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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
Note