Help the development of the site, sharing the article with friends!
There are modern methods of treating non-small cell lung cancer in Poland. Despite this, the survival rate of patients, especially those with locally advanced, inoperable form of this disease is still too low. Meanwhile, as many as seven out of 10 such patients could live longer if they were treated in accordance with current standards. We talk to prof. dr hab. n. med. Jacek Fijuth, president of the Polish Society of Oncological Radiotherapy.
Professor, the diagnosis of "lung cancer" sounds like a sentence to many people. How long do patients live on average after diagnosis?
Prof. Jacek Fijuth:Unfortunately, lung cancer is associated with poor prognosis, mainly because it is diagnosed too late. As many as one third of patients have the third stage of clinical advancement, i.e. the lesion is inoperable. In 2013, only 10 percent. patients in the third stage of advancement have survived for five years from diagnosis, so this is a very bad result. In the first and second stage of advancement, where the lesion may be operative, survival depends on many clinical factors, mainly on the local advancement, complete resection, lymph node involvement, and the need for adjuvant treatment. Overall, lung cancer survival in Poland has improved somewhat, but the 2013 data are the benchmark. It is a late diagnosis cancer and satisfactory treatment results have been difficult to obtain until now.
Who gets sick more often, men or women? And is the number of sick people decreasing or increasing?
Currently, in the case of both sexes together, it is the most common cancer in Poland and in the world. And while the incidence of this cancer is slightly lower in men, it is unfortunately increasing in women. In Poland, we have about 22.5 thousand. new cases every year. It is forecasted that in 2025 it will be 23.5 thousand patients annually with an upward trend. It is worth emphasizing that in the case of both sexes, it is also the most common cause of death. So it all speaks for itself: the most common cancer, the most common cause of death, poor treatment results. So there is something to be afraid of. The problem is that this tumor is inin its early form, it is virtually asymptomatic, and the symptoms, if they appear, may mimic other, more banal diseases. Only in its advanced form does it produce typical symptoms such as chronic inflammation, recurrent pneumonia, shortness of breath, cough or hemoptysis.
What is the diagnosis of this cancer?
Any person who has lung related symptoms should see a general practitioner who should refer such a patient to a pulmonologist, i.e. a specialist who deals with the treatment of lung diseases. Most cancer patients are diagnosed in pulmonary departments, where the stage of the cancer is also determined. This is where the diagnosis should be made.
As part of the diagnosis, a number of tests are carried out, including bronchoscopy and microscopic examination to confirm that we are dealing with cancer. After performing a complete set of diagnostic tests, a multidisciplinary consultation should be held, at which a decision should be made as to what form of treatment will be appropriate for the patient. Such a council should be attended by a pulmonologist who also has knowledge in the field of pharmacological treatment of cancer, as well as a thoracic surgeon and a radiotherapist oncologist.
Well, unfortunately that doesn't happen often. The decision to start chemotherapy in a third stage patient, for example, is usually made by the treating physician. Treatment begins in a pulmonary department, and the patient is given four, sometimes six courses of treatment, and only after the end of chemotherapy, the patient is transferred to a strictly oncology center.
In Poland, only a few centers have multidisciplinary departments, pulmonology and oncology clinics. An example is the Oncology Center in Warsaw, where there are organ clinics, where such diagnosis and qualification for treatment is complete and appropriate.
It is worth remembering that lung cancer is actually two groups of cancers that are treated differently. The first group is small cell lung cancer, where chemotherapy is mainly used and radiotherapy is of complementary importance. The second group is non-small cell lung cancer, accounting for 80-85 percent. all cases.
What are the current treatment options for patients with non-small cell lung cancer?
In surgical forms, i.e. in the first and second stage, where these lesions can be removed, where the mediastinal lymph nodes are not affected and the mediastinal structures have not been infiltrated, surgical resection is performed. Then, depending on the situation, an adjuvant treatment, usually chemotherapy, is given. In onein the third case, the tumor cannot be operated on. This group of patients is very diverse, with more or less advanced primary tumors, more or less advanced nodal lesions, where the tumor is locally advanced but has not crossed the chest border, and there are no distant metastases.
The vast majority of such patients in Poland are treated inconsistently with the standards, i.e. treatment begins with chemotherapy, and then the patient is referred for radiotherapy. This treatment regimen is known as sequential treatment. This treatment strategy replaced independent radiotherapy several years ago. However, from the point of view of current standards, this is a wrong approach.
Already in 2010, a meta-analysis was published, which showed that simultaneous radiochemotherapy, when several courses of chemical treatment are administered during six weeks of radiotherapy, is much more beneficial for the patient compared to sequential treatment. It is enough to combine these two methods, and it translates into an improvement in overall survival. And it is in the American, European and recently also Polish recommendations that it is considered a standard of conduct.
There are also patients whose disease is diagnosed in the fourth stage as metastatic disease, with distant metastases. Until recently, the main form of treatment here was chemotherapy. At the moment, there are various drug programs available, also in Poland, which allow to apply - depending on the molecular profile - molecularly targeted treatment or immunotherapy.
Why are patients not treated in accordance with the standards?
This is due to several factors. The big problem is that the cases of many patients are not discussed at multidisciplinary councils, which is an absolute basis in oncology. After determining the stage of advancement, a group of at least these three specialists in pharmacological treatment, radiotherapy and surgery should discuss the case and decide on the appropriate course of action. Meanwhile, these councils either do not take place or are limited in number, the radiotherapist often has no influence on the procedure.
A certain percentage of patients in the third stage of advancement after chemical treatment could be operated on, but this requires an initial consultation of a thoracic surgeon. Unfortunately, often this treatment begins with chemotherapy in the intention that it will be possible to perform surgery, but it turns out that this procedure, despite chemotherapy, was and is impossible to perform, and this closes the way to modernconsolidation treatment with immunotherapy.
Several years ago, a multicentre study called PACIFIC was launched, involving several hundred patients. His results show that thanks to the use of concurrent radiochemotherapy with consolidating immunotherapy, the percentage of patients surviving 5 years increased to 43%. against 36 percent after radiochemotherapy, without consolidation treatment. But both in the world and in Poland, the drug program requires that patients qualified for such treatment have simultaneous radiochemotherapy. Sequential treatment closes the way to immunotherapy, i.e. to this modern treatment, which is an absolute standard all over the world in the United States, Japan, Canada, and throughout Western Europe.
Our recommendations also say that the patient should undergo simultaneous radiochemotherapy, but unfortunately the reality is far from ideal, because for about 2,000 patients - these are estimates based on the data of a national consultant in the field of clinical oncology - who would be eligible for radiotherapy and chemotherapy, after selecting patients who meet these criteria, about 1,000 patients a year should receive simultaneous radiochemotherapy, and about 300 patients, i.e. less than 1/3 of patients.
And the other reasons?
First, radiochemotherapy lasts six weeks, and if the patient requires hospitalization - and these patients often have overlapping lung diseases such as asthma, COPD, circulatory failure, and pulmonary fibrosis - there is no way that the NHF will pay for transport of a pulmonary patient to a radiotherapy unit. The NHF regulation favors combination treatment carried out in one center, it has a higher price. However, there is no regulation to reward standardized radiochemotherapy if it is performed in two different centers. In view of such barriers, pulmonary centers are not interested in subsidizing this treatment, for example in the form of covering the costs of transport for several weeks.
Anyway, the diagnosis itself, which includes a number of different procedures, is often priced below or on the border of the own costs of these tests.
Another problem is psychological resistance due to the fact that radiochemotherapy has one small defect in the form of radiation reaction from the esophagus, which runs through the mediastinum. In a few or a dozen or so percent of patients, an intense radiation reaction from the esophagus may be a problem. This reaction is associated with pain and difficulty in swallowing and it is common in the community of oncologists and pulmonologists that simultaneous radiochemotherapy is too toxic.
ZI regret to say that despite the fact that the leaders of the medical community are trying to promote this method of treatment, because it translates into a much better survival of patients and opens the way to immunotherapy, which is a breakthrough at all, there is still knowledge about the effectiveness of this treatment and the benefits resulting from it are insufficient, We constantly encounter administrative barriers that hinder cooperation between centers or the reluctance to the method itself resulting from excessive fear of toxicity.
In many centers, doctors also take the easy way, because patients may require more intensive, more expensive care. Importantly, from the technical point of view, in all radiotherapy units in Poland, it is possible to perform modern radiochemotherapy, which allows to significantly reduce esophageal toxicity. There should be no problem with this, but only 1/3 of patients receive this treatment.
Sir, professor, what should be changed, then, in order for every sick person to receive the correct treatment? Will the National Oncology Network improve anything in this respect?
Constant education is absolutely necessary, especially in the field of molecular biology, diagnostic and therapeutic methods, as well as close multidisciplinary cooperation in the field of modern treatment methods for patients with non-small cell lung cancer.
I also hope that the National Oncology Network will change a lot in this respect. This is a new concept of the functioning of oncology centers, hierarchical in a sense. The tool for assessing the correctness of the functioning of this network are the so-called measures, i.e. parameters by means of which the functioning of oncological centers is assessed from various angles.
One of such parameters is the use of simultaneous radiochemotherapy in the appropriate indication. If the center does not use such treatment, information about it will appear in the report, because the centers will have to report the time of diagnosing patients, the completeness of the diagnostics performed, the completeness of the multidisciplinary consultation and the treatment used - and whether it was properly applied to patients who a given organizational unit underwent diagnostics, as well as what was the effectiveness of this treatment, its toxicity, and what safety.
This concept is not to everyone's liking, but the network will discipline the centers a lot. For those involved in he althcare, this will mean much more work, but for the benefit of the sick. And actually, it's for all of us, because, unfortunately, cancer is a civilization disease, so we should think noonly for people who are sick now, but also for those who will fall ill in the future.
PROF. DR HAB. N. MED. JACEK FIJUTH
President of the Polish Society of Oncological Radiotherapy, head of the Department of Radiotherapy of the Medical University of Lodz and the Department of Teleradiotherapy of the Regional Oncology and Hematology Center in Lodz, member of the Committee for Medical Physics, Radiobiology and Image Diagnostics of the Polish Academy of Sciences, member of the Scientific Council of the National Institute of Oncology. Academic teacher, co-author of over 150 scientific publications and Polish guidelines for combined treatment in the field of cancers of the central nervous system, urinary and digestive system. One of the authors of the report "Simultaneous radiochemotherapy in the treatment of patients with non-small cell, inoperable lung cancer."