Interview with Joan H Schiller, MD
Dr Schiller is Chief of the Division of Hematology and Oncology, Deputy Director of the Simmons Comprehensive Cancer Center and Andrea L Simmons Distinguished Chair in Cancer Research at the University of Texas Southwestern Medical Center in Dallas, Texas.
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Introduction to adjuvant chemotherapy
DR LOVE: For another perspective on adjuvant therapy for lung cancer, I visited with Dr Joan Schiller, who reviewed many of the concepts discussed by Dr Wakelee but from another perspective. To begin, Dr Schiller commented on how patients end up in her office for a consultation to consider adjuvant treatment.
DR SCHILLER: Usually they come from either a pathologist or an interventional radiologist who’s done a biopsy. And someone has told the patient that they have cancer and have referred them to me. And the patient usually comes in pretty scared, not knowing what’s going to happen.
DR LOVE: And so in the adjuvant situation, are you usually seeing them after the surgery?
DR SCHILLER: After the surgery, yes.
DR LOVE: Right. So, at that point they’ve had the surgery and they’ve come to you. Can you talk a little bit about what adjuvant therapy is, what the idea is behind it?
DR SCHILLER: Although hopefully the thoracic surgeon really did get it all, so to speak, the thoracic surgeon’s not perfect. And there’s always a chance that a couple of cancer cells may have been left behind, either at the site of the original tumor or may have gotten into the bloodstream even before the operation and gone someplace else. So, there’s a chance that there might be microscopic amounts of cancer somewhere in your body that we just don’t have any good enough tests to see.
And so for that reason, because we know that based upon the size of your tumor, that there is a chance this cancer will come back, – there’s a chance that that has, in fact, happened to you, that we would recommend giving some additional form of systemic therapy. And we would suggest systemic therapy, meaning whole-body therapy, because the cancer cells may have gone essentially anywhere in your body. Now, they may not have. You may be cured just sitting there. That may never have happened, but unfortunately none of our tests are good enough for us to be able to say this person’s got residual cancer cells, and that person does not.
DR LOVE: So, what about the possibility of just waiting and seeing whether the cancer comes back and then just treat it at that point?
DR SCHILLER: That certainly is a possibility; however, once lung cancer comes back, it’s rarely curable. Not 100 percent of the time, but usually it comes back kind of in spades, so to speak. And it’s usually not resectable and not curable.
DR LOVE: And if, by taking this additional chemotherapy, does that mean that pretty much it’s not going to come back, period?
DR SCHILLER: Unfortunately, no. Realistically, there’s always the possibility that just sitting there, you don’t have any micrometastases and you don’t really need this therapy. And realistically, there is the possibility that you do have micrometastases, but they are not all killed by the chemotherapy, and that the cancer will come back regardless.
Now, having said all that, we do know from studies, however, that as a group, patients with lung cancer who have this additional therapy are more likely to live longer than those who have not.
DR LOVE: And how do you determine what the actual risk is of the cancer coming back and how much that might drop by taking the chemo?
DR SCHILLER: So, the risk of it coming back is based upon the size of the tumor. Obviously, the larger the size, the more chance that it’s had to grow and to kind of sit around and to possibly still be there. And the other big risk factor that we look at is whether or not any lymph nodes are involved, because cancer will often spread through the lymph nodes to elsewhere in the body. So, if lymph nodes are involved, what that may mean, although we don’t know for sure, but what it may mean, that they actually escaped out of those lymph nodes and have also gone someplace else.
