PATIENTS SEMINAR LUNG CANCER

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PATIENTS SEMINARLUNG CANCER

• Paris A. Kosmidis , MD
• Hygeia Hospital
• Athens , GREECE
• LUGANO, JULY 2007

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LUNG CANCER

• Epidemiology
• Etiology Risk factors
• Histology
• Symptomatology
• Diagnosis
• Staging

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EPIDEMIOLOGY
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LUNG CANCER IN 2004

• E.U. 130000 deaths
• U.S.A. 155000 deaths
• JAPAN 52000 deaths
• WORLD 1200000 deaths

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Lung cancer

• Responsible for about one-third of all cancer
  deaths
• Accounts for more deaths than breast cancer,
  prostate cancer and colon cancer COMBINED
• 85 of patients who develop lung cancer will die
  of the disease

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LUNG CANCER

• 5 year survival
• 1974 76 12
• 1992 97 15
• Cancer statistics 2002 CA Cancer J. Clin
  

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THERAPEUTIC OPTIONS IN NSCLC
I
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Surgery Radiotherapy Chemotherapy
II
IV
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IIIA
IIIB
Radiotherapy Chemotherapy Surgery
Chemotherapy Supportive care
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ETIOLOGY RISK FACTORS
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LUNG CANCERETIOLOGY RISK FACTORS

• Smoking
• 90 of cases
• Number of cigarettes smoked
• Age of starting point
• Length of smoking time
• Smoking secession
• It takes 15 years to decrease risk

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LUNG CANCERETIOLOGY RISK FACTORS

• Pre-existing pulmonary disease
• 1. Idiopathic pulmonary fibrosis (15)
• 2. Chronic airway obstruction (4)
• 3. Tuberculosis (1.5)
• Occupational exposure
• Asbestos, Radon, Arsenic
• Ionizing radiation
• Haloethers, Nickel, Silica

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LUNG CANCERETIOLOGY RISK FACTORS

• Atmospheric pollutants
• 1. Polycyclic aromatic hydrocarbons
• Family history of Lung cancer

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HISTOLOGY
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LUNG CANCERHISTOLOGY

• 1. NON-Small cell 2. Small cell
• Squamous
• Adenocarcinoma
• Bronchoalveolar
• Large cell
• Pleomorphic
• Neuroendocrine
• Carcinoid
• Small cell
• Large cell

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SYMPTOMATOLOGY
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SIGNS AND SYMPTOMS FROMREGIONAL SPREAD OF LUNG
CANCER

• Nerve Entrapment
• Cardiovascular Involvement
• Mediastinal Involvement

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PARANEOPLASTIC SYNDROMESIN LUNG CANCER PATIENTS

• Endocrine
• Neurologic
• Skeletal
• Hematologic
• Cutaneous
• Other

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DIAGNOSIS
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DIAGNOSIS

• Chest x- Rays
• Chest Computed Tomography
• Chest MRI
• PET
• Sputum Cytology
• Pleural paracentesis
• Fiberoptic Bronchoscopy
• CT guided FNA
• Video assisted thoracoscopy
• Open thoracotomy
• Mediastinoscopy

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STAGING
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LUNG CANCERTNM System

• T x , 1, 2, 3, 4 Limited
• N 0, 1, 2, 3 Extensive
• M 0, 1

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• EARLY STAGES

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NSCLC Pre- and Postoperative chemotherapy

• Paris A. Kosmidis , MD
• Hygeia Hospital
• Athens , GREECE
• PARIS ECCO 13, 2005

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OPTIONS FOR IMPROVEMENTS

• Adjuvant treatment
• Neo-adjuvant treatment

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Overall Survival - Stage II (pT 1-2, N1)
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Overall Survival - Stage III A (pT1-2 N2, pT3
N0-3)
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Neoadjuvant chemotherapyin resectable NSCLC

• 
  
• S CT S
  
• Median survival (m) 26 37
• 1-year survival 73 77
• p0.15
• 3-year survival 41 52
• Depierre A. et al
  

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CONCLUSION 1

• Platinum-based adjuvant chemotherapy
  significantly improves relapse-free and overall
  survival in completely resected NSCLC patients.
• This treatment should be considered as a standard
  of care for stages IIA, IIB and IIIA .
• There is not agreement for stage IB .

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CONCLUSION 2

• Neo-adjuvant chemotherapy is a feasible approach.
• There is no conclussive evidence from all trials
  to consider this approach a standard of care.
• Neo-adjuvant chemotherapy still has a lot of
  merit.
• Randomized studies comparing adjuvant vs
  neo-adjuvant chemotherapies are warranted.

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• ADVANCED DISEASE

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• PLATINUM
• COMBINATIONS

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MEDICAL TREATMENT ON NSCLC

• Table 2 . NSCLC Platinum combinations
• 
  .
• All different regimens
• Platinum - based newer agents are
• EQUALLY EFFECTIVE
  .
• From ECOG study

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• NON - PLATINUM
• COMBINATIONS

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MEDICAL TREATMENT ON NSCLC NSCLC
CHEMOTHERAPY PC vs PG

• P. Kosmidis

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MEDICAL TREATMENT ON NSCLC

• NSCLC Comparison of treatments
• 
  
  .
• Treatment
  Survival (mo) 1 - year survival
  (mo)
• Best supportive care
  6
  10
• Platinum older agents
  7 - 8 20
• Platinum newer agents
  8 - 9 30 - 40
• Non - Platinum newer agents 8
  - 9 30 - 40
• Targeted
  ?
  ? .

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• SECOND LINE
• TREATMENT

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Pemetrexed vs Docetaxel- Survival -
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BR.21 Overall Survival
Erlotinib
Placebo
HR 0.72, p0.001

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22
Months
Adjusted for stratification factors
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• TARGETED
• TREATMENT

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EGFR Mutations
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• LATEST PROGRESS
• Interaction between chemotherapy and
  anti-angiogenesis

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Bevacizumab recombinant humanised monoclonal
antibody to VEGF-A

• Bevacizumab plus chemotherapy has provided a
  survival advantage to patients with metastatic
  colorectal carcinoma

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Survival by treatment
12 months
24 months
1.0 0.8 0.6 0.4 0.2 0
PC PCB
43.7 16.9 51.9 22.1
HR0.77 (0.65, 0.93) p0.007
Medians 10.2, 12.5
Probability
0 6 12 18 24 30 36
Months
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Conclusions

• Better selection of patients
• Better 1st line treatment
• Better 2nd and 3rd line treatment
• Better strategy for PS2
• --------------------------------------------------
  -----------
• Better prevention
• Better adjuvant chemotherapy

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Epidemiology
Evolution of cancer death rates, males
Pancreas Liver Prostate Stomach Lung
bronchus Colon rectum Leukemia
70
60
50
40
30
20
10
Adapted from Greenlee RT, et al. CA Cancer J
Clin. 20005027.
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