The Lung Cancer Journalism Awards

Daniel Cassola
Cancer de Pulmon (Pulmonary Cancer)
60 Minutos Con Daniel Cassola, Radio El Mundo, AM1070

As our special guest on this programme we have Dr Silvia Garsd, psychology specialist, Chair and President of the “Betting on life Association” and coordinator for several support groups at the Ramos Mejia Hospital; Dr Moises Rosemberg, Head of the Maria Ferrer Hospital of the Buenos Aires public Hospital and Head of the rib cage surgery division of the Alexander Fleming Institute; Dr Mario Branda, Head of the surgery division of the Centrangolo Hospital and late President of the Argentine rib cage surgery association; Dr Vicente Donato, medical Director of the Argentine league against tuberculosis and associate Professor at the University of Salvador; Dr Carlos Sparrow, medical specialist in clinical oncology.

D.C.: Today’s subject is lung cancer; let us start by defining this condition.

Dr C.S.: Cancer is a combination of illnesses that can affect any organ of the human body.
Under normal conditions, for example, a cell only grows when it must accomplish a task, without attacking the neighboring cells.
With cancer all of this changes. Cell growth is disproportionate and not related to an actual task the cell must carry out and in the long run it will bring the death of the individual unless it is correctly treated. An entire series of cell functions is altered and this results in having a cell that is almost “immortal” with unlimited growth attacking its neighboring cells.

D.C.: What are the leading causes for this illness?

Dr: C. S.: Some the causes are known while others still are not clear, in most cases there are both internal and external reasons that bring about the disease. There can be physical causes, for example, radiations; chemical substances such as asbestos or tobacco byproducts or a virus.
Therefore, there can be a number of reasons and each tumor will have certain characteristics according to the cause and where it originates in the human body.

D.C.: When we talk about tumors, we refer to them as benign or malignant. When do we define a tumor as malignant or benign?

Dr C.S.: To start we can say that a tumor is a lump and that the lump can be benign or
malignant. In the first case the growth in size and volume has no affect on the neighboring cells, It is confined to the place where it originated and if treated properly with surgery or with other solutions it is cured completely. The malignant tumor instead even if properly treated, according to how soon it is diagnosed, often does not respond to therapy or needs combined types of care to be cured. Furthermore, the malignant tumor has the tendency to grow permanently and to spread from one organ to the other.

D.C.: When you say spread, are we talking of metastasis? What exactly is this condition?

Dr C.S.: Metastasis is the trace of the original tumor, originating in the breast or lung for example, and spreading to the cells of other organs where the malignant cells nest and grow, creating a new tumor with similar characteristics to the original one.
For example, lung tumors often spread to the ganglions, to the other lung, to the brain to the bones and liver. These conditions are known as metastasis.

D.C.: Concerning lung cancer in particular, how do we define it?

Dr C.S.: This type of cancer which originates in the lung is a malignant tumor with a high death rate.
Roughly speaking there are two main types of this cancer: those known as non-small cells containing adenocarcinomas, and others known as small cells, with biological characteristics that need to be treated differently. Therefore the tumor that originates in the lung tissue can develop in these two distinct types.

D.C.: So, there are two types of lung cancer. When we refer to lung cancer that originates in other organs, why is this significant? What difference is there?

Dr C.S.: When lung cancer has spread from other organs, this is a lung tumor rather than lung cancer. Therefore, a metastasis originated in the large intestine, or in the pancreas or in the breast. This is a case of a metastases tumor in the lung but it is not lung cancer.
Thus therapy will vary in accordance with the organ the tumor originated in: if it is in the breast, it will have certain characteristics that require the same treatment as that administered for breast cancer, or if it originated in the bladder the same applies. Therefore, this is not a case of lung cancer but cancer originating in another organ that brought upon metastasis in the lung.

D.C.: Are there statistics regarding the number of people affected by this condition in this country?

Dr M.B.: According to what Dr Vasallo said in the 2001 report of the Argentine Rib Cage Surgery Association, comparing European and the US statistics on the topic, as I recall the numbers were around sixteen thousand people of which fourteen thousand were men. This figure is very useful as it gives an idea of the magnitude of the disease, because if we divide the death rate by the number of days a year, it would be comparable to a jumbo jet crashing every nine days. This gives a sense of the size of the panorama that we are looking at.

Dr. S.G.: I find this very interesting, and here is where we notice the different practices, we speak about lung cancer or cancer in general and about organs that are effected. Obviously we deal with people who live with this condition, its consequences and how they deal with the disease, their quality of life and abandoning habits such smoking. I work at the Ramos Mejia Hospital, on average I treat fifteen hundred patients for psycho therapy. I am amazed at the number of patients with cancer that arrived last year and this year, and not all of them are smokers which is what caught my attention all the more. Yesterday I visited a girl with a type of cancer called Peter (Pedro) because it is a squamous type of cancer. From the psychological point of view there are so many effects both before and after that play a role and make the patient give in, or fight for his life, what is truly important however is the quality of life the patient is able to achieve.
We believe that life expectancy for a patient is not the essential issue. From a psychological stand point however, I am happy the statistics reflect it, what I look at is the empirical evidence: those who live better also live longer, as anxiety or smoking as these do not favour at all the correct functioning of the immune system. This is my daily experience at the Hospital.

D.C.: How can you have a reliable national statistic figure if this illness is not necessarily identified from the start? Is there any control to ensure the illness is reported? How do you put together a statistic such as this? For those hypothetical cases what would the age and sex distribution be? Would you run this based more on your experience or according to national data?

Dr C.S.: No, there are no statistics in the country, tumors are not registered anywhere. There are some ongoing attempts and some work well. In the province of Buenos Aires for example we now register the cases and cover the most important provinces. I believe there is another one in San Luis but not at national level. To gather the data the most reliable source, as with any other pathology, are the local hospitals which are registering other cases or deaths. It can be misleading however as not always do the registries mention the actual reason for the death. It is frequent for example to find death certificates indicating death as a result of a heart attack and only after the real reason that brought upon death is listed. Until recently, the word cancer was considered to be a social stigma, now this has changed, but until a few years ago, people did not want to say they had cancer similarly to what happens today with different pathologies.

Dr S.G.: It is still a difficult subject to speak about. This is because it is directly linked to the idea of death and infections.

Dr C.S.: It used to be like talking about AIDS today or leprosy.

Dr M.R.: A few years ago a group of us got together while working for the state or privately to try to generate a statistic to identify the incidence of lung cancer on the population. However this effort worked only in part. What is certain is that we rely heavily on US statistics. The figures show that in the US in the last years there are about eighty thousand new cases per year. This is the data we base our opinions on as we do not have our own figures.

D.C.: A few minutes ago Silvia made a remark worth mentioning, on weather cancer is contagious? In the medical profession we often assume that many things are clear to the patients as well so it is better for us to clear any doubt on this.

Dr S.G.: Fear and terror are contagious, so the person seeks self isolation or is isolated by others. After working for so many years in the mental health programme, we have noticed that cancer does not cause people to stay together nor apart but rather it exacerbates an existing situation. If a couple was not doing well, they split, whereas if they were doing great, the illness makes them stronger.

Dr V.D.: Obviously, cancer is not contagious. Its possible viral nature has often been the object of studies as to the possible viral origin of certain types of cancer, in general however cancer is not contagious. With regards to the reliable figures which we do not have, what we do know is that the correlation between cancer and tobacco is very strong, as mentioned by Dr Sparrow, almost every lung cancer patient is a smoker (ninety percent). There is also a small percentage, which is difficult to evaluate, but probably less than ten per cent, where there can be a beginning of lung cancer just like a person who smokes although he or she might have never smoked but it is very odd indeed. We see this in women as well. Those of us who belong to the older generation, who have witnessed an increase in the number of women smokers have also seen an increase of cases of lung cancer in women which thirty or forty years ago was extremely rare. If we had a case of lung cancer it was maybe one a year in women and she would usually was a smoker. This figure has risen considerably.
What we do know is that tobacco related deaths are around forty thousand per year in Argentina. At the same time, of these smokers, we know that fifteen on twenty percent only develop lung cancer.

Dr S.G.: You are talking about oncogenesis, right?

Dr V.D.: Of course, cigarette unleashes the effect of the substances that cigarettes are made of such as tobacco.

Dr S.G.: It enhances the development of cancer.

Dr V.D.: Certainly. As Ortega y Gasset said: “It is myself and my circunstance”. Meaning that there is something in the genes, there is oncogenesis, there are protooncogenes, there is an entire series of cancer related substances that are activated in tobacco but in absestos too and there are other substances too.

D.C.: Your last remark was that ninety percent of those with lung cancer were smokers. Of the other ten percent, what can be said about passive smokers?

Dr V.D.: Well, passive smokers may be included within that percentage. However they are difficult subjects to identify, are they not? Usually they are people who have never smoked, for example, but who have worked for many years in an office where almost everyone smoked. There is a court case pending in the province of Córdoba against the government on this issue. Here is a case of a sixty year old woman who died of lung cancer she had worked for many years, almost all of her life, in a working environment where all the employees smoked. She developed lung cancer and this gave way to many controversies on the topic. Of course, passive smokers do not have the same rate of developing lung cancer as smokers.
But the percentages are high, and illnesses like cardiovascular problems and hypertension, for the passive smoker are significant.
When the smoker inhales, the cigarette’s temperature is around a thousand degrees Celsius. This combustion is less harmful. However, when the person is between inhaling moments, the cigarette’s temperature drops between 500 to 600 degrees Celsius. It is at this time that the combustion is not complete and the more toxic substances are released. An analogy would be fanning a fire to provide it with more oxygen. The person inhaling is doing this at the time of smoking probably taking in less toxic substances.
Lastly, passive smokers or the actual smokers are inhaling what is is called lateral smoke; which is the most toxic one. Smokers inhale both. But even so, we do not have statistics on this either, however, if a person is constantly exposed to smoke at the workplace he could develop similar illnesses as those developed by smokers.

Dr S.G.: This is true. There are many cases that are seen on the “Betting on life” programme of people having lung cancer and never having smoked but who are in direct contact with smokers. My question is: might there be a predisposition for the illness? The body has somatic complacency, it discharges in certain places. The risk factors lie here we try to deal with them and eliminate them. Quite obviously cancer comes through smoking or likewise other illnesses, then, if the person stops smoking and is not in a place where people do smoke, he or she will not develop the illness.
The psychological aspect and the way we develop our lives is totally linked to the illnesses, it is not the reason but it is linked.

Dr V.D.: Of course, because cigarette smoke has more than four thousand toxic substances and among them more than fifty cancerogenic substances. There also are the specific body characteristics of each individual. That is to say, if one is depressed, the inmunologic system is too, so one can get infected or develop any given illness, develop cancer and so it all adds up. Many factors add up, the protoncogenes and many other complicated mechanisms which we will not mention here and the inmunologic state as well as the psychological state of the person.

D.C.: You mentioned the close link between tobacco and lung cancer, in terms of time how long does it take for tobacco and toxic agents to result in cancer? Or should I be asking you: are there youths with lung cancer even if they have not had time to smoke for a long period due to their young age?

Dr V.D.: No, it takes years for the illness to develop. This is why when you tell a smoker to quit he laughs. The same goes with EPOC, cardiovascular illnesses, which do not spring up out of nowhere, this occurs only after years of smoking. These symptoms can vary as well, because it depends on the characteristics of each different person. However, there is a study that goes back to 1976 by Doll and Peto in England, where they monitored smoking and non-smoking doctors for many years. It is important to know the number of cigarettes and years of smoking involved. There are situations that are not so clear, for example people who have smoked very little and yet have developed lung cancer whereas others who have smoked a lot and have not devolop the illness. But in this study on English doctors, for those who smoked less than fourteen cigarettes per day, there was a mortality rate of sixty eight over one hundred thousand. Amongst non-smokers there was a mortality rate of ten over one hundred thousand, which is eight times higher. For those who smoke there were thresholds but we extrapolated the peek figures, more than twenty cigarettes per day had a mortality rate of two hundred and fifty over one hundred thousand. Therefore there are no doubts that the number of cigarettes and time combined are very important.

Dr S.G.: And what about youths? I was very interested in this aspect of the query.

Dr C.S.: I do not remember, but I think that the youngest person was twenty eight years old. It is extremly odd to come across youngsters under twenty five, in fact I have never seen a case of lung cancer in this age bracket.

Dra S.G.: What about mothers who smoke? Doesn’t cigarette penetrate the placenta?

Dr C.S.: Sure, but due to the short time span of the exposure there are no dangers of developing cancer, however it could alter the development of the foetus in other ways.

D.C.: Yes, throughout the nine months of pregnancy the lungs do not work, as all interaction and exchange is via the umbilical cord.

Dr V.D: For cancer to develop, smoke has to be in contact with the epithelias cells. There smoke, meaning the canciregenous and toxic components, run along the blood system. The smoker damages his/her respiratory system and the cells that coat the bronchi, bronchiole etc, which are the ones causing the illness.

Dr S.G.: However, the tobacco companies make a wonderful profit with this.

Dr V.D.: Well, this is an entirely different story.

D.C.: What does a person have to do to know if he/she has lung cancer? Can you be aware that you may have lung cancer? What are symptoms be that the GP should be looking for?

Dr C.S.: Preciseley, those at a highest risk, the smokers, cough in a chronic way, and therefore no longer worry when they cough, except when the type of cough changes or when the cough comes along with other things, for example spitting blood, that is when they decide to pay the doctor a visit. I think there are very few people who think they have lung cancer except hypochondriacs. The typical smoker coughs, and one of the most common symptoms for lung cancer is coughing.

Dr A.S.G.: People going to psychotherapy session at the hospital who come to the programme “Betting on life” all say, both smokers and patients with other types of cancer, that they already knew they had cancer. This is because they spat blood, because they coughed too much or because they were in pain. They were frightened, but they were not surprised by the news.

Dr M.R.: Unfortunately this illness only shows symptoms at an advanced stage, this is extremely important because the population knows that lung cancer has a higher death rate than other malignant illnesses. The reason being its late diagnosis symptoms and when the symptoms manifest themselves, the illness has already reached an advanced stage. For this reason several programmes were developed to run health studies and monitoring but regretfully we have not had the expected results, even if several studies were conducted all over the world.

D.C.: What other pathologies can be mistaken with lung cancer? What would the difference in the diagnosis be? Because in our country tuberculosis, for example, is growing and if one diagnoses coughing and expectorating blood as lung cancer when in reality it is tuberculosis then treatment and prognosis are different as well. What would the difference be in a lung cancer diagnosis then?

Dr C.S.: The fact alone that the person coughs and expectorates blood, is not a definite diagnosis. Only a histology or citology exam can assess this, just as with tuberculosis it has to be proven that the person is infected with the tuberculosis bacillus. Thus, the fact that the patient goes for a check-up due to blood expectorating symptoms is by no means a determining factor. Some symptoms are more significant than others, but only tests can provide certainty in diagnosis.

D.C.: What are the studies to diagnose lung cancer? How is this diagnosis carried out?

Dr M.R.: Being inquisitive and suspicious, as with any other illness, is maybe the most important thing when a doctor visits a patient for the first time.
That is when the physician gets the patient’s background history: age, habits and cigarettes which have a very important impact on the diagnosis. To follow there should be a routine analysis and a rib cage x-ray. If anything out of the norm is detected further exams should be run; this is by no means an aggressive way for lung cancer detection, increasing the level of invasive diagnosis little by little. From the moment an x-ray detects an abnormality in the lungs, at this point there are grounds to proceed with more targeted tests with images, such as computerized tomographies, resonances, or through invasive instruments like punctures and fiber bronchoscopy to get to the specific anathomopathologic diagnosis.

Dr M.B.: I thought Dr Rosemberg´s remark on the different cancer detection methods was interesting; our problem is that our lung cancer diagnosis elements are overdue. What happens if we were to graph the development of the tumor cell from the moment it forms to the patient´s death, we would see that two thirds of the evolution of the illness is subclinical and this is the great challenge that we face, we have no diagnosis
procedure to implement prevention at the early stages of the illness. This is the reason why all the tests mentioned here by Dr. Rosemberg were of no benefit to smoking patients, in patients older than fifty, known as the “high risk population”. This is the issue we have to face.

D.C.: Did you want to add anything about diagnosis Dr Sparrow?

Dr C.S.: Concerning coughing if a patient who does not cough usually starts to present this symptom, on his own initiative or his family´s initiave, he will go to see the doctor about it. The person who does not do this is the one that coughs cronically, the smoker, because he thinks it is normal.
Therefore, he waits longer for a diagnosis. I will summarize here what Dr Branda was saying although the fact that we are aired by radio limits the visual aspect.
When a lesion in an x-ray is one centimetre, which can be seen in a simple x-ray, many years have gone by from the growth of the first cell so the lifespan of that tumor has completed 60% of its time by then. As of that moment, if the person was lucky enough to have an x-ray, maybe for other reasons, such as pre-surgical reasons after a hernia, a nodule appears.
If the doctor considers it to be of importance he will start investigating for tumor cells.
But when it reaches this size, it practically gives no symptoms, about twenty months must go by before a one centimetre spot could possibly give the patient symptoms. So basically a one centimeter lump could possibly be a tumor and only give symptoms after two years; in accordance with the statistics two months go by before the patient goes to the physician for a check-up and another two months go by before the diagnosis is drawn up. Unfortunately, in this country these periods are extremely long, much longer than two months sometimes reaching the six month range. This is not due to the physicians, but rather the social medical system. If you ask for a test to be run you are put on the waiting list and the wait begins. The most common practice is that around six months go by.

Dr V.D.: I would like to add something to what the Doctor here is saying. Regarding the early detection of symptoms, they may turn up in a radiologic study for example. But we treat it in the same way we deal with tuberculosis. All types of cough with or without expectoration that last for more than two weeks without a clear explanation, which could, for example be a flu condition, have to be investigated and the first thing to do is a rib cage x-ray. If the person is a chronic bronchial case, an EPOC, all changes in his cough, if there was no expectoration and now there is, or if there is some blood, blood streaks, or some change, the person has to go for a consultation. Having a rib cage x-ray is essential, and from there, as Dr. Rosemberg said, the rest of the tests can be run. We also know that regretfully, an early diagnosis is almost impossible. Out of a hundred people that come to us with a lung cancer diagnosis, seventy percent cannot have surgery. Between seventy and eighty percent of all cancer patients, when they arrive to us they no longer have the possibility to save their lives with surgical intervention. A very small percentage can be saved, at least for small cell tumors.

Dr S.G.: That is why I think since diagnosis is always late in coming, why isn’t there another way other than a check up to diagnose the tumor? how many cells, roughly, ought there be, so that the tumor can be spotted?

Dr C.S.: A one centimeter tumor, is estimated to have 10.

Dr A.S.G.: Nine thousand million, imagine the time it took, I don’t know how long it takes... Two years or more...

D.C.: From the two years period, it is has reached at least one centimeter, you were just mentioning.

Dr C.S.: Usually from the moment when it is a one centimeter the lesion, which was seen accidentally, something that has happened to all of us, the patient was operated on for hernia, the surgeon has an x-ray done and the lump is spotted.

Dr A.S.G.: I was thinking that regretfully, the sale, the consumption and tobacco companies are all there and growing. It would be extremely interesting to launch some health campaigns but real ones, not just “smoking is a health hazard” that nobody reads.

D.C.: Yes but tobacco was consumed before the tobacco companies started their business. What must be understood is that tobacco is an addictive substance. This is frequently said on radio shows, for example that marihuana is less dangerous than tobacco. In reality nobody smokes twenty marihuana cigarettes a day. I would like to see what would happen if someone did smoke twenty cigarettes of marihuana per day.

Dr A.S.G.: What I mean is that industry needs consumers to make profits. That is the reason why it would be interesting to pursue really good prevention campaigns.

Dr M.R.: In any case, I think that the mentality in the world is changing but this takes many years. The truth is that today campaigns are more globalized in the world and in our country too, this is a fact. The campaigns to ban smoking in airports, public places, would have been unheard of just a few years ago.

Dr A.S.G.: We will have to see if this ban has really any effect; I remember the ban on alcohol.

Dr M.R.: This does not matter, it is gaining ground and I think this is important.

Dr V.D.: There is an important story about this in Argentina. There is a “Formal Agreement on tobacco control”. It was signed in Geneva in 2003 by the one hundred and ninety two members of the World Health Organization. The government of Argentina signed this agreement as well. But the agreement then had to be ratified and Argentina did not. What is this agreement really all about? The issue here is actually closely related to what we were just talking about. People were slowly starting to understand the dangers involved with smoking cigarettes, but there are extremely important tobacco companies and lobby interests that block everything. The agreement would bind countries under supra national power agreeing to a complex set of articles aimed at reducing the number of people smoking. Here in South America, Argentina did not ratify the agreement, however, Uruguay and in the Caribbean, Panama, Peru and Mexico did and there was a noticeable improvement. Recently Brazil, an important tobacco exporting country, also ratified the agreement. We have not taken action. However now, the City´s government has passed a law which, although short of what we need, marks a hopeful beginning.

Dr A.S.G.: It is very difficult to beat the habit and walk away from the addiction. Because you say it is an addiction both, physiological and mental, right? Cigarettes have the role of filling a void for something. Once it becomes a habit, I see quite a few patients that arrive to the hospital, and as soon as the doctor tells them: “Well, now you are better ” they revert to cigarette consumption even if they know that it causes cancer.

Dr V.D.: Addiction is not just rational, it is emotional. As is also true with all other addictions...

Dr A.S.G.: Yes, but addiction is one thing and the desire or need is another thing. I was a smoker and I quit. I quit the addiction but I still feel the desire to smoke, I love the smell of cigarettes.

Dr V.D.: Cigarettes are very peculiar. Not all smokers are addicted to smoking. We have to take this into consideration as well. There are people who smoke socially, while having a cup of coffee for example. They can quit at any time. This person is not an addict. A person is considered to be an addict when he or she smokes a great number of cigarettes and cannot stop, even when that person is ill and is recommended to stop. We treat people who had lung cancer surgery, we know them, people with cardiovascular problems and they continue to smoke.
A few days ago I was reading that people who are undergoing chemotherapy and continue smoking are actually hindering the treatment.

D.C.: Let’s talk about lung cancer treatment? Once it is diagnosed how is it treated? A moment ago Donato mentioned that many patients had already lost the opportunity for surgery.
When can lung cancer be treated with chemotherapy and when does it require surgery?

Dr M.R.: This has changed a lot in recent years. I would say that until approximately ten years ago, the only valid treatment was surgery and the patient´s highest chances of recovery only came with surgery. But in reality what has changed, as we said before, is that it is frequent to find patients with and advanced state of the illness; this had brought about a new medical focus to treat the illness. We are used, given the development in images´ technology to have more patients with an early state of lung cancer. When it is at an early stage surgery is still the preferred treatment, removing the cancer completely. Yet…

D.C.: We spoke about lung cancer surgery treatment. What are the existing chemotherapy treatments and what are the side effects?

Dr C.S.: Chemotherapy is considered solely as a cancer treatment. But in reality it is a chemical mechanism. Taking aspirins or antibiotics for example is also a chemotherapy treatment. Chemotherapy for cancer treatment is administered by way of the intravenous system with globally accepted therapy methods. All lung cancer treatments with chemotherapy must contain platinum. There are drugs which are byproducts of platinum as cilplatinum and carbon platinum. This must be the base with a second drug in combination that is known as “Third generation drug”and there three of these. One is called vinorelvine, I am speaking of generic names, the others are Taxanos, paclitaxel and gencitabine.
Any one of these, depending on the patient´s condition or the experience of the person prescribing the treatment, must be combined with platinum. This is the first line

treatment. For second line treatment, in case the patient does not respond to the first treatment, there are presently two new drugs that might work, Docetaxel and Pemetrexed, this is the newest available chemotherapy. The side effects are similar for all. As this treatment does not have a specific target, it does not take into account any of the specific characteristics of the cells with a faster growth rate. This is why they try to stop growth by killing all the cells that are actively multiplying.
In the body, there are other normal cells that multiply themselves actively, like hair, which explains why it falls, or globules that can change in number or like the digestive tissue cells that can be affected. Therefore the toxic effects are similar for all actively dividing cells.

D.C.: That is to say that all tissues that renew themselves often like, hair, nails and the digestive tract are altered because these drugs attack all those quickly growing cells?

Dr C.S.: That is correct. As an unwanted side effect one has to deal with those that are derived from platinum. Luckily with new drugs called Cetrones, this is now under control and I would say that ninety percent of the patients no longer throw up. Before, this was a real drama. The other female worry is hair loss, for which there is still no alternative. Lack of will and appetite loss are the other side effects that can occur.

Dr A.S.G.: One can deal with everything except cancer, is that right?

D.C.: When a patient undergoes one of these chemotherapy treatments, having lost the option of surgery, these side effects become a certainty.
How is it dealt with? How do the people close to the patient help to deal with all of this? How do the professionals deal with treatments such as these that entail such strong side effects?

Dr A.S.G.: None of the people I know, regardless of the type of cancer accept too well the possibility of a relapse which means undergoing other treatment. People hope to get better or at least for remission. We associate cancer with the idea of imminent death and we do not realize that death is just around the corner. Just the other day a mentally disturbed person shot and killed a boy, that is to say, anything can happen. That is why I ask you the physicians, teachers and those in other disciplines, we should be paying attention to what the patients need for example it is a mistake not to tell the patient he or she has cancer. They need a physician to guide them in the battle, this is more important than knowing how many days they still have to live; what we have seen in this programme is that what really makes a difference is to have guidance and support in the battle, it is amazing what an impact this can have on the patient’s wellbeing, the will to continue fighting and the good this does to the family that does not live with a predominating mood of death looming over but rather “I am alive, I am alive now” this is what is important.

D.C.: A colleague once said that “life is an illness of sexual transmission that ends with death”. If one analyzes this diagnosis it is correct. It is not so important to talk about the diagnosis of how long someone has left to live as no one lives for ever.

Dr A.S.G.: Not just how much time is left but the quality of life at the moment is what matters.

D.C.: There are people sitting down like we are now and an airplane knocks down the building… True, or we are crossing the street and a bus runs over us, right?
That is the idea. Anyway, how does one tell a patient with such a severe pathology how to cope with it?

Dr A.S.G.: As the professionals say I am far more interested in listening, because the majority of patients say that one has got to go on. The majority of patients arrive full of hope, while others do not. In any case the patient arrives to us in a bad condition. Now, if the physician and patient establish a relationship based on trust and confidence this can become a real drama. If the physician moves, or is not around or something happens to him the patient feels as though he has become an orphan. I have strong empirical evidence about this, with people getting much worse if their physician moved away. Recently for example: an oncologist moved and the patient was devastated, but he left her his telephone number because of the trust and confidence relationship, and this became a burden more for the patient than the physician.

Dr M.R.: I think we ought to clarify this. Frequently, I believe we have all experienced this when we are treating a patient with cancer, a relative comes to us and says “I would rather that you do not breach the news”. This, from my point of view is very negative. The patient should be aware of his condition but of course, that does not mean that one is telling the patient that his or her life has come to an end, no way. Because this is exactly how the physician is going to establish a rapport with the patient and develop trust and a dialogue and set those guidelines that we think might be useful for him/her.

Dr A.S.G.: Unless the patient is in permanent denial. Otherwise, if the patient goes to the oncologist, has chemotherapy treatment, looses his hair and learns he has cancer.

Dr M.R.: This is the other problem. For society, discussing chemotherapy is like swearing and it ought to be another of the fantasies doctors should clamp down on and eliminate. In general, chemotherapy, as the physician mentioned, is tolerated better.
We have drugs to solve the worst complications and the damage caused by chemotherapy. It is our duty to make all this known rather than accepting the family’s suggestion to keep the patient in the dark.

D.C.: You as professionals know only too well that in all pathologies there are alternative therapies. For example, what can we say about the sale of miracle drugs. What can we say about lung cancer and alternative therapies?

Dr C.S.: I wanted to add that there are new alternative drugs to chemotherapy aimed at a specific target contained in certain tumor cells. These are targeting growth factors and therefore they only kill the cells that contain this alteration, not like chemotherapy that kills whatever is near, the growth receptors.
At this moment there are those that act by inhibiting growth and others that inhibit the blood vessel growth which is key for tumor growth. These are new therapies and are not as toxic in a second stage of a chemotherapy treatment. I think this is the future because they only attack the altered part of the cell.

D.C.: Are we speaking of biotechnology for lung cancer treatments?

Dr C.S.: Yes, precisely. These drugs are tailor made to block this factor which is present in these cells and that is going to prevent it from developing new vessels. Without it the tumor does not receive blood and it cannot grow, or the cell is not able to transmit necessary information for reproducing itself from the surface to the interior and therefore the reproduction and growth stops.

D.C.: I would like a comment from all of you who are present here on this topic.

Dr V.D.: Regretfully, regarding surgery, in the past forty or fifty years up to date, even taking into account the great work of surgeons and the medical discoveries, lung cancer deaths still reach staggering figures.
The main reason for this is tobacco addiction. That is, we have to go on doing all that we have done so far. It will never be completely eradicated, because human beings have got the tendency to use drugs. But we should continue to discourage and limit people from smoking. It is better not to smoke, and it is even harder to stop once the addiction has set in, but by curbing the habit we can limit considerably a pandemia.
This is an illness which is clearly closely related with a toxic substance, thus if we can reduce the numbers of smokers, we will also reduce the number of people with lung cancer. This is why we have to advocate with the authorities to raise a stronger awareness and run educational projects. Children start smoking at the age of seven or eight at schools and there are statistics about this. So there is a lot of groundwork to be done to fight tobacco addiction, if we were to succeed we would not be here discussing lung cancer.

Dr C.S.: Let me show you a few figures. In the western world the main cause of death is cardiovascular with thirty three per cent, the second in order of importance is tumors with twenty three per cent. Among tumors, the main cause of death is lung cancer and this cancer if detected after five years, only has a thirteen percent survival rate. We see an important difference when we compare it with the most frequent cancer in human beings, both in men and women, which is colon cancer which at the five year threshold has fifty eight percent survival rate. Now it should be clear to all of you that lung cancer has a very high death rate, and therefore is an important health issue.

Dr A.S.G.: I think that today’s meeting is quite extraordinary because word will spread and it will be helpful for people. It is interesting for patients to know what they are up against. Is it the same for you to have a patient who is unaware because he was lied to about the diagnosis or a patient that comes to you saying “What should I do about this doctor?” A patient that has some fear as our premise is “Where there is life, there is a fight for life” as Darwin said. Those patients coming to “Betting on life” are terrified, anguished and they forsee the coffin and the death mask.
After meeting with us, where the patients discuss with others their condition together professionals, there is hope for life again. And life is now, now we have a project, this is what I deem to be essential. There cannot be a most serious pathology than oncology or cardiology without a psycologic test of all the phenomena regarding the patient’s fear, anguish, panic, the permanent good-byes, “I look at my children and I say good-bye to them”, many of them say. There is no reason for this if you are alive now and a new drug comes along changing the quality of your life.

Dr M.B.: I think that summing up your different opinions and the progress over the past sixty years, there haven’t been life changing discoveries for this type of cancer, and when a person is affected for that person the figure is hundred percent, which is what Dr Donato was referring to by curbing tobacco addiction; if you think of car crashes for example, there is something that can be done, if seat belts help prevent deaths in accidents, in the same way smoking should be a must, this is the first thing that can be done. The rest I think is debatable, it can be planned and a solution for the future can be found.

Dr M.R.: We have spoken about cigarettes and there is no arguing about the impact they have on lung cancer. But responsibility also lies with us and the health authorities. I think that, as mentioned before, it cannot take between six to eight months to diagnose a patient, for this we are all responsible.

These are the two aspects I would like to be emphasize. First, the habit of smoking and secondly the time it takes for a diagnosis. The most common medical mistake we see occurring is patients who on discovery of the first lump in the lung were told by their physician “Ok, in three months we will repeat the x-ray”.

D.C.: I thank you all, firstly for the dedication and depth with which you have helped us discuss this illness. I would divide the main issues discussed in three parts. One is the diagnosis, you are the most appropriate spokespersons and able to give us such an accurate description. The second issue is communication and here is where I come in because by discussing the illness we are raising awareness. To my audience I say: those that regretfully have lung cancer, there are professionals that are dealing with this subject as Dr. Sparrow said, there is chemotherapy, and in some cases there can be surgery. Your role, however, is prevention and this is entirely up to you. We have explained the importance of prevention here today in detail. Tobacco is the principal cause, and you can all prevent this.