Stereotactic Radiosurgery for Lung Cancer

Transcript

00:00 --> 00:03Funding for Yale Cancer Answers is
00:03 --> 00:06provided by Smilow Cancer Hospital.
00:06 --> 00:08Welcome to Yale Cancer Answers
00:08 --> 00:10with Doctor Anees Chagpar.
00:10 --> 00:11Yale Cancer Answers features
00:11 --> 00:13the latest information on cancer
00:13 --> 00:15care by welcoming oncologists and
00:15 --> 00:17specialists who are on the forefront
00:17 --> 00:19of the battle to fight cancer.
00:19 --> 00:21This week it's a conversation about
00:21 --> 00:23stereotactic radiosurgery for lung
00:23 --> 00:25cancer with doctor Nadine Housri.
00:25 --> 00:27Dr. Housri is an associate professor
00:27 --> 00:29of therapeutic radiology at
00:29 --> 00:30the Yale School of Medicine,
00:30 --> 00:32where Doctor Chagpar is a
00:32 --> 00:33professor of surgical oncology.
00:35 --> 00:36So, Nadine, maybe we can start off
00:36 --> 00:38by you telling us a little bit more
00:38 --> 00:40about yourself and what it is you do.
00:40 --> 00:44Sure. So I am a radiation oncologist,
00:44 --> 00:47which is a physician who treats
00:47 --> 00:49cancer patients with radiation.
00:49 --> 00:52Typically along the cancer journey,
00:52 --> 00:55a patient will see a medical oncologist
00:55 --> 00:58who treats with medications such
00:58 --> 01:01as chemotherapy or immunotherapy,
01:01 --> 01:03a surgeon who operates and
01:03 --> 01:06surgically removes tumors and a
01:06 --> 01:08radiation oncologist who uses ionizing
01:08 --> 01:11radiation like Xrays to treat cancer.
01:13 --> 01:15And your specialty is in lung cancer,
01:15 --> 01:17is that right?
01:17 --> 01:19Maybe you can lay out a bit for
01:19 --> 01:22us the landscape of lung cancer.
01:22 --> 01:24How are lung cancers most
01:24 --> 01:25frequently managed and when
01:25 --> 01:27do patients get to see you?
01:27 --> 01:28So it all depends
01:28 --> 01:32on the stage. Patients typically present
01:32 --> 01:35with stage one to four lung cancer,
01:35 --> 01:38one being lung cancer that is only
01:38 --> 01:41in the lung and four being lung
01:41 --> 01:43cancer that has spread elsewhere
01:43 --> 01:45outside of the lung and lymph nodes.
01:45 --> 01:48There's a role for radiation for
01:48 --> 01:51patients along any of these stages.
01:51 --> 01:53For the most advanced lung cancer,
01:53 --> 01:55typically my role is to help palliate
01:55 --> 01:57symptoms and make patients more comfortable
01:57 --> 02:00and have a good quality of life and
02:00 --> 02:03radiation is excellent in this regard.
02:03 --> 02:06For very early stage lung cancer patients,
02:06 --> 02:08radiation is curative.
02:08 --> 02:11We often treat with stereotactic radiation
02:11 --> 02:14therapy to treat early stage lung cancer
02:14 --> 02:17and in the middle among the patients who
02:17 --> 02:19have stage two or stage 3 lung cancer
02:19 --> 02:21we work very closely with
02:21 --> 02:23medical oncologists and
02:23 --> 02:27surgeons to do a combination of surgery,
02:27 --> 02:27chemotherapy,
02:27 --> 02:29immunotherapy to treat these
02:29 --> 02:30patients as well.
02:30 --> 02:33So patients may see me with
02:33 --> 02:34any type of lung cancer.
02:37 --> 02:39And you mentioned stereotactic
02:39 --> 02:42radiosurgery for early stage lung cancer.
02:42 --> 02:44Can you help our audience to understand
02:44 --> 02:46what exactly is a stereotactic
02:46 --> 02:49radiosurgery and how does it work?
02:49 --> 02:52Sure. A very long time ago,
02:52 --> 02:55you know 20 plus years ago when
02:55 --> 02:57patients had early stage lung cancer
02:57 --> 02:59and we're not surgical candidates
02:59 --> 03:01for some reason that they couldn't
03:01 --> 03:03have a lobectomy or they couldn't
03:03 --> 03:04have the tumor removed surgically,
03:04 --> 03:06there really weren't very
03:06 --> 03:08many options for them.
03:08 --> 03:11One of the alternatives was radiation,
03:11 --> 03:14but it didn't work to
03:14 --> 03:17really control the tumor longterm.
03:17 --> 03:18Over the past 20 years or so,
03:18 --> 03:20this newer technology called
03:20 --> 03:22stereotactic radiation therapy
03:22 --> 03:25has been developed to deliver very
03:25 --> 03:27high doses of radiation that are,
03:28 --> 03:29we would say,
03:29 --> 03:31ablative or curative and it can
03:31 --> 03:34actually kill cancer cells
03:34 --> 03:35and deliver excellent local control
03:35 --> 03:38and actually cure patients who
03:38 --> 03:40cannot otherwise undergo surgery.
03:40 --> 03:41In other situations,
03:41 --> 03:43for one reason or another,
03:43 --> 03:46a patient chooses not to undergo
03:46 --> 03:49surgery and chooses to undergo
03:49 --> 03:51radiation therapy and there's
03:51 --> 03:53a role for stereotactic radiotherapy
03:53 --> 03:54for those patients as well.
03:55 --> 03:58So can you tell us kind of the
03:58 --> 04:01pluses and minuses of choosing to
04:01 --> 04:04have radiation as opposed to surgery
04:04 --> 04:06for these early stage cancers?
04:06 --> 04:08Sure. So one thing
04:08 --> 04:10that's important to note is that at
04:10 --> 04:12Yale we work very closely together.
04:12 --> 04:16I'm constantly speaking to
04:16 --> 04:18the surgeons, the thoracic surgeons
04:18 --> 04:20who oftentimes are seeing these
04:20 --> 04:22patients with early stage disease first.
04:22 --> 04:25And so these conversations are
04:26 --> 04:28discussions with myself,
04:28 --> 04:31the surgeon, the patient, perhaps the
04:31 --> 04:34medical oncologist and
04:34 --> 04:35they're not made overnight.
04:37 --> 04:39And at the end of the day,
04:39 --> 04:41often times it is the patient who
04:43 --> 04:44is the captain of the ship.
04:45 --> 04:45And at the end of the day,
04:45 --> 04:47they're the ones who are making decisions
04:47 --> 04:50that they feel are best for the.
04:50 --> 04:53IN terms of benefits, I would
04:53 --> 04:56say the first thing is for patients,
04:57 --> 04:59many people who develop lung
04:59 --> 05:03cancer have other medical issues,
05:03 --> 05:06especially if they have a history of smoking.
05:06 --> 05:08And so there's always a risk
05:08 --> 05:10to undergoing anesthesia.
05:10 --> 05:12There's always risk to perhaps a
05:12 --> 05:15worsening of their pulmonary function,
05:15 --> 05:17their breathing function
05:17 --> 05:20following surgery if they're not in
05:20 --> 05:22the best of shape to begin with.
05:22 --> 05:24And in these situations I very strongly
05:24 --> 05:26advocate for
05:26 --> 05:29radiation therapy as opposed to surgery.
05:29 --> 05:32The first thing to understand is that
05:32 --> 05:35it's not invasive radiation it is xrays.
05:35 --> 05:39So just like when you get a chest X-ray,
05:41 --> 05:42you don't
05:42 --> 05:43see anything, smell anything,
05:43 --> 05:43feel anything.
05:43 --> 05:45You just hear a machine buzz and you're done.
05:46 --> 05:47You walk out and you don't really
05:47 --> 05:48feel anything.
05:48 --> 05:50It's very similar to what it
05:50 --> 05:53feels like to undergo radiation therapy.
05:53 --> 05:55It's also delivered in a small
05:55 --> 05:56number of treatments,
05:56 --> 05:59anywhere from 3 to 5 to 8 treatments.
05:59 --> 06:01So within a week and a half or so
06:04 --> 06:06your entire treatment is done.
06:06 --> 06:08It is not much of a hassle to your life.
06:08 --> 06:10You're doing all the things
06:10 --> 06:12that you love and there's no real
06:12 --> 06:14restrictions and patients don't
06:14 --> 06:17have side effects during this treatment.
06:17 --> 06:19And so it's not invasive.
06:21 --> 06:23I never say anything's easy to go
06:23 --> 06:24through, especially cancer treatment,
06:24 --> 06:26but if I were to say something
06:26 --> 06:28is easy it would be stereotactic
06:28 --> 06:31radiation therapy or SBRT and then
06:31 --> 06:33following this treatment
06:33 --> 06:35side effects are not very common.
06:35 --> 06:3780% of patients will not have
06:37 --> 06:38any side effects.
06:38 --> 06:40There's always those risks
06:40 --> 06:42of someone developing something
06:42 --> 06:43called radiation pneumonitis,
06:43 --> 06:46which is inflammation of the lung which
06:46 --> 06:48is treatable and that's small,
06:48 --> 06:49it's less than 15%.
06:49 --> 06:51There's always risk that the tumor is
06:51 --> 06:54very close to the ribs or the chest
06:54 --> 06:56wall that someone could develop a rib
06:56 --> 06:57fracture which will heal on its own.
06:57 --> 07:00But otherwise patients do incredibly well
07:00 --> 07:03with stereotactic radiation therapy.
07:03 --> 07:07In terms of you know why I
07:07 --> 07:08really recommend patients who
07:08 --> 07:10are young, who are healthy and
07:10 --> 07:11will do very well with surgery.
07:11 --> 07:14I do recommend that they still go on and
07:14 --> 07:16talk to the thoracic surgeon
07:16 --> 07:20and very strongly consider surgery.
07:20 --> 07:22You know, it's been the standard of care
07:22 --> 07:25for a very long time and we've never
07:25 --> 07:27really compared radiation and surgery
07:27 --> 07:30in a head to head randomized trial,
07:30 --> 07:33especially in patients who are
07:33 --> 07:36very healthy and can undergo either option.
07:36 --> 07:38And so especially in younger patients,
07:38 --> 07:41people who are in their 50s or 60s,
07:41 --> 07:44we do often times really advocate for
07:44 --> 07:47surgery if they can undergo surgery.
07:48 --> 07:49One of the great things about surgery
07:49 --> 07:51is when you take out a lobe of the lung,
07:51 --> 07:53there's no chance of the cancer
07:53 --> 07:55coming back in that lobe because it's gone.
07:55 --> 07:56Whereas with radiation,
07:56 --> 07:58it's incredibly unlikely the tumor will
07:58 --> 08:01come back where we delivered the radiation,
08:01 --> 08:02but it could pop up in a different
08:02 --> 08:03part of the lobe.
08:04 --> 08:07So why is it that there hasn't been
08:07 --> 08:09a randomized control trial comparing
08:09 --> 08:12stereotactic radiotherapy to surgery?
08:12 --> 08:14Because the way you paint the picture,
08:14 --> 08:16it sounds like, you know,
08:16 --> 08:18for most people they're looking at
08:18 --> 08:20this saying, well, geez, you know,
08:20 --> 08:23if these two are truly equivalent in
08:23 --> 08:26terms of outcomes and there's next to no
08:26 --> 08:28side effects with the radiation therapy,
08:28 --> 08:30I won't feel anything.
08:30 --> 08:34I won't have a big cut or even a little cut.
08:34 --> 08:36I won't need to be in hospital.
08:36 --> 08:38I won't need to take too much
08:38 --> 08:39time off of work.
08:39 --> 08:42Presumably we can fit these treatments
08:42 --> 08:44in between my work schedule.
08:44 --> 08:46Why wouldn't I do radiation therapy
08:46 --> 08:49even if I am young and healthy?
08:49 --> 08:51Yeah, that's a great question and
08:51 --> 08:53I think somewhat you answered it.
08:53 --> 08:55People all have a bias and
08:55 --> 08:57that's what makes it difficult to
08:57 --> 08:59enroll patients to randomized studies.
08:59 --> 09:00Even if I can say, hey,
09:00 --> 09:02I don't really know if one is
09:02 --> 09:04better than the other or if they're
09:04 --> 09:07equal and we will randomize you and
09:07 --> 09:08you would either undergo surgery
09:08 --> 09:11or undergo radiation therapy,
09:11 --> 09:13many people have a very strong
09:13 --> 09:15preference for one or the other.
09:15 --> 09:16And in addition,
09:16 --> 09:19physicians often have a strong preference.
09:19 --> 09:21I think that we often
09:21 --> 09:22say the surgeons want to
09:22 --> 09:24operate and the radiation oncologist wants
09:24 --> 09:26to give radiation and so
09:26 --> 09:28for those two reasons it has been
09:28 --> 09:30difficult to actually enroll patients.
09:30 --> 09:31The trials have been developed,
09:31 --> 09:33the trials have opened and the
09:33 --> 09:34real issue has been enrolling
09:34 --> 09:36patients to the clinical trials.
09:38 --> 09:40That all being said,
09:40 --> 09:43I will say having
09:43 --> 09:45worked in many places,
09:45 --> 09:48a number of places, Yale
09:48 --> 09:50being the one I've been at the longest.
09:50 --> 09:54Our team really has a very cooperative
09:54 --> 09:57and very measured approach.
09:57 --> 09:59You know I think everybody has
09:59 --> 10:01biases but if you look for
10:01 --> 10:03a place where the surgeons are skilled,
10:05 --> 10:06and the radiation
10:06 --> 10:08oncologists are skilled
10:08 --> 10:10and try to be really fair in the
10:10 --> 10:12recommendations, I do think
10:12 --> 10:14that this is a great place for that.
10:14 --> 10:16But unfortunately we don't
10:16 --> 10:17have that randomized data.
10:18 --> 10:22So you know this, this goes to
10:22 --> 10:25the point of why everyone should
10:25 --> 10:27enroll patients and patients should
10:27 --> 10:30enroll in clinical trials because
10:30 --> 10:33otherwise we are in a data free zone.
10:33 --> 10:35We don't have the information
10:35 --> 10:38as to whether there is truly a difference
10:38 --> 10:40in terms of outcomes for these two.
10:40 --> 10:43But if we look at the data that we do have,
10:43 --> 10:47so presumably there are some longterm
10:47 --> 10:50data on Stereotactic radiotherapy
10:50 --> 10:53versus longterm data on surgery.
10:53 --> 10:55If we look at cohort studies,
10:55 --> 10:58do the outcomes appear to be the same
10:58 --> 11:00or is one slightly inferior to the other?
11:00 --> 11:04I mean does that play in to this
11:04 --> 11:05decision making particularly
11:05 --> 11:07for young healthy patients?
11:07 --> 11:10Yeah, exactly. So I did a lot of the data and
11:10 --> 11:12the retrospective data does appear
11:12 --> 11:15to say probably they are very
11:15 --> 11:17similar to each other in patients
11:17 --> 11:20who don't have medical comorbidities.
11:20 --> 11:23The data is more in favor
11:23 --> 11:25of surgery in that cohort.
11:25 --> 11:29In patients who do have more medical issues,
11:29 --> 11:31the data shows either a
11:31 --> 11:33little more equivalence or
11:33 --> 11:35more towards radiation therapy.
11:35 --> 11:37So that's why I'm saying someone's
11:37 --> 11:40very young, they're very healthy,
11:40 --> 11:42my preference, my bias, you know,
11:42 --> 11:44is they undergo surgery,
11:44 --> 11:46but many people are not.
11:46 --> 11:48Many of our patients have emphysema,
11:48 --> 11:51they have COPD, they have a smoking history,
11:51 --> 11:54you know, high blood pressure, diabetes,
11:54 --> 11:55you know, in those kinds of situations,
11:55 --> 11:56I think that we should very,
11:56 --> 11:58very strongly consider radiation therapy.
12:00 --> 12:04And so one of the other issues that you kind
12:04 --> 12:09of raised about radiation therapy is that
12:09 --> 12:13while tumors may recur anywhere, I mean,
12:13 --> 12:16whether you've had surgery or radiation,
12:16 --> 12:19they won't recur where the
12:19 --> 12:21radiation treatment was delivered.
12:21 --> 12:24Whereas if somebody removes an entire lobe,
12:24 --> 12:26it certainly won't recur in that lobe.
12:26 --> 12:27It may recur in other lobes,
12:27 --> 12:30but not in that lobe or the lymph nodes.
12:30 --> 12:34Yeah, and the same would be for
12:34 --> 12:36radiation therapy as well.
12:36 --> 12:39Can you talk a little bit about some of
12:39 --> 12:41the multidisciplinary efforts that go
12:41 --> 12:44on to ensure that the rest of the lung,
12:44 --> 12:47the lymph nodes, etcetera,
12:47 --> 12:49that we reduce the risk of recurrence
12:49 --> 12:50in those areas?
12:50 --> 12:52I mean, is it kind of you have your
12:52 --> 12:54surgery and your radiation therapy
12:54 --> 12:56and then you're done and then we
12:56 --> 12:58just monitor you or do patients
12:58 --> 12:59have other kinds of treatments?
12:59 --> 13:01Can you talk a little bit about that?
13:02 --> 13:04Sure. And I also just want to take a
13:04 --> 13:06moment and remind listeners that we are
13:06 --> 13:07talking about early stage lung cancers,
13:07 --> 13:09often stage 1 or sometimes
13:09 --> 13:11stage two lung cancer.
13:12 --> 13:15All of these conversations are not
13:15 --> 13:17about stage 3 or stage 4 lung cancer.
13:17 --> 13:21That's a very different treatment paradigm. NOTE Confidence: 0.9421368
13:24 --> 13:27So one of the things that's incredibly
13:27 --> 13:30important is that we do a thorough work
13:30 --> 13:32up before we even consider the options.
13:32 --> 13:35And that means that we're doing a
13:35 --> 13:37biopsy on the primary tumor
13:37 --> 13:39that we are checking the lymph nodes
13:39 --> 13:41in the middle of the chest with either
13:41 --> 13:43an endobronchial ultrasound procedure
13:43 --> 13:47which is done by a pulmonologist
13:47 --> 13:49or a mini signoscopy which is done
13:49 --> 13:51by a thoracic surgeon and of
13:51 --> 13:53course doing a PET scan as well.
13:53 --> 13:54These are all incredibly important
13:54 --> 13:57before we even move forward and consider
13:57 --> 13:59surgery and radiation as options.
13:59 --> 14:02I think it's always better for
14:02 --> 14:04the patients that we have all of the
14:04 --> 14:05information because then we're making
14:05 --> 14:07the best decisions based on that.
14:08 --> 14:11So we're going to pick up this
14:11 --> 14:13conversation right after we take a
14:13 --> 14:15short break for a medical minute,
14:15 --> 14:17but please stay tuned to learn more
14:17 --> 14:18about stereotactic radio surgery,
14:18 --> 14:21and the overall treatment of
14:21 --> 14:23lung cancer with my guest,
14:23 --> 14:24Doctor Nadine Housri.
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14:37 --> 14:40Find a Smilow location near you
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15:38 --> 15:41You're listening to Connecticut Public Radio.
15:41 --> 15:42Welcome
15:42 --> 15:43back to Yale Cancer Answers.
15:43 --> 15:45This is Doctor Anees Chagpar,
15:45 --> 15:47and I'm joined tonight by my guest,
15:47 --> 15:49Doctor Nadine Housri.
15:49 --> 15:50We're talking about stereotactic
15:50 --> 15:53radiosurgery for lung cancer.
15:53 --> 15:55And Nadine, during the break,
15:55 --> 15:56you made a good point,
15:56 --> 15:58which is that there are many synonyms
15:58 --> 16:00for stereotactic radiosurgery.
16:00 --> 16:03Do you want to kind of walk our audience
16:03 --> 16:05through all of the terminology?
16:05 --> 16:07So you you might hear different terminology.
16:07 --> 16:10So stereotactic radiosurgery was a term
16:10 --> 16:12initially developed
16:12 --> 16:15very similar to the type of treatment
16:18 --> 16:20that we started doing in the brain for brain
16:20 --> 16:22metastases many years ago and
16:22 --> 16:25going back to like the 60s and 70s and
16:25 --> 16:27we've adopted that terminology
16:27 --> 16:29for what we do in the lung.
16:29 --> 16:31Another term we often use and I
16:31 --> 16:33used was stereotactic radiotherapy
16:33 --> 16:36or stereotactic radiation therapy
16:36 --> 16:39and then one I didn't use but often
16:39 --> 16:41comes up is stereotactic
16:41 --> 16:43ablative radiation therapy and
16:43 --> 16:45these all mean the same things.
16:45 --> 16:49This is all very high doses of radiation
16:49 --> 16:52delivered to a very small area.
16:52 --> 16:54And the reason we were able to
16:54 --> 16:56transition from doing this only in
16:56 --> 16:58the brain so many years ago to now
16:58 --> 17:00doing it all over the body is because of technology.
17:02 --> 17:05Our technology has improved so much in
17:05 --> 17:08how we can deliver radiation therapy
17:08 --> 17:10where we can be incredibly meticulous
17:10 --> 17:13in targeting the radiation in a
17:13 --> 17:16very specific area, we can visualize
17:16 --> 17:19with every single treatment and
17:19 --> 17:22really maximize the dose of radiation
17:22 --> 17:25to that tumor and minimize the dose
17:25 --> 17:27to the things that are not tumor,
17:27 --> 17:29your lungs, your esophagus,
17:29 --> 17:31your spinal cord, your chest wall.
17:31 --> 17:32And that's why
17:32 --> 17:35I mentioned that patients do so well
17:35 --> 17:37with this treatment because of that
17:37 --> 17:39and we're delivering a very high
17:39 --> 17:41dose to the tumor and minimizing the
17:41 --> 17:43dose to what we call normal organs.
17:44 --> 17:46Yeah. And I want to pick up on
17:46 --> 17:48that topic because right before the
17:48 --> 17:50break we were talking about one of
17:50 --> 17:52the differences between stereotactic
17:52 --> 17:56radiotherapy versus surgery being that
17:56 --> 17:58you know in surgery if somebody
17:58 --> 18:01takes out a lobe of the lung then
18:01 --> 18:03cancer can't come back in that lobe.
18:03 --> 18:06But in stereotactic radiotherapy, as you say,
18:06 --> 18:09it's very localized to that tumor.
18:09 --> 18:11So of course cancers can come back
18:11 --> 18:13to the rest of the lung because the
18:13 --> 18:15rest of that lobe is still there.
18:15 --> 18:17But on the other hand,
18:17 --> 18:19patients don't have the deficit
18:19 --> 18:22in lung function that they would
18:22 --> 18:23have by losing a lobe.
18:23 --> 18:26So a couple of questions on that.
18:26 --> 18:29First, how many patients have a
18:29 --> 18:32recurrence and these are early stage
18:32 --> 18:34patients that we were talking about
18:34 --> 18:38when you ablate a tumor in a lung,
18:38 --> 18:40how many patients will have a
18:40 --> 18:42recurrence come back in that
18:42 --> 18:47same lobe versus not?
18:47 --> 18:50So in terms of the recurrence in the
18:50 --> 18:53site that we treated that's less than
18:53 --> 18:555 or 10%, that is incredibly rare.
18:55 --> 18:59In the past, let me think,
18:59 --> 19:01six years since I've been back
19:01 --> 19:05at Yale I've only seen that maybe one
19:05 --> 19:08or two times and
19:08 --> 19:11this is all I do is lung cancer.
19:11 --> 19:13radiotherapy and what time it wasn't lung
19:18 --> 19:21So that's incredibly rare for it
19:21 --> 19:24to come back either in that lobe,
19:24 --> 19:26in another lobe in the lung or in the
19:26 --> 19:28lymph nodes in the middle of the chest,
19:28 --> 19:31that is closer to probably about 25
19:31 --> 19:36to 30% and
19:38 --> 19:40very meticulously after we do
19:40 --> 19:44SBRT or stereotactic radiotherapy,
19:44 --> 19:46we follow patients very,
19:46 --> 19:46very closely.
19:46 --> 19:49So we're getting a CAT scan every three
19:49 --> 19:51to four months after your treatment
19:51 --> 19:54for the first year and up until five
19:54 --> 19:56years we're getting them
19:56 --> 19:58about every four to six months
19:58 --> 20:01generally once patients get to five years
20:02 --> 20:04they don't tend to occur as
20:04 --> 20:07commonly and I'll usually get
20:07 --> 20:10a CT every year at that point.
20:10 --> 20:13So if something were to pop up,
20:13 --> 20:17we find it very quickly and
20:17 --> 20:18often times it's treatable if you
20:18 --> 20:20have another lesion pop up in that
20:20 --> 20:23lobe or in another lung.
20:23 --> 20:26I've treated many patients
20:26 --> 20:29with stereotactic radiosurgery
20:29 --> 20:32multiple times for either new primary,
20:32 --> 20:36oftentimes it's a new primary lung cancer
20:36 --> 20:38or recurrence in the lung.
20:38 --> 20:40If I can't do radiation therapy often
20:40 --> 20:43we still do have options whether that's
20:43 --> 20:45surgical resection, not removing the
20:45 --> 20:46whole lobe because often patients
20:48 --> 20:50were not able to tolerate that to begin with.
20:50 --> 20:52But just taking out the tumor or
20:52 --> 20:54we have also options with our
20:54 --> 20:55interventional radiologist who can
20:55 --> 20:57do ablation if we were to
20:57 --> 20:59find some an additional tumor
20:59 --> 21:01and for some reason I can't give
21:01 --> 21:03stereotactic radiation therapy again.
21:04 --> 21:07So that's an interesting concept, right.
21:07 --> 21:12There are interventional
21:12 --> 21:15radiologists who can ablate tumors also
21:15 --> 21:18targeted just directly to the tumor
21:18 --> 21:20itself and surgeons can potentially,
21:20 --> 21:23depending on where of course the tumor
21:23 --> 21:26is in the lung, not take out the whole
21:26 --> 21:28lung but take out or or the whole lobe
21:28 --> 21:31even but just take out that portion.
21:31 --> 21:34So we went through
21:34 --> 21:37some of the comparison contrast
21:37 --> 21:39between surgery for a lobectomy,
21:39 --> 21:42but can you talk a little bit about
21:42 --> 21:44some of the ablative techniques that
21:44 --> 21:46the interventional radiologists use
21:46 --> 21:48and why stereotactic radiation therapy
21:48 --> 21:52is used as first line versus some
21:52 --> 21:54of these other ablative techniques?
21:55 --> 21:57Absolutely. So feasibly if techniques
21:57 --> 22:01are pretty good often times
22:01 --> 22:04the local control is 70 to 80%
22:04 --> 22:07which means the tumor
22:07 --> 22:10only comes back in that area that
22:10 --> 22:13was treated maybe 20-30% of the time.
22:13 --> 22:16So 78% of the time
22:16 --> 22:17it won't come back.
22:17 --> 22:19That being said with
22:19 --> 22:21external beam radiation therapy
22:21 --> 22:23which we've been talking about,
22:23 --> 22:26that risk is less than 10%.
22:26 --> 22:30So the reason that we tend to do
22:30 --> 22:32the stereotactic radiation therapy as
22:32 --> 22:35opposed to an ablation with an
22:35 --> 22:36interventional radiology techniques
22:36 --> 22:39is because we know that
22:39 --> 22:41the local control is much better.
22:41 --> 22:43But there sometimes
22:43 --> 22:46reasons why we not might not
22:46 --> 22:48be able to do the stereotactic
22:48 --> 22:50radiation therapy and I think that
22:50 --> 22:54doing an ablation is a very good
22:54 --> 22:56alternative in those situations. NOTE Confidence: 0.931678308
23:01 --> 23:03So maybe there was a new tumor that's very close
23:03 --> 23:05to the previous treatment fields.
23:05 --> 23:07And then we're worried about the
23:07 --> 23:09chest wall or we're worried about
23:11 --> 23:13your breathing tubes or the assault,
23:16 --> 23:19etcetera.
23:19 --> 23:22For the most part it sounds like
23:22 --> 23:24if you can use stereotactic radiation
23:24 --> 23:27that would be your preference.
23:27 --> 23:28But if you can't, there are other
23:28 --> 23:30tools in the toolbox. Is that right?
23:31 --> 23:32Yeah. And the nice thing
23:32 --> 23:33about a place like Yale, and I
23:33 --> 23:35don't want to be too promotional,
23:35 --> 23:37but I really love working here
23:37 --> 23:38is that
23:38 --> 23:40we all work together.
23:42 --> 23:45We're all discussing all of
23:45 --> 23:48these cases and we can
23:48 --> 23:50get patients in fairly quickly in a
23:52 --> 23:54very short period of time.
23:54 --> 23:55And the conversation will
23:55 --> 23:56have been a multidisciplinary
23:56 --> 23:58one where we're all really
23:58 --> 24:00focused on what's best for the patient.
24:01 --> 24:04We've been talking a
24:04 --> 24:07lot about early stage lung cancer,
24:07 --> 24:09but as you kind of alluded
24:09 --> 24:11to during our conversation,
24:11 --> 24:15there are some roles for stereotactic
24:15 --> 24:18radiation therapy for later stage disease.
24:18 --> 24:22And you had mentioned that really
24:22 --> 24:24the genesis of much of these
24:24 --> 24:27techniques was in treating metastases
24:27 --> 24:29and particularly brain metastases.
24:29 --> 24:32Can you tell us a little bit more
24:32 --> 24:34about other potential uses of
24:34 --> 24:36stereotactic radiation therapy?
24:36 --> 24:38Sure, in patients who have
24:38 --> 24:40stage 4 lung cancer, and this
24:40 --> 24:42means that the cancer has now
24:42 --> 24:44spread outside of the lungs and
24:44 --> 24:45the lymph nodes in the chest,
24:45 --> 24:48so it could be the
24:48 --> 24:50bone or the liver
24:50 --> 24:52or the brain or
24:52 --> 24:53somewhere outside of the lung.
24:58 --> 25:00And patients are not all the same.
25:00 --> 25:01So many years ago stage
25:01 --> 25:044 was just stage 4 cancer, it has spread.
25:04 --> 25:06And and this is the treatment
25:06 --> 25:08we recommend for you. What we have found is
25:08 --> 25:11actually not all stage 4 is created equal.
25:11 --> 25:14There's patients who have
25:14 --> 25:16widespread disease that's gone
25:16 --> 25:18to multiple organs that's causing
25:18 --> 25:23a lot of problems and maybe
25:25 --> 25:26There's patients who have,
25:26 --> 25:28we say a legal metastatic disease.
25:28 --> 25:29They've got one spot,
25:29 --> 25:32in the rib where cancer is,
25:32 --> 25:35one spot in the brain or
25:35 --> 25:38a few spots.
25:38 --> 25:41We also say low volume disease in
25:41 --> 25:44those situations and the standard
25:44 --> 25:47treatment has been and remains
25:50 --> 25:52systemic therapy.
25:54 --> 25:56Chemotherapy, a targeted therapy,
25:56 --> 25:58maybe immunotherapy
25:58 --> 26:00that's still the main treatment.
26:00 --> 26:01It's incredibly important,
26:02 --> 26:03but there is a role for
26:03 --> 26:06radiation therapy and perhaps targeting
26:06 --> 26:08these metastatic regions.
26:10 --> 26:12If the tumor spreads to just a few spots,
26:12 --> 26:14we can actually go and do this
26:14 --> 26:16high dose ablative treatment with
26:16 --> 26:19with very few side effects to get
26:19 --> 26:21these other areas under control.
26:21 --> 26:23And then the systemic therapy,
26:23 --> 26:25whether it's chemo or
26:25 --> 26:27immunotherapy or a targeted drug or
26:27 --> 26:29a combination of any of these,
26:29 --> 26:30that's going to be that main treatment
26:30 --> 26:32that's going to go everywhere in the body.
26:32 --> 26:36So it's going to go after microscopic
26:36 --> 26:40cells and in addition to
26:40 --> 26:42these areas where it's spread.
26:42 --> 26:44And so in those situations we
26:44 --> 26:46work very closely with the medical
26:46 --> 26:48oncologist to determine
26:48 --> 26:50if we're going to give radiation,
26:50 --> 26:51when it's going to happen,
26:55 --> 26:56how to sequence it
26:56 --> 26:58with the
26:58 --> 27:00systemic therapy etcetera,
27:00 --> 27:01who are the appropriate
27:01 --> 27:03patients to get
27:03 --> 27:04the stereotactic radiation in
27:04 --> 27:06addition to their systemic therapy.
27:07 --> 27:09Can you talk a little bit
27:09 --> 27:12about kind of the interaction
27:12 --> 27:14between some of the medications,
27:14 --> 27:15the chemotherapies,
27:15 --> 27:17the targeted therapies,
27:17 --> 27:19immunotherapy and radiation?
27:19 --> 27:22For example, do some drugs make
27:22 --> 27:24the radiation work better?
27:24 --> 27:27Do some drugs make the toxicities
27:27 --> 27:30of radiation worse and how do
27:30 --> 27:32you kind of navigate that?
27:32 --> 27:35That's a great question.
27:35 --> 27:37It's a very complicated answer.
27:37 --> 27:40So I would start by saying we're
27:40 --> 27:43still learning a lot about this area.
27:43 --> 27:45If you just look at immunotherapy,
27:45 --> 27:47which many people have heard
27:47 --> 27:49about is this huge
27:49 --> 27:51breakthrough in cancer treatment that's
27:51 --> 27:53really been only been around since
27:53 --> 27:572014 or or approved since 2014, 2015.
27:57 --> 28:01We often are finding that radiation therapy
28:01 --> 28:04and immunotherapy complement each other
28:04 --> 28:07very well where sometimes
28:07 --> 28:09you'll give immunotherapy and the
28:09 --> 28:10radiation therapy works better or
28:10 --> 28:12you give the radiation therapy and
28:12 --> 28:13the immunotherapy works better.
28:13 --> 28:14And again,
28:14 --> 28:17this is still a very active area of research,
28:17 --> 28:19but we know that immunotherapy and
28:19 --> 28:22chemotherapy as well oftentimes will
28:22 --> 28:24make radiation work better on the tumor.
28:24 --> 28:25But again, like you mentioned,
28:25 --> 28:26it might also make side
28:26 --> 28:27effects of treatment worse.
28:27 --> 28:29So we just have to be very
28:29 --> 28:30careful with how we select,
28:30 --> 28:32how we sequence the treatments.
28:32 --> 28:35Dr. Nadine Housri is an associate
28:35 --> 28:37professor of therapeutic radiology
28:37 --> 28:39at the Yale School of Medicine.
28:39 --> 28:41If you have questions,
28:41 --> 28:43the address is canceranswers@yale.edu,
28:43 --> 28:45and past editions of the program
28:45 --> 28:48are available in audio and written
28:48 --> 28:49form at yalecancercenter.org.
28:49 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:55cancer here on Connecticut Public Radio.
28:55 --> 28:57Funding for Yale Cancer Answers is
28:57 --> 29:00provided by Smilow Cancer Hospital.

Information

Stereotactic Radiosurgery for Lung Cancer with guest Dr. Nadine Housri August 27, 2023 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095