The role of the medical oncologist in lung cancer care is overall treatment planning, and the use of medicines to kill cancer cells.
When possible, we always seek cure. However, when not possible, or not consistent with patient values, we believe that the purpose of care is to maximize quality of life and duration of life.
To this end, we seek treatments that minimize side effects and maximize efficacy. Whenever possible, we attempt to use cutting-edge molecular diagnostics, clinical trials, immunotherapy, and targeted therapy to avoid the use of chemotherapy.
Non-Small-Cell Lung Cancer (NSCLC)
Targeted therapy: We believe that advanced molecular testing is critical to finding the least toxic and most effective therapy. To this end, our standard molecular testing includes next-generation sequencing with an RNA-fusion panel, as well as PD-L1 by immunohistochemistry (IHC).
When cancer grows on targeted therapy, our approach is to seek ways to extend benefit, before moving to new agents. This includes treatment beyond progression (in the case of slow growth neither threatening to end life nor threatening quality of life), stereotactic radiosurgery to oligoprogression (fancy radiation to obliterate growing sites if there are few of them), next line targeted therapy, and repeat molecular testing to identify and target resistance mechanisms. Targets are constantly evolving, but some targetable alterations include:
- KRAS G12C
Immunotherapy for NSCLC
- PD1 and PDL1 agents, such as pembrolizumab
- CTLA4 immunotherapy (ipilimumab)
- Clinical trials in cellular therapeutics (CAR-T and TILs)
- Clinical trials in novel immunotherapy, such as antibody-drug conjugates, bi-specific antibodies, and novel checkpoint targets
Chemotherapy: While we may favor non-chemotherapy options, chemotherapy can still be the best answer for some patients in some situations. In this case, we attempt to minimize toxicity by optimizing chemotherapy choice by histology (subtype of canacer), and providing aggressive supportive care (hydration and nutrition support, powerful anti-nausea regimens, pain medicines, and medicines to reduce the risks of allergic reaction).
Regimen choice is highly personalized by patient values and biology, but the most commonly used 1st chemotherapy regimens are as follow:
Carboplatin + pemetrexed + pembrolizumab: The basic “formula” for chemotherapy in lung cancer has long been a platinum + a partner agent. Carboplatin is the least toxic platinum agent. Pemetrexed is perhaps the least toxic chemotherapy for any indication and the most active against non-squamous NSCLC (mostly adenocarcinoma). Even when the immunotherapy marker PDL1 is negative, the addition of pembrolizumab immunotherapy improves survival.
Carboplatin + pemetrexed + bevacizumab: For patients who have a contraindication to pembrolizumab (such as organ transplant or active autoimmune disease) or whose cancer has already grown on it, bevacizumab can be considered. Bevacizumab works by cutting off the blood supply to cancers.
Carboplatin + paclitaxel or nab-paclitaxel + pembrolizumab: This is typically our favored regimen for squamous disease. The response rate to nab-paclitaxel is higher than paclitaxel, but requires weekly infusion. Paclitaxel is more convenient in that it can be given every three weeks. The regimens are more similar than different.
Multiple agents can be considered when these first line therapies are no longer working. We always consider and discuss clinical trials. Approved agents include docetaxel, ramucirumab, gemcitabine, and vinorelbine.
Small Cell Lung Cancer (SCLC)
Small cell lung cancer has long been understudied and advances have been slow. At UNC, we highly value the small cell lung cancer patient and take pride in contributing to advances in care.
Carboplatin/Etoposide/Atezolizumab with Trilaciclib support: The combination of carboplatin and etoposide has been the standard regimen in SCLC for decades. Recently, it has been proven that the addition of a PDL1 inhibitor, such as atezolizumab, improves survival. Critically, this includes an increased chance of durable control. Trilaciclib reduces the side effects of chemotherapy by reducing damage to the bone marrow cells that make new blood cells; it is particularly helpful in reducing fatigue. When control is long after stopping chemotherapy, this regimen can sometimes be repeated and work again.
Lurbinectedin: Lurbinectedin is a new and now standard option for the second line care. It seems a bit less toxic and a bit more effective than the prior standard of topotecan.
Topotecan: Topotecan can be a difficult agent for some patients. When it is considered, we use aggressive supportive measures including adjustment of dosing scheduling and the use of Trilaciclib.
Other agents: There are multiple other agents useful to patients in particular situations. We personalize recommendations, considering paclitaxel, gemcitabine and temozolamide amongst others.
Mesothelioma, thymoma, thymic carcinoma, adenoid cystic carcinoma, NUT carcinoma. Our treatment of these cancer is guided by best available clinical and biologic evidence and tailored to each patient.
Our team is organized around MTOP—multidisciplinary thoracic oncology program. MTOP is composed of all clinicians, from all related specialties, with a shared passion to reduce suffering from lung cancer. It includes thoracic surgery, interventional pulmonary, radiation oncology, thoracic radiology, and medical oncology. MTOP meets every Tuesday morning to discuss patients.
We believe strongly that this collaborative approach, with everyone reviewing and discussing imaging, pathology and other data together improves care. We have also physically structured our clinics so that we all see patients in the same space. We believe that this improves care by facilitating interdisciplinary discussions.
Nurse navigators are the heart of our program. Nurse navigators provide a single point of contact for patients and their families, allowing us to bring to bear the powerful resources of a large and advance program, with the ease of a smaller hospital. Nurse navigators provide supportive care, patient counseling and care coordination.
They meet and are in constant contact with patients and their families to help patients through all aspects of cancer education, support, touch with patients to help with education, supportive services, diagnosis adjustments and coping and supportive care needs with medications and financial considerations. Navigators work closely with the patients and families and provide the gateway to all providers are supportive care.
We have a dedicated thoracic oncology clinical pharmacist. Our pharmacists are experts in treatment selection, side effects, and monitoring. They assist with patient access to medications, counseling on how to take new treatments, and strategies to decrease side effects related to cancer therapy.
Rapid healing is not possible without adequate nutrition, so we are passionate about optimizing it.
We greatly value all patients, regardless of ability to pay. We are proud to work at UNC because UNC accepts almost any insurance, as well as patients with no insurance (charity care). We recognize that despite charity care, many patients still have significant barriers to optimal care and work closely with social work to help however we can. They also provide mental and psychosocial support to patients and families as they face and cope with the cancer diagnosis.