new therapies. This is a very exciting time for lung cancer research, and we are getting long-awaited results in a very short period of time.

What should people to know about lung cancer?

I think it's important to give some key messages:

• Lung cancer prevention is very important. Screening programs like the one we have in our center are saving lives.
• Smoking cessation is crucial.
• We need to avoid the stigma of lung cancer and tobacco because some of our patients have never smoked.
• New therapeutic options are bringing much-needed hope to people diagnosed with this disease.
• We need to invest more in research in this field.
• For many, lung cancer is a very treatable disease, especially if it is diagnosed early. Specialized care by a multidisciplinary team of lung cancer experts can help improve outcomes for patients.