Lec 7: Lung Cancer Flashcards
Epidemiology: Lung Cancer
Clinical Presentation: Common symptoms, Metastatic symptoms, and Paraneoplastic Syndrome (small cell
lung cancer symptoms)
Common symptoms
- Cough
- Hemoptysis
- Chest pain
- Dyspnea
- Hoarseness
- Fatigue
- Weight loss
.
Metastasis
- Bone pain
- Lymph node swelling
- Jaundice
- Neurologic symptoms
.
Paraneoplastic Syndrome (small cell lung cancer)
- Syndrome of inappropriate antidiuretic hormone - eg. hyponatremia
- Cushing syndrome
- Neurologic syndrome
Risk Factors of lung cancer
- Smoking
- Second-hand smoking
- Radon exposure
- Occupational exposure
- Previous radiation therapy to the lungs
- Lung disease (COPD, pulmonary fibrosis)
- First degree relative with lung cancer
Screening . . . general … also how do you calculate Pack Year?
BR is a 65-year-old male presenting for a PCP routine visit. He is a former smoker who had quit smoking in two years ago and reports smoking 2 packs of cigarette per day for 10 years. Based on his smoking history, would the patient be eligible for low-dose CT screening?
A. No, patient is not indicated based on number of years smoking per USPTF
B. Yes, patient is indicated due to pack-year history and age per NCCN
C. Yes, patient is considered moderate-risk per NCCN and USPSTF
D. No, patient is a former smoker
Pack Year? 10 years x 2 packs per day = 20 pack years
.
Based off of pack year and patient’s age.. B!
Types of Lung Cancer (flowchart)
Focusing on Small Cell Lung Cancer first.
SCLC Staging
Just know that Stage I - III is limited stage and Stage IV is extensive stage (metastatic)
SCLC Initial Management
BR is a 65-year-old female recently diagnosed with extensive stage SCLC. Past medical history include hypertension, stage III CKD, and COPD. Which regimen is the most appropriate according to his past medical history and guideline recommendations?
A. Carboplatin + etoposide + atezolizumab
B. Carboplatin + irinotecan + durvalumab
C. Carboplatin + irinotecan + radiation
D. Cisplatin + etoposide + radiation
Patient is fraile haev has CKD/ renal dysfunction! so needs to use Carbo (instead of Cis). Patient also have EXTENSIVE STAGE SCLC …so for extended stage you use Carbo or Cis platinum agent (in this case you use Carbo) + etoposide + and immunotherapy !
.
The correct answer is A!
Platinum Agents used for lung cancer, their class side effects, and special considerations
1.) Cisplatin
- Hydration and electrolyte repletion required
- Ototoxicity
- generally better/ preferred over Carbo unless patient is frail or have CKD/ renal dys.
.
2.) Carboplatin
- Dosed by AUC via the Calvert Formula
- Thrombocytopenia
.
Class Side Effects
- Hypersensitivity reactions
- Nephrotoxicity (cisplatin > carboplatin)
- High emetogenic (cisplatin and carboplatin AUC > 4)
- Neuropathy
- Myelosuppression
Calvert Formula for Carboplatin dosing
BR is a 65-year-old female (Height 5’5”, Dosing Body Weight 120kg) recently diagnosed with extensive stage SCLC. Past medical history include hypertension, stage
III CKD (Scr 1.22), and COPD. The prescriber decided to start carboplatin (target AUC 5) + etoposide + atezolizumab. Calculate the patient’s carboplatin dose.
A. 750 mg
B. 310 mg
C. 560 mg
D. 435 mg
Patient is female so use female formula!
.
STEP 1: GFR: Female: 0.85 * (((140 – age) * (weight in kg)) / (72 * Scr))
.
0.85 * (((140-65)(120))/ (721.22))
0.85 * ((9000)/(87.84))
0.85 * 102.459 = 87.1
.
STEP 2: Carboplatin dose (mg) = AUC x [GFR + 25]
GFR Capped at 125 ml/min!!! (in this case 87.1+25 = 112 so no need to cap!)
.
AUC x [GFR + 25]
5 * (87.1 + 25) = 560mg - so ANSWER IS C
Etoposide -part of the initial regimen for SCLC…talk about MOA and AE
SCLC Second-Line Management
- Assess disease-free interval to guide treatment decision
- If patient has progressed on maintenance atezolizumab or
durvalumab, immune checkpoint inhibitor should not be used
.
-Disease-free Interval >6 Months After 1st Regimen ? SENSITIVE: Rechallenge the 1st regimen or similar platinum-based
regimen If there has been a disease free interval of at least 3-6
months, may also considered this approach
.
-Disease-free Interval <6 Months After 1st Regimen? NOT SENSITIVE TO FIRST TREATMENT SO YOU NEED TO SWITCH AGENT!
.
NOTE:
Knowing that the patient is not sensitize to the treatment received in the first-line setting is adequate. There is no preference in agent selection in the second line setting.
Non Small Cell Lung Cancer: Stage I-IIIA (Resectable Disease) - general guide lines
Observation would follow surgery in patients with IA – IB disease without high-risk features!
.
For IB high risk and IC patients, it would be adjuvant chemotherapy x 4 cycles and if those patients harbor the indicated EGFR mutation, then osimertinib is considered.
NSCLC: Adjuvant Chemotherapy Pearls
Non-squamous cell = adenocarcinoma and large
cell, otherwise not specified
Pemetrexed - key MOA and CI and special consideration
CANNOT USE IN SQUAMOUS CELLS !!!!!
Paclitaxel - key MOA and SE and special consideration
Stage IIIB (Unresectable Disease) - regimen guideline
Stage IV Metastatic or Advanced Disease - regimen guideline
PD-1 and PDL-1 Inhibitors AKA Programmed Death Protein 1 and Programmed Death Ligand 1 … drug examples? AE? Contraindication?
Bevacizumab (VEGFi) - MOA, SE, consideration
EGFR Inhibitors: Place in Therapy in Metastatic Setting, Oral Medications Options, Class Adverse Event
ALK Inhibitors: Place in Therapy in Metastatic Setting, Medications Options, Class Adverse Event
MET Inhibitors: Place in Therapy in Metastatic Setting, Medications Options, Class Adverse Event
ROS1 Inhibitors: Place in Therapy in Metastatic Setting, Medications Options, Class Adverse Event
BRAF V600E Inhibitors: Place in Therapy in Metastatic Setting, Medications Options, Class Adverse Event
NTRK Inhibitors: Place in Therapy in Metastatic Setting, Medications Options, Class Adverse Event
DISEASE PROGRESSION ONLY
EGFR Exon 20 Insertion Inhibitor: Place in Therapy in Metastatic Setting, Medications Options, Class Adverse Event
DISEASE PROGRESSION ONLY
KRAS G12C: Place in Therapy in Metastatic Setting, Medications Options, Class Adverse Event
DISEASE PROGRESSION ONLY
HER-2 Directed Antibody Drug Conjugate: Place in Therapy in Metastatic Setting, Medications Options, Class Adverse Event
