Interview conducted by Ivanhoe Broadcast News in May 2019.
Is it still the case where lung cancer is difficult to diagnose and maybe it may be at a later stage before people actually catch it? And why?
STILES: Well there’s a lot that’s changed about lung cancer. We now have screening for lung cancer. But unfortunately, it’s still often diagnosed at a very late stage. In fact, it’s one of the few cancers where more cases are diagnosed at a late stage than at an early stage. That’s often because there’s no symptoms until it’s too late.
Are there a particular risk factors for the cancer? And are you finding that some patients don’t fit that mold or that stereotype that happened 20 or 30 years ago?
STILES: The obvious risk factor is cigarette smoking. The problem is that everybody thinks lung cancer can only be in cigarette smokers. We now know that there’s lots of other reasons people get it. Secondhand smoke, radon, environmental exposures, air pollution and sometimes just bad luck. There’s probably also a genetic component that we haven’t begun to understand completely yet.
Standard treatment?
STILES: Well, depends on the stage really. For early stage when we’re lucky enough to find it early, we can often take it out and cure lung cancer surgically. As it gets more advanced, then we have to add in other therapies. And sometimes that’s a combination of surgery, chemotherapy and radiation. For stage four traditionally it was just chemotherapy. But now the lung cancer world has really changed. We have a lot of different therapies and in particular targeted therapies for cancers that are driven by particular mutations. But also, immunotherapy for cancers that may not have those mutations.
Stage four, what kind of cancer are you talking about? Is it advanced, has it spread, where usually has is spread at that point?
STILES: So stage four usually means that it’s broken outside of the organ where it started. And that holds true for just about any cancer. For lung cancer, that means it’s gone to other organs in the body. And typically, that maybe the bones, the brain, the adrenal glands, and the liver.
What is immunotherapy essentially?
STILES: There’s lots that you hear about it. And it seems like a breakthrough for everybody. It doesn’t work for everyone. But there’s really been some spectacular results in particular in melanoma and lung cancer. The way that that works is that the drugs basically unlock a break that your cancer puts on your body’s immune system. And they let your own immune system attack your cancer. So, in many ways, that’s a very personalized therapy. It’s letting your own immune system work to kill the cancer.
I want to talk a little bit about Bruce. He had had some difficulty in diagnosis. At what point did you diagnose him?
STILES: At first I laugh when Bruce says he didn’t have the lung capacity he used to have because I think he was swimming eight or 10 miles and he got more tired. So for me that would be the most incredible lung capacity in the world. But for Bruce it was a noticeable difference. I met him after he got sent to me really thinking that he had potentially pneumonia or some other problem with his lungs not particularly a lung cancer.
And what was he feeling?
STILES: He was just short of breath and I think he was frustrated. He was short of breath which prompted him to get a chest X-ray which promptly got a C.T. scan. He didn’t really have classic findings for lung cancer. And I think most importantly for Bruce, he didn’t look like a lung cancer person. It’s really hard in a person like Bruce, a young person, never smoker, as fit as can be for lung cancer to come to the top of your mind when you see a guy like that. And so people just looked for other things.
Tell me what you found when you saw the scans.
STILES: Well, the amazing thing he had gotten sent to me by one of our pulmonologist who thought things just weren’t quite right. And so that pulmonologist had ordered a PET scan which hadn’t been read yet by the time that Bruce saw me. When I looked at the PET scan unfortunately, I immediately knew that this wasn’t pneumonia. This was a cancer. And even worse this was a stage four cancer. There were multiple spots throughout Bruce’s body that lit up on the PET scan suggesting that he had stage four disease and quite advanced.
At that point, what could you offer him?
STILES: Well, that’s where it gets tricky. And I think that’s the amazing thing about research and where it’s gotten us to in lung cancer today. A few years ago, we really just would have offered chemotherapy and maybe hoped to get sort of 12 – 15 months. With Bruce though, I really had a feeling and knowing what we know about lung cancer now that he was going to have one of these mutations. And this is different from immunotherapy. This is the idea of targeted therapy. So, there’s a handful of mutations in lung cancer that can drive a person’s lung cancer. And they’re typically associated with never smokers like Bruce. The most common is EGFR. There’s others, for example, Ross1. But Bruce ended up having something called an ALK rearrangement which is like a mutation but different parts of the chromosome fused together. And fortunately, that has amazing drugs now. When I saw Bruce and we had this talk about his stage four lung cancer, I just told him. I said I know that you’re going to have one of these mutations. I just feel like you’re going to have to have one of these mutations.
Could you tell me what that mutation was and If you could describe it in layman’s terms what the outcome is?
STILES: It’s just called an ALK rearrangement. And now there is an amazing group of lung cancer patients out there called the ALK positive group. It often fits that mold of never smokers, a little bit younger who often present with advanced disease. For the bad luck of the draw, one of your chromosomes rearranges and that causes just a driving of abnormal cells. Some people call them driver mutations. Those cells continue to mutate and accumulate and to grow sort of outside the body’s control. Ideally though, there are drugs which can be very well targeted because if you can just block that one interaction that the rearrangement causes can often stop the cancer in its tracks.
Talk to me about the new drug.
STILES: Well, it was amazing. Bruce got diagnosed in 2017. What I didn’t tell you, he had the PET scan but then I sent him for a brain MRI which we routinely do in that setting of metastatic lung cancer. And he had over 20 spots in his brain. It was really unbelievable and it was just kind of one punch after another to this guy who walked in to my office thinking I was going to tell him about his pneumonia. Alectinib had had some studies in later stage, in the second line setting really just the month that Bruce got diagnosed, the drug got approved as first line therapy for ALK rearranged lung cancer. The important part about that was that the study had shown the drug not only worked better everywhere in the body, but it works significantly better in the brain. And so for Bruce, this was a tremendous medical breakthrough at the perfect time.
So what did he have to do to take this therapy? It’s an oral therapy?
STILES: It’s an oral therapy which is also pretty convenient for patients obviously instead of having to get infusion or chemotherapy all the bad things about that, this was just a pill that he could take. Because it got FDA approved at the time, he was immediately eligible for it and started on it right away.
How long was he on it? And what kind of progress did you see?
STILES: Well, he’s been on it since that time. Amost all of his spots have almost completely shrunk. He still has some that are visible. But we don’t think any are active. And Bruce I don’t know if he told you, he comes with me to give the medical students the lecture on lung cancer the last two years. And we show a scan when he got diagnosed. And we show his scans now. It’s really incredible to put the brain scan side by side in particular and see that these things have gone away. We would have never thought that 10 or 20 years ago.
What does this mean in terms for Bruce? Is it a cure?
STILES: Well, Bruce is really pragmatic. And so, in the targeted therapy world the problem is that the cancers find a way to get around these things. So, they develop secondary mutations, they develop other ways to proliferate and move forward. In particular, that’s pretty well described in the ALK rearranged cancers. The idea though is that if we can push it and keep Bruce well, until we find the next drug – and we’re already on the second and third generation of many of these drugs that then work against the secondary mutations or potentially down the road could we add an immunotherapy that we can keep Bruce going. There was an incredible report from especially center that treats ALK rearranged lung cancer and they reported average survival of their stage four patients out to over six years. And if you think about it, this is a disease for stage four, we were lucky to get him to a year to a year and a half. So to see patients living for six years is really just an incredible feeling. It’s incredible tribute to the research that’s going on across the country and to the patients who volunteer for these trials. I hope that we’ll get Bruce on another drug. So the next thing, if Bruce does progress, that we’ll have a drug that we can slip in and get him better and keep him going.
Is there anything I didn’t ask you this you want to make sure that people know?
STILES: Bruce has spoken with the medical students, he’s talked for some lung cancer groups that I’m a part of. He’s just a great ambassador. He goes out and he tells people this is what it is. I’m going to do the best with it. And I really attribute my success to research. And he puts the importance on that and on the medical community and thanks them and gives back to the medical community and he tries to teach the students also. And, for example, you know, the students we always laugh with Bruce that any student could see the guy who’s smoked his whole life was sitting there coughing, they could say oh, that person might have lung cancer. But Bruce challenges people to think outside the box. And say hey, this guy who’s out swimming an eight-mile race who looks perfectly healthy, who has lung symptoms maybe he has lung cancer too. And that really helps raise awareness for the disease. And it really helps people relate to the idea that anybody can get lung cancer and that’s really helped to move the disease forward.
Do you know what percentage of lung cancers are ALK positive?
STILES: Only about 2% to 4%.
So we’re talking about a small group of success for this.
STILES: Small group. But of never smokers who have lung cancer, it’s probably 15% to 20%.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Anna Sokol, PR
646-962-9472
Sign up for a free weekly e-mail on Medical Breakthroughs called First to Know by clicking here
