non-surgical management of lung cancer

Question 1

doubling time for non-small cell lung cancer

Answer 1

~4mths

Question 2

ECOG performance status measure

Answer 2

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

Question 3

NSCLC surgery

Answer 3

survival depends on stage
5YS ~40%
surgery is the definitive treatment - should have it if possible ASAP

Question 4

NSCLC adjuvant therapy

Answer 4

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

Question 5

NSCLS adjuvant immunotherapy

Answer 5

evidence for durvlumab after chemoradiation for stage III NSCLC
no significant effect on QOL

Question 6

NSCLC neoadjuvant therapy

Answer 6

stage III: pre-op chemo demonstrated some advantages (no NA chemo in stage I/II)
use induction chemo prior to RT

Question 7

radical RT for stage III NSCLC

Answer 7

5YS ~20%
pulmonary function tests are essential
dose 55Gy +

Question 8

chemo RT for stage III NSCLC

Answer 8

survival better than w/ RT alone - 9mths vs 13mths

2YS ~27%

Question 9

SABR

Answer 9

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

Question 10

NSCLC advanced disease

Answer 10

~80% present w/ incurable disease
palliative treatment to improve QOL and survival
decisions affected by comorbid disease

Question 11

stage IV NSCLC treatment options

Answer 11

incurable
palliation essential
RT to 1y tumour - 70% symptomatic benefit
chemo gives equal symptomatic benefit and survival advantage
median survival >12mths w/ chemo alone

Question 12

stage III/IV NSCLC treament

Answer 12

avg 4 cycles of chemo
QOL should be measured - RT for painful bone mets, surgery/steroids for brain mets
1YS >40%
immunotherapy for mets

Question 13

bone pain from mets

Answer 13

pathological fracture can be presenting symptoms esp in load bearing areas
consult orthopaedic (prophylaxis )and neurosurgery (if cord compression)
palliative RT

Question 14

give 4 examples of targeted drugs for adenocarcinoma w/ driver mutation

Answer 14

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

Question 15

when are targeted drugs useful

Answer 15

patients unfit for chemo (PS 0-3)

2nd line treatment options at progression

Question 16

tyrosine kinase inhibitors

Answer 16

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

Question 17

how does nivolumab act

Answer 17

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

Question 18

doubling time of small cell lung cancer

Answer 18

29 days

much more aggressive

Question 19

what syndromes is SCLC associated with

Answer 19

secretory syndromes

e.g. SIADH, Cushing’s

Question 20

SCLC limited disease treatment

Answer 20

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

Question 21

SCLC outcomes in limited disease

Answer 21

chemo response rate 90% - but short lived
complete remission ~60%
median survival w/o treatment ~8mths
MS w/ treatment ~16mths
2YS ~25%

Question 22

SCLC extensive disease treatment

Answer 22

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

Question 23

SCLC outcomes in extensive disease

Answer 23

response rate ~80%
complete remission ~30%
median survival w/o treatment ~8wks
median survival w/ treatment ~8mths

Question 24

side effects of chemotherapy

Answer 24

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

Question 25

side effects of radiotherapy

Answer 25

general: lethargy, risk to surrounding organs
acute: pneuomitis, dysphagia (oesophageal irritation)
late: fibrosis, increased risk MI, 2nd malignancies

Question 26

side effects of immunotherapy

Answer 26

commonly colitis, pneumonitis, dermatitis, endocrinopathies (thyroid)