Non-Operative Management of Lung Cancer Flashcards
How is a tissue diagnosis done?
Due to biopsy
Can be bronchoscopy or EBUS and can be CT guided or US guided
What are the types of NSCLC?
Adenocarcinomas
Squamous cell carcinomas
Large cell carcinomas
Others
What is the PET-CT scan used for?
Helps to look at lymph nodes and extra-thoracic disease
If LN status not entirely clear on PET then can consider EBUS or mediastinoscopy
What is discussed during an MDT meeting?
Staging
Tumour type
Patients history and wishes
Patient fitness
What are some therapeutic options discussed by MDTs?
Curative or palliative, radiotherapy, surgery, chemo, immunotherapy, combination or targeted therapies
Describe what 0 and 5 mean on ECOG performance status
0 - asymptomatic and well
5 - dead
Describe what 1-4 means on ECOG performance status?
1 - symptomatic but can do light work
2 - has to rest but for less than half the day
3 - has to rest for more than half the day
4 - bedbound
What is the doubling time for NSCLC?
129 days so has long division time
What percentage of NSCLC cab be operable/ resectable?
Max. of 25%
Describe requirement for surgery in NSCLC?
Only offered as curative treatment option and survival depends on stage.
Good lung function is necessary and lymph node sampling is essential
What is good lung function performance that allows surgery in NSCLC?
FEV1 > 1 for lobectomy
FEV1 > 2 for pneumonectomy
When is adjuvant treatment?
Post-operatively
What is the aim of adjuvant therapy - chemo?
Is chemo given to increase chance of cure and reduce risk of recurrence
When can radiotherapy be used in adjuvant therapy?
Detrimental in stage I and II
Some benefit if mediastinal nodes or involved margins
When is neoadjuvant therapy given?
Pre-operatively
When is radical radiotherapy given to patients with NSCLC?
Patients are reviewed in clinic to assess fitness and discuss plan. Radiotherapy planning scan
Given with curative intent
What are the regimes for radical radiotherapy in NSCLC?
55Gy in 20 fractions - Mon - Fri for 4 weeks
54Gy in 36 fractions - 3 times daily for 12 days
What are the side effects if radical radiotherapy?
Lethargy, oesophagitis, SOB due to pneumonitis
Long term - fibrosis, strictures and cardiac
What is the requirement for radical RT?
Pulmonary lung function test is essential
Poor lung function precludes radical RT
Typically FEV1 < 1 or < 50% pred
Explain concurrent chemoRT for NSCLC?
Chemo is systemic treatment and survival is better in combination with RT
Addition of chemo increases toxicity so can increase side effects
Explain the chemoRT regime?
No standard chemo regime but most centres use doublet regime and each cycle is 21 days
RT planning process is the same - typically starts with cycle 2
Does adjuvant immunotherapy have any significance to QoL?
PACIFIC trial carried out and shows no significant effect on QoL
Explain SABR - stereotactic ablative radiotherapy?
Has similar outcomes as surgery and is useful if patients are not fit for surgery.
For tumours up to 4cm and more than 2cm away form airways and proximal to bronchial tree
What is the regime for SABR?
54Gy in 3 fractions so high dose
Given in one week M/W/F usually
What patients undergo palliative treatment for NSCLC?
Stage 3 (distant metastases) or 4 (very locally advanced) lung cancer
Treatment decisions also affected by co-morbid disease ex. angina or COAD
Poor fitness precludes curative treatment
What are the options for palliative treatment?
Chemo
Immunotherapy
TKI
Palliative radiotherapy
Combination
Explain Palliative chemo regimes?
Given as doublet regime - 2 drugs IV every 3 weeks
Most centres give 4 cycles
Then maintenance chemo with pemetrexed improves survival
Regular CT scans
Explain palliative chemo for NSCLC?
QoL if measured
Given as doublet regime in 4 cycles
2nd line chemo options available but depends on patient fitness
Explain palliative immunotherapy for NSCLC?
New treatment modality
PDL1 is the protein that prevents immune system attacking cells in the body - cancer promotes PDL1 expression
Immunotherapy works by upregulating immune system
How are patients fit for palliative immunotherapy?
Can be the first in line if PDL1 score > 50%
Otherwise can be used in second line
What does Nivolumab do against immune system?
Blocks binding of PD-1 to PDL1 and PDL2 which prevents T-lymphocytes from being inactivated
Explain what is targeted in palliative TKIs
Targeted drugs for adenocarcinomas with driver mutation (EGFR and BRAF mutation, ALK and ROS translocation)
Who is suitable for palliative TKIs in NSCLC?
Suitable for patients unfit for chemo
Second line treatment options at progression
What is a rebiopsy used for?
Understanding mechanisms of resistance
What is the aim of palliative radiotherapy for NSCLC?
Management of symptoms - bone metastases, cord compression and haemoptysis
What is the regime for palliative radiotherapy for NSCLC?
Typically sing dose or up to 5 fractions
When is high dose palliative radiotherapy for NSCLC given?
If disease is too large to encompass radically and has survival advantage
What is the doubling time for small cell lung cancer?
29 days
What is the presentation like for small cell lung cancer?
Presentation is similar symptomatically
More association with secretory syndromes ex. SAIDH and cushings
What is small cell lung cancer historically staged as?
Limited disease - defined to one hemithorax
Extensive disease - more advanced
What is the treatment used for limited disease SCLC?
CRT curative treatment followed by prophylactic cranial radiation (PCI)
Combination of drugs
What is the outcome in limited disease SCLC?
Response rate to treatment is 90% and complete remission is 60%
Median survival doubles with treatment
What is the treatment for extensive disease SCLC?
4 cycles of combination chemo
Consolidation thoracic RT
PCI is recommended
What treatment would be used if brain metastases in extensive SCLC?
RT and steroids
What are the outcomes for Extensive disease SCLC?
Response rate is 80% and complete remission is 30%
Median survival w treatment is 8 months
What are the side effects of chemo?
Marrow suppression, neutropenic sepsis, nausea, GI upset, mucositis, fatigue, lethargy, neuropathy, increased risk of stroke and renal impairment
What are the side effects of radiotherapy?
Lethargy, risk to surrounding organs, pneumonitis, dysphagia, fibrosis, stricture and increased risk of MI
What are the side effects of immunotherapy?
Anything ‘itis’
Commonly colitis, pneumonitis, dermatitis and endocrinopathies
