ON10 Lung Cancer

Epidemiology​ - Lung cancer rates [blank_start]increasing[blank_end] worldwide​ Rates in males higher in developed vs. developing countries but decreasing due to tobacco control initiatives ​ Leading cause of [blank_start]cancer[blank_end]-related deaths in NZ (1600 per year)​ 1 in 5 people diagnosed have [blank_start]never[blank_end] smoked​ Lung cancer incidence and mortality 4x higher in [blank_start]Maori women[blank_end] and 3x higher in [blank_start]Maori men[blank_end] vs. non-Maori populations​

Which of these is NOT a risk factor for lung cancer?

Screening​ - For [blank_start]high[blank_end] risk patients. - [blank_start]Low-dose helical CT[blank_end] scanning - only intervention to influence mortality​ - X-ray and/or sputum cytology has shown [blank_start]no benefit ​[blank_end]

Which of these is not a clinical presentation of lung cancer? ​

CT scan, chest x-ray, and biopsy are all used for diagnosis of lung cancer.

Types of Lung Cancer​ 1. Non-Small Cell Lung Cancer ​ [blank_start]80-85[blank_end]% of lung cancers​. Origin from [blank_start]epithelial[blank_end] cells​. Includes adenocarcinomas, squamous cell carcinomas, large cell carcinomas​. Staged using [blank_start]TNM[blank_end]​. Better [blank_start]survival[blank_end] outcomes​. 2. Small Cell Lung Cancer ​ [blank_start]5-20[blank_end]% of lung cancers . Origin from [blank_start]nerve producing[blank_end] cells in bronchi. Rarely occurs in [blank_start]non-smokers[blank_end]​. Limited vs. Extensive staging​. Rapidly [blank_start]spreading[blank_end] (metastases)​; poor [blank_start]prognosis[blank_end].

Which of these is NOT a feature of an adverse (poor) prognosis?

Staging NSCLC​ Stage 0 – [blank_start]carcinoma in situ​[blank_end] Stage 1 – small tumor (<[blank_start]3[blank_end]cm), [blank_start]no[blank_end] lymph node involvement or mets​ Stage 2 – small to medium tumor (<3cm or 3-[blank_start]5[blank_end]cm), [blank_start]regional lymph[blank_end] node involvement, no metastases​ Stage 3 – medium to large tumor, more [blank_start]extensive[blank_end] lymph node involvement, no metastases Stage 4 – any size / lymph node involvement, [blank_start]presence[blank_end] of metastases

Match the stage to the estimated 5 year survival rate. (Randomised order.) 53-60%​ - Stage [blank_start]2[blank_end] 77-92%​ - Stage [blank_start]1[blank_end] 13-36%​ - Stage [blank_start]3[blank_end] 0-10%​ - Stage [blank_start]4[blank_end]

Match the Tx to the staging. Stage 0​ - [blank_start]Surgery[blank_end]​ Stage I​ - [blank_start]Surgery, Radiation​[blank_end] Stage II​ = [blank_start]Surgery, Radiation, Adjuvant CT,​[blank_end] ?Neoadjuvant CT Stage III​ - Surgery, Radiation​[blank_start], Adjuvant CT, Neoadjuvant CT,[blank_end] Stage IV​ - [blank_start]Combination[blank_end] CT, monoclonal [blank_start]antibodies[blank_end], maintenance therapy, EGFR tyrosine kinase inhibitor (EGFR mutations), ALK inhibitors (ALK translocations), ROS1 inhibitors (ROS1 rearrangements), BRAFV600E and MEK inhibitors (BRAFV600E mutations), immune checkpoint inhibitor, local therapies…

Treatment – Stage II​ Adjuvant​ (post-primary tx): - [blank_start]Cisplatin[blank_end] based therapy (5 year survival absolute benefit of 5.4%)​ - Combination drugs include [blank_start]vinorelbine, etoposide, vinca alkaloid ​[blank_end] Neoadjuvant​ (pre primary Tx) Absolute benefit of 5 year survival of 6% across all stages. ​Largest study (most patient Stage I) showed [blank_start]no[blank_end] survival benefit. Controversial.

Treatment – Stage III​ Adjuvant​ - Modest survival benefits shown in FRE-IALT and ANITA trials​. [blank_start]Cisplatin and vinorelbine[blank_end] typically regimen of choice . [blank_start]Durvalumab[blank_end] immunotherapy for patients with no progression after 2 or more cycles of chemoradiation therapy) - interim analysis showed progression-free survival [blank_start]16.8[blank_end] months (durvalumab) vs. 5.6 months placebo (HR 0.52)​.

Cisplatin toxicity - [blank_start]Nephrotoxicity[blank_end] (stay hydrated) - Dose dependent [blank_start]ototoxicity[blank_end] - Severe [blank_start]nausea and vomiting[blank_end], loss of appetite and taste - Myelosuppression Vinorelbine toxicity - Peripheral [blank_start]neuropathy[blank_end] - [blank_start]Constipation[blank_end] - Neutropenia - [blank_start]Vesicant[blank_end] (as are all vinca alkaloids)

SCLC Tx Limited disease​ standard Tx = [blank_start]Cisplatin / Etoposide[blank_end] (21 day cycle x 4 cycles)​\ Extensive disease​ standard Tx = [blank_start]Doxorubicin / Vincristine[blank_end] / Cyclophosphamide (21 day cycle x [blank_start]4-6[blank_end] cycles)​. Can also use cisplatin / etoposide as above​.