Non-surgical management of lung cancer

Question 1

What are the types and prevalence of non-small cell lung cancer?

Answer 1

85%
Adenocarcinoma 55%
Squamous 30%
Large cell undifferentiated 5%
Not otherwise specified (NOS) 10%

Question 2

What is the 4 type of lung cancer and its prevalence?

Answer 2

Small cell lung cancer 15%

Question 3

What are the types of pleural mesothelioma?

Answer 3

Epithelioma
Sarcomatous
Biphasic

Question 4

What can a PET scan show/help with?

Answer 4

Done to patients with potential for curative treatment.
Picks up lymph node metastasis out with thoracic area.
PET scans often upstage patients.

Question 5

What sort of things are discussed in and MDT meeting?

Answer 5

Discuss each new cancer diagnosis
Discuss therapeutic options

Question 6

Explain further the discussion about each new patient in an MDT meeting?

Answer 6

Resp team = patient wishes, fitness, lung function
Radiologists = discuss imaging
Pathologists = type of tumour, biopsy breakdown

Question 7

What are therapeutic questions to ask in an MDT meeting?

Answer 7

Curative or palliative?
Radiotherapy?
Surgery?
Chemotherapy?
Immunotherapy?
Combination therapy?
Targeted therapy?
Supportive care in community?

Question 8

What is the performance status measurement?

Answer 8

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

Question 9

What is the doubling time for non-small cell lung cancers?

Answer 9

129 days

Question 10

How is staging done for non-small cell lung cancer?

Answer 10

TNM
T = tumour size
N = nodal involvement
M = distant metastasis

Question 11

When do you offer surgery?

Answer 11

Only for curative treatment

Question 12

What is the survival from surgery dependent on?

Answer 12

The stage of the cancer and its location

5-year survival is around 40%

Question 13

What is necessary to undergo surgery?

Answer 13

Good lung function
- FEV1 > 1 for lobectomy
- FEV1 > 2 for pneumonectomy
Lymph node sampling

Question 14

What are some adjuvant (post op) therapy options and what are their aims?

Answer 14

Chemotherapy - increase chance of cure/reduce risk of recurrence
Radiotherapy - Some benefit possible if mediastinal nodes or margins are involved

Question 15

Explain neoadjuvant therapies (pre-op)?

Answer 15

Not used in clinical practice for lung cancer!

Small benefit for stage 3 cancers

Question 16

What is radical radiotherapy?

Answer 16

High does therapy given with the intent to cure

Question 16

What is radical radiotherapy?

Answer 16

High does therapy given with the intent to cure

Question 17

How is radical radiotherapy given?

Answer 17

Highest prescribed dose to the disease as possible and minimum dose to surrounding structures.

Question 18

What are some acute side effects of radical radiotherapy?

Answer 18

Lethargy
Oesophagitis
SOB due to pneumonitis

Question 19

What are some long term side effects of radical radiotherapy?

Answer 19

Pulmonary fibrosis
Oesophageal stricture
Cardiac

Question 20

What is the survival rate after radical radiotherapy?

Answer 20

5-year survival rate = 20%

Question 21

Why is pulmonary lung function tests essential?

Answer 21

Poor lung function (FEV1 < 1 or <50% predicted) precludes radical RT

Question 22

What is concurrent chemotherapy?

Answer 22

Systemic treatment into the blood stream

Question 23

What are some side effects of chemotherapy?

Answer 23

Nausea
Diarrhoea
GI upset
Marrow suppression
Risk of life threatening infection
VTE disease - blood clots, heart attacks, strokes
Neuropathies - numbness in fingers

Question 24

What is the common chemo regiem?

Answer 24

Using a combo of 2 drugs Each cycle is about 21 days

Question 25

When does chemo and radiotherapy commence?

Answer 25

Start chemotherapy instantly Start radiotherapy with cycle 2 or chemo

Question 26

What is the 2-year survival of concurrent chemotherapy?

Answer 26

27%

Question 27

What is an example of adjuvant immunotherapy?

Answer 27

PACIFIC trial - only available for stage 3 patients who've had chemoradiotherapy. - Didn’t affect quality of life and improved length of survival.

Question 28

What is SABR?

Answer 28

Stereotactic ablative radiotherapy - Very high dose per fraction - Has similar outcomes to surgery - For tumour up to 4cm - Has to be >2cm from airways and proximal bronchial tree

Question 29

What are the types of biopsy?

Answer 29

Bronchoscopy EBUS CT guided US guided

Question 30

How can treatment decisions be influenced?

Answer 30

Patient wishes Co-morbidities (angina, COPD etc.) - poor patient fitness precludes curative treatment

Question 31

What does a course of chemotherapy look like?

Answer 31

Two drugs given as IV infusion every 3 weeks Most centres give 4 cycles Regular CT scans to ensure ongoing response

Question 32

What is important to keep in mind throughout chemo/treatement?

Answer 32

Quality of life!

Question 33

How does immunotherapy work?

Answer 33

If PDL1 score > 50% them give option of first line immunotherapy. It works by upregulating immune system and "unmasking" cancers *PDL1 = protein that prevents immune system attacking cells in the body

Question 34

What is tagerted therpy?

Answer 34

Tyrosine kinase inhibitor - Drugs targeted for adenocarcinoma with driver mutation Suitable for patients unfit for chemo (PS 0-3)

Question 35

What drugs do you use for a EGFR mutation?

Answer 35

Erlotinib Gefitinib Afatinib

Question 36

What drugs do you use for a ALK translocation?

Answer 36

Crizotinib Ceritinib

Question 37

What drugs do you use for a BRAF mutation?

Answer 37

Vemurafenib Dabrafenib

Question 38

What drug do you use for a ROS alteration?

Answer 38

Crizotinib

Question 39

What can palliative radiotherapy be used for?

Answer 39

To manage symptoms of: - Bone metastasis - Cord compression - Haemoptysis

Question 40

When do you use higher dose palliative radiotherapy?

Answer 40

If disease is too large to encompass radically Has a survival advantage

Question 41

What is the doubling time of small cell lung cancer?

Answer 41

29 days

Question 42

What is small cell lung cancer more associated with?

Answer 42

Secretory syndromes: - SIADH - Cushing's

Question 43

When small cell disease is limited what are the curative treatments?

Answer 43

Chemoradiotherapy Eradiate brain prophylactic (PCL)

Question 44

With small call lung cancer what treatments give no advantage?

Answer 44

High dose chemo Alternating chemo Maintenance chemo Chemo "on demand" Maintenance interferon, MMPI, targeted therapies

Question 45

What are the outcomes in treatment of localised small cell lung cancer?

Answer 45

Cell divide quickly so respond to treatment quickly (response rate = 90%) Complete remission = 60%

Question 46

What are the survival rates of small cell lung cancer?

Answer 46

Median survival with no treatment = 8 months Median survival with treatment = 16 months 2-year survival rate = 25%

Question 47

What treatments are done in extensive small cell lung cancer?

Answer 47

4 cycles of combo chemo Consolidation thoracic radiotherapy PCI recommended Palliative RT if not fit for chemo

Question 48

What are the survival rates for extensive small cell lung cancer?

Answer 48

Median survival with no treatment 8 weeks Median survival with treatment is 8 months

Question 49

What are the side effects of chemotherapy?

Answer 49

Marrow suppression - Neutropenic sepsis Nausea, vomiting, GI upset Mucositis Fatigue, lethargy Neuropathy (numbness in fingers) Hair loss Nail changes

Question 50

What are the general side effects of radiotherapy?

Answer 50

Lethargy Risk to surrounding organs (oesophagus etc.)

Question 51

What are the acute side effects of radiotherapy?

Answer 51

Pneumonitis Dysphagia

Question 52

What are the late side effects of radiotherapy?

Answer 52

Fibrosis Stricture Increased risk MI. 2nd malignancies

Question 53

What are the common side effects of immunotherapy

Answer 53

Colitis (diarrhoea) Pneumonitis (breathless) Dermatitis Endocrinopathies

Question 54

In immunotherapy what can be given to counteract side effects if bad enough?

Answer 54

Steroids

Question 55

Who should be screened by lung cancer screening program?

Answer 55

At risk population e.g. smokers, those in certain jobs

Question 56

What would screening involve?

Answer 56

Low dose CT

Question 57

What is the big ethical question about lung cancer screening?

Answer 57

Radiation risk to population vs risk of lung cancer cure by catching early?

Question 58

What are some logistical challenges to lung cancer screening?

Answer 58

Machine time Reporting scans Stress of false positives Lung nodules needing follow up