Dr A.J.France, Ninewells Hospital, Dundee Lung cancer treatment 2010 © A.J.France 2010.

Dr A.J.France, Ninewells Hospital, Dundee

Lung cancer treatment 2010

© A.J.France 2010

Lung cancer treatment 2010• Giving the diagnosis• Surgery• Radiotherapy• Chemotherapy• Supportive care

© A.J.France 2010

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

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

© A.J.France 2010

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

© A.J.France 2010

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” ?

© A.J.France 2010

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

© A.J.France 2010

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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Treatment of lung canceris determined by• The cell type• The extent of the disease• Co-morbidity

• The patient's wishes

© A.J.France 2010

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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Scotland leads theworld for lung cancer

Key points

• Surgery can be curative• Radio and Chemo therapy can be

beneficial• Prognosis remains poor• Prevention is a better option

© A.J.France 2010

Dr A.J.France, Ninewells Hospital, Dundee Lung cancer treatment 2010 © A.J.France 2010.

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