One of the most common medical conditions in the world, lung disease challenges one of our body’s most important tasks. Learn how new treatments are helping those with lung conditions to breathe easier.
Some things in life are as easy as breathing. But for those with pulmonary disease, simply breathing can be a daily struggle. Lung disease is experienced by tens of millions of Americans, making it one of the most common medical conditions in the world.
The lungs are part of a complex apparatus, expanding and relaxing thousands of times each day to deliver oxygen and expel carbon dioxide. Lung disease can result from problems in any part of this system, though most cases are connected to smoking, infections and genetics. Fortunately, new treatment options that more effectively target the disease and its causes are delivering hope to many patients.
Lung Cancer: Pulmonary Enemy No. 1
Lung cancer is arguably the most formidable of pulmonary diseases. This year alone, the American Cancer Society estimates that 221,000 new cases will be diagnosed.
Both major types of lung cancer – small cell (SCLC) and non-small cell (NSCLC) – are caused by smoking and inhaling other toxins. However, adenocarcinoma, a type of NSCLC, is being found in non-smokers, women and younger adults under age 60.
Deaths from lung cancer remain substantial; more than 158,000 people will die from it this year. Although cancer remains the second greatest cause of death in the U.S., it’s now ranked as the No. 1 cause of death in patients age 20 to 79. And, according to the Illinois Department of Public Health, cancer could soon overtake heart disease as the most common cause of death.
“Formidable? Yes. Preventable? Very often,” says Dr. Terrence J. Bugno, FACR, medical director of radiation oncology at Centegra Sage Cancer Center in McHenry. “Earlier detection is promising. The toxic effects from smoking go well beyond global cancer risk. They adversely affect proper function of virtually all body systems.”
If prevention isn’t possible, Bugno says, then early detection of cancer seems reasonable. In fact, clinical trials have shown that, when caught early, the death rate by lung cancer is reduced by 20 percent.
In February 2015, commercial insurance agencies and Medicare endorsed a free, low-dose CT lung screening, comparable to mammography for early breast cancer detection. It monitors those at the highest risk: patients age 55 to 80 who are current or ex-smokers of 30 or more packs per year and who agree to be screened. Medicare covers the screening to age 77.
“At Centegra, we’ve embraced this program and have screened more than 1000 patients in the past year,” Bugno says.
But there’s much work ahead. Survival rates for lung cancer remain disappointing: less than one in five will survive for five years. By comparison, breast and prostate cancer patients have an 80- to 90-percent rate of overall five-year survival. Even in early detection lung cancer, five-year survivals are 50 percent; when locally advanced, it’s down to 25 percent, and when spread throughout the body, survival is less than 5 percent. When diagnosed, lung cancer can be treated with a multidisciplinary approach that combines the best of surgical, radiation and medical oncology.
“Supportive care before, during and after cancer-directed therapies can often be a major factor in overall outcome,” Bugno says.
Radiation is typically applied locally. A 3-D energy drug targets cancerous tumors and adjacent microscopic areas while sparing normal tissue. The 3-D treatment planning, computer modeling and sophisticated technology provide greater uniformity in radiation dosing. Proper timing and sequencing with other therapies achieves the best results, says Bugno.
Radiation therapy can be the sole treatment for early cancer; for locally advanced cancers it’s used in conjunction with chemotherapy and other systemic therapies. In recurrent and metastasized cancers, it can improve quality of life and symptom relief.
“SCLC is typically fast-growing and is found beyond the local lung site, making surgery ineffective,” Bugno says. “Best practices incorporate radiation as the non-surgical alternative. While chemo treats body-wide, radiation optimizes the clearance of localized disease. Research confirms that, despite necessary aggressiveness, outcomes are improved when chemo/radiation is used together, especially for limited stages of cancer.”
About 85 percent of cancers are NSCLC. Since lung cancers can be local, regional or metastatic, a multidisciplinary, individualized approach is now standard.
“Radiation has specific roles in each setting,” Bugno says.
A new technique, Stereotactic Body Radiation Therapy (SBRT), can arrest and clear localized cancer deposits by delivering high doses of radiation into precise locations.
Bugno says the procedure takes fewer than five sessions, using focused radiation beams and 3-D computerized planning, proper patient immobilization, radiation delivery algorithms and image guidance in which the actual region is viewed as it’s treated. SBRT for early lung cancers in selected patients achieves long-term cancer clearance of more than 80 percent, says Bugno.
“When cancer spreads, SBRT techniques now offer hope with less effort and toxicity,” Bugno adds. “Small brain tumors, symptomatic cancer to bone and other local areas can be controlled in one to five sessions of dose intense radiation beams.”
The facilities for performing radiation are also evolving. Future refinements are likely to include greater precision in targeting, timing of treatment, tumor sensitization and radiation protection of critical tissues, says Bugno.
For lung cancers, radiation implants are not routinely used, but Bugno says that embedding radioactive substances into arteries that feed the tumors has shown promise for treating lung metastases to the liver. Radioimmunotherapy, which tags immune molecules with radioactivity to provide a “double hit” against cancer cells, is in the pipeline.
“Relying not on new technology, but on better ways to use what we have, offers benefits, while minimizing risk, resulting in better survival and better quality of life,” Bugno adds. Along those lines, functional, psychosocial and spiritual support are a growing part of helping cancer survivors.”
Bugno says that, as an experienced oncologist, he must be a communicator and a champion for patient care while also being an ardent, passionate supporter of prevention and early detection efforts. It’s always better to prevent than to treat a cancer, he says.
In the future, Bugno sees continuing exploration into technologies and standards that can improve upon current methods of cancer treatment.
“Many routine radiation oncology approaches that are now considered standard were just being explored 25 to 30 years ago, when I was in residency,” he says. “New advances accelerate almost daily. We must remain prepared to adapt and adopt this new information to ensure that radiation therapy’s judicious use can remain available to all.”
Blockages From COPD
Chronic obstructive pulmonary disease (COPD) refers to a group of lung diseases that block airflow and make breathing difficult. Damage to the lungs from COPD can’t be reversed, but treatment can help to control symptoms and minimize further damage.
“Smoking is the single most common cause of COPD,” says Colleen Grabowski, coordinator of Pulmonary Function and Pulmonary Rehabilitation at Presence Saint Joseph Hospital in Elgin. “Exposure to secondhand smoke, air pollution, dust or irritants in the workplace are other causes.”
Two of the most common forms of COPD, according to The Mayo Clinic, are chronic bronchitis and emphysema. The former is an inflammation of the lining of the bronchial tubes, which carry air to and from the lungs. Emphysema occurs when the air sacs (alveoli) at the end of the smallest air passages (bronchioles) in the lungs are gradually destroyed. Emphysema results in the loss of elasticity in a patient’s lungs, trapping air and making breathing more difficult.
“The alveoli gradually lose their shape, thus making it harder for gas exchange to take place,” says Grabowski. “This means less oxygen enters the blood vessels. This in turn can lead to exacerbations (flare-ups) that can be severe enough to require hospitalization.”
Exacerbation is a natural extension of COPD in which the patient’s baseline cough and congestion go beyond the normal day-to-day variations. The main causes are bacterial or viral lung infections and air pollution.
“COPD patients have good and bad days,” Grabowski says. “Education, proper nutrition, exercise that encourages deep breathing, and consistent use of prescription medications and nebulizers help to keep patients in what we call the green zone.”
Patients in this zone manage their COPD fairly well and have acceptable day-to-day fluctuations. Patients in the yellow zone experience elevated symptoms, such as more coughing and expelling more phlegm, that make it difficult for them to breathe and function comfortably.
“When a patient moves into the red zone, it’s time to call 911 or call their go-to person, who can bring them into the emergency room,” Grabowski says. “These red-zone patients have severe shortness of breath even at rest, may be acting confused or very drowsy, and may also experience chest pain, fever or shaking chills.”
When COPD patients are hospitalized, Grabowski helps them to get their symptoms back under control, often through a carefully constructed action plan.
“Hospitalization lasts for just a few days or much longer, depending on how severe the flare-up is,” Grabowski says.
Flare-up treatments may include taking steroids to reduce inflammation and using bronchodilators to open up airways. In order to prevent these dangerous flare-ups, patients must follow strict sanitation rules.
“They should be washing their hands often and using hand sanitizer whenever hand washing is unavailable,” Grabowski says. “Healthy people who come down with a cold or the flu can shake it off, but a COPD patient who catches cold or the flu can be in real trouble. We tell them to get all of the immunizations, including flu and pneumonia, and to stay as well as possible.”
Beyond sanitation, a patient’s environment may also aggravate COPD symptoms.
“For COPD patients, it’s a constant effort every single day to stay well and take good care of themselves,” Grabowski says. “Anything from bitterly cold air to the heavy, humid ozone-laden air of midsummer is a threat to their health.”
Cystic Fibrosis in Children
As pulmonary diseases go, cystic fibrosis (CF) is not all that common, nor is it widely recognized and understood as the serious threat to children that it is. The Cystic Fibrosis Foundation estimates that about 70,000 children and young adults worldwide have been diagnosed with CF, with 30,000 of those patients in America. About 1,000 new cases are diagnosed each year, mostly in children under the age of two.
Jessica Rush, a registered nurse at Northwest Community Hospital in Arlington Heights, spent more than four years treating children who were hospitalized with CF. Now a specialist in respiratory nursing, Rush says the effects of CF are devastating to children and their families.
“Children with CF look normal, in that they don’t really show how very ill they are,” she says.
This life-threatening genetic disease affects the lungs and digestive system. A defective gene and its protein byproduct cause the child’s body to produce unusually thick, sticky mucus that clogs the lungs, leading to potentially fatal infections. The sticky mucus also obstructs the pancreas, stopping its natural enzymes from helping the body to break down food and absorb important nutrients. Rush says that, on top of the serious consequences of CF, these young patients also may develop diabetes.
“In the 1950s, few children with CF lived to attend elementary school,” Rush says. “Now, some are able to live into their 30s and 40s. In my experience, I’ve seen a lot of children with CF pass away in their late teens or early 20s. Sadly, I have also witnessed children as young as 4 or 5 lose their lives to CF and its effects.”
Today, infants at Northwest Community Hospital are screened for CF risk within a few days of birth, Rush says, although symptoms may not show up for a while. Warning signs include salty-tasting skin, persistent cough, frequent lung infections, poor growth and slow weight gain.
“Once you hear a child with CF cough, you never forget the sound,” Rush says. “It’s extremely harsh and uncontrollable.”
Treatment for CF patients is constant, beginning with oral medications to compensate for the loss of digestive enzymes not being produced by the pancreas. These medicines are given with every meal as part of the treatment regimen.
“It’s an all-day routine,” Rush says. “It begins with airway clearance to loosen the sticky junk in the lungs using aerosolized medications administered by nebulizers that help to expel the mucus and fight infections. Then there is percussion therapy or Chest Physical Therapy (CPT) on the child’s chest and back.”
Several times a day, parents and medical staff must use their cupped hands to beat on the back and chest of the child in an effort to loosen the accumulating mucus. In addition to, or in place of CPT, a special vest can accomplish the same task by shaking the child three or four times each day.
“When the child is hospitalized, we use the vest about every four hours,” Rush adds.
And with CF, hospitalization is a fairly common event.
“Some CF patients come in through the emergency room,” Rush says. “But most are admitted when they have drops in their pulmonary function tests (PFTs) performed at pulmonary clinics that closely monitor these patients on an outpatient basis. The child is put into a glass enclosure and blows into a tube that measures lung volume. If the child’s capacity is not at baseline or above, the child is admitted to the hospital for what we call a tune-up.”
In the hospital, the child is immediately given intravenous antibiotics to treat lung infections and inflammation. The average stay for a tune-up is two weeks, depending on how severely the child has been affected.
“For the parents, CF means nonstop care,” Rush says. “Medications including blood sugar monitoring and insulin, chest and back percussion, vest treatments, hospitalizations and nebulizer/breathing treatments take a huge toll on everyone in the family.”
Fortunately, tremendous advances in CF treatment have helped children to survive longer, and a new medication has shown promise in changing the statistics and fatality rates substantially.
“The mutated gene responsible for the development of CF controls the flow of salt and water in the cells throughout the body,” Rush explains. “This new drug actually targets the CFTR protein defect, allowing more chloride to move in and out of the cells, which potentially creates a better balance of salt and water in the lungs. It can only be used with specific candidates and isn’t available for all CF patients. But it’s a glimmer of the possibilities that genetic engineering offers toward a cure, or at least vastly improved management, of the disease.”
Looking Toward the Future
Continuous advances in the field of pulmonary disease prevention and treatment are helping more and more patients to breathe easier, thus extending lives and improving the quality of life. The future promises not only management but also outright cures for the lung diseases that have plagued mankind for millennia.