Lung Cancer Flashcards
(35 cards)
What are the red flag symptoms indicating lung cancer?
• Cough (dry/productive)
o if productive then send sputum for microscopy, sensitivity and cytology
• Haemoptysis
o remember to clarify amount. Many lung cancers do not present with this, but it is very worrying if present
• Dyspnoea
o check if this has changed recently
• Hoarse voice
o could be a symptom of recurrent laryngeal nerve involvement which would imply mediastinal involvement with cancer.
• Chest pain
o character important
- Fatigue
- Appetite loss
• Weight loss
o how much over how long. Intentional? Proportion of usual weight. Implies more advanced disease
When should you refer patients to a lung clinic for suspected cancer?
• Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for lung cancer if they:
o have chest X-ray findings that suggest lung cancer or
o are aged 40 and over with unexplained haemoptysis.
When should you refer patients for urgent CXR?
• Offer an urgent chest X-ray (to be performed within 2 weeks) to assess for lung cancer in people aged 40 and over if they have 2 or more of the following unexplained symptoms, or if they have ever smoked and have 1 or more of the following unexplained symptoms: o cough o fatigue o shortness of breath o chest pain o weight loss o appetite loss.
• Consider an urgent chest X-ray (to be performed within 2 weeks) to assess for lung cancer in people aged 40 and over with any of the following:
o Persistent or recurrent chest infection
o finger clubbing
o supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
o chest signs consistent with lung cancer
o thrombocytosis.
Information and support offered to lung cancer patients
• Ensure that a lung cancer clinical nurse specialist is available at all stages of care to support people and (as appropriate) their family members or carers.
• Consider tailor-made decision aids to help people to:
o understand the probable outcomes of treatment options
o think about the personal value they place on benefits versus harms of treatment options
o feel supported in decision-making
o move through the steps towards making a decision
o take part in decisions about their healthcare.
- Offer people a record of all discussions that have taken place with them and a copy of any correspondence with other healthcare professionals. Ensure all communications are worded in such a way to assist understanding.
- Respect the person’s choice if they do not wish to confront future issues.
- Avoid giving people unexpected bad news in writing. Only give unexpected bad news by phone in exceptional circumstances.
What advice should be given about smoking cessation?
- Advise people to stop smoking as soon as the diagnosis of lung cancer is suspected and tell them why this is important.
- Inform people that smoking increases the risk of pulmonary complications after lung cancer surgery.
- Offer nicotine replacement therapy and other therapies to help people to stop smoking.
- Do not postpone surgery for lung cancer to allow patients to stop smoking.
Why is asking about social and family history important when lung cancer is suspected?
• Smoking history:
o causation and opportunity to improve prognosis by stopping. If a never smoker then increased likelihood of EGFR mutation and response to Tyrosine kinase inhibitors
• Alcohol intake:
o poorer ability to tolerate chemotherapy
• Occupation:
o asbestos exposure.
o Compensation.
o Inability to work and loss of income
• Who’s at home
o i.e. who are they supporting and who will support them through treatment and the side-effects of therapy
• Family history of cancer.
o Patients may have pre-conceived ideas about their diagnosis that can either be positive or negative
What are the investigations for lung cancer
CXR CT scan EBUS-TBNA PET-CT Biopsy Blood tests Pulmonary function tests
Why do you do CXR as part of investigations for lung cancer?
- Shows the tumour on CXR
- Simple and easier to perform than CT
- An abnormal CXR report triggers a CT scan
Why do you do CT scan as part of investigations for lung cancer?
- Offer people with known or suspected lung cancer a contrast-enhanced chest CT scan to further the diagnosis and stage the disease. Include the liver, adrenals and lower neck in the scan.
- Perform CT before any biopsy procedure.
- CT alone may not be reliable when assessing mediastinal and chest well invasion.
What should you assess before performing a CT scan?
o Ask about previous contrast reaction
o Check renal function - if GFR <40ml/min then increased risk of contrast-induced acute kidney injury.
o Check for diabetes Mellitus – metformin therapy – (metformin may need to be stopped pre contrast if renal impairment).
Why do you do EBUS-TBNA as part of investigations for lung cancer?
Offer EBUS (endobronchial ultrasound)- TBNA (transbronchial needle aspiration) for biopsy of paratracheal and peri-bronchial intra-parenchymal lung lesions.
Why do you do PET-CT scan as part of investigations for lung cancer?
- The preferred first test after CT with a low probability of nodal malignancy (lymph nodes below 10 mm maximum short axis on CT) and for people with lung cancer who could potentially have treatment with curative intent.
- Offer image-guided biopsy to people with peripheral lung lesions when treatment can be planned on the basis of this test.
- Offer PET-CT followed by EBUS
Which investigations are offered if lymph nodes are affected in a lung cancer patient?
- Biopsy any enlarged intrathoracic nodes (10 mm or larger maximum short axis on CT) or other lesions in preference to the primary lesion if determination of nodal stage affects treatment.
- Offer flexible bronchoscopy to people with central lesions on CT if nodal staging does not influence treatment.
- Offer PET-CT scan followed by EBUS-TBNA to people with suspected lung cancer who have enlarged intrathoracic lymph nodes (lymph nodes greater than or equal to 10 mm short axis on CT) and who could potentially have treatment with curative intent.
Why do you do blood tests as part of investigations for lung cancer?
- Full blood count - to check he is not anaemic as this may signal more advanced disease or co-morbidities
- Renal function – to check fitness for chemotherapy (most Lung cancer chemotherapy is platinum- based and as this is excreted predominantly through the kidneys requires good renal function)
- Bone profile – a raised calcium could be a sign of bone metastases or a paraneoplastic syndrome due to the secretion of PTH related hormone in squamous cell cancer.
- Liver function – if abnormal may not tolerate chemotherapy or indicate Liver secondaries
Why do you do pulmonary function tests as part of investigations for lung cancer?
• essential before surgery and radical radiotherapy to measure Lung reserve.
How should you manage brain metastases from lung cancer?
- Offer people with clinical features suggestive of intracranial pathology CT of the head followed by MRI if normal, or MRI as an initial test.
- Offer contrast-enhanced brain CT to people with clinical stage II NSCLC who are having treatment with curative intent. If CT shows suspected brain metastases, offer contrast-enhanced brain MRI.
- Offer contrast-enhanced brain MRI for people with stage III NSCLC who are having treatment with curative intent.
- Do not offer dedicated brain imaging to people with clinical stage I NSCLC who have no neurological symptoms and are having treatment with curative intent.
What is the treatment for NSCLC?
Surgery
• Radiotherapy:
o For people who decline surgery or surgery is contraindicated (check Y3 notes for CI)
o For people who can’t tolerate or decline chemoradiotherapy
o SABR (first line) or conventionally fractionated radical radiotherapy
• Chemoradiotherapy:
o People with stage 2 or 3 that are not suitable for or decline surgery.
o Durvalumab monotherapy is recommended in adults whose tumours express PD-L1 after platinum-based chemoradiation.
Surgical options for NSCLC
o Lobectomy:
For people with NSCLC who are well enough and for whom treatment with curative intent is suitable, offer lobectomy (either open or thoracoscopic).
o Bronchoangioplastic surgery, bilobectomy or pneumonectomy:
Offer more extensive surgery (bronchoangioplastic surgery, bilobectomy, pneumonectomy) only when needed to obtain clear margins.
o Sublobar resection:
For people with stage I-IIa (T1a-T2b, N0, M0) NSCLC who decline lobectomy or in whom it is contraindicated, offer radical radiotherapy with SBAR (stereotactic ablative radiotherapy) or sublobar resection.
Management of SCLC?
• Surgery:
o Consider surgery in people with early-stage SCLC
• Chemotherapy
• Radiotherapy:
o Offer prophylactic cranial irradiation at a dose of 25 Gy in 10 fractions to people with limited-stage disease SCLC and WHO performance status 0 to 2, if their disease has not progressed on first-line treatment.
Chemotherapy treatment in SCLC
o Offer people with limited-stage disease SCLC (broadly corresponding to T1–4, N0–3, M0) 4 to 6 cycles of cisplatin-based combination chemotherapy. Consider substituting carboplatin in people with impaired renal function, poor performance status (WHO 2 or more) or significant comorbidity.
o Offer twice-daily radiotherapy with concurrent chemoradiotherapy to people with limited-stage disease SCLC (broadly corresponding to T1–4, N0–3, M0) and a WHO performance status of 0 or 1, if they present with disease that can be encompassed in a radical thoracic radiotherapy volume. Start the radiotherapy during the first or second cycle of chemotherapy.
o Offer platinum-based combination chemotherapy to people with extensive-stage disease SCLC (broadly corresponding to T1–4, N0–3, M1a/b – including cerebral metastases) if they are fit enough.
What are the factors to consider before deciding treatment for lung cancer
- The stage of his disease i.e. is it operable or localised for radiotherapy
- His fitness or performance status
- His co-morbidities
- The histology and other characteristics of the tumour that may mean it would respond to specific systemic anti- cancer treatments
- His preferences for treatments
- His social support networks
- Check lung and cardiac function for surgery
- Check liver and renal function for chemotherapy
- Assess musculoskeletal problems i.e. ability to lie flat for radiotherapy
What does palliative care involve?
• Identify and refer people who may benefit from specialist palliative care services without delay and address:
o Symptom control: e.g. Steroids can cause side-effects that may need addressing. For more complex problems, referral to the palliative care team is recommended
o Benefits: If someone has a probable life expectancy of less than 12 months, they are eligible for the top rate of Disability Living Allowance. This isn’t means tested and it isn’t backdated. They can be referred for this by their GP or the Macmillan nurse or social worker if available.
o Discussion regarding life expectancy: think about how this could be approached, and the issues and uncertainty involved?
o Discussion regarding place of death
o Hospice: day hospice or an inpatient stay can be helpful for support or symptom control or end of life care
o DNAR (Do not allow Resuscitation) /AaND (allow a natural death): this becomes important if the patient gets admitted to hospital. The earlier this can be discussed with patients and their loved ones the better.
o Family/social concerns: some patients can benefit from referral to a social worker
How do you treat bone metastases?
o Administer single-fraction radiotherapy to people with bone metastasis who need palliation and for whom standard analgesic treatments are inadequate.
o Bisphosphonates
o Denosumab
When should you offer bisphosphonates as a treatment for bone metastases?
Offer patients with vertebral involvement from myeloma or breast cancer bisphosphonates to reduce pain and the risk of vertebral fracture/collapse.
Offer patients with vertebral metastases from prostate cancer bisphosphonates to reduce pain only if conventional analgesia fails to control pain.
Bisphosphonates should not be used to treat spinal pain in patients with vertebral involvement from tumour types other than myeloma, breast cancer or prostate cancer
