2. Lung Cancer for General Practitioners By Richard Nabhan Senior Consultant Physician Cardiologist & Diabetologist

3. FACTS: Lung Cancer Is the most common tumor worldwide (900,000) New Cases each year in Men & (330,000) in women Globally it is the leading cause of death from cancer In Men, > 80% of Lung Cancer cases are caused by smoking More deaths from lung cancer than breast, ovarian & uterine cancers combined Women are more susceptible to tobacco effects – 1.5 times more likely to develop lung cancer than men with same smoking habits (3) people/ minute die from Lung Cancer in the world (WHO)

4. Risk Factors Smoking77 % Hypertension35 % Diabetes30 % Overweight-obesity65 % Dyslipdaemia60 % Physical Inactivity85 %

5. What is Lung Cancer? Uncontrolled growth of malignant cells in one or both lungs, and tracheo-bronchial tree Arises from protective or ciliated cells in the bronchial epithelium Begins as a result of repeated carcinogenic irritation causing increased rates of cell replication Proliferation of abnormal cells leads to hyperplasia, dysplasia or carcinoma in situ 4

6. What Causes Lung Cancer? Smoking Radiation Exposure Environmental / Occupational Exposure Asbestos Radon Passive smoke 5

7. Smoking & Lung Cancer The association between Lug Cancer & Smoking is probably the most intensively investigated relationship in epidemiology Simply, smoking causes Lung Cancer An increase in Tobacco consumption is paralleled by increase in incidence of Lung Cancer Smoking cessation is very effective in reducing the risk of Lung Cancer even in later life

8. Smoking & Lung Cancer Tobacco-induced death and diseases are preventable: Halving current smoking rates would avoid 30 million deaths before 2025 & 150 million by 2050. It is generally recognized that tobacco smoking is the etiologic carcinogen in 90% of all lung cancer cases An association between exposure to passive smoking and lung cancer risk in non-smokers has been shown in a number of case-control & cohort studies

9. Smoking & Lung Cancer 1.Amount smoked (pack years: # Cigs/Day x # yrs) 2.Age of smoking onset 3.Product smoked (tar/ nicotine content, filters) 4.Depth of inhalation 5.Gender Risk of Lung Cancer in Smokers depends on: 8

10. Screening for Lung Cancer Screening for Lung Cancer with Chest X-Ray &/or Sputum Cytology OR Screening for Lung Cancer with spiral CT scan BENEFITS: based on fair evidence, Screening does not reduce mortality from Lung Cancer HARMS: based on good evidence, screening would lead to false-positive tests & unnecessary invasive diagnostic procedures & treatments There is no population-based screening procedure 9

11. Clinical Presentation Local Symptoms: –Cough –Dyspnea –Hemoptysis –Recurrent infections –Chest pain General Symptoms: –Weight Loss –Fatigue 10

12. Sites of Intrathoracic Spread 11

13. LungCancer: Clinical Presentation Lung Cancer: Clinical Presentation Syndromes/ Symptoms secondary to regional metastases Esophageal compression  dysphagia Laryngeal nerve paralysis  hoarseness Sympathetic nerve paralysis  Horner’s syndromes Cervical / thoracic nerve invasion  Pancoast syndrome Lymphatic obstruction  Pleural effusion Vascular obstruction  SVC syndrome Pericardial/ cardiac extension  effusion, tamponade

14. PANCOAST’s Syndrome Vagus nerve Sympathetic trunk Brachial plexus Recurrent laryngeal Subclavian artery & vein Horner’s syndrome Wasting, pain, paraesthesia, & paresis of arm & hand

15. SVC Syndrome Obstruction of SVC by cancerous invasion of mediastinal lymph nodes. Edema & rubor of face, neck & upper chest. Arm veins fail to empty on elevation.

16. Classification of Bronchogenic Carcinoma type histology incidence (% of all lung carcinoma) Males vs Females location tendency (variable) smoking relation growth rate metastatic tendency resectability Small Cell Lung Ca Non Small Cell Lung Ca

17. Lung Cancer: Paraneoplastic Syndromes Inappropriate secretion of ADH Ectopic ACTH secretion Neurologic/ myopathic syndromes Small Cell Lung Cancer (SCLC)

18. Lung Cancer: Paraneoplastic Syndromes NSCLC Hypercalcemia Skeletal-connective tissue syndromes Gonadotropin Effect Non Small Cell Lung Cancer

19. Lung Cancer: Metastatic Sites Lymph nodes Brain Bones Liver Lung/ pleura Adrenal gland Pain Organ-related Symptoms secondary to distant metastases From Lung To Lung

20. Lung Cancer: Diagnosis History & Physical exam Diagnostic tests Chest x-ray Sputum for Cytology Biopsy (bronchoscopy, needle biopsy, surgery) Staging tests CT Chest / abdomen Bone scan Bone marrow aspiration

21. Varieties of Lung Cancer

22. Lung Cancer: Prognostic Factors Stage at diagnosis Performance status Lung Cancer: Cell Types Non Small Cell Lung Cancer (NSCLC) Small Cell Lung Cancer (SCLC)

23. NSCLC: Histologic Cell Types Adenocarcinoma Squamous Cell Carcinoma Large Cell Carcinoma Non Small Cell Lung Cancer (NSCLC) 80% of all lung cancers Better survival rates when found in early stages

24. NSCLC: TNM Staging STAGEIaT1N0M0 IbT2N0M0 IIaT1N1M0 IIbT2N1M0 T3N0-1M0 IIIaT1-3N1M0 IIIbany T4any N3M0 IVany M1 T = tumor size (T1 3cm + atelectasis), tumor site ( T3 extension to pleura, chest wall, pericardium or total atelectasis), local involvement. (T 4 invasion of mediastinum or pleural effusion); N = lymph node spread N1 bronchopulmonary, N2 (ipsilateral mediastinal) and N3 (contralateral or supraclavicular); M = absence (M0) or presence (M1) of metastases

25. StageDescriptionTreatment Options Stage I a/b Tumor of any size is found only in the lung Surgery Stage II a/b Tumor has spread to lymph nodes associated with the lung Surgery Stage III a Tumor has spread to the lymph nodes in the tracheal area, including chest wall and diaphragm Chemotherapy followed by radiation or surgery Stage III b Tumor has spread to the lymph nodes on the opposite lung or in the neck Combination of chemotherapy and radiation Stage IV Tumor has spread beyond the chest Chemotherapy and/or palliative (maintenance) care NSCLC: Treatment by Stage

26. SCLC: Cell Types Oat Cell Intermediate

27. SCLC: Staging Limited Stage Defined as tumor involvement of one lung, the mediastinum and ipsilateral and/or contralateral supraclavicular lymph nodes or disease that can be encompassed in a single radiotherapy port. Extensive Stage Defined as tumor that has spread beyond one lung, mediastinum, and supraclavicular lymph nodes. Common distant sites of metastases are the adrenals, bone, liver, bone marrow, and brain.

28. Lung Cancer: Conclusions Smoking cessation is essential for prevention of lung cancer. New screening tools offer promise for detection of early lung tumors. Clinical trials are testing promising new treatments. New treatments offer improved efficacy and fewer side effects. Treatment can palliate symptoms and improve quality of life.