Lung Cancer Flashcards
*What is the #1 cause of lung cancer?
What are the #2 and #3 causes of lung cancer?
cigarette smoking!
Radon
Asbestos exposure
*Which type of cancers are most associated with smoking?
squamous cell
small cell
What is the average age of diagnosis of lung cancer?
70
T/F the risk of lung cancer decreases with age
false
Increases with age
There is an 80-90% reduction in risk for lung cancer after _____ years smoking cessation
15
*What is the only prevention for lung cancer?
Smoking cessation
*When is screening recommended for lung cancer and what?
annual low-dose CT imagining for HIGH risk patients
*Who are high risk patients for lung cancer?
- Age 55-77
- > /= 30 pack year history
- Smoking cessation < 15 years
S/S of lung cancer
chest pain, cough, hoarseness, weight loss, dyspnea
T/F most lung cancer is metastatic disease at diagnosis
True!
NSCLC 55%
SCLC 66%
Where does lung cancer like to travel? (4)
- brain
- bone
- liver
- adrenal glands
S/S of distant spread in lung cancer
Neurologic deficits
Bone pain
Jaundice
Common paraneoplastic syndromes in SCLC
- SIADH
- Cushing’s syndrome
- Eaton-Lambert Syndrome
Common paraneoplastic syndromes in NSCLC
Hypercalcemia
Other S/s of paraneoplastic syndromes in lung cancer
nail clubbing
hypercoagulability
What can be used for diagnosis in lung cancer surgical candidates?
Chest X ray
Chest CT
PET scan
Why is molecular testing done in lung cancer?
establish prognosis and treatment course
How do you confirm diagnosis in lung cancer?
tissue biopsy
*T/F SCLC is more common than NSCLC
false!
80-85% = NSCLC
*T/F SCLC and NSCLC are rapid growing
False!
SCLC = rapid
NSCLC = slow
*What are the 3 histologic subtypes of NSCLC?
- Adenocarcinoma (40%)
- Squamous cell (30%)
- Large cell (10%)
What are the 2 stages for SCLC?
Limited stage
Extensive stage
Limited stage in SCLC
tumor confined to 1 radiation field
stage I-III
Extensive stage in SCLC
Multiple lung nodules or distant spread
Stage IV
T/F surgery is the mainstay treatment in SCLC
False!
It is a fast growing tumor, so has limited role!
What is definitive treatment for limited stage SCLC?
radiation
Radiation in extensive stage SCLC
palliation of symptoms
T/F maintenance therapy of chemo is used in limited stage and not extensive stage
false!
only in extensive stage!
*Treatment for limited stage SCLC
cisplatin + etoposide + radiation
*Treatment for extensive stage SCLC
Same as limited + CPI
CPI = atezolizumab or durvalumab
*What 2 check point inhibitors are used in extensive stage SCLC?
atezolizumab
durvalumab
*Treatment for relapse <6 months in SCLC
Topotecan or clinical trial
*Treatment for relapse >6 months in SCLC
Use original regimen
Carboplatin dosing
use Calvert equation
based on AUC
Squamous cell NSCLC is more common in who?
Male, smokers
Adenocarcinoma NSCLC is more common in who?
Women, non-smokers
What is staging based on in NSCLC?
TNM system
Testing for KRAS is important for what in NSCLC?
predicts resistance
Testing for EGFR is important for what in NSCLC?
predicts response to EGFR TKIs
What is a common EGFR mutation in NSCLC?
T790M
ALK mutations in NSCLC are common in who?
97% adenocarcinoma
No/light smokers
Young age
Men
ROS-1 mutations in NSCLC are common in who?
Adenocarcinoma
No/light smokers
Women
What is the most common BRAF mutation in NSCLC?
V600E
Who are BRAF mutations in NSCLC common in?
Current or former smokers
T/F if you have a PD-L1 expression you typically have other rearrangements
False!
Typically do not
Same with BRAF!
*T/F surgery is the initial treatment for resectable tumors in NSCLC
True
Radiation in NSCLC
alternative to surgery or with chemo in stage III
Chemotherapy in NSCLC
can be in all stages but mainly in II-IV
*Non-squamous stage I-III treatment
cisplatin + pemetrexed
*Squamous cell stage I-III treatment
cisplatin + gemcitabine
cisplatin + docetaxel
*T/F pemetrexed can be used in any type of NSCLC
false!
NEVER in squamous cell
*Supportive care with pemetrexed and why given
folic acid: GI and myelosuppression
vitamin B12: GI and myelosuppression
dexamethasone: rash
Other ades of pemetrexed
nephrotoxicity
pulm toxicity
*Stage IV NSCLC what is the mainstay treatment?
chemo
*When deciding chemo in stage IV NSCLC what factors do you consider?
- performance status
- histology (squamous/non-squamous)
- molecular/biomarker testing
*PS 3-4 treatment NSCLC
best supportive care
PS 0-2 treatment
chemo
targeted therapy
immunotherapy
*Treatment (-) or unknown mutational status for non-squamous PS 0-2
pemetrexed + platinum +/- pembrolizumab
*carboplatin/cisplatin
(-) or unknown mutational status for non-squamous PS 0-2 maintenance therapy
Continuation maintenance
Switch maintenance: pemetrexed
Treatment (-) or unknown mutational status for non-squamous/squamous progressive disease PS 0-2
*immune checkpoint inhibitors (no previous PD-1/PD-L1 inhibitor)
only exception: NO pemetrexed in squamous!
*Bevacizumab indication in NSCLC
combo therapy for non-squamous NSCLC
*When do you hold bevacizumab?
4 weeks prior to elective surgery
at least 4 weeks after
BBW of bevacizumab
hemorrhage
GI perforation
wound healing complications
Other ADEs of bevacizumab
HTN: hold in uncontrolled
Proteinuria: hold if >/= 2 g/24 hours
*Treatment (-) or unknown mutational status for squamous PS 0-2
Platinum + 2nd agent
paclitaxel + carboplatin +/- pembrolizumb
carboplatin + gemcitabine (PS 2)
*In squamous cell carcinoma what drugs have NO role? (3)
pemetrexed
bevacizumab
atezolizumab
Negative or unknown mutational status for squamous PS 0-2 maintenance therapy
continuation maintenance switch maintenance (docetaxel)
*Treatment EGFR+ NSCLC
Osimertinib
*squamous or non-squamous
*Treatment EGFR+ NSCLC progression T790M+
Osimertinib
*Treatment EGFR+ NSCLC progression T790M(-)
Switch TKI agent
*Which EGFR inhibitors are used in NSCLC?
OAGED
Osimertinib Afatinib Geftinib Erlotinib Dacomitinib
*T/F all of the EGFRs in NSCLC are oral
true
Class reactions of EGFRs
rash
diarrhea
Which EGR has risk of QT prolongation?
Osimertinib
When would you reduce EGFR dose in rash?
severe!
*Treatment ALK rearrangement NSCLC
Alectinib
*squamous or non-squamous
T/F you can use standard acne therapies for EGFR associated rash
false!
May worsen rash
*ALK inhibitors in NSCLC
ABCCL
Alectinib Brigatinib Certinib Crizotinib Loriatinib
ALK inhibitor class ADEs
hepatotoxicity (except briga) pulmonary toxicity (rare)
ADE of alectinib
photosensitivity
nephrotoxicity
ADE of brigatinib
arthralgia/myalgia
hyperglycemia, pancreatitis (IGF-IR)
ADE of certitinib
hyperglycemia, pancreatitis (IGF-IR)
MOLA of ceritinib
inhibits ALK, ROS1, IGF-IR
*Treatment ROS1 rearrangement + NSCLC
Crizotinib
Entrectinib
*squamous or non-squamous
*Treatment BRAF V600E+ NSCLC
Dabrafenib + trametinib
What type of drug is trametinib?
MEK inhibitor
*ADE of trametinib
retinal detachment
retinal vein occlusion
ADE of dabrafenib
fever
*Treatment PD-L1+ non-squamous NSCLC
PD-L1 >50%
pembrolizumb
*Treatment PD-L1+ non-squamous NSCLC
PD-L1 <50%
platinum + pemetrexed + pembrolizumab
*cis/carb
*Treatment PD-L1+ squamous NSCLC
PD-L1 >50%
pembrolizumab
*Treatment PD-L1+ squamous NSCLC
PD-L1 <50%
carboplatin + paclitaxel + pembrolizumab
T/F chemotherapy ADEs are usually acute onset and immunotherapy typically delayed onset
true!
ADE of immunotherapy
inflammatory or autoimmune effects
*any organ system involved
Common ADE of immunotherapy
dermatitis
colitis
endocrine toxicities
hepatitis
Life threatening ADE of immunotherapy
Neurologic effects
Cardiac toxicity
Pneumonitis
Colitis
Grade I ADE with immunotherapy tx
continue ICI
Grade II ADE with immunotherapy tx
hold ICI
resume at grade I
Grade III ADE with immunotherapy tx
Hold ICI
High dose steroids
Grade IV ADE with immunotherapy tx
Permanently discontinue ICI
High dose steroids
*High dose steroids for immunotherapy ADEs
prednisone/methylpred 1-2 mg/kg/day
taper over 4-6 weeks
