"For those of us with cancer, the fear of death lingers coyly. ... It creeps up at the oddest moments, like when it was time to renew my passport and I realized I could expire before the document does."
Those words -- written by Newsday reporter Lauren Terrazzano shortly before she lost a three-year struggle with lung cancer -- resonate far too loudly with the majority of today's lung cancer patients.
"The large majority of patients diagnosed with lung cancer continue to die of lung cancer," said Dr. Charles Rudin, an oncologist at Johns Hopkins in Baltimore. "We've improved the duration of survival and the quality of life, but the disease remains highly, highly fatal."
Only 15 percent of lung cancer patients can expect to be alive five years after their diagnosis. It is the leading cause of cancer-related mortality, not only in the United States, but worldwide.
That's despite decades worth of research. Although the last 25 years have seen improvements in surgical techniques, chemotherapy protocols, radiation therapy, and disease staging, researchers generally characterize the progress in lung cancer treatment as slow, calling it "step-wise" or "incremental."
Yet some say progress has increased "exponentially" over the past five years, thanks to a better understanding of tumor biology that has led to the development of targeted agents that can extend survival in certain susceptible patients.
Although these treatments have yet to prove curative, they may bring at least a glimmer of hope to the 160,000 patients in the U.S. expected to die this year from the disease.
There was no defined role for chemotherapy in lung cancer patients 25 years ago. The data was starting to come together for small cell lung cancer, which today accounts for 15 percent of cases, but there was little reliable evidence for its role in non-small cell disease.
"There was disagreement if it improved survival in advanced stages of the disease, and there were some promising studies of it in combination with radiation therapy, but nothing was definitive," said Dr. Jeffrey Crawford, chief of medical oncology at Duke University in Durham, N.C. "There was no recommended use of it after surgery, and no adjuvant use."
But as clinical trials in the 1990s began producing data, researchers became somewhat more confident that chemotherapy could extend survival.
"It ended up generating drugs that changed survival from six months to 10 months," said Dr. Bruce Johnson, a thoracic oncologist at Dana Farber Cancer Institute in Boston. "So it prolonged median survival by four months, or for the real optimists it was a 67 percent increase in survival."
Crawford said being able to define the role of chemotherapy in non-small cell lung cancer has been one of the major advances over the last quarter-century.
"Now in advanced disease, it's approved for front-line use, and we have regimens approved for second- and third-line use," he said. "We have standard regimens incorporated with radiation, and we have adjuvant chemotherapy which has proven benefit in improving survival."
The availability of better chemotherapy drugs has been part of that equation, as has been better pairing of those agents.