Interview with Heather Wakelee, MD
Dr Wakelee is Assistant Professor of Medicine in the Division of Oncology at Stanford University in Stanford, California.
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Introduction to adjuvant chemotherapy and risk assessment of cancer recurrence
DR LOVE: Welcome to this patient information program on adjuvant systemic therapy of lung cancer. This is medical oncologist Dr Neil Love. Our education group in Miami has been producing interview programs on cancer treatment for more than 20 years. On this program, we visit with two medical oncologists and a nurse practitioner specializing in lung cancer research and treatment, and four patients who have received systemic treatment in addition to surgery for their early-stage disease. We have asked these people the questions we think patients and families may pose. We hope you will take what is useful and leave the rest behind.
To begin, oncologist Dr Heather Wakelee comments on the background for the development of this important and commonly utilized therapy.
DR WAKELEE: We’ve known for many years that giving additional treatment after surgery for breast cancer and colon cancer can significantly improve cure rates and for lung cancer, we didn’t really have that data until about the last five years or so.
The risk with lung cancer and most other cancers is that there could be small tumor cells that have escaped. Most of them, before the surgery happened. Theoretically there could have been a few even at the time of surgery and what we would hope to do is to go after those escaped tumor cells.
DR LOVE: Well, what about just waiting until they become a problem?
DR WAKELEE: Once they do come back, they’re more likely to show up in other parts of the body. And once cancer has shown up in other parts of the body though we can still treat, give people time, we don’t know how to cure at least with the treatments we have today. And so what we’d like to is prevent the cancer from coming back at all.
DR LOVE: So can you actually figure out who it is that’s going to have the cancer come back?
DR WAKELEE: We have some things that can give us a hint. We know that if the cancer has spread to lymph nodes it’s more likely to come back. But other than that, we don’t have a lot of data. People have been doing a lot of research, trying to identify particular proteins that the tumor might express to indicate it’s more or less likely to come back, but that’s all still very experimental. And so at this point, the best that we have are looking at how many lymph nodes were involved, if the tumor looked particularly aggressive under the microscope, that can give us hint. If it looked like it was invading into blood vessels, that might give us a hint.
DR LOVE: So you look at all these things and you come up with kind of what, a percentage of the chance that you think it might come back?
DR WAKELEE: Pretty much.
DR LOVE: So if you have a situation where, let’s say there’s a 40 percent chance that it might come back, it also means there’s a 60 percent chance the person’s cured.
DR WAKELEE: Exactly. And when I’m talking to a patient, we highlight that and talk about the fact that there’s a more than likely chance that they’ve already been cured, that there’s a percentage of people even if we give them treatment, who will not be cured, and so we’re, at this point, probably impacting five to ten percent of people. And I usually go through the analogy if there are one hundred people who get treated with adjuvant chemotherapy, chemotherapy after surgery and one hundred people that don’t, in the group that got the chemotherapy there’ll be five to ten more of them alive at five years versus in the group that did not get the treatment.
And some people look at that and decide, that’s enough. I’m willing to go through three months of treatment or a year on a trial to be one of those five to ten people. And other people say, “well if it’s not a 20 percent difference, I’m not going to do it.” And so I try to bring it into that, that discussion of percentage cure at five years. I think that’s a concept that people are able to understand.
I think most people have done at least a little bit of gambling and can understand odds when we’re talking about percentage rates.
DR LOVE: So, what’s the range of the risk without any treatment that is involved with these patients? What’s the low and high end?
DR WAKELEE: Well, for patients who have the mediastinal nodes involved, the Stage III patients, the chance of the cancer coming back with surgery alone is going to be 70 percent, maybe even higher.
DR LOVE: And when you say mediastinum, that’s in the middle of the chest.
DR WAKELEE: Exactly. So the lymph nodes have spread to the center, the mediastinum, that central part. For patients who have lymph nodes that are in the lung themselves, we call those the N1 nodes. Those would be patients we would call Stage II. Their chance of having the cancer come back is somewhere between 40 and 50 percent. And if there are no lymph nodes at all, the chance of the cancer coming back is still as high as 30, maybe even 40 percent. And so this is a very dangerous disease for that reason because it does tend to come back, even when the surgeon’s gotten everything.
DR LOVE: So you’re looking at people who have a risk, maybe in the range of 30 to 70 percent depending upon a lot of factors they need to ask their doctor about to really find out about them. And then decreasing it, but not bringing it down to zero.
DR WAKELEE: Correct.
DR LOVE: The word “adjuvant”is often used for this. Why do they use that word?
DR WAKELEE: It’s a term we use for treatment after the surgery. So I think postoperative chemotherapy is probably a better term and it’s more understandable.
