The Lung Cancer Journalism Awards

Charlotte Elberling Almasi, Barbara Malene Fischer, Trine Juhler-Nøttrup, Halla Skuladottir & Helle Pappot
A Better Life With Lung Cancer
Månedsskrift for praktisk lægegerning

The authors of the article are all members of FOLK (Focus on Lung Cancer). FOLK is an open group of young female doctors/academics with a research related interest in lung cancer. The group’s purpose is to increase the attention for lung cancer through events such as the International Lung Cancer Day and by having direct contact to interested healthcare workers etc. For any further information about FOLK, please visit: www.folk.suite.dk

Lung cancer is known as one of the big killers. It is necessary to act against this disease in new areas. Read today’s article which is published on International Lung Cancer Day 17 November.

There is an increase in the number of patients with lung cancer who are being cured and the average survival after being diagnosed is now longer. At the same time there is a gradual change in the division between genders as well as the fraction of smokers versus non-smokers. Today, nearly as many women as men get the disease and the fraction of former smokers is increasing (1). These changes in patient composition involve a modification of the group’s needs. Now it is not only a question of optimizing treatment and/or receiving a worthy terminal treatment, but it is also a well-founded request for advice and counselling on obtaining the best quality of life during and after treatment. Many patients want to do an effort themselves to improve their situation. Our hope is that this article will answer some of the questions one might be asked as a doctor by present or former patients with lung cancer and their relatives.

Rehabilitation of lung cancer patients

Lung cancer patients’ need for rehabilitation was reviewed in 2003 by a group of doctors from the Clinical Unit for Illness Prevention at Bispebjerg Hospital. They estimated that patients with more than six months survival have a potential need for rehabilitation equivalent to 70 per cent of the newly diagnosed). After reading through the existing material, it was concluded that the need for describing and developing programmes concerning cancer rehabilitation is substantial, especially to examine the evidence of such programmes (2). Effective rehabilitation adjusted to each patient’s need is an important part of the new national cancer plan in Denmark (June 2005). Among other things, this work should be done by setting up coordinated research programmes to develop rehabilitation methods and to examine the evidence of the rehabilitation effects. The Danish Cancer Steering Committee already suggested in Cancer Plan 1 (2000) that the local governments should work specifically with rehabilitation offers, which e.g. should consist of: psychosocial support, physical training and relaxation, dietary counselling, advice on sexual problems etc. However, there have been very few attempts to initiate rehabilitation of cancer patients, which could be because of the very poor documentation stating the importance of rehabilitation in relation to several cancer diseases.

For patients with lung cancer the documentation of the effect of rehabilitation is very scanty. From international research groups there have been few reports, where they have reported about the effect of rehabilitation from a small group of lung cancer patients. Hately et al have described the effect of physiotherapeutic intervention regarding respiratory distress with patients suffering from lung cancer (n=30). The study showed a reduction of respiratory distress, a better physical function and less stress with patients receiving physiotherapeutic training (3). In 2004, a Cochrane Review was published concerning non-invasive intervention for the purpose of increasing the well-being and improving the quality of life for patients with lung cancer (4). The review of the literature is based on a few reports, but there seems to be a clear tendency that respiratory intervention by a nurse improves the patient’s general condition (performance status), reduces their difficulty of breathing and improves their psychological symptoms. Furthermore, there seems to be indications that structured conversations with specially trained nurses make the lung cancer patients less dependent on nursing and relieve physical and psychological symptoms. Meanwhile, the review also concludes that further research is required. Therefore, it is positive to learn that an initiative has just been taken to contribute with research within this area in Denmark.

Recently, at the Department of Thoracic Surgery at Odense University Hospital, a new project has commenced where lung cancer patients who have had surgery are being examined at regular intervals and are being offered the opportunity to have conversations with a nurse about their quality of life. It will be analysed whether these measures will increase their quality of life and survival amongst the tested patients. The time span of the project POREFU (Post-Operative Rehabilitation and Follow Up) is five years and consists of a randomization of the patients to an intervention through structured conversations, patient satisfaction and life quality studies or no measures. As it is apparent from the above, rehabilitation of lung cancer patients consists of many elements. In the following, aspects like diet, smoking, physical activity, use of alternative treatment and psychological reactions will be discussed further, not solely as an element of rehabilitation, but also as an important factor in connection with lung cancer prevention and treatment.

Diet and lung cancer

The relationship between diet and lung cancer has been examined in several epidemiological studies (5). Among persons with a high intake of fruit and vegetables retrospective studies have shown halving the risk of lung cancer compared to persons with a low intake of fruit and vegetables. The results of prospective studies have been less evident with a variation of 0-30 % reduction in the risk of lung cancer. In the positive studies, the risk reduction is not dependent on smoking anamnesis, and presumably independent of the histological type of lung cancer (6).

Primary prevention of lung cancer among smokers with a number of specific vitamins has been tested in controlled clinical tests without any effect. On the contrary, in two big randomized studies on persons with an already increased risk for lung cancer (smokers and asbestos exposed) the intake of beta-carotene ±retinol or alpha-tocopherol has shown a significant increase in the number of cases with lung cancer (7). Not even as a secondary prophylaxis to patients with non-small cell lung cancer (NSCLC) specific vitamin supplement has shown any effect. During the last couple of years, it has been acknowledged that it is to a higher extent the combination of several factors that together have a protective effect instead of a single substance. Information about foods (e.g.carrots, apples) and diet patterns (e.g. Mediterranean diet versus other diets) are now being used more often in diet studies.

Experimental studies, with the purpose to find the answer of how fruit and vegetables can protect against the development of cancer, have among other things shown that some factors in fruit and vegetables can modulate programmed cell death (apoptosis), cell proliferation, immune response, antioxidative processes etc. However, a final clarification hereof is not available today.

Cancer patients often ask if there is anything they can do to support their treatment and their chance of survival, e.g. by changing their diet, taking diet supplements or similar. It is difficult giving advice that is valid for all patients with lung cancer (8): For patients in active treatment it is important that they do not lose any weight, and patients with reduced appetite enjoy eating small frequent meals. After ended treatment a normal diet is recommended with lots of fruits and vegetables. This is explained further in the Danish National Board of Health’s campaign “Six a Day”, which you can read more about on www.6omdagen.dk, and on the Danish Veterinary and Food Administration’s website: www.altomkost.dk.

To address the question whether a non-specified vitamin/mineral supplement benefits or damages the patient suffering from lung cancer, it has been analysed in a recent published questionnaire whether unspecified vitamin/mineral supplement changes survival and quality of life corrected for multiple prognostic factors incl. stage of illness (9). Among the 63 % who took diet supplements, a significant increased chance of survival was discovered as well as a better score in life quality compared to the others. However, these results should be considered with subject to reservations since it is not a clinical study, and therefore, bias can occur. Results from several prospective studies of specific vitamin supplement’s effect on lung cancer are being awaited.

Smoking and treatment effect – what is the point of quitting?

Active smoking is responsible for at least 90 per cent of all cases with lung cancer (10). Men who stop smoking in their sixties, fifties, forties and thirties have a cumulated risk of dying from lung cancer of respectively 10, 6, 3 and 2 % compared to the risk of dying from lung cancer after life-long smoking of 19 %. If you quit smoking when you are 30 years old you can reduce your risk of dying from a tobacco related cancer disease by 90 % (11). Over the years there is increased evidence that smoking cessation is beneficial – even when the diagnose lung cancer has been established. However, we as doctors are not very aware of guiding and helping the patients to a smoking cessation at this time, and often the patients remain unaware that by quitting, their chance of survival can be improved and receive a better treatment result.

Continuous smoking after being diagnosed with small-cell lung cancer (SCLC) is associated with a bad diagnosis. In a study with 112 patients, the patients were divided into continuous smokers, smokers who quit when diagnosed and non-smokers at the time of diagnose (incl. one never-smoked). A significant trend was discovered in regard to prolonged survival in these three groups. Continuous smokers lived the shortest, second shortest were the smokers who quit when diagnosed and longest lived the non-smokers at the time of diagnose. Moreover, there were several long-time survivors in the group of patients who quit when diagnosed (12). Long time survivors from SCLC have a significant risk of a secondary tumour, which is reduced by a smoking cessation (13).

A recent study has tried to discover whether patients who have had surgery for NSCLC benefit from a smoking cessation at the time of diagnosis. It was demonstrated with 311 patients that those who stopped smoking had a significant better chance of survival – also patients who quit smoking in the time period from diagnosis to surgery (14). Smoking cessation is therefore beneficial at any time prior to surgery. When it comes to radiotherapy, smokers have an increased risk of 20 % for radiation pneumonitis compared to non-smokers (15). Furthermore, it has been shown that continuous smoking during radiotherapy for NSCLC is significantly correlated to weight loss during treatment (16).

The reasons for this improved survival with those who are non- or former smokers are without doubt many. Tammemagi et al have looked at a survival analysis with 1,155 lung cancer patients to see whether the reason is to be found in the differences in occurrence of other diseases, social status, ethnicity, age, smoking habits, stage, histology, treatment etc. amongst the groups, and smoking becomes a significant and independent predictor of reduced survival even after adjusting comorbidity and important sociodemographic differences (17).

The effect of ionized radiation is dependent on the presence of oxygen and generation of free radicals. A well oxidized tumour is more radiation-sensitive than a tumour with poor oxygen supply. CO in tobacco smoke incorporates haemoglobin which results in relative tissue hypoxia, which is believed to be the reason for a poorer effect with radiotherapy. The oxygen level in a tumour also influences the cell-destroying effect with chemotherapy. The mechanisms for this context are only partly known and are presumably many (18). Seemingly, a hypoxia triggered change of the gene expression takes place, which might mediate chemo resistance. In addition, hypoxia can change the expression and the activity of different enzymes in the cytochrome P450-system, and thereby change the activity and the metabolism of chemotherapy.

Physical activity and cancer – is exercise beneficial?

It is suggested in both Danish and American studies that the occurrence of colon cancer can be reduced by increased physical activity. A similar correlation is not known for lung cancer. The correlation between exercise and development of lung cancer is complex. The Danish Ministries of Health and Environment have previously warned the people of Copenhagen against outdoor physical activity during the rush hours. The pollution is so massive during the morning rush hour that regular running at that time of day is considered to increase the risk of getting lung cancer significantly.

When the diagnosis of lung cancer has been made, it is often important for the patient to know whether exercise is good or possibly should be avoided. Several overview articles have been dealing with the topic physical activity and cancer (19-21), but the referred studies are often non-randomized studies with few patients, relative short sequences and with various effect measures. Most studies have shown that exercise during cancer treatment increase the patients’ physical and psychological functions. Whether exercise is beneficial for life quality or survival on a longer term cannot be determined from the existing studies, as well as there is very little information on which type of exercise (cardio/weight training) that is good for which type of patients at what stages. Studies about lung cancer patients are very few. Only one study qualified for the selection according to Cochrane Collaboration’s standards for a clinical study: Wall et al have published a study with 104 NSCLC patients who were randomized to either a 7-10 days pre-surgery programme (walking and stairway and training of arms, legs and breathing) or no intervention. A significantly improved personal strength (defined as the ability to consciously participate in changes) was found in the intervention group, but no difference in the feeling of hope between this group and the control group (22).

From the Danish University Hospitals’ Centre for Nursing and Care Research in Copenhagen there are results from a pilot project with 23 participating patients in chemotherapy with different types of cancer at different stages, hereof one single patient with lung cancer (23, 24). 85 % of the patients completed the six weeks long intervention programme, consisting of nine hours weekly cardio and weight training, relaxation exercises, massage and body-consciousness exercises. The patients increased their physical capacity significantly, measured from aerobic capacity (maximum O² absorption) and muscle strength (23). There was a non-significant improvement of life quality and relief of both physical and psychological symptoms. In the same project, exercise’s effect on fatigue was analysed qualitative (24). Fatigue was the most frequent side-effect to chemotherapy, but the participants in the programme experienced a physical fatigue in the project period that was considered positive compared to negative chemotherapy induced fatigue. They learned how to handle the intense fatigue by using exercise as a strategy against the feeling of physical weakness. The patients stated that they felt more energetic and that exercise increased their physical well-being.

That the patients are demanding guidance on physical activity is shown in an analysis of 300 lung cancer patients’ requests (25). 60 % wants instruction, 77 % wants this from a specialist in physical education at a cancer centre. Most want instruction before treatment. This information implies a great need for conclusive studies, not least with research about which type of exercise that specifically response well with lung cancer patients.

Alternative treatment

The description “alternative treatment” covers the treatments which go beyond the options offered by the government financed healthcare in Denmark, and which is not comprised by the Danish National Board of Health’s supervisory control. The most consulted are zone therapy, massage/manipulation, natural medicine and acupuncture. The National Institute of Public Health in Denmark have in one of their publications (Health and Illness studies), latest in year 2000, tried to identify the Danes’ use of alternative treatment: 20.6 % have used alternative treatment during the last year, and 43,7 % have tried alternative treatment at some point in their lives. This spreading will probably retrieve among lung cancer patients. A bigger prospective study from Norway has tried to cover the use of alternative treatment in a population of patients suffering from different cancer diagnoses: 45 % of these had used alternative treatment at some point (26). The use of alternative treatment was rarely reasoned by dissatisfaction with medical practitioner. However, four out of ten users felt that they had been given little or hardly any hope from the doctors compared to two out of ten amongst the non-users. Several studies imply that especially cancer patients consider alternative treatment as a supplement rather than an alternative to the established treatment. The patients still expect/hope for a recovery and relief from the established system, but to a higher degree they seek the feeling of hope, compassion, absorption and spirituality from the alternative therapist (27, 28). These needs are understandable to most practitioners in the established healthcare system, but they can be hard to satisfy. Partly because of time pressures, partly because the doctor often has to bring bad news and carry out the ordination of unpleasant examinations and treatments. A Danish study has examined oncologist nurses’ attitude towards alternative treatment (29): The majority support the patients in their use of alternative treatment as a supplement, but two out of three would never encourage the patients directly.

The increased use of alternative treatment has resulted in new demands for the doctors, both in regard to attitude and the factual aspect, but also to the alternative therapists on research according to the established healthcare standards. Only a few studies exist about lung cancer patients and alternative treatment. The use of anti-oxidants, e.g. vitamin C and Q10, has been the subject of quite some research, but the disagreement is still rather significant when it comes to the benefits of these as prevention as well as treatment. Antioxidants used in large doses for cancer patients, either alone or as a supplement to chemo- and radiotherapy, have been tested in small clinical studies, though without any conclusive results. Several oncologists are very concerned about the use of anti-oxidants, since it is possible that they counter the effect from the types of treatment which mediate their activity through the generation of free radicals. This includes radiotherapy and certain types of chemotherapy, and therefore, oncologists want to warn against large doses of anti-oxidants in this connection (30). More specifically, there is a reason to warn against ingesting the ingredient Echinacea, which can be found in several natural medicines and diet supplements. Simultaneous use of Echinacea and chemotherapy containing metrotrexat might trigger hepatitis (www.cancer.dk).

Acupuncture plays an increasing part of smoking cessation. A Cochrane review from year 2000, based on 22 randomised studies, found that acupuncture is not any better than placebo or other interventions in regard to smoking cessation (31). However, there is some evidence that acupuncture might relieve pain, nausea and vomiting in connection with cancer treatment (32, 33).

A follow-up on the previous mentioned Norwegian study about cancer patients’ use of alternative treatment gave surprising results: There was a tendency of excess mortality among patients using alternative treatment. Only looking at the group of patients in performance status 0 (the least affected by the disease) the excess mortality was significant
(34). The authors chose to interpret this finding meaning that patients in good performance who choose to seek alternative treatment have a deeper perception of the gravity of the disease and/or try to hide how bad he or she is feeling. It could not be concluded that it was the natural medicine that caused the increased mortality.

Overall, it can be concluded that nearly half of all cancer patients seek alternative treatment at some point. As a doctor this is important information in order to being able to provide the patients with information on side-effects and interactions, but also to ensure a good and open-minded communication.

In this article’s bibliography there are included two references where both patient and doctor can get much useful information (27, 35).

Lung cancer and psychological reactions

Many studies have shown that patients associate stress and psychological effects with the progression of cancer. This has in particular been studied in regard to breast cancer, while no study has specifically covered this area when it comes to lung cancer. In animal testing it has been shown that increased stress has an impact on progression of cancer, among other things through an effect on the immune system (36). Such a connection has never been demonstrated in humans. In a large Danish study record, the relationship between severe depression and the progression of breast cancer was examined, and it was found that patients with former or present depression did not have a higher risk of developing breast cancer. On the contrary, breast cancer patients had a higher risk of getting a depression than others (37). Similar studies have not been conducted for patients with lung cancer. It is far from all psychological symptoms in response to lung cancer that are established. There is also a lack of knowledge about which interventions that are effective for the psychological reactions, and whether an early intervention might reduce the risk of developing these reactions.

In a recent published overview article the few existing studies were examined concerning psychological symptoms following lung cancer, as well as studies which look upon whether there can be intervened against these symptoms (38). Overall, the referred studies provide an image of the lung cancer patient as a human being with reduced quality of life, increased mental stress and increased risk of depression. These tendencies are stronger with patients with bad prognosis, among patients with physical symptoms of lung cancer (in particular dyspnea and pain) and among those who are not being offered active treatment for their cancer disease. In the intervention studies it was demonstrated that psychosocial intervention in the follow-up period after active treatment can reduce physical symptoms, increase quality of life and reduce the risk of developing a depression in the process of the lung cancer disease. The interventions have either been conversations, home visits, instructions about the possibility of symptoms relief, regular contact nurses or contact doctors. The referred studies bear the stamp of the fact that inclusion and follow-up on patients are difficult since their physical health is bad and their morality is high. This weakens the possibility to describe in details which type of intervention that is best.

Hopefully, in the future there will be conducted more comprehensive studies about the possibilities for psychological support for patients with lung cancer. If a more thorough presentation of the topic is requested, please refer to (39).

Quality of life is also an important parameter when the effect of different types of cancer treatment is being evaluated. This especially applies when the treatment is done with a palliative aim rather than curative, which is often the case when treating patients suffering from lung cancer. Studies have shown that chemotherapy on its own not only increase survival for lung cancer patients, but also the quality of life compared to the best supportive care (40).

Whether the patient is among the potential curable or among those to whom treatment does not seem to be an option, most patients still seem to have a need for guidance or support, when actively facing their course of disease, and to plan and prioritize their new everyday life. With this article we have tried to go through some of the topics relevant in this connection, and which will change over a period where quality of life not only is important to the patient, but also to a high degree is an obligation for the treatment system. Only few of the presented topics have been thoroughly examined, but preliminary studies indicate that smoking cessation is beneficial at all times, and a healthy diet and exercise also plays a role – also for the wellbeing of the lung cancer patient. Recommendations specifically targeted for this group is still not available.

For the third year in a row the International Lung Cancer Day will be marked in Denmark
on 17 November 2005, with among other things a symposium at the University Hospital of Copenhagen, where this article’s topics will be discussed.