Lung Cancer Four Grandchildren: ages 2,4,7

1

Lung Cancer Mary Jo Sarver ARNP,

AOCN, CRNI, LNC, VA-BC

Cancer Partnership

Everett, Washington

[email protected]

Let’s Meet Samantha

• Age: 56

• Caucasian Female

• 23 pack/yr. history and

continues to smoke

• Marijuana (inhaled) for

anxiety

• Parents both smoked

• Job: Flagger

• Married 5 years

• Chronic bronchitis

• Over all good health

• Mother died of lung cancer age

59

• 2 Daughters: 26 & 21 live locally,

accompany to all appointments

• Four Grandchildren: ages 2,4,7

and 9

Cancer Facts & Figures 2017(ACS) New Cancer Cases & Deaths- 2017 Estimates from ACS

2

5 Year Survival Rates by Race & Stage Cancer Death Rates for Males 1930-2014

1964 1st Surgeon

Generals Report on

Smoking & Health

Cancer Death Rates for Females 1930-2014

Geographic Patterns in

Lung Cancer Death Rates *

By State 2010-2014

3

Probability Related to Age 2009-2013

88-90% of lung cancer cases are caused by voluntary or

involuntary “second hand” cigarette smoke. (NCCN Guidelines NSCLC Feb 2017)

a) Dose exposure relationship

b) # of cigarettes per day

c) Duration/pack years

d) Degree of inhalation

e) Unfiltered verses filtered

f) Age at initiation

Chemoprevention agents are not yet established patients are

encouraged to enroll in trials NCCN 2017

Smoking

Example: Mary states a pack of cigarettes last her three days and she has been smoking for 30 years

.33 packs/day X 30 years= 9.9 pack years

Calculated in Pack Years

She quit for five years and restarted five years ago at ½ pack/day .5 packs/day X 5 years = 2.5 pack years

Total smoking history: 9.9 + 2.5 = 12.4 pack years http://www.cancer.org/Healthy/ToolsandCalculators/Calculators/app/cigarette-calculator

Smoking Facts ACS 2017

• Annually cigarette smoking

results in an estimated 480,000

premature deaths

• In 2012 accounted for $176

billion in health care-related cost

• Cigarette smoking decrease by

nearly 40% from 2000-2015 ,

cigar consumption increased by

92%

• FDA expanded regulatory

authority to include all tobacco

products, including e-cigarettes,

cigars, hookah, pipe tobacco,

nicotine gels and those not yet

on the market.

(For more information fda.gov/tobacco products/default.htm)

Deaths 35 years and older US 2011

• Lung, bronchus & trachea 80%

• Larynx 77%

• Esophagus 51%

• Oral & Pharynx 47%

• Bladder 45%

• Live & Interhepatic bile duct 24%

• Uterine cervix 22%

• Stomach 20%

• Kidney & renal pelvis 17%

• Myeloid Leukemia 15%

• Pancreas 12%

• Colon & rectum 10%

4

Types of Tobacco Products Second Hand & Third Hand Smoke

• No safe level of exposure

• Annually, about 7,000 nonsmoking adults die of lung cancer

as a result of breathing SHS

• Increases risk of coronary artery disease, heart attacks,

coughing, wheezing, chest tightness and reduced lung

function

• 20-30% increased risk of lung cancer associated with living

with a smoker

2017 NCCN Guidelines NSCLC , 2017 Facts & Figures ACS)

Washington State

• Tax Rates: $3.02 per pack

• Smoke free laws in workplaces, restaurants and bars

Surgeon Generals Goals

•Prevent the initiation of tobacco use among youth

•Promote quitting at all ages

•Eliminate nonsmokers exposure to secondhand smoke

•Identify and eliminate the disparities related to tobacco use and its effect among different population groups

•Comprehensive funding levels for prevention and cessation programs

•USDA: “The Real Cost Program active since 2014

Free Programs

• The Quit For Life: offered by 27 states and more than 675 employers

and health plans participate. An evidence-based combination of

physical, psychological and behavioral strategies to enable participants

to over come their addiction. Mix of medication support, phone-based

cognitive behavioral coaching, text messaging, web-based learning and

support tools. Average quit rate of 46%.

• The Fresh Start: group-based program assist in planning a successful

quit attempt by providing essential information, skills for coping with

cravings and social support

• Tobacco Policy Planner: online assessment of company policies,

benefits and programs relate to tobacco control. Can assist employers

in creating a safe, tobacco free environment that enhances employee

well being while improving the company's bottom line.

5

Risk Factors Continued

• Radon Gas released from soil and building materials

• Occupational Exposure: Asbestos, coal smoke/soot, diesel

exhaust, radiation, paving, roofing, painting, rubber

manufacturing

• Medical history of tuberculosis, chronic obstructive pulmonary

disease, pulmonary fibrosis

• Genetic Susceptibility/Family History: young age

• Metals: arsenic, beryllium, cadmium, chromium, nickel

• Age

2017 NCCN Guidelines NSCLC , 2017 Facts & Figures ACS)

Samantha's Risk ?

What are they?

• Smoker (23 pack/yr. history)

• Second hand smoke growing up

• Prior Lung Dysfunction (chronic bronchitis)

• 1st degree relative (mother)

• Marijuana usage?

• Possible exposure to chemical or material irritants based

on career

Samantha's Office Visit

History:

• Persistent cough for seven

months

• Blood tinged sputum

• 3 courses of antibiotics in seven

months for respiratory infections

• Intermittent shooting Rt arm

pain, constant ache

• Inhaler use multiple times daily

• SOB with minimal activity,

sleeping in a recliner

• Always tired

• 20 pound weight loss in 3

months

Examination

• SOB with ambulation, oxcimetry

90% ambient air

• R 24, no accessory muscles

• Decreased Breath sounds RUL,

dullness on percussion, positive

for egophony, wheezes

• Clubbed fingers

• Weight loss of 20 lbs. confirmed

in EMR

• Frequent moist cough & sputum

stained with small streaks of

bright red blood

6

History and Physical Exam

A careful history and physical exam will guide diagnostic testing

and may prevent unnecessary surgery.

• Chief Complaint: location, quality, severity, timing,

aggravating and alleviating factors and associated factors

• Past Medical History (Co-morbid disease)

• Environmental/Tobacco History: pack years, passive

smoking exposure, other known carcinogens

• Family History

• Review of systems to include constitutional symptoms such

as fatigue, weight loss, weakness and fever

Physical Exam

Head and neck:

• Nasal flaring

• Cyanosis

• Palpation may reveal enlarged cervical or supraclavicular

nodes

• If superior vena cava obstruction is present, swelling of the

face and neck may be observed

• Redness or flushing of the face (plethora) may be present

Physical Exam

Chest

• Accessory muscles (retraction/bulging)

• SOB/Tachypnea

• Prominent vascular markings

(SVCS/blood clot)

• Decreased breath sounds, dullness on

percussion, egophony (pleural effusion)

• Muffled heart sounds (pericardial

effusion)

• Wheezing/Stridor

• Elevation of the hemi diaphragm (phrenic

nerve paralysis)

Physical Exam

Assessment of cranial nerves I-XII

• May unmask CNS metastases or findings consistent with

Horner's Syndrome

Extremities

• Clubbing

• Swelling (clot/obstruction)

Abdomen

• Hepatomegaly

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Local-Regional Manifestations

• Cough

• Dyspnea

• Hemoptysis

• Wheezing

• Chest Pain

• Stridor

• Hoarseness

• Hiccups

• Atelectasis

• Pneumonia

• Pancoast Syndrome

• Horner’s Syndrome

• Pleural Effusion

• Pericardial Effusion

• Superior Vena Cava Syndrome

• Bone Pain

Ptosis: Drooping eyelid

Miosis: Constriction of the pupil

Systemic Symptoms

• Weakness

• Fatigue

• Anorexia

• Cachexia

• Weight Loss

• Anemia

• Symptoms associated with Paraneoplastic Syndromes

Manifestations of Extra Thoracic Involvement

• Headache

• CNS disturbances

• GI disturbances

• Jaundice

• Hepatomegaly

• Abdominal Pain

Clinical Presentation: Cancer Facts & Figures 2017 (NCCN 2017)

Primary tumor

• Persistent Cough

• Voice Changes/Hoarseness

• Hemoptysis

• Chest pain /shortness of breath/high pitched sounds

when breathing/pain with swallowing

• Recurrent pneumonia or bronchitis

(Mimic pneumonia, asthma, bronchitis, flu, etc.)

8

Samantha's Office Visit

History:

• Persistent cough for seven

months

• Blood tinged sputum

• 3 courses of antibiotics in seven

months for respiratory infections

• Intermittent shooting Rt arm

pain, constant ache

• Inhaler use multiple times daily

• SOB with minimal activity,

sleeping in a recliner

• Always tired

• 20 pound weight loss in 3

months

Examination

• SOB with ambulation, oxcimetry

90% ambient air

• R 24, no accessory muscles

• Decreased Breath sounds RUL,

dullness on percussion, positive

for egophony, wheezes

• Clubbed fingers

• Weight loss of 20 lbs. confirmed

in EMR

• Frequent moist cough & sputum

stained with small streaks of

bright red blood

Samantha's Symptoms/Exam Findings

What were they?

• Persistent cough

• Hemoptysis

• Chest pain/SOB

• Recurrent respiratory infections

• Fatigue

• Weight loss of 20lbs

• Physical examination findings: Decreased breath sounds,

dull to percussion, + egophony, wheezes in RUL. Pain in

Right shoulder and slight tingling down arm “on occasion”

Screening Guidelines:

(NCCN Guidelines Version1.02017 Samantha: Age 56, 23 pack year

history, still smoking

2017 NCCN Lung Cancer Screening Guidelines

NCCN Update 2017: Screening Follow Up

2017 NCCN NSCLC Guidelines

Samantha 6cm

? Ground glass verses Part solid

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Benefits: cost, availability, can reveal the primary tumor as well

as the presence of pleural or pericardial effusions.

Characteristics of malignant lesions

a) > 3cm in size

b) Irregular or spiculated border

c) distortion of surrounding vascular markings

d) Thick irregular walled cavity lesions

Problems: variable in sensitivity depending on size and

location of tumor , quality of image, skill of interpreting

physician

CXR posterior-anterior and lateral views:

Standard for evaluating patients with suspected or documented lung cancer. (include adrenals)

Benefits:

a) Single breath

b) No IV contrast

c) Lower cost than a standard chest CT

d) Sensitive for nodules as small as 2-3mm

e) Construction of 3-dimensional images to assess sizes

and changes

Problem: Unnecessary pain, cost, benign findings, radiation

exposure

High Resolution or Conventional CT of Chest & Upper Abdomen:

2017 NCCN NSCLC Guidelines

Magnetic Resonance Imaging (MRI):

Problem: Not routinely used for several reasons:

a) Does not offer significantly more information than chest CT

b) Longer test time

c) Affected by respiratory motion, which creates motion artifact.

Benefits: MRI Is helpful however in:

a) Evaluation of superior sulcus tumors in which chest wall,

brachial plexus and/or subclavian vessels and vertebral body

involvement may exist

b) Evaluation of the brain for metastasis (stage II, IIIA, IB optional)

2017 NCCN NSCLC Guidelines

Positron Emission Tomography/CT PET: Need pathologic or

other radiologic confirmation including lymph nodes

Sputum Cytology: with new technology sensitivity may

increase.

Bronchoscopy: Lung imaging fluorescence endoscopy (LIFE)

uses blue light which can more clearly identify areas of

dysplasia, carcinoma in situ, and invasive carcinoma

Endobronchial Ultrasound (EBUS/EUS):

Navigational Bronchoscopy:

2017 NCCN NSCLC Guidelines

10

Laboratory Test of hematological and metabolic systems:

NSCLC: CBC, Platelets, Chemistry Profile

SCLC: CBC with differential, platelets, Electrolytes, Liver Function,

Ca, LDH, BUN, Creatinine

Thoracentesis/Pericardiocentesis:

Genetics/Markers: K-ras, Epidermal Growth Factor Receptors

(EGFR), ALK, ROS1, PD-L1

Pulmonary Function Test:

Immunohistochemical Staining: differentiates

pulmonary from metastatic adenocarcinoma, adenocarcinoma

from malignant mesothelioma & determines neuro endocrine

status.

Needle Aspiration/Biopsy: Tissue Histology

• CT Guided Transthoracic needle aspiration (through chest

wall)

• Transesophageal endoscopic ultrasound (EUS_FNA)

• Endobronchial ultrasound guided transbronchial needle

aspiration (EBUS/EUS)

• Intraoprerative needle aspiration (mediastinoscopy)

Considered the “gold standard” for evaluation of

mediastinal lymph nodes

• Chamberlain Procedure (anterior mediastinoscopy) for

aortopulmonary lymph nodes

• Navigational Bronchoscopy

• Thoracoscopy (video-assisted thoracic surgery [VATS]: can

assess aortopulmonary widow lymph nodes, chest wall

lesions, lung parenchymal abnormalities and pleural

effusions.

• Thoracotomy: reserved for patients with a high probability of

lung cancer but for whom other diagnostic measures have

failed to provide a diagnosis

Samantha's Work Up

• CXR: Right Upper lobe mass with right pleural effusion

• PET CT: RUL 6 cm mass, spot on the liver, enlarged upper

supraclavicular & paratracheal nodes, increased SUV

• Tissue Biopsy from mediastinoscopy: Adenocarcinoma

with 9/10 positive nodes

• Liver Biopsy: Positive for metastasis

• Marker: Positive for k-ras

• MRI of Brain: negative

• MRI Chest: invasion into first rib and impingement of brachial

plexus nerve

• PFT: WNL

• Labs: Anemia, slight increase in calcium, LFT’s norm

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NSCLC Prevalence and Presentation

• 80-85% of lung cancer diagnosis

• Two major types:

• Non-squamous carcinoma (including

adenocarcinoma, large-cell carcinoma and other

cell types)

• Squamous Cell (epidermoid) carcinoma

• Adenocarcinoma is the most common type of lung cancer in

the US and most frequently occurring histology in

nonsmokers

• Hypercoagulabe states common

Good Prognostic Indicators for NSCLC

• Early stage at diagnosis

• Good performance status (ECOG 0,1 or 2)

• No significant weight loss (5% or more in the six weeks

preceding diagnosis)

• Female gender

If Samantha's weighs 158 pounds and was 178 six weeks ago

did he lose over 5%?

178 pounds X .05 = 8.9 pounds

178 pounds – 8.9 pounds = 169.1 pounds

Primary Tumor (T)

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Regional Lymph Nodes (N)

NX Regional lymph nodes cannot be

assessed

N0 No regional lymph node metastasis

N1 Metastasis in ipsilateral

peribronchial and/or ipsilateral hilar

lymph nodes and intrapulmonary

nodes, including involvement by

direct extension

N2 Metastasis in ipsilateral mediastinal

and/or subcaninal lymph node(s)

N3 Metastasis in contralateral

mediastinal, contralateral hilar,

ipsilateral or contralateral scalene,

or supraclavicular lymph node(s)

Most common sites:

• Brain

• Bone

• Adrenal glands

• Contra lateral lung

• Liver

• Pericardium

• Kidney

Metastasis (M)

Samantha's Stage & Prognostic Indicators

Stage IV : Due to liver metastasis

Poor Prognostic Indicators

• Advanced stage at diagnosis

• Weight loss

Good Prognostic Indicators

• Good Performance Status

• Female Gender

Treatment Options

• Surgery

• Ablation

• Radiation

• Systemic Chemotherapy

• Targeted Therapy

• Immunotherapy

• Clinical Trials

13

Principles of Surgical Resection (NCCN 2017)

• CT or PET staging should be within 60 days of evaluation

• Resection is a preferred local treatment

• Overall plan and studies should be completed prior to

non-emergent cases.

• Active smokers should be provided counseling and

smoking cessation support

Types of Surgical Resections (NCCN 2017)

Types of Surgery:

Wedge resection Small part of a lobe

Segmentectomy Large part of a lobe

Lobectomy Removal of an entire lobe

Types of Surgical Resections (NCCN 2015)

Sleeve lobectomy: Removal of an entire lobe and part of the

bronchus

Pneumonectomy: Removal of an entire lung

VATS or minimally invasive surgery (including robotic) should be

strongly considered for patients with no anatomic or surgical

contraindications.

Potential Surgical Side Effects (NCCN 2017)

• Unhealthy or unpleasant physical or emotional responses

• General anesthesia: sore throat, nausea and/or vomiting,

confusion, muscle aches and itching

• Pain

• Swelling

• Scars

• Numbness near the surgical area

• Chance of infection

• Pneumothorax

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Ablation (NCCN Guidelines for Patients)

• Destroys small tumors with

little harm to nearby tissue

• Not used often

• Radiofrequency ablation

kills using heat from

electrodes passed through

a bronchoscope

• Done by an interventional

radiologist

Potential Side Effects:

• Prolonged pain

• Hemoptysis and

pulmonary hemorrhage

• Pneumonia/abscess

• Pleural effusion

• Pneumothorax

• Broncho pleural fistula

• Cerebral air embolism

• Acute respiratory

distress syndrome tumor

seeping

Radiofrequency Ablation in Lung Cancer: Promising Results in Safety and

Efficacy

October 01, 2005 | Oncology Journal, Lung Cancer Robert Suh, MD, Karen Reckamp,

MD, Michelle Zeidler, MD, and Robert Cameron, MD

Radiation Therapy: Types and Length of Treatment (NCCN 2017 Patient Guidelines)

3D-CRT: 3-dimensional conformal radiation therapy. About 6 weeks

uses photon beams that match the shape of the tumor

IMRT: intensity modulated radiation therapy. About 6 weeks uses

photon beams of different strengths based on the thickness of the

tumor

SABR: stereotactic ablative radiotherapy. Completed in 1-2 weeks,

uses precise, high-dose photon beams

SRS: stereotactic radiosurgery. Treats cancer in the brain with precise,

high dose photon beams Completed in 1-2 weeks

WBRT: whole brain radiation therapy. Treatment completed in 2

weeks and uses small amounts of radiation to treat the entire brain

Proton Therapy: Treats cancer with proton beams that deliver

radiation mostly with the tumor. Completed in a about 6 weeks.

Principles of Radiation Therapy (NCCN 2017)

General Principles:

• Potential role in all stages as definitive or palliative

• To maximize tumor control & minimize treatment toxicity

(minimum standard is CT-planned 3DCRT)

Principles of Radiation Therapy (NCCN 2017)

Specific Parameters for:

• Early Stage Lung Cancer (Stage I, selected node negative

Stage IIA)

• Locally Advanced Lung Cancer (Stage II-III)

• Advanced /Metastatic Lung Cancer (Stage IV)

• Target Volumes, Prescription Doses & Normal Tissue

Dose Constraints

• Node negative early Stage/SABR

• Locally Advanced Stage/Conventionally Fractionated RT

• Advanced Stage/Palliative RT

15

Principals of Radiation Therapy (NCCN 2017)

Simulation, Planning & Delivery

• CT should be in treatment position with proper

immobilization devices

• IV contrast with or without oral contrast is recommended

• CT/PET improves target accuracy, prefer within 4 weeks

of starting

• Tumor & organ motion should be assessed or accounted

for at simulation

• Respiratory motion should be managed when motion is

excessive. Resource AAPM Task Group Report

Chemotherapy with Radiation (NCCN 2017)

Side Effects of Radiation:

• Skin changes

• Red

• Dry

• Painful to touch

• Sore

• Potential hair loss over treatment site

• Inflammation of the lungs or esophagus

• Fatigue

• Loss of appetite

Principles of Pathologic Review (2017)

Pathologic Evaluation Purpose:

• Histology, size, extent of invasion, +/- surgical margins, +/-

nodes, molecular abnormalities

Immunohistochemical Staining Purpose:

• Differentiate primary pulmonary adenocarcinoma from

squamous carcinoma, large cell carcinoma, metastatic

carcinoma and from malignant mesothelioma

• Determine if neuroendocrine differentiation is present

Molecular Diagnostic Studies Purpose:

• Selection of therapy

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Molecular Diagnostic Studies: Selection of therapy (NCCN 2017)

• Over lapping EGFR and KRAS mutations occur in <1% lung cancers

• EGFR mutations: Erlotinib, Afatinib, Gefitinib (First-Line)

Sensitive to TKIs

In adenocarcinomas are 10% of Western and up to 50% of

Asian patients

Frequency in non-smokers, women and non-mucinous

cancers

• KRAS Mutations:

Resistant to EGFR TKIs

Most common in non-Asians, smokers and in

mucinous adenocarcinoma

Samantha is Positive for

KRAS: How would this effect

potential treatment options?

Molecular Diagnostic Studies: Selection of therapy (NCCN 2017)

• ALK Rearrangement

Positive: Crizotinib (First-

Line)

• PDL-1 expression

positive (>50% and

EGFR, ALK, ROS1

negative or unknown):

Pembrolizumab (First-

Line)

• ROS1 Rearrangement

Positive: Crizotinib (First-

Line)

Emerging Targeted Agents Immunotherapy

• Nivolumab (Opdivo®)

• Pembrolizumab (Keytruda®)

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Systemic Therapy for Advanced or Metastatic Disease (NCCN 2017)

• Benefit with toxicity acceptable to both the physician &

patient given as initial therapy

• Stage, weight loss, performance status & gender predict

survival

• Histology is important in the selection of systemic

therapy

• Unfit of any age (PS 3-4) do not benefit, except erlotinib ,

afatinib, or gefitinib for EGFR mutation-positive and

crizotinib for ALK-positive tumors NSCLC/NSCLC NOS

• 2 drugs preferred, 3rd increases response not survival

• Response assessment after 2 cycles, then every 2-4

cycles with CT or when clinically indicated

Systemic Therapy for Advanced or Metastatic Disease (NCCN 2017)

• New agent/Platinum-based combination chemotherapy

prolongs survival, improves symptoms and yields superior

quality of life compared to best supportive care

1. Plateau in overall response rate 25-35%

2. Time to progression 4-6 months

3. Median survival 8-10 months

4. 1 year survival rate 30-40%

5. 2 year survival rate 10-15% in fit patients

First Line Systemic Therapy (NCCN 2017) First Line Systemic Therapy (NCCN 2017)

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Maintenance/Subsequent Therapy (NCCN 2017)

Continuation Maintenance:

• Use of at least one of the agents used in first line,

beyond 4-6 cycles, in the absence of disease

progression

Switch Maintenance:

• Initiation of a different agent not in the first line

regimen, beyond 4-6 cycles, in the absence of

disease progression

Subsequent Therapy:

• Response assessment with CT of known sites of

disease with or without contrast every 6-12 weeks

Pearls Related to Therapy

• Squamouse verses Non-Squamouse plays a role in

chemotherapy selection

• Molecular markers play a role in therapy selection

• Platinum Therapy: What do you watch for?

Kidney function

Hydration

Hearing

Neuropathy

Nausea

Hypersensitivity reactions

Electrolytes require monitoring

Cancer Survivorship

Follow-up Care

• H&P

• Chest CT + contrast 6-12

months/2 years then non-

contrast enhanced CT

annually

• Smoking status assessment

each visit; counseling and

referral as needed

Immunizations

• Annual influenza

• Herpes Zoster

• Pneumococcal with

revaccination as appropriate

Counseling Regarding Health

Promotion & Wellness

• Healthy weight

• Physically active lifestyle

• Healthy diet emphasis on

plant sources

• Limit alcohol

Cancer Survivorship Continued

Additional Health Monitoring for Average Risk Patients

• Routine BP, cholesterol and glucose

• Bone health: bone density testing

• Dental health: routine dental examinations

• Routine sun protection

Resources NCI Facing Forward: Life After Cancer Treatment

http://wwwlcancer.gov/cancertopics/life-after-treatment/all pages

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Samantha's Treatment

Adenocarcinoma

• Thoracentesis for 700 mL’s

• IVAD (port) left chest

• Cisplatin 100 mg/m2 on day 1

• Etoposide 100mg/m2 days 1-3

• Every 28 days for 4 cycles

• Smoking cessation advice and counseling

Small Cell Lung Cancer

Over View of Small Cell Lung Cancer

• Estimated 31,000 cases in US predicted in 2017

• Rapid doubling time and earlier development of widespread

metastases

• Highly sensitive to chemotherapy and radiotherapy

• Strong relationship with cigarette smoking if continued

through treatment increase toxicity and shorter survival

• 1/3 of patients present with limited disease confined to the

chest

• Surgery is only appropriate for 2-5%

• Male to female ration 1:1

Clinical Manifestations (NCCN 2017)

• Usually large hilar mass and bulky mediastinal

lymphadenopathy that cause cough and dyspnea

• Symptoms of metastatic disease: weight loss, debility, bone

pain and neurologic compromise

• Neurologic syndromes include: Lambert-Eaton myasthenic

syndrome, encephalomyelitis and sensory neuropathy,

Cushing's syndrome and hyponatremia (SIADH)

20

Staging for SCLC Response Rates & Survival

Limited Disease:

• Response rates are 70-90% with chemotherapy and radiation

• Median Survival: 14-20 months

• 2 year post treatment survival rate 40%

• Thoracic radiation improves local control by 25%

Extensive Disease:

• Response rates 60-70% with a combination chemotherapy

alone

• Median Survival: 9-11 months

• After Treatment 2 year survival rates less than 5%

Treatment of SCLC

• Chemotherapy is the corner stone of treatment for both

limited and extensive disease

• Surgical resection: Adjuvant

• Limited Disease: Excess of T1-2 N0 and PS 0-2:

Concurrent radiation

• Extensive: Chemotherapy alone

• Surgery: only 2-5% are canidates

• Radiation

Prognostic Factors

Poor prognostic factors

• Extensive stage disease

• Poor performance status (3-4)

• Weight loss

• Markers associated with bulk of disease (increased LDH)

Favorable prognostic factors

Limited: Female, less than 70, stage I disease, normal LDH

Extensive: Younger age, good PS, normal creatinine,

normal LDH and a single metastatic site

21

Surgical Considerations (NCCN 2017)

• Staged disease in excess of T1-2, N0 do not benefit from

surgery

• Prior to surgery all patients should undergo mediastinoscopy or

other mediastinal staging to rule out occult nodal disease

• Patients who undergo complete resection

Without nodal disease : chemo alone.

With nodal metastases: post op concurrent chemotherapy

and mediastinal radiation therapy

• PCI is recommended after adjuvant chemotherapy in patients

who have undergone a complete resection. Not recommended

in patients with poor performance status or impaired

neurocognitive functioning

Chemotherapy for SCLC (NCCN 2017)

Response Assessment for Systemic Therapy Principals of Radiation in SCLC (2017)

Limited Stage:

• Dose & Schedule: Have not been established

• Timing: Concurrent with chemotherapy is standard,

should start with cycle 1 or 2

• Target Definition: Based on pretreatment PET and CT

within 4-8 weeks ideally, treatment position

• Elective Nodal Irradiation: Consensus is evolving

Extensive Stage:

• Consolidative thoracic RT is beneficial for selected

patients who respond to chemotherapy

22

Principals of Radiation in SCLC (2017)

Normal Tissue Constraints:

Doses: based on tumor size and location

PCI :

• Decreases brain mets and increases overall survival

• 25 Gy in 10 daily fractions preferred. Shorter course may

be appropriate in selected pts (20Gy in 5 fractions)

• Not recommended in patients with poor performance

status or impaired neurocognitive function

• Increase age & high dose most predictive of chronic

neurotoxicity.

Principals of Supportive Care (NCCN 2017)

• Smoking Cessation Counseling

• Granulocyte Colony-Stimulating Factors or Granulocyte-Macrophage Colony-Stimulating Factors during RT is Not recommended

SIADH:

Fluid restriction

Saline infusion for symptomatic patients

Antineoplastic therapy

Demeclocycline

Vasopressin receptor inhibitors (conivaptan, tolvaptan)

Cushing Syndrome

Consider ketoconazole if ineffective metyrapone

Try to control before initiation of antineoplastic therapy

Principals of Supportive Care (NCCN 2017)

• Leptomeningeal Disease

• Pain Management

• Nausea/Vomiting

• Psychosocial Distress

• Palliative Care

All bullets at the NCCN website are set up to provide a link

to recommendations at NCCN or ASCO

Nursing Considerations for Patients with Lung Cancer

Monitor/Treat/Prevent/Counsel:

• Venous thrombo-embolisms

• Dyspnea

• Smoking Cessation

• Potential for spinal cord compression, superior vena cava

syndrome and other neurologic symptoms

• Neuropathy

23

Evidence Based Practice: Resources

• American Society Clinical Oncology (ASCO)

www.asco.org

• National Comprehensive Cancer Network (NCCN)

NCCN.org

• Lung Cancer Alliance: www.lungcanceralliance.org

• American Cancer Society: www.cancer.org

• National Cancer Institute: www.cancer.gov

• Oncology Nursing Society: ons.org

• Cancer Net work: cancernetwork.com

• LUNGevity Foundation: