Advances in the treatment of lung cancer

I enjoy going to meetings of the Mainzer Medizinische Gesellschaft [Mainz Medical Society] but they have have been in digital form for a long time now due to the pandemic. Recently I attended one of these (digital) events on the subject of the development of the treatment of lung cancer. There was a talk by Roland Buhl about general aspects of the treatment of lung cancer and one by Eric Roessner on surgery in lung cancer. Before going further I want to say something about my own relation to cancer. When I was a schoolchild my mother got cancer. In Orkney, where we lived, there was no specialist care available and for that reason my mother spent a lot of time in the nearest larger hospital, Foresterhill in Aberdeen. During my first year as a student in Aberdeen there was an extended period where I visited my mother in hospital once a week. I was not intellectually engaged in this issue and I do not even know what type of cancer my mother had. I seem to remember that at one point her spleen was removed, which suggests to me that it was a cancer of the immune system, lymphoma or leukemia. After some months my mother had reached the point where no useful further therapy was possible. She returned to Orkney and died a few months later. I must admit that at that time I was also not very emotionally involved and that I was not a big help to my mother in those troubled times for her. While I was a student I was friends with two other students, Lynn Drever and Sheila Noble. At one time I frequently heard them talking about a book called the ‘The Women’s Room’ by Marilyn French. I was curious to find out more but they did not seem keen to talk about the book. After the end of my studies I read the book myself. It is a feminist book and I think a good and interesting one. The reason I mention Marilyn French here is another good and interesting book she wrote. It is called ‘A Season in Hell’, which is a translation of the Rimbaud title ‘Une saison en enfer’. In the book she gives a vivid inside view of her own fight with a cancer of the oesophagus. After very aggressive treatments she was eventually cured of her cancer but the side effects had caused extensive damage to her body (collapse of the spine, kidney failure etc.). Parallel to the story of her own illness she portrays that of a friend who had lung cancer and died from it quite quickly. This book gave me essential insights into what cancer means, objectively and subjectively, and what lung cancer means. My own most intensive contact with cancer was in 2013 when my wife was diagnosed with colon cancer. I do not want to give any details here except the essential fact that she was cured by an operation and that the disease has shown no signs of returning. Motivated by this history I recently did something which I would probably otherwise not have done, namely to have a coloscopy. I believe that this is really a valuable examination for identifying and preventing colon cancer and that it was my responsibility to do it, although I was anxious about how it would be. In fact I found the examination and the preparations for it less unpleasant than I expected and it was nice to have a positive result. It is also nice to know that according to present recommendations I only need to repeat the examination ten years from now. A few years ago in the month of November my then secretary got a persistent cough. After some time she went to the doctor and was very soon diagnosed with lung cancer. She only survived until February. I attended a small meeting organised by her family in her memory and there I learned some more details of the way her disease progressed.

Now let me come back to the lectures. The first important message is nothing new: most cases of lung cancer are caused by smoking. Incidentally, the secretary I mentioned above smoked a lot when she was young but gave up smoking very many years ago. The message is: if you smoke then from the point of view of lung cancer it is good to stop. However it may not be enough. In the first lecture it was emphasized that the first step these days when treating lung cancer is to do a genetic analysis to look for particular mutations since this can help to decide what treatments have a chance of success. In the case of the secretary the doctors did look for mutations but unfortunately she belonged to the majority where there were no mutations which would have been favourable for her prognosis under a suitable treatment. In the most favourable cases there are possibilities available such as targeted therapies (e.g. kinase inhibitors) and immunotherapies. These lectures are intended to be kept understandable for a general audience and accordingly the speaker did not provide many details. This means that since I have spent time on these things in the past I did not learn very much from that lecture. The contents of the second lecture, on surgical techniques, were quite unfamiliar to me. The main theme was minimally invasive surgery which is used in about 30% of operations for lung cancer in Germany. It is rather restricted to specialized centres due to the special expertise and sophisticated technical equipment required. It was explained how a small potential tumour in the lung can be examined and removed. In general the tumour will be found by imaging techniques and the big problem in a operation is to find it physically. We saw a film where an anaesthetised patient is lying on an operating table while the huge arms of a mobile imaging device do a kind of dance around them. The whole thing looks very futuristic. After this dance the device knows where the tumour is. It then computes the path to be taken by a needle to reach the tumour from outside. A laser projects a red point on the skin where the needle is to be inserted. The surgeon puts the point of the needle there and then rotates it until another red point coincides with the other end. This fixes the correct direction and he can then insert the needle. At the end of the needle there is a microsurgical device which can be steered from a computer. Of course there is also a camera which provides a picture of the situation on the computer screen. The movements of the surgeon’s hands are translated into movements of the device at the end of the needle. These are scaled but also subject to noise filtering. In other words, if the surgeon’s hands shake the computer will filter it out. There is also a further refinement of this where a robot arm connected to the imagining device automatically inserts the needle in the right way. The result of all this technology is that, for instance, a single small metastasis in the lung can be removed very effectively. One of the most interesting things the surgeon said concerned the effects of the pandemic. One effect has been that people have been more reluctant to go to the doctor and that it has taken longer than it otherwise would have for lung cancer patients to go into hospital. The concrete effect of this on the work of the surgeon is that he sees that the tumours he has to treat are on average in a more advanced state than they were than before the pandemic. Putting this together with other facts leads to the following stark conclusion which it is worth to state clearly, even if it is sufficiently well known to anyone who is wiling to listen. The reluctance of people to get vaccinated against COVID-19 has led to a considerable increase in the number of people dying of cancer.

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