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. • 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. 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. 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
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. 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. 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. 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. • 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
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. 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
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. 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. Cranial Irradiation
• 10# of 25Gy
• WHO ≤ 2 and whose disease has not
progressed on first line treatment
21. Case One
Brenda
Aged 56
Cough and Haemoptysis
Otherwise well. Independent.
CT: 4cm lesion with ipsilateral node
Tissue Confirmation: NSCLC
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. 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. •
•
•
•
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
