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Chris Atack, Atack Associates

From the Toronto Star, Special Supplement on Cancer

Lung cancer: blaming the victims, starving the research
Victims and their families are beginning to react to underfunding of research

Chris Atack
Special to the Star

Lung cancer is an epidemic. Last year it killed more Canadians than breast cancer, prostate cancer and colon cancer combined. It's by far the largest cause of cancer death in North America. Yet lack of funding, driven, some say by a "blame-the-victim" attitude has put the brakes on much-needed research into better diagnosis and treatment of this deadliest of cancers.

Compared to the money being shoveled into research of higher profile diseases, dollars for lung cancer research are pitifully inadequate. In the U.S. in 1999, researchers received about $900 for each lung cancer death, compared with $9,000 per breast cancer death and $34,000 for each AIDS death.

With about 18,000 Canadians expected to die this year of lung cancer, and no breakthroughs in sight, it's no wonder victims and their families are beginning to react to the underfunding of research in this area.

Lung cancer victim Robert Miller put it eloquently: "Lung cancer kills far more people than any other form of cancer, but somehow the message isn't getting out to the public Some people blame the smokers, some blame the tobacco lobby, still others blame environmental pollution. Wherever you put the blame, something must change and change now."

It didn't change soon enough for Miller, who died in September 1999 of his cancer. Nor will it change nearly soon enough to save many of the estimated 21,000 Canadians who will be diagnosed with lung cancer this year. Only about 13 per cent of them will live more than five years.

Poor survival rates may be one reason why lung cancer research is so spectacularly underfunded. "Most patients die quite fast, so there's no-one to speak out for the cause," explains Dr. Stephen Lam, Director of the Lung Cancer Prevention Program at the B.C. Cancer Agency. "With breast cancer or prostate cancer, people live for some time after the diagnosis, so they can champion the cause, and drum up support for research. But most lung cancer patients die within five years. You can't find many survivors to run around Canada saying "we need to do something.?"

A number of other factors may also contribute to the lack of research funding for lung cancer. "For one thing, it's perceived as one of those very resistant tumours that maybe we're not going to find easy cures for," says Dr. Michael Johnston, thoracic surgeon and oncologist at Toronto's Princess Margaret Hospital. "Also, it has a social stigma attached."

Lung cancer is often viewed as a disease that patients 'deserve" to get if they stubbornly refuse to quit smoking. That perception is now under attack by activists such as Glenn Davis, lung cancer survivor and spokesperson for ALCASE, a U.S.-based lung cancer advocacy group. In a recent speech, Davis had this to say:

"I smoked cigarettes and if that means that I deserve to have lung cancer then I've got news for you - I don't. No more than someone who loves a person of their own gender deserves to have HIV. No more than someone who eats fatty foods deserves to have colon cancer or a heart attack. No one deserves to be sick or to die. We need to get beyond that and deal with the issues facing us all right now."

One urgent issue is how to detect lung cancer at a far earlier stage. The disease is usually detected after the tumour has spread to other organs. Most often, it first shows up as an unexplained blotch on a chest X-ray. While there's no exact way to know how old a tumour is, scientists can usually estimate its age based on its size. "Most lung tumours we see have probably been growing for five to 10 years," says Dr. Johnston. "There's a long lead time between when they start and when we catch them."

One reason for slow diagnosis is that the lung is just plain hard to get at. "It's not like cancer of the mouth for example, where you can simply look inside and spot an abnormality," says Dr. Lam. "The lungs are deep inside the body, and they're large. To look inside you have to use a special instrument like a bronchoscope (a fibre optic tube), or do imaging work, for example, take an x-ray. But even with an x-ray it's hard to tell whether you're seeing a tumour or just a scar."

To confirm a diagnosis of lung cancer, a small tissue sample is often taken from the suspected tumour, using a needle. Sometimes, a technique called sputum cytology is used. Sputum (thick fluid coughed up from the lungs) is examined under a microscope to see if it contains cancerous cells.

Advances in sputum cytology may soon make detection of lung cancer easier. "We're looking at new sputum tests using computer image analysis to detect abnormal cells," says Dr. Lam. "It's very promising but we need to do more work on it to make it reproducible in different sites. We estimate we'll have something useful within three to five years."

Private companies are also hot on the trail of better sputum tests for lung cancer. International Medical Innovations (IMI) Inc., a Toronto-based company, has already reported promising results from a 76-patient trial of LungAlert, a simple, economical test that identifies cancer markers in sputum. "In the pilot study, LungAlert performed better than existing screening methods for lung cancer," says IMI president Dr. Brent Norton.

"We're undertaking a new two-year study to confirm and extend these results." The two-year study involving 500 patients is expected to begin at St. Joseph's Hospital in Hamilton this spring.

The other promising diagnostic tool is known as spiral computerized tomography, or a spiral CT scanning. A spiral CT scan can produce detailed images of the lung. Research strongly suggests spiral CT scanning can detect lung cancer at an earlier stage than chest x-rays. "There are a number of studies going on in this area," says Dr. Johnston. "In Japan for instance, where they've been using this for a while, results suggests you can pick up lung cancer at an earlier stage using spiral CT technology, and you can get a better survival rate."

While spiral CT scans can be very effective, they have drawbacks. For one thing, they sometimes give 'false positive results,' detecting possible tumours which turn out to be scar tissue on closer examination. Another is the availability of the equipment. "If we were to scan every smoker over the age of 50, we wouldn't have room to do any other CT scans," says Dr. Johnston. "Also, there haven't been enough studies done to assure doctors this is a valuable early screening technique, although research suggests it's a good way to go."

Improved screening techniques should start to come into general use within five years. Quite possibly, they will rely on a combination of sputum cytology and spiral CT scans.

If lung cancers can be diagnosed earlier, then survival rate should soar, even without significant advances in treatment. "If we can pick these cancers up at an early stage then we can cure a large percentage of them," says Dr. Johnston.

The later lung cancer is diagnosed, the worse the chances of a cure. Lung cancers are classified by how far advanced they are. In stage one (the earliest), about 70 per cent of lung cancers are curable. That drops to about 50 per cent in stage two, and to between 10 and 30 per cent in stage three. Patients with stage four disease have less than five per cent chance of survival. Now the bad news: by the time they are diagnosed, about 50 per cent of patients have stage four lung cancer. For most of these patients, there is palliative therapy, but little more.

"It's tempting to say that treatment for lung cancer hasn't progressed much in the last few years," says Dr. Johnston. "In fact though, there have been some changes, some subtle progress. We know more about chemotherapy for lung cancer, and more agents are becoming available. Also, we're better with surgery, and patient selection is better. But all that hasn't changed the five-year survival rate very much."

Patients with stage one and two lung cancer usually have surgery to remove their tumours. In the majority of these patients, the cancer is limited to their lungs and the surrounding lymph nodes. Patients with stage three disease usually undergo surgery as well as chemotherapy and radiation therapy. Stage four patients receive palliative treatment to help relieve symptoms.

Treatment for lung cancer is often debilitating, with many patients losing part of the affected lung. Many patients are also long-time smokers who have underlying lung disease and often other smoking-related health problems such as heart disease. With many patients already in poor health before cancer surgery, it's surprising that the death rate from lung cancer surgery is as low as it is -- about three per cent.

Some new treatments are finally appearing on the horizon, largely thanks to advances in genetics. Among them: drugs that inhibit the growth of new blood vessels around tumour sites (angiogenesis inhibitors) and drugs that may prevent lung cancer cells from spreading. Some of these new agents have now reached the stage of human testing. However, results so far are not that encouraging warns Dr. Johnston.

"We'll have a lot of negative results before we find something, because this is still early days,' he says. "It's impossible to say when we might see significant new therapies emerging for lung cancer. And even when we do, none of them are going to be a 'magic bullet' sort of thing. If they work at all, they'll give us modest incremental gains. In other words, patients with stage two disease who have 50 per cent survival rate with surgery, might achieve a 60 per cent survival rate with one of these new drugs."

With diagnosis and treatment so difficult, much attention has focused on the war against smoking. An estimated 85 per cent of all lung cancers are caused by smoking, and another three per cent by second-hand smoke.

So far, that war is not going well. True, a smaller proportion of today's men smoke than 30 years ago -- a fact reflected in lung cancer statistics. However, more women smoke than they used to, and lung cancer deaths are now almost five times as high in females as they were in 1971. In 2000, lung cancer killed an estimated 7,000 women -- far more than breast cancer, which claimed an estimated 5,500 lives. Tobacco use is skyrocketing in many parts of the Third World, driven by aggressive marketing. Worst of all perhaps, large numbers of young people are still becoming smokers.

"The only thing that's worked so far in any substantive way is increasing the cost of a pack of cigarettes -- and the age group that really helps is the young people," says Dr. Johnston.

Stamping out tobacco use is key to controlling lung cancer in the long term. But even if everyone stopped smoking tomorrow, lung cancer would still continue to take a toll for many years. While it's certainly far better to stop smoking right away than to continue, the cancer risk only begins to drop for long-time smokers years after they butt out for good. After 20 smoke-free years, their lung cancer risk falls by about one third.

"Some people seem to think that if everyone simply gave up smoking, the problem would disappear overnight," says Dr. Lam. "Unfortunately, it doesn't work that way. For long-time smokers, the risk doesn't go down much at first, even if they stop smoking. It's not like emphysema or heart disease. In fact, about 50 per cent of people with lung cancer now are former smokers. So smoking cessation alone won't solve the problem in the next two or three decades."

With tobacco use still rampant, and better therapies as yet only a distant prospect, Dr. Johnston advocates making young people the primary target of smoking cessation campaigns. "The way tobacco companies market either overtly or covertly to young people is despicable," he says. "Above all, we have to target the kids when we're thinking about tobacco control strategies, and we have to do something very strong, very pointed. We have to focus on the kids."

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