Pressing Issue: The High Incidence of Lung Cancer

Maria Valeria Hernandez Quintana

Maria Valeria Hernandez Quintana grew up in the vibrant city of Buenos Aires, Argentina, and was raised by two loving parents who happened to smoke cigarettes. Her maternal grandfather died of lung cancer.

But the city’s issues with air pollution, the second-hand smoke, and the family medical history were hardly on her radar until, at age 48, doctors found a fist-sized tumor on her lungs. She was officially diagnosed with adenocarcinoma, the most common form of lung cancer, on Jan. 2, 2020, and went through surgery and months of chemotherapy and radiation.

“The whole experience felt surreal,” says the Victor resident, who has never smoked.

“What kept me sane was a positive attitude,” she says. “Telling myself: ‘I’m going to get through this. Cancer is messing with the wrong woman.’”

The Data Story

In the 27-county Rochester region from which Wilmot Cancer Institute draws patients, the lung cancer incidence rate is a startling 70 cases per 100,000 people. That’s much higher than in all of New York State, at 58 cases, and in the U.S., which is about 53 cases per 100,000 people.

Although in some areas cigarette smoking seems to be less prevalent these days, data tell a different story. The Rochester region’s smoking rates are higher than state and national averages, and combined with other risk factors such as heredity, the lung cancer problem is compelling.

“The data have been a wake-up call to the University and to all of us in health care,” says Carolyn Jones, M.D., who leads Wilmot’s Lung Cancer Service Line and is also chief of Thoracic and Foregut Surgery at the University of Rochester Medical Center. “If we have these pockets of very high incidence rates of lung cancer, are we really doing all we can to help those neighborhoods, those zip codes, and to look for solutions?”

Jones believes the high rates may boil down to three things: “Not quitting, not getting screened, and not getting linked to proper care.”

Lung cancer is the second most common cancer in the U.S. and the leading cause of cancer deaths in men and women. As in the case of Maria Valeria Hernandez Quintana, 20 percent of lung cancer patients have never smoked.

And yet cigarette smoking — or what some call “the disease of tobaccoism” — is still the cause of 80 percent of lung cancer deaths, according to Patricia Rivera, M.D., Wilmot’s associate director for Diversity Equity and Inclusion, and the C. Jane Davis and C. Robert Davis Distinguished Professor of Pulmonary Medicine at URMC.

“For decades, we’ve shamed these individuals instead of leading them to treatment and helping them to quit smoking,” she says.

Patricia Rivera, M.D.

Racial and ethnic differences in how health care is accessed and delivered, lack of insurance, and lack of education about risks, are likely factors that play out in this region, as they do across the country. For example, the lung cancer incidence rates locally are even higher among Black people, at 75 cases per 100,000 people. Rivera notes that Black men in the U.S. are at the highest risk for being diagnosed with lung cancer and dying — even if they smoke less than white men.

Lack of awareness about lung cancer screening contributes to the problem.

“Everybody knows about breast cancer screening or colon cancer screening,” Rivera says, “but lung cancer screening is lagging, which leads to the higher death rates.”

“It’s a very complex problem,” she adds. “And that makes it more difficult to come up with the best approaches.”

Screening

Detecting lung cancer early, at stage 1, is a key to survival.

Strong Memorial Hospital and affiliates offer low-dose CT scans to screen those who qualify. The scan shows detailed images of the lungs and air tubes, and can pick up small tumors, using less radiation than conventional CT scans but with more specificity than chest x-rays.

Studies show that individuals whose cancers are detected via low-dose CTs are 20 percent less likely to die from lung cancer than those who received chest x-rays, Rivera says.

Who qualifies? Individuals 50 to 80 years old, who are currently smoking or have quit within the last 15 years. Smoking history must include at least one pack of cigarettes a day for 20 years, or a halfpack for 40 years.

Rivera emphasizes that shared decision-making between doctor and patient is required; the screening can occasionally turn up benign nodules, and if a person seeks screening but is still smoking, that individual must enter a tobacco-cessation program.

Lung cancer screening is currently underutilized. Nationally, only about 6.5% of people who are eligible take advantage of it.

The Patient Experience

The days leading up to Hernandez Quintana’s diagnosis are vivid. She is a longtime fall allergy sufferer, and in August of 2019, the usual dry cough started. In November, she was still coughing, which was unusual. She remembers that it got so intrusive she was “begging my allergist to make it stop.”

“I felt like something was different,” she says.

She received a chest x-ray, which showed a shadowy lesion on the lung. After a second x-ray, doctors ruled out pneumonia and other illnesses, and then a bronchoscopy revealed the full mass.

“I’m still not thinking it’s cancer,” she recalls. “I’m a runner, I eat healthy, I’ve never smoked in my life. We’re like, what could it be?”

It was stage 3 lung cancer. The next step was to find out if it was operable — and this is when she caught a lucky break.

“My oncologist, Dr. (Deborah) Mulford, called one of the surgeons, Dr. (Christian) Peyre, and he happened to be in his office at that moment, three floors away, and agreed to see me immediately. He reviewed my films and scans and says, ‘I can operate.’ Well, I started crying with joy, and I hugged him and kissed him! His
mother is from Honduras, so he understands our kissing culture — but he says, ‘Don’t kiss me yet. Let’s bring your case to the tumor board and get the surgery done first.’“

In January 2020, Peyre removed the upper lobe of her left lung and nine nearby lymph nodes, three of which were malignant.

“It’s a traumatic thing to go through,” says Hernandez Quintana, who works as a Spanish interpreter for the Victor Central School District. She is known as “Val Cleary” to her local friends and family, which includes husband Jason Cleary and two sons.

“But everyone was so amazing at Wilmot,” she adds. “They treat you like a human.”

She remains in remission. “Every morning, I thank God that I’m here — and I move forward.”

Her advice for others?

“If you feel like something is wrong in your body, push, push, push. Don’t just think it will go away.”

Lung Cancer Treatment

Acting quickly in a multidisciplinary fashion and being able to find the best combinations of treatment for each individual is the goal, says Mulford, M.D., professor of Clinical Medicine and a Wilmot leader in clinical research. She prizes Hernandez Quintana as a model of self-awareness.

“Her story — a person who keeps trying to uncover why they don’t feel well — is what we like to see. New therapies, sometimes, can make a difference in patient’s lives but there are a lot of other factors and, obviously, that’s not the end of the story.”

For those who are diagnosed with certain types of lung cancer or cannot have their tumor removed, immunotherapy drugs, such as Keytruda and Optivo, have completely changed the landscape of lung cancer care, Mulford says. When the cancer is active, she explains, it sets up checkpoints that block the body’s
healthy immune cells from attacking cancer.

The newer drugs release the blockade, allowing immune cells to clear out the cancer cells. Immunotherapy can also provide the possibility of a long-lasting response to therapy.

Clinical trials are available that evaluate new ways to stimulate the immune system or to use immunotherapies in combination with chemotherapies at different stages of disease. Many Wilmot patients have benefitted, Mulford says.

Other innovations also provide exceptional care options:

• Wilmot has the only state-of-the-art Varian Edge Linear Accelerator in upstate New York. This technology is for individuals with non-small-cell, early-stage lung cancer who do not qualify for surgery. The device uses imaging and customized high-energy beams to target a tumor’s shape and deliver radiation therapy as precisely as possible.
• For biopsies, which are critical for an accurate diagnosis, Wilmot has a super-dimensional robotic tool called the Davinci Ion system. It allows physicians to navigate to small tumors located deep in the lungs for streamlined diagnosis and staging in difficult cases.
• UR Medicine has a dedicated lung cancer pathology team that works closely with Wilmot surgeons, pulmonologists, medical oncologists and radiation oncologists. Led by Moises Velez, M.D., the pathologists provide detailed molecular studies of the tumor with an eye toward gene mutations, so that patients can receive the most effective and personalized therapy possible. They also store tissue for re-evaluation in the future, when new treatments become available.
• Surgery and recovery are often faster and more efficient, as Wilmot surgeons are able to use minimally invasive robotic systems in about 50% of cases. One new type of technology offers a one-stop shop for eligible patients: an imaging scan that marks the lesion, and the ability to perform a biopsy and remove the tumor in a single surgery.

“Long gone are the days of King George VI’s lung cancer,” says Jones. The former King of Great Britain, who was the late Queen Elizabeth’s father, notoriously had his left lung removed in a makeshift operating room in Buckingham Palace, in 1951. He died a year later.

Carolyn Jones, M.D.

That was 70 years ago. In more recent times, research-based improvements have come fast and are continuing. “And that’s a good thing,” Jones says.

Lung Cancer Research

Wilmot scientists are studying many aspects of lung cancer, including prevention, lung damage at the cellular level, and protecting the lungs from injury during treatment.

The latter is the focus of Brian Marples, Ph.D., the Dr. Sidney H. and Barbara L. Sobel Professor of Radiation Oncology. A renowned radiation biologist, he and his Wilmot team recently received an award from the National Institute of Allergy and Infectious Diseases to investigate how to reduce pulmonary injury in patients undergoing radiation therapy, especially when those patients have recently been infected with a virus in the lungs.

Another top investigator of lung diseases, Irfan Rahman, Ph.D., has multiple publications in high-impact medical journals on the harms of cigarette smoke and vaping chemicals on lung tissue and cells deep within the organs. He has shown that vaping associated with wheezing, for example, can be a precursor to emphysema, lung cancer, and other illnesses. With the popularity of vaping in recent years among younger people, Rahman is also focused on providing evidence to inform the U.S. Food and Drug Administration and other regulators about the adverse effects of vaping products on health. He is a Dean’s Professor of Environmental Medicine, and a professor of Public Health Sciences and of Medicine.

Prevention research is also a priority for Wilmot.

“Lung cancer is something that you cannot examine by touch, so you have to reply on symptoms, which unfortunately don’t always happen until tumors are big,” Jones says. “So, it’s essential that we focus on who’s at risk and on preventing cancer.”

Francisco Cartujano, M.D., operates clinical studies in community-based settings for people underrepresented in health systems. Many of his projects are smoking cessation-related — in one case evaluating what types of text messages via mobile phones work best to motivate people to quit. He works closely with the local and regional Latino and Puerto Rican communities to stem their high rates of smoking, and he is a co-leader of Wilmot’s Community Outreach and Engagement Office.

Carlos Santana, a community building in action coordinator for Action for a Better Community in Rochester, is a success story. A former heavy cigar smoker, he says he challenged Cartujano and actually set out to prove that his quit-smoking program wouldn’t work. But to Santana’s surprise, he was able to quit.

“I quit smoking through the text messaging program and then with the help of patches,” Santana says. “The chemicals in my lungs went from 100% to zero. You can make believers out of those who think quitting is a joke!”