Lung cancer

Question 1

What are the two types of lung cancer? Briefly outline their differences

Answer 1

SCLC - 15% of cases, aggressive tumour, usually metastatic at diagnosis so surgery not usually involved, responds well to chemo.

NSCLC - most cases, several different types, surgery is more often used

Question 2

What are the symptoms of lung cancer?

Answer 2

Persistent chronic cough, SOB/wheezing, Haemoptysis (coughing up blood), weight loss, fatigue

Question 3

What can lung cancer often be misdiganosed as?

Answer 3

COPD

Question 4

How is lung cancer diagnosed?

Answer 4

Chest X-ray (to detect mass)
Biopsy (to determine type)
Sputum cytology
CT scan (to assess suitability for surgery and look at common sites of metastases)

Question 5

What are the common sites of metastases in lung cancer?

Answer 5

Liver, bones and brain

Question 6

What is meant by limited stage disease?

Answer 6

Cancer is confined to one side of the chest and involved lymph nodes can be treated with radiotherapy and chemo.

Question 7

What is meant by extensive stage disease?

Answer 7

Cancer has metastasized to distant organs, treatment involves pallative chemotherapy.

Question 8

When is surgery considered?

Answer 8

Only in NSCLC Stage I and II disease (occasionally for stage IIIa when tumour has shrunk by chemotherapy first)

Question 9

What is the most common type of lung cancer surgery?

Answer 9

Lobectomy

Question 10

What are common biomarkers in NSCLC that will affect the treatment of choice in advanced NSCLC?

Answer 10

ALK gene translocation

EGFR mutation

Question 11

If a patient has adenocarcinoma with ALK translocation what treatment would they be offered?

Answer 11

Crizotinib - oral ALK receptor inhibitor.

Question 12

If a patient has advanced NSCLC adenocarcinoma with no EGFR/ALK-positive mutations what is the treatment of choice?

Answer 12

1st line is cisplatin/pemetrexed chemotherapy 4-6 cycles.

Question 13

What pharmaceutical care issues are associated with the cisplatin/pemetrexed chemotherapeutic regimen?

Answer 13

need to monitor renal function
antiemetics needed
ensure pre and post hydration prescribed (3L IV fluids before and after)
Ensure urine output >100ml/hr during and for 6-8 hours afterwards. Diuretics might be needed to achieve this.
Monitor patient for cisplatin induced wasting of electrolytes (Mg, Ca and K supplements might be needeD)
Pemetrexed needs pre-med with vit b12 and folic acid. Also dexamethasone

Question 14

What pre meds must be prescribed with pemextrexed?

Answer 14

Vitamin B12 (hydroxycobalmin) 1mg IM in the week preceding the first cycle and then every 9 weeks until treatment is completed
Folic acid 400mg OD PO, should be started at least 1 week before first cycle and continued until 3 weeks after the last cycle.
Dexamethasone 4mg BD PO for 3 days starting the day before. 
Antiemetics as per the local guidelines.

Question 15

How do you calculate pack years?

Answer 15

No. of pack years = no. of packs per day x no. of years smoking

Question 16

What is the treatment of choice in patients with advanced NSCLC with EGFR mutation?

Answer 16

Afatinib/Gefitinib/erlotinib

Question 17

What is Pembrolizumab?

Answer 17

mAB that acts on the programmed death 1 protein (PD-1).

Question 18

When is pembrolizumab used?

Answer 18

NICE approved in Jan 2017 for PD-1 positive NSCLC - in adults who have had at least one chemotherapy (and targeted treatment if applicable)

Question 19

What is meant by WHO performance status?

Answer 19

An attempt to quantify cancer patients general well-being and activities in daily life. Runs from 0 (perfect health) to 5 (death)