Non-operative Management of Lung Cancer

Question 1

What is the most cancer worldwide ?

Answer 1

Lung cancer

Question 2

What type of cancer makes up 85% of lung cancer ?

Answer 2

Non-small cell lung cancer:

- adenocarcinoma
- squamous carcinoma
- large cell carcinoma

Question 3

What type of cancer makes up 15% of lung cancers ?

Answer 3

Small cell lung cancer

Question 4

What is the ECOG performance status ?

Answer 4

0- asymptomatic, well 
1- symptomatic, able to do light work
2- has to rest for <50% of the day
3- has to rest >50% of the day
4- bedbound
5- dead

Question 5

What is the doubling time for NSCLC ?

Answer 5

129 days

Question 6

How is NSCLC staged ?

Answer 6

Using TNM

Question 7

What does stage IV mean ?

Answer 7

Distant metastasis

Question 8

What % of NSCLC is operable ?

Answer 8

Maximum of 25%

Question 9

What are all the therapeutic options for cancer ?

Answer 9

Surgery
Adjuvant therapy
Neo-adjuvant therapy 
Radiotherapy 
Chemotherapy 
Combination 
Targeted therapies

Question 10

What determines the therapeutic options ?

Answer 10

Tumour type
Stage
ECOG performance status
Patient wishes and options
Aims of therapy (curative or palliative)

Question 11

What is the average 5 year survival for non-small cell lung cancer ?

Answer 11

Overall 40%

Question 12

When is surgery only offered ?

Answer 12

Only offered as a curative treatment

Question 13

What is necessary for surgery ?

Answer 13

Good lung function necessary:
- FEV1 >1 for lobectomy
- FEV1 >2 for pneumectomy
Lymph node sampling essential

Question 14

What is adjuvant therapy ?

Answer 14

When the cancer has appeared to all have been removed – but it is post operative treatment to ensure all cancer has been removed
Reduces risk of recurrence

Question 15

What is neoadjuvant therapy ?

Answer 15

Neoadjuvant chemotherapy is delivered before surgery with the goal of shrinking a tumour or stopping the spread of cancer to make surgery less invasive and more effective.

Question 16

What is radical radiotherapy ?

Answer 16

potentially curative treatment in NSCLC

Delivered in conventional 2-Gy fractions, hypo-fractionated and ablative stereotactic courses

Question 17

What is the side effects of Radical radiotherapy ?

Answer 17

Acute- lethargy, oesophagitis, SOB due to pneumonitis

Long term- pulmonary fibrosis, oesphageal stricture, cardiac

Question 18

What is the 5 year survival rate after radical radiotherapy ?

Answer 18

20%

Question 19

What treatment is a systemic treatment ?

Answer 19

Chemotherapy

Question 20

What is concurrent chemoradiotherapy ?

Answer 20

Highly efficacious locoregional treatment option for solid tumours
Better than with RT alone
no standard regime

Question 21

What does the addition of chemo increase ?

Answer 21

Toxicity

Question 22

What is the 2 year survival rate of concurrent chemoradiotherapy ?

Answer 22

27%

Question 23

What percent of Non small cell lung cancer patients have advanced disease ?

Answer 23

80%

Question 24

What is stage III ?

Answer 24

Very locally advanced disease

Question 25

What are the palliation options ?

Answer 25

``` Chemo Immunotherapy TKI Palliative Radiotherapy Combination of all ```

Question 26

What is palliative chemotherapy ?

Answer 26

Given as a doublet regime | 3 as good as 6 cycles of chemo (4 is average in UK)

Question 27

What is palliative immunotherapy ?

Answer 27

PDL1- prevents immune system attacking cells in the body Cancers are good at masking themselves from immune system via PDL1 expression Can be used 1st line if PDL1 score >50%

Question 28

What should be considered in the case of Painful bone metastases and Brain metastases ?

Answer 28

Painful bone metastases - radiotherapy | Brain metastases - resection

Question 29

What is pemetrexed used for ?

Answer 29

Maintenance chemotherapy

Question 30

What is palliative TKIs ?

Answer 30

Targeted drugs for adenocarcinoma with driver mutations Available for patients unfit for chemo (PS 0-3) 2nd line treatment options at progression Understanding mechanisms of resistance- REBIOPSY

Question 31

What are examples of Driver mutations for NSCLC ?

Answer 31

EGFR mutation ALK translocation BRAF mutation ROS alteration

Question 32

What is the concept for Tyrosine Kinase Inhibitors ?

Answer 32

Blocks Tyrosine Kinase which is a membrane receptor protein - This stops the formation of a protein causing the tumour to grow

Question 33

What drugs are Tyrosine Kinase Inhibitors ?

Answer 33

Erlotinib Gefitinib Afatinib

Question 34

What is palliative radiotherapy used for ?

Answer 34

Management of symptoms: - bone metastasis - cord compression - haemoptysis

Question 35

What is SABR ?

Answer 35

Stereotactic ablative RT Can have similar outcomes to surgery Tumours up to 4cm >2cm away from airways and proximal bronchial tree

Question 36

What % of patients have SCLC ?

Answer 36

15%

Question 37

What is the doubling time for SCLC ?

Answer 37

29 days

Question 38

What are the two classifications of Small cell lung cancer severity ?

Answer 38

Limited Disease - Staged to one hemithorax | Extensive disease - more advanced disease

Question 39

How do you treat SCLC of limited disease ?

Answer 39

Chemotherapy Combination of drugs including cisplatin and etoposide Early thoracic radiotherapy is better Prophylactic cranial radiation

Question 40

In SCLC is there any benefit from any of the following? High Dose chemo? Alternating Chemo? Maintenance Chemo? Chemo 'on demand'? Maintenance interferon?

Answer 40

NO

Question 41

What is median survival of limited disease SCLC with and without treatment ?

Answer 41

With - 8 months | Without - 16 months

Question 42

What is the rate of two year survival with SCLC in limited disease ?

Answer 42

25%

Question 43

What are the side effects to chemotherapy ?

Answer 43

Marrow suppression ( + risk of threatening infection) Nausea, vomiting GI upset, mucositis, fatigue, lethargy Neuropathy, increased risk of MI/ stroke, renal impairement Hair loss, nail chnages

Question 44

What are the side effects of radiotherapy ?

Answer 44

Lethargy, risk to surrounding organs Acute: pneumonitis, dysphagia Late: fibrosis, stricture, increased risk MI

Question 45

What are the side effects of immunotherapy ?

Answer 45

Colitis, pneumonitis, dermatitis, endocrinopathies