1. Department of Hematology/Oncology
LUNG CANCER
Marianna Strakhan, MD
Attending Physician
Department of Hematology/Oncology
Jacobi Medical Center
Bronx, NY
March 30, 2010

2. Incidence
2nd most common type of malignancy in the U.S. among both men and women
Most common form of cancer mortality in the U.S. in both men and women
In 2007 – approximately 215,000 new cases of Lung cancer were diagnosed in the U.S, with 162,000 deaths
Between 1990 and 2003 – incidence of lung cancer have remained stable in men, however in women, incidence increased by 60% (incidence in African american females being partially higher than white females).
**Incidence increase is seen among large portion of never-smokers, healthy, and active women)

3. Incidence
Although deaths have begun decreasing in MEN (likely due to decrease in smoking), mortality in WOMEN has reached a plateau
Almost ½ of all cancer deaths now occur in women
10 – 15% of lung cancer victims are non-smokers. Among that group, women are 2-3x more likely than men to get the disease

4. Incidence Median age of diagnosis is 66 y.o. in both women and men.
More of the patients <50 y.o. at time of diagnosis were women
In women, 45% of all lung cancers were adenocarcinoma, followed by 22% small cell cancer, 21% squamous cell, rest as other subtypes
(in men, squamous subtype is most common, followed by adeno, followed by small cell)

6. Risk Factors Cigarette smoking - in the U.S, nearly 25% of women smoke
- some studies suggest women have more difficulty quitting smoking than men
– risk is increased 10 – 30 x than in non-smokers
- smoking > or = 25 cig/day increases risk more than smoking less than 25 cig/day
- age at onset of smoking
- degree of inhalation correlates with risk of developing disease
- Tar and nicotine content of cigarettes
- use of unfiltered cigarettes
- smoking cessation decreases risk significantly, with decline in risk starting > 5 years of abstinence.
- after 15 years, risk is reduced by 80%. The longer one the person is not smoking, the lower the risk becomes – however risk still remains higher than in never smokers
2nd hand smoke
- the longer the exposure the higher the risk
- approximately 17% of all lung cancer in never smokers is due to second hand smoking
during the person’s childhood and adolescence
- risk doubles with 25 or > years of exposure
- ban of smoking in restaurants/enclosed spaces decreases undesired exposure of non-smokers

7. Risk Factors Asbestos Radon Arsenic Ionizing radiation
Polycyclic aromatic hydrocarbons
Nickel
Pulmonary Fibrosis
HIV infection
Family History
Beta Carotene (initially used for chemoprevention, noted to be associated with higher risk of lung cancer in smokers)
Race (African Americans and Hawaiians have higher risk of lung cancer incidence among persons who smoke <30 cig/day, no difference between the races among persons smoking >30 cig/day)

8. Risk Factors *Lung cancer in women is a biologically and genetically
different disease than in men:
Genes that cause women to be more vulnerable to the harmful effects of tobacco smoke
Differences in how the chemicals in tobacco are metabolized (broken down) by the body
Changes to genes that control cell growth, which may result in the development of cancer
A decreased ability of the body to repair damaged DNA, as DNA damage can promote the development of cancer
Hormones, such as estrogen, which could directly or indirectly affect cancer growth

9. Signs and Symptoms Cough Hemoptysis Dyspnea Chest Pain
Hoarseness (due to involvement of recurrent laryngeal nerve)
SVC syndrome (dilated neck veins, facial edema)
– due to pressure on SVC by the tumor
Pancoast’s syndrome
– pain in shoulder or arm, Horner’s syndrome (miosis, ptosis, anhidrosis), atrophy of hand muscles
Weight loss
Paraneoplastic syndromes
-example: Hypercalcemia in Squamous cell ca
SIADH in Small Cell Ca
Thrombosis
Leucocytosis and thrombocytosis

10. SVC Syndrome
Etiology: -result of compression of SVC by either malignancy (RUL mass) or thrombosis (mainly due to use of intravascular device) -most common etiology is lung cancer -may also be due to infections (TB, etc..) or hematological malignancies such as lymphoma/leukemia Signs/Symptoms: -symptoms may develop over weeks or longer -increased venous pressure leads to edema of head, neck and arms -headache -cyanosis -cough, dyspnea -dysphasia, stridor

11. SVC Syndrome

12. SVC Syndrome

13. SVC Syndrome
Diagnosis -CXR (mediastinal widening, mediastinal mass) -CT neck/chest -ultrasound/doppler to r/o thrombosis of SVC Treatment -Oxygen -elevation of the upper body -diuretics, fluid restriction -anticoagulation if thrombosis -biopsy – obtain pathology prior to treatment -*chemotherapy -radiation therapy -steroids (benefits unproven) -endovascular stents (if conventional therapy unsuccessful) Prognosis -patients with malignant obstruction of SVC have Overall survival of <7 months

14. Pathology
Adenocarcinoma (including bronchioloalveolar carcinoma) — 38%
Squamous cell carcinoma — 20%
Large cell carcinoma — 5%
Small cell carcinoma -13%
Other non-small cell carcinomas (not further classified) -18%
Other (mesothelioma, carcinoids)-6%

15. NSC Lung Cancer Adenocarcinoma
-Bronchioloalveolar subtype (more common in never smokers and women)
Squamous cell Carcinoma
-Centrally located
-Often cavitates
Large Cell Carcinoma
*prognosis is similar among the subtypes

16. Staging – NSC Lung Cancer

17. Small Cell Lung Cancer Typically centrally located
Comprises 13% of all lung cancers
Smoking is a major risk factor
s/s: cough, dyspnea, weight loss, chest pain
Approximately 70% present with metastatic disease at diagnosis
Frequent mets to liver, bone, bone marrow, brain
Overall prognosis is poor

18. Staging – Small Cell Lung Cancer
Limited Stage
-disease confined to ipsilateral hemithorax
-confined to a single radiotherapy port
Extensive Stage
-evidence of disease outside of ipsilateral hemithorax
-disease which can not be covered by a single
radiotherapy port

19. Mesothelioma Rare type of cancer
Almost always caused by exposure to asbestos
Malignant cells develop in the mesothelium– the lining of the body’s organs (example: pleura)
There is no association between mesothelioma and smoking, although smoking greatly increases risk of asbestos induced cancer

20. Screening NO SCREENING TEST (CXR, CT, OR SPUTUM CYTOLOGY)
HAS BEEN SHOWN TO REDUCE MORTALITY FROM LUNG CANCER

21. Diagnosis History and Physical Laboratory studies
Radiographic Imaging (CT, PET, bone scan)
Tissue sampling

22. Imaging

23. Imaging

24. Treatment Approach to treatment is multifactorial Depends on:
type of cancer (Non-small cell including subtype or small cell)
stage of disease
patient’s age
performance status
patient’s smoking status
patient’s preference
Options include:
Surgery
Radiation therapy
Chemotherapy
Combination of above

25. Pharmacology Chemotherapy side –effects
Carboplatin – neuropathy, renal toxicity
Cisplatin – neuropathy, renal toxicity, renal wasting of electrolytes, hearing loss
Paclitaxel – neuropathy, allergic reactions to cremaphor (preservative), chest pain, fluid retention
Navelbine – neurotoxicity, cytopenias, fatigue
* all – cytopenias, nausea/vomiting, hair loss, fatigue

26. IPASS Study
EGFR inhibitor (Iressa in Europe, oral form -Tarceva in U.S.)
Compared with standard chemotherapy (Carbo/Taxol)
Found that in women, Asian descent, non-smokers, with adenocarcinoma, with EGFR mutation – PFS >3x higher with EGFR inhibitor than with standard chemotherapy.

27. Prognosis NSC Lung Cancer: 5 year overall survival: -Stage I – 50-60%
-Stage IV – 1%
-Stage IV disease median survival 9 months
Small Cell Lung Cancer:
-Limited disease – 20%
-Extensive disease - <1%

28. Prognosis
stage specific survival rates are better in women than in men in both NSC and small cell lung cancer
women who underwent surgical resection of disease had longer O.S. than men with same stage and surgery

29. THANK YOU