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Lung cancer -8-Summary of stage 4 Treatment and Palliative Care


(All the articles published in past are available at

(All the articles published in past are available at
Question: Thank you Chiragbhai for explaining treatment of stage 4, and how overall survival has more than doubled in last decade or so. We learned about role of ALK inhibitors and the latest, most exciting new form of treatment i.e. immunotherapy as well. So now we have many options. Can you summarize the treatment of stage 4 lung cancer for us, as it seems fairly complicated now.
Ans: Definitely. Even for oncologists, it is getting complicated, as the options are so many. New research excites the scientist inside a doctor, and the average human inside him too. On the realistic side, however, oncologists also realize that:
1. Stage 4 lung cancer is essentially incurable. It is important to focus our scarce resources on prevention of lung cancer by promoting reduction in smoking, passive smoking, avoidance of coal for cooking, pollution etc. Focus on youth, to avoid new smokers, as quitting is difficult. Policy level changes by government such as increasing cost of tobacco products and stringent laws for public places are proven to reduce smoking. For your patients who cannot quit, at least encourage them to reduce amount smoked.
2. A large number of lung cancer patients are too weak to tolerate any chemotherapy, from the time of diagnosis itself. They may tolerate targeted therapies however.
3. With all new advances, survival is still modest on average i.e. about 2 years. Few patients live longer however.
4. COST of this life prolongation is not small. First line chemotherapy, and first line targeted therapy at least EGFR inhibitor is now very low in India (of course still high for a person below poverty line, but increasingly being supported by various government schemes, at least in some states). Government spending for health care in general is still dismal in India, only about 1.5% of GDP, much worse than most other developing countries, including our neighbours.
5. COST of very new options, like targeted therapies for ALK, second line EGFR, immunotherapy run in several thousands to few lacs per month, still out of reach for large majority Indians.
6. PALLIATIVE CARE is MOST IMPORTANT aspect of medical care for these patients and often the ONLY POSSIBLE care, due to either lack of nearby quality facility or lack of finances.
Ans: YES it is important for doctors in general to be trained in reasonable quality palliative care, and to know where to get help. Most doctors are not trained in this aspect during our formal training, except good oncology programs. Fortunately however, at least in cities, there is rising trend towards more facilities, including focused centers, more trained psychologists. This is a good news for patients. It is important for anyone (general practitioner, physician, surgeon, paramedical staff…) dealing with an advance cancer patient to find available resources in your region, from internet, or by asking your oncologist, or sometimes even by asking local NGOs. For example, Gujarat has few palliative care centers, such as two in Ahmedabad (GCRI, Karunalay), one in Jamnagar, Anand etc.
Advance lung cancer patients may have many symptoms such as pain, intractable cough, recurrent effusion, hemoptysis, difficulty breathing, weakness, paralysis and others. Many advance cancer patients in general also may have serious psychosocial issues, spiritual concerns, issues related to caregivers. Palliative care centers can provide holistic care by covering all aspects. Patients may visit these centers once or intermittently throughout course of disease. From diagnosis till end, they need not wait till terminal stages. Medical community and public at large have lots of myths or lack of awareness regarding role of morphine, role of radiation for pain control/hemoptysis, psychosocial issues etc. Government rules related to morphine add to the suffering of these patients. Lack of resources in general also is a reason why such patients are left to suffer. Readers PLEASE NOTE THAT MOST OF THE PALLIATIVE CARE CENTERS PROVIDE COMPLETELY FREE OR HIGHLY SUBSIDIZED CARE, and there is no need to let these patients suffer. Palliative care improves quality of life significantly, and even overall survival, as shown in various randomized trials. So this is not just some tender loving care, which can be provided simply by “talking to patients nicely or by asking them to be positive”. There are well studied scientific principles and a formal training is also available in western world, including MD in palliative medicine. Short courses for palliative training are now available in India, including in Gujarat, at GCRI for example. Interested readers can contact Dr Geeta Joshi at GCRI and visit website too.
October 15th 2016.

Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad.

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