NICE guidelines for the
treatment of Lung Cancer
Michael-John Devlin (F2)
Aims
• Background
• Discuss the treatment options for SCLC
and NSCLC as recommended by NICE
• Identify which treatments ar...
• The most common cancer
• Lifetime risk ♀ = 5% ♂ = 7%
• Most common cause of cancer related
deaths 35,000/annum
• 5 year ...
TNM
Stage
0
1A

TNM
Carcinoma in situ
T1A NO MO
T1B NO MO

1B
2A

T2B NO MO, T1A N1 MO,
T1B N1 M0, T2A N1 MO

2B

T2B NI M...
WHO/ECOG Performance Status
Grade

Description

0

Fully active, able to carry on all pre-disease performance
without rest...
Smoking Cessation
NSCLC
•
•
•
•
•
•

Surgery
Surgery and Chemotherapy
Radiotherapy
Radiotherapy and Chemotherapy
Chemotherapy
Other
SURGERY
Lobectomy

Segmentectomy

Bi-lobectomy

(either open or thorascopic)

Wedge Resection

Pneumonectomy
Bronchoangiop...
• Hilar and mediastinal lymph node sampling/ en
bloc resection for all patients undergoing surgery
with curative intent
• ...
Work-Up For Surgery
• Perioperative Mortality
• CV Function
– NO if <30days post MI
– Optimise cardiac treatment including...
Chemotherapy and Surgery
• OFFER it if they have a good performance
status (WHO 0,1) and T1-3 N1-2 M0
• CONSIDER if they h...
Radiotherapy
• Indicated in patients who are:
– Stage 1, 2 or 3
– Good performance status
– Disease can be encompassed in ...
• CHART
Continuous Hyperfractionared Accelerated RadioTherapy
• Stage 1 and 2 who are medically inoperable but suitable fo...
ChemoRadioTherapy
• Offered to stage 2 or 3 who are not
suitable for surgery
Chemotherapy
• Stage 3 or 4 NSCLC with good performance
status
• Dual therapy with:
• 3rd generation drug: docetaxel, gemc...
Other
• Gefitinib
• First line treatment for locally advanced or metastatic NSCLC
• +ve for EGFR-TK mutation AND manufactu...
SCLC
Limited Stage

Extensive Stage

T1-4 N0-3 M0

T1-4 N0-3 M1a/b

Chemotherapy

Chemotherapy ±
Radiotherapy

ChemoRadiot...
Limited Stage
• Chemotherapy
• Offer 4-6 weeks of Cisplatin based chemotherapy

• Chemoradiotherapy
• Limited stage with g...
Extensive Stage
• Chemotherapy
• Platinum based to a maximum of 6 cycles
• Radiotherapy can be considered if complete resp...
Cranial Irradiation
• 10# of 25Gy
• WHO ≤ 2 and whose disease has not
progressed on first line treatment
Case One
Brenda
Aged 56
Cough and Haemoptysis
Otherwise well. Independent.
CT: 4cm lesion with ipsilateral node
Tissue Con...
• NSCLC
• T2 N1 M0 = Stage 2a
• WHO = 0
• Lobectomy and node clearance
• 6 weeks of post-operative chemotherapy
• Still al...
Case Two
• Frank
• 70
• T2DM, IHD, CABG, Osteoarthritis
• Has carers x3 daily, spending most
of time in his chair
• Confus...
•
•
•
•

Extensive Stage SCLC
T3 N3 M1
WHO = 3
Multiple Co-Morbidities

• Assessed for ? 6 cycles of platinum chemo +/radi...
Further Supporting Evidence to Q4 (Part 2) - Dr MJ Devlin
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Further Supporting Evidence to Q4 (Part 2) - Dr MJ Devlin

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Further Supporting Evidence to Q4 (Part 2) - Dr MJ Devlin

  1. 1. NICE guidelines for the treatment of Lung Cancer Michael-John Devlin (F2)
  2. 2. Aims • Background • Discuss the treatment options for SCLC and NSCLC as recommended by NICE • Identify which treatments are appropriate for which patients • Cases
  3. 3. • The most common cancer • Lifetime risk ♀ = 5% ♂ = 7% • Most common cause of cancer related deaths 35,000/annum • 5 year survival rate 8% – 1970’s survival rate was 4% – NI better prognosis than rest of UK at 9% • 1 year survival ~ 37% – Median survival 203 day
  4. 4. TNM Stage 0 1A TNM Carcinoma in situ T1A NO MO T1B NO MO 1B 2A T2B NO MO, T1A N1 MO, T1B N1 M0, T2A N1 MO 2B T2B NI MO, T3 NO MO 3A 3B 4 T1A NO MO, T1B N2 M0, T2A N2 M0, T2B N0 MO, T3 N1 M0, T3 N2 M0, T4 N0 M0, T4 N1 MO T2A NO MO T1A N3 MO, T1B N3 M0, T2A N3 M0, T2B N3 M0,T3 N3 M0, T4 N2 MO, T4 N3 MO Any T, N with M1
  5. 5. WHO/ECOG Performance Status Grade Description 0 Fully active, able to carry on all pre-disease performance without restriction 1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work 2 Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours 3 Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours 4 Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair 5 Dead
  6. 6. Smoking Cessation
  7. 7. NSCLC • • • • • • Surgery Surgery and Chemotherapy Radiotherapy Radiotherapy and Chemotherapy Chemotherapy Other
  8. 8. SURGERY Lobectomy Segmentectomy Bi-lobectomy (either open or thorascopic) Wedge Resection Pneumonectomy Bronchoangioplasic
  9. 9. • Hilar and mediastinal lymph node sampling/ en bloc resection for all patients undergoing surgery with curative intent • T3 NSCLC surgery should involve complete resection of tumour either extrapleural or en bloc chest wall resection
  10. 10. Work-Up For Surgery • Perioperative Mortality • CV Function – NO if <30days post MI – Optimise cardiac treatment including prophylaxis for cornary disease – Cardiology Imput if needed • Lung Function – FEV1 = Normal/Good Exercise Tolerance – FEV1/TLCO <30% OK IF they accept risk of dyspnoea – If they’re high risk can assess with shuttle walk or segment counting
  11. 11. Chemotherapy and Surgery • OFFER it if they have a good performance status (WHO 0,1) and T1-3 N1-2 M0 • CONSIDER if they have a good performance status and T2-3 N0 M0 with tumours >4cm
  12. 12. Radiotherapy • Indicated in patients who are: – Stage 1, 2 or 3 – Good performance status – Disease can be encompassed in the radiotherapy volume without undue risk to normal tissue
  13. 13. • CHART Continuous Hyperfractionared Accelerated RadioTherapy • Stage 1 and 2 who are medically inoperable but suitable for radical radiotherapy • Stage 3a or 3b who are not medically fit for (or simply don’t want to have) chemoradiotherapy • 32/33 # of 64-66 Gr in 6 ½ weeks • 20 # of 55 Gr in 4 weeks
  14. 14. ChemoRadioTherapy • Offered to stage 2 or 3 who are not suitable for surgery
  15. 15. Chemotherapy • Stage 3 or 4 NSCLC with good performance status • Dual therapy with: • 3rd generation drug: docetaxel, gemcitabine, paclitaxel • Platinum drug • If unable to tolerate platinum: single 3 rd generation agent • Locally advanced relapse: docetaxel monotherapy
  16. 16. Other • Gefitinib • First line treatment for locally advanced or metastatic NSCLC • +ve for EGFR-TK mutation AND manufacturer provides it at fixed price • Pemetrexed • First line with cisplatin for locally advanced or metastatic • Adenocarcinoma or large cell • Erlotinib • Alternative to docataxel
  17. 17. SCLC Limited Stage Extensive Stage T1-4 N0-3 M0 T1-4 N0-3 M1a/b Chemotherapy Chemotherapy ± Radiotherapy ChemoRadiotherapy Topotecan Surgery
  18. 18. Limited Stage • Chemotherapy • Offer 4-6 weeks of Cisplatin based chemotherapy • Chemoradiotherapy • Limited stage with good preformance status that can be encompassed in a radical thoracic RTx volume. • Surgery • Consider in patients with early stage T1-2a NO MO
  19. 19. Extensive Stage • Chemotherapy • Platinum based to a maximum of 6 cycles • Radiotherapy can be considered if complete response at distal sites and a partial response within the thorax • Relapse • Topotecan • Oral but not intravenous • Relapsed SCLC where: – Treatment with first agent is inappropriate – CAV are contraindicated
  20. 20. Cranial Irradiation • 10# of 25Gy • WHO ≤ 2 and whose disease has not progressed on first line treatment
  21. 21. Case One Brenda Aged 56 Cough and Haemoptysis Otherwise well. Independent. CT: 4cm lesion with ipsilateral node Tissue Confirmation: NSCLC
  22. 22. • NSCLC • T2 N1 M0 = Stage 2a • WHO = 0 • Lobectomy and node clearance • 6 weeks of post-operative chemotherapy • Still alive at One Year
  23. 23. Case Two • Frank • 70 • T2DM, IHD, CABG, Osteoarthritis • Has carers x3 daily, spending most of time in his chair • Confusion • CTB metastatic disease • CT shows >7cm lesion with contralateral mediastinal nodes • Tissue Confirmation: SCLC
  24. 24. • • • • Extensive Stage SCLC T3 N3 M1 WHO = 3 Multiple Co-Morbidities • Assessed for ? 6 cycles of platinum chemo +/radiotherapy depending on response • Felt not appropriate for this gentleman and a palliative approach was adopted. • Frank was deceased at One Year

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