dr a.j.france, ninewells hospital, dundee lung cancer treatment 2010 © a.j.france 2010
TRANSCRIPT
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Dr A.J.France, Ninewells Hospital, Dundee
Lung cancer treatment 2010
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Lung cancer treatment 2010• Giving the diagnosis• Surgery• Radiotherapy• Chemotherapy• Supportive care
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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
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Types of lung cancer 1• Small cell
• Rapidly progressive disease• Early metastases• Rarely suitable for surgery• Good initial response to
chemotherapy
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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
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Treatment choices• Surgery• Radiotherapy
• Chemotherapy• Palliative care
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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
• Vocal cord palsy• Proximity to carina• Cell type
• Mediastinoscopy• Lymph nodes
• CT scan of thorax• Tumour size• Lymph nodes• Metastases• Local invasion
• PET scan• Positron Emission
Tomography
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Surgery for lung cancer
• Pneumonectomy or lobectomy• 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• Small cell / non-small cell
• CT scan• Tumour size• Local invasion• Nodes• Metastases
• Performance status ECOG score© A.J.France 2010
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Cytotoxic chemotherapy• 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• Whole body treatment• Targets rapidly dividing
cells• Blood brain barrier
• Prophylactic cranial irradiation
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Chemotherapy - Side effects• Nausea and vomiting• Tiredness• Bone marrow suppression
• Opportunistic infection• Anaemia
• Hair loss• Pulmonary fibrosis
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Radiotherapy• Ionising radiation
• Usually X-rays• External beam
• Radical• Curative - target < 5cm diam
• Palliative• A delaying tactic• Useful for metastases
• Well tolerated
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Radiotherapy - the snags• Maximum cumulative dose• Collateral damage
• Spinal cord• Oesophagus
• Only goes where you point the beam• No good for subclinical metastases• Except prophylactic cranial
irradiation
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Collateral damage
Tumour
Spinal cord
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Clinical trials.Some words of caution…• Most trials are sponsored by the
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” ?
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Further information 1• 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 2• 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 stridorPhotodynamic therapy
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Endobronchial therapy
• 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 canceris 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• COPD: FEV1 < 1 litre• Ischaemic Heart Disease
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Palliative care
• Pain• Breathlessness• Cough• Anxiety• Poor mobility
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Palliative radiotherapy
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Prognosis for lung cancer• 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 smokingAsbestosRadon
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© A.J.France 2010
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Scotland leads theworld for lung cancer
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Key points
• Surgery can be curative• Radio and Chemo therapy can be
beneficial• Prognosis remains poor• Prevention is a better option
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