A Lot of Good News About Lung Cancer

Alicia: This is the Good News About Cancer. I’m Dr. Alicia Morgans. 

Chuck: And I’m Dr. Chuck Ryan.

Alicia: We're oncologists, and we've spent our careers working to understand cancer. We believe that there's more progress now in research and treatment than ever before, and we're here to share that with you.

Chuck: In each episode of this show, we talk with one of our colleagues about a promising development in oncology. We'll break down what's new, why it matters, and how it points the way forward.

Christine: We're constantly, constantly, constantly trying to say: can we understand this better, to make treatment better? And that's what research is, right? Research is basically just: we want to understand cancer better so we can make treatments better. It's really that simple. 

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Chuck: So, Alicia lung cancer is a bit of a paradox for us here at the Good News About Cancer, isn't it? 

Alicia: You love a good paradox. It makes me think of your book, The Virility Paradox, right? Came out a few years ago? So why is lung cancer a paradox? 

Chuck: Sure. So before we get to lung cancer, let me just say: The Virility Paradox came out in 2018, still available probably at your public library through online booksellers and maybe at your local independent bookstore.

So, yeah, lung cancer is really an area where I see sort of paradoxical results. We are making so much progress. We have early detection, we have prevention through smoking cessation and other means. We have some novel therapies that have helped us dive into new areas of biology where we thought we couldn't ever develop a drug against that particular biological process.

So, great areas of progress, great areas of biotechnology, public health, et cetera, et cetera. And yet, it's still the number one cancer-related killer in the United States and many, many other countries. 

Alicia: Yeah, that's right. It's not just here in the US, it is around the world. And even as we do better, I think there's still a lot of work to do.

Chuck: There is a lot of work to do, and I think it's a great opportunity for us to talk to an expert about this complexity. 

Alicia: Well, we had a wonderful opportunity, just as you said, to sit down with my good friend and former colleague, Dr. Christine Lovly, who's the Division Chief of Thoracic Medical Oncology at City of Hope Comprehensive Cancer Center, and a professor in the Department of Medical Oncology and Therapeutics Research. She has been thinking about all of this in a very deep way for many years and has been heavily involved in many of the points of progress in this disease.

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Alicia: Dr. Christine Lovly, thank you so much for being here. We have been friends for many years, and I have admired all that you have done in a very, very busy career. 

But one of the things that has been a constant in your career has been your focus on lung cancer, and I'd love if you could start us off by sharing, from your perspective, out of all of the things that have happened in lung cancer over the last few decades, what do you think is the really most important good news about lung cancer?

Christine: Thank you Dr. Morgans. It's such a pleasure to be here. And later we're going to get into how Dr. Morgans and I used to study for our medical oncology exams together. 

Chuck: Can't wait.

Christine: But let's start with lung cancer. So here's a lot to be excited about in lung cancer in 2026. And I think, actually, I'm going to answer your question – instead of giving one answer, I'm going to give two. 

And first is a decreased number of lung cancers. And I'm going to temper that with: it's still the number one cause of cancer-related death in the United States, but we have seen a reduction in the number of lung cancers, and that in part is due to a reduction in smoking. And so prevention of lung cancer from reduced exposure.

Another is a literal explosion of drugs to treat lung cancer and better options for treatments. And that really is, you know, the advent of personalized medicine or precision medicine research that has told us how to treat lung cancer better. Completely transformative. And even in my practice, which has been a little over 10 years now, it's amazing, like mind-blowing, how much it's changed in that time. 

Chuck: Let's talk a little bit about smoking. Let's dive deep there. Because if we're going to eliminate lung cancer as a significant cause of death in this country and around the world, I think that is job number one. So tell us about what progress has been made and how it's been made.

Christine: Yeah, and you know, smoking has traditionally been a major risk factor for lung cancer. Cigarette smoking is still the number one cause of preventable cancers in the United States, and it's not just lung cancer, it's other cancers as well. There are more than 20 different cancers that have been related to cigarette smoking.

So there's lots of reasons for us to think about reducing cigarette smoking, but I also think we need to make sure that we're not sending a message of shame and blame about people who were cigarette smokers in the past, because frankly we just didn't know. 

I remember even being a kid in the eighties, like there was, you know, cigarettes in McDonald's, cigarettes in all the restaurants. Like there wasn't an attribution between cigarette smoking and lung cancer or cigarette smoking in head and neck cancer, cigarette smoking and bladder cancer, and not just cancer, but all the other diseases that cigarette smoking causes. 

And frankly, the shame and blame has caused a lot of stagnation in lung cancer research, and so absolutely we want to send a message of: smoking cessation is incredibly important for overall health, it's incredibly important for decreasing the amount of lung cancer. But you know, if anyone who's listening was or is a smoker, there is no shame or blame in that it is not your fault. We have learned as a field, as humans, that you know what we didn't know about smoking years ago. We know now, and that's what research is all about. 

Alicia: And just to round out the conversation on smoking, and thank you so much for just drawing out the fact that no one should be shamed here. This is really, in many ways, a success that we are now aware and we are able to reduce smoking dependence and, and hopefully stop people from starting.

We also know that if people have been smoking themselves or exposed to secondhand smoke, we're getting a lot better at screening, which is the opportunity to detect lung cancers before they become things that are much more challenging to treat or perhaps not curable anymore. And I wonder if you can comment on how screening has been rolled out in ways that has been helpful to reducing deaths from lung cancer.

Christine: You know, the goal for any type of cancer is to not get it in the first place. That's always the best case scenario. And if you get it, can we find it early? 

So let's talk about what screening exists for lung cancer. Right now there's something called low dose CT screening, and it's only been within not even 10 years that this has really come into our clinical toolbox. It is shown – this low dose screening – to not only detect lung cancers earlier, but improve mortality, improve life from lung cancer diagnoses. So proven benefit from low dose CT screening. 

Here are the caveats: It's not for everyone. It is for patients ages 50 to 80 who have a certain amount of smoking history, what we call “pack years,” and it is not something that you can just like a mammogram, Most people can just go and get a mammogram if to screen for breast cancer. This requires a little bit of an extra step. It requires what we call a shared decision-making visit, where you have to actually go and consent for the low dose CT. So just just a couple more logistical hurdles to go through to get low dose CT screening. 

What I want to convey to anybody who's listening is: if you have any smoking history at all, please ask your doctors, am I eligible for lung cancer screening? It involves a simple CT scan, or sometimes called a CAT scan, where they just take a picture of your chest. It's better than a chest x-ray and it is shown in multiple studies from the US and outside the US that this actually saves lives. 

Chuck: Hugely important point. The American Cancer Society projects that if 100% of those eligible were to be screened, there would be an estimated 30,000 deaths prevented and an additional 482,000 additional years of life gained, which is an incredible amount when you think about it, you know, simply through getting this yearly CT scan.

Christine: Yeah. The good news is we have a screening test. The challenge is it is very underutilized if you look across the United States. On average, less than 10% of eligible patients get screened, and we're still at a point in lung cancer care where 50% approximately of patients that we're seeing at initial diagnosis already have cancer that spread, already have metastatic disease. We have to do better.

Alicia: As I've watched this over the last number of years and have seen how all of oncology has changed since the two of us finished with training and became oncologists, one of the areas of most change has actually been in lung cancer treatment. And it's hard for me to scratch the surface. I would love if you could walk us through how things have changed and what the good news is there.

Christine: Yeah, so, so much good news. And so Dr. Morgans and I used to study for our oncology board exams together, and it was amazing and we have been friends for over a decade now, and I really value that time we spent together at Vanderbilt in my office. 

Chuck: Looks like you both passed, by the way. 

Alicia: We did. 

Christine: We both passed. We both passed.

Alicia: It was touch and go for a while there. But we passed. 

Chuck: Just checking.

Christine: We had a fabulous time studying for our exams together and you know, if we rewind, you know, like more than 10 years ago now, the things that Dr. Morgans and I were studying for our board exams: completely different now. What we would be studying now: completely different. Which is a testament to the way the field moves forward to research and advances, why we need research and why we continue to push forward. 

And I'm a medical oncologist and so I use medicines to treat lung cancer. But I also– I want to acknowledge there's also been huge advances in surgical practices for lung cancer in radiation practices for lung cancer. That's almost a whole separate conversation.

So let's talk about the sort of different buckets or different bins of therapy we use for lung cancer. Let's think about sort of three big classes: chemotherapy, targeted therapies and immunotherapy. And within each of those buckets, there's even tons of nuance. And so let's start with chemotherapy.

Chemotherapy, probably most people have heard of. I would say this remains a foundation for use of lung cancer, but there's even new ways to deliver chemotherapy. Chemotherapy is a way to interrupt the growth of a tumor cell. It's sort of a way to disrupt how one tumor cell becomes two, how two becomes four. Traditionally, we've been using chemotherapy for cancers for decades now. 

In lung cancer we use chemotherapy, but we also have things called antibody drug conjugates, where we use markers on the tumor cell to deliver the chemotherapy. And the, the whole idea is, can we just deliver chemotherapy better and in a more precise way. There's already several that are approved by the US FDA. 

And let me zoom out for a second: all of these buckets are predicated on understanding the biology of lung cancer better. We are constantly trying to say, can we understand this better, to make treatment better? And that's what research is. Research basically just wants to understand cancer better so we can make treatments better. It's really that simple. 

Chuck: Absolutely.

Christine: The second big bucket is a huge, huge bucket as well. It's targeted therapies. And targeted therapies basically means: let me understand the blueprints of the tumor, the blueprints being the DNA of the tumor, in order to deliver therapy. That is based on basically what went wrong in the cancer. Cancer is yourself gone wrong, and if we can exploit– if we can try to understand what got messed up in a tumor, can we block that somehow? Can we change that somehow? Can we, you know, inhibit, to use the medical word, that somehow? Will that halt the growth of the tumor? 

And in lung cancer, this is a paradigm that works extremely well. This is where we use the idea of personalized medicine, precision medicine, where we actually take the tumor, test the blueprints, the DNA, and say: if you have a certain change or – the medical word being mutation – in your tumor, can we direct a specific therapy, a targeted therapy for your treatment. And these targeted therapies are often not always pills, which in and of itself is transformative.

Chuck: We've talked in the podcast before about how in the previous generation, in oncology specifically, there was sort of this expectation that therapy was going to be hard, you are going to suffer if you are going to benefit from the therapy. And I think as you just alluded to, lung cancer may be one of those areas where not only are the therapies more effective, but the patients don't have to suffer while they receive them. I mean, not to say there are no side effects, but it's a different mindset. 

Christine: Yeah. I'm continually impressed by the way that drug development happens. And that's actually a great pivot to the third bucket, which is immunotherapy, which also is mindblowingly transformative in lung cancer. 

And so, the current immunotherapies and the current immunotherapies we use are predominantly what we call immune checkpoint inhibitors. Drugs like Keytruda, which is pembrolizumab, or Opdivo, which is nivolumab. And there are many others for certain patients. Not for everyone, and this is where we need to get smarter. 

These drugs work, in my opinion, miraculously. We see many patients have such responses to immunotherapy that it's– not just the tumor shrinks, but it's controlled even off immunotherapy. And the goal here is you use your body's own immune system to actually attack the tumor and make memory against the tumor. And how I sort of explain it when I'm talking in clinic is: if you get the flu or you get COVID or you get chickenpox, your body recognizes that as foreign. And it says, you're not supposed to be here, chickenpox. I'm going to activate the immune system, my natural defenses, to get rid of you, chickenpox virus. 

So cancer is not supposed to be in your body, so why doesn't your immune system get rid of it the same way it gets rid of chickenpox? Well, it's because the cancer is really smart and it finds ways to hide from the immune system. So we have to be smarter than the cancer. We have to be one– try to be one step ahead of the cancer. And these– some of these immunotherapy medicines, they take away the ability of the cancer to hide from the immune system. They don't work for everyone, but when they work, it is miraculous. 

Chuck: So break it down for us. If you're seeing a patient, you know, your new, new diagnosis coming in to see you, how many– what proportion of them are going to have a really significant response to immunotherapy off the bat? 

Christine: Yeah, about one out of five. 

Chuck: Okay. 

Christine: Roughly, which, you know, again, when you consider that in 2026 there's going to be 229,410 new lung cancer cases, that's a huge number. 

Chuck: There's tens of thousands of people that– you said one in five and there's tens of thousands of people who are out living life, and as you point out, getting the immunotherapy and then maybe coming off the immunotherapy.

Christine: And then coming off of it, right. And, you know, chemotherapy is used as are all the therapies that I'm talking about across all stages of disease. And so, you know, we still want to shift the curve. We want to shift it to that patients are diagnosed with early stage disease because that gives us the best fighting hands, always. 

Chuck: So we've seen improvements in outcome across the board, declining in numbers of patients dying of the disease, et cetera. But as you point out, we're still using therapies that are helping in a significant way, a minority of patients. 

So what do we need to do to get to the next level? What is exciting about the next five to 10 years? If you could write the script as how this goes, what, what would you see happening? 

Christine: I'm going to frame that in four ways, because we started with three, I'm going to add one more. First, prevention. And prevention's not just stopping cigarette smoking. It is also: what are other exposures that actually may lead to lung cancer, like radon. Like, you know, for veterans, burn pit exposure, fire exposures, the things in our environment that actually may, you know, damage the lungs long-term. There's an enormous amount of research that's going into that, and I think over the next five to 10 years, we'll have a lot more insights and maybe even things like chemo prevention that will help heal damaged lungs from exposures. 

The second: screening. You know, we have to get better at putting out what already works. We're not doing a good enough job at implementing what we know already works, and so huge, huge, huge push is we have to innovate, but also implement, use what we have in our toolbox already.

Third bin is a literal explosion– we could talk a whole other hour about new therapies that are coming down the pipeline, new immunotherapies, cancer vaccines that are gonna be transformative in my opinion, especially for early stage disease, earlier detection of when treatments work or don't work, use of liquid biopsies or circulating tumor DNA in lung cancer to say, okay, you had a surgery, but now we're going to call it molecular relapse, detecting the cancer earlier so we can intervene sooner. Really not, you know, we're kind of doing a watch and wait approach right now, but using advanced technologies and truly like AI is the answer for everything in 2026. So it sounds cliche, but it will transform so many aspects of our care.

The fourth bin that I'm going to add that we haven't talked about yet, but I think is so important, is survivorship. We haven't had survivorship in lung cancer because there haven't been lung cancer survivors. We have lung cancer survivors now, and so we really need to understand betterL what does it mean to be a long-term lung cancer survivor? What are the medical problems that may happen in long-term lung cancer survivors, and how do we best support those patients over time?

Chuck: What you're doing is you're really surrounding every aspect of lung cancer, from prevention to early detection, screening to the most advanced therapies. So this is, this is how you, how you solve a problem. You have to attack it from every different angle. And it's really encouraging to see that there’s pretty much just progress on every one of those angles that we're, that we're attacking. 

So we're looking forward to seeing what you and the proverbial they are able to do over the coming generation in eliminating this as a major cause of death and suffering in the United States and globally.

Christine: Amazing. Thank you so much for having me. I really appreciate that opportunity.

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Alicia: I think it's so exciting though that we have made such progress. Even in our very first episode, we talked about the amazing public health changes that have happened in Puerto Rico and how smoking rates have gone down substantially there, and this kind of work, if it happens around the world, will continue to improve things in terms of lung cancer rates. And we'll just add to that good news about lung cancer. 

Chuck: I mean, amazing. I remember, you know, being in a car with my sisters and my brother and my dad smoking a cigar in the front seat while driving and all the windows were closed and, you know, us yelling at my dad about smoking. And he was an oncologist!

But the other thing that I think about was my mom actually, she was a nurse and she always told this story, funny story about when she was in her early days – we're talking now like the late fifties, maybe early sixties or so – working as a ward nurse in a hospital. And the way it worked there was if you smoked, you would get a break to go smoke. You get a smoke break. But if you were a non-smoker, you didn't get a break. And so, you know, this is like a workplace, a hospital no less, incentivizing smoking in their workers. 

And of course that would just be completely ludicrous to see today. And that reflects really what's happened with the public perception and the public health world in terms of reducing smoking. And we see concomitant reductions in lung cancer death as a result of that. So that's good to see. Uh, but still a lot of work to do. And it does tell us that even though there is a paradox about lung cancer, it certainly belongs in the conversation on a podcast called the Good News About Cancer.

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Chuck: So thank you for listening to the Good News About Cancer. I'm Dr. Chuck Ryan at Memorial Sloan Kettering Cancer Center in New York. 

Alicia: And I'm Dr. Alicia Morgans at Dana-Farber Cancer Institute in Boston. The views we express on this show are our own and do not represent the views or opinions of the institutions where we work.

Chuck: Thanks to Lilly for support of the show. Our production partner for this series is CitizenRacecar. This episode was produced by Anna Van Dine with post-production by Alex Brouwer.

Alicia: And there's a whole lot more good news to talk about, so make sure you subscribe to this wherever you listen to your podcasts. And if you like the show, share it with someone you think might find it interesting. 

Chuck: And we'll be back again soon with some more good news about cancer.