Many lung cancer patients find that they have different treatment plans when they talk to their patients. Why do doctors “treat” them differently? In fact, this is called “individualized treatment” in professional circles, which is a new model of lung cancer treatment in recent years. In simple terms, it means that physicians “tailor” the most appropriate treatment plan for each patient based on their pathological staging, clinical stage, molecular test results, age, physical condition, underlying disease, and so on.
Lung cancer is the same, but there are many faces
Lung cancer is divided into small cell lung cancer (SCLC), which accounts for about 20% of all cases, and non-small cell lung cancer (NSCLC), which includes adenocarcinoma (about 35%), squamous carcinoma (about 30%), and large cell lung cancer (about 10%) subtypes. It is clear that lung cancer is not an “individual” disease, but a “group” of diseases.
In addition to the complex pathology, lung cancer is also a highly heterogeneous disease, which means that during the rapid division and proliferation of cancer cells, genetic changes occur in daughter cells, resulting in differences in tumor growth rate, invasion ability, and sensitivity to drugs. In different patients, or the same patient in different states, lung cancer has different gene and protein expression characteristics, thus determining that lung cancer patients have different individual characteristics.
As we can see, the situation of lung cancer is extremely complex, with different tumor growth sites, stages, pathological staging, genotyping, and paraneoplastic syndrome (systemic manifestations other than symptoms caused by tumor compression and metastasis), etc. In addition, patients’ age, physical condition (PS score), comorbidities, etc. are very different, so doctors cannot use one treatment plan to “beat the world”. “The patient’s age, physical status (PS score), comorbidities, etc. vary, and the physician cannot use one treatment plan.
Treatment options are varied and need to be “tailored”
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The treatment options for lung cancer are varied, including surgery, radiation therapy (radiotherapy), chemotherapy (chemotherapy), targeted therapy, immunotherapy, and more. The treatment plan for each patient also usually requires the combined opinion of multidisciplinary physicians from respiratory medicine, thoracic surgery, oncology, radiation therapy, imaging, pathology, and other disciplines, just like a joint multiservice battlefield in the modern era. This is called multidisciplinary therapy.
Specifically, the individualized treatment package for lung cancer includes individualized surgical plan, individualized radiotherapy based on precise positioning technology and imaging technology, individualized chemotherapy, interventional therapy, targeted therapy for driver mutations, immunotherapy for immune checkpoint CTLA-4/PD-1/PD-L1, etc. .
Currently, a two-drug regimen of third-generation chemotherapeutic agents combined with platinum is the standard of care for lung cancer chemotherapy and has improved the overall survival of patients with advanced NSCLC, but its efficacy has largely reached a “ceiling” and it is difficult to make further breakthroughs.
With the development of molecular biology, pharmacogenetics, and high-throughput gene sequencing technologies, it is inevitable to find the unique genetic “identity code” of each patient’s tumor cells and to select the appropriate drugs to deliver “precision hits”.
How does “individualized” therapy work?
The process of individualized treatment of lung cancer is usually a matter of “individualized” treatment.
The process of individualized treatment for lung cancer is usually as follows: the thoracic surgeon determines whether the tumor can be removed surgically; if not, the physician (respiratory medicine or medical oncology) develops a drug regimen (including traditional chemotherapy, targeted drug therapy, or immunotherapy), and the physician may consult with a radiation therapist. In addition, treatments to destroy local tumor lesions include radiofrequency ablation, radioactive particle placement, thermal perfusion chemotherapy (a combination of chemotherapy and thermotherapy), etc. The doctor in charge will also ask the appropriate specialist to discuss. In addition, China has special national conditions, and some patients will also seek the help of professional herbalists to take appropriate herbal medicines to regulate their bodies and alleviate the adverse effects of radiotherapy and chemotherapy.
Below, we introduce chemotherapy and targeted therapy in particular.
Chemotherapy
For patients with advanced lung cancer, the first-line (preferred or standard choice) chemotherapy regimen is usually a two-drug platinum-containing regimen for 4 to 6 cycles. When the “first-line” drugs are resistant, then the “second-line” regimen is chosen.
In clinical practice, physicians have found that the same chemotherapy regimen for patients of the same gender and pathology can have different results.
Although recognized as the “standard of care” by the profession, two-drug platinum-containing regimens such as paclitaxel + cisplatin are only 25% to 45% effective, meaning that at least 60% of patients do not benefit.
For chemotherapy, there are no effective selective markers. One study reported that patients without EGFR mutations and with low expression of the ERCC1 gene (excision repair cross-complementation group 1) might benefit from platinum-containing chemotherapy regimens, but this was rejected in a large clinical trial.
Targeted therapy
The efficacy of targeted therapy is more directly related to the specific target of the drug, for example, gefitinib and erlotinib work well in patients with EGFR-sensitive mutations, but if the molecular type of the tumor is not EGFR mutation but “ALK gene rearrangement”, another targeted therapy is needed. However, if the molecular type of the tumor is not EGFR mutation but “ALK gene rearrangement”, another targeted drug, crizotinib, will be required for treatment.
Thus, with the development of medical technology, the diagnosis and treatment of lung cancer are now advanced to the molecular level. The treatment plan differs according to the patient’s specific situation and the genetic information carried by the tumor. This precise individualized treatment can kill tumors more effectively while protecting normal tissues to the greatest extent.
Co-reviewed by: Guangdong Provincial People’s Hospital Guangdong Lung Cancer Institute Dr. Wang Zhen, Deputy Chief Physician Dr. Liu Siyang