lung cancer

risk factors for lung cancer

Smoking

• 10-30 fold RR compared to nonsmoker

• 87% of lung cancer deaths due to smoking

• dose respons effect

• risk decreases when quit, never back to baseline

• women are more susceptible to tobacco effects and are 1.5x more likely to develop lung cancer than men

Personal + Fam Hx of lung cancer

Asbestos- 5x increased risk

Age- unusual in <40yrs, 40+ risk increases every year

second hand smoke - spouse of someone who smokes has 30% increased risk

radiation exposure

local sx lung cancer

cough (nonspecific) - also bc of COPD

dyspnea- also bc of COPD

hemptysis

recurrent infections

chest pain

metastasis sx lung cancer

brain: h/a, NV, focal neurologic symptoms, seizures, confusion, personality changes

bone: pain

Hepatic- weakness, weight loss

adrenal- asymptomatic

most common sites of distant metasasis lung cancer

brain, bone, liver, adrenals

small cell carcinoma is __% of all lung cancer

15

non small cell carcinoma is __% of all lung cancer

85%

squamous cell carcinoma is __% of all lung cancer

25-30%

large cell carcinoma is __% of all lung cancer

5-10

adenocarcinoma is __% of all lung cancer

45-50%

what type of lung cancer is most aggresive if left untreated

small cell

distinguishing favtors btwn small cell and non small cell lung cancer

rapid doubling time, high growth fraction, early development of widespread metastasis (in SCLC)

Which cancer has a clear relationship to smoking

SCLC, squamous cell NSCLC

location of SCLC

central

which lung cancer causes paraneoplastic syndrome

SCLC

what is paraneoplastic syndrome

produce imitations of some of the body’s hormones (i.e: SiADH, hypercalcemia)

3 types of NSCLC

adeno, squamous, large cell

sensitivity of SCLC to chemo and radiation

highly sensitive to both

sensitivity of NSCLC to chemo and radiation

moderate sensitive to radiation, low sensitive to chemo

where does adenocarcinoma originate

mucos producing cells in lung (2/3 outer regions, 1/3 central)

why is adenocarcinoma incidence increasing

partially due to better histologic staining techniques

most common lung cancer in non smokers

adenocarcinoma

which gender is adenocarcinoma more predominant in

women

where does squamous cell carcinoma occur

centrally- near main stem bronchi

which gender does squamous cell carcinoma predominant in

males

where does large cell carcinoma occur

outer periphery of lung

which lung cancer tends to metastasize early

large cell

negative prognostic factors

weight loss

poor performance status

mediastinal lymph node metastases

male gender

elevated serum LDH

bone or liver metastasis

adeno and large cell worse than squamous for NSCLC

extensive worse than limited for SCLC

limited stage is __% of small cell lung cancers

30-40

extensive stage is __% of small cell lung cancers

60-70

what is limited stage carcinoma

SCLC confined to one side of chest

what is extensive stage SCLC

SCLC spread to both sides of chest of metastasized to distant locations outside of chest

stage I lung cancer

small tumor and has not spread to any LN or other chest structures

difference btween stage IIIa/IIIb

IIIa- negative mediastinal nodes- resectable

IIIb- positive mediastinal nodes- unresectable

Stage I NSCLC treatments used

surgery is primary Tx

1A- no adjuvant chemo, 1B- adjuvant chemo

if surgical resection margins are + use radiation (after chemo)

stage II NSCLC treatments

surgery is primary treatment

adjuvant chemo ± immunotherapy

radiation if surgucal resection margins are +

stage IIIa NSCLC treatment

surgery primary treatment

adjuvant chemo ± immunotherapy

if surgical resection margins are positive- radiation

stage IIIB NSCLC treatment

combined chemo and radiation

maintenance durvalumab x 12mo

stage IV NSCLC treatment

chemo or targeted therapy or immunotherapy

± radiaition (if a lot of pain, tumor pressing on smth, or issue needing localized Tx)

how long to treat curable stages of NSCLC (I,II,IIIa)

4-6 cycles of chemo

potentially maintenance treatment (of 1 immune drug or chemo drug)

how long to treat non curative stage IIIb NSCLC

4-6 cycles of chemo

maintenance durvalumab x 12mo

if progression potential for another Tx

what is durvalumab

PD-L1 antibody

what genes are tested for when treating NSCLC

EGFR, ALK

If patients do not have EGFR/ALK mutation what is next step for managing advanced NSCLC

Test PD-L1 expression

advanced NSCLC treatment if PD-L1 expression is >/=50%

monotherapy with pembrolizumab

advanced squamous NSCLC treatment if PD-L1 expression is <50%

four cycles of pembrolizumab, carboplatin, and paclitaxil

followed by pembro maintenance

advanced adenocarcinoma NSCLC treatment if PD-L1 expression is <50%

four cycles of carboplatin, pembrolizumab, pemetrexed

followed by pembro and pemetrexed maintenance

__% of NCLC has EGFR mutations

12-17%

preferred treatment for patients with previously untreated metastatic NSCLC and an activating mutation of EGFR

monotherapy w/ EGFR TKI (erlotinib, afatiniv, osimertinab) is preferred rather than chemo

preferred EGFR TKI

osimertinib

ALK rearrangements are in __% of NSCLC

5-7%

preferred treatment of metastatic NSCLC patients with a tumour with ALK rearrangement

crizotinib, alectiinib, lorlatinib (ALK TKIs)

second line therapy for tumors with ALK rearrangements

try another ALK TKI (crizotinib, alectinib, lorlatinib)

which ALK TKI cross BBB

alectinib and lorlatinib but lorla more

limited stage SCLC treatment of choice

radiation plus combo chemo

how long to treat limited SCLC with chemo

4-6 cycles

goal of Tx for SCLC limited stage

cure

should radiation be given concurrently or sequentially with chemotherapy in SCLC limited stage

concurrently

what kind of chemo regimen are most common for SCLC limited stage

cisplatin based

when is a prophylactic cranial irradiation considered

limited SCLC because brain metastases is a frequent problem

extensive stage SCLC treatment

4 cycles of chemo with durvalumab (PDL1 inhbitor)

then durvalumab monotherapy until disease progression or unacceptable toxicities

goals of Tx of extensive stage SCLC

improve QoL and duration of survival

generally incurable