lung cancer four grandchildren: ages 2,4,7
TRANSCRIPT
1
Lung Cancer Mary Jo Sarver ARNP,
AOCN, CRNI, LNC, VA-BC
Cancer Partnership
Everett, Washington
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
7
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
9
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
11
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)
12
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
14
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
16
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®)
17
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)
18
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
19
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: