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New treatment buys more time for late-stage lung cancer patients, but it’s costly

SINGAPORE — When he learnt that he had Stage Four lung cancer, the first thing Mr Jeffrey Leong fretted over was how to break the news to his daughters.

Mr Jeffrey Leong’s biggest challenge during his cancer journey was its psychological impact but he found ways to cope. Throughout his cancer treatment, he pushed himself to continue exercising. He would do 45-minute walks on the treadmill daily and lift weights.

Mr Jeffrey Leong’s biggest challenge during his cancer journey was its psychological impact but he found ways to cope. Throughout his cancer treatment, he pushed himself to continue exercising. He would do 45-minute walks on the treadmill daily and lift weights.

SINGAPORE — When he learnt that he had Stage Four lung cancer, the first thing Mr Jeffrey Leong fretted over was how to break the news to his daughters.

“We are a close-knit family. If something happens to their dad, I knew it would be tough for them to accept it,” said Mr Leong, 57, who is self-employed.

His daughters were aged 17 and 21 when, in July 2016, an MRI scan for a muscle tendon injury incidentally uncovered three huge tumours in his lungs.

The largest, inside his right lung, was 10cm in length.

Lung cancer is one of the most lethal cancers here, and a late-stage diagnosis is considered a rapid death sentence.

“My wife and I decided to present my diagnosis like a ‘business plan’ and how we would move on from there. With cancer, not only do you have to remain positive, you also have to instill a sense of positivity in people around you,” said Mr Leong.

Despite his upbeat attitude and two gruelling rounds of chemotherapy, the cancer continued to spread. As it grew and blocked one of the key arteries leading to his heart, breathing became a challenge.

Four months after the diagnosis, Mr Leong was offered immunotherapy as his last lifeline. The relatively new cancer treatment, which was combined with chemotherapy in his case, harnessed the immune system to fight the cancer.

“I knew that with Stage Four lung cancer, there won’t be a miraculous cure. The biggest challenge at the time was whether I should continue trying (standard treatment) or go for something new,” he said.

The new treatment worked, shrinking the large tumours drastically within a few months. From mid-2017, scans showed he was free of the cancer.

In Singapore, lung cancer is the second- and third-most common cancer in men and women, respectively. But it is the leading cause of cancer deaths.

From 2011 to 2015, about 930 new cases of lung cancer were diagnosed in men each year, and around 500 new cases in women per year, said Dr Kong Hwai Loong, a medical oncologist at Icon SOC Singapore at Paragon Medical Centre, who treated Mr Leong.

Lung cancer accounts for 27.1 per cent of cancer deaths in men and 16.6 per cent in women, said Dr Shang Yeap, another oncologist at Icon SOC.

NON-SMOKERS NOT IMMUNE

Smokers have a higher risk of getting lung cancer but non-smokers are not exempted, said experts.

Emerging evidence shows that environmental factors like secondhand tobacco smoke may contribute to the risk. Lung cancers arising in non-smokers are more likely to harbour a specific mutation, which allows patients to be treated with an oral targeted drug initially, said Dr Kong.

“Noone is immune to lung cancer. Lifetime non-smokers may also be affected by lung cancer, especially non-squamous non-small cell lung cancer,” said Dr Kong.

Non-squamous non-small cell lung cancer – which Mr Leong, a former smoker, had – make up the majority of all lung cancers. They are mostly adenocarcinomas, or cancers which form in the mucus-secreting glands throughout the body, said Dr Yeap.

Stage Four cases are usually regarded as incurable, said Dr Kong.

Until two to three years ago, such patients would be treated with either oral targeted drugs or chemotherapy, said Dr Kong. Targeted cancer therapy works by blocking the growth and spread of cancer by interfering with specific molecules driving the cancer’s spread and progression.

The aim of the treatment is to manage symptoms and for the patient to live longer, he said.

On average, patients who respond to initial treatment might live anywhere between one and three years, but those who do not, live for a few months to a year, said Dr Kong.

“While a significant proportion of treated patients would initially show a response to treatment, the shrinking tumours would invariably rebound,” said Dr Kong.

HARNESSING THE IMMUNE SYSTEM

Newer treatments that harness the immune system to fight cancer aim to buy extra time for patients whose lung cancers have spread.

“Immunotherapy, especially pembrolizumab, has significantly and positively changed the lung cancer treatment landscape,” said Dr Kong.

In November last year, the Health Sciences Authority approved pembrolizumab, in combination with chemotherapy, as a first-line treatment for patients with metastatic non-squamous non-small cell lung cancer who do not harbour certain mutations that drive the cancer.

The approval was based on promising data from a randomised, multi-centre clinical trial.

The treatment, which saved Mr Leong’s life, is also used for other cancers such as melanoma (skin cancer), bladder cancer and classical Hodgkin’s lymphoma.

“When pembrolizumab is used with chemotherapy, the chance of death of such patients would reduce by half, compared to patients who are treated using just chemotherapy. They were also much more likely to enjoy a longer period of stability than those treated with chemotherapy alone,” he added.

The treatment is relatively well-tolerated although some patients may develop significant organ injuries due to an overactive immune system attacking one’s own body, said Dr Kong.

Two other immunotherapy drugs, nivolumab and atezolizumab, are also available in Singapore for lung cancer treatment, said Dr Wong Seng Weng, medical director and consultant medical oncologist at The Cancer Centre.

All three therapies have reported prolonged control of advanced stages of lung cancer, said Dr Wong.

“Some patients who entered initial phase one clinical trials, before approval of treatment, are still doing well and remain on it after more than seven years,” said Dr Wong.

There are also new targeted therapies available to treat patients with non-small cell lung cancer who have become resistant to their previous treatment, said Dr Yeap.

COSTS CAN BE ‘A HEADACHE’

Immunotherapy does not come cheap, however, and long-term treatment cost is a major consideration for many patients.

“Immunotherapy can sometimes achieve very extended period of cancer control, even for advanced lung cancer. This is good news from the point of view of extension of life but clearly a headache as far as cumulative treatment cost goes,” said Dr Wong.

According to him, the cost of immunotherapy treatment ranges from S$7,000 to S$15,000 every three weeks, depending on the dosage. If chemotherapy is added, there will be extra costs.

Chemotherapy costs between S$3,000 and S$7,000 per three weeks, depending on the choice of drugs, he said.

Current expert opinion is to continue immunotherapy treatment for two years or longer, if the disease does not develop resistance to treatment and patients do not experience significant side effects, said Dr Wong.

Immunotherapies are usually claimed under the category of chemotherapy for Medisave and Medishield, subject to limits of individual plans, said Dr Wong. Basic Medishield Life and Medisave may not be adequate to cover the total costs, he said.

Dr Wong said that some patients who achieve remission after several months of treatment choose to halt treatment early due to its cost. But he has observed a few patients who showed no evidence of cancer progression even after some time.

“It appears that for some patients, once their immune system has been mobilised to attack the cancer, the momentum can be maintained even without continuous use of the drug,” said Dr Wong.

The best bet for a good treatment outcome, however, would be early detection. In the early stages, surgery may be curative, said Dr Kong.

Dr Kong advised smokers to speak to their doctors about participating in a periodic lung cancer screening programme.

Smokers and non-smokers who have persistent lung symptoms, such as cough or shortness of breath, for more than two weeks should see a doctor for further evaluation.  Other telltale symptoms include unexplained weight loss and loss of appetite.

MUCH TO LIVE FOR

Mr Leong’s biggest challenge during his cancer journey was its psychological impact but he found ways to cope. Throughout his cancer treatment, he pushed himself to continue exercising. He would do 45-minute walks on the treadmill daily and lift weights.

“I was so weak I couldn’t even do a 1 kg bicep curl when I used to lift 10 to 12 kg. But I didn’t want to rest in bed, stay at home – that’s when people give up on life. I wanted to live life as normally as I could. Even though I walked slower, I could still move,” he said.

Besides remaining upbeat, Mr Leong advised cancer patients to find a doctor they trust.

“People gave me a lot of advice, from boiling a certain root to eating a certain leaf. Well, I’ve not done any of those. All I did was to listen to my doctor,” he said.

Currently still on immunotherapy, Mr Leong’s thyroid gland was damaged as a side effect of treatment but he counts himself lucky.

He has stopped smoking two packets of cigarettes a day and now embraces a healthier lifestyle consisting of more fresh whole foods, less processed food and regular exercise. He has also taken “a step backwards” in his career and now works on a contract basis.

“I used to be the first person to step into the office, and the last to leave. No more chasing after materialistic goals. There’s too much in life to live for,” he said.

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