Precision in Pulmonary, Critical Care, and Sleep Medicine by Jose L. Gomez & Blanca E. Himes & Naftali Kaminski

Author:Jose L. Gomez & Blanca E. Himes & Naftali Kaminski
Language: eng
Format: epub
ISBN: 9783030315078
Publisher: Springer International Publishing

Conclusion

The evolution of diagnosis, evaluation, and treatment of lung cancer is an ideal model for understanding precision medicine and the personalization of care. Lung cancer research extends from large-scale studies providing insight into the epidemiology of lung cancer, permitting earlier identification and intervention, to molecular evaluation of single tumors. We have gained enormous insight into the heterogeneity of lung cancer and a profound appreciation that more precise understanding of genetic and biochemical differences informed by the backdrop of behavioral and social characteristics should guide individualized decisions relating to screening, staging, and treatment for a given patient. The old, nihilistic perception of lung cancer as a uniformly morbid disease with limited treatment options should be firmly rejected.

We can now return to our patient PM and compare his experience from 2008 as described above with what he would experience today, based on the remarkable advances made in the field of lung cancer over the past decade. This comparison highlights multiple ways in which scientific discoveries have been implemented into patient care, with emphasis on an individualized approach.

PM is a 65-year-old male current smoker with moderate COPD, who presented for routine health evaluation. His primary care physician initiated a discussion about lung cancer risk, as PM met USPSTF criteria for screening. PM was counseled about smoking cessation, and after a shared decision-making discussion, he elected to undergo screening low-dose chest CT (LDCT). The LDCT identified a solid 2.1-cm right upper lobe (RUL) nodule, without hilar or mediastinal adenopathy. PET-CT showed intense FDG uptake only in the nodule. EBUS biopsy of the nodule confirmed squamous cell carcinoma; biopsies of right hilar and mediastinal nodes were negative. The clinical stage was T1cN0M0. PM had comprehensive physiologic evaluation, which demonstrated adequate predicted postoperative function. He underwent RUL lobectomy; pathologic stage was pT1cN0M0 (stage IA3). PM successfully quit smoking and was followed for several years without evidence of disease recurrence, but was then lost to follow-up. Ten years after the original LDCT, PM presented with several months of worsening cough and dyspnea. A chest radiograph demonstrated a right lower lobe abnormality; chest CT confirmed a 3.5-cm right lower lobe mass and enlarged right hilar and subcarinal lymph nodes, without abnormalities in the liver, adrenal glands, or bones. PET imaging showed intense FDG uptake in the mass and in mediastinal and hilar lymph nodes; brain MRI demonstrated two enhancing 1.0-cm lesions in the right parietal and temporal regions. Bronchoscopy with EBUS confirmed adenocarcinoma in the RLL mass as well as in multiple mediastinal nodes. The clinical stage was T2aN2M1c (stage IVB). Molecular testing was negative for EGFR or BRAF mutations or ALK or ROS1 rearrangements; tumor PD-L1 was >50%. PM indicated that, at his age of 75 and with other health conditions, he wanted treatment that would balance survival benefit while limiting adverse reactions. After discussions with his multidisciplinary team, PM started immunotherapy with pembrolizumab, underwent stereotactic radiosurgery for the brain metastasis, and initiated care with the palliative medicine service. PM tolerated immunotherapy well with measurable response to treatment.

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