Transcript: Ask Us Anything about lung cancer with Adam Marcus, PhD, & Suresh Ramalingam, MD

Transcript: Ask Us Anything about lung cancer with Adam Marcus, PhD, & Suresh Ramalingam, MD

Welcome everyone to the very first Ask Me Anything on the HealthUnlocked Free to Breathe community. We are excited to have all of you here!

Adam Marcus is an Associate Professor in the Dept. of Hematology and Oncology, a former Georgia Cancer Coalition Scholar, and directs a federally funded cancer research laboratory. His research focuses on understanding how cancer cells become malignant with the goal of developing new treatments that could help stop the spread of cancer. He also runs a science education community outreach program that brings microscopes into classrooms across Georgia.

Suresh Ramalingam is the Chief of Thoracic Oncology at Winship Cancer Institute. He leads a multi-disciplinary team for the treatment of lung cancer and is a well-known specialist in thoracic oncology. His research focuses on development of new treatments for lung cancer, including immunotherapies and targeted drugs. Dr. Ramilingam also has a strong interest in early phase clinical trials with novel translational endpoints to identify molecular effects of experimental agents. His work has lead to more than 200 publications.

For the next hour, ask Dr Adam Marcus and Dr Suresh Ramalingam about lung cancer, the future in personalized cancer medicine, the research they are doing, what food they like to eat; Ask them Anything through a reply to this post! Be sure to refresh the page to see responses.

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  • We’re really excited about the AMA for lung cancer and are looking forward for all your questions!

    We’ve also had some great questions from some users in advance of today’s AMA, and we will be posting some of these on their behalf. We may have edited them for clarity.

  • Hello Dr Marcus and Dr Ramalingam, thank you very much for doing this AMA. What do you recommend as sources of information for lung cancer patients who want to learn more on their own, besides the information that they get from their doctors?

  • The American Cancer Society and Free to Breathe websites have lots of useful information for patients. Please be aware that the information is broad and general, and should be taken in context with the conversations with the treating physician.

  • Hello. I'm a 45 year old healthy woman living with stage 4 metastatic NSCLC since April 2015. Cancer is remaining stable in my chest as I continue chemo (Alimta) every three weeks. My next line will be either keytruda or opdivo. What are the benefits of staying on Alimta only rather than adding an immunotherapy drug at this time? Are there trials that would add immunotherapy on top of my current Maintanance? My oncologist prefers to wait until the Alimta is no longer effective, but it is tempting to want to try something else to see if I might have a more remarkable response with potentially easier side effects. Longevity is the goal, but raising 3 small kids on this chemo regiment is tough

  • You bring up an important issue about combination approaches. I am pleased to hear that your cancer is stable. I also want to make sure that you have been tested for EGFR, ALK and ROS1 to determine whether targeted therapy would be an option. At this time, continuing a treatment that seems to be working is preferred. The addition of immunotherapy to maintenance chemotherapy has not been studied yet. We are in very early days with immunotherapy and there are lot of open questions. It is clear that immunotherapy will be important for your care down the road.

  • Thank you. Stay the course. I can do that.

    I do not have any of those markers, but my Foundation One testing did identify a mutation of MSH2, which I understand can be a possible predictor of potentially good response to immunotherapy down the road.

  • That is true- in colon cancer patients immunotherapy appears to work well in patients with certain DNA repair mismatch deficiency.

  • And thank you so much for your work in this field. The landscape has changed even in the 17 months since my diagnosis. Research is where I place my hope...that the research findings outrun the cancer progression. I pray in gratitude for you researchers and other medical professionals often and specifically when I receive a treatment.

  • Yes, the landscape is completely changing. Researchers are working hard here at Winship and across the country!

  • This question came from Ricefam:

    "I feel that a diet plays a big role in fighting cancer, but my doctor says there is no scientific proof. Do you agree?

    I feel that spiritual, mental, stress, diet, environmental are all important when fighting cancer

    As a stage IV NSCCA lung cancer survivor (just celebrated my 1 year anniversary of no evidence of disease) God is good."

  • There have been big investments recently in understanding diet (precision diet for example) and how it impacts prevention as well as treatment. The jury is still out on how this data will impact clinical care, but overall results do show an impact on treatment at least in the laboratory. Nevertheless, maintaining a healthy lifestyle has been proven over and over again to decreasing cancer risk.

  • I'd like to add to this great question. Is there a sugar-cancer connection?

  • Laboratory studied indicate that cancer cells preferentially utilize glucose for their metabolism. However, i am not in favor of patients completely avoiding sugar when they are being treated for cancer. This often has undesirable consequences that could actually make the situation worse. Cancer cells have other ways to find their fuel even if one stops taking sugar altogether.

  • Can you elaborate on why avoiding sugar can make the situation worse?

  • I was dxed with adenocarcinoma, EGFR pos. Started Tarceva. Progression after 6 months. A year later a biopsy shows squamous, and blood biopsy shows there is a little t790M. I'm on Tagrisso and there's one resistant tumor. Others are stable or shrunk slightly (even the squamous one). Should I have another biopsy to see what this growing tumor is, or is there another way to go. Stage 4, mets to brain. Thanks!

  • Sorry to hear about the quick progression while on tarceva. Your tumor appears to have a mixed histology with both adeno and squamous components. If there is on resistant tumor, depending on the location, one could give radiotherapy to that lesion and then continue on with tagrisso.

  • Thank you for your response. My doctor is not confident that we can contain the cancer without knowing what it is. He is ok with radiation after a biopsy, though. I don't think this is technically oligometastasis since I have new tumors in other places that appeared on Tarceva but now are quiet for now on Tagrisso. Thank you again for doing this AMA.

  • ChelleG asks: "Are the new immunotherapy treatments available to those who have already had chemo and radiation?"

  • If the cancer has progressed after chemo and radiation then immunotherapy can be given, if however the cancer has not progressed this is still being determined.

  • MD_Suresh and PhD_Adam Are you both interested in Flipping Out for lung cancer this month? I think it would be great to see what you guys come up with! Fliptobreathe.com

  • Absolutely! Flipping tables is my specialty :)

  • That's what I like to hear! We'll talk to you a bit later on how to get set up. :D

  • Happy to do it!

  • Have you had any patients with driver mutations (EGFR, ALK, ROS1) use immunotherapy in your practices? If so, what kind of results are you seeing? If some people are responding, do you see any patterns? The sub-group analyses from the big trials are looking rather gloomy.

  • I have used immunotherapy after I run out of chemotherapy and targeted therapy options for patients with EGFR and ALK. So far, the results have not been great. The tumors have low PDL1 expression and do not respond often to check point inhibitors (immunotherapy).

  • Would you recommend that all such patients get PD-L1 testing if possible before starting immunotherapy ?

  • Are you referring to Keytruda and Optivo? Are there immunotherapies that respond well to EGFR/ALK patients?

  • Davidatp asks:

    "Are the new immunotherapy treatments available to those who have already had chemo and radiation?"

  • A large clinical trial with immunotherapy after chemotherapy and radiation has been completed and the results are awaited. There are some other ongoing trials as well.

  • My Dr. uses CEA blood tests to monitor my lung cancer. My CEA number had gone down completely after my 111A lung cancer tumor was removed but now its is tripling every month. After tests and scans it has now progressed to Stage IV with mets to brain and adrenals. I also have the EGFR mutation which they just tested for now. I have two questions.

    1. Would it of made of difference if they tested for the mutation at the 1st diagnosis of lung cancer instead of waiting for it to progress? I had asked them too but they said that they only test for mutations only if I did not respond to treatment.

    2. I was wondering if I should have a colonoscopy as well since the CEA is more for Colon Cancer?

  • CEA is nonspecific marker- which means it can go up and down in a variety of other situations. If your tumor bears an EGFR mutation, treatment with an EGFR inhibitor is the best next step. I take it that they are doing radiotherapy for the brain spots. In general, if the mutation is found in one specimen, there is no need to test every specimen. best wishes.

  • Yes, Im on Tarceva and just finished a grueling two week brain Radiation :( Could I have started the Tarceva while stage III before my progression? I feel they could have stopped it sooner if they had check for the mutation then as I asked instead of now in stage IV :(

  • Davidatp asks:

    "What causes mucus post lung cancer treatment and what are the best ways to treat it?"

  • It commonly happens after radiation that involves exposure of the airway. The inflammation created by the treatments is the primary reason behind the mucus formation. Some forms of lung cancer also produce large amount of mucus. Treatment approaches include scopolamine patches, certain inhalers, etc- none of these can be considered as proven options, but are worth trying.

  • Hi i'm Jo Taylor I was wondering I have stage three lung left upper it was in my lympnodes.I wouldn't do the radiation.they removed my lung. I did six months of chemo . I have been in remission for three years and was told recently it was'nt in my lympnodes anymore. how much of a percentage Would I have to make it to the five year mark.

  • Jo- first of all, I am happy to hear about how well you have done. Most of the recurrences happen early. Since you have passed three years, i would rate your likelihood of cure as high. You still need regular follow up with scans until at least 5 years. JoTaylor

  • FtB_Travis I don't hear i'm on my tablet I do not have a smart phone.

  • There is no audio. It is just text responses.

  • LynnHollandKelley asks: "Every now and then out of nowhere I suddenly cannot catch my breath. I have to be conscious about it and each breath. It is almost like I am choking and that is such a horrible fear of mine. Have you got any advice?"

  • That is concerning.. it would be helpful to review your scans and see if there is anything that could impair your breathing. Have you discussed with your physician about this?

  • My Dad was diagnosed with Stage 4 adenocarcinoma lung cancer, mets to the brain, in Aug. He's on Gefitinib and since started has developed bilateral pulmonary emboli in segental arteries in both lungs. Fragmin has been prescribed. Would mechanical approaches like sequential compression devices while he sleeps, elevating feet while sleeping, compression socks during the day, help? He is mobile and exercises regularly, less so now due to the increased shortness of breath. Thanks so much for this AMA!

  • Unfortunately blood clots are common in patients with lung cancer. Blood thinner (anticoagulation) is the best treatment for this. if he has leg swelling, elevating the leg during night might be helpful. Compression devices are not necessary, and could increase the risk of the clot breaking off into the lungs.

  • Yes, he has a swollen ankle, so I will ask him to keep his legs elevated on a pillow during sleep! He also sleeps like a log for long hours and when he wakes has started to have shortness of breath immediately - I'm concerned it's the blood clotting during sleep. Is there anything that could help, short of waking up every few hours?

  • Who should now get PD-L1 testing as standard of care, and when should patients get this testing? How does an oncologist wend his/her way through the confusion caused by there being so many competing tests on the market? Is the approval of Keytruda as first-line likely to result in converge on the test associated with that drug?

  • Since keytruda is the only drug approved as first line therapy, PDL-1 testing is recommended. We test patients with newly diagnosed stage IV lung cancer if they dont have EGFR or other treatable mutations.

  • WE test using the Merck antibody. You are correct about multiple tests being available- the good news is many of them pick up PDL-1 expression at similar rate as their counterparts.

  • FtB_Travis I don't know why I can't hear I hear alot of stuff on hear.So I don't understand.

  • I sent you a message JoTaylor

  • My maintenance chemo schedule is Alimta every three weeks. Sometimes I go four weeks to accommodate vacation or Thanksgiving for example.Is there any research to indicate whether outcomes differ by having treatment every four weeks instead of three? Or long term side effects?

  • It should be perfectly OK to do it every 4 weeks whenever necessary. I don't think it makes a difference in outcomes.

  • MD_Suresh 2015 was a banner year for approval of lung cancer treatments, what do you think was the most important breakthrough and why?

  • I think immunotherapy and tagrisso approval are important breakthroughs in lung cancer. Immunotherapy now provides the hope that long term survival can be achieved for patients with advanced stage disease. Tagrisso fills in an unmet need for patients that develop resistance to tarceva, gefitinib or gilotrif.

  • Thank you for your answer!

  • Hi PhD_Adam -

    What does the future hold in terms of making more personalized medicine a reality?

  • I believe that right now we are in a transition period. Some personalized medicine approaches are being implemented and many are still being tested. We are generating lots of exciting and interesting data in the lab, the big question is what all this data means and how can we implement these new findings in the clinic. Research funding will continue to make this a reality.

  • Very true - research funding will continue to fuel progress. Thank you for all the work that you do.

  • Are there any immunotherapy options that work well for EGFR+ patients?

  • My hope is that combination approaches might help overcome the initial disappointment regarding lack of efficacy with PD-1 inhibitors in EGFR mutated patients. however, the research is still at a very early phase.

  • Thank you for your response.

  • Are there any clinical trials right now, both currently running and also in the process of starting up, that you think are especially exciting?

  • There are a number of immunotherapy combination trials that are exciting. I also excited about trials studying immunotherapy for early stage lung cancer after patients undergo surgery- this could be a way to increase cure rates.

  • Dano2222 asks: "Is it true that chemotherapy in not effective with lung cancer?"

  • That is not true. Chemotherapy still remains a major cornerstone for lung cancer treatment. It improves survival and quality of life.

  • Fasting to recycle damaged immune cells / regenerate immune system - can't quite believe the research on this and how it might fight cancer. Thoughts?

  • Not familiar with this. Is it from the primary science literature?

  • Thanks to everyone who participated. It has been our pleasure to be on this forum today.

  • Thank you so much Dr Ramalingam. You had great answers. Enjoy the rest of your day and the upcoming holiday!

  • Thank you everyone for the great questions! It was our pleasure to participate.

  • Thanks a bunch Dr Marcus! It was great to hear about the future of personalized medicine. We hope you enjoy the upcoming holiday!

  • It is now 2pm Eastern Time, which means we are going to wrap up this Ask Me Anything session.

    I want to thank PhD_Adam and MD_Suresh for taking the time out of their busy schedules to answer the questions from our community.

    Also, a big thank you to the HealthUnlocked staff for serving as proxies and asking questions on behalf of community members who couldn't make it.

    Thanks everyone who participated!

  • Thanks to all at Free to Breathe and to PhD_Adam and MD_Suresh for presenting this AMA. Great session with lots of good infor!

  • Great questions from you as well!

  • Thank you for this AMA, it was interesting and enlightening.