1. Dr A.J.France, Ninewells Hospital, Dundee Lung cancer treatment 2010 © A.J.France 2010

2. Lung cancer treatment 2010 Giving the diagnosis Surgery Radiotherapy Chemotherapy Supportive care © A.J.France 2010

3. Giving the diagnosis Prepare the ground Bring a relative Make sure they understand Prepare for obvious questions What can you do about it ? How long have I got ? Tell their GP Arrange follow up © A.J.France 2010

4. Types of lung cancer 1 Small cell Rapidly progressive disease Early metastases Rarely suitable for surgery Good initial response to chemotherapy © A.J.France 2010

5. Types of lung cancer 2 Non small cell Includes Squamous and adeno carcinomas Sometimes cured by surgery or radical radiotherapy Less responsive to chemotherapy Accounts for the majority of lung cancers © A.J.France 2010

6. Treatment choices Surgery Radiotherapy Chemotherapy Palliative care © A.J.France 2010

7. Treatment choices Surgery Can we cut it out ? Is the disease localised ? Will the patient survive the operation ? What will the residual lung function be ? © A.J.France 2010

8. Staging for surgery Bronchoscopy Vocal cord palsy Proximity to carina Cell type Mediastinoscopy Lymph nodes CT scan of thorax Tumour size Lymph nodes Metastases Local invasion PET scan Positron Emission Tomography © A.J.France 2010

9. Surgery for lung cancer Pneumonectomy or lobectomy Thoracotomy Minimal access VATS Curative objective Peri-operative mortality Post-operative morbidity Only 1 in 20 are suitable for surgery © A.J.France 2010

10. Video Assisted ThoracoScopic Surgery © A.J.France 2010

11. VATS. pre & post op CXR © A.J.France 2010

12. Staging - for chemotherapy Bronchoscopy or other tissue sampling Small cell / non-small cell CT scan Tumour size Local invasion Nodes Metastases Performance status ECOG score © A.J.France 2010

13. Cytotoxic chemotherapy Rarely curative but longer survival Better response in small cell cancer Major side effects A complex postgraduate subject Intravenous infusions every 3-4 weeks Outpatient visits More detailed imaging © A.J.France 2010

14. Cytotoxic chemotherapy Whole body treatment Targets rapidly dividing cells Blood brain barrier Prophylactic cranial irradiation © A.J.France 2010

15. Chemotherapy - Side effects Nausea and vomiting Tiredness Bone marrow suppression Opportunistic infection Anaemia Hair loss Pulmonary fibrosis © A.J.France 2010

16. Radiotherapy Ionising radiation Usually X-rays External beam Radical Curative -target < 5cm diam Palliative A delaying tactic Useful for metastases Well tolerated © A.J.France 2010

17. Radiotherapy - the snags Maximum cumulative dose Collateral damage Spinal cord Oesophagus Only goes where you point the beam No good for subclinical metastases Except prophylactic cranial irradiation © A.J.France 2010

18. Collateral damage Tumour Spinal cord © A.J.France 2010

19. Clinical trials. Some words of caution… Most trials are sponsored by the manufacturer of the drugs in question. Sales talk “ a 25 % response rate” But…… “ 75 % do not respond” And…... “ 100 % get side effects” Also….. What do you mean by “Response” ? © A.J.France 2010

20. Further information 1 Small-cell lung cancer. Lancet 2005; 366: 1385-96 Median survival – small cell 17 months – limited stage disease 8 months – extensive stage disease © A.J.France 2010

21. Further information 2 Non-small cell. “The big lung trial” (3 cycles of) Chemotherapy vs supportive care… Thorax 2004;59: 826-836 Chemotherapy prolongs median survival by 9 weeks. (8.0 months vs 5.7 months) No difference in quality of life NB 3 cycles of chemotherapy takes 9 weeks © A.J.France 2010

22. Endobronchial therapy  Mechanical stents for stridor  Photodynamic therapy © A.J.France 2010

23. Endobronchial therapy Stent insertion for stridor Photodynamic therapy Other laser therapy Radioactive pellets © A.J.France 2010

24. Stent insertion 1 © A.J.France 2010

25. Stent insertion 2 © A.J.France 2010

26. Treatment of lung cancer is determined by The cell type The extent of the disease Co-morbidity The patient's wishes © A.J.France 2010

27. Co-morbidity Smoking related diseases COPD: FEV 1 < 1 litre Ischaemic Heart Disease © A.J.France 2010

28. Palliative care Pain Breathlessness Cough Anxiety Poor mobility © A.J.France 2010

29. Palliative radiotherapy © A.J.France 2010

30. Prognosis for lung cancer Half will be dead in 6 months 1 in 20 survive for 5 years Very little change over past 15 years What about prevention ? © A.J.France 2010

31. Causes of lung cancer Tobacco smoking Asbestos Radon © A.J.France 2010

33. Scotland leads the world for lung cancer

34. Key points Surgery can be curative Radio and Chemo therapy can be beneficial Prognosis remains poor Prevention is a better option © A.J.France 2010