Recent TV commercials are stating that lung cancer prognosis is 50% worse in African American men than Caucasian men. Is this true, or are the statistics misleading?
It's misleading because the confounding variables have not been controlled in these studies. Many studies have been conducted showing that African-American populations do worse than Caucasians with many different kinds of cancers, and this is a very complex issue in terms of stage at diagnosis, access to health care, nutritional and socioeconomic factors. It's not a simple issue to sort out. I published a retrospective analysis on veterans in St. Louis. I felt that the veterans had equal access to health care regardless of race, and therefore race wouldn't matter. For stage I and II non small cell lung cancer treated with surgery at the St. Louis VA hospital, I analyzed survival and outcome by race, and found no statistically significant difference in that group of patients. Genetic factors are probably not as closely related for lung cancer as a combination of extraneous factors that makes prognosis worse for African-American patients.

What are the different types of lung cancer?
There are two main categories and many different types of lung cancer; I believe that genetically there are dozens more that have not yet been described. From prognostic and treatment standpoints, we separate small cell lung cancer from the other categories. Small cell lung cancer tends to be more disseminated at presentation, with two thirds of the patients having clinically detectable metastases while two thirds of the remaining one third have microscopic metastases. This kind of lung cancer tends to be exquisitely sensitive to chemotherapy and radiation with up to 90% response rate, but most responders relapse and those who relapse are usually incurable. All the other varieties of lung cancer are categorized together as non-small cell because they don't share these same characteristics. Other lung cancers are metastatic only about 40% of the time at presentation and tend to be slower growing, and are not as sensitive to chemotherapy and radiation. Only about 30-50% of these patients respond to chemotherapy and radiation. At the end of five years, the cure rate for both types of lung cancer is about 15%. For non-small cell lung cancer, the main categories are squamous cell carcinoma, adeno carcinoma, large cell carcinoma, and bronchioloaviolo carcinoma. Squamous cell and small cell lung cancer are more closely associated with smoking than the other sub-types.

Does histology play a role in prognosis? There is a perception that squamous cell lung cancer may be more sensitive to chemotherapy compared to the other cancers. Whenever there has been a detailed analysis of databases to look for prognostic factors, histology doesn't consistently fall out. What falls out generally is that patients who have advanced stage cancer, have a high white count, elevated LDH levels, or those who have lost more than 10% of their body weight, and who spend more than half the day in bed, do poorly, and those with opposite characteristics do better.

What are the major causes and risk factors associated with lung cancer, and what can be done to prevent it?
Smoking is the major cause and risk factor associated with lung cancer. It's a sobering statistic that 85% of lung cancer is caused by smoking. Three percent more is attributed to passive smoking. Only 12% of lung cancer occurs in patients who have not been exposed to tobacco smoke. For example, the risk for male smokers is elevated above that of a male non-smoker by 22 fold; a 2,200% increase in risk! This puts minor risk factors, such as radon gas, in perspective. Other risk factors include asbestos exposure, fumes, etc. There is not a well-described familial syndrome of lung cancer, although there is debate about some genetic association. Again, smoking is such a powerful risk factor that it confounds most epidemiological studies of other risk factors.

What new breakthroughs in treatment are especially exciting?
I'm always excited about new developments in research and treatment, but we have to be patient and realize that progress is very slow. Lung cancer is so common that even modest strides in improving survival save thousands of lives. In the 1950s we used to cure about 8% of lung cancer. In 2001, we cure about twice that. This year we estimate a 15.8% cure rate. The optimists would say we have doubled the cure rate. Since we have over 160,000 cases per year, 8% of that is about 13,000 patients. To put that in perspective, although we cure the majority of Hodgkin's disease and testicular cancer patients, we only have about 7,000 each with these diagnoses. The number of lives we can save due to the progress in lung cancer treatment still outnumbers these other highly curable diseases. Even though the progress is slow, we have been treating lung cancer as a single disease, and in reality it is probably a group of diseases leading up to the same common end result of an uncontrollably growing collection of cells originating in the lung. The mutations in the cells are all different as are the ways to attack them, and their response to treatment. Once we learn to stage patients according to their genetic defects and intervene that way rather than staging patients based on the shadows they cast on a piece of film, we will make real progress. With decoding of the human genome, we have the framework within which to work. We will see a quickening pace of progress with fingerprinting of these cancers, which will allow us to tailor therapeutic interventions to block the events or abnormal signals that genetic errors create leading up to cancer.

I think advances in imaging have already helped us to stage cancer better. Chest x-rays are not the best way to screen for lung cancer. What we consider early lung cancer on a chest x-ray is often not early enough. A spiral CT scan is much more sensitive, and we're waiting for it to become cost-effective. Once that happens, it will probably be applied to more populations. The other exciting imaging modality in lung cancer is Positron Emission Tomography or PET scan. I think every newly diagnosed lung cancer patient should undergo a PET scan because it more accurately stages the patient and saves many people from unnecessary surgery.

Advances in supportive care have made a difference, as have advances in surgery. Other developing techniques include DNA analysis of the sputum, and fluorescence bronchoscopy. Interventions with differentiating agents, prevention agents, signal transduction inhibitors, vaccines, gene therapy, and addition of these biologicals to traditional chemotherapy will take us to the next level of therapy. I think the next decade is really crucial in turning the corner in lung cancer and seeing an incremental cure rate.

I want to mention a new exciting drug, Iressa. Previously we only had cytotoxic chemotherapies, which destroyed not only the tumor but other rapidly dividing normal cells in the patient and caused hair loss, sore mouth, diarrhea, low blood counts and risk of infection. Now that we have new drugs such as Iressa to specifically block the enzymes that promote cell growth and mediate the growth signals in the tumors, we have eliminated these side effects. Iressa has only minor side effects, is generally very well tolerated, and has shrunk tumors in phase I trials in patients who have failed multiple lines of chemotherapy.

Please describe any clinical trials that are currently being conducted. Are new patients eligible to participate in these trials?
Two large randomized trials were conducted recently for Iressa. Salick Health Care participated in one of them, and we will have the results in about a year. We have a third line trial of Iressa where patients who have not only failed the platinum-based therapy but have also failed Taxotere can take Iressa as their treatment, and this study is not placebo controlled; everyone gets the real drug. We have access to another protocol of Iressa also where patients who have received traditional chemo but do not want to receive further chemo can enter into a lottery system and get Iressa. We've recruited quite a few patients to that study as well.

What special services can patients expect at the Boca Raton Comprehensive Cancer Center?
I think we are unique in this place in that we have the most sophisticated cancer research program in the area. We don't have any surrounding universities that give us any competition at all. Tampa and Miami are the closest university centers, so we cover a large area where we provide the most sophisticated cancer research program as well as access to clinical trials that patients can't get elsewhere. Our services are integrated so that everything happens under one roof. Radiation, chemotherapy, and nutritional services are all available in one place. We have more than 30 studies open right now, and we have dedicated staff for research. Patients can receive treatment here in a very warm and convenient environment. If patients are interested in state-of-the-art therapies, this is the place to be.