Case 2: A case of advanced Non-Small Cell Lung Carcinoma Texte courant Shane O’Hanlon (IE) and Andrea Luciani (IT)

No conflict of interests Disclosure No conflict of interests

Learning objectives: Explain how a CGA can help optimise patients before treatment Describe the management of advanced Non-Small Cell Lung Carcinoma Explain the role of immunotherapy in advanced Non-Small Cell Lung Carcinoma Describe the role of supportive care, including palliative care, in advanced lung cancer

Case abstract: Rosa is an 82 year old lady who is in generally good health. She enjoys gardening and still writes part-time for a seniors blog. She is widowed and lives alone. She has had increasing shortness of breath for a few months, despite being treated with diuretics for a presumptive diagnosis of heart failure. She had been started on frusemide after a chest x-ray showed bilateral pleural effusions. She also complains of increasing fatigue, reduced appetite and has started sleeping in a chair in the afternoon.

She was referred for admission to have further investigation She was referred for admission to have further investigation. Unfortunately her pleural aspirate showed an exudate, so she was referred to a respiratory specialist. The workup reveals that she has non-small cell lung cancer, with metastases to the liver, the opposite lung, and malignant pleural effusions, T3N3M1b. Her performance status is currently 3. She is referred to a geriatrician for assessment before the possibility of treatment.

Geriatric assessment: Cognition – normal at baseline. Currently 26/30 on MoCA, losing marks for orientation and attention. Mobility – usually independent; has not mobilised since admission 5 days ago. Medications: Frusemide 40mg bd Zopiclone 7.5mg nocte Ramipril 10mg od Oxycodone 5mg BD Chlorphenamine 4mg tds Aspirin 100mg Bendroflumethiazide 2.5mg od

Geriatric assessment: Comorbidities Hypertension Arthrosis Insomnia

On examination Drowsy but responsive. Looks dry. Slightly confused. Needs assistance of two people to transfer from bed to chair Orthostatic blood pressure drop from 110/80 to 86/55  Never smoker Weight loss: 5kg in last month

Investigations Bloods: Hb 78 g/L (130-180), Mcv 76 fL (80-100) Urea 14 mmol/L (2.5-7.8), Creat 90 mcmol/L (59-104) Na 122 mmol/L (133-146), K 3.6 mmol/L (3.5-5.3) Albumin 25 g/L (33-50) Echo – normal ejection fraction

1. Which interventions do you think the geriatrician made? The geriatrician makes several alterations to her medications and some other important interventions. As a result, after two weeks her performance status is 1. Case 2 questions for Course students: 1. Which interventions do you think the geriatrician made? 2. Given her PS of 1, what treatment should she have? 3. What is the role of molecular testing in classifying and treating NSCLC? How are the relevant treatments tolerated in older people? 4. How can palliative care help and when should we refer?

Optimisation Stop bendroflumethiazide (low Na) Stop frusemide (no heart failure) Stop ramipril (low BP) Stop zopiclone and chlorphenamine (drowsy) Stop aspirin (no previous stoke or MI) Dietician r/v for nutrition Physiotherapy r/v for mobility Consider palliative care r/v (SOB)

Optimisation Regular reorientation, allow family extended visiting hours, optimise hydration (delirium) Check iron levels, consider IV iron Consider blood transfusion if symptomatic Add laxatives if still on oramorph, ensure bowels open each day Check for urinary retention OT r/v to promote independence

What really happened Fall -> hip fracture Persistent delirium post-op Immobility continued Low oxygen level acutely - Bilateral PE Subsequent hospital acquired pneumonia Died 10 days after surgery Never treated for her lung cancer