In an interview with ETHealthworld, Dr Ullas Batra, senior consultant medical oncology, chief of thoracic medical oncology, Rajiv Gandhi Cancer Institute, talks about the developments in the treatment of lung cancer. Edited excerpts:
How has the healthcare scenario, in terms of quality treatment options available for cancer patients, changed over the years?
If you look back at 1990s, there were only four drugs available for lung cancer and people used to live for 6-8 months. In 2000 there were 5 drugs available for lung cancer and people used to live for a year. I remember in 2006 or 2007, a new drug came, and people used to live for a year with stage 4 lung cancer. There was excitement about how people can beat lung cancer.
Now, with the quantity of drugs available, and different options like targeted therapies and immunotherapies available, people are living with stage 4 lung cancer for years and years together. Moreover, individuals are living on maintenance chemotherapy for two-three years. People are living on targeted therapies and oral medicines, and experiencing no side effects like hair loss and vomiting and they are living with a huge quantity and quality of life.
Targeted therapy is seen as the next step forward in tackling the huge lung cancer burden in the country. Has it been successful in improving the survival chances of lung cancer patients?
The problem with chemotherapy was that chemotherapy kills the bad cells and the good cells. So when the bad cells get killed you are happy but since your good cells get killed, there is a limit to what chemotherapy you can take. People used to take 4 -6 cycles of chemotherapy and their quality of life used to deteriorate, so much that they refused to take any more chemotherapy. On an estimate only one-third of people took the second line of chemotherapy, with the median survival of only 8-10 months.
With the targeted therapy, you don’t kill the good cells, you only kill the bad cells. And targeted therapy for lung cancer is oral pills. There will be no nausea or vomiting. You can just pop a pill and do your daily work without being hospitalized. Once a month you have to visit the hospital. Again, I would like to add that it has increased survival. Whilst we were talking about one-year survival of about 30% of the patients around 5 years back. Now people with brain metastases, who used to live only for 3 months, today live for five, five and a half years.
Five years may not be a huge time for some people. But just imagine the family of the individuals who must have been diagnosed with stage 4 cancer. On one hand you were telling them 10 years back that you just have two more months to live and now with the help of targeted therapy you can improve both the quality and quantity of life and that is wonderful.
At this point of time, how important are clinical trials for reducing the disease burden in India?
Clinical trials are very important and we should understand what they are. A layman equates the clinical trials with a guinea pig. No, there are established guidelines for even clinical trials. You go through trials on the mice first, phase 1 and then phase 2 trials, then phase 3 and 4 trials. The NCCN guidelines, which are to most of the people the bible of all the cancer guidelines, say that the best way to treat a patient is through clinical trials.
Now a person in India is very different from a person in US. So why should a drug that is approved and conducted a clinical trial in USA, be equally efficacious for a person in India? For example, the EGFR mutation in lung cancer in India is 40% or 33% of our patients. In USA, it is only in 15% of the patients. In China it is in 55% of the patients. Hence, the lung cancer in India is not similar to the lung cancer in USA or China. So why should the therapy for lung cancer be the same in USA, India and China? And to address this difficulty and discrepancy, clinical trial is very important.
It is a common trend that most of the ground-breaking research pertaining to cancer treatment is conducted in foreign universities and organization. What are the measures that can be taken to encourage such research within the country itself?
Practically, there are very few clinical researches that are happening in India. We only follow the research. The research is done in the western population and we just follow the drugs, and if it is approved then we start using it.
India has huge amount of potential in clinical research. In fact, the first thing that should be done is that we should encourage people to participate in the clinical trials and the doctors to conduct the clinical trials. Also, all doctors should join hands together.
With the amount of cancer burden that we have, the need is to conduct multi-centered clinical trials. Let us all pool in our data. Why should my treatment be different from any other doctor? If we all pool in our data and keep our patients on one common protocol, we will lead the way and the west is just going to follow.
Were there any new trends witnessed in the field that have the potential to change the treatment scenario for lung cancer?
In the last decade if there is a change which has occurred in solid tumors, it is in lung cancer. Lung cancer is a poster boy for personalized treatment. Let’s say there are two patients diagnosed with lung cancer, then both will not get the same medicines. One of them may get an oral medicine while the other one may get an IV chemotherapy or immunotherapy.
Immunotherapy is when you enhance your body to fight against the cancer cells. Additionally, targeted therapy has changed the way we look at lung cancer. In fact, we did our own analysis of the data and in thousand odd patients we found out, 33% of our patients were EGFR mutant, 11% of patients were ALK positive, and 1-2% of the patients were BRAF mutant. That adds up to 46, hence 46% of our adenocarcinoma patients will not require chemotherapy. And another 20% of the patients may get benefit from immunotherapy. So, around 50-55% of people do not require chemotherapy in a disease that is as fatal as lung cancer. Lung cancer was once uniformed in the most fatal of our diseases, but hope of survival is coming in our lung cancer patients, which is only because of the personalized treatment of lung cancer.