non surgical treatment of non small cell lung cancer

Question 1

What are the top cancers?

Answer 1

Breast/Prostate followed by lung

Question 2

What are the options for biopsy’s

Answer 2

EBUS, Bronchoscopy, guided CT or ultrasound

Question 3

Tissue, then decide what? What % diagnoses?

Answer 3

Then decide if non-small cell lung cancer (approx 85%) or small cell lung cancers (appprox 15%)

Question 4

When do you do a PET scan?

Answer 4

If you are considering radical surgerical treatment so that you have further information if the disease ahs become metastatic

Question 5

What % patients are upstaged post PET

Answer 5

About 15%

Question 6

If lymph node status still unclear, then what?

Answer 6

EBUS/mediastinoscopy to take samples to check

Question 7

Who is at a MDT team and what do they present?

Answer 7

Respiratory team - present patient history, wishes, fitness ,performance status etc
Radiologists - discuss scans etc
Pathologists - discuss tissue etc
Surgeons/Oncologists to help decide the next stages

Question 8

Performance measurement (again) what is it and what is it also known as?

Answer 8

ECOG - Eastern Corporate Performance status:

0 - no symptoms, no effect
1 - symptoms but can still do everything
2 - Can still do most things (>50%) but ha stopped work
3 - Can’t still do most things and needs help (<50%) more than half day in chair/bed
4 - Bed/Chair confined

Question 9

NSCLC cell doubling time = ?

Answer 9

129 days

Question 10

What % patients are potentially operable?

Answer 10

up to 25%

Question 11

What is stage 4 cancer mean?

Answer 11

There has been distant metastatic spread

Question 12

FEV requirements for pneumonectomy/lobectomy

Answer 12

Pneumonectomy = greater than 2 litres (so will be greater than 1 without one of the lungs)
Lobectomy = greater than 1L

Question 13

Why is lymph node sampling essential for surgery options

Answer 13

To check for metastatic spread that hasn’t been detected and avoid unneccesary surgery. Imaging isn’t a definite way of staging

Question 14

Post operatively What is given to reduce risk of recurrence in stage 1B and 2

Answer 14

Adjuvant chemotherapy, reduces risk of reoccurance by 4.5-5% within 5 years

Question 15

Adjuvent means? Neoadjuvently

Answer 15

Adjuvent = added on post operatively
Neoadjuvent = before surgery

Question 16

Is Neoadjuvent therapy routine before lung cancer surgery?

Answer 16

No, not at the moment

Question 17

What is the aim in Radical radiotherapy for NSCLC

Answer 17

Radiotherapy given with curative intent

Question 18

What happens in Radical radiotherapy NSCLC planning and how ling does it take?

Answer 18

The take another scan with the equipment that will be used for treatment to plan treatment. Takes about 2 weeks to plan. In this time they may be given Chemotherapy to take to start their treatment.

Question 19

What is a fraction?

Answer 19

One dose of radiotherapy, radiotherapy is often given in 20 fractions, so once a day mon-fri for 4 weeks.

Question 20

Side effects of radiotherapy?

Answer 20

Tiredness
If close to oesophagus may get oesophagitis - struggle to eat/drink
Breathlessness from pneumonitis.

Risk of pulmonary fibrosis, oesophageal stricture (narrowing) and cardiac problems.

Question 21

5 year survival radical radiotherapy

Answer 21

Around 20%

Question 22

What is SABR, how often is it given? Who is it given to? Can it have similar outcome for surgery?

Answer 22

Stereotactic Ablative Radiotherapy, normal does given in 3 fractions(!) V strong fractions. Only takes 1 week (M/W/F).

Given if:
Tumour under 4cm and more than 2cm away from airways and proximal bronchial tree
Unfit for surgery

Can have similar effect to surgery

Question 23

Is Chemotherapy specific?

Answer 23

No, it’s systemic

Question 24

Survival benefit at 5 years for adding Chemo onto radiotherapy for NSCLC

Answer 24

4-5% survival benefit

Question 25

Does Chemo help the radiotherapy be more effective?

Answer 25

Yes

Question 26

Does chemo increase toxcitiy

Answer 26

Significantly!

Question 27

What are the Side effects of adding Chemo on?

Answer 27

Nausea, diarrhoea, marrow suppression - riskof neutropenic sepsis. Neuropathy/numbness in fingers.

Risk increase also of VTE (venous thromboembolism),

Question 28

How long is a chemo cycle usually, can it be started imminently?

Answer 28

yes, usually given in 21 day cycles. Can be alternated with radiotherapy (sequential therapy) if not fit enough for both together

Question 29

Who is adjuvant immunotherapy for?

Answer 29

Usually stage 3 NSCLC who have completed Chemoradiotherapy.

Question 30

What % patiennts not curale, what given, and why not curable?

Answer 30

Around 80%, either due to late presentation (stage 4, distant metastases or stage 3) or involvemtn of major structures

Question 31

Palliative care options now are:

Answer 31

Chemotherapy, palliative radiotherapy, immunotherapy

TKI (Tyrosine Kinase inhibitors) - target specific mutations

Question 32

What is palliative radiotherapy used for?

Answer 32

Symptom relief

Question 33

How is palliative chemo given?

Answer 33

3/4 cycles, same way so IV infusion every 3 weeks (with oral drugs(?))

Question 34

What PDL1 is required for immunotherapy to be the first line treatment palliativly?

Answer 34

> 50%, otherwise used as secondary line

Question 35

What are TKIs and when are they typically used?

Answer 35

Tyrosine Kinase Inhibitors

Question 36

EGFR mutation drugs

Answer 36

erlotinib, gefitinib, afatinib

Question 37

ALK translocation drugs

Answer 37

crizotinib, ceritinib

Question 38

BRAF mutation drugs

Answer 38

vemurafenib, dabrafenib

Question 39

ROS alteration drug

Answer 39

ROS alteration: crizotinib