In a way, Pope Leo XIV may be lucky he got lung cancer now and not, say, six years ago. Treatments have changed so much, specialists say, that the old days are almost unrecognizable.
For many patients, said Karen Knudsen, the chief executive of the Parker Institute, lung cancer is no longer the dire diagnosis it was in the past.
Dr. Lecia Sequist, a thoracic oncologist at Mass General Brigham Cancer Institute, said, “I think a lot of people have that gut reaction about lung cancer — that it can be rapidly fatal — but that is a little bit outdated, especially if it’s caught early.”
She added, “It’s really just a whole new paradigm in lung cancer, and patients are living much longer and cure rates are higher than they were 10 to 20 years ago.”
Lung cancer is still the leading cause of cancer deaths for both men and women, killing more than 124,000 Americans each year. But the death rate today is half what it was in the 1990s, partly because fewer people smoke but also because newly developed treatments are working.
Pope Leo’s cancer, an adenocarcinoma, was discovered during a routine medical test. The pope’s doctors removed a lobe of his lung on Tuesday and are doing additional tests to determine what additional treatments, if any, are warranted.
But, said Dr. Robert Merritt, a thoracic surgeon at the Ohio State University Wexner Medical Center, “the fact that the pope was offered surgery as a primary treatment is an indication the tumor is most likely early stage, was detected early and was completely removable with surgery.” That means, he added, that “in most cases there’s a reasonable chance there could be complete cure.”
Still, the pope’s doctors almost certainly will do genetic tests of his tumor, and at that point, doctors said, his treatments and prognosis will be part of the new world of lung cancer therapy.
A first step is to determine which mutations might be driving the cancer’s growth. There are as many as 14 or 15 genetic mutations that are often found in lung cancer, said Dr. Roy Herbst, a lung cancer specialist and head of the cancer institute at Dartmouth.
The most common is a mutation in a gene called EGFR. Targeted drugs to attack it in early stage disease didn’t exist six years ago, Dr. Herbst said. Tumors eventually become resistant to the drugs, but they can offer patients years of life.
Dr. David Barbie, chief of thoracic oncology at the Dana-Farber Cancer Institute, said that if a patient has Stage 2 lung cancer — meaning it has spread to the lymph nodes or is greater than four centimeters — and has chemotherapy after surgery, the risk that the cancer will recur drops to 30 percent from 40 percent. But the addition of a drug that attacks EGFR mutations reduces that risk to 10 percent.
EGFR is not the only gene mutation that can be hit with targeted drugs. Others include genes with names like ALK, RET and ROS1. And the drugs keep getting better. Some patients have mutations in a different gene, KRAS, that can be attacked with an exciting new class of drugs that are in clinical trials.
Dr. Barbie said that if a tumor had a distinct mutation, like one in EGFR, doctors could use blood tests to see if an initial surgery actually got rid of all of the tumor. The tests look for shards of cancer DNA that float in the bloodstream. If they find it, the patient is not cured and needs additional therapy, Dr. Barbie said.
But, Dr. Herbst said, 70 to 80 percent of nonsmokers do not have any genetic mutations that can be hit with a targeted drug.
They have other options, Dr. Knudsen said.
“There’s a whole new world we heard about at ASCO,” she said, referring to a recent meeting of the American Society of Clinical Oncology. There are antibodies, she said, that can see a tumor and bring a chemotherapy to it. Clinical trials using these drugs in patients with advanced cancer have had “phenomenal results,” she added.
Then there is immunotherapy. It’s useful mostly in smokers whose cancers tend to have so many mutations that they can escape attacks by targeted drugs. But those mutations make them vulnerable to attacks by the immune system. Cancers use various tricks to hide from the immune system. But immunotherapies can remove the cancer’s cloak and allow white blood cells to destroy the tumor.
The problem with the revolution in treatments for lung cancer is that too many patients are not offered them. In one comprehensive study, 34 percent of patients with non small cell lung cancer never got a genetic test of their tumors.
Others cannot afford the pills, which can cost $10,000 or more a month. Medicare has a yearly cap on co-pays, but patients who are uninsured or have private insurance can be hit with prescription bills that can bankrupt them.
There’s no easy solution, but the pope’s care can show what is possible, specialists said.
The pope, Dr. Herbst said, “is getting what every patient should have.”
“My dream is that every cancer patient in the world gets treatment like the pope’s,” he added.
