Lung cancer treatment has progressed significantly over the past century. Early advances included the development of bronchoscopy in the early 1900s to examine the lungs, as well as the identification of tobacco as a major risk factor in the mid-1900s. Important milestones since then include the introduction of chemotherapy, targeted therapies, and immunotherapy. Screening trials now show that low-dose CT scans can reduce lung cancer mortality in heavy smokers. While lung cancer prognosis remains poor, targeted treatments and screening hold promise for improving outcomes over time.

1. Historyof Lung
CancerTreatment
Mauricio Lema Medina MD
Clínica de Oncología Astorga / Clínica SOMA
Medellín

3. Lung Cancer: A man-
made epidemic

4. Progress Against Lung Cancer
Tobacco
Undurraga P. Rev Chil Enf Respir 2012; 28: 35-50

5. James Albert Bonsack (1889)
- 70.000 cigarettes in 10 hours

7. “You ask me what it is we need to win this
war. I answer tobacco as much as
bullets.” – Black Jack (WWI)

8. Progress Against Lung Cancer
Tobacco

9. Progress Against Lung Cancer
Smoking in the US
Source: National Cancer Institute

10. Progress Against Lung Cancer
Smoking in the US

14. Progress Against Lung Cancer
1970–1979
Saracci R. Asbestos and Lung Cancer: An Analysis of the Epidemiological
Evidence on the Asbestos-Smoking Interaction. Int J Cancer. 1977; 20:323-331

15. …May be hazardous
to your health.

16. Source: National Cancer Institute

17. Progress Against Lung Cancer
Pioneers
Richard Doll (1912-2005)

19. Progress Against Lung Cancer
Pioneers

21. Getting to know your body

22. Progress Against Lung Cancer
Bronchoscopy
Undurraga P. Rev Chil Enf Respir 2012; 28: 35-50
1904

23. Progress Against Lung Cancer
Bronchoscopy
Undurraga P. Rev Chil Enf Respir 2012; 28: 35-50
1904

24. Progress Against Lung Cancer
Flexible bronchoscopy
Undurraga P. Rev Chil Enf Respir 2012; 28: 35-50
1966

25. Progress Against Lung Cancer
Technology

26. Progress Against Lung Cancer
Pioneers
Sir Godfrey Hounsfield
CT (EMI) Scanner
-1972
-Nobel Prize 1979

28. Progress Against Lung Cancer
2000–Present
Sharples LD, Jackson C,
Wheaton E, et al. Clinical
effectiveness and cost-
effectiveness of endobronchial
and endoscopic ultrasound
relative to surgical staging in
potentially resectable lung
cancer: results from the
ASTER randomised controlled
trial. Health Technol Assess.
2012; 16: 1-4.

29. Surgery: a glimpse of hope

30. Progress Against Lung Cancer
Pioneers
Evarts A. Graham

31. Progress Against Lung Cancer
Pneumonectomy
1933

32. Progress Against Lung Cancer
Pneumonectomy
EA Graham
JL Gimore

33. Chemotherapy

34. Progress Against Lung Cancer
Technology
Cisplatin

35. Progress Against Lung Cancer
Technology
Cisplatin

36. Progress Against Lung Cancer
1970–Present
Timmerman R, Paulus R, Galvin J, et al. Stereotactic body
radiation therapy for inoperable early stage lung cancer. JAMA.
2010; 303:1070-1076.

37. Progress Against Lung Cancer
1970–1979

38. Progress Against Lung Cancer
1970–1979
Early-1970s: Radiotherapy included in combined
modality treatment trials for SCLC and NSCLC
Early-1970s: Lymph-node mapping introduced
Early-1970s: Sublobular resection found to be
adequat por limited-stage lung cancer

39. Progress Against Lung Cancer
1970–1979
Mid-1970s: Chemotherapy combinations prove
effective in small cell lung cancer
1974: First data-driven revision of TNM
classification of lung cancer
1974: ACTH research identified SCLC as an
ectopic hormone-producing tumor

40. Progress Against Lung Cancer
1970–1979

41. Progress Against Lung Cancer
1980–1989

42. Progress Against Lung Cancer
1980–1989

43. Progress Against Lung Cancer
1980–1989
1986: Second-hand smoke formally declared a
carcinogen

44. Progress Against Lung Cancer
1980–1989
1987: Scientists discover key genetic vulnerability
in tumor cells – EGFR

45. Progress Against Lung Cancer
1990–1999

46. Progress Against Lung Cancer
1990–1999

47. Progress Against Lung Cancer
1990–1999

48. Progress Against Lung Cancer
1990–1999
1990–1992: Combining chemotherapy and
radiation prolongs survival for non-small cell lung
cancer

49. Progress Against Lung Cancer
1990–1999
1993: Simultaneous radiation and chemotherapy
boosts survival for small cell lung cancer

50. Progress Against Lung Cancer
1990–1999
Mid-1990s: New generation of chemotherapy
drugs for non-small cell lung cancer

51. Progress Against Lung Cancer
1990–1999
1995: Analysis affirms benefits of chemotherapy
for advanced non-small cell lung cancer

52. Progress Against Lung Cancer
Technology

53. Progress Against Lung Cancer
1990–1999
1996: Topotecan approved as second round of
treatment for small cell lung cancer
1998: PORT increases mortality in NSCLC

54. Progress Against Lung Cancer
Technology

55. Progress Against Lung Cancer
1990–1999
1999: Cranial radiation reduces risk of small cell
lung cancer spreading to the brain
1999: Simultaneous chemotherapy and radiation
proven most effective for stage III non-small cell
lung cancer
1999: Giving radiation to the chest twice-daily
increases survival for small cell lung cancer

56. Progress Against Lung Cancer
2000–Present

57. Progress Against Lung Cancer
Pioneers

59. Progress Against Lung Cancer
2000–Present

60. Sandler A et al. N Engl J Med 2006;355:2542-2550.
Kaplan–Meier Estimates of Overall Survival (Panel A) and
Progression-free Survival (Panel B).

61. Progress Against Lung Cancer
2000–Present
Timmerman R, Paulus R, Galvin J, et al. Stereotactic body
radiation therapy for inoperable early stage lung cancer. JAMA.
2010; 303:1070-1076.

62. Progress Against Lung Cancer
2000–Present

63. Progress Against Lung Cancer
2000–Present
2000: Study links household radon exposure to
lung cancer
2000: Second round of chemotherapy boosts
survival in advanced non-small cell lung cancer

64. Progress Against Lung Cancer
2000–Present
2003: First targeted drug approved for non-small
cell lung cancer

65. Progress Against Lung Cancer
2000–Present
2004: Studies show that specific EGFR mutations
are associated with response to gefitinib
2004: FDA approves second targeted drug,
erlotinib, for non-small cell lung cancer
2004–2005: Adjuvant therapy proven effective in
lung cancer

66. Progress Against Lung Cancer
2000–Present
2005: Anti-angiogenic drug bevacizumab extends
survival for advanced lung cancer
2005: New project to map lung cancer genome

67. Progress Against Lung Cancer
2000–Present
2008: Circulating tumor cells in the blood can help
track treatment response in select patients

68. Progress Against Lung Cancer
2000–Present
2009: Maintenance therapy improves survival for
advanced non-small cell lung cancer

69. C/P vs C/G in Advanced NSCLC: OS by
Histology
Survival Time (Mos) in All Patients
With Squamous Histology
SurvivalProbability
SquamousNonsquamous
Survival Time (Mos) in Patients
With Nonsquamous Histology
SurvivalProbability
Scagliotti GV, et al. J Clin Oncol. 2008;26:3543-3551.
C/P
C/G
C/P vs C/G
Median Survival
11.8 mos
10.4 mos
Adjusted HR: 0.81
(95% CI: 0.70-0.94)
C/P
C/G
C/P vs C/G
Median Survival
9.4 mos
10.8 mos
Adjusted HR: 1.23
(95% CI: 1.00-1.51)
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
300 6 12 18 24
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
300 6 12 18 24

70. Progress Against Lung Cancer
2000–Present
2010: Older patients should be considered for the
same aggressive chemotherapy as younger
patients
2010: Adding palliative care to standard
chemotherapy improves survival for advanced lung
cancer patients
2010: New lung cancer staging system is adopted
2010: Drug aimed at a newly identified target
causes dramatic tumor shrinkages
2010: CT scanning reduces lung cancer deaths
among heavy smokers

71. Survival Pem + Cb + Bev Pac + Cb + Bev
Median OS, mos 12.6 13.4
HR (95% CI; P value) 1.00 (0.86-1.16; P = .949)
Survival rate, %
1 yr 52.7 54.1
2 yr 24.4 21.2
Patel J, et al. 2012 Chicago Multidisciplinary Symposium in Thoracic Oncology. Abstract LBPL1.
PointBreak: OS From Randomization (ITT)
Censoring rate for Pem + Cb + Bev: 27.8%; Pac + Cb + Bev: 27.2%
0 3 6 9 12 15 18 21 24 27 30 33 36 39
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Mos From Induction
SurvivalProbability
Pem + Cb + Bev
Pac + Cb + Bev

72. Lung Cancer
Screening

73. The National Lung Screening Trial Research Team . N Engl J Med 2011;365:395-409.
Cumulative Numbers of Lung Cancers and of Deaths from
Lung Cancer.

74. National Lung Screening Trial:
Survival Curves
 Relative reduction in all-cause mortality of 6.7% (P = .02)
 1877 deaths in LDCT group, 2000 in CXR group
Lung Cancer
Mortality
All Mortality
National Lung Screening Trial Research Team, et al. N Engl J Med. 2011;365:395-409.
0 1 2 3 4 5 6 7 8
1.00
0.99
0.98
0.97
0.96
0.95
0.94
0.93
0.92
0.91
0.90
CT arm lung cancer
CXR arm lung cancer
CT arm all-cause
CXR arm all-cause
ProbabilityofSurvival:
AllParticipants
Yrs From Randomization

75. Progress Against Lung Cancer
Five-YearSurvival
11
12
13
14
15
16
17
18
19
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
Year of Diagnosis
%ofPatientsSurvivingFiveYears
Source: National Cancer Institute

76. Progress Against Lung Cancer
Mortality
32
37
42
47
52
57
621970
1972
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
Year of Death
CancerDeathsper100,000People
Source: National Cancer Institute

77. Progress Against Lung Cancer
New Cases
46
51
56
61
66
711973
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
Year of Diagnosis
NewCancerCasesper100,000People
Source: National Cancer Institute

80. Conclusions
• Lung cancer therapy
– Surgery may cure some
– RT may prolong OS in some
• Cure even less
– Metastatic disease
• Dismal prognosis for most patients
• Selected patients may have a hope
– Tobacco cessation / screening / targeted
therapy and Immunotherapy MAY hold the
key