Transcript lung cancer - Jacobi Medical Center

Marianna Strakhan, MD
Attending Physician
Department of Hematology/Oncology
Jacobi Medical Center
Bronx, NY
March 30, 2010
Incidence
 2nd most common type of malignancy in the U.S. among both men and
women
 Most common form of cancer mortality in the U.S. in both men and
women
 In 2007 – approximately 215,000 new cases of Lung cancer were
diagnosed in the U.S, with 162,000 deaths
 Between 1990 and 2003 – incidence of lung cancer have remained
stable in men, however in women, incidence increased by 60%
(incidence in African american females being partially higher than
white females).
**Incidence increase is seen among large portion of never-smokers, healthy,
and active women)
Incidence
 Although deaths have begun decreasing in MEN (likely due
to decrease in smoking), mortality in WOMEN has reached
a plateau
 Almost ½ of all cancer deaths now occur in women
 10 – 15% of lung cancer victims are non-smokers. Among
that group, women are 2-3x more likely than men to get the
disease
Incidence
 Median age of diagnosis is 66 y.o. in both women and men.
 More of the patients <50 y.o. at time of diagnosis were
women
 In women, 45% of all lung cancers were adenocarcinoma,
followed by 22% small cell cancer, 21% squamous cell, rest
as other subtypes
(in men, squamous subtype is most common, followed by adeno,
followed by small cell)
Risk Factors
 Cigarette smoking
- in the U.S, nearly 25% of women smoke
- some studies suggest women have more difficulty quitting smoking than men
– risk is increased 10 – 30 x than in non-smokers
- smoking > or = 25 cig/day increases risk more than smoking less than 25 cig/day
- age at onset of smoking
- degree of inhalation correlates with risk of developing disease
- Tar and nicotine content of cigarettes
- use of unfiltered cigarettes
- smoking cessation decreases risk significantly, with decline in risk starting > 5 years of
abstinence.
- after 15 years, risk is reduced by 80%. The longer one the person is not smoking, the lower the
risk becomes – however risk still remains higher than in never smokers
 2nd hand smoke
- the longer the exposure the higher the risk
- approximately 17% of all lung cancer in never smokers is due to second hand smoking
during the person’s childhood and adolescence
- risk doubles with 25 or > years of exposure
- ban of smoking in restaurants/enclosed spaces decreases undesired exposure of non-smokers
Risk Factors

Asbestos

Radon

Arsenic

Ionizing radiation

Polycyclic aromatic hydrocarbons

Nickel

Pulmonary Fibrosis

HIV infection

Family History

Beta Carotene (initially used for chemoprevention, noted to be associated with higher risk of lung
cancer in smokers)

Race (African Americans and Hawaiians have higher risk of lung cancer incidence among persons
who smoke <30 cig/day, no difference between the races among persons smoking >30 cig/day)
Risk Factors
*Lung cancer in women is a biologically and genetically
different disease than in men:
 Genes that cause women to be more vulnerable to the harmful effects of tobacco
smoke
 Differences in how the chemicals in tobacco are metabolized (broken down) by the
body
 Changes to genes that control cell growth, which may result in the development of
cancer
 A decreased ability of the body to repair damaged DNA, as DNA damage can
promote the development of cancer
 Hormones, such as estrogen, which could directly or indirectly affect cancer growth
Signs and Symptoms

Cough

Hemoptysis

Dyspnea

Chest Pain

Hoarseness (due to involvement of recurrent laryngeal nerve)

SVC syndrome (dilated neck veins, facial edema)
– due to pressure on SVC by the tumor

Pancoast’s syndrome
– pain in shoulder or arm, Horner’s syndrome (miosis, ptosis, anhidrosis), atrophy of hand muscles

Weight loss

Paraneoplastic syndromes
-example: Hypercalcemia in Squamous cell ca
SIADH in Small Cell Ca
SVC Syndrome
Etiology:
-result of compression of SVC by either malignancy (RUL mass) or
thrombosis (mainly due to use of intravascular device)
-most common etiology is lung cancer
-may also be due to infections (TB, etc..) or hematological malignancies
such as lymphoma/leukemia
Signs/Symptoms:
-symptoms may develop over weeks or longer
-increased venous pressure leads to edema of head, neck and arms
-headache
-cyanosis
-cough, dyspnea
-dysphasia, stridor
SVC Syndrome
SVC Syndrome
SVC Syndrome
Diagnosis
-CXR (mediastinal widening, mediastinal mass)
-CT neck/chest
-ultrasound/doppler to r/o thrombosis of SVC
Treatment
-Oxygen
-elevation of the upper body
-diuretics, fluid restriction
-anticoagulation if thrombosis
-biopsy – obtain pathology prior to treatment
-*chemotherapy
-radiation therapy
-steroids (benefits unproven)
-endovascular stents (if conventional therapy unsuccessful)
Prognosis
-patients with malignant obstruction of SVC have Overall survival of <7 months
Pathology
 Adenocarcinoma (including bronchioloalveolar carcinoma) — 38%
 Squamous cell carcinoma — 20%
 Large cell carcinoma — 5%
 Small cell carcinoma -13%
 Other non-small cell carcinomas (not further classified) -18%
 Other (mesothelioma, carcinoids)-6%
NSC Lung Cancer
 Adenocarcinoma
-Bronchioloalveolar subtype (more common in never smokers and
women)
 Squamous cell Carcinoma
-Centrally located
-Often cavitates
 Large Cell Carcinoma
*prognosis is similar among the subtypes
Staging – NSC Lung Cancer
Small Cell Lung Cancer
 Typically centrally located
 Comprises 13% of all lung cancers
 Smoking is a major risk factor
 s/s: cough, dyspnea, weight loss, chest pain
 Approximately 70% present with metastatic disease at diagnosis
 Frequent mets to liver, bone, bone marrow, brain
 Overall prognosis is poor
Staging – Small Cell Lung Cancer
 Limited Stage
-disease confined to ipsilateral hemithorax
-confined to a single radiotherapy port
 Extensive Stage
-evidence of disease outside of ipsilateral hemithorax
-disease which can not be covered by a single
radiotherapy port
Mesothelioma
 Rare type of cancer
 Almost always caused by exposure to asbestos
 Malignant cells develop in the mesothelium– the
lining of the body’s organs (example: pleura)
 There is no association between mesothelioma and
smoking, although smoking greatly increases risk of
asbestos induced cancer
Screening
NO SCREENING TEST (CXR, CT,
OR SPUTUM CYTOLOGY)
HAS BEEN SHOWN TO REDUCE
MORTALITY FROM LUNG
CANCER
Diagnosis
 History and Physical
 Laboratory studies
 Radiographic Imaging (CT, PET, bone scan)
 Tissue sampling
Imaging
Imaging
Treatment
 Approach to treatment is multifactorial
 Depends on:
1.
2.
3.
4.
5.
6.
type of cancer (Non-small cell including subtype or small cell)
stage of disease
patient’s age
performance status
patient’s smoking status
patient’s preference
 Options include:
1.
2.
3.
4.
Surgery
Radiation therapy
Chemotherapy
Combination of above
Pharmacology
Chemotherapy side –effects
 Carboplatin – neuropathy, renal toxicity
 Cisplatin – neuropathy, renal toxicity, renal wasting of electrolytes,
hearing loss
 Paclitaxel – neuropathy, allergic reactions to cremaphor (preservative),
chest pain, fluid retention
 Navelbine – neurotoxicity, cytopenias, fatigue
* all – cytopenias, nausea/vomiting, hair loss, fatigue
IPASS Study
 EGFR inhibitor (Iressa in Europe, oral form -Tarceva in
U.S.)
 Compared with standard chemotherapy (Carbo/Taxol)
 Found that in women, Asian descent, non-smokers,
with adenocarcinoma, with EGFR mutation – PFS >3x
higher with EGFR inhibitor than with standard
chemotherapy.
Prognosis
 NSC Lung Cancer:
5 year overall survival:
-Stage I – 50-60%
-Stage IV – 1%
-Stage IV disease median survival 9 months
 Small Cell Lung Cancer:
5 year overall survival:
-Limited disease – 20%
-Extensive disease - <1%
Prognosis
 stage specific survival rates are better in women than in
men in both NSC and small cell lung cancer
 women who underwent surgical resection of disease had
longer O.S. than men with same stage and surgery
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