Non-surgical management of lung cancer Flashcards
What are the types and prevalence of non-small cell lung cancer?
85%
Adenocarcinoma 55%
Squamous 30%
Large cell undifferentiated 5%
Not otherwise specified (NOS) 10%
What is the 4 type of lung cancer and its prevalence?
Small cell lung cancer 15%
What are the types of pleural mesothelioma?
Epithelioma
Sarcomatous
Biphasic
What can a PET scan show/help with?
Done to patients with potential for curative treatment.
Picks up lymph node metastasis out with thoracic area.
PET scans often upstage patients.
What sort of things are discussed in and MDT meeting?
Discuss each new cancer diagnosis
Discuss therapeutic options
Explain further the discussion about each new patient in an MDT meeting?
Resp team = patient wishes, fitness, lung function
Radiologists = discuss imaging
Pathologists = type of tumour, biopsy breakdown
What are therapeutic questions to ask in an MDT meeting?
Curative or palliative?
Radiotherapy?
Surgery?
Chemotherapy?
Immunotherapy?
Combination therapy?
Targeted therapy?
Supportive care in community?
What is the performance status measurement?
0 = asymptomatic, well
1 = symptomatic, able to do light work
2 = has to rest but for < 50% of the day
3 = has to rest for > 50% of the day
4 = bedbound
5 = dead
What is the doubling time for non-small cell lung cancers?
129 days
How is staging done for non-small cell lung cancer?
TNM
T = tumour size
N = nodal involvement
M = distant metastasis
When do you offer surgery?
Only for curative treatment
What is the survival from surgery dependent on?
The stage of the cancer and its location
5-year survival is around 40%
What is necessary to undergo surgery?
Good lung function
- FEV1 > 1 for lobectomy
- FEV1 > 2 for pneumonectomy
Lymph node sampling
What are some adjuvant (post op) therapy options and what are their aims?
Chemotherapy - increase chance of cure/reduce risk of recurrence
Radiotherapy - Some benefit possible if mediastinal nodes or margins are involved
Explain neoadjuvant therapies (pre-op)?
Not used in clinical practice for lung cancer!
Small benefit for stage 3 cancers
What is radical radiotherapy?
High does therapy given with the intent to cure
What is radical radiotherapy?
High does therapy given with the intent to cure
How is radical radiotherapy given?
Highest prescribed dose to the disease as possible and minimum dose to surrounding structures.
What are some acute side effects of radical radiotherapy?
Lethargy
Oesophagitis
SOB due to pneumonitis
What are some long term side effects of radical radiotherapy?
Pulmonary fibrosis
Oesophageal stricture
Cardiac
What is the survival rate after radical radiotherapy?
5-year survival rate = 20%
Why is pulmonary lung function tests essential?
Poor lung function (FEV1 < 1 or <50% predicted) precludes radical RT
What is concurrent chemotherapy?
Systemic treatment into the blood stream
What are some side effects of chemotherapy?
Nausea
Diarrhoea
GI upset
Marrow suppression
Risk of life threatening infection
VTE disease - blood clots, heart attacks, strokes
Neuropathies - numbness in fingers
What is the common chemo regiem?
Using a combo of 2 drugs
Each cycle is about 21 days
When does chemo and radiotherapy commence?
Start chemotherapy instantly
Start radiotherapy with cycle 2 or chemo
What is the 2-year survival of concurrent chemotherapy?
27%
What is an example of adjuvant immunotherapy?
PACIFIC trial
- only available for stage 3 patients who’ve had chemoradiotherapy.
- Didn’t affect quality of life and improved length of survival.
What is SABR?
Stereotactic ablative radiotherapy
- Very high dose per fraction
- Has similar outcomes to surgery
- For tumour up to 4cm
- Has to be >2cm from airways and proximal bronchial tree
What are the types of biopsy?
Bronchoscopy
EBUS
CT guided
US guided
How can treatment decisions be influenced?
Patient wishes
Co-morbidities (angina, COPD etc.)
- poor patient fitness precludes curative treatment
What does a course of chemotherapy look like?
Two drugs given as IV infusion every 3 weeks
Most centres give 4 cycles
Regular CT scans to ensure ongoing response
What is important to keep in mind throughout chemo/treatement?
Quality of life!
How does immunotherapy work?
If PDL1 score > 50% them give option of first line immunotherapy.
It works by upregulating immune system and “unmasking” cancers
*PDL1 = protein that prevents immune system attacking cells in the body
What is tagerted therpy?
Tyrosine kinase inhibitor
- Drugs targeted for adenocarcinoma with driver mutation
Suitable for patients unfit for chemo (PS 0-3)
What drugs do you use for a EGFR mutation?
Erlotinib
Gefitinib
Afatinib
What drugs do you use for a ALK translocation?
Crizotinib
Ceritinib
What drugs do you use for a BRAF mutation?
Vemurafenib
Dabrafenib
What drug do you use for a ROS alteration?
Crizotinib
What can palliative radiotherapy be used for?
To manage symptoms of:
- Bone metastasis
- Cord compression
- Haemoptysis
When do you use higher dose palliative radiotherapy?
If disease is too large to encompass radically
Has a survival advantage
What is the doubling time of small cell lung cancer?
29 days
What is small cell lung cancer more associated with?
Secretory syndromes:
- SIADH
- Cushing’s
When small cell disease is limited what are the curative treatments?
Chemoradiotherapy
Eradiate brain prophylactic (PCL)
With small call lung cancer what treatments give no advantage?
High dose chemo
Alternating chemo
Maintenance chemo
Chemo “on demand”
Maintenance interferon, MMPI, targeted therapies
What are the outcomes in treatment of localised small cell lung cancer?
Cell divide quickly so respond to treatment quickly (response rate = 90%)
Complete remission = 60%
What are the survival rates of small cell lung cancer?
Median survival with no treatment = 8 months
Median survival with treatment = 16 months
2-year survival rate = 25%
What treatments are done in extensive small cell lung cancer?
4 cycles of combo chemo
Consolidation thoracic radiotherapy
PCI recommended
Palliative RT if not fit for chemo
What are the survival rates for extensive small cell lung cancer?
Median survival with no treatment 8 weeks
Median survival with treatment is 8 months
What are the side effects of chemotherapy?
Marrow suppression
- Neutropenic sepsis
Nausea, vomiting, GI upset
Mucositis
Fatigue, lethargy
Neuropathy (numbness in fingers)
Hair loss
Nail changes
What are the general side effects of radiotherapy?
Lethargy
Risk to surrounding organs (oesophagus etc.)
What are the acute side effects of radiotherapy?
Pneumonitis
Dysphagia
What are the late side effects of radiotherapy?
Fibrosis
Stricture
Increased risk MI. 2nd malignancies
What are the common side effects of immunotherapy
Colitis (diarrhoea)
Pneumonitis (breathless)
Dermatitis
Endocrinopathies
In immunotherapy what can be given to counteract side effects if bad enough?
Steroids
Who should be screened by lung cancer screening program?
At risk population
e.g. smokers, those in certain jobs
What would screening involve?
Low dose CT
What is the big ethical question about lung cancer screening?
Radiation risk to population vs risk of lung cancer cure by catching early?
What are some logistical challenges to lung cancer screening?
Machine time
Reporting scans
Stress of false positives
Lung nodules needing follow up
