Standardized and personalized treatment makes tumor less scary
Lung cancer incidence and mortality rates top the list in developed countries and large and medium-sized cities in China. According to the growth, invasion and metastasis speed and scope of lung cancer as well as the sensitivity to chemotherapy drugs and radiotherapy, lung cancer is clinically divided into small cell lung cancer and non-small cell lung cancer, the latter accounting for about 80% of the incidence of lung cancer. Director Wang Fengwei of the Department of Oncology of Tianjin People’s Hospital emphasized in the interview that the treatment of non-small cell lung cancer is not as simple as surgery. However, many patients in the clinic mistakenly think that they are cured after cutting the tumor and do not receive standardized lung cancer treatment, resulting in recurrence of the disease within a short period of time. In fact, only with reasonable application of surgery, radiotherapy, chemotherapy, Chinese and Western medicine combination and other treatment methods can we obtain better control rate and prolong survival.
During the interview, the reporter learned that the treatment of lung cancer is now moving from discipline-centered treatment mode to disease-centered multidisciplinary and multicenter collaboration, such as the combination of targeted therapy and chemotherapy, and the combination of chemotherapy and immunotherapy, etc.; in the selection of treatment strategy, it gradually changes from “single mode” to “individualized mode”. In the selection of treatment strategy, it gradually changes from “single model” to “individualized model”. Wang Fengwei, director of the Department of Oncology of People’s Hospital, especially emphasized the standardized and individualized integrated treatment of lung cancer. According to him, integrated treatment of lung cancer includes two levels: first, combining local treatment and systemic treatment. Local treatment includes surgery and radiation therapy; systemic treatment includes chemotherapy, targeted therapy, and Chinese medicine, which is unique to China. Second, the combination of various treatment methods. This requires multidisciplinary participation and consultation and discussion among doctors from related departments to combine the five major treatment methods for lung cancer, such as surgery, radiotherapy, chemotherapy, targeted therapy, Chinese medicine, and now psychotherapy “talk therapy”, and immunotherapy, to develop a scientific, reasonable and standardized treatment plan. In this way, the first thing to do when admitting a tumor patient is clinical staging, followed by personalized discussion and the application of scientific and standardized lung cancer treatment plans.
Four sets of treatment plans help the elderly overcome cancer
In the process of tumor treatment, a scientific, standardized and individualized treatment plan is the starting point of life for patients. In July 2005, Mr. Liu, who is over 70 years old, suffered one of the most violent blows in his life when he was found to have central lung cancer in his left lung, with a tumor size of 6 cm, multiple lymph node metastases in mediastinum, stage T3N2M0, IIIB, and small cell undifferentiated carcinoma in his bronchoscopy.
The word “tumor” seemed to be engraved in his heart, no matter how to distract himself, they still haunted Mr. Liu and his family’s mind. Treatment! It must be treated! This was the word that kept spinning in their minds at that time. Soon, Mr. Liu accompanied by his family came to a tertiary hospital in the city for consultation and treatment. After four cycles of chemotherapy, Mr. Liu’s body was already a bit overwhelmed and he had no choice but to return home and recuperate. The interruption of treatment put heavy pressure on Mr. Liu and his family: Does the interruption of treatment mean that it is impossible to follow? Is that life also to the final stage?
In a morning exercise, Mr. Liu’s family listened to his neighbors and heard that the oncology department of People’s Hospital was doing a good job, so with the idea of seeking medical help, Mr. Liu came to People’s Hospital for the next consultation. Director Wang Fengwei, as the receiving doctor, understood Mr. Liu’s first consultation experience. 4 cycles of CE regimen chemotherapy (carboplatin + etoposide) allowed Mr. Liu’s tumor lesions to shrink significantly. This coincided with Director Wang’s treatment idea that locally advanced small cell lung cancer is relatively sensitive to radiotherapy and systemic metastases are more common, so surgery should not be used and radiotherapy should be its main treatment. However, there is a more serious loophole in the first diagnosis. Patients with limited-stage small cell lung cancer should be treated with synchronous radiotherapy (radiotherapy and chemotherapy are administered simultaneously at an early stage) or sequential radiotherapy (radiotherapy and chemotherapy are administered alternately); if hematogenous metastasis is present, systemic chemotherapy should be considered first, and additional radiotherapy treatment should be considered in specific cases. In contrast, the first diagnosis of pure multi-course chemotherapy alone will hardly achieve the desired treatment effect.
For this reason, Director Wang decisively formulated the next treatment plan. Although the first diagnosis missed the timing of simultaneous radiotherapy and chemotherapy treatment, it was not too late to add radiotherapy to the patient’s treatment, because radiotherapy is very critical in small cell lung cancer. Subsequently, Mr. Liu was given synchronized radiotherapy and chemotherapy treatment, 60Gy/6 weeks, and two cycles of synchronized chemotherapy CE regimen, and the post-treatment evaluation was complete disappearance. When asked about the reason of synchronous radiotherapy, Dr. Wang explained that the initial use of synchronous radiotherapy for limited-stage small cell lung cancer is more effective than the later use of synchronous radiotherapy, and synchronous radiotherapy is better than sequential radiotherapy, and sequential radiotherapy is stronger than radiotherapy or chemotherapy alone. Synchronous radiotherapy can cure nearly 30% of patients, which is 5 times more effective than 20 years ago, and is the current standard of care. In response to the people’s concern about the side effects of the treatment, Director Wang said that synchronous radiotherapy has been used internationally for nearly 20 years, treating tens of thousands of patients, and after a large number of long-term clinical verification, the response can be tolerated by the majority of patients, and most of the side effects are reversible and can be completely relieved by the treatment.
After the first stage, Mr. Liu’s tumor was under control, but considering that small cell lung cancer has a very high risk of recurrence and metastasis, clinical statistics show that the brain metastasis rate of small cell lung cancer is up to 40% or more. And brain prophylactic irradiation is an important part of small cell lung cancer treatment, one of the main means to reduce the failure of small cell lung cancer, a guarantee of long-term survival for patients, and a standardized treatment. For this reason, after Mr. Liu’s tumor completely disappeared with simultaneous radiotherapy and chemotherapy, Director Wang performed two cycles of adjuvant CE regimen chemotherapy, and after a comprehensive evaluation of no signs of recurrence and metastasis, brain prophylactic radiotherapy was administered, followed by a follow-up review phase.
In the head-to-head battle with tumor, Mr. Liu obtained a stage victory with the assistance of the Department of Oncology of People’s Hospital, which also strengthened his confidence in living a healthy life. However, life did not favor his hard-earned life in his later years, and during the review in September 2008, Mr. Liu was found to have fullness of the right lung hilar and the intensive CT showed local recurrence, while the clinical symptoms of the patient’s lung became obvious again. As they were familiar with Mr. Liu’s medical history, doctors from the Department of Oncology of People’s Hospital, under the leadership of Director Wang Fengwei, immediately formulated a treatment plan for him, namely, local small field simultaneous radiotherapy with a radiotherapy dose of 50Gy and chemotherapy man with CE protocol. At this point, Mr. Liu looked much more calm than 3 years ago, he said, “I have died once, the People’s Hospital has given me a new life, I trust the doctors here.” Confidently, Mr. Liu actively cooperated with the treatment and insisted on completing 4 cycles of CE chemotherapy after radiation therapy. At this time, Mr. Liu got the result that the tumor was evaluated as completely disappeared, with localized radiofibrosis in the right upper lung, and clinical symptoms were not obvious and did not require clinical management. This meant that he had once again won the war against the disease and the sunshine of life still shone on his old age.
However, fate did not stop there, the tumor came for the third time, and Mr. Liu’s mental defense seemed to be broken by the recurring disease. the CT found that his lymph nodes under the bulge were significantly enlarged, and lymph node metastasis was clinically considered. His family and doctors noticed the subtle changes in his psychology and started psychological counseling and encouragement. Director Wang Fengwei always talked with him kindly during each consultation, asking about the subtle reflections in the treatment; during the infusion, the nurses were in front of his bed, never leaving him to feel the care; the patients would also encourage him with their own experiences, “Brother Liu, recurrence is frequent, you have to hold on, this disease in time you are strong it is weak, you are weak it is strong “! The warmth from around him made Mr. Liu see hope again and actively engaged in treatment. This time, Director Wang Fengwei, from the patient’s drug resistance, radiotherapy effect, the patient’s economic conditions and other aspects of comprehensive consideration, abandoned the previous CE chemotherapy regimen, and switched to the COA regimen chemotherapy (cyclophosphamide, vincristine and epi-amycin) adjuvant chemotherapy for four cycles. At the end of the treatment, Mr. Liu reaped health once again, and the lymph node metastasis disappeared after local radiotherapy adjuvant chemotherapy.
In June 2010, Mr. Liu was again found to have cancer metastasis with metastasis in the left upper neck and submandibular lymph nodes. Director Wang Fengwei adjusted the treatment plan at the right time and gave radiotherapy to the lymphatic drainage area of the neck, and the lymph nodes disappeared after the treatment. Subsequently, Topotecan chemotherapy was given to date, and no sign of tumor has been detected.
During the four times of treatment, relapse and treatment, Director Wang Fengwei was not confined to one treatment method, he adjusted the treatment plan according to the development of the patient’s condition, and used second or even third radiotherapy to make Mr. Liu overcome the disease again and again. In this regard, Director Wang said that radiotherapy again has its certain clinical significance, and for lung cancer, grasping the indications has a better chance for some patients, and patients, families and doctors should not give up.
Radiotherapy is effective in tumor treatment
During the interview, the reporter learned that at present, about 60-70% of lung cancer patients in the clinic have to receive radiotherapy, only the time of radiotherapy may be different. The role of radiotherapy in different stages of lung cancer patients is different. Radiotherapy is one of the three major treatments for malignant tumors, and domestic and international statistics show that about 60%-70% of cancer patients need to receive radiotherapy. Three-dimensional conformal intensity-modulated radiotherapy is a new radiotherapy technique that can make the high dose distribution of radiotherapy in three-dimensional direction completely consistent with the shape of the tumor (target area), and the radiation high dose distribution area produced by intensity-modulated radiotherapy is consistent with the three-dimensional shape of the tumor target area, which can minimize the irradiation range of surrounding normal tissues and organs, so it can further improve the radiotherapy dose and reduce the complications of surrounding normal tissues. Generally speaking, intensity-modulated radiotherapy is like that precision-guided missile, which can deliver a devastating blow to cancer cells while normal body tissues are not damaged much.
Some elderly patients with early-stage lung cancer who have other diseases, such as diabetes, or cardiovascular diseases, cannot tolerate anesthesia and open-heart surgery, and are unable to undergo surgery, should undergo radiotherapy. In recent years, due to the advancement of radiotherapy technology, the effect of radiotherapy for early stage non-small cell lung cancer has been improving and is close to the radical treatment effect of surgery, thus a randomized clinical study comparing stereotactic radiotherapy with surgical resection for early stage lung cancer has been conducted abroad to answer the question of whether early stage lung cancer needs surgical resection, which is worthy of our expectation. It is worth looking forward to the randomized clinical study to answer the question of whether surgery is needed for early-stage lung cancer.
For intermediate stage non-small cell lung cancer, combination therapy is the mainstay. Locally advanced non-small cell lung cancer, in general, in patients under 70 years of age, if surgical resection is not possible, simultaneous radiotherapy and chemotherapy is the standard treatment aimed at resolving the local lesion. Chemotherapy can increase the intensity of local radiotherapy and work on systemic lesions. It is not necessary to postpone systemic treatment because radiotherapy is done first, which affects the systemic effect, or to postpone local treatment by doing chemotherapy first.
For patients with brain metastases, bone metastases and other distant metastases, including stage IV lung cancer patients, palliative care is needed. If brain metastases have many compression symptoms, radiation therapy may be required first; if brain metastases are disseminated or the lesions are relatively small and asymptomatic, but the lesions elsewhere in the body are more obvious, systemic chemotherapy may be given first, and radiation therapy will be given after three or four cycles of chemotherapy are completed. For bone metastases with single or few bone metastases, radiotherapy is the first choice to reduce pain, and on top of that, choosing bisphosphonates can improve the efficacy. For this reason, Director Wang Fengwei reminded the patients that they must go to the oncology hospital to cooperate with doctors after diagnosis, and only by taking the correct treatment, the local control rate of tumor can be improved, so as to achieve the purpose of prolonging the survival.
When introducing the new state-of-the-art tumor treatment method emphasizing radiotherapy, Director Wang Fengwei said that radiotherapy can be applied to the treatment of almost all tumors, and showed the obvious advantages of radiotherapy. For prostate cancer, intensity-modulated radiotherapy obtained the same efficacy as surgery, while patients were spared the pain and damage of surgery; for nasopharyngeal cancer, intensity-modulated radiotherapy improved the efficacy while reducing the damage of parotid gland, alleviated the pain of dry mouth, and reduced the damage of brain and spinal cord; in addition, for recurrent nasopharyngeal cancer, a second radiotherapy can be easily performed without increasing the complications of radiotherapy; for brain tumors, intensity-modulated radiotherapy improved the efficacy while reducing the pain of dry mouth. For breast cancer, intensity-modulated radiotherapy can reduce the damage to the heart; for lung cancer, intensity-modulated radiotherapy can reduce the damage to normal lung tissue, heart, esophagus and other organs, which can make the combined treatment of radiotherapy and chemotherapy easy to implement because of the reduction of side effects and obviously improve the efficacy; for gastrointestinal tumors, liver, kidney and other abdominal tumors, in the past, due to the normal The emergence of 3D conformal intensity-modulated radiotherapy technology has made radiotherapy possible for such patients. Since intensity-modulated radiotherapy can maximize the protection of normal organs, it expands the indications for radiotherapy, improves the dose and efficacy of radiotherapy, reduces the damage of radiotherapy, and improves the survival rate and quality of life.
Tumor treatment needs to be standardized and individualized
Nowadays, malignant tumor has become a common disease and multi-morbidity threatening people’s health. Normative treatment is to abide by the treatment principles and apply the evidence-based, advanced, reasonable and effective clinical treatment methods to clinical practice, with the collaboration of physicians from various oncology departments and the cooperation of physicians, patients and families to achieve the best effect of malignant tumor treatment.
In the interview, Director Wang pointed out that many tumors in early stage often lack symptoms enough to attract people’s attention, and many tumors in early stage have already occurred subclinical microscopic lesions which are still difficult to be detected by current examination means. Therefore, many patients who have obvious symptoms and come to the clinic are already in advanced stage of tumor. Whether a tumor patient should have surgery or radiotherapy first, chemotherapy or surgery first, whether surgery is needed or not, whether chemotherapy should be given in high or low doses, all of these are on the verge of being regulated or not. The results of these standardized and unstandardized treatments are very different, and sometimes even cause irreparable harm to patients. Therefore, from the viewpoint of clinical efficacy, while continuing to improve the level of existing effective treatments, it is necessary to apply the existing treatments, including surgery, radiotherapy, chemotherapy, biologically targeted therapy, Chinese medicine, etc., in a reasonable and effective manner and at an appropriate cost, according to the patient’s body condition, pathological type, invasion range (stage) and development trend of the tumor. The most appropriate treatment is provided to patients in the most reasonable and effective way and at the appropriate cost, so that pain and complications are minimized and the patient’s quality of life is substantially improved and survival is prolonged.
Director Wang further pointed out that once a patient is diagnosed with tumor, he/she should go to a tumor specialist, and experts from various tumor departments including surgery, radiotherapy, chemotherapy and imaging should discuss together to formulate an effective overall treatment plan and fully communicate with the patient and his/her family, so that various treatments can be applied in a correct and orderly manner to achieve the best treatment effect. In the development of comprehensive standardized treatment plan, we should not only pay attention to the recent efficacy of patients, but also pay attention to the long-term efficacy and quality of life of patients. Because tumor treatment has entered the era of multidisciplinary comprehensive treatment, not only emphasizing radical treatment, but also palliative treatment and end-of-life care. Early stage tumors can not only be cured but also preserve the function; middle stage tumors can increase the chance of cure; late stage tumors can expand the surgical resection rate; recurrent malignant tumors can strive for better efficacy. Only after comprehensive standardized treatment, tumor treatment can show good curative effect.
Due to the lack of specialist knowledge, many patients and their families, including some doctors, mistakenly equate surgical resection with cure, resulting in patients not coming to oncology specialists for comprehensive treatment and regular follow-up after surgery, and only after local recurrence and systemic metastasis, do they come to the clinic, regretting too late. Even early non-invasive lesions are clinically found to have the possibility of recurrence and metastasis, therefore, we should never think that early lesions do not need follow-up and regular review. Almost all recurrences after radical resection of gastrointestinal malignancies occur within 5 years, while 80% of recurrences occur within 2 years after surgery. Therefore, it is difficult to have a miracle by surgery alone, and regular follow-up by oncology specialists after treatment is very important, which is an important link for early detection of recurrence and then timely adoption of appropriate treatment methods so as to improve the efficacy.
Director Wang said, it is generally believed that the first follow-up visit should be made to oncology specialist 3 to 4 weeks after surgery, and the post-operative adjuvant treatment plan should be determined. In the first 3 years after surgery, the patient should be reviewed in oncology specialist once every 3-6 months, and after 3 years, the patient can be reviewed every 6 months, and after 5 years, the follow-up visit should be once a year. Each follow-up review includes medical history, physical examination, routine laboratory tests, serum tumor marker measurement and ultrasound examination, etc. These tests are non-invasive and economically inexpensive, so the price of the whole follow-up review is acceptable. The purpose of the examination is to understand whether there is local review for gastric cancer patients and whether there is simultaneous or heterochronous multiple primary cancer and precancerous lesions for bowel cancer patients, so as to facilitate early detection and timely treatment. If there is no abnormality in the first endoscopy, the examination can be done again in 1 year interval.