Tony Ricciardi remembers precisely when he quit smoking. It was 1 a.m., on Martin Luther King Jr. Day in 2001. A late night trip to buy cigarettes left him feeling so disgusted by his need for nicotine that it became the last trip he ever made to support behavior he knew was bad for his health.

But he has no idea when his lung cancer began to grow inside him. It might have already been there, starting a journey Ricciardi didn't notice until several years later, when he happened to notice a lump on his neck, just above his collar bone. "It felt like a bug bite," he said, "and it didn't hurt." But he mentioned it to an acquaintance who was a retired physician. He recommended that Ricciardi have it examined by a doctor.

This doctor "did some kind of X-ray and then called me back to his conference room," Ricciardi said. The man looked so serious that Ricciardi tried a joke. "Could I buy green bananas?" he asked. The answer was not what Ricciardi expected. That tiny, bug-bite-like growth near his collarbone was actually the tip of a cancerous tumor that had expanded out of his lungs up into his neck. If Ricciardi responded to treatment, he might have a year left. Ricciardi, stunned at this verdict, talked to another doctor acquaintance who sent him to see Heather Wakelee, MD, at Stanford Hospital & Clinics. Her special focus is lung cancer, and she is the lead medical oncologist of the Stanford Cancer Center's Thoracic Oncology group. 

Wakelee ordered more detailed images to be taken of Ricciardi's chest and then told him what she thought. "She just handled it like I had a runny nose," Ricciardi said. He remembers her saying,  "'We cure people like you all the time.' I was confused a little bit—this other person was saying, 'Curtains'—but I liked her and I liked her manner and I just kind of surrendered myself to her. What did I have to lose?"

Options still open

Each year, 225,000 Americans are diagnosed with lung cancer. Eighty-five to 90 percent of them has a history of smoking, although the number of lung cancer patients with no such history is growing. The disease is the leading cause of cancer deaths, in large part because the vast majority of patients are not diagnosed until the cancer has reached its later stages.

"When Tony came to us, he had a large mass of cancer in his chest and in his lymph nodes," Wakelee said. "Many believe that when it's spread like that there's no hope. We work hard to overcome that, to let people know that there is hope, even within the reality that this is a hard disease to treat. There are patients who get through it, who survive to tell about it."

Ricciardi's cancer had spread to his lymph nodes, making surgery no longer an option. In such cases, "we look to other treatment modalities," Wakelee said. "Radiation is critical, but we know from many studies that adding chemotherapy to the radiation is far more effective than doing either radiation alone or doing radiation after chemotherapy or vice versa."

The big advantage of the combination treatment is that chemotherapy is a radiation sensitizer, Wakelee said. "It improves the effectiveness of radiation, and unlike focused radiation, it reaches throughout the body. When someone comes in with cancer as developed as Tony's, the likelihood is that cancer cells have escaped to other areas of the body. That's why we do both therapies and why we do them together." 

Both the chemotherapy and the radiation alter the DNA of cancer cells so they are less able to divide and grow. Patients can experience side effects from both types of treatment. "We chose to go through an aggressive course of treatment for him because he was relatively young—62 and otherwise healthy," Wakelee said. "The prognosis of advanced lung cancer is poor, and in the minds of many people, even physicians, what often gets overlooked is that there are patients who are cured with aggressive therapy and we don’t want to take away hope." 

Taking precise aim

The radiation Ricciardi received was delivered by technology that has advanced so rapidly that the physician in charge of Ricciardi's care, Billy W. Loo Jr., MD, PhD, has learned a completely new set of skills from those he acquired during his radiation oncology residency training at Stanford. "The change of pace has been really impressive," said Loo, Stanford's program leader in thoracic radiation oncology and an expert in image-guided focused radiation therapy. "The main changes have been in the way we can focus the radiation from many different directions. We can focus so precisely that we minimize the spillover radiation to healthy surrounding organs."

Keeping the radiation contained just to cancerous areas means fewer side effects; in the past, many patients who received radiation to the chest experienced such damage to the esophagus that they could not swallow without difficulty and needed temporary feeding tubes. "Since implementing focused radiation techniques for lung cancer at Stanford I've never had to place a feeding tube in a patient," Loo said. "That's a dramatic change from the past."

The newer radiation machines can also deliver more radiation in a short period of time, which reduces the number of dosage sessions. But that intensity of dose makes it all the more important that the target is hit accurately. "In the lungs we're aiming at moving targets," Loo said. "That's a technical challenge. We have to be able to see how the tumors are moving—and advances in imaging technology allow us to do that. We can make three-dimensional moving pictures so we can adjust the radiation beams to turn on only at a certain portion of the breathing cycle, and we can track tumors as they move."

In the past, Ricciardi might have received just radiation or just chemotherapy; by treating him with both at the same time, he became someone who represents "the best outcomes we've seen to date," Loo said.

A solid future

Even in the short time since Ricciardi's treatment was completed, new advances have become available. If he arrived at Stanford now, his cancer cells would be analyzed with greater molecular detail and typed for their response to chemotherapies designed to attack certain gene mutations or cellular growth factors. "We now know that almost every tumor is going to have one of these specific molecular changes," Wakelee said, "and as we get smarter, and add more knowledge, we're able to define that in more and more patients."

Ricciardi is still rather amazed at his survival, now four years since completing radiation and chemotherapy. "The echo of that guy's voice still rings in my ears," he said. "I haven't done any victory dances, but I did get a reprieve for however long that might be—and it's given me so much."