This is a case study of a 66-year-old gentleman who was diagnosed with Stage 4 Lung Cancer. Despite receiving chemotherapy, his cancer had progressed. The patient sought additional treatment options and was treated with targeted therapy resulting in significant improvement in symptoms and the ability to resume work.
History:
This doctor came to me with complaints of six months duration. He gave a history of increasing cough since a few months, initially dry, now associated with hemoptysis ( blood in sputum ). He was now experiencing breathlessness at rest along with a generalised chest pain. He had lost 15 kg weight in the past 6 months, and at that point had a very poor oral intake. As he sat before me in my clinic, he looked extremely tired and weak.
Investigation:
Being a Radiologist himself, the patient had already undergone a CT Scan followed by a PET-CT scan. The imaging had shown a large lung mass with spread to the opposite lung, mediastinal lymph nodes, bones and the liver. A biopsy had confirmed an Adenocarcinoma of the Lung. The doctor had no vices, he was a non-smoker.
Concerns:
The doctor had already undergone 6 cycles of chemotherapy for his cancer, with little benefit. His cancer had progressed. He understood that he was suffering from a terminal cancer but still wished to try any new therapy that could extend his life. Unfortunately , his treating doctors in another city had followed a tried and tested method of treatment, using chemotherapy, but had failed to implement the new options using molecular profiling.
Treatment Offered:
Lung cancer treatment has undergone a radical change from 8 to 10 years ago when chemotherapy was the only option. With the new therapies available, a stage 4 lung cancer patient can still enjoy an extended life span with a good quality of life.
I informed the patient that there were still treatments available that would benefit him. I asked for molecular profiling to be performed on his biopsy specimen. As he had a stage 4 cancer, surgery wasn’t an option for him. I could not cure him of his cancer but I could bring it under control. The molecular profiling showed the presence of an EGFR mutation. This meant the patient could be treated using an oral tablet.
The cancer showed an Exon 19 deletion. This was the mutation which was driving the cancer. Accordingly, I started him on tablet Gefitinib. The patient was reluctant to trust a tablet alone but after a lot of persuasion he agreed to take the medicine. Gefitinib is a targeted therapy, not a chemotherapy. It specifically blocks the lung cancer driving mutation, suppresses the cancer cells and brings the tumour under control. Adenocarcinoma lung patients with EGFR mutations do extremely well on targeted therapy and do not require chemotherapy.
The doctor’s cancer responded to Gefitinib within a week of starting. His pain, breathlessness and cough resolved, his appetite improved, he felt much better and was able to resume his work as a Radiologist.
Long Term Care:
It has been five years since the doctor first met me. Since then, he has remained on oral tablets, though he has changed the medication to another tablet called Osimertinib, after 3 years on Gefitinib, due to disease progression. He currently continues his work as a Radiologist. He will eventually loose response to the tablet, after which a repeat molecular profiling on a new biopsy sample may be required. Immunotherapy remains a second line option for him after the oral medication. He remains hopeful for the future.
