4: Lung Cancer Epidemiology II

Question 1

Give examples of the 2 types of lung cancer treatment

Answer 1

Curative:
- Surgery
- Radical radiotherapy (eg stereotactic ablative, SABR)
- Radical chemoradiotherapy

Palliative:
- Radiotherapy
- Systemic anticancer therapy
- Combinations

Question 2

What factors act as independent predictors of survival

Answer 2

Sex
Age
Stage
Performance status

Question 3

What is performance status, how is it categorized?

Answer 3

Symptoms and function of ability of patient
0 = normal ability
1 = small restriction to daily abilities
2 = capable of self care >50% of time
3 = capable of self care <50% of time
4 = bedridden

Question 4

What factors may contribute to why performance status has effect on the prediction of survival

Answer 4

A better PS means..
- better response to treatment
- more likely to be in receipt of treatment

Question 5

What are the most important predictors of survival for lung cancer, how much % can it effect?

Answer 5

Stage (up to 458% more likely to die in highest stage)
Performance status (up to 439% more likely to die in worst PS)

Question 6

How much % difference is there between male and females in prediction of survival

Answer 6

1 : 1.13
Males 13% more likely to die than female

Question 7

Describe the variation in treatment across the regions in the UK for surgery, and why this is significant

Answer 7

There is a up to a 2 fold difference across the country in % patients receiving surgery for NSCLC (eg from SE coast -=> Thames)

This is important as surgery makes a big difference to number of patients cured

Question 8

What is VATS, what benefit does it have over open/ traditional surgery

Answer 8

VATS: video assisted thoracic surgery
Impede results in complications, atelectasis (lung collapse), deaths.

Question 9

What types of lung cancer are more radiosensitive ?

Answer 9

Squamous & small cell

Question 10

Describe the types of radiotherapy with curative intent

Answer 10

• Stereoablative body RT (SABR): high dose, low number doses (concentrated). Doesn’t rely on hitting cells in metaphase.
  55-65 Gy x3-7
• Conventional: 66 Gy over 6-7 weeks (USA)
• Continous Hyperfractionated Accelerated RT (CHART): lower radiation dose, slightly superior to conventional. 55 Gy, 3x daily for 14 days.

Question 11

What areas of the lung are SABR versus Radical RTs directed at?

Answer 11

Radical RTs: larger, central cancers
SABR: peripheral, outside ‘no fly zone’

Question 12

List complications that occur when SABR is given inside the ‘n fly zone’

Answer 12

Too close to blood vessels and air ways therefore:
- massive haemoptysis (coughing blood)
- pneumonia
- airway necrosis
- perciardial effusion (fluid accumulation)

Question 13

Above what Gy is considered ‘ablative’

Answer 13

20 Gy

Question 14

What is ‘ablative’

Answer 14

Destroyed, dead cells

Question 15

What is radio frequency / microwave ablation, why is it no longer used?

Answer 15

• cathodes inserted into solid tumour region
• heats tumour to 60C
• allow to cool, cycles repeat to cause ablation

Not used anymore due to development of SABR technology

Question 16

Under what circumstance is post-op radiotherapy often administered?

Answer 16

If resection margins are positive (cancer cells are found at the edge where surgery was performed)

Question 17

When and why are these forms of pre- and post-operative chemo therapies used:

• induction
• neo-adjuvant
• adjuvant

Answer 17

• induction: prior to operation, aims to down-stage tumour with curative intent.
• neo-adjuvant: pre-operative, reduces chance of metastasis
• adjuvant: post-op to reduce chance of metastasis

Question 18

What are the adjuvant TKIs after surgery for these pathways, and what clinical trials do they belong to:
- ALK
- MET
- KRAS G12
- ROS1, NTRK
- BRAF
- RET

Answer 18

ALNEO trial:
- ALK: alectinib

Geometry-N trial:
- MET: Capmatinib

NAUTIKA-1 trial:
- KRAS G12: Divarasib
- ROS1, NTRK: Entrectinib
- BRAF: Vemurafenib/ cobimetinib
- RET: Pralsetinib

Question 19

What was the % increase of event-free survival for patients with neo-adjuvant immunotherapy (nivolumab & chemo) versus those with chemo alone?

Answer 19

13% increase at 12 months
18% increase at 24 months

Question 20

What are some examples of treatment for lung cancer with palliative intent?

Answer 20

• Radiotherapy (symptom relief)
• SACT (chemoradiotherapy)
• Supportive & palliative care
• Endobronchial treatment

Question 21

How can radiotherapy be used as palliative intent?

Answer 21

• symptom relief:
• treats haemoptysis or pain with a 60-70% response rate

Question 22

What is prophylactic cranial irradiation (PCI) and when is it used?

Answer 22

Used to kill brain cancer cells that have metastasized, arising from small cell lung cancer.
It improves survival, but is associated with cognitive decline.

Question 23

What mutation positive lung cancer does osimertinib show increased progression-free survival against?

Answer 23

EGFR T790

Question 24

Which drug is more effective against ALK-EML4: crizotinib or alectinib

Answer 24

• alectinib has a lower cumulative incidence of CNS progression (metastasis to brain), 9.4% (compared to criztotinib 31.4%)
• crizotinib has a lower overall survival %

Question 25

Describe the interactions between immune cells and cancer cells

Answer 25

T cells respond to cancer cells via presentation of abnormal antigens via MHC molecules on cancer cell surface.
Cancer cells can evade by expressing PD-L1, binding to PD-1 receptor on T cell, inhibiting T cell activity.

Question 26

What do immune checkpoint inhibitors do?

Answer 26

Targe PD-L1/PD1 to disrupt inhibitory effect of cancer cells

Question 27

What are some example of PD1 and PD-L1 inhibitors?

Answer 27

PD1: pembrolizumab
PD-L1: devalumab, ivolumab

Question 28

What are some biomarkers measured when deciding on the treatment for NSCLC?

Answer 28

• EGFR-TK +/-?
• ALK +/-?
• ROS-1 +/-?
• T790M +/-?
• PD-L1 >/<50%?

Question 29

Is early palliative care or standard more effective and why?

Answer 29

Early
- Increase % patients survival (possibly due to less toxic 4th line treatment)
- diminished depression scores

Question 30

What are the options for endobronchial palliative?

Answer 30

If urgent clearance of airway is needed:
- Laser / Surgical stent
If not:
- External beam radiotherapy
- Brachytherapy
- Cryotherapy