This document provides an overview of lung cancer presented by Dr. Zeba Firdous. It discusses the epidemiology, risk factors, clinical features, investigations, pathological classification, staging, treatment options including surgery, chemotherapy and palliative care, differences between young and elderly patients, and the role of geriatricians in caring for older lung cancer patients. Lung cancer is a leading cause of cancer deaths worldwide and often presents at advanced stages with poor survival rates. Thorough evaluation, early detection, and multidisciplinary care are important to optimize outcomes.
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Lung cancer in Geriatric Population
1. Lung Cancer
Presented by : Dr Zeba Firdous , JR-III
Under Guidance : of Dr Mangala Borkar , Professor & Head ,
Dr Shailaja V Rao , AssociateProfessor
Dr Ganesh Sonvane, Lecturer , Dr Nilesh Wagh SR ,
Department of Geriatrics, GMCH Aurangabad .
2. “When an individual has
symptoms suggestive of lung
cancer but waits to seek
medical evaluation , it can
advance exponentially.
2
3. Various Presentations in Geriatrics OPD
and Ward
◦ Patient brought to OPD as case of COPD
exacerbation , on history gave h/o operation for
carcinoma breast and incomplete postoperative
chemotherapy , on Radiology – Carcinoma Lung
with Metastases
◦ Operated one year back for Aortic Thrombosis and
on anticoagulation since then , after that developed
cough and weight loss on CECT – b/l lung cancer
carcinoma with pulmonary artery involvement – cant
3
4. ◦ Patient brought with left sided hemiplegia , CT
suggestive of Cerebral neoplasm , and x ray chest
showed mass in left lung
◦ Patient with retroviral disease , came with cough
and effusion , suspected tuberculosis but CT scan
done diagnosed lung mass
◦ Patient with chronic cough , fever , back pain –
started on empirical AKT – lung carcinoma with
vertebral metastasis on CT 4
5. Epidemiology
◦ Leading cause of cancer related deaths in world GLOBACON
report 2018 - affected about 2.1 million people ( 11.6 percent
of all cancers ) and caused 1.8 million deaths ( 18.4 % of all
cancer related deaths
◦ 67,795 new lung cancer cases in 2018 in India
5
6. ◦ The median age at lung cancer diagnosis is 70.
◦ Despite advances in screening, diagnosis, and
treatment, the majority (80%) of lung cancer is
diagnosed with either spread to regional lymph
nodes or distant sites (ie, stage III or IV).
◦ More patients die from lung cancer than from
colon, breast, and prostate cancers combined.
6
7. Risk factors
◦ Smoking
◦ Air pollution
◦ Asbestos , Radon exposure
◦ Biomass exposure
◦ Prior radiation therapy to the chest for other malignancies
◦ Previous lung disease
◦ Family history
◦ Immunocompromised states
◦ COPD
7
9. Symptoms depending on site
◦ Central tumors : cough, dyspnea, hoarseness, stridor,
hemoptysis, and postobstructive pneumonia.
◦ Superior sulcus tumors : shoulder pain, arm pain, brachial
plexopathy, or Horner syndrome.
◦ Peripheral lesions : pleuritic chest pain due to pleural
involvement.
◦ Mediastinal disease : hoarseness caused by the involvement
of the left recurrent laryngeal nerve with left-sided tumors
and obstruction of the superior vena cava with right-sided
tumors or associated lymphadenopathy.
9
10. Prevention
◦ Avoid risk factors
◦ Use of Air Filter mask in c/o occupational exposure
◦ Avoid unneccesary Imaging
◦ Avoid taking beta carotene supplements if you are
heavy smoker
◦ Diet and physical activity
◦ Cancer awareness and Screening 10
11. Investigations
◦ Chest X Ray
◦ Sputum cytology
◦ CECT Chest
◦ Biopsy
◦ Liquid Biopsy
◦ Pleural fluid analysis
◦ USG to r/o metastasis
◦ PET SCAN BONE SCAN 11
12. Liquid biopsy
◦ Uses invasive character of lung cancer as its “Achilles’
heel”
◦ Cancer derived components that circulate in blood
◦ Detects CTC , ctDNA, EXOs
◦ 7.5 ml of blood sample taken
◦ Useful in inaccessible tumor location, no result with
biopsy or where biopsy cant be performed, in COPD
◦ Cost – 30,000
12
13. Pathological Classification
◦ NSCLC – COMMON 80%
◦ SCLC- 20% . More responsive to chemotherapy
and radiation, requires prophylactic cranial
irradiation (PCI), and often has a more
aggressive clinical course
13
14. Staging of NSCLC
◦ Stage I : less than or equal to 5 cm without
mediastinal involvement
◦ Stage II :(> 5 cm or local obstruction without nodal
involvement) and/or ipsilateral hilar nodal
involvement (ie, N1 disease).
◦ Stage III : chest wall involvement with OR without
nodal involvement
◦ Stage IV : Distant metastasis
14
16. Physiologic Staging
◦ .Patients with a forced expiratory volume in 1 s (FEV1) of greater than 2 L or
greater than 80% of predicted - pneumonectomy, and those with an FEV1
greater than 1.5 L - lobectomy.
◦ In patients with borderline lung function but a resectable tumor,
cardiopulmonary exercise testing - a Vo2max <15 mL/(kg.min) high risk of
postoperative complications.
◦ Unable to tolerate lobectomy or pneumonectomy - limited resections, eg
wedge or anatomic segmental resection
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26. Contraindications to Thoracic
Surgery
◦ A myocardial infarction within past 3 months -20% of
patients will die of reinfarction
◦ Uncontrolled arrhythmias
◦ FEV1 of less than 1 L
◦ O2 retention (resting Pco2 >45 mmHg)
◦ DLco <40%
◦ Severe pulmonary hypertension
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27. Treatment NSCLC
◦ Stage I : Surgery +/- postoperative chemotherapy ,
SBRT
◦ Stage II : Surgery + postoperative chemotherapy ,
Radiotherapy +/- Chemotherapy
◦ Stage III : Chemoradiation , surgery in selected cases
◦ Stage IV : Chemotherapy /Targeted therapy
27
28. Chemotherapeutic Agents
◦ Stage I/II : Carboplatin/Paclitaxel
◦ Cisplatin/Etoposide
◦ Cisplatin/Pemetrexed
◦ Cisplatin/Vinorelbine
◦ Stage III : Usually with radiation
◦ Cisplatin/Etoposide
◦ Carboplatin/Paclitaxel
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31. Palliative and End of life care
◦ Improves quality of life
◦ Palliative surgery
◦ Palliative Pharmacotherapy
◦ Palliative Chemotherapy
◦ Palliative Radiation
◦ Others
31
32. Palliative Surgery
◦ Airway Obstruction : Palliative bronchoscopy , short term intubation,
tumor debulking , balloon dilatation, laser therapy , electrotherapy ,
cryotherapy ,airway stent
◦ Massive Hemoptysis : Therapeutic ronchoscopy with balloon
tamponade and infusion of epinephrine, laser coagulation or
embolization of feeding vessel
◦ Pleural effusion : Chemical pleurodesis, surgucal pleurodesis pleral
drain catheter
◦ SVC Syndrome : caval bypass , stent placement
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33. Palliative Pharmacology
◦ NSAIDs AND Acetaminophen for pain management
, opiods, anticonvulsants , tricyclic antidepressants
◦ Steroids – edema caused by spinal and intracranial
mets
◦ Bisphosphonates – pain by bony metastasis
◦ Bronchodilators , steroids, oxygen ; dyspnea
◦ Cough suppressants
◦ Scopolamine and Glycopyrolate for copius
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35. Cause of Death
◦ Respiratory failure
◦ Sepsis
◦ Pneumonia
◦ Hemopericardium from pericardial mets
◦ Myocardial mets
◦ Brain mets
◦ Pulmonary hemorrhage , embolism
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36. Problems in Indian Set up
◦ Stigma of tuberculosis and lung cancer
◦ Lack of awareness about treatment and
complete cure
◦ Denying investigations like CECT and
Biopsy
36
37. Cost of Care
◦ Comparative effectiveness studies ( Of
investigations and treatment options ) are
needed to inform and help contain cancer health
care costs.
37
38. Govt of India Support for Lung
Cancer
◦ Health Minister’s Cancer Patient Fund
◦ The Central Govt Health Scheme
◦ PMJAY/MJPJAY
◦ The Prime Minister’s National Relief Fund
◦ Chief Minister’s Relief Fund
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39. Lung Cancer and COVID 19
◦ Risk of contracting COVID 19 and Mortality
increases in lung cancer patients
◦ COVID 19 related pneumonia may mimic
radiotherapy induced pneumonitis
◦ Lung cancer patient should strictly follow mask use ,
hand hygiene , social distancing
◦ Minimize visit to hospital , use telemedicine
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40. Difference between young and elderly
Comorbidities, especially those linked to tobacco use (coronary disease,
obliterans arteritis of lower limbs, hypertension, chronicobstructive
pulmonary disease (COPD), etc.all of which may compromise the
administrationof chemotherapeutic agents, forexample cisplatin in
the case of cardiac insufficiency or severe COPD, which do not allow
hyperhydration.
Polypharmacy :interaction between carboplatine, gemcitabine, paclitaxel
or etoposide and warfarin (increased anticoagulant effect), between
cisplatin and phenytoin with a reduced control of seizures but also
with erlotinib or gefitinib with phenytoin, carbamazepine and
primidone with a reduced activity of those targeted therapies.
40
41. ◦ Physiological Alterations with Aging: although the outcome
with carboplatin is slightly inferior to cisplatin
◦ Carboplatinis preferred in elderly patients because the
dosage is adapted to renal function and because it does not
require hyperhydration
◦ Haematological toxicityis more in elderly and prophylactic
antibiotics should be used
◦ CGA should be done instead of Performance status
41
42. Role of GERIATRICIAN …
◦ Help older adults with lung cancer and their caregivers
define goals of care, optimize the management of geriatric
syndromes and comorbid conditions, and better assess
functional, cognitive, and psychosocial reserve to undergo
treatment.
◦ Early integration of palliativecare improves mood and
quality of life and may prolong survival
42
43. Take Home Message
◦ Keep a high suspicion of lung malignancy esp in
case of chronic cough even if an alternative
diagnosis is available
◦ Encourage de-addiction counselling and therapy
◦ Early diagnosis is crucial
◦ Keep in mind the atypical presentations
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