Online Health Chat with Dr. Peter Mazzone and Dr. Nathan Pennell

August 22, 2011


Cleveland_Clinic_Host: Lung cancer is the most common malignancy worldwide, with more than 1 million cases diagnosed yearly. In the United States, an estimated 200,000 new cases were diagnosed in 2009, and more than 150,000 deaths were due to lung cancer – making it the leading cause of cancer death in both men and women. At Cleveland Clinic, lung cancer is diagnosed and managed in collaboration among pulmonologists (lung specialists), pathologists (doctors who study tissue under the microscope), medical and radiation oncologists (cancer treatment specialists), and thoracic (chest) surgeons.

Lung cancer is a very challenging cancer to treat. The most critical factor in determining the survival rate is the stage at the time of diagnosis. Using a multidisciplinary approach to lung cancer care is vital to managing the disease. The Chest Cancer Center at Cleveland Clinic, which includes specialists from the Respiratory Institute, Taussig Cancer Institute, and Heart and Vascular Institute, uses a multidisciplinary approach to cancer care. This allows us to focus our entire team’s expertise and energy on providing the best outcomes for our patients. Patients with lung cancer, mesothelioma, and rare tumors of the chest wall and mediastinum (mid-chest cavity) can benefit from this comprehensive, coordinated care. While there is no one solution for treating lung cancer, there are many options.

Peter Mazzone, MD, MPH, is Director of Education at Cleveland Clinic's Respiratory Institute. In addition, he is Director of the Lung Cancer Program for the Respiratory Institute and Director of the Pulmonary Rehabilitation Program. Dr. Mazzone’s treatment interests include lung nodules, lung cancer, and intensive care unit medicine. His research interests focus on breath analysis, lung cancer diagnostics, lung nodule evaluation, lung physiology assessment, and lung cancer screening. Dr. Mazzone is board-certified in internal medicine, pulmonary medicine, and critical care medicine

Nathan Pennell, MD, PhD, is a medical oncologist in Taussig Cancer Institute. He specializes in the treatment of thoracic malignancies and is the Director of the Lung Cancer Medical Oncology Program for the Taussig Cancer Institute. with a focus on lung cancer. Dr. Pennell's research interests include clinical trials using novel therapies, with a goal of facilitating the movement of new treatments from the laboratory to the clinic. Dr. Pennell is board certified in internal medicine and medical oncology.

Cleveland_Clinic_Host: If you have additional questions or if you would like to set up a consultation with a Cleveland Clinic specialist, please call the Cancer Answer Line at 216.444.HOPE (4673) or 866.223.8100. Same-day appointments are available.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Peter Mazzone and Dr. Nathan Pennell. We are thrilled to have them here today for this chat. Let’s begin with some of your questions.


jallop: What are the symptoms of lung cancer? How do you differentiate the symptoms of lung cancer from other lung diseases/disorders?

Dr_Peter_Mazzone: The symptoms of lung cancer are not very specific; that is, they are common symptoms that can be present for many reasons. For example, coughing is a common lung cancer symptom but also a very common symptom in the general population (particularly in smokers). More specific lung cancer symptoms include coughing up blood, progressive chest pain, and unintentional weight loss. Unfortunately, these symptoms often present late in the course of lung cancer when the cancer has advanced and become more difficult to treat. Very early stage lung cancer often has no symptoms and may be found when an imaging test of the lungs is performed for a different reason.

hello: What can be done to help coughing with lung cancer being treated by chemotherapy? Coughing can be really bad with lots of mucus.

Dr__Peter_Mazzone: Coughing related to lung cancer can be a very difficult issue. The treatment to help coughing depends a bit on why the cancer is causing the cough. If the cancer is growing within a breathing tube, then treatment to the tumor through a camera inserted into the breathing tube can be helpful. If the cancer is blocking a breathing tube, it may result in a lung infection because the mucus cannot be drained well. Treatment of the infection may help. Other general treatments of coughing may include breathing medications (puffers) or cough suppressants (often containing a narcotic).

Bobich05: A loved one has recently been diagnosed with Stage IV adenocarcinoma suspicious of non-small cell lung cancer. Diagnosis was made after a visit to the emergency doctor due to severe back pain. Cancer is in lungs, spleen, and spine. We are currently awaiting a treatment recommendation and have been prescribed pain medication for the back pain. Fatigue is a major issue. Do you have any recommendations for relieving fatigue during this time?

Dr__Nathan_Pennell: Fatigue is one of the most common symptoms in patients with advanced lung cancer, and it can be from many different causes. The cancer itself often saps a patient's energy, but the pain medication and often the treatments we use to fight the cancer can also make patients tired. It is first important to figure out the underlying cause of the fatigue before treating it. If it is the cancer itself, then treating the cancer can be beneficial. If it is the pain medication, then strategies to reduce the need for the medication (radiation, different medication) can be helpful. If nothing else works, there are stimulants, such as Ritalin, that can be used, although these also have side effects and need to be monitored closely to be sure they are helping.

connie: When cancer spreads and 'hits' a vein, causing the coughing up of a lot of blood, what does this indicated toward a patient's prognosis? How does it change treatment?

Dr_Peter_Mazzone: Coughing up blood is a concerning symptom. Fortunately, not everyone who has lung cancer and coughs up blood has advanced lung cancer. It may be that the area where the cancer started to grow was near a small blood vessel, and this led to blood being produced. Ultimately, the treatment of the cancer will depend on the type of cancer and how far it has spread. Sometimes, the amount of blood coming up is significant enough that it can be dangerous for the person. In this situation, treatment intended to stop the bleeding, separate from the treatment that is being used to help the cancer, is given. This may include procedures that block the blood vessels supplying the cancer or surgery to remove the cancer (if otherwise appropriate).


spgautam555: What type of investigation or screening should be done regularly to detect early stage lung cancer?

Dr_Peter_Mazzone: Until very recently, there has been no evidence that screening for early lung cancer was of benefit. Within the past year, a large study was published (called the National Lung Screening Trial) that showed CT scans performed on those at very high risk of developing lung cancer were able to reduce the number of people dying of lung cancer by 20 percent. We are currently establishing a CT-based lung cancer screening program. We will follow the NLST plan -- ages 55 to 74 years, smoked at least 30 pack-years and if quit, quit < 15 years ago. It is unclear if CT-based screening would help other groups. Insurance does not currently pay for CT screening, though we hope they may change within the next year or so. Issues about the many lung nodules found, the risk for CT-related radiation, and cost-effectiveness remain to be studied.

rjfp: What is your position regarding CT scan testing for smokers 50 and older? Do most health insurance policies cover this? Does Medicare? Thank you.

Dr_Peter_Mazzone: Many are interested in this topic. CT screening for lung cancer has recently been shown to reduce the number of lung cancer deaths by approximately 20 percent. This has only been proven in a very high risk group -- age 55 to 74 years, smoked 30 pack-years (e.g. 1 pack per day for 30 years), and if quit smoking, then quit for less than 15 years. We are establishing a screening program based on the above criteria. Currently, insurance does not cover the scan. Hopefully, insurers will begin to cover CT screening in the next 12 to 18 months. Unresolved issues include the management of small lung nodules found frequently on these scans, the risk of the low dose of radiation received from the scan, and the cost effectiveness of screening programs.

HBobich05: Once treatment begins, how often are follow-up scans typically performed to check for further spread beyond originally diagnosed sites (lungs, spleen, spine), and is there a typical timeline along which you may expect to see tumors forming in other expected areas?

Dr__Nathan_Pennell: There are some variations in practice depending on who you see, but I usually do scans after every two rounds (or cycles) of treatment to check and see how the treatment is working. Usually, this comes out to every six or eight weeks. There is no general timeline for how quickly lung cancer can spread or come back after initially responding to treatment. Lung cancer is a very heterogeneous disease, and every individual case is different, with some growing very fast (week to week), and others changing little over months. I hate to say it, but "it depends."

gem: Can lung cancer be diagnosed via X-ray? How is it most often diagnosed?

Dr__Nathan_Pennell: Lung cancer is often initially picked up on chest X-ray, although X-rays are not terribly sensitive for picking up small tumors and much of the lung is hidden by the heart. Most often, lung cancer is discovered once the patient develops symptoms such a cough or shortness of breath that prompts the doctor to order some sort of test, most often initially chest X-rays. We then generally move to a more sensitive and higher resolution test such as a CT scan.

Metastatic Cancer

pineledge: My husband's kidney cancer is now in his lungs. Will the cancer behave the same way primary lung cancer does?

Dr__Nathan_Pennell: Although kidney cancer can spread to the lungs, it is still considered cancer of the kidney with regard to treatment and behavior, so it would not be expected to behave like primary lung cancer.

Zoya: My brother is in his late 50s and worked in construction most of his life. He was diagnosed with kidney cancer four months ago. Just recently, the doctor learned that his cancer is in his lungs (early stages). Doctors found three tumors: one is 9mm, the second is 6mm, and the third is 5mm. What treatments are best to combat lung cancer and prevent it from spreading? What are the pros and cons of surgery, chemotherapy, or medicine? Which do you recommend? Are there foods/diet that can be followed in conjunction with the best treatment approach? My brother goes to San Francisco Medical Hospital for medical attention.

Dr_Nathan_Pennell: Similar to the previous question, cancer that spreads from the kidneys to the lungs is considered metastatic kidney cancer and not lung cancer. Unfortunately, I am not a kidney cancer specialist so I cannot recommend specific treatments for this condition.

As for diet recommendations, this is one of the most common questions I receive when I meet with a new patient. Unfortunately, there is very little good evidence that specific diets can affect the course of cancer once it has already developed. If someone is maintaining an otherwise healthy diet, the person should continue with what he or she is already doing.

HBobich05: Please discuss typical pathways through which lung cancer spreads to other parts of the body. If masses are present in the lungs, spleen, and spine, is there an expected "route" along which further cancer may spread, or is it random?

Dr_Nathan_Pennell: Lung cancer can spread either through the lymphatic channels, which can sometimes behave predictably, or "hematogenously," through the bloodstream. When cancer has spread to such a broad number of places such as the spleen and bone, it is in the bloodstream and really can spread about anywhere. There is really no good way to predict at that point.

To some extent, though, lung cancer can be predictable. Once it travels to the bone, for example, we must always be alert for other areas in the bones. Other common areas for lung cancer to travel are the adrenal glands, the liver, and the brain.


spgautam555: The tobacco in smoking form is a causative agent for lung cancer. Are there any substances that can be added with tobacco to reduce the risk of lung cancer?

Dr_Peter_Mazzone: There is currently no evidence that any additive can reduce the risk of developing lung cancer from cigarette smoking. There is no safe cigarette. Studies looking at vitamins, supplements, and drugs given to help prevent lung cancer from developing have not shown beneficial results to date.

jodo: How quickly can smoking affect your lungs and cause cancer?

Dr_Nathan_Pennell: It has never been determined that there is any "safe" number of cigarettes with regard to lung cancer risk, so the best answer would be "immediately." However, the flip side of this is that quitting smoking at any point in your life dramatically cuts the risk of lung cancer, so it is never too late!

donny: I know that smokeless tobacco can cause different types of oral cancers, but can it also contribute to lung cancer?

Dr_Peter_Mazzone: Yes, I would consider smokeless tobacco a risk factor for lung cancer though certainly not as big a risk as cigarette smoking. I would encourage anyone concerned about lung cancer to avoid all types of tobacco.

monday: What effect does second hand smoke have on lung cancer risk, in particular, for children of smoking parents?

Dr_Peter_Mazzone: Second hand smoke is considered a risk factor for lung cancer. It is very difficult to know exactly how big a risk factor this is. Most feel the risk is increased by around 20 percent to 30 percent. The heavier the exposure to second hand smoke and the longer the exposure occurs (as in children), the higher the risk is likely to be.


spgautam555: Some of the main causes of any cancer include carcinogens (such as those in tobacco smoke, CO clad smoke), ionizing radiation, and viral infection. This exposure causes several cumulative changes to the DNA in the tissue that lines the bronchi of the lungs (the bronchial epithelium). As more and more tissues become damaged, eventually a cancer develops. Is there any prophylaxis treatment available to prevent the changes in DNA?

Dr_Peter_Mazzone: There is currently no evidence that any additive can reduce the risk of developing lung cancer from cigarette smoking. There is no safe cigarette. Studies looking at vitamins, supplements, and drugs given to help prevent DNA damage leading to lung cancer has not shown beneficial results to date. Anti-inflammatory and anti-oxidant drugs have been the main categories studied. Work is ongoing.

grownup: Do the symptoms, severity, treatment plan, etc. change based on what caused the cancer (i.e. smoking, asbestos, genetics, etc.)?

Dr_Peter_Mazzone: The presentation, course, and treatment of lung cancer can be affected by the type of lung cancer that develops. The type of lung cancer may be related to the exposures that led to the cancer and the person's genetics. Very recently, testing of lung cancer for specific molecular changes has been found to help in selecting treatment for a small portion of our lung cancer patients. Hopefully, as we learn more, we will be able to pick the treatments that will be most helpful and least toxic based on each person’s cancer characteristics.

lottie: Are some people predisposed to getting lung cancer? I know some people who have smoked 30 years or more and whose lungs are fine and vice-versa. What makes a person more prone toward cancer? Is it really just gene specific?

Dr_Peter_Mazzone: It is true that everyone is different in their risks of developing lung cancer. Some people may smoke for many years and not develop lung cancer while 15 percent of all lung cancer patients have never smoked. That said, we are not currently able to predict who will be predisposed to the harmful effects of cigarettes. A family history of lung cancer is a clue to increased risk. Women may be more affected than men by equal cigarette exposures. Certain ethnicities appear to be more susceptible to the effects of tobacco exposure. Even if one is not prone to developing lung cancer, the effects of cigarettes on developing emphysema or heart disease can still be present.

pondon: Can other lung ailments, such as COPD, emphysema, chronic bronchitis, etc., cause or lead to lung cancer?

Dr_Peter_Mazzone: Though these ailments don't cause lung cancer, those with other lung diseases do have a higher risk of developing lung cancer. It seems that the reasons someone may develop lung cancer have an overlap with the reasons they may develop other lung diseases, beyond just the fact that smoking may lead to both problems.


klank59: With Stage IV lung cancer, what other treatment alternatives are available when chemotherapy does not work and the patient is too weak to continue with further chemo treatments?

Dr_Nathan_Pennell: That is a really tough situation, and unfortunately one to which almost every patient eventually arrives.

Once the patient is too weak to continue with further chemotherapy, which usually means spending the majority of time in bed or on the couch, the options generally shift away from active treatment of the cancer and toward a focus on the patient's quality of life and symptoms. Management of pain with drugs and possible radiation can offer benefits in this situation.

Sometimes we offer treatments other than chemotherapy, such as the oral drug Tarceva® (erlotinib), in situations where chemotherapy has stopped working. However, this drug does have significant side effects, and the general rule of being relatively fit still holds to avoid doing more harm than good.

herrig: My mother's lung cancer has come back. Three very small spots were found very early. Her doctors want to treat her with some shots and not chemotherapy. She is calling them booster shots. What is this and does it really work?

Dr_Nathan_Pennell: Is this being done as part of a clinical trial? The standard treatment for lung cancer that has returned and spread to multiple areas in the lungs is chemotherapy, but there are certainly alternative treatments such as shots to stimulate the immune system that are being investigated in clinical trials. However, these are not yet established in general practice and should not be used outside of a well monitored study.

ajhart: Can you talk about using such treatments as Iressa® (gefitinib) and Tarceva® instead of chemotherapy or radiation?

Dr_Nathan_Pennell: Drugs such as Iressa® and Tarceva® are called "targeted" drugs and are daily pills that turn off a protein called the epidermal growth factor receptor (EGFR). Iressa® is not approved in the United States, but Tarceva® is approved for the treatment of advanced NSCLC after the failure of one or two previous chemotherapy treatments. It has been shown, on average, to prolong survival in these patients. There are also some patients with mutations in the EGFR gene (about 10 percent of patients in the US) who can get dramatic and prolonged remissions with these drugs. The most common side effects are skin rash and diarrhea.

HBobich05: So with Stage IV lung cancer, it would seem that a month-long lag between diagnosis and starting treatment could be a problem. How would you recommend we get this process moving along faster?

Dr_Nathan_Pennell: I can sympathize with your frustration. We all wish delays would be shorter than they often are. The data we have on the influence of treatment delays suggests that it is not that critical unless the delay is very long (months) in terms of how long the patient will live. Although there are some cases where the lung cancer progresses in a period of weeks, on average I think of NSCLC changing more over a period of months; and so a four-week delay, while not ideal, may not be that big a deal. As far as speeding things up, being a strong advocate for yourself (or the patient) is always helpful; being a squeaky wheel really can move things faster if you keep calling!

trying_to_help: How exactly does one go about getting involved in a treatment study? My father has lung cancer that is not responding well to conventional treatment. Is this something his doctor would bring up to him or is this something I can research online and bring up to the doctor?

Dr_Peter_Mazzone: I think the best way to explore options is to discuss what's out there with your oncologist. A referral to a tertiary care level cancer center can be helpful, and your oncologist may be familiar with the places in your area that are most likely to provide you with the best opinions. Researching online can also be valuable if the information received is obtained from a reputable website (e.g. NCI, local cancer centers).


try_me: With all the new city-wide smoking bans, the price of cigarettes, and better informed consumers on the dangers of smoking, have you seen a decrease in the number of lung cancer cases? Can you tell if lung cancer is related to smoking or not?

Dr_Peter_Mazzone: Lung cancer is definitely related to smoking. The number of lung cancer cases has mirrored the number of smokers for both men and women. The rate of lung cancer in men began to decline in the late 80s as the smoking rates declined 10 to 20 years prior. The rate of lung cancer in women has just plateaued as the smoking rates lagged behind those of men. Hopefully, all of the measures you mention will decrease the smoking rates substantially, leading to further reductions in lung cancer deaths.


goblue: Someone sent me an article about a study that was done that dogs can sniff out lung cancer? I know this is a strange question, but is there any basis to this and what would this even mean to medical science if true?

Dr_Peter_Mazzone: Some of the chemicals in our breath represent changes in the way our body is working. Cancer cells work differently than normal cells and thus the chemicals produced (or consumed) by these cells may lead to a different pattern of chemicals in our breath. Studies looking at chemical-detecting devices have shown that these unique patterns exist. The study using dogs to detect lung cancer in the breath further supported this line of research. We are currently performing a study using an advanced sensor device (the sensor changes its colors based on the chemicals it comes in contact with) to determine how accurately we can detect lung cancer from a person’s breath. We hope that within three to five years we will be able use this type of device for our patients' benefit.

just_so: What is the latest research being done on lung cancer treatment?

Dr_Nathan_Pennell: I'm afraid that is too broad a question to answer completely, so I'll just pick something I am excited about.

We are making tremendous strides in determining the underlying genetic changes in the different types of lung cancer. Now that these "targets" are being identified, we can design treatments to attack these vulnerabilities. One example is the ALK translocation that is present in about 5 percent of lung cancers. We have a drug called crizotinib that is in late stage trials that appears to be very effective in this type of cancer, and it may be approved by the FDA later this year. This is only one example of treatments that may eventually lead to true personalized therapy for individuals with lung cancer.

General Questions

vista: What are the suggestions/implications for a woman who is pregnant and finds out she has lung cancer?

Dr_Nathan_Pennell: This is not terribly common, but certainly happens. It is very important to discuss the risks of testing (CT scans) etc. to the fetus with the patient so she can make the most informed choices possible. The risks would depend on the stage of the cancer.

Outside the first trimester, most of the chemotherapy agents used for lung cancer are reasonably safe to the fetus. Surgery carries some risks, but may be OK in most circumstances as well. Radiation definitely carries risks and needs to be tailored to the specific situation.

Our general recommendation is to treat the patient as we would otherwise, taking the mother's preferences into account.


Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Nathan Pennell and Dr. Peter Mazzone is now over. Thank you again doctors for taking the time to answer our questions today about lung cancer.

Dr_Nathan_Pennell: Thanks so much for inviting us to participate in this chat session. And thank you to the patients and caregivers who gave up their time to ask questions!

Dr_Peter_Mazzone: Thank you very much for everyone's interest. The way we find and treat lung cancer is changing quickly. I look forward to interacting with you again in the future.

More Information

Cleveland_Clinic_Host: If you have additional questions or if you would like to set up a consultation with a Cleveland Clinic specialist, please call the Cancer Answer Line at 216.444.HOPE (4673) or 866.223.8100. Same-day appointments are available.

A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit

This chat occurred on 8/22/2011

This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. ©Copyright 1995-2011 The Cleveland Clinic Foundation. All rights reserved.