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Lung Cancer 2017 Standard of Care Screening, Diagnosis, Management
Jeremiah Martin MBBCh FRCSI MSCRD
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DISCLOSURE The speaker and members of the planning committee do not have a conflict of interest in this topic. There is no commercial support for this program.
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Now we will turn our attention to cancer mortality
Now we will turn our attention to cancer mortality. Lung cancer is by far the leading cause of cancer death among males (27%), followed by prostate (8%) and colorectal (8%) cancers. Among females, lung (26%), breast (14%), and colorectal (8%) cancers are the leading causes of cancer death.
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Smoking as a risk factor
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Smoking Cessation
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Smoking Demographics
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Lung Cancer Age-Adjusted Incidence Rates by State
Data Source: CDC
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Lung Cancer Age-Adjusted Mortality Rates by State
Data Source: CDC
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Incidence by Area Development District
Data Source: Kentucky Cancer Registry
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What is cancer? In all types of cancer, some of the body’s cells begin to divide without stopping and spread into surrounding tissues.
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Numbers… … we can change
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15% Survival at 5 years
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Patients discovered with stage III / IV
70% Patients discovered with stage III / IV
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Patients stage I/ II don’t get surgery
40% Patients stage I/ II don’t get surgery
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Lung Cancer Survival Dependent on cell type Non-Small Cell (NSCLC)
Adenocarcinoma / Squamous Cell Large Cell Neuroendocrine Small Cell Represents 15% of lung cancers 6% 5-year survival Treatment can add 6-12 months
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Improving Outcomes in Lung Cancer
Increase Awareness Decrease risk factors Early detection Clinical suspicion Screening Early stage-directed therapy
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Lung Neoplasms Where do they come from?
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Differential Diagnosis
Pulmonary Nodule Benign Infectious Treat Inflamm. Observe Malignant Carcinoma Staging
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Differential Diagnosis
Structural / Inflammatory Possibilities (benign) Arteriovenous Malformation Atelectasis Rheumatoid nodule Sarcoidosis Wegener Granulomatosis
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Differential Diagnosis
Infectious Possibilities (benign) Aspergillosis Blastomycosis Coccidiomycosis Histoplasmosis Hydatid Cysts Lung Abscess Nocardiosis Tuberculosis
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Differential Diagnosis
Malignancy Non small cell lung cancer Small cell lung cancer Carcinoid tumor
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Imaging Tools CXR CT PET MRI
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Diagnostic / Therapeutic Tools
Needle biopsy Bronchoscopy Endobronchial Ultrasound Mediastinoscopy VATS (Video-assisted thoracic surgery) Thoracotomy Less Invasive More Invasive
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Workup of a pulmonary nodule
History Generally asymptomatic May have cough Occasionally may present with pain, hemoptysis, weight loss, neurologic symptoms - concern for advanced disease Any prior malignancy? Smoking history? Exposure history?
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Workup of a pulmonary nodule
History Look for smoking-associated diseases Coronary artery disease Peripheral vascular disease Ask about general health screening (possibility of metastatic disease) Colonoscopy Mammography in women
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Workup of a pulmonary nodule
Physical Examination General appearance Signs of smoking Lymphadenopathy Detailed pulmonary examination
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Workup of a pulmonary nodule
Look at all available images, and ask for old studies for comparison At this point consider referral for evaluation by a thoracic surgeon
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Workup of a pulmonary nodule
LIKELY BENIGN LIKELY MALIGNANT
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Workup of a pulmonary nodule
If it’s cancer: Treatment depends on stage, type If it’s an infectious nodule: May need treatment, may resolve If it’s old scar tissue: It will remain the same
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Which is most likely?
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Risk Assessment Age Gender Smoking history History of prior malignancy
Surgical risk Cardiac risk assessment Pulmonary function testing
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“assume the worst hope for the best!”
Risk Assessment “assume the worst hope for the best!”
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Stage-Based Treatment of Cancer
LOCAL THERAPY SYSTEMIC THERAPY Surgery Radiation Chemotherapy I II III IV
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Stage-Based Treatment
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“TNM” staging system Tumor Nodes Metastases
Lung Cancer Staging “TNM” staging system Tumor Nodes Metastases
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Chart illustrates the descriptors from the 7th edition of the TNM staging system for lung cancer.
UyBico S J et al. Radiographics 2010;30: ©2010 by Radiological Society of North America
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Lung Cancer Staging From a clinical perspective: work by outruling the worst possibilities: 1) Metastatic Disease 2) Nodal Disease 3) Local Tumor Invasion / Surgical Candidacy
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Lung Cancer Staging Look for evidence of metastatic disease PET scan
Brain MRI If Mets present: confirm tissue diagnosis by least invasive means possible then definitive chemo-/radiation therapy
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Lung Cancer Staging Most common sites for metastases Other lung Brain
Bone Adrenal glands Liver
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Lung Cancer Staging Primary Tumor Mediastinal Lymph Node
Adrenal metastases Left iliac bony metastasis
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Lung Cancer Staging Look for evidence of nodal disease EBUS
Mediastinoscopy If N2 disease present: refer for chemo-/radiation therapy may be a candidate for resection depending on response to treatment
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Mediastinal Staging N3 N1 N2 Tumor N1 – Ipsilateral (Intrapulmonary)
N2 – Ipsilateral medistinal and subcarinal N3 – Contralateral mediastinal
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Mediastinal Staging Better if directed towards target
EBUS Non-invasive Immediate results Mediastinoscopy More invasive (still outpatient) ‘Gold standard’ More tissue
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Lung Cancer Staging Clinical Stage: Pathologic Stage:
Operative candidate? Pathologic Stage: Final resected specimen and lymph nodes
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Multi-Disciplinary Care
Radiology Pulmonology Thoracic Surgery Medical Oncology Radiation Oncology
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Lung Cancer Staging Clinical Stage: Pathologic Stage:
Operative candidate? Pathologic Stage: Final resected specimen and lymph nodes
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Surgical Management Anatomic dissection of the hilum
Remove the entire lobe Remove draining lymph nodes Multi-specialty discussion of treatment plan
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Surgical Approach
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Minimally Invasive Surgery
Video Assisted Thoracoscopy (VATS) Variety of techniques Common feature: Thoracoscope anatomic hilar dissection no rib spreading Anterior two-incision approach video
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VATS / Thoracoscopic Lobectomy
Video File MiddleLobectomy.wmv?dl=0
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Advantages of VATS Better tolerated in the elderly with fewer complications Increased likelihood of compliance with adjuvant therapy Decreased length of stay, decreased hospital cost Quicker return to function / less pain Cattaneo SM, et al. "Use of video-assisted thoracic surgery for lobectomy in the elderly results in fewer complications". Ann. Thorac. Surg. 85 (1): 231–5; Nicastri DG, et al. "Thoracoscopic lobectomy: report on safety, discharge independence, pain, and chemotherapy tolerance". J Thorac Cardiovasc Surg 135 (3): 642–7. Casali G, et al. "Video-assisted thoracic surgery lobectomy: can we afford it?". Eur J Cardiothorac Surg 35 (3): 423–8.
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Advantages of VATS 3 weeks postoperatively
Todd L Demmy, Jackie J Curtis, Minimally invasive lobectomy directed toward frail and high-risk patients: a case-control study, The Annals of Thoracic Surgery, Volume 68, Issue 1, July 1999, Pages ,
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Why is VATS not standard of care
National adoption is very slow Only 50% of anatomic resections in the US are performed using minimally invasive techniques Learning curve Robotics is helping
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KCR Data 2010-2012 Review of Kentucky Cancer Registry data
Robust pathology information Survival data updated with linkage to external sources
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Results
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Results All p1a 12 mo 24 mo VATS 94% 86% Open 88% 79%
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Other New Technologies
Navigational Bronchoscopy Allows biopsy of peripheral nodules
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Lung Cancer Surgery – The Future
Minimally Invasive VATS Robotics Parenchymal Sparing operations Segmentectomy Extended wedge-resection
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Advances in Radiation / Chemotherapy
Stereotactic radiation (SBRT) Cyberknife
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SBRT Large radiation dose per fraction
Precisely delivered to target area Minimal damage to surrounding tissues Disadvantage – no tissue, no lymph nodes
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SBRT Treatment of choice for early stage, medically inoperable patients. Control of symptomatic metastases. Ongoing trials: SBRT vs Surgery for small peripheral tumors RTOG 0236: 59 biopsy proven T1/2N0M0 3-year primary control rate was 98% 3-year disease free survival was 48% Distant relapse
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Advances in Chemotherapy
Traditional management: Platinum based chemotherapy Systemic toxicities high, tolerance poor Poor response rate, particularly in NSCLCA
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Advances in Chemotherapy
NSCLCA Adenocarcinoma EGFR expression seen in 15 % Erlotinib – 150mg PO daily EML4-ALK gene rearrangements / fusion seen in 4% Crizotinib – 250mg PO BID Newer targets: RAS, BRAF, MET, RET etc.
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Advances in Chemotherapy
Immunotherapy Nivolumab (approved March 2015) Pembrolizumab (approved October 2015)
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Advances in Chemotherapy
Immunotherapy Nivolumab (approved March 2015) Pembrolizumab (approved October 2015)
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Lung Cancer Screening National Lung Screening Trial
55 – 74 years of age 30 pack-year history of smoking Low-dose helical CT scanning Mortality reduction of 20% when compared with CXR screening How to implement this…
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Lung Cancer Screening
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Lung Cancer Screening Program
Positive Referral to Surgeon Consultation Counselling Smoking Cessation Intermediate Short Followup CT-Scan Negative Return in 1 year AACR Database
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Summary Lung cancer is the most common cause of cancer death in the US
Smoking is the biggest risk factor Prevention, risk factor modification are the keys to improving survival
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Summary Screening may effect a stage-shift in lung cancer diagnosis
Early stage-directed therapy is key Significant advances in Surgery, Chemotherapy, and Radiation therapy for lung cancer
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Safety Quality Service Relationships Performance
Any Questions? Jeremiah Martin Marion Hochstetler (740) Safety Quality Service Relationships Performance
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