Cancer Treatments Chemotherapy

my name is giuseppe giaccone.patients actually call me peppe, and i'm the director ofthe lung cancer program for the medstar georgetownuniversity hospital. my role here at medstar is mainly topromote research, clinical research and also translation of research especiallyin the area of drug development and lung cancer.lombardi cancer center is the only nci designated cancercenter in this area, washington d.c. lung cancer is a challenging disease,however, in the last 5 years there has been a wealth of knowledgeon the biology

that has brought a lot of new drugsespecially for the treatment of patients with advanced stage, that has dramatically improvedtheir survival. and in addition to that, thesedrugs are also much better tolerated than chemotherapy, so if people thinkabout treatment of advanced stage disease as chemotherapy, this has changed.we have now drugs that are oral drugs with very little side effects.so that's clearly a change in the way that things are for patientseven with advanced stage lung cancer. what i love about my job isthe challenge.

this is a difficult to treat tumor type.we have now treatment that would allow, i guesswithin the next 5-10 years to cure even patientswith advanced stage disease. i've been a member of the americansociety for clinical oncology, asco, and the american association for cancerresearch for many many years. being part of these large organizationsis important, especially for research but not only. this provides a network of peoplethat are essentially in contact every day so that if something happens, somethingimportant happens somewhere else,

we are immediately aware.and it also allows collaboration. many of the research studies that weare doing here in lombardi are in collaboration with other centers,other big centers in the united states and even outside,this is a benefit to the patient because the patient knows thatif they come here they don't only comefor the lombardi cancer center, but they will have the wealth of knowledgethat is available worldwide. many patients, when they come inthey want to know the prognosis of their tumor. and this is adifficult discussion most of the time

because there are many factors that playinto the prognosis. the most important oneis the stage of the disease. so patients with early stage canbe cured and that's easy to explain. patients with advanced stagecannot be cured at this time, but we can prolong life and that'srelatively easy to explain too. but then there is a category of patientsthat stay in between where things are much moredifficult to explain because the prognosis can changenot only depending on stage but also depending on the biologyof the tumor and we don't always

have all the facts at handto explain that. my role at the national cancer institutewas the chief of the medical oncology branch which is the largest branchin the intramural program. at the nci,the national cancer institute, all patients participatein clinical research. you don't essentially dostandard care for those patients so what i learned at nci is reallyto study patients on a research side in very big depth. the benefit of having the laboratory ofscience attached to the clinical research

is big. essentially you can transferthe knowledge that you gain from laboratory researchto the clinical studies much more rapidly than you wouldif you had no access to laboratory research, and especiallynow that so much is going through knowledge of the biology of lung cancer,and then transferring it to treatment, new treatment possibilities it isextremely important to have a good collaboration with science,with laboratory research. so what i'm doing here at lombardi,i also have a laboratory and i'm studying drugs or new treatmentmodalities in the laboratory

and then transferring it intoclinical protocols for patients. that is a question that i get askedquite frequently. and in fact, when you're proposingresearch protocols, sometimes there are risksthat you cannot really totally foresee, so you have to behonest with a patient. patients offer themselves, their lives,for that particular protocol, so you have to be honest and explainthat you don't know everything and when they ask you: "would you dothe same with your mother or your wife", i think you have to answer honestlyand if the answer is no,

then you have to let them knowand why. most of the times i try to pick the researchin the way that i would be comfortable saying "yes, i would offer itto my wife or to my mother", because i think it's important to decidethat the research that i'm doing is important to the patient first of alland not just for research. patients with advanced diseaseusually go around shopping for treatment opportunities.so they would go to lombardi, they would go to other hospitals in the areaor even far away if there are good opportunities.i think that's reasonable

and i think that people should feelconfident that i would let them know if there's something bettersomewhere else because we work in a network, we'renot working in isolation anymore. so if there's something that is verypromising somewhere else, i am obliged to let them know,and even to help them out seeking that opportunitysomewhere else. traditionally lung cancer and many othertumor types have been treated with chemotherapy and side-effectsof chemotherapy are well-known to most people so they're sometimespretty bad.

so hair loss, nausea and vomiting,myelosuppression, infection... what is changing though,is that especially in lung cancer we have now a number of targeted agentsthat are much more specific for the tumor and that give much less side-effects.and because they are specific for the tumor, they attack much less severelythe normal cells and therefore we don't have the classicalside-effects that chemotherapy has. we have other side-effect which are usuallymuch more tolerable. so especially when you deal withan experimental treatment you have to explain the potentialrisk of side-effects to the patients

and also be able to balancethis potential risk with what is known of thestandard chemotherapy for instance and be able to make the comparison. i think this is very important forthe patients who understand and to understand especiallywhen there is a comparison in the research protocolthat is being proposed, to be able to take the right decisionif they want to. when patients are treated for...especially for an advanced disease with chemotherapy or withan experimental treatment,

they need to know that they aredoing that under careful monitoring. so they need to know that there'salways somebody here at lombardi cancer center thatis available in case they have questions or in case somethingunexpected happens. so there's always somebody actuallythat is available in the center to answer any questions any timeof day and night and during the weekends. no, for as far as we know,lung cancer is not hereditary. however, there have been sporadiccases of lung cancer present

in multiple members of the family. it is difficult usually to know ifthere is a hereditary component because smoking is the primary causeof lung cancer and smoking is very common in thehousehold, so if one person smokes, usually there's another personthat also smokes, and if the other persons that don't smokeare exposed to second-hand smoking, which can also cause lung cancer.so it's very difficult to distinguish a potential hereditary formof lung cancer because of the confoundingfactor of smoking.

so in general the answer is no,it is no hereditary, but i cannot exclude that theremay be some rare forms of hereditary lung cancer. many patients wonder why theygot lung cancer. my father got lung cancer for instance,and he smoked all his life. and yet when he developedlung cancer, he asked me: "why did i get this?it cannot be due to smoking." so i had to explain to him that it wasprobably due to smoking. so smoking is the most importantcause of lung cancer

and we as doctors must make an effortto help patients quit smoking if they are still smoking,even if they have advanced disease, even if the treatmentwill not cure the disease because smoking is causingcomorbidities, and comorbidities are important alsofor side-effects of treatments so quitting smoking at any time isan important issue. this is an important question.in the recent years we've seen more and more lung cancer patientswho never smoked and also many lung cancers in patientswho quit smoking 20-30 years ago

as a result of the campaigns againstsmoking, especially in the united states. the reasons for lung cancer innever-smokers is completely unclear still, it is more common in women,more common in young patients, and usually has a better prognosis thanthe classical lung cancer in smokers. but the real cause of lung cancerin never-smokers is not well understood. one of the potential causes is2nd hand smoking, which we know is important, and radon is another potential causeand there may be others as well. biologically, lung cancers in never-smokersare better behaved,

they're usually called adenocarcinomas,which is a sub-type which is now the most frequentsub-type of lung cancer and it has a prognosis that is definitelybetter than lung cancer in smokers. the survival is actually almostdoubled even without treatment compared to the survival of thelung cancer in the smokers. the reason for this big difference is againpossibly the biology of the tumor but also the comorbidities. comorbiditiesin patients who've never smoked are much less and much less severeand also patients are younger in general. comorbidities include mainly cardiovasculardisease that is associated with smoking.

smoking increases the risk ofmyocardial infarction for instance or cardiac disease. so those comorbiditiesin addition to lung comorbidities as well: asthma, copd, are important in patients who've smokedtheir whole lives. and actually, patients who haveall these comorbidities may die of those rather than lung cancer. now that people quit smoking and there are so many more cancersthat are caused by something we do not understand, radonhas been studied and investigated

as a potential cause of lung cancerand radon, especially in this area, is found in basements of houses.so there's been a big public discussion about potentialrisks of having radon in the environment. scientifically, we really don't havevery strong evidence that radon can cause lung canceralthough there are a few studies that might suggest that radon couldplay a role. i think we need much more datato be able to say this consistently. in talking about treatment,i'm talking here about chemotherapy or some targeted agents for patientswith advanced disease.

so usually these treatments are givenfor a test period and the test period is between6-8 weeks. so 6-8 weeks is usually sufficientto know if the tumor is responding to the treatment. this is an important piece of information.many patients come to the clinic and they ask: "well, what if i don'twant chemotherapy?" and i usually suggest to at least give ita test trial for 2 months and then repeat the scans.if the treatment works, then it will be worthwhile continuing.if the treatment doesn't work

or doesn't work sufficiently, then thepatient may decide to stop treatment at that point. so usually a couple of monthsor sufficient to know what direction the responseto the treatment is taking. many patients want to helpthemselves, of course, during the treatment, and so manypatients also think that vitamins or diet supplementations are important. there's not much data supportingthis evidence frankly, so if one has a normal diet,it's sufficient, usually there's no need for a supplement.however, many people feel

that this may help and if that ispsychologically important to them, i usually have no problemallowing that to continue. a different story is however when patientsare undergoing research protocols. at that point you really need to knowwhat patients are taking and many of these supplementsare not only vitamins but also supplements that includesubstances that we do not know and that could potentially interactwith the treatment that you're given, especially the experimental treatment.so you really want to avoid potential interaction in that case.

usually we discourage the use ofsupplements during the treatment because of potential interactions.this is not a 100% exclusion. some patients may take vitamins,there's nothing wrong against it but when it comes to experimentaltreatment, one wants to avoid potential interaction, so we usuallytend to ask to stop all supplements and complimentary medicine,whatever they're taking. this has not been systematically studiedso we really don't know. the only thing that you want to avoidis an interaction, a potential pharmacologicalinteraction.

and when you startadding multiple drugs together, that is something you could expecttheoretically, so really it is not a good idea to take somethingthat is not well documented together with your anti-cancertreatment in general. my laboratory research is mainly based ontrying to identify new targets for treatment and then developing new drugsfor those targets. this is mainly in the area ofthoracic malignancies, so lung cancer in particular,but also other tumors like thymomas. so we have identified in the pastin the laboratory a number

of noble genes that could be potentiallytargeted with noble treatment and the idea is really to bring thisto patients as soon as we can, as soon as we can identifymolecules that could be used as target agents for these specificabnormalities that we found in the tumors. so i think that this is nota short term project, but this is a continuing effortof trying to bring what is known on the biology of this specific tumorand the patient as well into the clinic as fast as we can, again, transferringthe knowledge from the laboratory to something that can benefitthe treatment of the patient.

the medstar network is organizedin a way that patients can go to any center that belongs to the networkand have access to the same type of research capabilities that we couldhave here at lombardi cancer center. so what we have done is organize groups,disease oriented groups, lung cancer is one of these,and we will discuss... we discuss the research protocolsthat will be opened in each center. and therefore even if a patient would likemaybe to have a second opinion at lombardi cancer centers, in manyinstances this would be unnecessary because we will have direct networkcapabilities of discussing the patients

and the potential research betweenthe different centers of the network. and the american associationfor cancer research for many many years. and even outside. so these majororganizations are really important to provide a platformwhere this can happen and this is a benefit to the patient