non-surgical management of lung cancer Flashcards
doubling time for non-small cell lung cancer
~4mths
ECOG performance status measure
0 = asymptomatic, well 1 = symptomatic, able to do light work 2 = has to rest for <50% of day 3 = has to rest for >50% of day 4 = bedbound
NSCLC surgery
survival depends on stage
5YS ~40%
surgery is the definitive treatment - should have it if possible ASAP
NSCLC adjuvant therapy
post-op
chemo - increases chance of cure
RT - some benefit if mediastinal nodes or involved margins, detrimental in stage I and II
adjuvant therapy reduces risk of systemic disease
NSCLS adjuvant immunotherapy
evidence for durvlumab after chemoradiation for stage III NSCLC
no significant effect on QOL
NSCLC neoadjuvant therapy
stage III: pre-op chemo demonstrated some advantages (no NA chemo in stage I/II)
use induction chemo prior to RT
radical RT for stage III NSCLC
5YS ~20%
pulmonary function tests are essential
dose 55Gy +
chemo RT for stage III NSCLC
survival better than w/ RT alone - 9mths vs 13mths
2YS ~27%
SABR
stereotactic ablative radiotherapy
high dose 3x/wk
similar outcomes to surgery, useful if not for for surgery
tumours up to 4cm
>2cm away from airways and proximal bronchial tree
NSCLC advanced disease
~80% present w/ incurable disease
palliative treatment to improve QOL and survival
decisions affected by comorbid disease
stage IV NSCLC treatment options
incurable
palliation essential
RT to 1y tumour - 70% symptomatic benefit
chemo gives equal symptomatic benefit and survival advantage
median survival >12mths w/ chemo alone
stage III/IV NSCLC treament
avg 4 cycles of chemo
QOL should be measured - RT for painful bone mets, surgery/steroids for brain mets
1YS >40%
immunotherapy for mets
bone pain from mets
pathological fracture can be presenting symptoms esp in load bearing areas
consult orthopaedic (prophylaxis )and neurosurgery (if cord compression)
palliative RT
give 4 examples of targeted drugs for adenocarcinoma w/ driver mutation
15% EGFR mutation e.g. erlotinib, gefitinib, afatinib
5% ALK mutation e.g. crizotinib, ceritinib
2% BRAF mutation e.g. vemurafenib, dabrafenib
1% ROS alteration e.g. crizotinib
when are targeted drugs useful
patients unfit for chemo (PS 0-3)
2nd line treatment options at progression
tyrosine kinase inhibitors
targeted therapy for a broad range of common solid tumours
improved response and survival in treatment of advanced solid tumours, well tolerated
e.g. erlotinib, gefitinib, afatinib
how does nivolumab act
blocks the binding of PD-1 to PD-L1 and PD-L2
potentiates the activity of T lymphocytes by preventing them from being inactivated –> attack cancer cells
doubling time of small cell lung cancer
29 days
much more aggressive
what syndromes is SCLC associated with
secretory syndromes
e.g. SIADH, Cushing’s
SCLC limited disease treatment
chemotherapy is treatment of choice
combination of drugs e.g. cispaltin and etoposide
early (concurrent) thoracic RT better
prophylactic cranial raidation (PCI)
no advantage from: high dose chemo, alternating chemo, maintenance chemo, chemo on demand
SCLC outcomes in limited disease
chemo response rate 90% - but short lived complete remission ~60% median survival w/o treatment ~8mths MS w/ treatment ~16mths 2YS ~25%
SCLC extensive disease treatment
4 cycles of combination chemo
consolidation thoracic RT (if fit enough)
PCI recommended
consider RT for symptom palliation if not fit enough for chemo
RT and steroids for brain mets
SCLC outcomes in extensive disease
response rate ~80%
complete remission ~30%
median survival w/o treatment ~8wks
median survival w/ treatment ~8mths
side effects of chemotherapy
marrow suppression (risk of life threatening infection) nausea, vomiting, GI upset mucositis fatigue, lethargy neuropathy, increased risk MI/stroke renal impairment hair loss, nail changes
side effects of radiotherapy
general: lethargy, risk to surrounding organs
acute: pneuomitis, dysphagia (oesophageal irritation)
late: fibrosis, increased risk MI, 2nd malignancies
side effects of immunotherapy
commonly colitis, pneumonitis, dermatitis, endocrinopathies (thyroid)
