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Members of our armed services have protected our country for generations, providing us with national security and personal freedoms. However, many of our veterans receive a diagnosis of lung cancer, which the federal government has acknowledged can be attributable to risk factors such as environmental exposures during military service, smoking exposures and age. This November, our country celebrates 76 years of Veterans Day, and we want to increase awareness of 

“We certainly have a lung cancer problem in this country,” said Dr. Drew Moghanaki of UCLA Health in California. “It also stems from very aggressive tobacco marketing campaigns, (with military contracts) to push cigarettes into the ration bags of our soldiers, who were just kids when they joined.”

We spoke with three doctors about appropriate treatment options for veterans, potential causes of lung cancer based on chemical exposures, and inequities regarding socioeconomic status and geographic location.

“We know that lung cancer disproportionately affects our veterans,” said Dr. Charles B. Simone II of Memorial Sloan Kettering Cancer Center in New York and the New York Proton Center. “We know that lung cancer in general is one of the most common cancers in the United States, but ... people that are in (or are) retired from the armed forces have disproportionately high rates of lung cancer, such that really 1 in 5 of all cancer diagnoses in our veterans are in lung cancer.”

also looks at the approach of altering treatment doses of therapy, which can ultimately change the lives of patients for the better.

This approach, known as treatment de-escalation, can not only continue to control cancer, but it can also improve patients’ quality of life. When treatment leads to symptoms that interrupt daily life, such as fatigue, it’s important for patients to know that they can speak with their doctors about potentially lowering their dose.

Other news covered in this issue includes the recent approval of a targeted therapy drug from the Food and Drug Administration for some patients with RET fusion-positive non- small cell lung cancer (NSCLC), a novel vaccine for the disease, a drug combination that may improve survival in patients with extensive- stage small cell lung cancer and more.

A patient also shares her story about the day she received her diagnosis of ALK-positive NSCLC, and how she believed there was a “divine interaction” that helped her get the care and support she needed.

We hear from a doctor from one of our cancer center partners who discusses unmet needs regarding treatment options for patients with NSCLC and the impact of the platinum-based chemotherapy shortage on patients, as we continue our coverage of the shortage that continues to affect so many patients and their families.

“In patients who have had an early stage, say a stage 1 or stage 2 lung cancer, the mainstay of therapy is surgery. That’s where we often would use cisplatin chemotherapy, as a prevention or as an adjunct ... after the surgical treatment,” Dr. Gene G. Finley from Allegheny Health Network Cancer Institute, Allegheny Clinic Medical Oncology, told 

. “That strategy has also been pretty effective. And that’s where the 

has been most difficult for us, not in the majority of patients who present with advanced disease.”

As always, we hope you find our stories inspirational and informative.

For more news on cancer updates, research and education, don’t forget to 

Articles

This November, our country celebrates 76 years of Veteran’s Day, and we want to increase awareness of veterans with lung cancer in this special issue of CURE.

On the Front Lines With Veterans Facing Lung Cancer

Gene G. Finley, assistant professor at Drexel University’s College of Medicine in Philadelphia and medical oncologist at Allegheny Health Network (AHN) Cancer Institute, Allegheny Clinic Medical Oncology in Monaca, Pennsylvania, has his eyes on the future.

Finley, who spoke with CURE as part of its “Speaking Out” video series, discussed unmet needs regarding treatment options for patients with non-small cell lung cancer, such as a broader range of drugs to modulate T-cell function and ways that patients’ own T cells can be engineered to fight cancer — a therapeutic tactic already shown to be effective for patients with blood cancers.

With the platinum-based chemo- therapy shortage still on patients’ and providers’ minds, Finley also discussed how the shortage has impacted the treatment of patients with lung cancer.

Q: What are some unmet needs regarding treatment and advances that are hoped for the future? 

 I think that there are a number of threads going on. Now one thing to bear in mind is although we have some very effective reagents, they are only interacting with two pathways that occur on the T cell, and there are literally more than two dozen pathways that regulate T-cell function. One of the areas of drug development is looking at different molecules that can help or inhibit the function of those T cells, both for the treatment of cancer and perhaps other autoimmune diseases. That’s one broad swath of how things are moving forward.

I think the other major area of interest is in cellular immunotherapy. 

There’s been a lot of work done demonstrating that if you can engineer a T cell to fight cancer by genetically modify- ing your own T cells, that’s a very good strategy and it’s been highly effective in leukemias and lymphomas, the so-called liquid tumors. It hasn’t really made the jump to solid tumors, such as lung cancer, but this is a work in progress, and we are conducting a clinical trial in lung cancer using lymphocytes (a type of white blood cell), not derivatized lymphocytes, but lymphocytes derived from tumor cells. And that strategy seems to be a good avenue.

I would say those are the two things: better drugs to modulate T-cell function and engineering T cells to fight cancer directly. Obviously, there are a lot of other threads out there that are important as well.

Q: What impact has the chemotherapy drug shortage had on patients with non-small cell lung cancer? 

Well, we’ve been pretty successful at AHN in anticipating these drug shortages. One of the key shortages (has been) of a drug called cisplatin, that’s been a common one.

(For) that drug, there are other medicines that work similarly — for example, a drug called carboplatin. We tend to use more carboplatin than cisplatin because cisplatin is harder to tolerate. It causes more nausea and vomiting than carboplatin, and it causes more kidney damage than carboplatin.

Many of our lung cancer patients (are older), they’re already infirm, so we like to use drugs that are more tolerable so that we can actually get the treatments into the patient. For most lung cancer patients — remember that two-thirds of lung cancer patients present in an advanced stage that traditionally has not been felt to be curable — in that setting, that’s where we use the bulk of these platinum-based chemotherapies.

In patients who have had an early stage, say a stage 1 or stage 2 lung cancer, the mainstay of therapy is surgery. That’s where we often would use cisplatin chemotherapy, as a prevention or as an adjunct ... after the surgical treatment. That strategy has also been pretty effective. And that’s where the drug shortage of cisplatin has been most difficult for us, not in the majority of patients who present with advanced disease.

This transcript has been edited for length and clarity.

Dr. Gene G. Finley spoke about current patient treatment obstacles as part of CURE’s ‘Speaking Out’ video series.

Patients With Lung Cancer Face Unmet Needs During Drug Shortages

Brian Sturgill has spent 45 years serving his country. When the U.S. Air Force veteran and longtime registered nurse with the U.S. Department of Veterans Affairs (VA) in Miami received a diagnosis of metastatic lung cancer 11 years ago, he trusted his country to take care of him.

“Current workings at that time (were) basically (to say), ‘Oh, sorry, Mr. Sturgill, we’ll start you on hospice. It spread; there’s not much we can do,’ ” Sturgill, 65, tells 

. “Luckily, Dr. Michael Campos at the VA said, ‘We’re going to fight through this, Brian.’”

Sturgill, who served as a medic and respiratory therapist in the Air Force, is among the nearly 8,000 veterans who, according to the VA Lung Precision Oncology Program (LPOP), receive diagnoses of lung cancer each year. The VA also states that approximately 5,000 veterans die of lung cancer annually and “an estimated 900,000 (veterans) are at risk for lung cancer due to age, smoking and environmental exposures during and after military service.”

Veterans, the VA states, have higher rates of lung cancer and lower rates of survival than the general population.

The Veterans Affairs Lung Cancer Surgery or Stereotactic Radiotherapy (VALOR) trial, which is sponsored by the VA Cooperative Studies Program, launched in 2017 and is expected to run through 2027. The trial is aiming to determine whether traditional lung-resection surgery or stereotactic body radiation therapy is preferrable for treating stage 1 non-small cell lung cancer (NSCLC).

UCLA Health calls it “the largest lung cancer treatment study ever,” with a patient population of 670 veterans.

Chief of thoracic oncology in the radiation oncology department at UCLA Health in California and co-chair of the VALOR trial, Dr. Drew Moghanaki, explains that while veterans with cancer face many of the same inequities that members of the general population do — stemming from intertwined factors including geography, socioeconomic strata and structural racism — those imbalances level out under the VA system due to its long commitment to tackling disparities at an enterprise level.

“We don’t see the same racial inequities that are observed in the general public,” Moghanaki says. “And the question, really, is ‘Why?’ Well, I think it’s primarily because in the VA, we espouse a culture to leave no veteran behind.”

'All in the Name of Protecting Our Country' 

Sturgill, whose cancer had spread to his small intestine, underwent a small bowel resection and the removal of the upper lobe of his right lung and he also underwent chemotherapy.

“I had surgery, I had horrible chemo, but afterward, I was OK,” says Sturgill. “I’ve been OK until a recent PET (positron emission tomography) scan where it looks like something is brewing, but I’m not overly concerned about it in that sense. ... All the lymph nodes lit up this time, indicating something’s going on.”

“We know that lung cancer disproportionately affects our veterans,” says Dr. Charles B. Simone II of Memorial Sloan Kettering Cancer Center in New York and the New York Proton Center. “We know that lung cancer in general is one of the most common cancers in the United States, but whether it’s based on smoking exposure, environmental exposures or age, people that are in (or are) retired from the armed forces have disproportionately high rates of lung cancer, such that approximately 1 in 5 of all cancer diagnoses in our veterans are in lung cancer.”

Simone is a co-author of updated consensus quality measures for standards of care for veterans with lung cancer published in 

 the result of a partnership between the VA’s National Radiation Oncology Program and the American Society for Radiation Oncology as part of the VA Radiation Oncology Quality Surveillance program.

“Two-thirds or more (of veterans with lung cancer) should be receiving radiation therapy as part of their multi-modality therapy or as their only therapy in some curative-intent purposes for early-stage lung cancer, yet fewer than half of our veterans do receive radiation therapy,” Simone says.

Interviews with 24 veterans with lung cancer at the VA Palo Alto Health Care System in California revealed that “social and economic disadvantages can prevent routine delivery of evidence-based cancer care,” with researchers also noting that “fragmented care contributes to worsening patient mental and emotional well-being,” “lack of health system interventions to address limited health literacy inhibits patient engagement in shared decision-making regarding diagnosis, genomic and molecular testing, targeted and other treatments and end-of-life care” and “deep appreciation for care and VA trustworthiness facilitates adherence to cancer care recommendations,” according to the authors of a report published in 

The same team of researchers reported that “the main barrier to lung cancer care was transportation with inadequate financial coverage for gas and extensive commutes that contributed to significant anxiety and stress regarding (patients’) cancer care” in a study published in the 

. They also noted that participants had difficulty comprehending and interpreting their diagnosis and were universally unaware of precision medicine such as molecular tumor testing and genomic cancer sequencing.

A study of racial disparities in lung cancer screening among veterans from 2013 to 2021 at Durham VA Health Care System in North Carolina, findings of which were published in JAMA Network Open, showed that Black veterans were 34% less likely to complete a lung cancer screening program than White veterans, with researchers noting that the disparity “persisted even after accounting for numerous demographic and socioeconomic factors.”

Nearly 19,000 veterans with clinical stage 1 NSCLC treated under the VHA system found that Black patients, while slightly less likely to receive lymph node sampling, were less likely to experience major post-surgery complications, according to results published in 

 Black patients also had better risk-adjusted overall survival (length of time from diagnosis when a patient is still alive) and equivalent 30-day readmission and mortality as well as disease-free survival (period after primary treatment when a patient survives without signs of that cancer) when compared with White patients, the results established.

Veterans with clinical stage 1 NSCLC undergoing surgery who received treatment through the VHA had lower 30-day mortality (1.9% versus 2.8%) and higher media overall survival (71.4 months versus 65.2 months) when compared with similar patients from the general population of nearly 7,000 pairs of patients, according to findings published in 

“Veterans are unique. They tend to be older, they have other medical problems that go along with lung cancer that impact potentially how you treat their lung cancer, (and) more veterans live in rural areas,” says Dr. Shadia I. Jalal, director of the multidisciplinary thoracic oncology clinic at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana. “What might work in an academic center is not something that you can simply transplant and do at the VA, so there has really been rightfully a shift to really personalized care significantly in multiple ways at the VA, and this spans multiple things such as standardizing care. You want to make sure that every veteran in the country who is seen at a VA facility gets the optimal lung cancer care. The VA is the largest integrated health care system in the country, and so you really want to make sure you provide physicians (with) the tools (they need) to make sure that they are delivering the best care.”

One year after the 2021 launch of the VA’s LPOP, President Joe Biden signed the bipartisan Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics (PACT) Act into law, heralded by the White House as “the most significant expansion of benefits and services for toxic exposed veterans in more than 30 years.”

During the first year of the PACT Act, according to the White House, more than 4.1 million veterans received free toxic exposure screenings through the VA, with the government processing nearly half a million PACT Act claims and delivering more than $1.85 billion in PACT Act-related benefits to veterans and survivors, including $215 million in benefits to veterans with cancer.

Under the PACT Act, respiratory cancers are considered presumptive conditions — meaning veterans do not have to prove that the cancer started during or worsened because of their military service — for veterans who experienced toxic exposures including Agent Orange during the Vietnam War and burn pits during the Gulf War and post-9/11 eras.

Burn pits, as detailed by the Associated Press in its 2022 reporting on the passage of the PACT Act, were utilized in Iraq and Afghanistan for the disposal of material including chemicals, medical equipment, human waste, cans, tires and plastics. Prior to the PACT Act, 70% of disability claims involving exposure to the pits were denied by the Department of Veterans Affairs, the Associated Press stated.

“There are large databases that provide a long list of chemicals on military bases that are carcinogenic. Some of them can be absorbed through the skin, some of them can be inhaled through vapors. Our veterans were also exposed to many of these chemicals when deployed to combat zones and were exposed to even more toxic chemicals” Moghanaki tells 

“So, the list is long, and I tell you, someone who grows up and works in an office building and never worked around chemicals has a much different (level of ) risk (for) lung cancer than veterans who were on military bases touching this stuff (and) breathing this stuff, all in the name of protecting our country.”

Carl Schuck, now 76, was enlisted in the Air Force from 1966 to 1970, and during his Vietnam-era service, he worked in ground radio maintenance, stationed in Germany and then in Alaska. Schuck received a diagnosis of prostate cancer in 2017, and “during all of the testing and imaging, they noticed something on the X-rays, something on my lung,” he says.

He was sent to a pulmonologist for further tests. “I was diagnosed with lung cancer, which was followed very shortly by surgery,” he says. “They resected my upper right lobe in my lungs.” He subsequently received five radiation treatments to treat nodules that were discovered in his left lung in the spring of 2022 and is now monitored by CT scans every three months.

Between those two treatment periods, Schuck experienced an early case of COVD-19 in March 2020, which resulted in him being placed on a ventilator for 15 days.

Schuck, a retired electronics engineer, made headlines in 2021 when through Florida donation center OneBlood, he hit the milestone of having donated 100 gallons of blood, a practice he began as a teenager and that he is unsure if he will be able to continue due to his cancer and treatment experiences.

Schuck, like Sturgill, says he did not experience any toxic exposures during his service, noting that “my duty assignments were pretty mediocre as far as environmental (exposures). Except for the cold in Alaska, it was pretty tame.”


“The only thing is, I didn’t start smoking until Germany,” he says, “and then, I smoked about a pack a day for 18 years until I quit. So, that would be my only (exposure) but that wasn’t the Air Force’s fault, that was my own doing. ... You’re a young guy far away from home (in a) foreign land, peer pressure, just one of those things.”

As of 2005, 32% of active-duty military personnel and 22% of veterans smoked, compared to slightly more than 20% of the general population, with prevalence in smoking more than 50% higher among personnel who had been deployed, according to the 2009 National Academies Press publication “Combatting Tobacco Use in Military and Veteran Populations.”

Among the 18.8 million military veterans in 2015, 29.2% reported current tobacco use, according to an analysis of the 2010 to 2015 National Survey on Drug Use and Health cited in the Centers for Disease Control and Prevention’s “Morbidity and Mortality Weekly Report” in 2018.

C-rations, military field ration kits developed in 1938, included “chocolate or other candies, gum, biscuits and cigarettes,” according to the Department of Defense, and the practice of supplying troops with cigarettes didn’t end until 1975. Tobacco products are sold on military bases and for lower prices than off-base, according to research published in 

“We certainly have a lung cancer problem in this country, and in particular among our veterans who were exposed to carcinogenic chemicals,” says Moghanaki. “It also stems from very aggressive tobacco marketing campaigns, including contracts with our military branches to push cigarettes into the ration bags of our soldiers who were just kids when they joined.”

Schuck says his care was covered through his own insurance.

“I’ve been told a number of times that I should have (applied) for VA benefits but in both mine and my wife’s careers, we had very good health insurance,” he says.

Nine million, or approximately half, of U.S. veterans are enrolled in the VA health care program, which includes more than 1,300 health care facilities, according to the U.S. Department of Veterans Affairs. As of September 2022, the VA reported that it was caring for more than 450,000 veterans with cancer and makes approximately 43,000 new cancer diagnoses annually.

Since retiring in February after nearly 40 years of service, Sturgill has returned to the VA to work on a South Florida Research Foundation lung cancer screening program research study housed at the Bruce W. Carter Department of Veterans Affairs Medical Center in Miami. His trust in the care he continues to receive through the VA remains unflappable.

“As an employee there and as a veteran, I feel very safe there,” Sturgill says. “And as a veteran, I feel safe at all the VAs with the care (they provide).”

Feature

U.S. veterans face exposures during military service and disparities at home.

On the Front Lines of Lung Cancer

In 2015, Michele Altizer developed a persistent cough and shortness of breath, eventually receiving her first diagnosis of stage 3 adenocarcinoma, leading to a variety of side effects. 

"I thought the surgery was bad and very painful, but (chemotherapy) was equally as bad," Altizer says. "There were a lot of side effects (from surgery and chemotherapy) ... I have nerve damage from the surgery, like in my ribcage. I have hearing damage from the chemo burning the nerves in my ears. ... My taste isn’t right. ... I don’t have (a) good memory anymore. I have to write everything down now, and it just goes from there.”

Three years later, the cancer returned, but now in both of her lungs, making this stage 4 metastatic cancer. Altizer underwent next-generation sequencing of the tumor, which determined that she had the KRAS mutation, making her a fit for a clinical trial assessing Lumakras (sotorasib), a biological drug that targets the mutant form of certain KRAS mutations.

She started with the highest dose of Lumakras — 960 milligrams — which left her feeling very fatigued; so tired, in fact, that she said that she was sleeping 18 hours a day and could barely lift her toothbrush.

“ ‘That’s not how I want to live my life,’ was how it was brought up to (my doctor),” she recalls. “I want to be able to do stuff before I do die. So, is there anything we can do to where I can stand the drug, (and) my cancer’s still gone, but have a life as well? And that’s when they started talking about the dose reduction.”

This involved a process of stopping Lumakras altogether for one 21-day cycle, then starting again at a 480-milligram dose. Altizer took that for a while and was still really tired. She ended up stopping the drug again for a week before starting a 240-milligram dose, when she noticed an improvement in her side effect.

Now, at 61 years old, the mother of three sons resides in Madison Heights, Michigan and is “doing great” on her reduced dose of treatment.

Altizer is one of many patients whose cancer teams adjusted the dose of a drug to address side effects like fatigue. This decision may leave patients with anxiety while wondering if a lower dose may lead to other effects like the cancer spreading. Close monitoring by the patient’s cancer team allows them to keep a close eye on the disease while managing side effects.

Treatment de-escalation in lung cancer can pertain to several. approaches, all of which are aimed to reducing exposure to a given therapy. What most patients with lung cancer are accustomed to as treatment de-escalation refers to adjusting the intensity of a therapy to potentially manage any side effects from that treatment. For most cancer drugs, there is a set regimen with specified changes in the doses and schedule that is used for first, second or beyond de-escalations due to side effects.

“For patients with advanced disease, if they start to have side effects that become intolerable, we lower the dose or we deescalate the intensity of the treatment, in an attempt to preserve or maximize quality of life while still keeping cancer in control,” explains Dr. Ryan Gentzler, associate professor in the division of hematology and oncology in the department of medicine at the University of Virginia in Charlottesville.

That’s what happened with Altizer; after her dose was decreased, she felt better, despite still feeling a little tired, she says, which she believes could be something else.

Dose de-escalation may also be linked to purposely omitting a component of treatment from the outset in hopes that it is not as critical, and that the patient with lung cancer can achieve the same results.

A focused radiation approach may be beneficial to patients with lung cancer that has metastasized (or spread) to the brain. The traditional paradigm for patients with meta- static lung cancer is whole-brain radiation, which is associated with a lot of toxicity. Researchers have developed new treatment with stereotactic radiosurgery, allowing cancer teams to just treat focal spots (limited to a specific area) in the brain compared with the whole brain, especially in patients with oncogene-driven mutations like ALK, EGFR and ROS1. This approach has been found to have the same results, if not better, with fewer side effects for eligible patients.

In April of this year, Dr. Jacob Langston, chief resident PGY-5 in the department of radiation oncology at the University of Colorado Anschutz Medical Campus Aurora, and his colleagues published results from a study in the journal 

, in which 12 patients with non-small cell lung cancer (NSCLC) were treated with tyrosine kinase inhibitors first before they proceeded to stereotactic radiotherapy.

“All these patients, ... who would always be a candidate for whole- brain radiation, we converted them into stereotactic radiosurgery patients at that point,” Langston explains. “So that was a pretty significant thing that we were able to do, was spare the toxicity of whole brain and just treat them focally.”

Even with lowering the dose or using a different tactic to minimize the burden of side effects, there is still a chance that treatment may not go the way a patient expected it to, Langston adds. That’s not to say that there are no other options.

“That’s always a risk,” he notes. “The downside would be potentially not getting a response ... or having progression. ... But I think that’s where the component of monitoring those people very closely comes in. That way, if they start to show that they’re not having a response, you can switch lines of therapy, think about new systemic therapies to introduce.”

Many studies assessing treatment de-escalation have been conducted with retrospective data, meaning that researchers have assessed either events that have already happened or trials with established data. In these instances, statistical models are used to predict certain scenarios.

An example of this is a study published in the 

 in August 2022, in which researchers analyzed data from 1,006 patients with stage 3 NSCLC previously treated with chemoradiotherapy followed by at least one dose of Imfinzi (durvalumab).

The patients treated with immunotherapy certainly lived longer and had a longer time without their cancer recurring, says Dr. Nithya Ramnath, professor of medicine and Marylou Kennedy Research Professor of Thoracic Oncology at the University of Michigan in Ann Arbor and section chief of oncology at the VA Ann Arbor Healthcare System in Michigan. Despite this benefit, patients in this study had significant side effects such as inflammation of the lungs (pneumonitis). Side effects like these led to 15% of patients to discontinue the treatment for immune-related side effects and 6% for non-immune-related side effects.

Ramnath and her colleagues delved deeper into the data to learn more about which duration of immunotherapy would provide patients with the most improved survival: three months, six months, nine months or 12 months. The “sweet spot,” as Ramnath calls it, seemed to be in the six-month range, which demonstrated that there may be patients in the real world that may be receiving immunotherapy for longer than they may benefit from it.

“There is a possibility that some patients can have a de-escalation of therapy and still obtain the same degree of benefit,” she says. “But who these patients are and how we do this sort of a study becomes the big question.”

The type of studies needed to potentially change the standard of care are large prospective, randomized clinical trials. The challenge is that these trials are difficult to do, Gentzler explains, because they require both a lot of time and patients to conduct. Until those trials emerge that show that de-escalation is equally effective or even more effective than standard of care, cancer teams proceed with knowledge from retrospective studies and real-world experience.

Jordan Meyerson, a 59-year-old Long Island native living in Boca Raton, Florida, received a diagnosis of stage 4 metastatic, ALK-positive lung cancer in September 2016. He was treated with several tyrosine kinase inhibitors — three, to be exact, over a two-year period — before his cancer no longer reacted to the therapy. His cancer team switched him to chemotherapy, which he underwent from 2018 to 2019.

In December 2019, his treatment changed to Lorbrena (lorlatinib), an ALK inhibitor indicated for patients with ALK-positive metastatic NSCLC, when his team discovered that the disease spread to his liver. Meyerson first started with a 100-milligram dose, but after six to eight weeks of the treatment, his wife noticed some side effects.

“My wife noticed that I was having mood swings, cognitive issues, anger issues, so she asked me to speak with a doctor,” he says. “And they reduced me down to 75 milligrams.”

That approach helped address Meyerson’s side effects, and by May 2020, he was considered having no evidence of disease.

He continued with the 75-milligram dose of Lorbrena until November 2021, when he developed severe neuropathy in his hands and feet. His team recommended dropping the dose from 75 milligrams to 50 milligrams, which made him anxious at first.

“Needless to say, I was petrified,” Meyerson explains. “Going from 100 (milligrams) to 75 (milligrams) wasn’t so bad, but (from) 100 (milligrams), being no evidence of disease, and now I’m down to 50 (milligrams) to see if it would take away my neuropathy. ... The doctor assured me that ‘It’s OK, we’ll monitor you, we’ll scan you. And if something comes up, we can always put (your dose) back up. Don’t worry about it.’ ”

He proceeded with the 50-milligram dose, which eliminated his neuropathy. Three months later, his scans showed that there was no evidence of disease, which remains his status today.

Even with the limited prospective trials in this space, this approach of dose reductions is still being applied in clinical practice to help patients address their side effects.

“I do this in my practice,” Gentzler says. “I think there’s always how people practice compared to what the data show. And patients (proceed with) informed decision-making and discussions about risks and benefits of treatments, and we make a joint decision to de-escalate therapy in that individual patient.”

Even with the information needed to make this decision, patients may still have anxiety, as Altizer recalls having, despite having knowledge from her experience being a pharmacy tech. She says her husband was also nervous about this approach.

“My husband was very edgy when they discussed taking me off (Lumakras) just to recover myself for a while,” she says. “(He’d say,) ‘Well, what if it comes back? And what if the drug doesn’t work now because you went off it?’ ”

Meyerson remembers a similar anxiety of the disease coming back, especially with the second dose reduction.

“The fear factor, it’s like taking a teddy bear away from a baby,” he says.

Several sources are available for patients with lung cancer including advocacy groups, which allow patients to potentially speak with others who have experienced a similar situation. Patients with lung cancer may also benefit through online resources, with the caveat that they discuss findings with their care teams to ensure they obtain the most accurate information.

Experts also urge patients to make sure there’s a plan in place with their care team.

“What does the surveillance period look like? How often is your physician going to be getting scans? What is that interval? That’s an important question to ask, how often the follow up is, how often you’ll be seen by your physician,” Langston says.

Ramnath says that patients know their bodies best, so listening to it can be very helpful in making a decision about treatment de-escalation.

“(Patients) know how something is affecting them,” she explains. “And if they have seen certain side effects, they’re going to say, ‘You know what, I’m actually comfortable with this approach. ... And (when) something happens, we go back to treatments.’”

Altizer emphasizes the importance of trusting the care team when it comes to decisions like reducing the dose.

“That would be my No. 1 thing, is just trust the team you’re with,” she says. “And if you’re not, if you don’t trust what’s happening, find somebody else. That’s the biggest part right there.”

Meyerson also advises patients listen to their doctor’s suggestions, as the course of treatment can change if any negative effects occur with a dose reduction.

“With de-escalation, if your doctor feels that you could do it, try it,”
he says. “You can also go back up (in dose). That’s a real possibility. I know a lot of people that have been on a different drug than myself that were feeling lethargic on one dosage, their (dose) went down, they didn’t feel right, and they had a little bit of progression. They went back up (in dose), and the progression went away.”

Managing side effects from lung cancer treatment with dose reductions is an approach experts have been using more, even though some patients voice concerns about lowering a drug’s impact on the disease.

Lung Cancer Special Issue 2023 | CURE

On the Front Lines With Veterans Facing Lung Cancer

Patients With Lung Cancer Face Unmet Needs During Drug Shortages

On the Front Lines of Lung Cancer

Lowering Doses to Increase Quality of Life in Lung Cancer

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