Dr. Nicholas Rohs:The prognosis for lung cancer is actually moving absolutely in the right direction. This still is a very challenging disease. And unfortunately still there are patients who don't have as good of a prognosis. But for the vast majority of patients, given the new treatment options that we have, their prognosis has significantly improved. Dr. Raja Flores:I define advanced lung cancer as cancer that you cannot take to surgery. So something that started in the lung and now it's in your bones or it's in other parts of your body, in multiple areas. Rasha:How have treatments for late stage lung cancer evolved? Dr. Viera Lakticova:We used to treat with chemotherapy only. Over the last 10 years, we discovered that non-small cell lung cancers have mutations, different mutations, and we can call them weaknesses. And we learn how to target those weaknesses. The second major discovery was the discovery of immunotherapy. Rasha:Can you explain to us what exactly is immunotherapy? Dr. Nicholas Rohs:Immunotherapy is one of the most dramatic changes in all cancer care in the past 5 to 10 years, and has really revolutionized the space in lung cancer. Rasha:When you diagnose someone with advanced lung cancer, what is that conversation typically like? Dr. Nicholas Rohs:Each patient approaches their care differently, and has different goals, expectations, concerns. So first I make sure that I go over all the information so I really understand what's going on. I ask the patient what their understanding of the situation is, and then really talking to them as much in English as I can, instead of medical mumbo jumbo, what's going on with their disease, what this means for their health, what their treatment options are. Dr. Raja Flores:It was interesting. I had a buddy of mine, who, when we were residents, had colon cancer. And he explained to me, he said, "We see these statistics. We get it as doctors." He goes, "But when I was a patient, the only thing that gave me comfort was that when I saw a patient next to me that was my similar age, same cancer, and he was still doing fine 5, 10 years later," he said, "that gave me more hope than any statistics that we read in the medical books." So that always stuck with me. Rasha:Do you have a patient success story that you could share with us? Dr. Viera Lakticova:Every time I hear that the patients are enjoying vacations, they're able to participate in the family events and create memories, that's a success story for me. Rasha:What do you think the future looks like when we look at cancer treatments? Dr. Nicholas Rohs:I think the future for lung cancer particularly is really, really bright. Dr. Raja Flores:I'm extremely optimistic, but I have to stress the real cure early on is to get that cancer as early as possible. There's a lot of room for hope. Having a lung cancer diagnosis is not a death sentence. Dr. Nicholas Rohs was compensated for his time.

Heather:I am more fully alive now than I have ever been. Jules:When I get up, the determination and the fire I have in my gut and my heart every day, I'm probably more empowered now as a woman than I ever have been. Jules:The minute from my diagnosis, it wasn't the word cancer that hurt; it's the word incurable. I just don't like that word, dirty word in my dictionary. Heather:The news is shocking. That first year, I really was just going through the motions until the disease progression. And then it was just like, I'm not doing any of this right. I have become a victim to my diagnosis. I do not have to be a victim. I've already outlived the statistics for my particular mutation twice. I mean, I plan on outliving the statistics for at least another 10 years. Jules:Do you feel that once you make peace with it, then you feel that you could achieve more? Carrie:Anybody who has cancer has to deal with these severe emotional roller coasters. You're dying one day. You're living the next day. You have to get over that PTSD from the dying. Then you have to release yourself into a freedom that says I'm allowed to live and pursue life. So it's a whole lot of outward "fake it 'til you make it" kind of thing, but you're doing what you have to do to literally survive. And you're in battle with that cancer every darn day. Carrie:I really need to feel understood. I need to feel heard. I need to feel that what I say matters and my concerns are valid. Heather:One of my favorite questions is, "Is there anything that I may have missed that I should be asking you?" And I think that's part of that partnership where you're creating that open dialogue. Jules:The hardest part, I think, on my journey now is you have to put your faith and everything you have into those people. I remember my lung nurse said to me, "Let us do the worrying, you do the living." And that's what I decided to do, is let them worry. They're the experts. I'm not. Carrie:The choices that I made was to connect as big as possible, and not live like I'm going to die tomorrow. My choice has been to live a legacy, what kind of impact, what kind of connections. Do these people know that I love them? Let me make sure that they know that I love them. Jules:You get two choices when you're in this situation. You can either crawl under a rock or you can embrace every day. If I can give that gift to someone else, of strength and hope when they hit that dark day like we once did, then I'm happy.

Non-Small Cell Lung Cancer 101 There are two types of lung cancer: non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). NSCLC is more common. It typically develops more slowly than SCLC, and is treated differently, too. Because NSCLC often progresses slowly, you might not notice symptoms until it’s reached advanced stages. Common signs include a persistent or worsening cough, shortness of breath, chest pain, wheezing, hoarseness, and fatigue, among others. Your doctor will give your cancer a stage from 1 to 4, which signifies how advanced your cancer is and which treatments may work best. They will also test the genetic makeup of your tumor to detect if there are specific mutations or processes helping your cancer grow. Certain treatments work to stop cancer growth based on these tumor characteristics. Treatment for NSCLC may include surgery, chemotherapy, radiation, immunotherapy, targeted therapy, or a combination of these. Your cancer care team can help you make healthy choices so you can stay strong and feel better during treatment. Ask your care team for help quitting smoking, preparing nutritious meals, starting an exercise routine, and managing stress levels. Turn to Healthgrades to connect with the right oncologist for diagnosis and treatment of non-small cell lung cancer. And share this video to help spread the word!

All About Telehealth for Lung Cancer Telehealth allows doctors to care for people virtually over a phone call, text message, or most commonly, video chat. Although some situations require an in-person visit, telehealth is a great option when you can't get to the doctor's office for your lung cancer. If you're new to telehealth, here's what you need to know. Medicare will cover telehealth visits just like in-person visits, but state Medicaid programs and private insurers vary, so confirm your coverage in advance. With telehealth, even though you're not in the doctor's office, your private health information is still covered by HIPAA, so it will remain confidential and secure. Although your oncologist can't give you a physical exam via telehealth, they can write you prescriptions and offer quality care, especially if you prepare in advance. Before your telehealth appointment:- List any lung cancer symptoms (including dates and severity), like a persistent new cough, coughing up blood, shortness of breath, chest pain, or hoarseness- Note any side effects from your lung cancer medications or therapies- Record your vital signs if you own a thermometer, blood pressure monitor, or another device- Compile a list of your health conditions and medications- Write down any questions you have for your oncologist about test results- Charge your computer or phone- Make sure your internet is reliable- Download any telehealth apps your specific provider may require- Find a quiet, private space to conduct the call- Be prepared with pen and paper or a note-taking app Turn to Healthgrades to connect with the right oncologist to treat lung cancer via telehealth. And share this video to help spread the word!

Dr. Arena: If we talk about the effectiveness of immunotherapy in lung cancer, you have to know a little bit about where are we now, or where were we? Dr. Sacher: Immunotherapy is the first class of agents that I've seen within lung cancer that really offer the promise of a durable, long-term response to therapy in patients with metastatic disease. Dr. Subramaniam: There are two major types of lung cancer. Dr. Arena: One is called small cell cancer of the lung, which occupies about 15% of all lung cancers ... Dr. Sacher: ... and tends to be more heavily associated with smoking. Dr. Arena: And then there's non-small cell cancer of the lung. Dr. Subramaniam: And that may or may not be associated with smoking. Dr. Sacher: Small cell cancer tends to grow very quickly and very explosively, but also is very sensitive to traditional treatments like chemotherapy and radiation treatment. Non-small cell lung cancer also responds to those treatments, but perhaps is not as sensitive. Dr. Arena: The vast majority of cases of non-small cell cancer of the lung are what we call adenocarcinomas of the lung. Adenocarcinomas of the lung, there are about four or five different mutations which are so very important, because we have medicines, actually pills, that can be used for these specific mutations. The other most common is something called squamous cell cancer of the lung. We have multiple mutations in squamous cell cancers, and we don't have any medicines for them. So when I see a patient with non-small cell cancer of the lung, the first thing I want to know, is this a squamous cell cancer? Is this an adenocarcinoma of the lung? Dr. Sacher: Lung cancer is an extremely aggressive malignancy. And for the majority of patients, it's diagnosed at a late stage. Dr. Arena: And there are really no screening types of tests that one can do that really can make this an early diagnosis. Dr. Sacher: The use of immunotherapy in lung cancer really is defined by specific biomarkers. What a biomarker is, is just a test that we perform either on a patient's tumor or sometimes on their blood in order to determine what treatment will be most effective for them. Dr. Subramaniam: Markers in the tumors of patients that will give us a clue as to whether immunotherapy will be effective in that patient or not. Dr. Sacher: We discovered that the expression of a protein called PD-L1 on the surface of tumor cells helps us to identify patients whose cancers are likely to respond to immunotherapy. Dr. Arena: So I'm going to ask the pathologist, "Can you measure, on that cancer cell, the PD-L1?" And they can, within a few days, come back, "Yes, this tumor has got tons of that." Dr. Sacher: Patients whose tumors express that high level are the exact patients who should be treated first with immunotherapy as opposed to starting with chemotherapy. I think it's important for patients to be cognizant of this because the testing for that biomarker really is so key to directing their care, which sometimes is immunotherapy, but sometimes it's not. The most positive thing about immunotherapy is that, in a subset of patients, it can really give them back a chance to have a durable response and a normal life. And that remission from their cancer can actually last years in the best-case scenario.

Dr. Subari: There are two major subtypes of lung cancer. The most common one is non-small cell lung cancer, and the second type of lung cancer that we see is a lot less common and is a more aggressive subtype called small cell lung cancer. Dr. G: We don't do surgery for small cell lung cancer. Usually, it's a combination of chemotherapy and radiation. Dr. Kazmi: Non-small cell lung cancer, if the cancer is early stage, surgery is the mainstay of the therapy. If, however, it's more advanced, sometimes surgery is not enough. When a cancer is metastatic, patients need systemic treatments, such as chemotherapy, immunotherapy, or targeted therapy. Dr. G: Targeted therapy is based on the idea that there are specific gene mutations that drive a person's cancer. If we can figure out what those gene drivers are for that particular patient's cancer, we can then find a drug that can then target that gene mutation. Dr. Rohs: One of the really nice things about these pills is that they are well-tolerated and they can get to disease that other treatments can't get to. Dr. Subari: If we're not able to identify a genetic abnormality that we can match with a pill, we're then going to talk to you about chemotherapy and/or immunotherapy. The way that we decide which one to use depends on something called PD-L1 that sits on the surface of the cancer cell, and if you have a high level of this PD-L1, we generally recommend immunotherapy first, and if a person has a low level, we're going to recommend chemotherapy and immunotherapy as the first treatment option. Dr. G: Chemotherapy is treatment basically that kills cancer cells, but it also kills the good cells. Dr. Kazmi: Chemotherapy tends to work really well for certain cancers. However, it has side effects on the body in terms of the blood counts, the hair, the weakness, so it's not a long-term, sustainable plan. Dr. Lackey: The newest evolution of therapy is what's called immunotherapy. Our immune system is probably the best tool we have to keep our bodies healthy. Question always was, why can't the person's immune system fight off the cancer? Dr. Subari: Cancer is able to fool the immune system to prevent it from recognizing it. With immunotherapy, we're able to move the disguise, remove the brakes from the immune system, to then allow the immune system to better recognize and attack the cancer. Dr. Kazmi: Immunotherapy comes in a variety of forms. The most common of these are called checkpoint inhibitors or PD-L1 inhibitors. They are the drugs that turn on the immune system and turn your T-cells on to go and attack cancer. Dr. Rohs: Immune therapy, one of the most amazing parts of it is that it's very tolerable. Many patients don't have many side effects. Sometimes, they're a little bit more tired, their appetite can be down, and they can have something called immune phenomena. Because we're using your own immune system to attack the cancer, occasionally the immune system gets a little confused, and it can attack your own body. Dr. Subari: I think this is an extremely exciting time in the treatment of people with lung cancers. Dr. Kazmi: Immunotherapy has been a beacon of hope that cancer has needed for decades. Dr. Rohs: The pace of discovery for lung cancer right now is so staggering. I think we really are coming into the era of personalized medicine where we can hopefully minimize treatments and maximize benefits for our patients and have them live longer and live better.

Dr. Sabari: Lung cancer is a tough diagnosis, especially lung cancer that starts in the lung and learns how to travel to another part of the body. We refer to that as stage 4 lung cancer. We're not able to cure stage 4 lung cancer, but we are able to treat it. Dr. Kazmi: We think of it as a chronic disease. You may be able to take breaks from therapies, but the disease is never quite gone, and so we think of it as something we have to contain. Dr. G: When a patient is going through treatment for lung cancer, I think the most important thing to keep in mind is mentally to stay positive. Dr. Rohs: I think the best way to stay mentally strong is actually to be vulnerable. When you come to a diagnosis like lung cancer, it's really important for you to utilize all of the resources available to you. Dr. Sabari: It's important to talk to your family and friends. Dr. Kazmi: I suggest patients see support groups or individual therapy. Sometimes talking with family is not enough. Dr. Lackey: I do tell patients they need to be as active as possible. Dr. G: Get some exercise if you can. Even light exercise like walking is very good for patients. Dr. Rohs: Eat well-rounded diets. Veggies, fruits, lean meats. Stay well-hydrated. Dr. G: If you need to, consult with a nutritionist. Dr. Lackey: If they're not taking a multivitamin, I ask they start doing that. Dr. Kazmi: It is important to avoid processed foods and a ton of sugar and caffeine. Dr. Lackey: It's very important that patients quit smoking. We don't want them to continue smoking and get another cancer in five years. Dr. Rohs: The healthier you are going into therapy, the healthier you are going to be during and after therapy. Dr. Sabari: The goal of any treatment is so that a patient or a person can get back to do the normal things that they love to do. So having an open line of communication with your physician and the team is critical. Dr. Rohs: Whenever I sit down with a patient to start a new therapy, we talk about the risks, the benefits, the alternatives, and really notably, the side effects that I expect may happen so they can keep an eye out for it. You have to be honest and open with me so I can do the best to care of you. Dr. Lackey: Take a notebook with you. I find that as soon as patients walk out the door, they think of five more questions in the car that they then forget when they call my office when they get home. Dr. Kazmi: Lung cancer is the deadliest cancer in the country. There is a lot of hope for lung cancer now and other cancers than there's ever been. Dr. Sabari: If you look at the overall survival or how long people live with lung cancer, we're doing better and better. Dr. Lackey: Personally, I hate cancer. So, the day that we can actually have a hundred percent cure for every patient is the day that I can take out that part of my business happily. Dr. Kazmi: I recommend patients always ask a lot of questions of their care team, always try to get a second opinion, and stay on top of their treatment options as best as they can.

Amanda: You hear that word. You hear “cancer” and the world sort of stops spinning. It feels like you're in an alternate reality. Amanda: My name is Amanda, and I have thyroid cancer. Yoohnee: I have kidney cancer. Michael: I have prostate cancer. Alexia: I have breast cancer. Teela: My name is Teela, and I am a cancer survivor. Yoohnee: Mentally and emotionally, I took care of myself by seeing a lot of friends, making sure that I spent a lot of quality time with people I love. Alexia: I'm actually a doctor, so I pretty much practice what I preach, in terms of taking care of myself. From the very beginning, I just took on an attitude of 'No matter what happens, I'm going to choose joy.' Like every day, I'm going to find something to be happy about. Michael: I tend to look at the world with a very, very full and positive perspective. Amanda: I looked online a little for other people who have been through similar things, and I just found that it was helpful knowing I wasn't alone. Alexia: Prayer has been a very big part of my journey. Teela: You know, there's the Serenity Prayer. Basically, be able to recognize the things which I have power over, and be able to change them, and recognize the things I don't have power over, and just let them go. Amanda: I am meditating a lot. Teela: Physically, I stay strong by working out. Michael: I play soccer every single week. I watch what I eat. Yoohnee: I slept a lot, and eating whatever I wanted, although it was pretty unhealthy, it was a way for me to feel like I was living my best life. Amanda: I love going on hikes. I'm just trying to do a lot of really healthy and stress-releasing things to kind of get me through until I'm feeling really good. Teela: What is something that I wish somebody had told me when I'd just been diagnosed? The biggest thing is you're gonna get hit by chemo brain, and you're gonna get discombobulated, and again, that is okay. Start writing things down. I always keep a little planner/notebook on me at all times. I also have a notation app on my phone. Michael: I smile a lot more now. You go out in the world and you're trying to infect other people with that goodness and with that positiveness. You get that in return. Amanda: My advice would be reach out to the people that you love, and lean on them. Alexia: As strong and independent as I am, this is not something that I could do alone, and nobody could do alone, so allow people to be there and be present for you, and acknowledge that you need help. Yoohnee: Also, sharing your story, if you can, without any harm to yourself can uplift your voice. And I think that's so important to have control of when you have an illness like this. Teela: You know, every day is very up and down, but all in all, what keeps me going right now is the promise of being able to get to live.

Dr. Sabari: When I started treating patients, we initially started treatments with chemotherapy alone. There were really no other great options. Dr. Rohs: The changes that we've made in the treatment and the advances we've had, even in the past year or two, are amazing. The treatments are much more effective and more durable, as well as more tolerable. Dr. Lackey: The classic chemotherapy that people think of when they hear the term chemotherapy, doctors call that cytotoxic therapy. Cytotoxic means toxic to cells. Not just cancer cells, but all the cells in the body. Dr. Liaw: The tough thing with traditional chemotherapy is that, because it can affect both cancer cells as well as normal cells, that we do have a lot of potential issues with side effects. Dr. Lackey: But in this day and age, it's very exciting because we have additional therapies we can offer patients. Dr. Kazmi: Targeted therapies attack cancer at the level of the mutation. So, what turns a cancer on to grow and spread is usually a mutation or two or three. There are certain drugs that target those specific mutations that turn that on button on and stop it. Dr. Liaw: Targeted therapy's really revolutionized how we treat things like lung cancer, colorectal cancer, some skin cancers, without causing quite as much of the side effects that we traditionally ascribe to a classic chemotherapy. Dr. Rohs: Targeted therapies only work for patients with these genetic mutations. I wish we could be able to give this to everybody, but we have to make sure we're giving it to the right patient at the right time. Dr. Lackey: Now, the newest evolution of therapy is what's called immunotherapy. Dr. Sabari: Normally, our immune system is able to recognize and attack things that are foreign. Interestingly, cancer is able to fool the immune system to prevent it from recognizing it. With immunotherapy, we're able to remove the brakes from the immune system to then allow the immune system to better recognize and attack the cancer. Dr. Kazmi: Immunotherapy has the benefit over chemotherapy in that it doesn't give you the nausea, the vomiting, the hair loss; however, immunotherapy can have different side effects. Dr. Sabari: What we do worry about most is if we actually rev up the immune system to an extent where it can recognize and attack your own body, we worry about auto-immune or inflammatory conditions. But these side effects are rare, and actually, very well tolerated and they're very well treated. Dr. Kazmi: There are also new studies that show us that a combination of immunotherapy medicines with chemotherapy has a significant amount of synergy. There's also immunotherapy medications combined together with different types of immunotherapy to increase that synergy. Dr. Liaw: I think it's still a little bit too early for us to say that chemotherapy will be entirely phased out. If things like targeted therapy is, for whatever reason, not that effective, or if things like immunotherapy are not giving us the desired results, it's still important for us to have things like chemotherapy in our back pocket to be able to use when necessary. Dr. Sabari: I think over the next five to 10 years, we'll start to see more and more combinations of therapies, and I do hope that in my career, in my lifetime, we do see this disease cured.