CANCER- LUNG CANCER

Question 1

Smoking is a big cause of lung cancer, it causes over ____% of cases.
Period of time smoking / number of cigarettes smoked a day- which is more important?
Stopping smoking immediately reduces the risk of lung cancer: after ____ years the risk is the same as that of a non smoker

Answer 1

Smoking Causes over 90% of lung cancers

Period of time smoking is more important in causing it

Stopping smoking: after 15 years risk is the same as a non smoker

Question 2

What are the risk factors of lung cancer??

Answer 2

Smoking
Passive smoking
Asbestos exposure (plumbers etc) 
Radon gas exposure 
Previous lung disease
Family history (but not as strong link as breast cancer)

Question 3

Which is more common, Small cell lung cancer (SCLC) or Non small cell lung cancer (NSCLC)?

Answer 3

Non small cell lung cancer = 80% of all cases

Question 4

In terms of their pathology, what’s the different between NSCLC and SCLC??

Answer 4

SCLC consists of small cells that are uniform

NSCLC consists of several different types of cells, may be squamous cell, adenocarcinoma, large cells

SCLC is usually Metastatic at diagnosis (I.e usually already spread)

Question 5

In terms of their treatments, what’s the different between NSCLC and SCLC??

Answer 5

Surgery is more often used with NSCLC, it has limited use in SCLC.

SCLC responds well to chemotherapy and radiotherapy, whereas NSCLC is less responsive to this

Question 6

Where can NSCLC metastasise to??

Answer 6

Brain liver and bones

But remember it’s SCLC that’s usually metastasised at diagnosis

Question 7

What are the symptoms of lung cancer??

Answer 7

Note: There are no symptoms in the early stages and symptoms appear later due to tumour causing pressure, pain or obstruction.

Persistent chronic cou
SOB
Wheezing 
Haemoptysis (coughing up blood) 
Chest, shoulder or back pain 
Weight loss
Fatigue

Question 8

How do we usually diagnose lung cancer?

Answer 8

Chest x ray- early diagnosis usually found on routine chest x rays (I.e. Patient doesn’t think they have cancer at this point as no symptoms in early stages)

Bronchoscopy and biopsy (tube placed down into trachea to take a biopsy)

Sputum cytology- testing peoples flem

CT scan: can be used to look for metastases

Question 9

Limited stage disease : cancer confined in one side of chest. Involved Lymph nodes can be treated with radiotherapy.

Extensive stage disease: cancer has metastised to distant organs.
Which type of lung cancer are these stages of ?

Answer 9

SCLC

Either limited stage disease or extensive stage disease

Question 10

How is NSCLC staged?

Answer 10

By stages I- IV

Or can use TNM system seen in breast cancer

Question 11

What is the usual treatment pathway for SCLC?

Answer 11

Good initial response to chemotherapy but a lot of patients relapse

If they have at least 6 months with the cancer being stable they will be retreated with the same chemo regimen again as we know that has worked for them.

If relapse happens In under 6 months then look to second line chemo or “best supportive care” used when patients unfit/ unsuitable for other therapies.

Question 12

What are the first line drugs in chemotherapy for SCLC??

Answer 12

Carboplatin plus etoposide

Question 13

Radiation can be used in SCLC.
The radiation dose is limited as the thorax contains many sensitive vital organs.
When is radiation usually used in SCLC??

Answer 13

Used in combination with chemotherapy in limited (early) stage SCLC. Better than using chemotherapy alone.

Can be used palliatively to control symptoms such as bone pain and large airway narrowing in advanced disease.

Radiation is Usually used post surgery as an adjuvant to eradicate any cells not removed in surgery.

Also used In patients not suitable for surgery.

Question 14

When can surgery be used in treatment of NSCLC??

Answer 14

Only in NSCLC
For stages I and II disease
(Occasionally in stage IIIa disease when tumour is shrunk by chemotherapy first)

Question 15

Surgery for NSCLC involves either an lobectomy or a pneumonectomy. What are these??

Answer 15

Lobectomy: most common, remove the affected lobe of the lung

Pneumonectomy: remove the entire lung. High rate of mortality, long term debility. Only for patients who have good pre-op performance

Question 16

Chemotherapy can be used as an adjuvant therapy post surgery (in stage 1 and 2 NSCLC) to eradicate any cells that weren’t removed in surgery. This involves using a ______ based chemotherapy regimen.
We can also use chemo in stage 3 and 4 NSCLC to improve survival and symptoms. What combo of chemo drugs does this involve using?

Answer 16

Using cisplatin based chemo in stage 1 and 2

Use cisplatin in combo with pemetrexed in ADENOCARCINOMA in stage 3 and 4 disease.

Question 17

Chemotherapy can also be used as a neo-adjuvant (before surgery) to shrink the tumour in NSCLC.

Answer 17

This means less extensive surgery is needed
Eradicates any small metastases at the start of treatment.

Not sure whether neo-adjuvant (before surgery) or adjuvant (after surgery) is superior.

Question 18

How common is lung cancer??

Answer 18

Second most common cancer in the UK (following breast cancer)
Most common cancer world wide

Incidence peaks between 75 and 85 years old

Question 19

An example chemotherapy regimen for NSCLC involves CISPLATIN (IV infusion) And VINORELBINE (IV stat)
This requires an inpatient stay in hospital as they will need rehydration. Why do they require this??

Answer 19

Cisplatin is nephrotoxic
They’ll do a lot of weeing
So need to stay in hospital to get fluids pumped in

NB: vinorelbine is a vinca alkaloid

Question 20

What are the side effects of the cisplatin and vinorelbine Chemotherapy regimen used in NSLC?

Answer 20

Nausea and vomiting
Bone marrow suppression 
Mucositis (pain and inflammation of the mucous membrane lining the digestive tract) 
Constipation 
Alopecia
Peripheral neuropathy (tingly fingers and toes: comes from vinorelbine as it's a vinca alkaloid) 
Nephrotoxicity 
Ototoxicity (hearing loss and tinnitus)

Question 21

What are the pharmaceutical care issues with the chemotherapy regimen cisplatin + vinorelbine used in NSCLC?

Answer 21

Need to check Full Blood Count
Need to check renal function before treatment as eGFR must be over 55. Cisplatin is nephrotoxic so doses need to be reduced.

Ensure that anti-emetics have been prescribed

Ensure that pre and post HYDRATION has been prescribed- before and after cisplatin; 3L of IV fluids

Measure urine output as it needs to be over 100ml per hour during and for 6 -8 hours post cisplatin administration. If it’s not then patient may need diuresis.

Question 22

In the chemotherapy treatment of NSCLC, We need to monitor patients for cisplatin induced wasting of ______. Patients May need supplements.

Answer 22

Cisplatin induced Wasting of electrolytes

Question 23

Why must Vinorelbine be diluted ? (Used in chemotherapy for NSCLC)

Answer 23

Because in the past it’s been injected into the spine and vinca alkaloids are lethal if done, if it’s 50mls then they won’t attempt this so mistake won’t be made again!!

Question 24

What is the name of the oral agent that is a targeted therapy for NSCLC?

Answer 24

Gefitinib!!

Question 25

How does Gefitinib work??

Answer 25

It’s a selective inhibitor of the EGF receptor Tyrosine Kinase!!
(EGFR-TK)
This means it blocks the signal pathway involved in cell proliferation.
If you remember back to Christine’s stuff, the EGFR has a tyrosine kinase domain that undergoes and conformational change and receptor dimerisation when the EGF binds.

This dimerisation stimulates kinase active and activating signal transduction pathways and downstream signalling proteins.
So stopping this results in less signalling, less cell proliferation, slower growth of the cancer

Question 26

Gefitinib is recommended by NICE as an option for first line treatment in patients with locally advanced or metastatic NSCLC. But only if they test positive for what?? And what is the other criteria that must be met?

Answer 26

Positive For EGFR tyrosine kinase MUTATION.

Also only if the manufacturer provides Gefitinib at the fixed price agreed under the patient access scheme (where it’s paid for at end of third month, but doctors won’t stop treatment before the third month so everyone ends up paying!)

Question 27

What is erolitinib ?

Answer 27

A new therapy used for NSCLC

It’s licensed first line for locally advanced metastatic NSCLC or 2nd line after failure of previous chemo

It’s also oral

Question 28

How does eroltinib work?

Answer 28

It’s targets and inhibits the tyrosine kinase region of the EGF receptor. (Just like Gefitinib!)

This blocks signalling pathways and cell division and proliferation

Question 29

So we know eroltinib and Gefitinib are both EGFR-TK inhibitors. Eroltinib is the newer version, what’s the difference?

Answer 29

Eroltinib (newer agent) Suggested to be more efficacious.

Eroltinib is the only agent licensed for treatment of locally advanced or metastatic NSCLC after failure of at least one prior chemotherapy regimen.

Question 30

What can erolitinib now be used as an alternative to SECOND line? Why?

Answer 30

NICE now approves eroltinib as an alternative to docetaxel SECOND line in treatment of NSCLC for locally advanced or metastatic NSCLC.

This is because Roche (drug company) agreed to provide eroltinib at the same price as docetaxel, so now either treatment can be used.

Question 31

What are the side effects of EROLTINIB??

Answer 31

Acne like skin rash (good sign as it shows patients are responding to the treatment)
Diarrhoea

Eroltinib is generally well tolerated.

Question 32

When can radiotherapy be used for NSCLC in terms of measurements of the tumour?

Answer 32

Tumour must be under 3cm

Radiation dose given to tumour and 2cm around it

It’s the treatment of choice for early stage NSCLC (stages 1-3) in patients who are not suitable for surgery.

Question 33

How do we work out the number of pack years a patient has smoked?

Answer 33

Number of pack years= number of packs per day X number of years smoking

where 1 pack = 20 cigarettes

Question 34

What treatment can patients receive if the test EGFR-TK mutation positive?

Answer 34

Gefitinib