1. Genesis Oncology Trust Palliative Care Lecture Series Dr Helen Winter 3 rd July 2014 1

2. Learning Objectives Understand why histology and getting the subtype of lung cancer is important When to do EGFR testing and use EGFR receptor inhibitors The common side effects of the new treatments Consider the evidence for early palliative care referral for lung cancer 2

3. Lung cancer - subtypes The beginning of wisdom is to call things by their right names Chinese proverb Small Cell – Limited, extensive stage Non small cell lung cancer Squamous, Adenocarcinoma, Other Molecular Subtypes EGFR, Alk-Fusion, Kras 3

4. Small Cell Limited Platinum doublet with concurrent or sequential radiation Extensive Platinum doublet Role of PCI 4

5. Non Small Cell Squamous Platinum doublet Role of Palliative radiation Adeno Platinum doublet Role of Pemetrexed EGFR positive Alk Fusion positive 5

6. New treatments for lung cancer Aux grands maux les grands remèdes. Desperate times call for desperate measures. "To the great evils great remedies.“ French proverb 6

7. How do TKIs work? - specific gene mutations found in NSCLC tumors have an enhanced sensitivity to TKIs (Iressa, Tarceva, Afatanib) 4- 6 - The TKIs block the signalling pathways that are initiated by EGFR by selectively inhibiting the tyronaise kinase domain of the EGFR molecule 7 TKI 7

8. Side effects of therapy No hay rosa sin espinas No rose without thornsSpanish Proverb 8

9. Side Effects of Treatment – Chemotherapy vs Iressa 8 9

10. Most Common Side Effects of Iressa 8 10

11. How to Manage Rash 9 11

12. How to Manage Rash 9 12

13. How to Manage Rash 9 13

14. Palliation Early palliative care evidence Quality of care – Canadian study 14

15. Summary To talk much and arrive nowhere is the same as climbing a tree to catch a fish Chinese proverb Lung cancer is changing Histology is important – subgroups of patients with different prognosese, treatments and side effects If EGFR positive Chemotherapy is not the best option first line In future Pemetrexed is a better tolerated drug In future funding for Alk Fusion test and then Crizotinib Earlier diagnosis and smoing cessation still major contribution Palliative care, symptom control, ACP and how do we measure good outcome 15

16. Acknowledgments Moe atu nga ringa raupo Marry a man with calloused hands Maori saying Thank you to all the patients and their families who I have had the privilege to look after Thank you for listening and for all you do for patients with advanced lung cancer Thank you to Astra Zeneca for some of these slides 16