1. “No Air” Management of Lung Cancer
Elaine Bouttell, MD FRCPC
Medical oncology
GRRCC

2. Disclosures:
Advisory board for Novartis, RCC

3. Objectives
Review the diagnosis, treatment, and palliation of lung cancer
Review the types and demographics of lung cancer
Identify the differences between primary and secondary lung cancer
Function of the DAU
Screening and early diagnosis of lung cancer
Review differences between curative and non-curative treatment
Treatment modalities: surgery, chemotherapy, radiation therapy

4. Overview Review statistics (incidence, death rates) Etiology
Staging system for NSCLC (85%)
Life expectancy depending on stage
Management of NSCLC
Resectable Stage I, II, IIIA
Unresectable Stage IIIA, IIIB
Incurable Stage IV

5. Overview Staging system for SCLC (15%)
Life expectancy depending on stage
Management of SCLC
Limited stage
Extensive stage
Follow-up
Complications and Paraneoplastic conditions

6. Statistics
In 2008:
23,900 Canadians will be diagnosed with lung cancer
20,200 will die of lung cancer (more deaths than colorectal, prostate, and breast cancer combined)
1 in 12 men will develop lung cancer, 1 in 13 will die of it (incidence and death rates decreasing)
1 in 16 women will develop lung cancer, 1 in 18 will die of it (incidence and death rates increasing)

8. Risk Factors Smoking (including second hand smoke exposure)– 80-90%
Previous radiation therapy
Previous diagnosis of lung cancer
Exposure to asbestos, arsenic, chromium, nickel (especially in smokers), radon gas
Family history of lung cancer
Air pollution?

9. Second Hand Smoke causes Lung Cancer
Meta-analysis of 52 studies prepared for the Surgeon General’s report in 2006 concluded that the odds ratio for spouse of smoker is (dose response)
SHS exposure in the work place, OR 1.22
Exposure to children leads to OR 1.10, >25 smoker-years doubled the risk, <25 smoker-years did not appear to increase the risk

10. Lung Cancer in Never Smokers
Percentage of never-smokers among lung cancer patients appears to be increasing
incidence in never smokers increasing, or prevalence of never-smokers in the population increasing?
US women age 40-79: /100,000 person-years
US men:
adenocarcinoma, different biology

11. Risk Reduction after Quitting Smoking
Cutting back from 1ppd to ½ ppd decreased risk 27%
Risk of lung cancer falls over 15 years after quitting then remains about 2x risk of a never smoker
Risk reduction appears to be related to age at quitting

12. Screening for Early Detection
No test in asymptomatic patients (CXR, sputum cytology, CT scan) shown to reduce mortality from lung cancer
Reasonable to do CXR in any smoker presenting with symptoms

13. Best Treatment
1. Prevention
2. Prevention
3. Prevention

15. Non Small Cell Lung Cancer
Staging
I T1-2 N0
II T1-2 N1
T3 N0
IIIA T1-2 N2
T3 N1-2
IIIB T N3
T4 N0-3
IV T N M “wet” IIIB

16. Management of Potentially Resectable Stage I, II, IIIA NSCLC
Surgery

17. Life Expectancy by Stage
5 year overall survival rates for surgically resected:
Stage I 60-75%
Only 57% clinical stage I are pathologic stage I,
and 13% are actually pathologic stage IIIA
Stage II 36-60%
Stage IIIA %

18. Medically Inoperable Stage I and II
Radiation therapy alone
11-43% die of non-cancer causes
70% 5 yr OS for Stage I
60% 3 yr OS for Stage II

19. Adjuvant Therapy Post-Surgical Resection
Radiation: consider if close/positive margin, ?N2
Chemotherapy (4 months weekly vinorelbine + cisplat d1 d8)
Overall increase in cure rate 5-15% stage II and IIIA
controversial for stage IB (?benefit if T>4cm)
no proven additional benefit for stage IA

20. Unresectable Stage IIIA and IIIB
Treatment with curative intent vs Palliation
Curative Intent:
Sequential chemo followed by RT better than RT alone
Concurrent chemo/RT better than sequential (4 yr OS 21% vs 14%)
10 early (within 6 mths) toxic deaths in concurrent arm vs 3 in the sequential arm
?PCI (prophylactic cranial irradiation)
Decreased brain mets as first site of failure at 5 yrs
35% to 8%

21. Follow-up Post Curative Treatment
Non-small cell lung cancer post surgery +/- adjuvant chemotherapy, or concurrent chemo/RT
No proven survival benefit to ANY routine investigations in asymptomatic patients
Recurrent disease rarely curable, unless second primary lung cancer
Directed history and physical +/- CXR q 3 mth x 2 yr, then q 6mth x 3 yr, then annual

22. Metastatic Non-Small Cell Lung Cancer
Palliative chemotherapy vs BSC
Response rate 30%
Survival benefit (30 vs 20% 1 year OS) with no adverse effect on QOL (BLT JCO 2005)
if wt loss <10% and ECOG PS <2
PS 0 No activity restrictions
PS 1 Strenuous physical activity restricted
PS 2 Capable of self care, no work, up and
about >50% waking hours
PS 3 Confined to bed or chair >50%
PS 4 Confined to bed or chair

23. Metastatic Non-Small Cell Lung Cancer
Survival benefit with chemo:
Previously 2 months (incr from 7 mth to 9)
30% 1 year survival
Now 35-50% 1 year survival, up to 25% 2 yr survival with treatment
First line cisplatin/carboplatin + gem (squamous), vin, taxane
Second line taxotere, pemetrexed (adeno), erlotinib
Third line erlotinib

24. Small Cell Lung Cancer Staging
Limited – potentially curable
Extensive - incurable

25. Small Cell Lung Cancer Limited Stage
Disease encompassable within a radiation field
Response rate to chemotherapy 80-90%
Median survival mth with treatment, 12 mth without
Potentially curable
3 yr OS 20%, 5 yr OS 15%

26. Small Cell Lung Cancer Extensive Stage (metastatic)
Median survival 8-13 mth with treatment vs 7 mth without
Response rate to first line chemo 60-80%
ECOG PS not as important, often poor due to disease, improves with treatment

27. Small Cell Lung Cancer Management
Limited Stage
Concurrent Chemo/RT, ideally RT (3 wk) starting with cycle 1
Cisplatin/etoposide daily x 3d x 4 cycles
(3 mth)
Response rate 80-90%
PCI results in decrease in symptomatic brain mets at three yrs from 59% in untreated to 33% in patients treated with PCI
PCI increases 3yr OS from 15% to 20%

28. Follow-up Post Treatment
Limited Stage Small Cell Lung Cancer
No proven survival benefit to ANY routine investigations in asymptomatic patients
Recurrent disease rarely curable, unless second primary lung cancer
Most recurrences occur within first yr
Relapses more rapidly progressive
Consider directed history and physical + CXR q 2-3 mth for first year, q 3 mth for second yr, q 6 mth for yr 3-5, then annually

29. Small Cell Lung Cancer Management
Extensive Stage
Palliative chemotherapy
Response rate to first line 60-80%
Cis/etop, carbo/etop, oral etoposide x 3 mth
PCI decreases symptomatic brain mets at 1 yr from 40% to 15%, increases 1 yr OS from 13% to 27%
Second line treatment depends on time to progression

30. Follow-up Symptoms of concern: Complications to consider:
New or worsening SOB, cough, hoarseness, dysphagia, chest pain, lightheadedness/syncope, peripheral edema, RUQ pain, wt loss, bone pain (back pain, cord compression symptoms), headache/CNS symptoms
Complications to consider:
DVT/PE
SVCO
Pleural, Pericardial effusion
Cord compression
Brain mets
Paraneoplastic syndrome

31. Paraneoplastic Syndromes
Non-Small Cell Lung Cancer
Hypercalcemia
Squamous cell > adeno > small cell
Clubbing, Hypertrophic pulmonary osteoarthropathy
Adeno
DVT/PE

32. Paraneoplastic Syndromes
Small Cell Lung Cancer
SIADH
Cushing’s syndrome
Lambert-Eaton myasthenic syndrome
Limbic encephalitis
Cerebellar degeneration
Peripheral sensory neuropathy

33. Complications Treated with Palliative Radiation
Brain metastases
Spinal cord compression
Hemoptysis
SVCO
Painful bone metastases
Airway obstruction (+/- postobstructive pneumonitis)