Non-operative Management of Lung Cancer

Question 1

What type of lung cancer makes up 85% of lung cancer?

Answer 1

Non-small cell cancer

Question 2

What are the types of non-small cell lung cancer?

Answer 2

Squamous (30%)

Adenocarcinoma (55%)

Large cell undifferentiated

Question 3

What type of cancer makes up about 15% of ung cancers?

Answer 3

Small cell cancer - extremely aggressive - doubles in size every 29 days

Question 4

Where do you normally find squamous and adenocarcinoma cancers?

Answer 4

Squamous - usually more central (usually male, usually smokers)

Adenocarcinoma - more peripheral, usualy in woman

Question 5

What does stage 4 mean?

Answer 5

Distant metastases

Question 6

What is the percentage of non-small cell cancer is operable?

Answer 6

maximum of 25%

Question 7

What are all the therapeutic options for cancer?

Answer 7

Surgery

Radiotherapy (radical/curative or palliative)

Chemotherapy

Combination

Targetted therapies

Question 8

What determines the therapeutic options?

Answer 8

Tumour type, stage, ECOG performance status, patient wishes and options, aims of therapy (curative or palliative)

Question 9

NSCLC: What are the scores available for the ECOG performance status measurement?

Answer 9

Question 10

What is the average 5 year survival for non-small cell lung cancer?

Answer 10

Around 40%

Question 11

What is meant by adjuvant therapy?

Answer 11

When the cancer has appeared to all have been removed – but it is post operative treatment to ensure all cancer has been removed

Question 12

Is adjuvant therapy helpful in stage 1 and 2 non-small cell lung cancer?

Answer 12

Detrimental - but some possible benefits if mediastinal nodes (N2 or involved margins)

Question 13

NSCLC: When does preoperative chemotherapy demonstrate significant survival advantage?

Answer 13

Stage 3 Non small cell lung cancer

Question 14

What percent of Non small cell lung cancer patients have adbvanced disease?

Answer 14

80% of all patients

Question 15

What is the dose for stage 3 Non small cell lung cancer radiotherapy?

Answer 15

Question 16

What is the survival rate for stage 3 non small cel lung cancer?

Answer 16

20%

Question 17

What is survival of stage 3 non small cell cancer for patients treated with ChemoRT?

Answer 17

About 27%

Question 18

What is treatment for stage 4 NSCLC?

Answer 18

Incurable

Palliation essential

RT to primary tumour to releive symptoms (~70% symptom benefit)

(—Chemo gives equal symptomatic benefit AND survival advantage)

—Median survival now >12 months with chemo alone

Question 19

What is the average number of cycles of chemo for stage 3 NSCLC?

Answer 19

—3 as good as 6 cycles of chemo (4 is average in UK)

Question 20

NSCLC: What should be considered in the case of Painful bone metastases and Brain mets?

Answer 20

Painful bone mets - radiotherapy

Brain mets – resection

Question 21

NSCLC: What are the features of Bone pain from mets?

Answer 21

Occurs in any site

Often worse at night

Potential for pathological fracture

Need for palliative radiotherapy

Question 22

NSCLC: What is pemetrexed used for?

Answer 22

Maintainance chemotherapy

Question 23

What can drugs target in NSCLC?

Answer 23

Drugs that can target the driver mutation in ADENOCARCINOMA

Question 24

NSCLC: Give examples of Driver mutations for NSCLC

Answer 24

EGFR mutation

ALK translocation

BRAF mutation

ROS alteration

Question 25

NSCLC: Who are targetted drugs used by?

Answer 25

Patients who are unfit for chemotherapy

Question 26

NSCLC: What is the concept for Tyrosine Kinase Inhibitors?

Answer 26

Blocks Tyrosine Kinase which is a membrane receptor protein - This stops the formation of a protein causing the tumour to grow

Question 27

What drugs are Tyrosine Kinase Inhibitors?

Answer 27

Erlotinib, gefitinib, afatinib

Question 28

Whar us Tarceva?

Answer 28

Tyrosine Kinase inhibitor used to treat EGFR mutations

Question 29

What is the function of Nivolumab?

Answer 29

Blocks the binding of PD-1 to PD-L1 and PD-L2 This potentiates the activity of lymphocytes by preventing them from being activated

Question 30

What percentage of lung cancer patients have small cell lung cancer?

Answer 30

Roughly 15%

Question 31

What is different between the presentation of small cell lung cancer and NSCLC?

Answer 31

Presentation identical but secretory syndromes are present. e.g SIADH (The syndrome of inappropriate antidiuretic hormone (ADH) secretion) Low sodium - confusion ACTH (Adrenocorticotropic hormone - Its principal effects are increased production and release of cortisol by the cortex of the adrenal gland) - causing Cushings - hypersecretion of ACTH by the pituitary gland

Question 32

What are the two classifications of Small cell lung cancer severity?

Answer 32

Limited Disease - Staged to one hemithorax Extensive disease - more advanced disease

Question 33

How do you treat SCLC of limited disease?

Answer 33

Chemotherapy Combination of drugs including cisplastin and etoposide Early thoracic radiotherapy is better Prophylactic cranial radiation *Only resect about 1 lung cancer per year for those with small cell lung cancer – SURGERY IS NOT THE TREATMENT, chemotherapy dominated treatment*

Question 34

In SCLC is there any benefit from any of the following? High Dose chemo? Alternating Chemo? Maintainance Chemo? Chemo 'on demand'? Maintainance interferon?

Answer 34

NO

Question 35

What is response rate of limited disease treatment?

Answer 35

90% Complete remission is 60%

Question 36

What is median survival of limited disease SCLC with and without treatment?

Answer 36

With - 8 months Without - 16 months

Question 37

What is the rate of two year survival with SCLC in limited disease?

Answer 37

25%

Question 38

What is the treatment for SCLC in extensive disease?

Answer 38

4 cycles of combination chemotherapy Percutaneous coronary intervention (PCI) recommended - non-surgical procedure used to treat narrowing (stenosis) of the coronary arteries of the heart found in coronary artery disease Single fraction RT to palliate if not fit for chemo If brain Mets - RT and steroids

Question 39

What is the percentage of patients that are diagnosed too late to cure?

Answer 39

80%