Joan Schiller, MD
Joan H. Schiller, MD is Professor and Chief of the Hematology/Oncology Division at University of Texas Southwestern, and Deputy Director of the Harold C. Simmons Cancer Center, and holds the Andrea L. Simmons Distinguished Chair in Cancer Research. She graduated from the University of Illinois Medical School and completed her internship and residency in Internal Medicine at Northwestern Hospital in Chicago. She also completed a clinical fellowship in the Department of Human Oncology at the University of Wisconsin Clinical Cancer Center, before joining the faculty there. Dr. Schiller is Board Certified in Internal Medicine and Medical Oncology, and was a Professor of Medicine in the Department of Medicine Section of Oncology at the University of Wisconsin in Madison until moving to UT-Southwestern in 2006, where she is also Deputy Director of the Simmons Cancer Center. Dr. Schiller’s work focuses primarily on the treatment of lung cancer, specifically treatment modalities for small-cell and non small-cell lung cancer. She has been active in Phase I, II and III clinical trials, and sees patients with lung cancer with her radiation therapy and thoracic surgery colleagues. Dr. Schiller is an Associate Editor of the Journal of Clinical Oncology, former Chairman of the Thoracic Oncology Committee of the Eastern Cooperative Oncology Group, and Founder and President of the National Lung Cancer Partnership. She has published numerous articles related to the diagnosis and treatment of lung cancer and is internationally recognized for her work in this area.
University of Illinois - Chicago Medical Center
Northwestern Memorial Hospital
Northwestern Memorial Hospital
University of Illinois
Areas of expertise:
Non-Small Cell Lung; Small Cell Lung Cancer
Non-small cell lung cancer
Small cell lung cancer
Southwestern Medical Center
Simmons Comprehensive Cancer Center
2201 Inwood Rd 2nd Floor, Suite 106
Practice phone number:
Symptoms depend upon where the cancer recurs. For example, if it recurs in the lungs, symptoms might include shortness of breath, cough, coughing up blood, or pneumonia. Should it occur in the bones, pain is often a problem. Cancer presenting in the brain may cause signs or symptoms similar to a stroke – e.g. confusion, weakness on one side or another. Cancer in the brain also can cause headaches and nausea. If cancer spreads to the liver, typical symptoms are anorexia and fatigue, although these are not specific for liver metastases. Of note, since the inside of the lungs do not contain many nerves, pain is a relatively rare symptom of lung cancer, unless it occurs near the chest wall or ribs, which do contain nerves and thus can be painful.
Unfortunately, at this time there is no recommended chemopreventative agent for lung cancer, although there are a number of studies underway looking at this issue.
Treatment is usually stopped when it has stopped working (e.g. the patient has “progressed”) or if it has too many side effects. The later is relatively unusual; more often, physicians would recommend reducing the dose first. If your first line chemotherapy is no longer, ask your doctor about other chemotherapy options, since there are usually some. This may also be a good time to get a second opinion at a NCI designated Cancer Center or a major university or clinic, to see what other options are available. It may also be a good time to consider participating in a clinical trial. There is a lot of research going on in cancer in general, but lung cancer in particular, and new drugs are being evaluated all the time. Participating in a clinical study may give you access to some of these new drugs you may not otherwise have.
It depends upon whether or not the tumor has a EGFR mutation or anther type of mutation called the EML4/ALK fusion protein, since there are drugs designed very specifically for these mutations. However, these mutations only occur in roughly 20% - 25% of all adenocarcinomas, so the majority of patients will not have them. Nevertheless, ask your doctor if he or she has tested your tumor for them.
Generally speaking, chemotherapy for patients with Stage IV NSCLC usually involves a combination of two drugs (a doublet). In the past, one of the two drugs has been a platin, such as cisplatin or carboplatin (commonly called a platin doublet), although this does not necessarily have to be the case. There are an number of drugs which can be combined with the platin. These include paclitaxel (Taxol); docetaxel (Taxotere); pemetrexed (Alimta); or gemcitabine (Gemzar). The different two drug regimens differ in how frequently they are given (the schedule), how much they cost, and their side effects. As mentioned in this answer (http://www.talkabouthealth.com/what-are-the-differences-between-adenocarcinoma-and-squamous-cell-non-small-cell-lung-cancer-are-the-treatments-different), pemetrexed is slightly more effective in adenocarcinomas than non-adenocarcinomas.
Bevacizumab (Avastin) is a drug which is designed to stop the growth of new blood vessels, thus “choking off” the blood supply to the tumor. It is approved for use with the doublet chemotherapy carboplatin/paclitaxel (sometimes called Carbo/Taxol) in patients with non-squamous cell cancers only, since it caused increased bleeding in patients with squamous cell.
Typically, doublet chemotherapy is given 4 – 6 times (also called cycles) and then stopped, to give the patient a “chemo break.” More recently, there is some data to suggest that continuing one drug (maintenance therapy) until progression may be helpful.
There are actually four major types of lung cancer: squamous cell carcinoma, adenocarcinoma, large cell carcinoma, and small cell carcinoma. The primary difference between squamous cell, adenocarcinoma, and large cell carcinoma is how they look under the microscope. These three are sometimes collectively called non-small cell lung cancer (NSCLC) to distinguish them from small cell lung cancer (SCLC), which looks and behaves very differently. Of the four types, adenocarcinoma and squamous cell are the most common.
In the past, it really didn’t matter what type of NSCLC you had, since they were all treated the same way. However, more recent data suggests that some treatments might be more effective or safer in one subtype than another. Bevacizumab, for example, causes more coughing up blood in patients with squamous cell carcinoma, while pemetrexed may be slightly more effective in adenocarcinomas than squamous cell carcinomas. In addition, the EGFR mutation or anther type of mutation, the EML4/ALK fusion protein, is more common in adenocarcinomas.
Epidermal growth factor (EGF) is a protein made by some cancer cells, which binds to a receptor on the outside of the cell. Binding of the EGF to the EGF receptor (EGFR) activates the receptor, causing a chemical chain reaction that eventually ends up in the nucleus of the cell, stimulating the cell to grow. If a cancer cell has a mutation in the receptor, that causes the chemical reaction to continue all the time, even if it is not being activated EGF. The reason this is important is because there is a drug— erlotinib, or Tarceva – which can be very effective in patients whose tumor cells contain a EGFR mutation. In many cases, it causes dramatic shrinkage of the tumor, although it may grow back at some point. The drug is oral, and does not have the typical chemotherapy side effects of hair loss, nausea, and drop in the blood counts. Instead, its major side effects are skin rash, and to some extent, diarrhea and fatigue. There a number of clinical studies ongoing to identify more effective EGFR inhibitors.
Adjuvant chemotherapy is chemotherapy given after surgery, and it has been shown to reduce the chance of lung cancer coming back after lung surgery for patients with Stage II disease and some patients with Stage I disease who have very large tumors. It typically consists of two drugs, one of which is a platin 9eg either cisplatin or carboplatin). Cisplatin is slightly more effective than carboplatin, and is the drug of choice; however, it is also a little tougher on patients than carboplatin, and so in some instances physicians may substitute carboplatin for cisplatin for their elderly or sicker patients. The second drug may consist of any of the following: vinorelbine, etoposide; docetaxel, pemetrexed, or gemcitabine.
First, have as many as your records with you as possible, particularly if they are from another institution. I highly encourage patients to HAND CARRY them to your appointment. This cannot be stressed enough. Hospitals and clinics are often big institutions, and things have a habit of getting delayed or lost in the mail.
The records you need to bring include:
• Your pathology report. You should be able to get this from your referring physician.
• Your scans, which these days, are usually on a CD disk. . The most important scans are your most recent CT scans and PET scan. If you have had X-rays or scans done in more than one place, you will need to go to each place to get them. Do not assume that your primary care physician has them. Although they may have the reports, they are unlikely to have the actual CDs.
• A current list of the prescription and nonprescription drugs you are taking. (It is very helpful to bring the actual pill bottles along with EACH visit).
• Record of any treatments you may have had.
• If possible, a concise summary of your prior medical history.
• Ask the person who gives you the material to double check to make sure everything is complete. This cannot be overemphasized! Nothing is more frustrating than getting to the new doctor’s office and finding out the most recent scans or reports are not there, despite the fact you were assured they would be. (If you are hearing a lot of frustration from me, it comes from too often seeing new patients without their scans, who were assured “everything is in there”) (meaning the envelope they were told contains their records)
• Think about what you are going to say to your doctor ahead of time. Remember, he or she has a certain amount of time to spend with you. Before your appointment consider which concerns are most pressing and write them down in order of importance
• If you have symptoms to report, describe them clearly and concisely. Be prepared to answer your doctor’s questions, such as when the symptoms started, how often they occur, and how long they last. In most instances, you do not have to be exact; saying “early last week” or “about 2 months ago” will suffice.
• Always bring someone with you to your appointment. It is impossible to remember all that is said during an office visit and It helps to have someone else along who can write down what the doctor says.
First, make sure you have the right oncologist. The treatment of lung cancer is changing so quickly, you want a physician who specializes in lung cancer. Your primary care physician can refer you to the best lung cancer specialists in your area. If you cannot get a recommendation for a specific lung cancer specialist, you can contact the nearest cancer center or university hospital and ask for the names of their oncologists who specialize in lung cancer.
You should expect a physician with whom you feel comfortable, who is an expert in the area, is interested in you as an individual, and is willing to talk to you and answer your questions.
At the first visit, the doctor will ask you a number of questions about your prior health and your current symptoms. He or she will then examine you, and then review your films. Feel free to ask the doctor to go over the scans with you, if they have enough time. Finally, your doctor should go over your prognosis and different treatment options.