Ask the Lung Cancer Expert: Is Precision Medicine’s Reach Increasing in Lung Cancer?

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

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Andrew Schorr:  

And greetings from here, San Diego-Carlsbad, California. I’m Andrew Schorr from Patient Power. Welcome to this Patient Empowerment Network program. I am so excited. It is really a wonderful opportunity for anybody dealing with lung cancer. Whether you’re the patient or you’re a close friend or a family member, to get the latest information. And you can ask questions and particularly understand this new world of precision medicine and how does it apply to you or a loved one so that you get the right care. And there is a changing landscape in lung cancer.

There are people all around the world who watch this program and we invite your questions. Send them to lung@patientpower.info. Again, that’s lung@patientpower.info. We’ll have plenty of time for questions. Remember, not to make it too personal like, “Here the test said that. Here are the results. What should I do?” Because that would not be fair to you nor our medical experts, who you’ll meet in a minute, practicing medicine over the internet. So, take information from this program, discuss it with your own doctor, maybe get a second opinion somewhere, but then get what’s right for you.

All right. I wanna thank the companies that have been supporting this program. They have no editorial control, but they wanna support the lung cancer community. Those supporters are AbbVie Incorporated, Celgene Corporation, Foundation Medicine – which does a lot of the testing that we’ll discuss along the way – and Novartis. We thank them for their support.

And it is so important to get a patient perspective. So, you’re gonna meet a patient who’s been in a clinical trial and doing well as we’ve had this changing world of lung cancer. And we have a whole team from the Moffitt Cancer Center in Tampa, Florida. It’s one of our leading cancer centers in the world. And we’ll be hearing how they work together.

So, let’s meet that team. I wanna start with a medical oncologist and that is Dr. Jhanelle Gray. And she is director of thoracic clinical research in the Department of Thoracic Oncology at the Moffitt Cancer Center. Dr. Gray, thanks so much for being with us.

Dr. Gray:               

Thank you very much. It’s a pleasure to be here.

Andrew Schorr:  

Okay. We’re gonna understand the role of the medical oncologist. But it’s a bigger team than that. So, I wanna also have us meet Dr. Stephen Rosenberg who is a radiation oncologist and works in concert with medical oncology. He’s normally down in Tampa, but today – where are you in Wisconsin, Dr. Rosenberg?

Dr. Rosenberg:    

I’m currently in Madison, Wisconsin giving a talk later today and tomorrow.

Andrew Schorr:  

Okay. Home of the University of Wisconsin. Thanks for joining us.

And then there’s another member of the medical team none of us usually get to meet. And that is the pathologist who’s looking at our biopsy. Whether it’s taken from the lung or now increasingly liquid biopsies, our blood, and we’re gonna talk about that. And that is a pathologist and that is Theresa Ann Boyle who joins us. Dr. Boyle, thank you for being with us.

Dr. Boyle:             

Thank you for inviting me. It’s nice to be dragged out from behind the scenes.

Andrew Schorr:  

All right. Well, you won’t be beside the scenes anymore.

And of course, all of this – we have this whole group, but it doesn’t mean anything unless there’s a patient that they can help and maybe a family with them. So, let’s meet a patient from Tampa who’s been living with lung cancer for a number of years, Ed Cutler. Ed, thank you so much for joining us on this program and we’re gonna share your story. Hi, Ed.

Edward Cutler:    

Hi. It’s a pleasure to be here and an honor to be honest with you.’

Andrew Schorr:  

Well, Ed, so, you’ve been living with lung cancer how many years now?

Edward Cutler:    

Just over five years.

Andrew Schorr:  

Okay. But let’s face it, it wasn’t that long ago if somebody was told they had lung cancer they were not long for this world with more advanced lung cancer. So, modern medicine has made a big difference for you, hasn’t it?

Edward Cutler:    

It certainly has. When I received my diagnosis, I was given the quote average life expectancy statistics and they didn’t look very good.

Andrew Schorr:  

Right.

Edward Cutler:    

So, I went the whole way.

Andrew Schorr:  

And we should mention that for the last couple years you’ve been in a clinical trial and it’s an immunotherapy. And we’re gonna talk about immunotherapy along the way. We’re gonna talk about target therapies, immunotherapies. The doctors are gonna help us understand this whole idea of precision medicine. Which means, “How do you get what’s right for you?”

And you’ve had some changes along the way, right Ed? I mean there you are in Tampa continuing your work as a tax consultant, I know. And been married more than 50 years to Donna, which is great. Children and grandchildren. But you’ve had kind of a journey that’s had changes along the way, right?

Edward Cutler:    

It has been a journey. Yeah. Yeah. Initially I started out with standard of care chemotherapy. And that basically took over 16 months. Basically, the first two or three months I was on the full medication of three drugs. And then they dropped off one and then I was on maintenance. But at the end of the 16th month they discovered that there was a new tumor. And I was told I was now chemo-resistant and that was the end of chemotherapy for me.

So, my etiologist and I sat down, and we started searching. And at that point, I don’t think there were any other approved medications. Everything else I think was still in trials at the time. Now I know that there are maybe two, three, a half a dozen medications that are out of trials and FDA-approved. But at that time, I was limited to clinical trials. And Dr. Tan, who is my oncologist, gave me the options looking at two or three different trials. And my goal was to live as long as possible with good quality of life. And that’s what I was looking for in each of the trial descriptions.

And we ended up selecting one and I took all of the various testing to qualify for that trial and I was ultimately accepted. It was a two-drug combination of infusion. And unfortunately, I only lasted seven – roughly seven months in that trial because of side effects that almost killed me.

Andrew Schorr:  

But now there’s another trial?

Edward Cutler:    

And fortunately, it took another few months, but we located another trial that was being performed only at Moffitt. I said, “Well, that’s convenient.” So, I said, “Yeah.” Everything looked good on that. Sure, there were potential side effects, but I was willing to take my chances with it. And here I am nearly three years into that trial and I’ve been stable most of that three-year period. There was a little bit of tumor size reduction initially and basically stable the rest of the time. It’ll be three years come the end of January.

Andrew Schorr:  

That’s such great news.

So, Dr. Gray, you have lots of trials at a major center like Moffitt, maybe you could just tell us in this world of lung cancer, patients who participate in trials have not only paved the way for everybody, but it’s given them great hope, hasn’t it?

Dr. Gray:               

Absolutely. So, we have a lot of trials at Moffitt. We try to organize ourselves within a way of doing a personalized medicine approach. And basically, that means that any patient that comes to Moffitt we wanna give them the best treatment possible. And many times, that is a clinical trial. With clinical trials a lot of times you have access to more novel agents and things that you can’t necessarily get through your regular route through FDA approval. And also, a lot of that work is spurred by research developed here at Moffitt and partnering with the basic science researchers as well as us at a lot of the clinical – on the clinical side and making sure that we move these drugs forward and into the clinic for patients.

And Edward, I just wanna say I’m very happy about your story. And thank you for taking the time today to be with us and to share your journey with us. And give us your perspectives to this too.

Andrew Schorr:  

Yes. It’s very inspiring to all of us. And Ed, we know you’re a golfer. And so, you’ve been...

Edward Cutler:    

Well, I was.

Andrew Schorr:  

Well, please God you can do that and travel with Donna. And the main thing is you are with us.

Dr. Gray:               

Yes.

Andrew Schorr:  

And I know that means so much to you and your family.

We’re gonna talk about the team approach as we go forward. So, Dr. Rosenberg, radiation oncology comes into play here because often when somebody’s diagnosed radiation can help shrink the tumors, right? And also alleviate some of the pain and other issues that people may have, right?

Dr. Rosenberg:    

Yeah. No. I think you hit on a lot of big major points there. And it really is a team approach. Particularly at Moffitt when we approach lung cancer trying to think about how we can do best for the patients, whether it’s a clinical trial or not. Radiation plays a big role for patients who have a locally advanced disease. Some of the standard of care is combining chemotherapy with radiation for patients with some advanced disease. But for patients who have had cancer spread to other parts of the body as well, radiation’s really good to help alleviate pain and even approve breathing and the other things that are happening.

And with newer agents we often find that radiation may even be potentiating the immune effects of some of the new immunotherapy drugs that are out there. And so, we’re really excited about some of the trials and studies we’re doing with Dr. Gray and her team. And the team as a whole at Moffitt combining irradiation with some of their new – with targeted drugs and immunotherapy drugs right now.

Andrew Schorr:  

Wait. Let me see if I get that. And Dr. Gray, feel free to comment too. Are you saying that radiation can sort of boost the effect of some of these medicines?

Dr. Rosenberg:    

Yeah. There is a lot of anecdotal evidence out there. And some basic science that’s right now emerging about how the immune system and radiation really are so interconnected. And how that helps us actually attack cancer by actually basically releasing the immune system to recognize the cancer in the body. And so, by combining that with immunotherapy drugs we’ve really found our ability to potentiate some of the effects of these immunotherapies.

Most of this is basic science. There are some anecdotal case reports out there with some of the newer drugs that have just come out in the last year or two FDA-approved have been after chemoradiation and we think they really work together well. And some of the newer trials at Moffitt are gonna be trying to combine these things up front. And I know Dr. Gray has been helping to lead that effort with Dr. Perez and others within our kinda joint departments here.

Dr. Gray:               

Yes. Absolutely. And so that work that Dr. Rosenberg was just talking about was actually developed at Moffitt. So, there’s a trial out there that’s now published in the New England Journal of Medicine. It led to the FDA approval of a drug called durvalumab (Infinzi), which is actually named because the company, AstraZeneca, wanted to add durable responses and add value to patients. So, durvalumab is where the name came from, interestingly enough.

And the study, what we wrote, was to look at those patients getting chemotherapy plus radiation therapy completing what’s considered standard of care therapy for those patients with that particular type of non-small cell lung cancer. And following this with an immunotherapy agent, the durvalumab, for one year. And it significantly improved the outcomes for patients. Patients are living much longer when we utilize this method.

And now this has become the standard here in the United States. It’s working its way through the approval mechanisms over in Europe and through other companies. And I think this has really revolutionized how we approach and treat patients. And we are looking at – now we know it’s safe to give them sequentially. And so, can we safely and effectively – meaning can we actually improve outcomes for patients by moving these therapies upfront?

And so, it would be giving a lot of therapies together. So, it would be chemotherapy plus immunotherapy plus radiation therapy to patients. But at the end of the day, the goal here is to improve our outcomes in a – and still maintain quality of life for patients. So, it’s always challenging pushing the bar and reaching these goals for our patients.

Andrew Schorr:  

Right. Right.

So, Ed, just a little bit more about your story and then we’re gonna bring Dr. Boyle into this too as we talk about personalized medicine. So, when you were originally diagnosed, you were, I think, consulting with a doctor about a concern about an aortic aneurism. It had nothing to do with cancer.

Edward Cutler:    

Yeah.

Andrew Schorr:  

You went to one doctor and then maybe a GI specialist. That’s where they found a mass. And then you went to Moffitt and saw a lung cancer specialist. Did I get that right?

Edward Cutler:    

That’s right. Yeah. The triple-A test, the Abdominal Aortic Aneurism test, was negative. But down at the bottom of the report in the footnote was that they saw a mass in my liver and follow-up was recommended. So, we went from there. I went to my primary care and he referred me to a GI doc and they pretty much agreed that there was some kind of cancer, but they didn’t know what exactly. They recommended that I get a PET scan, which Medicare would not permit. They said you have to have a diagnosis before you can get a PET scan.

So, the alternative was to have the biopsy. I said, “Okay. But let me get a second opinion first.” And that’s when I came out to Moffitt and they confirmed everything. I had my biopsy here at Moffitt. And there was a tumor in my liver, but the biopsy traced it back to my lung. Therefore, I have lung cancer.

Andrew Schorr:  

Right. And I wanna explain that. Okay. So, let’s start with Dr. Boyle on that. So, Dr. Boyle, you look at the biology of tissue samples or sometimes blood.

Dr. Boyle:             

Correct.

Andrew Schorr:  

And so, somebody says, “Oh, I have liver cancer.” But that just came up where he said well, he didn’t really have liver cancer, he had cancer that originated in the lung and the biology of it was it needed lung cancer treatment, right? And that’s part of what you figure out, right?

Dr. Boyle:             

Right. Right. Right. And actually, within the pathologist group there’s different fields of pathology. There’s the anatomic pathology where they’re looking at the diagnosis, “Is it lung cancer origin or is it kidney cancer origin?” I’m in the field of molecular pathology. So, I’m looking at the genetic changes inside the tumor, or in the blood too, and I’m trying to understand what those changes might mean in terms of what would be the best therapy for the patient. I’m also in the lung cancer research field. So, trying to better understand all of these immune checkpoints and how can we look at them. Why do some patients respond, and others don’t respond?

So, pathology is a large field. So, I’m working very closely with the thoracic department. In fact, I belong to them. 50% of my job is with the lung cancer department and 50% with the pathology department. And we found that that was helpful because the field is expanding so dramatically. Even within every year there’s great advances. And for anyone to keep up with everything is too difficult these days. And so, we really do all work as a team here at Moffitt. And so, as Jhanelle and I talk back and forth – a lot of emails with.

Dr. Gray:               

Right. Yes.

Dr. Boyle:             

So, I even consulted them on some of these questions you have. So, it’s great.

Andrew Schorr:  

All right. Well, we’re gonna delve into this personalized medicine world. And the doctors will help us understand. We’ll understand how it applies to patients like Ed or others who may be watching. So, let’s put up the personalized medicine slide. Kat is our director and she’ll put it up.

I have a little dog barking here. I’m sorry.

Dr. Gray:               

No, you’re fine.

Andrew Schorr:  

Very cute.

Dr. Boyle:             

I like dogs.

Andrew Schorr:  

Kat, if you could put up this slide? There we go. Okay. So, help us understand – let’s start with you, Dr. Boyle.

Dr. Boyle:             

Yeah.

Andrew Schorr:  

This whole wheel around the right, what is this alphabet soup there? What is it?

Dr. Boyle:             

Right. Right. Right. So, this is showing the variety of different genes that can have genetic changes in the tumor. And it’s focused on the genetic changes that have potential clinical action or proven clinical action. EGFR is probably a more familiar one because that one came out first with better responds to EGFR inhibitor therapy than chemotherapy and others have come along. Like with ALK, ALK inhibitor therapy works well. With MEK, XM14 has become important, MET amplification.

Andrew Schorr:  

Okay. These are genes that have gone awry that are driving someone’s cancer, right?

Dr. Boyle:             

Correct. Right. Right. Right. And this wheel is trying to pick up on the driver mutations. There’s even more genes not on this wheel here that are passengers. Other mutations that might have some specs, but they might not necessarily be causing the tumor or driving the tumor but might be worth considering in terms of the therapy. In immunotherapy, tumor mutations burden has been something we look at. And they’re looking at many, many gene changes to see if there are more mutations than usual. And when that occurs, there might be a better likelihood of response to immunotherapy. So, we’re learning more and more everyday about all of these genes and more.

Andrew Schorr:  

Okay. We’re gonna define this. And Dr. Gray, you can help us. These kinda big bubbles to the right.

Dr. Boyle:             

Yes.

Andrew Schorr:  

So, first of all, a myth: All lung cancer tumors are the same. This right here says, “No,” right?

Dr. Gray:               

No. Absolutely. Yes. The fact is that each patient’s tumor has a unique biology. And the wheel on the left I think really helps to define this. That at the end of the day when we get a patient we’re concerned about, we get a biopsy, get a piece of tissue, send it over to pathology to Dr. Boyle’s team. She’s not only looking under the microscope to help us with, “What’s the diagnosis? What’s the origin of the tumor?” But we also wanna look at, “What is driving your tumor?”

And so, how I’ve explained it to patients is in two ways. You have a computer that has all these different parts, but at the end of the day what drives the computer is really that hard drive. And if you open up the hard drive there’s this little piece of hardware that’s actually making everything run. And that’s what we’re doing with the tumors is going into the cell, looking at the DNA level and seeing what is turning on your specific tumor.

Another way of thinking about it is as a hub for an airline, for example. So, a lot of us know Delta has a very big hub in Atlanta. They have a lot of flights that go through there. But if you were to shutdown Atlanta you would significantly impact the feasibility of Delta being able to function.

And that’s what we’re doing by looking at these driver mutations. We wanna find what’s turning on your tumor and then match that patient to the correct medicine. So, if you have the EGFR mutation, I wanna give you an EGFR inhibitor. If you have an ALK rearrangement, I wanna give you an ALK inhibitor. If you have a MEK mutation, I wanna give you a drug that targets MEK. What I don’t wanna do is if you have an EGFR mutation give you an ALK inhibitor. I’m doing you a disservice.

And so, it is very important – I think you brought up a very good point at the beginning of this that the team approach for lung cancer is imperative so that we can all work together to get the right patient the right treatment at the right time.

Andrew Schorr:  

We’re gonna look at a graphic for that in just a second. I wanna just go over a couple of other things you mentioned. So, somebody might have a lung biopsy. Get some tissue. That goes to Dr. Boyle and her colleagues.

Dr. Gray:               

Yes.

Andrew Schorr:  

Wherever in the world you get treatment. And they’re taking a look at it to see where in this wheel – what comes up for them?

Dr. Gray:               

Correct.

Andrew Schorr:  

And then also there’s a – in that purple bubble there it says, “Tumor testing can happen at any point.” And so, we talked about driver genes.

Dr. Gray:               

Yes.

Andrew Schorr:  

And then Dr. Boyle mentioned passenger genes.

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.