Treatment of Bronchial Carcinoma Flashcards
What are some examples of lung cancer treatment?
- Surgery
- Radiotherapy
- Chemotherapy
- Supportive care
What are the steps of giving a diagnosis of lung cancer?
- Prepare the ground
- Bring a relative
- Make sure they understand
- Prepare for obvious questions (what can you do about it? How long have I got?)
- Tell their GP
- Arrange follow up
What is the overall prognosis of lung cancer?
“How long have I got?”
Very poor overall prognosis
- Median survival 5.8 months (half of the patients will be dead within 6 months of the diagnosis)
- 30% 1 year survival
What are the features of small cell carcinoma?
- 12% of lung cancers
- Early metastases
- Rapidly progressive disease
What are the treatment options for small cell lung cancer?
- Rarely suitable for surgery (spread beyond primary site)
* Good initial response to chemotherapy (treatment of choice - often backed up by radiotherapy)
What are types of non-small cell lung cancer?
- Squamous and adenocarcinomas
What are the treatment options for non-small cell lung cancer?
- Curative options are surgery or radical radiotherapy
* Palliative options are chemotherapy and new targeted treatment
Is non-small cell lung cancer more common than small cell?
Non-small cell lung cancers account for the majority of lung cancers
When can non-small cell lung cancers be treated with surgery?
If the disease is recognised before it spreads beyond the primary site
What are the median survival (50% of patients) months of non-small cell, small cell and unknown lung cancers?
- Non-small cell - 7.7 months
- Small cell - 5.9 months
- Unknown - 4.9 months
What percentage of patients with non-small cell, small cell and unknown lung cancers survive for a year?
- Non-small cell - 39%
- Small cell - 24%
- Unknown - 26%
What is unknown lung cancer?
Unknown cell type includes those patients who were too ill to undergo a diagnostic procedure (have a shorter prognosis)
What is key to improved survival of lung cancer?
Making the diagnosis early (i.e. stage I, II)
When is surgery a viable treatment option for lung cancer?
- If you can cut the tumour out
- If the disease is localised
- If the patient will survive the operation
- If the residual lung function will be sufficient following surgery
How does surgical resection of cancer improve the chances of survival of patents with lung cancer?
Surgical resection
- Median survival 42.7 months
- 1 year survival 81 %
No surgery
Median survival 4.8 months
1 year survival 25 %
What is the risk of patients who have undergone surgical resection of lung cancer?
Risk of developing a second primary lung cancer later in life
What techniques are used to stage cancer in preparation for surgery?
- Bronchoscopy
- Mediastinoscopy/EBUS
- CT scan of brain
- CT scan of thorax
- PET scan
How is bronchoscopy used in lung cancer staging?
Can identify:-
- Vocal cord palsy
- Proximity to carina (if within 2cm of the carina, cannot operate)
- Cell type
How is mediastinoscopy used in lung cancer staging?
Assess the lymph nodes - ensure not to many are involved for surgery
How is CT scan of the brain used in lung cancer staging?
To reveal hidden metastases (surgery only if tumour is localised)
How is CT scan of the thorax used in lung cancer staging?
Can identify:-
- Tumour size
- Lymph nodes
- Metastases
- Local invasion
How is a PET scan used in lung cancer staging?
Identifies metastases
Why does tumour need to be more than 2cm away from the carina in order to operate?
- Need to have 2cm of disease free bronchus to close off the hole
- So if the tumour encroaches within 2cm of the carina, it will be impossible to remove it without leaving a hole in the side of the trachea.
What are types of surgery for lung cancer?
- Pneumonectomy
- Lobectomy
- Thoracotomy
- Minimal access VATS
What is a thoracotomy?
- Surgery involving a long incision around the length of the sixth rib to gain access to the lung in question
- It takes weeks to recover from this operation
- The patient may be in hospital for ten days before they are fit to return home
What is minimal access VATS?
Video Assisted Thoracic Surgery is a recent advance using key-hole surgical techniques
- This is far less traumatic and has the benefit of a much faster recovery
- Some patients may be in hospital for no more than five days
What are the risks associated with surgical resection of lung cancer?
- Peri-operative mortality
- Post-operative morbidity
- Only 1 in 20 are suitable for surgery
Why may the hemi-diaphragm of the diseased lung be elevated following surgical resection of lung cancer?
To compensate for the loss of volume on that side
What techniques are used to stage lung cancer for chemotherapy?
- Bronchoscopy or other tissue sampling
- Ct scan
- Performance status ECOG score
How is bronchoscopy or other tissue sampling used to stage lung cancer for chemotherapy?
Identified whether cancer is small cell or non-small cell (small cell responds better to chemotherapy, but non-small cell still responsive)
How is CT scan used to stage lung cancer for chemotherapy?
Can identify:-
- Tumour size
- Local invasion
- Nodes
- Metastases
What is performance status ECOG score?
Assessment of the fitness of the patient to undergo chemotherapy
What do new developments in chemotherapy include?
- The use of drugs which tackle epithelial growth factor
* Drug sensitivity testing on the material removed at biopsy
What are the advantages of chemotherapy?
- Rarely curative but longer survival
* Whole body treatment so will target rapidly dividing cells
What are the disadvantages of chemotherapy?
Major side effects
What are the side effects of chemotherapy?
- Nausea and vomiting
- Tiredness
- Bone marrow suppression (neutropenia) -opportunistic infection, anaemia
- Hair loss
- Pulmonary fibrosis
What is a potential very dangerous complication of chemotherapy?
Neutropenic sepsis
What are the new targets of chemotherapy?
- Genetic mutations within the tumour - EFGR, ALK1
* Immune therapy - PD-L1
What is radiotherapy?
Ionising radiation
- Usually X-rays
- External beam
What are the possible purposes of radiotherapy?
- Curative intent (intuition to cure)
* Palliative intent (a delaying tactic, used for metastases)
What is the advantage of radiotherapy?
Usually well-tolerated
What are the disadvantages of radiotherapy?
- Maximum cumulative dose required to kill tumour
- Collateral damage - spinal cord, oesophagus, adjacent lung tissue
- Only goes where you point the beam
- Not good for subclinical metastases
What is a common side effect of radiotherapy?
Temporary oesophagitis
What can result from collateral damage to lung tissue following radiotherapy?
Normal lung tissue can undergo post radiation fibrosis
When is post radiation fibrosis a significant challenge?
When dealing with a patient with precarious lung function e.g. advanced COPD
What can be done to overcome collateral damage whilst still delivering maximum cumulative dose to tumour?
Many beams coming from different angles aimed at the tumour
What is SABR?
Stereotactic ablative radiotherapy - much higher dose delivered to the tumour delivered through hundreds of small beams rather than 4 or 5
What are the advantages of SABR?
- Each beam is less powerful - less collateral damage
* Total dose delivered to tumour is higher and so more effective
What are the disadvantages of SABR?
4D scanning required
What is photodynamic therapy for lung cancer?
A type of endobronchial therapy
- Patient receives a photo-sensitising drug a few days before the bronchoscopy
- Then receives phototherapy to the tumour in the bronchus with laser light down a fibreoptic bundle
What are types of endobronchial therapy?
- Stent insertion for stridor
- Photodynamic therapy
- Other laser therapy
Is endobronchial therapy curative?
All of these treatments are palliative but can make a significant improvement to quality of life
What is treatment of lung cancer determined by?
- The cell type
- The extent of the disease
- Co-morbidity (can restrict treatment options)
- The patient’s wishes
What are examples of common co-morbities to lung cancer?
- Smoking related diseases: COPD: FEV1 < 1 litre, Ischaemic Heart Disease (IHD), peripheral vascular disease
What does palliative care for lung cancer aim to treat?
- Pain
- Breathlessness
- Cough
- Anxiety
- Poor mobility
Why is palliative care significant in lung cancer?
- Less than 10% of lung cancer patients will be cured of their disease
- The remaining 90% are likely to suffer significant symptoms as a direct result of their cancer
What is the prognosis for lung cancer?
- Half will be dead in 6 months
* 1 in 20 survive for 5 years
What are the causes of lung cancer?
- Tobacco smoking (the big one)
- Asbestos
- Radon
What are preventative measures for lung cancer?
Many public health measures have been introduced to make tobacco smoking less attractive
- In the UK, advertising of tobacco has been banned
- Smoking indoors has also been banned.
- In Australia, all cigarettes will have to be sold in bland green packs with no logos or other attractions
Which 2 cancer treatments are curative?
- Surgery
* Radiotherapy
