Transcript 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
– 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 noncurative treatment
– Treatment modalities: surgery, chemotherapy,
radiation therapy
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
Overview
• Staging system for SCLC (15%)
• Life expectancy depending on stage
• Management of SCLC
– Limited stage
– Extensive stage
• Follow-up
• Complications and Paraneoplastic
conditions
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)
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?
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
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
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
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
Best Treatment
• 1. Prevention
• 2. Prevention
• 3. Prevention
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
Management of Potentially
Resectable Stage I, II, IIIA NSCLC
• Surgery
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
– Stage IIIA
36-60%
3-34%
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
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
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%
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
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
• PS 1
• PS 2
PS 3
PS 4
No activity restrictions
Strenuous physical activity restricted
Capable of self care, no work, up and
about >50% waking hours
Confined to bed or chair >50%
Confined to bed or chair
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
Small Cell Lung Cancer Staging
• Limited – potentially curable
• Extensive - incurable
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%
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
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%
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
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
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:
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DVT/PE
SVCO
Pleural, Pericardial effusion
Cord compression
Brain mets
Paraneoplastic syndrome
Paraneoplastic Syndromes
• Non-Small Cell Lung Cancer
– Hypercalcemia
• Squamous cell > adeno > small cell
– Clubbing, Hypertrophic pulmonary
osteoarthropathy
• Adeno
– DVT/PE
• Adeno
Paraneoplastic Syndromes
• Small Cell Lung Cancer
– SIADH
– Cushing’s syndrome
– Lambert-Eaton myasthenic syndrome
– Limbic encephalitis
– Cerebellar degeneration
– Peripheral sensory neuropathy
Complications Treated with
Palliative Radiation
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Brain metastases
Spinal cord compression
Hemoptysis
SVCO
Painful bone metastases
Airway obstruction (+/- postobstructive
pneumonitis)