Lung cancerBackground:• 5 year survival 12-14%• Subtypes: NSCLC (85%)• SCLC (15%) o Subtypes determined treatment optionRisk factors: o Smoking (duration and quantify), Pack years = pack (20/day) x years o Age o Asbestos o Others (less common): silica, radiation (medical, ranium), cadmium (electroplasters), arsenic (copper smelter), nickel, beryllium (ceramics, electronics, mining), chromium, and diesel exhaust fumes.Screening: o No proven effect o Investigate symptomatic patientPrevention: Primary: o Avoid active and passive smoking (increased risk for non smoker) (stop smoking is beneficial at any age) o All smokers: smoking cessation advice. o Ask (about smoking at every opportunity) o Assess (willingness to quit) o Advice (all smokers to stop) o Assist (smoker to stop) Refer to Quitline 13 Quit (13 7848) o Arrange (follow up) Secondary: • No proven chemoprevention agents. Avoid supplemental beta-carotene as it increases risk.Clinical:• Common presentations: • Solitary pulmonary nodule/coin lesion o More likely to be malignant if >3cm, speculated, irregular enlarging • Symptoms: o Unresolved chest infection o Haemoptysis o New or changed cough or wheeze o Chest pain o Dyspnoea o Unexplained weight loss o Metastases (pathological fracture) o Other eg. Paraneoplastic, constitutional symptoms.
• Initial investigations: • CXR • Sputum culture (x3) – cannot rule out disease if negative • Chest CT – spiral not HRCT (including upper abdomen for staging)• Referral: • Suspected cases • Tissue diagnosis where possible • Fibreoptic bronchoscopy (FOB): proximal or endobronchial lesions • +/- transbronchial biopsy • FNA: peripheral lesions, risk of pneumothorax requiring intercostals catheter, bleeding • Pleural tap: for effusions.Initial management: • Breaking bad news: in a quiet private place • Allow enough uninterrupted time in the initial meeting • Assess the individual’s understanding • Provide information simply and honestly • Encourage individuals to express their feelings • Respond to individual’s feelings with empathy • Give a broad time-frame for the prognosis • Avoid the notion that nothing can be done • Arrange a time to review the situation • Discuss treatment options • Offer assistance to tell others • Provide information about support services • Provide written information • Offer a tape recording of the sessionQuality of life: • Discuss the potential impact of tests and treatments on quality of life for patient and carersStaging of disease: • Determines treatment options • Staging system differ: o NSCLC – TNM stage o SCLC – Limited (localized to 1 hemithorax) or extensive • Staging test options: o Chest CT: For staging tumour and hilar/mediastinal nodes Usually includes upper abdomen (liver and adrenals) o CT head (with contrast) NSCLC – for symptoms or abnormal signs o Bone scan: NSCLC – symptoms, abnormal clinical findings, lab tests
o Flluoro-deoxy glucose (FDG) positron emission tomography (PET) scan: Highly sensitive and specific for lung cancer Assess SPNs when bronchoscopy/ FNA unsuitable Helps stage NSCLC (appropriate staging will avoid fruitless surgery) o As SCLC staging and treatment is different, staging tests can stop if extensive disease confirmed.Specific management principles: Share decision making with patient and carers Address psychosocial issues Ensure patient’s questions are answered Evaluate prognostic factors: o TNM stage, performance status, and weight loss are prognostic factors in NSCLC. o Performance status guides treatment suitability.Treatment options (see appendix)Supportive care and quality of life:Treatment shown to improve QOL even if not curative: o Dyspnoea: breathing retraining; coping and adaptive strategies o Morphine – nebulised/systemic o Oxygen as indicated o Treat cause: pleural effusion (drainage +/-pleurodesis eg talc insufflation); large airway obstruction: stents, lawer, radiotherapy/brachytherapy o Cough: nebulised lignocaine, oral opioids. o Chest pain: palliative radiotherapy, analgesia including opioids. o Haemoptysis: Palliative radiotherapy. o Bone pain: palliative radiotherapy, analgesia (opioids, +/- cisphosphonates), +/- fixation (consult orthopaedic surgeon) o Anxiety/depression: o Psychological support and counseling o Medications (anxiolytics, antidepressants) o Agitations: midazolam o Address medication side-effects: o Drowsiness eg. Morphine – titrate, co-analgesia o Constipation: Laxatives, aperients, hydration.
Appendix:NSCLCStage Optimal Rx If not suitable for optimal Rx, treat depending on symptoms and performance statusI and II Surgical resection o Observation if no symptoms. o Good performance status: radical radiotherapy +/- chemotherapy. o Poor performance status: palliative managementIII A o Induction chemotherapy o Observation if followed by: surgery asymptomatic +/- mediastinal o Palliative radiotherapy radiotherapy/chemother o Radical combination apy chemoradiotherapyIII B Radical combination chemoradiotherapyIV o Chemotherapy and o Supportive care alone palliative o Palliative radiotherapy radiotherapy for specific sites of disease (brain, bone pain) o Some patients have solitary brain metastases may be suitable for surgical excision.
SCLCStage Optimal Rx If not suitable for optimal RxLimited Platinum based Palliative chemotherapy +/- chemotherapy (4-6 cycles) radiotherapy combined with thoracic radiotherapy concomitant with first or second cycle Prophylactic cranial irradiation for complete responders.Extensive Combination chemotherapy Symptom control (4-6 cycles) Prophylactic cranial irradiation for complete responders.