Transcript Slide 1

Lung cancer treatment 2010
Dr A.J.France, Ninewells Hospital, Dundee
© A.J.France 2010
Lung cancer treatment 2010
• Giving the diagnosis
• Surgery
• Radiotherapy
• Chemotherapy
• Supportive care
© A.J.France 2010
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
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
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
Treatment choices
• Surgery
• Chemotherapy
• Radiotherapy
• Palliative care
© A.J.France 2010
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 ?
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Staging for surgery
• Bronchoscopy
• CT scan of thorax
• Vocal cord palsy
• Tumour size
• Proximity to carina
• Lymph nodes
• Cell type
• Metastases
• Mediastinoscopy
• Lymph nodes
• Local invasion
• PET scan
• Positron Emission
Tomography
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Surgery for lung cancer
• Pneumonectomy or lobectomy
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Thoracotomy
Minimal access VATS
Curative objective
Peri-operative mortality
Post-operative morbidity
Only 1 in 20 are suitable for surgery
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Video Assisted ThoracoScopic Surgery
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VATS. pre & post op CXR
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Staging - for chemotherapy
• Bronchoscopy or other tissue sampling
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Small cell / non-small cell
• CT scan
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Tumour size
Local invasion
Nodes
Metastases
• Performance status ECOG score
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Cytotoxic chemotherapy
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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
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Cytotoxic chemotherapy
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Whole body treatment
Targets rapidly dividing cells
Blood brain barrier
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Prophylactic cranial irradiation
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Chemotherapy - Side effects
• Nausea and vomiting
• Tiredness
• Bone marrow suppression
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Opportunistic infection
Anaemia
• Hair loss
• Pulmonary fibrosis
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Radiotherapy
• Ionising radiation
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Usually X-rays
External beam
• Radical
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Curative
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target < 5cm diam
• Palliative
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A delaying tactic
Useful for metastases
• Well tolerated
© A.J.France 2010
Radiotherapy - the snags
• Maximum cumulative dose
• Collateral damage
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Spinal cord
Oesophagus
• Only goes where you point the beam
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No good for subclinical metastases
Except prophylactic cranial irradiation
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Collateral damage
Spinal cord
Tumour
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Clinical trials.
Some words of caution…
• Most trials are sponsored by the
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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
Further information
• Small-cell lung cancer.
Lancet 2005; 366: 1385-96
• Median survival – small cell
• 17 months – limited stage disease
• 8 months – extensive stage disease
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Further information
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• 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
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Endobronchial therapy
Mechanical stents for stridor
Photodynamic therapy
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Endobronchial therapy
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Stent insertion for stridor
Photodynamic therapy
Other laser therapy
Radioactive pellets
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Stent insertion 1
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Stent insertion 2
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Treatment of lung cancer
is determined by
• The cell type
• The extent of the disease
• Co-morbidity
• The patient's wishes
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Co-morbidity
• Smoking related diseases
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COPD: FEV1 < 1 litre
Ischaemic Heart Disease
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Palliative care
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Pain
Breathlessness
Cough
Anxiety
Poor mobility
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Palliative radiotherapy
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Prognosis for lung cancer
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Half will be dead in 6 months
1 in 20 survive for 5 years
Very little change over past 15 years
What about prevention ?
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Causes of lung cancer
Tobacco smoking
Asbestos
Radon
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Scotland leads the
world for lung cancer
Key points
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Surgery can be curative
Radio and Chemo therapy can be beneficial
Prognosis remains poor
Prevention is a better option
© A.J.France 2010