30. Non-operative Management of Lung Cancer

Question 1

What does lung cancer lead?

Answer 1

Most Common Malignancy

Leading cause of Cancer-related mortality

Question 2

How many cases were estimated worldwide in 2012?

Answer 2

1.8 Million

Question 3

What percentage of lung cancer is non-small cell?

Answer 3

~85%

• Squamous 30%
• Adenocarcinoma 55%
• Large cell undifferentiated ~5% and others ‘not otherwise specified’ or NOS <10%

Question 4

What percentage of lung cancer is small cell?

Answer 4

~15%

- Oat cell

Question 5

What are the there histological subtypes?

Answer 5

Non small cell
Small cell
Pleural mesothelioma: Epitheliod; Sarcomatous; Biphasic

Question 6

What is the doubling time for Non-small cell lung cancer?

Answer 6

~129 days

Question 7

What does stage IV mean?

Answer 7

Metastases (M!0

Question 8

What does T, N and M stand for?

Answer 8

Tumour size (T)
Mediatinal/Other major structure invasion
Nodal involvement  (N)
Distant Metastases (M)

Question 9

What percentage is operable.resectable?

Answer 9

Max 25%

Question 10

What are the results and therapeutic options?

Answer 10

Tumour type; stage; ECOG performance status; patient wishes and options; aims of therapy (curative or palliative)

• Surgery
• Radiotherapy - curative (radical) or palliative
• Chemotherapy
• Combination of above?
• Targeted therapies

Question 11

What are the performance status measurements?

Answer 11

0 = asymptomatic; well
1= symptomatic; able to do light work
2= has to rest but for <50% of the day
3= has to rest for >50% of the day
4= bedbound

Question 12

What are essential pieces of information used to determine optional therapy?

Answer 12

Pathology
Stage
PS

Question 13

What does surgical survival depend on?

Answer 13

Stage

Question 14

What percentage of people worldwide are diagnosed at a stage that it is possible for cancer?

Answer 14

15%

Question 15

What is adjuvant therapy?

Answer 15

IALT meta-analysis

Resected as much as possible

Question 16

What is neoadjuvant therapy?

Answer 16

LU22 and meta-analysis

Question 17

What does postoperative (adjuvant) chemotherapy do?

Answer 17

Increase the chance of a cure

Question 18

What does Stage 3: Preoperative chemotherapy demonstrate?

Answer 18

Very significant survival damage

But no proven long term benefit

Question 19

What percentage of patient have advanced disease?

Answer 19

~80% of patients

• Stage III ~30% locally advanced: mediastinal/major vessel invasion or mediastinal nodes involved
• Stage IV ~60%: distant metastases

Question 20

What is treatment decisions affected by?

Answer 20

Affected by co-morbid disease eg. angina, COAD

Question 21

What is really important before radial radiotherapy?

Answer 21

Pulmonary function test

Question 22

What are the facts about Radical RT?

Answer 22

Dose 55Gy +
No. of fractions? eg. 30 versus 36 in 12 consecutive days  in CHART study
5-year survival rate around 20%
Delays in access to RT machines?
Pulmonary function tests essential

Question 23

What are the facts about Chemo RT?

Answer 23

Chemo is systemic treatment
Survival better than with RT alone (median survival 9/12 versus 13/12)
Concurrent more toxic; better?
No standard chemo. regimen 
2-year survival ~27%

Question 24

What are the facts about Stage IV NSCLC?

Answer 24

Incurable
Palliation essential
RT to primary tumour ~70% symptom benefit
Chemo gives equal symptomatic benefit AND survival advantage
Median survival now >12 months with chemo alone

Question 25

What are 3 cycles of chemo as good as?

Answer 25

6 cycles

Question 26

What is given if they have painful bone metastases?

Answer 26

RT

Single fraction

Question 27

What is given if they have Brain metastases?

Answer 27

Resection
RT
Steroids
or Erlotinib?

Question 28

What are the signs for bone metastases?

Answer 28

Any site; often worse at night
Pathological fracture (may be presenting symptom)
Orthopaedic surgeons
Neurosurgeons (cord compression)
Palliative RT

Question 29

What must be worked out?

Answer 29

Molecular biology of patient as target drugs can be given to help

Question 30

What do the majority of tumour cells do?

Answer 30

Produces PD-L1 (Program death ligand 1)

Nivolumab BMS blocks the binding of PD-1 to PD-L1
and PD-L21

Question 31

What does this do to the activity of T-lymphocytes?

Answer 31

Potentiates activity preventing them from being inactivated

Question 32

What are they facts about Small cell lung cancer?

Answer 32

~15% of patients
Doubling time: 29 days
Presentation identical but note secretory syndromes eg. SIADH (low sodium – confusion), ACTH (Cushings)
Staged to one hemithorax LD (limited disease); 30% patients
More advanced disease is ED (extensive disease)

Question 33

What is the treatment of choice for SCLC?

Answer 33

Chemotherapy treatment of choice

Very treatment sensitive

Question 34

What is there no advantage in treatment from in SCLC?

Answer 34

High dose chemo
Alternating chemo
Maintenance chemo
Chemo ‘on demand’
Maintenance Interferon, MMPI, targeted therapies

Question 35

What is the current status of lung cancer?

Answer 35

~80% patients are still diagnosed too late to cure
Educate public/remind GPs about improvements in treatment
Minimise waiting times
Exciting new drugs are available
<6% treated in a trial of new agents/approache

Question 36

What are possible improvements in the status of Lung cancer?

Answer 36

Multi Disciplinary Team (MDT) meetings
Specialist nurses
Networks and National Cancer Research Institute (NCRI)
Smoking ban
Screening???

Question 37

What are the outcomes in ED?

Answer 37

MS no treatment ~8 weeks

MS with treatment ~8 months