Lung Cancer: Who Cares?

Posted: Nov 22, 2015
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by John Senall
Principal and Founder, Digital Healthcom Group

By mid-century, a known worldwide disease, lung cancer, will likely cause an additional 54 million deaths across the globe.

The number of lives taken will be greater than the total death count of soldiers and civilians from all nations killed during World War II; will be more than 3x the death toll of all international wars of the last 60 years; more than 15 million casualties greater than the total deaths of the international AIDS crisis since its start in 1981; and will be equivalent to losing the combined populations of Beijing, Los Angeles, Cairo and Rome.

Should we care? I tend to think we should.

Worldwide scope

Internationally, lung cancer now causes 1.6 million deaths annually. It’s the most common cancer worldwide, and kills more people (27%) than any other cancer. Its death toll annually is greater than the total deaths caused by colon cancer, breast cancer and prostate cancer combined.
 
Among the top 10 leading causes of death worldwide, lung cancer is number five. Cardiovascular disease continues to be the number one killer, followed by stroke, chronic obstructive lung disease (a heavy risk factor for lung cancer itself), and lower respiratory infections. After lung cancer are HIV/AIDS, diarrheal diseases, diabetes mellitus, road injuries and hypertensive heart disease.

While the five-year survival rate is 54 percent for cases detected, that’s only when the disease is localized within the lungs. Only 15 percent of lung cancer cases are diagnosed at that early a stage. The five-year survival rate drops to just 4% once the primary lung cancer has spread to other organs.

$6.4 Trillion Economic Impact by 2050

According to a 2010 research study, The Global Economic Cost of Cancer, issued by the American Cancer Society and LIVESTRONG, the annual worldwide economic impact of lung cancer is $188 billion. Next in line was colorectal cancers ($99 billion) and breast cancer ($88 billion). So it is possible we can expect a minimum worldwide economic toll of another $6.4 trillion by 2050.

The Smoking Gun?

No news here that the greatest negative force involved in lung cancer incidence is smoking. The American Lung Association estimates that active smoking is responsible for close to 90% of lung cancer cases. Other interrelated risk factors include exposures to radon, outdoor air pollution, asbestos, uranium, and radiation treatment to the chest (for diseases like breast cancer or lymphoma).
But while quitting smoking can decrease your risk, the devil is in the details. It depends on your age, the number of years smoked before quitting, and how many cigarettes you smoked each day on average.

As many as 20% of those who die of lung cancer annually never smoked or used tobacco. According to the American Cancer Society, “If lung cancer in non-smokers had its own separate category, it would rank among the top 10 fatal cancers in the United States.”

The Woman’s Cancer?

Most of us are grateful the breast cancer movement has succeeded so well in generating funds and awareness. Yet breast cancer is not actually the top women’s cancer. More women die from lung cancer than breast cancer and ovarian cancer deaths combined.

But in a survey conducted by the American Legacy Foundation, 80 percent of American women believe that breast cancer is the primary cause of cancer death among women. More worrisome is that experts predict a rising epidemic of female lung cancer. Incidence rates among women could quadruple by 2040 according to one source, for reasons including:
 
  • Young women have started smoking at younger and younger ages.
  • A women who smokes the same number of cigarettes as a man is twice as likely to develop lung cancer because men have a greater ability to detoxify toxins.
  • Estrogen increases cancer incidence and growth.

A Silent Parade

With such an impact, why isn’t lung cancer getting the attention and funding it seems to deserve? Where are the huge fundraising walks, runs, nightly news stories, advocacy efforts, celebrity stories of hope and cause-related fundraising programs at every retail store counter?

Sadly, there is no “mass movement” because…
 
1) There are very few lung cancer survivors to lead activities, fundraising or large-scale advocacy.

2) About two out of three lung cancers are diagnosed in people over age 65, and the average age at diagnosis is 71. 6 So our small number of survivors are often too tired or in poor health, mentally and/or physically to lead the movement anyway. In comparison, 34% of all invasive breast cancer incidences occur in women under age 55, and 12% of those women are younger than age 45.

3) Lung cancer continues to have its usual stigma related to cigarette smoking. The “they got what was coming to them and should have known better” issue.
 
4) Nearly 80% of the more than 1 billion smokers worldwide live in low- and middle-income countries. At the local level, this relation to low income and limited education also exists. It means that a great percentage of smokers and eventual lung cancer patients are poor, have little education, money, power or influence.

Funding Discrepancies

Using our war analogy again only for a comparison, total global defense spending annually is about $2 trillion. In comparison, we spend $750 million annually across the world on lung cancer research.

That’s 62% less funding each year for a killer we know about, and who we know will successfully kill 1.6 million people across the globe next year, and another 1.6 the year after that, and the year after that, and so on.

In more everyday context, the tobacco industry itself had a value of over $40 billion last year internationally. Our international lung cancer commitment in the same period was 2% of that.

Less deadly, coffee sales worldwide are more than $80 billion annually, and ice cream sales worldwide are over $74 billion. In context of dollars and cents only, lung cancer research got 1% as much money as either of those sales figures. While it’s an apples to bananas comparison, it does show economic perspective at simply a consumer spending level.

So Who Cares?

I’m not an advocate for aggressive military and defense budget chops. And I like coffee and ice cream (a bit too much). But I join with others who believe it is past time to take lung cancer much more seriously. Not as a single nation, but as a world of intelligent people. Frankly the numbers speak for themselves.

Awareness campaigns are still needed. Organizational or small- to mid-size collaborative research projects are inspiring and helpful. But however “promising” and hope-filled they seem, they are inadequate to make the major impact needed.

An unprecedented international collaboration and commitment of magnitude, resources and leadership is what is needed. The kind that wins not just battles, but wars.

Progress Being Made

I consider there to be three interwoven areas in this war:
 
  1. Catch lung cancer earlier while it is still treatable and either pre-cancerous or stage I.
  2. Create better, less toxic, less invasive treatments that have longer efficacy.
  3. Prevent lung cancer from happening in the first place.

The good news is that we are doing well at the first two.

Catching it Faster

Autofluorescence bronchoscopy is being used in many locations to help find some lung cancers earlier. So is low-dose computed tomography (LDCT) and spiral CT scanning (also called helical computed tomography). Spiral CT is used to help diagnose, plan treatment, and to monitor treatment progress or challenges.

Improved screening and its research movement began just several years ago. I was thankful to play a small part in one effort, the creation and funding of the Stacey Scott Lung Cancer Registry. The registry was one of the first international collections of biologic samples and corresponding scan and lifestyle data from high-risk patients at partner cancer centers in the United States, Canada, and Europe for research.

Low-dose computed tomography (LDCT) in high risk adults aged 55 to 80 years old is now recommended for individuals with a 30 pack-year smoking history and who currently smoke, or have quit within the past 15 years. This recommendation also took time to get wide adoption. In America alone, it is still endorsed by only 8 of 9 leading organizations in the field.

The one that did not is the American Academy of Family Practice (AAFP). AAFP’s reasons were because “favorable results, conducted in major medical centers with strict follow-up protocols for nodules, have not been replicated in a community settings. The long term harms of radiation exposure from necessary follow-up full dose CT scans are unknown.”

True. Community oncology diagnostics, care, treatment and follow-up for lung cancer (and most cancers) is typically of a different quality and consistency than that conducted in major medical centers and comprehensive cancer centers. In a perfect, collaborative environment, the solution would be easy: A generalist in the community would refer the high-risk case to the experts. Solved.

But we don’t live in that world. So that’s not about to happen.

Creating Better Treatments

This area, too, has seen progress. New immunotherapy drugs are being approved to boost the immune system’s natural ability to fight off and destroy cancerous cells in the lung. Two of the most recently approved by the FDA in 2015 are nivolumab (Opdivo®) and pembrolizumab (Keytruda®). These are approved for use by patients after their standard chemotherapy has stopped working. An impressive 25% of 129 patients with advanced lung cancer in the study released in June 2014 survived at least two years after starting nivolumab.

But while laudable in their early current phases, the immunotherapy drugs offer just an extra 3 to 9 months of life beyond standard chemo for the majority of advanced lung cancer patients.

New and targeted gene sequencing tests also are hitting the market. These can quickly sequence an advanced lung cancer patient’s DNA to see exactly which known lung cancer genes have mutations on them in that individual. A “prescription” is then provided using the available, already approved drugs (mostly pills) for each of the gene mutations. It’s an advanced lung cancer treatment cocktail approach—more targeted, and less toxic, than ever before.

This is tremendous progress and is saving lives. But still, this is only part of the solution.

Vaccines for Lung Cancer

While there is no vaccine for lung cancer, there are several vaccines being tested for nicotine addiction. Based on the math, it’s no surprise that so many experts consider this one route to help prevent lung cancer, as well as oral cancer, esophageal cancer, stomach cancer, cervical cancer, kidney cancer, bladder cancer, ovarian cancer, colorectal cancer, acute myeloid leukemia, heart disease, stroke, asthma, low birth weights, diabetes, cataracts, macular degeneration, blindness and more.

After some initial lessons from earlier vaccine NicVAX (by Nabi, and funded by the Dutch government), new vaccines and approaches are on the way it seems.

The most talked about is from researchers at The Scripps Research Institute and colleagues at Weill Cornell Medical College. It creates antibodies to “shut off” the brain’s reward system for nicotine. But it because nicotine is a small molecule, not seen by the immune system, the vaccine has to be joined to a larger molecule in order to get an anti-nicotine immune response. With help from Cornell, they announced in September that they have tied it to a purified protein delivery to increase the levels of anti-nicotine antibodies delivered to “shield the brain from nicotine.” Research continues.

Over at Massachusetts General Hospital in Boston, their peers are studying how to improve the clinical response rate to a nicotine vaccine using a laser-based, particulate vaccine and adjuvant-coated transdermal patch.
 
Top scientists at research centers across the world also are working at creating a better vaccine, securing patents, and constructing start-up spinoff companies to do so. So are scientists in the pharma and the biotech industry.

Like at Selecta Biosciences, in Watertown, New York. The company received $8.1 million from the National Institute on Drug Abuse (NIH) in June 2014 to continue development of a nicotine vaccine that uses nanoparticles to modulate the immune system. They previously secured $3 million from the same agency, “which paid for early research and an initial trial in 80 humans which found the drug (SEL-068) to be safe.”

What’s Next?

Many people, including me, think that a durable nicotine vaccine of some kind is the logical choice to put our money on—not just to help people quit smoking, but to prevent anyone from ever getting addicted to smoking.

This leads to the related discussion of creating an approved, international nicotine vaccine for children or even newborns. And that creates discourse and disagreement on ethical and moral grounds. I read one piece that even said teens might be more apt to smoke knowing they could not get addicted.

Yet if such a vaccine would allow no one to ever get addicted to cigarettes, we could prevent 30% of all cancers internationally, as well as millions of deaths from heart disease and other diseases each year. Financially we are talking about billions and trillions of dollars saved across the world.

And as we began this blog, we would save 160 million lives in the next century based only on current statistics.

I don’t buy the argument against it. But I seek your thoughts and expertise here. Thanks to LinkedIn, we have a dialogue opportunity with experts across the globe. Way smarter people than me for sure. And I want to learn the “why not” reasons so I can be better versed.

Other Factors

I do imagine that we would create a new investment by the tobacco industry in finding a way to thwart such a vaccine, legally and chemically. Scientists would work around the clock to create an “anti-anti-nicotine drug”—so we all could be sure no one would ever threaten our freedom to kill ourselves.

The nicotine vaccine approach also would have huge negative economic ramifications for those employed by the tobacco industry—from poor farmhands to middle class managers, and yes, extremely well paid VPs. Crime and criminal justice costs would likely eventually get sucked into the whole thing, too. We'd see criminal activity, worldwide violence, related deaths and other costs. Such international issues tend to face armies of opposition, with extremely deep pockets. 

In the end, here’s the rub. Lung cancer is not an American problem. It is not a smoker’s problem. It is not a male problem or a female problem. And it is not the problem of the poor, rich or middle class. Lung cancer is everyone’s problem. 

Taking it on for good requires deeper international collaboration, corporate collaboration, government funding collaboration, and moral and ethical discussion, debates and fights.The question is, are we really interested in going there?

Do we care about lung cancer, or don't we? 
 
PS: What's in a Ribbon?
Although a footnote to the lung cancer story, and seemingly unimportant to most, it seems sadly fitting to me that the official awareness ribbon color for lung cancer is clear, pearl or white—that which is hardly visible, attracts little attention, and hardly inspires anything. Did the disease get stuck with the most neutral colors of the spectrum because every other disease was in line first? Or was lung cancer just forgotten, and not even invited to the color party to begin with? A small thing, I know. But not really that small a thing in the scope of the colorful other awareness movements. 
 
Statistics and sources consulted in preparing this blog included:
American Lung Association, American Cancer Society, World Health Organization, National Cancer Institute (NCI), Department of Defense (DoD), Centers for Disease Control and Prevention (CDC), Harvard School of Public Health, Cancer Treatment Centers of America, Research and Markets, IBIS World, New York Times, and many more. 


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