Treatment

Summary of Treatment Approach to Patients with Lung Cancer

Harrison’s Principle of Internal Medicine 17th Edition p558

Non-small cell lung cancer NSCLC Stages I and II

• Surgery– Treatment of choice pulmonary resection– 5 year survival rate N0: 60-80%; N1: 50%– Lobectomy superior too wedge resection reducing

local recurrence– Pneumonectomy: multiple lobes, very central

tumors, patients with excellent pulmonary reserves– Wedge resection and segmentectomy (VATS): poor

pulmonary reserve and small peripheral lesions

Non-small cell lung cancer NSCLC Stages I and II

• Radiotherapy with curative intent– Refuse surgery or not candidates for surgery

• Extent of disease and volume of chest for irradiation• Distant metastases, malignant pleural effusion, cardiac

involvement– Long term survival: 20%– Potentially curative, increase quality and length of life

by controlling primary tumor and preventing symptoms related to recurrence

– Treatment for curative intent: 60-64 Gy– Palliative thoracic radiation 30-45 Gy

Non-small cell lung cancer NSCLC Stages I and II

• Adjuvant Chemotherapy for NSCLC Stages IB and II– Improvement of 5% at 5 years with cispaltin-

based adjuvant therapy– No role for stage IB disease

• Adjuvant Radiotherapy for NSCLC Stages I-II– Does not improve survival, may actually be

detrimental to survival in N0 and N1 disease

Non-small cell lung cancer NSCLC with T3, N0 disease (Stage IIB)• With peripheral chest wal invasion: resection

of involved ribs and underlying lung• Repaired with chest wall musculature or

Marlex mesh and methymethacrylate• 5 year survival rate: 35-50%• Adjuvant chemotherapy recommended

Non-small cell lung cancer NSCLC Stage III

• Local therapy (surgery or radiation therapy) + systemic chemotherapy

Non-small cell lung cancer NSCLC Stage IIIA

• Nonbulky IIIA• Adjuvant chemotherapy

Non-small cell lung cancer NSCLC Stage IIIA

• Bulky IIIA– No evidence suggests that patients with bulky

multilevel ipsilateral mediastinal lymph nodes (N2) have improved survival with surgery and either pre-or postoperative chemotherapy compared to treatment with chemotherapy plus radiotherapy.• Treatment-related mortality greater in the surgery arm • Surgery only conducted with clearing of mediastinal

lymph nodes by neoadjuvant chemotherapy• T4,N0 pr T4, N1 (Stage IIIB): preoperative

chemotherapy

Non-small cell lung cancer NSCLC Stage IIIA

• Bulky NSCLC Stage IIIA and Dry IIIB (IIIB without a Pleural Effusion)– Chemotherapy + radiation therapy: • treatment of choice• Improvement in median and long-term survival• Concurrently > sequential

Disseminated NSCLC

Palliative Radiation Therapy• To relieve urgent severe symptoms such as

bronchial obstruction with pneumonitis, hemoptysis, upper airway or SVC obstruction, brain or spinal cord compression, or painful bony mets

• Brain mets, spinal cord compression, symptomatic masses and bone lesions

Disseminated NSCLC

Chemotherapy• Palliates symptoms , improves quality of life,

improves survival in newly diagnosed patients with stage IV NSCLC

• Cost-effective palliation for stage IV NSCLC• For previously untreated, good-performance status

patients: – chemotherapy consisting of two drugs (“doublets”):

• Cisplatin/ carboplatin• Taxane (paclitaxel/ docetaxel), gemcitabine or a vinca alkaloid

Disseminated NSCLC

VEGF Targeted Therapy• Bevacizumab• Improves response rate, progression-free

survival and overall survival of patients with advanced disease when combined with chemotherapy

• SE: bleeding, hypertension and proteinuria

Disseminated NSCLC

EGFR Targeted Therapy• Erlotinib• 2nd or 3rd line therapy for NSCLC• For patients whose tumors respond to EGFR

TKI therapy

Small Cell Lung Cancer

Chemotherapy• Etoposide + Cisplatin/ carboplatin– Most widely used– given every 3 weeks outpatient basis for 4-6 cycles

Small Cell Lung CancerLimited-Stage Disease

Combined-Modality Chemoradiotherapy• More effective than sequential chemoradiation• More esophagitis and hematologic toxicity

Palliative Radiation Therapy• Cranial radiation decreases the signs and symptoms of

brain metastases

Surgery• Not routinely recommended• High cure rates if postoperative chemotherapy is used

Lung Cancer Prevention

• Encourage smoking cessation• Chemoprevention– No benefit has yet been shown– Vitamin E and β-carotene• Actually increased the risk of lung cancer in heavy

smokers