palliative treatments for lung cancer: what can the ... · pdf filedutch bone metastases study...

The Christie NHS Foundation Trust

Palliative treatments for lung cancer:

What can the oncologist do?

Neil Bayman

Consultant Clinical Oncologist


GM Cancer Palliative Care and Lung Cancer Education Event

Manchester, 31st January 2017


Most patients present with stage 4

disease

NLCA 2014


• Radiotherapy

• Systemic therapy

Palliative treatments for lung cancer:

What can the oncologist do?


Palliative Radiotherapy


Case Study

• 63 yr old man

• Stage 4 NSCLC

• WHO PS 1

• Pain in right hip

• Mobile

• No neurological signs

What next?


Radiotherapy for bone pain

• Systematic review 25 randomised trials, > 5500

patients

• Response rate

Any reduction in pain = 60%

Complete response = 23%

Overall and complete response rates 73% and 29% respectively

when excluding patients not assessed at follow-up

Chow, Clin Oncol (R Coll Radiol) 2012


Systematic review of single vs multiple fraction

radiotherapy for bone metastases

n Single

fraction

Multiple

fractions

OR (95% CI)

Overall

response

5617 60% 61% 0.98 (0.95-

1.02)

Complete

response

5263 23% 24% 0.97 (0.89-

1.06)

Re-irradiation 4632 20% 8% 2.60 (1.92-

3.47)

Pathological

fracture

4279 3.3% 3% 1.10 (0.65-

1.86)

Spinal cord

compression

2886 2.8% 1.9% 1.44 (0.90-

2.30)

Chow, Clin Oncol (R Coll Radiol) 2012

Response rate assessments ranged from 3 weeks to 3 months


Pain flare occurs in up to 40% patient following radiotherapy for

bone pain Hird IJROP 2009

Dexamethasone (8mg d1-5) reduces risk of pain flare

Chow, Lancet Oncol 2015


Guidelines

Royal College of Radiologists

For the initial therapy of pain from bone

metastases, a single fraction of 8 Gy is

recommended (Grade A)

RCR Radiotherapy Dose-Fractionation 2016


Palliative RT for bone pain in last 3

months of life: Worthwhile or Futile?

Prospective, population-based Canadian study

• Response rates

• 70% at 1 month

• 63% at 2 months Dennis, Clin Oncol (R Coll Radiol) 2011

Dutch bone metastases study

• 76% response rate overall

• 54-65% response rate in those dying < 3 months

Meeuse, Cancer 2010


Palliative Radiotherapy Audit

Christie

• 14 day mortality after RT = 5%

• 30 day mortality after RT = 18%


Palliative Radiotherapy Audit

Christie


Metastatic Spinal Cord Compression


Metastatic Spinal Cord Compression

(MSCC)

• > 4000 cases per year in UK

• Extradural compression or invasion from adjacent

metastatic vertebra

• Oncological emergency treated with surgery or

radiotherapy

Reversible

Venous obstruction

and oedema

Irreversible

Direct compression

• arterial compression

• axonal fracture

• neuropraxia

MSCC

Pain

Immobility

Loss of sphincter control


Tokuhashi

Score

• Validated score to

predict prognosis

after diagnosis

MSCC

• Surgical selection

tool

• Lung cancer poor

prognostic factor


Metastatic Spinal Cord Compression:

NICE guidance

1.5.1. Radiotherapy for painful spinal metastases

• Offer patients with spinal metastases causing non-mechanical spinal pain 8 Gy single fraction palliative radiotherapy even if they are completely paralysed.

• Patients with asymptomatic spinal metastases should not be offered radiotherapy with the intention of preventing MSCC except as part of a randomised controlled trial.


Metastatic Spinal Cord Compression:

NICE guidance

1.5.5 Radiotherapy for the definitive treatment of MSCC

• Urgent access (within 24 hours) to radiotherapy 7 days a week

• Offer a fractionated rather than a single fraction regimen to patients with a good prognosis.

• Routine fractionated radiotherapy to all patients after surgery

• Offer urgent radiotherapy (within 24 hours) to all patients with MSCC who are not suitable for spinal surgery unless:

• they have had complete tetraplegia or paraplegia for more than 24 hours and their pain is well controlled; or

• their overall prognosis is judged to be too poor.


SCORAD III

• Phase III RCT

• Eligibility

• MSCC

• Prognosis > 8 weeks

• Histological diagnosis

of malignancy

• Primary outcome

• Ambulation at 8 weeks


Palliative Radiotherapy for Brain

Metastases


Median survival

(weeks)

Whole brain RT 9.2

Supportive care 8.5

No difference in

QALY or OS


Palliative thoracic radiotherapy

Erridge et al. Clin Oncol (R Coll Radiol) 2005


Systemic Therapy


Case Study

• 60 year old lady

• Vietnamese

• Never smoked

• No co-morbidities

• Keen ballroom dancer

• PS2

• Fatigue

• Cough

• Dyspnoea

• Weight Loss


Where is it?


What is it?


Case 2

What is it?

• Adenocarcinoma

• EGFR mutation

• Started 1st line Gefitinib (tyrosine kinase inhibitor)


1st line Iressa vs chemotherapy in NSCLC

with EGFR mutation N Engl J Med 2010;362:2380-8


October November

December January


Case

• Symptoms resolved after 1st cycle

• Toxicity - Mild skin reaction (acneform rash over face

and dry skin)

• Restarted ballroom dancing

• Spent time visiting relatives and travelling with her

husband in SE Asia.

……with several boxes of gefitinib.


Prevention of Skeletal Related

Events (SRE)

• Bisphosphonates • Zolendronic acid (4mg every 3w for 9 months) reduced risk of

skeletal related events compared to placebo

• Increased time to first SRE

• NNT to prevent SRE at 9 months = 14 Rosen JCO 2003

• Denosumab • Non-inferior to ZA in delaying time to first SLE

Henry JCO 2011

• Improved OS compared to ZA on exploratory analysis (8.9 vs 7.7

months; hazard ratio [HR] 0.80, p=0.01) Scagliotti JTO 2012

Palliation of bone pain???


Take home messages

• Radiotherapy

• Very effective treatment for cancer induced bone pain and

heamoptysis

• Metastatic spinal cord compression is an oncological emergency

• Does not improve QALY for patients with brain metastases

(?young/good PS/controlled extracranial disease)

• Systemic therapy

• Can improve survival and offer holistic symptom relief

• Tissue for histological and molecular analysis is essential

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