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Breaking Down Lung Cancer

Editor’s Note: This article originally appeared in Biotech Primer Weekly. For more of the science behind the headlines, please subscribe.

Emily Burke, BiotechPrimer.com

Emily Burke, BiotechPrimer.com

The hit TV series Breaking Bad featured anti-hero Walter White, who starts out as a sympathetic character: a mild-mannered high school chemistry teacher with a nagging cough that turns out to be lung cancer. Money problems precipitated by costly treatments, poor insurance, and a modest salary push him to start cooking up meth to ensure the financial security of his family. The treatments succeed beyond his expectations, restoring his health long enough for him to become an unexpected meth kingpin.

Breaking Bad is a fictionally extreme example of the chaos that can arise from a lung cancer diagnosis. In fact, lung cancer is the leading cause of cancer-related deaths in the United States. Let’s take a closer look at the molecular causes, the different types, and some of the treatments available.

The Danger

While Walter White did not smoke cigarettes, 90 percent of those affected by lung cancer are smokers. Other causes of lung cancer include environmental or workplace exposure to carcinogens (known cancer-causing agents) such as radon, asbestos, or air pollution.

Smoking causes cancer because the inhaled smoke contains a range of chemicals, 70 of which are known to be carcinogens, including benzene, formaldehyde, methanol, and acetylene. Some carcinogens are genotoxic, meaning that they cause cancer by directly interacting with and damaging DNA. If that DNA damage occurs in a gene involved in regulating cell division, cancer may result. Non-genotoxic carcinogens have no direct interaction with DNA, rather they disrupt cellular structures and change the rate of either cell division or processes that increase the rate of genetic error.

Radon gas exposure can result in cancer because it is radioactive, and the high-energy radioactive particles given off as the gas decays can cause direct damage to cellular DNA. Radon gas is released from the normal decay of radioactive elements occurring naturally in soil and rocks. Radon is not considered dangerous because it is usually present at very low levels. However, it can sometimes build up to dangerous levels in well-insulated, tightly-sealed homes built on soil rich in uranium, thorium, or radium.

Asbestos used to be a common insulating material used in buildings and ships. The microscopic fibers in asbestos can be inhaled and become lodged in lung cells, triggering the activation of inflammatory pathways that result in the release of mutagens and factors that promote tumor growth. Since its hazards became well-documented in the mid-1970s, it is no longer used as insulation.

In addition to carcinogen exposure, there are likely genetic elements that make certain individuals more or less susceptible to lung cancer. Even though 90 percent of lung cancer cases are caused by smoking, only about 10 percent of smokers get lung cancer. In African-American populations, even when differences in smoking rates and access to healthcare are controlled for, the rates of lung cancer are higher. Both of these scenarios suggests that there may be genetic factors that make certain people more (or less) susceptible.

Small Cell

About 10 percent of lung cancer is small cell, meaning it occurs in the very small cells found in the bronchii—the tubes that branch off of the trachea, enter the lungs, and divide into even smaller branches within the air sac.

There are currently no targeted therapies available for small cell lung cancer, with chemotherapy and/or radiation as the main line of treatment. Broad ranging therapies that harness the immune system are in the pipeline.

Non-Small Cell

Cancer that occurs within any cell outside of small cells is referred to as non-small cell lung cancer (NSCLC), making up the majority (~90 percent) of lung cancer cases.

A number of drugs targeting new blood vessel growth—angiogenesis inhibitors—have been approved for the treatment of NSCLC.

There are also drugs that target specific NSCLC–associated mutations. For example, 10-35 percent of NSCLC cases are caused by the over-expression of the growth factor receptor EGFR. These types of NSCLC—more common in non-smokers—can be treated by drugs that target and inhibit this receptor. Asians are much more likely than other races to carry an EGFR mutation.

About five percent of NSLC cases are caused by mutations in a gene known as anaplastic lymphoma kinase (ALK). ALK proteins activate cell division, and mutated versions can drive cell division inappropriately. There are drugs currently on the market that inhibit ALK.

A checkpoint inhibitor drug has also been approved for NSCLC patients whose cancers start growing again after chemotherapy.

Cocktail Fodder: Walter’s Diagnosis

Diagnosed with NSCLC, Walter White specifically had an inoperable stage 3A adenocarcinoma. This means the cancer was initiated in the mucus-producing cells of the lungs and had spread to the lymph nodes (or other sites near the lungs), but had not spread to distant sites within the body. Some types of adenocarcinomas are caused by ALK mutations, so it is possible that Walter’s miraculous recovery was caused by an ALK inhibitor.

 

Give Patients the Gift of Hope and Health by Supporting HealthWell for #GivingTuesday

We are proud to announce that the HealthWell Foundation – an independent 501(c)(3) charity that provides financial assistance to insured patients living with chronic and life-altering illnesses – is joining the #GivingTuesday campaign, which launches today. 100 percent of your donation to HealthWell goes directly to grants and services that will benefit patients in need across the country. This week we are sharing some powerful real-world examples of how your gift to HealthWell will help transform lives.

Lynn Harcharik

Lynn, who received financial assistance from HealthWell for cancer treatments.

As one of our country’s most trusted independent charities, we believe that no patient, including those living with cancer, should go without health care because they can’t afford it. By donating to HealthWell for #GivingTuesday, you’ll join us in making that commitment a reality that will change lives for the better, one patient at a time – just like Lynn.

It was ovarian cancer spreading to the colon. My husband called many places, no cancer society would help! One society asked what type of cancer it was, and replied: there are no funds for ovarian cancer – we cannot help. Another organization had already used their funds. It was very discouraging, but my oncologist’s secretary told us about the HealthWell Foundation. After calling and talking to your group, the answer was YES, you would help. (Thanks!) In October of 2008, reversal surgery was done with the ileostomy. And yes, the cancer came back, or maybe was not completely gone from before, but-more chemo! Thank you for being there in my time of need. My prayers are with your group and your work. Thanks!

– Lynn (Streator, IL)

We want to make a difference for even more patients like Lynn so they can access critical medical treatments and get better. But that can only happen with your support.

That’s why, for this year’s #GivingTuesday, we’re urging Real World Health Care (RWHC) Blog readers to donate to the HealthWell Foundation’s Emergency Cancer Relief Fund (ECRF). Your generous holiday gift will help ensure that patients living with cancer are not forced to choose between paying the rent or buying food and affording life-saving care.

So what, specifically, will your tax-deductible #GivingTuesday donation do? Giving to ECRF will bring us closer to meeting our $100,000 goal by the end of the year so the fund can open in January. We are almost halfway there with more than $46,000 raised so far. Every dollar counts, and with just a little more help, we will hit our goal so that more cancer patients can start 2014 off right.

To help more families and patients afford the urgent medical treatments they desperately need, we need you to support #GivingTuesday starting today. Please contribute as generously as you possibly can.

Thank you for giving the gift of health this holiday season.

Categories: Cost-Savings

When the Health Care Blogger Becomes the Cancer Patient

The call came the day after my 48th birthday in April.

“The radiologist saw something suspicious on your mammogram from last week…an undetermined mass,” said the voice on the other end of the phone. “We’d like you to come in for an ultrasound so we can see better.”

Linda Barlow

Linda Barlow

During the ultrasound they assured me that it was probably nothing…that in most cases, it’s a benign lump and not cancer. Surely, I thought, as I scheduled a needle biopsy for a few days later, this would be the case for me as well.

But it was not the case. Once the results from the biopsy came back, I realized that I had become a cancer patient. I was now part of a community of more than one million other Americans who are diagnosed with cancer each year.

The days and weeks after that ultrasound and needle biopsy became a whirlwind of doctor’s appointments, tests, and procedures, as well as surgery to remove the lump in my breast, along with several lymph nodes. As of this writing, I’m undergoing six weeks of daily radiation treatments, and soon will be starting drug therapies that will last for at least five and up to 15 years.

Just when I started to recover from the surgery, the bills started to roll in. I have what I thought was pretty good (but expensive from a premium standpoint) medical coverage under my husband’s workplace plan. But even with premiums that are far higher this year than we’ve ever had to pay in the past, the system demanded more of our money:

  • $334.43 for one ultrasound
  • $106.04 for another ultrasound
  • $35.49 for an oncologist office visit
  • $131.15 for a nuclear medicine injection prior to my sentinel node removal
  • $421.80 for my lumpectomy
  • $468.61 for lumpectomy prep work
  • $181 for the surgeon who removed the lump
  • $60 for post-surgery physical therapy
  • $737.45 for oncotype diagnosis test

These are just a few examples and don’t include charges relating to the 30 radiation treatments I’ll be receiving or the genetic testing being done (since cancer runs in the family).

While these out of pocket costs are certainly hard to swallow – I can think of a hundred other things I’d rather spend my money on – for my family, they are doable. We won’t have to skip a mortgage payment or a utility bill. We won’t have to dip into a child’s college tuition fund. We certainly won’t have to worry about having enough money for food.

But I know – from my work on this blog and with its main sponsor, the HealthWell Foundation – that many families living with cancer aren’t so lucky.

I had the opportunity to help HealthWell create a White Paper, “When Health Insurance is Not Enough: How Charitable Copayment Assistance Organizations Enhance Patient Access to Care,” which investigated the devastating effects of not being able to afford needed treatments for chronic and life-altering medical conditions. For some individuals and families, out-of-pocket expenses including deductibles, copayments and coinsurance can total thousands of dollars each month – much more than many people earn.

That’s not the case for me. I’m one of the lucky ones.

“I’m lucky” is a statement you don’t often hear from cancer patients, but it’s how I feel about my situation. I’m lucky that my cancer was caught early by an astute reading of my mammogram. I’m lucky that my specific type of cancer was deemed “curable” and didn’t spread to my lymph nodes or other organs. I’m lucky that my job as a freelance writer gives me the flexibility to go to doctor’s appointments when needed. And I’m lucky to be in a two-income household with no kids and the easy ability to pay our bills. For now.

Of course, this could all change in a heartbeat. My freelance assignments could dry up, which would impact our income. My husband could lose his job or become disabled. We could be hit with an unexpected and costly disaster like a house fire or a tree crashing through our roof. The cancer could come back.

I am, in effect, a heartbeat away from being in a position to need real financial help.

If I need help, I’m thankful that charitable copayment assistance foundations like the HealthWell Foundation exist. Cancer isn’t something you can put on the back burner until the time or money is right. Treatment is costly. Premiums and copayments are high. For the 29 million Americans with limited incomes and/or inadequate insurance, the toll can be devastating – physically, emotionally and financially.

That’s why I’m calling on readers of this blog to help. Your donation to the HealthWell Foundation, the American Cancer Society or other charitable assistance foundations really will make a difference. Maybe not for me personally, but certainly for the millions who aren’t as lucky as me.

Categories: Cost-Savings

Companion Diagnostics Target Therapy to the Patients Most Likely to Respond

What cancer patient would want to use trial and error with various chemotherapies when he or she could know first from a diagnostic that one agent in particular would result in the most successful outcome?

David Sheon

David Sheon

A new field has emerged, companion diagnostics, to help predict a patient’s compatibility with chemotherapy or other cancer treatments.  This is a game changer to help ensure drugs are given only to the patients most likely to respond to them. 

According to the Food and Drug Administration (FDA), companion diagnostics already play an important role in determining which therapies are the safest and most effective for a particular patient.  By identifying treatments that work best for specific patients, less money is spent on those that do not work because patients no longer have to endure multiple treatments to find the one that is right for their case. Companion diagnostics, usually created in combination with targeted therapy, not only reduce cost and waste, but also reduce side effects for the patient.

Over the past several years, the FDA has approved the following five companion diagnostics: 

  • Zelboraf and the Cobas Test: The drug Zelboraf specifically treats the melanoma of patients whose tumors express a gene mutation called BRAF V600E. Alberto Gutierrez, Ph.D., Director of the Office of In Vitro Diagnostic Device Evaluation and Safety in the FDA’s Center for Devices and Radiological Health, said that approval “is a great example of how companion diagnostics can be developed and used to ensure patients are exposed to highly effective, more personalized therapies in a safe manner.”
  • Vysis ALK Break Apart FISH Probe Kit: Developed along with the targeted therapy drug Xalkori for patients with late stage, non-small lung cancer who express the abnormal anaplatic lymphoma kinase gene. The test determines if a patient possesses that gene to ensure that the correct treatment is applied.
  • therascreen KRAS RGQ PCR Kit: For those with colorectal cancer who are determining whether the drug Erbitux is right for them. This provides information about the KRAS gene mutation in patients whose colorectal cancer has spread to other parts of the body. If the test shows that the patient does not have the gene mutation, this demonstrates that Erbitux is the correct choice, but not the right one for those with the gene mutation.
  • EGFR Mutation Test: Administered in conjunction with the targeted therapy drug Tarceva, which detects the epidermal growth factor receptor gene mutation in patients with lung cancer. If the patient has the genetic mutation that Tarveca targets, then they are “candidates for receiving Tarceva as first line therapy,” Dr. Gutierrez says. Because this gene is present in approximately 10 percent of patients who have non-small lung cancer, it would go far to help improve the treatment and success rate among these patients.
  • THxID BRAF: Approved alongside two drugs (Tafinlar and Mekinist) – which treat the most dangerous type of skin cancer – this detects the BRAF V600E or V600K gene mutations associated with the disease. If the tumor of the patient contains either of these genes, both drugs are effective. 

Have you – or someone you know – ever been treated with one or more companion diagnostics? What was the experience like and would you recommend it for someone else?

Categories: Cost-Savings