Lung Cancer

Lung Cancer

Lung Cancer

The most common cancer worldwide, and the deadliest

1.37 million deaths worldwide (WHO 2008) 203,000 people diagnosed in the US each

year, 158,000 deaths (CDC 2007)

Risk Factors

Cigarette smoking Smokers are 10-20 times more likely to get

lung cancer85-90% of deaths from lung cancer are

smoking relatedRisk is dose dependent: the more a person

smokes, the higher the riskQuitting decreases a person's risk

Risk Factors

Radon accounts for 21,000 lung cancer deaths (EPA 2003)

Industrial exposures: Asbestos, coal tar fumes, nickel, chromium, arsenic, etc

Family historyHigh cholesterol diet? Alcohol?Beta carotene (Vitamin A) supplements in

heavy smokers

Prevention

QUIT SMOKING (or failing that, cut down)Decrease exposure to second hand smokeDecrease exposure to radon, asbestos and

other industrial carcinogensHealthy dietPhysical activity

National Lung Cancer Screening Trial

53,454 participants: 55-74 y/o> 30 pack year hx of cigarette smokingQuit smoking < 15 yrs prior if a former smokerNo hx lung ca or other life-threatening cancersNo sx's of hemoptysis or wt lossNo chest CT prior 18 mo

NLST

Participants randomized to low dose chest CT vs PA chest x-ray annually for 3 years

LDCT arm showed a 20% reduction in lung cancer deaths compared to the CXR arm (p=0.004)

NEJM 2011 Aug 4;365(5):395-409

Screening and Diagnosis

Chest x-rays have not been shown to be a good screening tool for lung cancers

NCCN guidelines for LDCT screening:55-74 y/o and> 30 pack years of smoking andSmoking cessation < 15 yrsOr > 50 y/o and > 20 pack year hx of smoking

and one additional risk factor (not second hand smoke)

Symptoms

About 25% of people with lung cancer have no symptoms

Central tumors: obstructive sx's, cough, dyspnea, atelectasis, postobstructive pneumonia, wheezing, hemoptysis

Peripheral tumors: pleural effusion, pain if invading pleura or chest wall

Symptoms

Pancoast tumor: tumor in the superior sulcus– Shoulder pain– Low brachial plexopathy– Horner's syndrome (ptosis, miosis,

anhidrosis)

Diagnosis

NCCN Guidelines

• Nodule < 8 mm: radiologic surveillance• Nodule > 8 mm, solid, non-calcified:

consider PET, bx or excise if suspicious• <10 mm non-solid or part-solid nodule:

radiologic surveillance• >10 mm non-solid or part-solid nodule:

LDCT in 3-6 mo

Beyond IHC

• Molecular analysis of certain mutations has become increasingly important for determining therapy

• EGFR mutations are a target for TKI's• KRAS mutations indicate a resistance to

TKI's• ALK mutations provide a target for ALK

inhibitors (crizotinib)

Further Work Up

PET scan, MRI of the brainBronchoscopyMediastinoscopy/USPFT's Lab tests: CBC, electrolytes