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  • 1. “ No Air” Management of Lung Cancer Elaine Bouttell, MD FRCPC Medical oncology GRRCC
  • 2.
    • Disclosures:
      • Advisory board for Novartis, RCC
  • 3. Objectives
    • Review the diagnosis, treatment, and palliation of lung cancer
      • Review the types and demographics of lung cancer
      • Identify the differences between primary and secondary lung cancer
      • Function of the DAU
      • Screening and early diagnosis of lung cancer
      • Review differences between curative and non-curative treatment
      • Treatment modalities: surgery, chemotherapy, radiation therapy
  • 4. Overview
    • Review statistics (incidence, death rates)
    • Etiology
    • Staging system for NSCLC (85%)
    • Life expectancy depending on stage
    • Management of NSCLC
      • Resectable Stage I, II, IIIA
      • Unresectable Stage IIIA, IIIB
      • Incurable Stage IV
  • 5. Overview
    • Staging system for SCLC (15%)
    • Life expectancy depending on stage
    • Management of SCLC
      • Limited stage
      • Extensive stage
    • Follow-up
    • Complications and Paraneoplastic conditions
  • 6. Statistics
    • In 2008:
    • 23,900 Canadians will be diagnosed with lung cancer
    • 20,200 will die of lung cancer (more deaths than colorectal, prostate, and breast cancer combined)
    • 1 in 12 men will develop lung cancer, 1 in 13 will die of it (incidence and death rates decreasing)
    • 1 in 16 women will develop lung cancer, 1 in 18 will die of it (incidence and death rates increasing)
  • 7.  
  • 8. Risk Factors
    • Smoking (including second hand smoke exposure)– 80-90%
    • Previous radiation therapy
    • Previous diagnosis of lung cancer
    • Exposure to asbestos, arsenic, chromium, nickel (especially in smokers), radon gas
    • Family history of lung cancer
    • Air pollution?
  • 9. Second Hand Smoke causes Lung Cancer
    • Meta-analysis of 52 studies prepared for the Surgeon General’s report in 2006 concluded that the odds ratio for spouse of smoker is 1.21-1.37 (dose response)
    • SHS exposure in the work place, OR 1.22
    • Exposure to children leads to OR 1.10, >25 smoker-years doubled the risk, <25 smoker-years did not appear to increase the risk
  • 10. Lung Cancer in Never Smokers
    • Percentage of never-smokers among lung cancer patients appears to be increasing
    • incidence in never smokers increasing, or prevalence of never-smokers in the population increasing?
    • US women age 40-79: 14.4-20.8/100,000 person-years
    • US men: 4.8-13.7
    • adenocarcinoma, different biology
  • 11. Risk Reduction after Quitting Smoking
    • Cutting back from 1ppd to ½ ppd decreased risk 27%
    • Risk of lung cancer falls over 15 years after quitting then remains about 2x risk of a never smoker
    • Risk reduction appears to be related to age at quitting
  • 12. Screening for Early Detection
    • No test in asymptomatic patients (CXR, sputum cytology, CT scan) shown to reduce mortality from lung cancer
    • Reasonable to do CXR in any smoker presenting with symptoms
  • 13. Best Treatment
    • 1. Prevention
    • 2. Prevention
    • 3. Prevention
  • 14.  
  • 15. Non Small Cell Lung Cancer
    • Staging
    • I T1-2 N0
    • II T1-2 N1
    • T3 N0
    • IIIA T1-2 N2
    • T3 N1-2
    • IIIB T N3
    • T4 N0-3
    • IV T N M1 “wet” IIIB
  • 16. Management of Potentially Resectable Stage I, II, IIIA NSCLC
    • Surgery
  • 17. Life Expectancy by Stage
    • 5 year overall survival rates for surgically resected:
      • Stage I 60-75%
        • Only 57% clinical stage I are pathologic stage I,
        • and 13% are actually pathologic stage IIIA
      • Stage II 36-60%
      • Stage IIIA 3-34%
  • 18. Medically Inoperable Stage I and II
    • Radiation therapy alone
      • 11-43% die of non-cancer causes
      • 70% 5 yr OS for Stage I
      • 60% 3 yr OS for Stage II
  • 19. Adjuvant Therapy Post-Surgical Resection
    • Radiation: consider if close/positive margin, ?N2
    • Chemotherapy (4 months weekly vinorelbine + cisplat d1 d8)
      • Overall increase in cure rate 5-15% stage II and IIIA
      • controversial for stage IB (?benefit if T>4cm)
      • no proven additional benefit for stage IA
  • 20. Unresectable Stage IIIA and IIIB
    • Treatment with curative intent vs Palliation
    • Curative Intent:
      • Sequential chemo followed by RT better than RT alone
      • Concurrent chemo/RT better than sequential (4 yr OS 21% vs 14%)
      • 10 early (within 6 mths) toxic deaths in concurrent arm vs 3 in the sequential arm
      • ?PCI (prophylactic cranial irradiation)
        • Decreased brain mets as first site of failure at 5 yrs
        • 35% to 8%
  • 21. Follow-up Post Curative Treatment
    • Non-small cell lung cancer post surgery +/- adjuvant chemotherapy, or concurrent chemo/RT
      • No proven survival benefit to ANY routine investigations in asymptomatic patients
      • Recurrent disease rarely curable, unless second primary lung cancer
      • Directed history and physical +/- CXR q 3 mth x 2 yr, then q 6mth x 3 yr, then annual
  • 22. Metastatic Non-Small Cell Lung Cancer
    • Palliative chemotherapy vs BSC
    • Response rate 30%
    • Survival benefit (30 vs 20% 1 year OS) with no adverse effect on QOL (BLT JCO 2005)
      • if wt loss <10% and ECOG PS <2
        • PS 0 No activity restrictions
        • PS 1 Strenuous physical activity restricted
        • PS 2 Capable of self care, no work, up and
        • about >50% waking hours
        • PS 3 Confined to bed or chair >50%
        • PS 4 Confined to bed or chair
  • 23. Metastatic Non-Small Cell Lung Cancer
    • Survival benefit with chemo:
      • Previously 2 months (incr from 7 mth to 9)
      • 30% 1 year survival
      • Now 35-50% 1 year survival, up to 25% 2 yr survival with treatment
        • First line cisplatin/carboplatin + gem (squamous), vin, taxane
        • Second line taxotere, pemetrexed (adeno), erlotinib
        • Third line erlotinib
  • 24. Small Cell Lung Cancer Staging
    • Limited – potentially curable
    • Extensive - incurable
  • 25. Small Cell Lung Cancer
    • Limited Stage
        • Disease encompassable within a radiation field
        • Response rate to chemotherapy 80-90%
        • Median survival 15-20 mth with treatment, 12 mth without
        • Potentially curable
          • 3 yr OS 20%, 5 yr OS 15%
  • 26. Small Cell Lung Cancer
    • Extensive Stage (metastatic)
        • Median survival 8-13 mth with treatment vs 7 mth without
        • Response rate to first line chemo 60-80%
        • ECOG PS not as important, often poor due to disease, improves with treatment
  • 27. Small Cell Lung Cancer Management
    • Limited Stage
      • Concurrent Chemo/RT, ideally RT (3 wk) starting with cycle 1
      • Cisplatin/etoposide daily x 3d x 4 cycles
      • (3 mth)
      • Response rate 80-90%
      • PCI results in decrease in symptomatic brain mets at three yrs from 59% in untreated to 33% in patients treated with PCI
      • PCI increases 3yr OS from 15% to 20%
  • 28. Follow-up Post Treatment
    • Limited Stage Small Cell Lung Cancer
      • No proven survival benefit to ANY routine investigations in asymptomatic patients
      • Recurrent disease rarely curable, unless second primary lung cancer
      • Most recurrences occur within first yr
      • Relapses more rapidly progressive
      • Consider directed history and physical + CXR q 2-3 mth for first year, q 3 mth for second yr, q 6 mth for yr 3-5, then annually
  • 29. Small Cell Lung Cancer Management
    • Extensive Stage
      • Palliative chemotherapy
      • Response rate to first line 60-80%
      • Cis/etop, carbo/etop, oral etoposide x 3 mth
      • PCI decreases symptomatic brain mets at 1 yr from 40% to 15%, increases 1 yr OS from 13% to 27%
      • Second line treatment depends on time to progression
  • 30. Follow-up
    • Symptoms of concern:
      • New or worsening SOB, cough, hoarseness, dysphagia, chest pain, lightheadedness/syncope, peripheral edema, RUQ pain, wt loss, bone pain (back pain, cord compression symptoms), headache/CNS symptoms
    • Complications to consider:
      • DVT/PE
      • SVCO
      • Pleural, Pericardial effusion
      • Cord compression
      • Brain mets
      • Paraneoplastic syndrome
  • 31. Paraneoplastic Syndromes
    • Non-Small Cell Lung Cancer
      • Hypercalcemia
        • Squamous cell > adeno > small cell
      • Clubbing, Hypertrophic pulmonary osteoarthropathy
        • Adeno
      • DVT/PE
        • Adeno
  • 32. Paraneoplastic Syndromes
    • Small Cell Lung Cancer
      • SIADH
      • Cushing’s syndrome
      • Lambert-Eaton myasthenic syndrome
      • Limbic encephalitis
      • Cerebellar degeneration
      • Peripheral sensory neuropathy
  • 33. Complications Treated with Palliative Radiation
    • Brain metastases
    • Spinal cord compression
    • Hemoptysis
    • SVCO
    • Painful bone metastases
    • Airway obstruction (+/- postobstructive pneumonitis)
  • 34.