Lung Cancer: Evolving Concepts in Management

Douglas Arenberg, MD.

Steven M. Dubinett, MD.

Lung cancer remains the world's leading cause of cancer death. Clinicians' and investigators' focused on lung cancer have long been concerned that the field lagged behind the clinical and research progress in other malignancies in terms of research funding and progress toward improved treatment. But recent groundbreaking discoveries have led to practice-changing innovations for individuals at risk for lung cancer as well as patients diagnosed with the disease. These rapidly evolving advances include, for example, lung cancer screening which is now being instituted throughout the United States and immunotherapy, as well as a new generation of targeted agents that are altering the approach to treatment of advanced disease. The goal for this issue of Seminars is to provide a current expert overview of the standard of care in addition to highlighting the evolving progress in lung cancer investigation. In the era of “personalized medicine,” one could make a strong argument that lung cancer is leading the way.

Importantly, this issue opens with an outstanding review of tobacco policy and practice by Drs. Emily Stone and Anil Vachani. This review ties together the important but seemingly disparate areas of global tobacco policy and tobacco-dependence treatment, and the obligation/opportunity for lung cancer clinicians to engage fully in both. A review by Dr. Peter Mazzone on the obstacles to, and solutions for, establishing a successful lung cancer screening program is an excellent addition, and this leads naturally to the topic of lung cancer diagnostic biomarkers, in a review by Drs. Atwater, Cook, and Massion. Dr. Konopka provides the pathologist's view of the information a pulmonologist and pathologist should know when discussing diagnostic lung cancer pathology, and the importance of interdisciplinary communication in this field.

Dr. Barjacktarevic and colleagues cover the age-old topic of the pulmonary nodule through the lens of modern imaging techniques and diagnostic options, followed by a thorough and well-written review of the surgical considerations in treating early-stage lung cancer by Dr. Donington. Lung cancer treatment for the medically unresectable early-stage patient is reviewed by Dr. Lee, including an historical look at radiotherapy, the current state, and future directions this field may take. Stage III lung cancer has been, still is, and will remain an area that is ripe for debate as far as the optimal treatment strategies, largely owing to the extremely heterogeneous population of patients and broad burden of disease they represent. This topic is covered with excellent nuance by Dr. Rusch.

An area of most rapid change is the management of stage IV disease, reviewed by Drs. Rehman and Ramalingam. This article covers what was once just a review of systemic cytotoxic chemotherapy, and now conveys the role for and proper selection of targeted tyrosine kinase inhibitors, monoclonal antibodies, and antiangiogenic agents. The identification of driver mutations, coincident with the development of drugs that target these mutated proteins, has resulted in a new era of lung cancer care, particularly for those with metastatic disease. In spite of these recent advances, for most patients, lung cancer remains a deadly disease requiring skilled palliation throughout treatment and in end-of-life care. Drs. Bade and Silvestri outline the benefits, components, and goals of a comprehensive approach to palliative lung cancer care in article “Palliative Care in Lung Cancer: A Review”.

A newer topic covered in this issue is the broad array of prognostic and predictive biomarkers that can be brought to bear upon treatment decisions for lung cancer patients. This review by Drs. Thakur and Gadgeel provides a thorough but succinct review of how biomarkers, which include topics ranging from simple histology to circulating micro-RNA, may be deployed to impact treatment decisions applicable either now or in the future. A separate review by Dr. Brahmer and colleagues covers the rapidly evolving area of immunotherapy and its unique considerations in the care of lung cancer patients. Finally, Dr. Kalemkerian discusses the current and future state of the art in treating small cell lung cancer. On behalf of the authors who provided these outstanding reviews, we anticipate that this issue of Seminars in Respiratory and Critical Care Medicine will serve as a useful resource for readers interested in the management of lung cancer.