WRNMMC, Bethesda, MD  –   Screening saves lives was the common theme discussed by the various speakers during the annual lung cancer summit hosted by the John P. Murtha Cancer Center (MCC) at Walter Reed National Military Medical Center (WRNMMC), Dec. 6.

“Lung cancer is the leading cause of cancer deaths for both men and women in the United States,” said Navy Capt. Felix Bigby, interim director of WRNMMC. Lung cancer accounts for approximately 25 percent of all cancer deaths, and each year, more
people die of lung cancer than of colon, breast, and prostate cancers combined, according to the American Cancer Society.

Bigby explained that while smoking poses the greatest risk for lung cancer, other factors contributing to the disease include exposure to secondhand smoke, radon gas, asbestos, secondhand smoke, and other carcinogens, as well as a family history of lung cancer. In addition, the mission of some military members exposes them to environmental factors that may increase their risk for lung cancer, such as burn-pit exposure.

Honoring A Service Member
“On June 16, Congress passed the Sgt. 1st Class Heath Robinson Honoring Our Promise to Address Comprehensive Toxics (PACT) Act of 2022,” Bigby said. The bill is named for the Ohio Army veteran who died from cancer in 2020 after being exposed to toxic smoke from trash burning pits during his deployment to the Middle East.

According to Kansas Senator Jerry Moran, who introduced the legislation with Montana Senator Jon Tester, “The SFC Heath Robinson Honoring Our PACT Act will deliver all generations of toxic-exposed veterans their earned health care and benefits under the Department of Veterans Affairs (VA) for the first time in the nation’s history. This legislation will provide comprehensive relief for all generations of veterans, from Agent Orange to the 3.5 million post-9/11 veterans exposed to burn pits during their deployments.”

Lung cancer screening increases survival rates of those at risk for lung cancer, Bigby said. He added that although the Department of Defense (DOD) was one of the first organizations to acknowledge the benefits of lung cancer screening, “we have fallen short in capturing and tracking a significant portion of our eligible population for screening. We can and must be better.”

He said the MCC at WRNMMC and military medicine are “actively engaged in the war to protect our warfighters from this terrible disease.”

Lung Adenocarcinoma
Matthew Wilkerson, Ph.D., discussed the novel discoveries of lung adenocarcinoma, stating lung cancer is a prevalent and heterogeneous disease causing approximately one million deaths annually worldwide, making is the number one cause of cancer deaths globally. The disease remains the deadliest cancer in the U.S., expected to claim an estimated 130,000 lives this year.

Lung adenocarcinoma occurs primarily in small airways, Wilkerson said. It’s the most common primary lung cancer seen in the United States and falls under the umbrella of non-small cell lung cancer (NSCLC). Some of the symptoms of adenocarcinomas in the lung include persistent cough; shortness of breath; chest pain; raspy voice; fatigue, difficulty breathing or swallowing; wheezing; cough that produces mucus with blood; loss of appetite; facial swelling or swelling in the veins of the neck; and unexplained weight loss.

Wilkerson, associate professor of Anatomy, Physiology and Genetics at Uniformed Services University (USU) and director of the Data Science Division in the Center for Military Precision Health (CMPH), discovered new molecular classifications of lung adenocarcinoma and squamous cell carcinoma using gene expression profiling, which have been used by the lung cancer research community. Treatment of adenocarcinoma of the lung depends on several factors including the stage and histology of the disease in the individual. Treatment can include surgery, chemotherapy, radiotherapy, targeted therapy, and immunotherapy.

Lung Cancer Imaging
Dr. John Lichtenberger stated lung cancer imaging is key to the diagnosis, staging, and posttreatment surveillance of lung cancer. “With over 200,000 new diagnoses of primary lung cancer per year, the evaluation of lung cancer is a common and important task for the radiologist. Furthermore, both the increasing use of imaging in medical practice and the increasing implementation of tools such as lung cancer screening in high-risk populations have resulted in increased rates of lung cancer detection.”

Lichtenberger, chief of Cardiothoracic Imaging and an associate professor at The George Washington University Hospital, stressed the importance of radiologists making appropriate recommendations for incidental thoracic imaging findings based on current American College of Radiology guidelines, and measuring and classifying pulmonary nodules according to the current Fleischner Society recommendations. In addition, he said radiologists should closely described key changes in Lung-RADS (Lung Imaging Reporting and Data System), a classification to assist with findings in low-dose CT screening exams for lung cancer.

“Ultimately, a collaborative approach is best for patient care, whether the imaging report provides a formal TNM [primary Tumor; regional lymph Nodes; distant Metastasis] stage or key information to assist in staging,” Lichtenberger stated.

Proton Therapy
Dr. Nitika Paudel, a radiation oncologist at Medstar Georgetown University Hospital, addressed proton therapy for lung cancer. She said treatment recommendations have to be based on clinical evidence, national guidelines, and consultation from a multidisciplinary team of providers and the patient. She explained the goal with proton therapy depends on the stage of the cancer. She explained with proton therapy as a treatment during the early stages of cancer, the goal is curative. If the cancer has spread outside the chest, the goal for radiation may be palliative.

“Using proton therapy to treat lung cancer, we are able to minimize radiation to the uninvolved lung, as well as the heart, and to limit side effects of treatment,” Paudel added. On average, each proton therapy treatment takes about 20 to 30 minutes, and depending on the stage of the cancer, therapy can include anywhere from one to 30 sessions (six weeks), she added.

Surgery at WRNMMC
Army Col. (Dr.) Philip Mullenix, cardiothoracic surgeon at WRNMMC and associate professor of surgery at USU, provided an update on lung cancer surgery at the medical center. He said since December 2015, he’s operated on 61 patients for lung cancer.

He added 52 of those cases were adenocarcinoma. The average age for those patients is 61 years, and they ranged in ages from 22 to 98 years. He added about an equal number are smokers and non-smokers, and many of their cancers are caught early because of the MCC’s lung cancer screening program.

Mullenix said the multidisciplinary conference of health-care professionals at WRNMMC in cancer treatment has been effective in the care provided beneficiaries and their outcomes. He said most of the surgeries have been anatomic lobectomies. “I try to do everything from a minimally invasive incision [video-assisted thoracoscopic surgery, or VATS],” he said.

Interventional Pulmonology
Navy Capt. (Dr.) Sean McKay, an interventional pulmonologist at WRNMMC, said central airway preservation in advanced lung cancer is important. He also explained the role for advanced bronchoscopy in diagnosis and treatment of lung cancer.

Bronchoscopy is an endoscopic technique of visualizing the inside of the airways for diagnostic and therapeutic purposes during which an instrument is inserted into the airways, usually through the nose or mouth, or occasionally through a tracheostomy so the provider can examine the patient's airways for abnormalities such as foreign bodies, bleeding, tumors, or inflammation.

“Interventional pulmonology can provide a full spectrum of respiratory care for the lung cancer patient,” McKay said. This care includes initial diagnosis (including staging and initial interventions); monitoring and intervening throughout treatment; restaging after treatments; optimizing lungs for enrollment in clinical trials; and strategies for end stage palliation to allow ventilator liberation and home hospice.

“The interventional pulmonologist can be a helpful member in the care of your thoracic-oncology patients,” McKay said. “Get us involved early,” he added.
NCR Lung Cancer Trials

Dr. Pramvir Verma, chief of Hematology and Oncology Service at Fort Belvoir Community Hospital, discussed lung cancer clinical trials in the National Capital Region (NCR). He said upcoming clinical trials include those involving metastatic NSCLC, locally advanced NSCLC, and early-stage EGFR (epidermal growth factor receptor, a protein on cells that helps them grow) mutated NSCLC. A mutation in the EGFR gene is one biomarker that physicians look for in NSCLC.

Targeted Therapy
Army Maj. (Dr.) Daniel Desmond, of WRNMMC’s Hematology Oncology, is discussing targeted therapy in lung cancer, said in most patients diagnosed with lung cancer, the disease has metastasized, and so most are going to be treated by medical oncologists. “We hope to change that, and in the past 10 years, we’ve been screening people more and more to identify cancer earlier,” he said.

Desmond stated that “NSCLC is histologically and molecularly heterogenous,” explaining the disease has diverse pathological features, which requires various multidisciplinary therapies, including immunotherapy.

Lung cancer detected at its earliest stage gives the patient a 64 percent survival rate, stated Dr. Robert F. Browning, a pulmonologist at WRNMMC. “At our institution, it’s an 86 percent five-year survival rate,” he added. He explained that with better and more lung cancer screening, survival rates can be even higher. “We have a ways to go. There are people out there who are not getting screened who need to get screened, and these are our beneficiaries,” he stated.

MCC Celebrates 10 years
Bigby noted the MCC recently celebrated its 10th anniversary earlier this month, and the lung cancer summit was the first cancer summit supported by the MCC back in 2012. Since that time, the MCC has annually hosted summits and lectures focused on breast cancer, skin cancer, multiple myeloma, and other cancers impacting beneficiaries of the Military Health System.