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“No Air” Management of Lung Cancer

“No Air” Management of Lung Cancer. Elaine Bouttell, MD FRCPC Medical oncology GRRCC. Disclosures: Advisory board for Novartis, RCC. Objectives. Review the diagnosis, treatment, and palliation of lung cancer Review the types and demographics of lung cancer

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“No Air” Management of Lung Cancer

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  1. “No Air”Management of Lung Cancer Elaine Bouttell, MD FRCPC Medical oncology GRRCC

  2. Disclosures: • Advisory board for Novartis, RCC

  3. 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

  4. 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

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

  6. 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)

  7. 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?

  8. Second Hand Smoke causes Lung Cancer • Meta-analysis of 52 studies prepared for the Surgeon General’s 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, >25 smoker-years doubled the risk, <25 smoker-years did not appear to increase the risk

  9. 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

  10. 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

  11. 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

  12. Best Treatment • 1. Prevention • 2. Prevention • 3. Prevention

  13. Non Small Cell Lung Cancer 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

  14. Management of Potentially Resectable Stage I, II, IIIA NSCLC • Surgery

  15. 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%

  16. 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

  17. 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 T>4cm) • no proven additional benefit for stage IA

  18. 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%

  19. 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

  20. 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 <10% and ECOG PS <2 • PS 0 No activity restrictions • PS 1 Strenuous physical activity restricted • PS 2 Capable of self care, no work, up and about >50% waking hours PS 3 Confined to bed or chair >50% PS 4 Confined to bed or chair

  21. 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

  22. Small Cell Lung Cancer Staging • Limited – potentially curable • Extensive - incurable

  23. 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%

  24. 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

  25. 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%

  26. 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

  27. 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

  28. 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

  29. Paraneoplastic Syndromes • Non-Small Cell Lung Cancer • Hypercalcemia • Squamous cell > adeno > small cell • Clubbing, Hypertrophic pulmonary osteoarthropathy • Adeno • DVT/PE • Adeno

  30. Paraneoplastic Syndromes • Small Cell Lung Cancer • SIADH • Cushing’s syndrome • Lambert-Eaton myasthenic syndrome • Limbic encephalitis • Cerebellar degeneration • Peripheral sensory neuropathy

  31. Complications Treated with Palliative Radiation • Brain metastases • Spinal cord compression • Hemoptysis • SVCO • Painful bone metastases • Airway obstruction (+/- postobstructive pneumonitis)

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