Remembering Bob Dole and Understanding Lung Cancer

Two sentences, in February 2021

Bob Dole was 97 when he wrote them. "Recently, I was diagnosed with stage four lung cancer. My first treatment will begin on Monday." He added that he faced significant health challenges, and that in doing so he joined millions of other Americans.

The American Cancer Society replied with a short public note wishing him well as he began treatment. He died on December 5, 2021, at the age of 98. The Elizabeth Dole Foundation announced his death and said he had died early that morning in his sleep.

He never said which type of lung cancer he had, and no further medical detail was released. This article stops at what he disclosed, and turns to what the words "stage four lung cancer" mean for anyone who hears them.

What stage four means

Staging describes how far a cancer has traveled, not how fast it grows or how a person feels. For lung cancer, doctors use the TNM system, which grades the tumor, the lymph nodes, and distant spread. Stage IV is the distant-spread category, and NCI divides it three ways.

M1a means the disease has stayed inside the chest but crossed a boundary. There may be a separate tumor nodule in the opposite lung, nodules on the lining of the lung or heart, or fluid around either organ containing cancer cells.

M1b means a single deposit outside the chest, in one organ.

M1c means several deposits outside the chest, either in one organ or in more than one.

Those distinctions matter because they change what treatment can realistically achieve. NCI says distant disease may be treated with systemic therapy, meaning chemotherapy, immunotherapy, or targeted drugs, with radiation used to relieve symptoms.

Which lung cancer, and why the label matters

Two families of lung cancer exist, and knowing which one is present drives every decision that follows.

Non-small cell lung cancer is the larger group. NCI breaks it into adenocarcinoma at roughly 40 percent of cases, squamous cell carcinoma at about 25 percent, and large cell carcinoma at about 10 percent.

Small cell lung cancer accounts for about 15 percent of lung cancers arising in the airways. It is staged differently, as limited or extensive disease, and about 70 percent of cases are already extensive when found. NCI reports median survival of 6 to 12 months for extensive-stage disease with treatment, and 2 to 4 months without it.

NCI is firm that an experienced lung cancer pathologist must review the tissue, because sorting small cell from non-small cell disease changes the entire plan.

What treatment involves at this stage

For advanced non-small cell disease, tumor tissue is now tested for changes in specific genes. NCI lists EGFR, ALK, BRAF, ROS1, RET, NTRK, MET, KRAS, and HER2 among the targets. ALK fusions appear in 3 to 7 percent of unselected cases, and EGFR changes are most common in adenocarcinomas in people who never smoked. Where a match exists, a targeted pill may be used instead of, or before, chemotherapy.

Immunotherapy, which enlists the immune system against the tumor, and chemotherapy are the other main systemic options. Radiation therapy is used to shrink deposits that cause pain, bleeding, or blocked airways.

The realistic goal at stage IV is control of the disease and relief of symptoms. Being clear about that at the start is not defeatism, and it is what allows a person to weigh treatments against how they want to spend their time.

Palliative care runs alongside, not after

NCI defines palliative care as care meant to improve quality of life for people with a serious or life-threatening illness. Two facts about it are widely misunderstood.

It can start at any point, including the day of diagnosis, and it runs at the same time as cancer treatment. It is delivered by a team that may include doctors, nurses, dietitians, pharmacists, therapists, chaplains, psychologists, and social workers.

Hospice is different. NCI says hospice care begins when curative treatment is no longer the goal and quality of life is the sole focus.

When to get checked

Age makes this harder, because breathlessness, fatigue, and a nagging cough all get written off as getting older. They should not be.

See a doctor about any of these:

• A cough lasting more than three weeks, or a long-standing cough that has changed.
• Coughing up blood, even a small amount, even once.
• Breathlessness doing something you managed six months ago.
• Chest, shoulder, or back pain that does not settle.
• Hoarseness lasting more than three weeks with no cold behind it.
• Repeated chest infections, or weight loss you did not intend.

Screening applies to a defined group. The US Preventive Services Task Force recommends annual low-dose CT for adults aged 50 to 80 with a 20 pack-year smoking history who still smoke or quit within the past 15 years. Twenty pack-years is roughly a pack a day for 20 years. Screening stops after 15 smoke-free years, or when other health problems would rule out surgery.

The numbers, and their limits

The American Cancer Society projects 229,410 new lung and bronchus cancers and 124,990 deaths in the United States in 2026, figures SEER reprints. That is 10.8 percent of new cancer diagnoses and 20.0 percent of cancer deaths.

Stage at diagnosis drives outcomes. Counting people diagnosed between 2016 and 2022, five-year relative survival is 65.5 percent for localized disease, 38.2 percent for regional spread, and 10.5 percent for distant disease. Around half of cases, 51 percent, are already distant when found.

These figures come from large groups of people diagnosed in earlier years, some before current targeted and immune treatments existed. They describe populations. They do not tell one person what to expect, and Bob Dole's own course is not a template for anyone else's.

Sources

• https://www.cancer.gov/types/lung/hp/non-small-cell-lung-treatment-pdq
• https://www.cancer.gov/types/lung/patient/non-small-cell-lung-treatment-pdq
• https://www.cancer.gov/types/lung/hp/small-cell-lung-treatment-pdq
• https://www.cancer.gov/about-cancer/advanced-cancer/care-choices/palliative-care-fact-sheet
• https://seer.cancer.gov/statfacts/html/lungb.html
• https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening
• https://www.nbcnews.com/politics/politics-news/bob-dole-diagnosed-stage-4-lung-cancer-n1258241
• https://kansasreflector.com/2021/12/05/bob-dole-kansas-political-icon-dies-at-98-after-battle-with-lung-cancer/
• https://pressroom.cancer.org/bob-dole