No Air Management of Lung Cancer

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No AirManagement of Lung Cancer

• Elaine Bouttell, MD FRCPC
• Medical oncology
• GRRCC

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• Disclosures
• Advisory board for Novartis, RCC

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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

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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

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Overview

• Staging system for SCLC (15)
• Life expectancy depending on stage
• Management of SCLC
• Limited stage
• Extensive stage
• Follow-up
• Complications and Paraneoplastic conditions

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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)

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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?

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Second Hand Smoke causes Lung Cancer

• Meta-analysis of 52 studies prepared for the
  Surgeon Generals 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, gt25
  smoker-years doubled the risk, lt25 smoker-years
  did not appear to increase the risk

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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

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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

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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

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Best Treatment

• 1. Prevention
• 2. Prevention
• 3. Prevention

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Non Small Cell Lung Cancer

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  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

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Management of Potentially Resectable Stage I, II,
IIIA NSCLC

• Surgery

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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

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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

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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 Tgt4cm)
• no proven additional benefit for stage IA

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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

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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

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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 lt10 and ECOG PS lt2
• PS 0 No activity restrictions
• PS 1 Strenuous physical activity restricted
• PS 2 Capable of self care, no work, up and
• about gt50 waking hours
• PS 3 Confined to bed or chair gt50
• PS 4 Confined to bed or chair

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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

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Small Cell Lung Cancer Staging

• Limited potentially curable
• Extensive - incurable

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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

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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

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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

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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

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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

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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

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Paraneoplastic Syndromes

• Non-Small Cell Lung Cancer
• Hypercalcemia
• Squamous cell gt adeno gt small cell
• Clubbing, Hypertrophic pulmonary osteoarthropathy
• Adeno
• DVT/PE
• Adeno

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Paraneoplastic Syndromes

• Small Cell Lung Cancer
• SIADH
• Cushings syndrome
• Lambert-Eaton myasthenic syndrome
• Limbic encephalitis
• Cerebellar degeneration
• Peripheral sensory neuropathy

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Complications Treated with Palliative Radiation

• Brain metastases
• Spinal cord compression
• Hemoptysis
• SVCO
• Painful bone metastases
• Airway obstruction (/- postobstructive
  pneumonitis)

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