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Lung Cancer

Lung Cancer. Elin Roddy, Lead Clinician for Lung Cancer at SaTH Elin.roddy@sath.nhs.uk @elinlowri. Overview. Some depressing statistics Some possible reasons for the depressing statistics Brief overview of diagnosis and treatment of lung cancer, explaining why we sometimes take so long

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Lung Cancer

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  1. Lung Cancer Elin Roddy, Lead Clinician for Lung Cancer at SaTH Elin.roddy@sath.nhs.uk @elinlowri

  2. Overview • Some depressing statistics • Some possible reasons for the depressing statistics • Brief overview of diagnosis and treatment of lung cancer, explaining why we sometimes take so long • Discussion around potential improvements

  3. Age-Standardised Ten-Year Survival for Common Cancers in Males and Females, England and Wales, 2010-2011

  4. Mesothelioma 2008 - 2012

  5. Reasons why lung cancer survival is still variable and poor? • Late presentation • Deprivation (not just smoking, but mainly) • Lack of advocacy & research • Stigma • Access to staff,diagnostics and treatment

  6. Late presentation • Late symptoms due to anatomy • Poor differentiation of symptoms by patients • Primary care gate-keeping? • Early diagnosis campaigns not a panacea

  7. Symptoms in patients who turn out to have lung cancer

  8. Red flags are not always reliable but……NICE says • Any haemoptysis • Three weeks of unexplained clubbing or….. • Cough • Breathlessness • Chest or shoulder pain • Weight loss • Hoarseness • Chest signs • Or just because smokes and tired? Unclear. But probably. • Don’t wait for antibiotics to work

  9. What about the radiation?

  10. What about the cost?

  11. We (you) do well in terms of routes of referral for lung cancer – very few ‘emergencies’

  12. Is there an ideal percentage?

  13. Lung cancer rates by deprivation quintile

  14. Smoking prevalence 22.8% vs. 19.5% national average vs. 30% highest

  15. Advocacy, stigma, research • Linked to deprivation and smoking • ‘It’s all my own fault’ • Deserving vs. undeserving cancers • Research spend per annum in the UK: Breast - £41million (£3500 per death) Leukaemia - £32million (£7000 per death) Lung - £15million (£400 per death)

  16. Diagnosis and Staging • Accurate diagnosis AND staging is important • CT should be before bronchoscopy • Most patients should have histology obtained • Nodal staging with EBUS is becoming important • ‘Radical’ treatment should be preceded by PET • ‘Open and close rates’ should be <5%

  17. TNM staging – T1 NO MO good, T4 N3 M1b bad At diagnosis 20% 10% 25% 45% 1 yr survival80% 70% 50% <20%

  18. Diagnostics

  19. Treatment • Surgery is preferred radical option • ‘Resectable’ versus ‘operable’ • Radical RT (or SBRT) should be considered even if patient not fit for surgery (‘operable’) • Performance status at diagnosis is crucial:

  20. Things that affect PS • Nutrition • Pain • Continued smoking • Low mood • Physical activity

  21. Surgery

  22. Radiotherapy • Radiotherapy – can be curative, good for pain, brain mets or in combination with chemo • Radical, long course palliative, single fraction • Side effects – skin redness, hair loss, fatigue • Spinal cord and lung damage concerns with higher doses but IMRT reduces risk • Previous RT (eg for breast) may affect current dose

  23. Chemotherapy • Neo-adjuvant • Adjuvant • Palliative – first-line, second-line, maintenance • Biologic treatments – gefitinib, erlotinib – oral, fewer side-effects – need receptor testing • Incremental gains • Histological diagnosis more & more important • In the future – a panel of receptors tested? • Treatment more likely with CNS support

  24. -

  25. Comparison LUCADA headline data 2013 (2012)

  26. Learning points • Smoking and deprivation influence incidence, treatment and outcomes • Improving early diagnosis is complex • X ray early • Aim to maintain PS - including smoking cessation • Surgery preferred treatment option • Accurate staging can be complex and time-consuming • Chemo is improving, individualised • Improving specialist nurse support improves outcomes • Inverse care law – perhaps equal resource not the answer?

  27. References • British Journal of Cancer (2015) 112, 207–216. doi:10.1038/bjc.2014.596 – evaluation of the early diagnosis campaign • http://www.bbc.co.uk/news/business-22310825 - Robert Peston on funding • http://www.rcgp.org.uk/clinical/clinical-resources/~/media/Files/CIRC/Cancer/ImprovingCancerDiagnosis • The Patient Paradox by Margaret McCartney • http://www.apho.org.uk/resource/item.aspx?RID=142221 – Health Profile for T&W • http://www.hscic.gov.uk/catalogue/PUB12719/clin-audi-supp-prog-lung-nlca-2013-rep.pdf

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