Lung Cancer - Non-Surgical Management

Question 1

What does a narrowed bronchus indicate?

Answer 1

Lung cancer.
Check with a bronchoscopy.
A tissue diagnosis would be required, as well as a biopsy (EBUS, CT / US guided).

Question 2

What is a PET scan used for in lung cancer?

Answer 2

If the patient is having curative treatment.
Accurately stages LNs and extrathoracic disease.
If LN status is not clear, an EBUS or mediastinoscopy can be considered.

Question 3

What does the MDT discuss for lung cancer?

Answer 3

Cancer diagnosis -
Staging (based on CT/PET).
Tumour type (based on biopsy).
Patient history, wishes and fitness.
Performance status and pulmonary function tests.

Therapeutic options -
Curative or palliative? Supportive care only?
Radiotherapy, surgery, chemotherapy, immunotherapy (or a combination).

Question 4

What is SCLC in lung cancer?

Answer 4

Doubling time = ~21 days.
Less common than NSCLC, but similar symptoms (more association with secretory syndromes).

Limited - confined to one hemithorax.
Extensive - more advanced.

Question 5

What is SCLC limited disease?

Answer 5

CRT curative treatment, followed by PCI.
Cisplatin and Etoposide (multiple drugs).
No advantage from high dose / alternating / maintenance chemotherapy, or targeted therapies.
Second line therapy is suboptimal.

Question 6

What are statistics about SCLC limited disease?

Answer 6

Response rate = 90%.
Complete remission = 60%.
Median survival with treatment doubles, from 8 months to 16 months.
2YS = 25%.

Question 7

What is SCLC extensive disease?

Answer 7

4 cycles of combination chemotherapy, consolidated with thoracic RT.
PCI (prophylactic cranial radiation) is recommended.
Consider RT to palliate symptoms, if patients are not fit for chemotherapy.

Question 8

What are statistics about SCLC extensive disease?

Answer 8

Response rate = 80%.
Complete remission = 30%.
Median survival with treatment improves from 8 weeks to 8 months.

Question 9

What are the side effects of chemotherapy?

Answer 9

Marrow suppression.
Risk of life threatening infection.
Neutropaenic sepsis.
Nausea, vomiting, GI upset, mucositis, fatigue, lethargy.
Neuropathy, increased risk of MI/stroke, renal impairment.
Hair loss and nail changes.

Question 10

What are the side effects of radiotherapy?

Answer 10

General - lethargy, increased risk to surrounding organs.
Acute - pneumonitis, dysphagia.
Late - fibrosis, stricture, increased risk of MI, second malignancies.

Question 11

What are the side effects of immunotherapy?

Answer 11

Colitis, pneumonitis, dermatitis, endocrinopathies.

Question 12

What is the current status of lung cancer therapy?

Answer 12

~80% of patients are too late to cure.
Education of the improvement in treatment to the public and GPs.
New drug availability.
MDT meetings.
Specialist nurses.
Networks, NCRI, smoking ban, screening.

Question 13

What is screening for lung cancer?

Answer 13

Low dose CTs for at risk populations.
Logistical challenges include machine time, false positives, and follow ups on lung nodules.
Possibly combined with smoking cessation.

Question 14

What is NSCLC in lung cancer?

Answer 14

Doubling time = ~129 days.
TNM staging.
<25% are operable or resectable.

Question 15

What is NSCLC surgery?

Answer 15

Curative treatment.
Survival depends on stage (5YS = ~40%).
LN sampling is essential.

FEV1 > 1 for lobectomy.
FEV1 > 2 for pneumonectomy.

Question 16

What is NSCLC adjuvant therapy?

Answer 16

Post-op chemotherapy - increases the chance of cure and risk of recurrence.
Stage 1B/2 - adjuvant cisplatin and vinorelbine improves 5YS by 4.5%.
RT is detrimental in Stage 1/2, but has some benefit if N2.

Question 17

What is NSCLC neoadjuvant therapy?

Answer 17

Pre-operative, not used in clinical practice.
Chemotherapy - some advantages in Stage 3.
A role for targeted treatment in the future.

Question 18

What is NSCLC radical radiotherapy?

Answer 18

Patients are reviewed in clinic to assess fitness and discuss a plan, then attend for RT planning scan (~2wks).

All involves areas of disease are treated with as much prescribed dose to disease as possible (minimum dose to surrounding structures).

Question 19

What are the two main forms of radical radiotherapy treatment?

Answer 19

55Gy in 20 fractions - daily, M-F, 4 weeks.
54Gy in 36 fractions - 3x a day for 12 days.

5YS = ~20%.
FEV1 < 1 or <50% predicted precludes radical RT.

Question 20

What are the side effects of radical radiotherapy?

Answer 20

Acute - lethargy, oesophagitis, SOB (pneumonitis).
Long-term - pulmonary fibrosis, oesophageal stricture, cardiac problems.

Question 21

What is NSCLC concurrent CRT?

Answer 21

Survival is better than with RT alone (5YS increases by 5%).
Chemotherapy increases toxicity.
Most centres use a doublet regime for 21 days.
RT planning is the same (RT starts with the second cycle of chemotherapy).

If patients are not fit enough for both at the same time, chemotherapy is given first, then RT.

Question 22

What is NSCLC adjuvant immunotherapy?

Answer 22

Evidence of adjuvant Durvlumab after CRT for Stage 3 increases overall survival with no effect on QoL.

Question 23

What is SABR?

Answer 23

54Gy in 3 fractions - high dose, 1wk M/W/F.
Useful if patients are not fit for surgery.
Peripheral tumours are more accessible.

Question 24

What is NSCLC palliative treatment?

Answer 24

~80% of patients have non-curable disease.
Treatment is affected by co-morbid disease.
Poor fitness precludes curative treatment.

Options - chemotherapy, immunotherapy, TKI, palliative radiotherapy (or a combination).

Question 25

What is NSCLC palliative chemotherapy?

Answer 25

Two drugs given as an IV infusion every 3wks.
4 cycles of chemotherapy (Pemetrexed improves survival by a further 3-5 months).
Regular CTs ensure an ongoing response.
QoL should be measured.
2nd line chemotherapy - available, depends on patient fitness.

Question 26

What is NSCLC palliative immunotherapy?

Answer 26

Cancers mask themselves via PDL1 expression.
Nivolumab potentiates the immune system and blocks the binding of PD1 to PDL1, and prevents T cells from being inactivated.

Question 27

What is NSCLC palliative TKIs?

Answer 27

Targeted drugs for a broad range of common solid tumours with driver mutations.
Suitable for patients unfit for chemotherapy.
Improves response and survival in treatment.

Question 28

What is NSCLC palliative radiotherapy?

Answer 28

Management of symptoms (bone metastasis, cord compression, haemoptysis) - 1 to 5 fractions.
High doses are used if the disease is too large, or a survival advantage is desired.

Question 29

What is a safety margin?

Answer 29

The space in which the dose is given.
The tumour is within the margin.

Question 30

Why are peripheral tumours easier to deal with?

Answer 30

More accessible.