Lung Cancer Flashcards
Risk Factors
Essentially a preventable disease with ___
abstinence
smoking
Etiology
EGFR mutations can predict ___ to TKI therapy
- ___ mutations: Resistance to therapies
- Present more in females, Asians, never smokers
K-RAS mutations
- K-RAS mutations predict ___ to TKI
- In adenocarcinomas, mutations are exclusive to ___
ALK inhibition (Anaplastic lymphoma kinase)
- Present: No/light smokers, younger age, adenocarcinoma
– Less sensitive to ___ inhibitors and chemo
ROS-1 mutations:
- Encodes a receptor kinase related to ___
- Present: Never smokers/light smoker, adenocarcinomas, younger pts
BRAF V600E:
- Typically, current or former ___
– Recommended to test in 1st line metastatic setting for ___
PD-L1 status
- Testing is not recommended for ___
- Recommended to test status in 1st line, metastatic setting
- sensitivity
- T790M
- resistance
- smokers
- EGFR
- ALK
- smokers
- NSCLC
- SCLC
T or F: Patients with EGFR mutations, ALK or ROS-1 rearrangements typically don’t have PD-1 expression
T
Histologic Classification - NSCLC
adenocarcinoma
- Most common in ___
- Tend to be located peripherally in the lung
squamous
- Clearly related to ___
- Tend to be located centrally in lung
large cell
- Tend to be located peripherally in the lung
- Tend to be a diagnosis of exclusion
- non smokers
- smoking
Histology - SCLC
small cell
- Related to ___
- ___ growing and rapidly progressive
- Can have presence of paraneoplastic
syndromes
- smoking
- fast
Comparing SCLC and NSCLC
Small Cell Lung Cancer
- Clear relationship to ___
- ___ syndromes common
- ___ cell growth fraction
- ___ sensitive to radiation and
chemotherapy
- ___ present with metastases
Non-Small Cell Lung Cancer
- ___ growth fraction
- ___ sensitive to radiation and chemotherapy
- ___ present with metastases
- smoking
- paraneoplastic
- rapid
- highly
- 2/3
- slower
- moderately
- 50%
Staging: SCLC
___ stage:
* Tumor is confined to hemithorax and contained in a radiation port
___ stage:
* Tumor not confined to hemithorax of origin, not contained in a
radiation port, distant metastasis
- limited
- extensive
T or F: Surgery is an option for SCLC
FALSE
Surgery is generally not a therapeutic option
SCLC Limited Stage Disease
- ___ intent
Combined modality:
- Radiation + combination chemo
- ___ + ___ (EP) for 4 - 6 cycles
- Radiation is daily for 6 - 7 weeks
- Best results if radiation is given concurrently with cisplatin
- Maintenance chemotherapy is of no value
– ___ does not play a role in therapy
- Prophylactic cranial ___ should be strongly considered for patients obtaining a complete response
- More than 50% of patients will develop brain
metastases
- curative
- cisplatin, etoposide
- surgery
- radiation
Extensive Stage: SCLC
- Rarely ___
- Treatment can prolong survival 9 - 11 months
- ___ based combination chemotherapy without ___ is preferred
- Cisplatin or carboplatin-based combination with ___ or ___
Use to be no maintenance chemotherapy but
now it is standard of care
- curable
- platinum, radiation
- etoposide, irinotecan
Extensive Stage: SCLC
Chest radiation does not improve results - pallative
Prophylactic cranial radiation if a patient achieves a response in the chest
if brain metastases are present, whole brain radiation therapy should be given
- If a patient is symptomatic, whole brain radiation should be started ___ to chemotherapy
- If asymptomatic, initiate radiation therapy ___ chemotherapy
- prior
- after
Immunotherapy: Extensive Stage
First-line therapy: IMpower133 trial
– ___ + Carboplatin + Etoposide
First line therapy: CASPIAN trial
– ___ + Carboplatin + Etoposide
- Atezolizumab
- Durvalumab
Small Cell Lung Cancer - Complications of therapy
Most cisplatin-based regimens:
- Serious chemotherapy-induced ___ , nephrotoxicity, ototoxicity and ___
- Radiation therapy may cause fatigue, esophagitis, radiation pneumonitis, and cardiac toxicity
- N/V, neuropathy
PD-1 Inhibitors - metastatic SCLC
___ : Option for metastatic SCLC in patients who have progressed on or after platinum-based chemotherapy and at least 1 prior line of therapy
– ** ___ of PD-1 status**
pembrolizumab
- Regardless
Non-Small Cell Lung Cancer
- ___ sensitive to radiation and low
sensitivity to chemotherapy - ___ is the most efficacious modalities for treatment of NSCLC
- ___ therapy may be given for early- stage NSCLC when surgery is not able to be performed
- moderately
- surgery
- radiation
Treatment of NSCLC
1) determine is it is ___ , ___ or ___ / ___
- resectable
- unresectable
- advanced/metastatic
Resectable NSCLC
1) Neoadjuvant - ___ plus
a ___ doublet should be considered in those with tumors ≥ 4 cm or node positive and no contraindications to immune checkpoint inhibitors
2) surgery
3) Adjuvant chemo is considered standard of care (Chemotherapy will be decided based on ___ - squamous versus non-squamous)
- nivolumab, platinum
- histology
NSCLC Adjuvant Options
non-squamous
- Cisplatin + ___
Preferred (squamous)
- Cisplatin + ___
- Cisplatin + ___
other:
- Cisplatin + Vinorelbine
- Cisplatin + Etoposide
if unable to tolerate cisplatin, do ___
- Pemetrexed
- Gemcitabine
- Docetaxel
Additional NSCLC Adjuvant Options
- ___ for ALK mutations
- ___ for EGFR mutations (exon 19 deletion, exon 21 L858R)
- ___ for high risk, PD-L1 ≥ 1% and no mutations
- ___ for high risk and no mutations
- alectinib
- osimertinib
- atezolizumab
- pembrolizumab
Unresectable NSCLC Treatment
Stage IIIB/IV
- Treatment is considered ___
Optimal regimen has not yet been defined - no difference in overall survival between these groups
* Cisplatin/paclitaxel
* Cisplatin/gemcitabine
* Cisplatin/docetaxel
* Carboplatin/paclitaxel
palliative
Stage III Unresectable: Immunotherapy
___ :Now an option for patients who aren’t candidates for surgery or definitive
chemotherapy with radiation
* PD-L1 ≥ 1%
Pembrolizumab
Immunotherapy Maintenance: NSCLC Unresectable
___ :Received accelerated approval for
unresectable, stage III NSCLC with disease that has not progressed following concurrent chemotherapy and radiation therapy
- Maximum of ___ months of therapy
Durvalumab
12
Treatment of Advanced NSCLC
need to determine histology
1) ___
2) ___
3) ___
- adenocarcinoma
- squamous
- other
Treatment of Advanced NSCLC - adenocarcinoma
If a patient has a targetable mutation and
is PD-L1 (+), it is preferred to use the oral
therapies first and then move to ___ later
- Guidelines recommend to check mutation
status for all advanced/metastatic
adenocarcinoma lung cancers
- immunotherapy
Treatment of Advanced NSCLC - adenocarcinoma
EGFR Targeting Therapies
- ___ 1st line (T790M mutation)
BRAF Therapies
- ___ + ___
K-RAS G12C Mutation
- ___
- Osimertinib
- dabrafenib, trametinib
- Sotorasib
NSCLC Treatment-Metastatic Disease - adenocarcinoma
If no mutation Or if targeted oral chemotherapy options have been exhausted for a positive mutation, check ___ status
PD-L1
pembrolizumab therapy
PD-L1 positivity of ≥ 1% will allow use of
NSCLC Treatment Metastatic Non-squamous
Mutation negative NSCLC:
- New standard with ___ + ___ + ___ for 1st line non-squamous
- carboplatin
- pemetrexed
- pembrolizumab
NSCLC Treatment Metastatic: Squamous
Platinum based doublet has been the
standard
- ___ is typically combined with:
* Gemcitabine or
* Paclitaxel or
* Nab-paclitaxel or
* Docetaxel
New standard with 3 drug regimen
* ___ + ___ + ___
- Carboplatin
- Pembrolizumab + Carboplatin + Paclitaxel
- or Albumin-paclitaxel
- Difference seen regardless of PD-1 status
NSCLC Treatment Metastatic: Squamous
Next Line of Therapy
- Tyrosine kinase inhibitor (if positive)
- Immunotherapy (if not previously given) or
non-platinum chemotherapy
Agents:
– Nivolumab, Atezolizumab, or Pembrolizumab
- Pembrolizumab requires PD-L1 ≥ 1% for single agent use
Other single agents:
– Pemetrexed, Paclitaxel, Docetaxel, Gemcitabine,
Vinorelbine
Patients may not be able to tolerate
additional therapy
– Poor response, rapidly progressing
– Performance status
– Symptoms
Immunotherapy Toxicities
Safety:
- Rare and serious immune mediated toxicities:
* Pneumonitis
* Colitis
* Hepatitis
* Nephritis
* Endocrine (thyroid and pituitary)
Screening
Can consider screening in patients considered
to be at high-risk:
Age ___ - ___ , have a 30-pack year history of smoking and are still smoking or have quit within the last 15 years, good health, and willing to have curative lung surgery if
detected
- 28% increase of lung cancer with ___
- 55-74
- beta carotene
