Natalie Dubbs, a 23-year-old medical engineer, had the world at her feet. Recently married, she was on holiday with her husband in Japan when she woke up one day feeling something just wasn’t right. Over the next few days she quickly grew more and more unhappy, developed searing headaches and dizziness, and started fighting with her loving husband. Three weeks later, after returning home, she went to her doctor.
A hospital admission and a series of scans revealed something she had never imagined could happen to her: she had cancer – a tumour on the brain. It was taking up a quarter of her skull, pressing on her optic nerve and causing the distressing symptoms that were turning her life upside down.
Natalie underwent surgery to remove the tumour, but it wasn’t until some days later that a CT scan uncovered the primary tumour: in her lung. The tumour in her brain turned out to be a secondary tumour that had spread from her right lung. Even though she’d never smoked in her life – she hated the smell of cigarettes and no one in her family had smoked, either – she had lung cancer.
Because the tumour in her lung was so close to the heart and aorta, surgery was impossible. Doctors prescribed a gruelling course of radiation while the tumour was sent for genetic profiling. Once the genetic mutation behind her lung cancer was identified, Natalie entered a clinical trial of a promising new anti-cancer drug called brigatinib.
Lung cancer – the constant black cloud on the horizon of anyone who has ever had a cigarette – is no longer just the domain of smokers. Younger people who have never smoked are being diagnosed with this deadly disease. And doctors are only just now starting to understand why.
More than 12,000 people will be diagnosed with lung cancer in Australia this year – it comprises about 10% of all cancers in this country and nearly 20% of all cancer deaths.
Although smoking is behind the vast majority of lung malignancies – 84% in men and 77% in women – exposure to certain substances, including asbestos, radon, hydrocarbons and metals (eg chromium and nickel) can also cause lung cancer, as can genetic mutations – the culprit behind Natalie’s cancer.
Genes are more often to blame when the illness strikes younger people, says cancer doctor Malinda Itchins from the Royal North Shore Hospital in Sydney. This sort of lung cancer often presents with neurological symptoms such as headaches, vision disturbances or seizures. The good news: genes help determine which treatments work best for each individual.
“We are finding that although the smoking prevalence in this part of Australia is decreasing, the incidence of lung cancer isn’t decreasing at the same rate. And we’re seeing many more young, Asian females with the disease,” Itchins says. (Natalie was born in Vietnam.)
“Now our understanding of what we classify as lung cancer is really changing – we’re identifying gene mutations and abnormal proteins that switch them on to drive tumour cells to replicate, so that means we can find drug therapy to switch off those proteins.”
Like any cancer, lung cancer is much more treatable when it is detected early, before it’s had a chance to spread, says Dr Brendan Adler, Director of Radiology at Envision Medical Imaging.
In recent years, in Europe and the US there’s been a push to screen for early signs with annual low-dose CT scans for those at increased risk, such as smokers. A large study published in 2011 found that early detection via such screenings resulted in a 20% reduction in lung cancer deaths thanks to quick treatment.
In Australia, smokers who go to their doctor with symptoms such as a persistent cough are likely to be sent for an X-ray rather than a CT scan, though trials are underway in this country into the use of CT scans to screen at-risk people. New technology means many low-dose CT scanners expose patients to just one tenth of the radiation of the old scanners – about the same amount as a normal X-ray, says Adler.
Screening is important because often, at the early stage, people will have no symptoms at all – yet their cancers are ‘eminently curable.’ Others might have vague symptoms such as a cough, shortness of breath or weight loss that can easily be dismissed, especially in smokers who probably cough anyway.
It is usually only after cancer has advanced that more troubling symptoms manifest, such as coughing up blood, chest pain, finger ‘clubbing’ (when the tips of the fingers enlarge and the nails bulge) and wheezing. By then, it can be much harder to treat the lung cancer successfully. While CT scanning isn’t routinely offered to pick up lung cancer in Australia, “if I had a friend who was a heavy smoker, I’d be encouraging them to have a CT scan,” Adler says.
Surgery is often a good option for people who have stage I or II cancers, while a newer, less-invasive type of operation, video-assisted thoracic surgery, allows surgeons to remove diseased tissue with a much smaller incision, reducing trauma and speeding recovery time.
Standard chemotherapy drugs and radiation can slow a tumour’s growth, shrink tumours and kill cancer cells. These therapies are often used after surgery to mop up any malignancy that might have been missed and are also typically the first-line treatments used for more advanced tumours when surgery isn’t feasible.
However, if the cancer is metastatic, meaning it’s spread to other parts of the body, surgery might not always be the best therapy. But there are numerous treatments today that can prolong life even in people with more advanced cancers.
These include immunotherapies, ‘vaccines’ against cancer that stimulate the body’s own immune system to fight off the cancer, as well as drugs that inhibit the way genes mutate to grow cancer cells. New technology means doctors can more accurately understand each tumour’s unique genetic profile, so that treatments can be targeted exactly, in what is known as ‘personalised medicine’. In other words, when treated in accordance to their specific genomic alterations, they should respond better than with standard chemotherapy and radiation.
One of the most promising discoveries in the history of lung cancer is a new cancer vaccine called CimaVax, developed in Cuba and soon to be tested on patients in the US and Europe. CimaVax produces an antibody that latches onto EGF, a naturally occurring growth factor. Once it’s nabbed these molecules, it whisks them off to the liver, where they’re eliminated before cancer cells can use them.
Without EGF, “the cancers starve and essentially stop growing,” says Dr Kelvin Lee, the Chair of the Department of Immunology at Roswell Park Cancer Institute in New York. In tests of CimaVax on people with aggressive late-stage cancers, for those who responded to the vaccine, the average survival time was 18 months, versus only six for those who didn’t get it or didn’t respond.
“The other amazing thing,” says Lee, “is that at five years after they start the therapy, about 20 per cent of the patients who got the vaccine are still alive.” CimaVax also has virtually no toxicity, he says. “It’s just a shot in your arm once a month.
“We think the most exciting piece of this is in prevention of lung cancer. The idea, at least initially, would be to vaccinate people that don’t have lung cancer but we know are at high risk to get it.”
Lee will be testing CimaVax on people with lung cancer in clinical trials in the US, once the US Food and Drug Administration gives the go-ahead to proceed.
You can improve your odds of not getting lung cancer right now. If you smoke, stop. Within ten years of giving up smoking the risk of dying from lung cancer drops by half. But it won’t drop to the levels of someone who’s never smoked. Nonetheless, people with lung cancer who stop smoking live about 50 per cent longer than those who continue to smoke.
And, of course, the sooner you get diagnosed and treated, the better your odds.
“Cancer can happen to anyone, at any age,” says Natalie Dubbs. “No matter what you’re doing in your life, health has to come first. If you have any symptoms, you need to check them out properly and just look after yourself.”
The Stages of Lung Cancer
Early, isolated in the lung where it originated, has not spread.
Has spread but not extensively, usually to nearby lymph nodes and possibly to membranes between the lungs or surrounding the heart.
Has advanced further, and has now spread to lymph nodes on the same side of the chest as the affected lung, as well as other parts of the body.
May have spread to both lungs, into the chest and throughout the body, possibly affecting bones and organs such as the brain or liver.