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Lung Cancer in 2008

Lung Cancer in 2008. Dr. Natasha Leighl, MD MMSc FRCPC Medical Oncologist, Princess Margaret Hospital Assistant Professor, Medicine, University of Toronto. Lung Cancer: a growing problem. Most common cancer in Canadians Leading cause of cancer deaths (27%)

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Lung Cancer in 2008

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  1. Lung Cancer in 2008 Dr. Natasha Leighl, MD MMSc FRCPC Medical Oncologist, Princess Margaret Hospital Assistant Professor, Medicine, University of Toronto

  2. Lung Cancer: a growing problem • Most common cancer in Canadians • Leading cause of cancer deaths (27%) • Lung cancer causes more deaths than breast, colon and prostate cancer combined • 1.4 million new cases per year, 1.2 million deaths • 85% of those who develop lung cancer will die of their disease

  3. Estimated new cases in Canada, 2008 24,700 21,500 22,600 23,900 Canadian Cancer Statistics 2008

  4. Estimated cancer deaths, Canada 2008 4,300 8,900 5,400 20,200 Canadian Cancer Statistics 2008

  5. Non-small Cell Lung Cancer (85%) Treatment Strategies Early Stage Locally Advanced Advanced 20% 25% 55% Stage 1, 2 3A, 3B 3B, 4

  6. Non-small Cell Lung Cancer (85%) Treatment Strategies Early Stage Locally Advanced Advanced 20% 25% 55% Stage 1, 2 3A, 3B 3B, 4 Surgery +/- Chemotherapy (or Radiation) Radiation Chemotherapy +/- Surgery Supportive Care Chemotherapy

  7. Stages of Small Cell Lung Cancer Limited Extensive 40% 60% Stage 1, 2, 3 Stage 4

  8. Stages of Small Cell Lung Cancer Limited Extensive 40% 60% Stage 1, 2, 3 Stage 4 Chemotherapy Thoracic radiation Prophylactic Cranial Irradiation Chemotherapy PCI Other radiation prn

  9. Incidence Mortality 100 93 Men 80 80 73 72 65 64 60 Age-standardized rates (1995 – 2004; rate per 100,000) 48 40 40 37 Women 28 20 15 12 0 1975 1980 1985 1990 1995 2000 2004 Year Incidence and Mortality Rates for Lung Cancer in Canadian Men and Women National Cancer Institute of Canada: Canadian cancer statistics 2004

  10. Incidence Mortality 40 30 New cases and death for cancer by age in 2004 20 10 0 20-29 30-39 40-49 50-59 60-69 70-79 80+ Age group (years) Estimated Incidence and Mortality for Lung Cancer by Age in Canada National Cancer Institute of Canada: Canadian cancer statistics 2004

  11. Causes of Lung Cancer • SMOKING!!!! (87%) • Occupational exposure • Asbestos, arsenic, nickel, petroleum • Radon, Radiation • Passive smoking • Age • ? Genetic predisposition • ?Environmental exposures-air pollution

  12. Lung Cancer Types 15% Small Cell 85% Non-small Cell (NSCLC)

  13. Lung Cancer Types Bronchial Pluripotential Stem Cell 15% Small Cell 85% Non-small Cell (NSCLC)

  14. 1972-1978 1963-1988 NCI 1962-1968 Histological Types of Lung Cancer Adenocarcinoma 75 Squamous cell 50 BAC Percent Large cell 25 Other 0 Gazdar and Linnoila, Seminars Oncol 1988; 15(3): 215

  15. Cough Hemoptysis Chest Pain Short of breath Hoarse voice pleura (visceralparietal) Weight loss

  16. T stage T1 -  3 cm, not in main bronchus

  17. T stage T1 -  3 cm, not in main bronchus T2 - > 3 cm,  2 cm from carina, inv’n visceral pleura, subtotal atelectasis

  18. T stage T1 -  3 cm, not in main bronchus T2 - > 3 cm,  2 cm from carina, inv’n visceral pleura, subtotal atelectasis T3 – inv chest wall, diaphragm, med pleura, parietal pericardium, total atelectasis

  19. T stage T1 -  3 cm, not in main bronchus T2 - > 3 cm,  2 cm from carina, invn visceral pleura, subtotal atelectasis T3 – inv chest wall, diaphragm, med pleura, parietal pericardium, total atelectasis T4 – inv med, hrt, grt vessels, trachea, esoph, vert body, carina, satellite nodules same lobe, malignant pl effusion

  20. N stage N1 – ipsilateral peribronchial, pulmonary nodes

  21. N stage N1 – ipsilateral peribronchial, pulmonary nodes N2 – ipsilateral mediastinal, subcarinal nodes

  22. N stage N1 – ipsilateral peribronchial, pulmonary nodes N2 – ipsilateral mediastinal, subcarinal nodes N3 – contralateral med, hilar, any scalene, supraclav nodes

  23. M Stage M1 – distant metastasis, nodule in another lobe Common Sites: Liver Bone Brain Adrenals Pleura, Pericardium, Other Lung

  24. SURVIVAL AFTER SURGERY BY PATHOLOGIC STAGE OF NON-SCLC Survival in Months

  25. Staging Stage TNM 5-yr survival 1A T1N0 67% 1B T2N0 57% 2A T1N1 55% 2B T2N1, T3N0 39% 3A any T3, any N2 25% 3B any T4, any N3 5% (clinical) 4 M1 <5%

  26. Stage 1 1A T1N0 1B T2N0

  27. Stage 2 2A T1N1 2B T2N1 T3N0

  28. Stage 1, 2 Surgery ± Chemotherapy

  29. Stage 1, 2 Surgery ± Chemotherapy 5 year survival  

  30. Stage 3 3A T3N1,2 T1,2N2 3B T4N0-3 T1-3N3

  31. Stage 3 Chemotherapy + Radiotherapy +/- Surgery

  32. Stage 3 Chemotherapy + Radiotherapy +/- Surgery 5 year survival 

  33. Stage 4 TxNxM1

  34. Stage 4 Chemotherapy + Supportive Care

  35. Stage 4 Chemotherapy + Supportive Care 5 year survival  Average 8 to 10 mos

  36. What tests do you need? • Diagnosis • Bronchoscopy (>90%) / mediastinoscopy (node) • Needle aspirate or biopsy (>95%), sputum x 3(80% v 20%) • Video-Assisted Thoracoscopic Surgery (VATS) • Thoracentesis (pleural effusion) • Staging • Chest X-ray / CT Scan (Chest + Upper Abdomen) • Mediastinoscopy (assess node involvement), EBUS • Blood counts, chemistry • Bone scan (if indicated) • CT / MRI brain (if indicated) • FDG PET scan in clinical trials in Ontario

  37. PET for NSCLC PET image courtesy of Dr Nevin Murray, BC Cancer Agency

  38. Proposed Changes to Staging - 2009 • Current system revised in 1996 • Key proposed changes: • Tumors more than 7 cm moving from T2 to T3 • Changing classification of same lobe satellite nodules from T4 to T3 • Changing ipsilateral lung but different lobe metastases from M1 to T4, and contralateral lung nodules from M1 to “M1a” • Changing malignant effusions from T4 to M1a

  39. Old Clinical Stage Proposed stage

  40. Old Pathologic stage Proposed stage

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