Lung Cancers

Risk factors for lung cancer

  1. Smoking (85% of lung cancer is due to smoking or second-hand smoke)
  2. Women at increased risk (decreased metabolism of nicotine so increased exposure to carcinogens)
  3. Radon (2nd leading cause of lung cancer)
  4. Occupational/environmental exposure:  Asbestos, arsenic, coal, petroleum
  5. Genetics, inflammatory diseases (COPD, asthma, TB, pulmonary fibrosis)

Signs and symptoms for lung cancer

  1. Cough (most common), hoarseness, dysphagia, anemia, fatigue, weight loss, SOB/wheezing, hemoptysis/sputum production, dysphagia (difficulty swallowing), anemia, fatigue, weight loss, chest/should/arm pain, centrally located lesions
    1. Centrally located lesions tend to become symptomatic earlier than peripheral lesions
    2. S & S appear similar to the flu

Differences between small cell and non-small cell lung cancer

  1. Small Cell Lung Cancer (SCLC)
    1. Survival:
      1. 14-20 months for patients with limited disease
        1. These patients will have unilateral hemithorax & regional lymph node involvement which allows them to be treated with one radiation field
      2. 9-11 months for patients with extensive disease
        1. These patients will either have distant metastases or pleural effusion or pericardial effusion
        2. 2/3 of patients present with the extensive diease
    2. Faster growing (the staging of this cancer shouldn’t delay the treatment for the patient by more than 1 week)
    3. Almost all cases are related to smoking
    4. Poor prognostic factors:  weight loss, extensive stage disease, poor performance status (P = 3-4), increased LDH, multiple metastatic sites, being a man, being > 70
    5. Paraneoplastic syndromes (treating SCLC will relieve these):
      1. Lambert-Eaton myasthenic syndrome:  leg weakness (antibody against voltage-gated Ca channels)
      2. SIADH (syndrome of inappropriate ADH):  small cell lung cancer (SCLC) cells produce vasopressin (ADH)  & thus the patient will present with hyponatremia.  Treatment:  fluid restriction.
  2. Non-small cell lung cancer (NSCLC)
    1. 85% of lung cancers, slower growing
    2. Treatment of choice: surgery
    3. May either be non-squamous cell (adenocarcinoma–common, or large cell carcinoma) or squamous cell
    4. Stage 1:  tumor confined to the lung
    5. Stage 4:  distant metastases
    6. Poor prognosis factors:   late stage @ time of diagnosis, poor performance status (3-4), significant weight loss, being a male, certain biomarkers
      1. EGFR, ERCC1, RRM1 biomarkers indicate possible longer survival
      2. K-ras, EML4-ALK fusion oncogene indicate possible shorter survival

Treatment for small cell lung cancer

  1. Limited disease:  Concurrent chemo + radiation therapy (chemoradiation)
    1. Survival w/o treatment is < 12 weeks, survival w/ treatment is 14-20 months
    2. Radiation + Cisplatin + etoposide (combo chemo) for 4-6 cycles
      1. Etoposide + radiation increases the risk of esophagitis & pulmonary toxicity
  2. Extensive disease: chemo (to extend survival; improve QOL)
    1. Survival w/o treatment < 5-7 weeks; survival w/ treatment is 9-11 months
    2. Very low survival rate
    3. Use cisplatin + etoposide for 4-6 cycles for patients w/ good performance status (0-2) (+ radiation for symptom relief)
      1. Patients w/ poor performance status (3-4) should just receive supportive care
  3. Recurrent disease: know that a clinical trial is preferred & that if the relapse occurs in less than 2-3 months that there are less options for treatment than if the relapse occurs after more than 2-3 months
    1. If relapse occurs after more than 6 months, then use the original regimen

Treatment for non-small cell lung cancer

  1. Stage 1 & 2 NSCLC:  surgery is the treatment of choice with lymph node dissection
    1. Important prognostic factors:  size of the tumor, lymph node involvement, residual tumor in the surgical margins
    2. High risk:  poorly differentiated tumor, vascular invasion, wedge resection, minimal margins, > 4 cm tumor, visceral pleural involvement
    3. Stage 1 w/ negative margins: observation
    4. Stage 2 w/ negative margins: chemo +/- radiation therapy
    5. Stage 3 w/ negative margins: chemo + radiation therapy
      1. Cisplatin-based regimen (+ vinorelbine/vinblastine/etoposide/docetaxel, etc) may improve survival in stages 1-3
  2. Stage 4 treatment:
    1. Brain:  surgery followed by radiation therapy
    2. Adrenal:  surgery is lesion is curable
    3. Basically use cisplatin + something else
      1. May also add bevacizumab if performance status = 0-1, NSCLC, no history of hemoptysis, no untreated CNS metastases
  3. Docetaxel, permetrexed & erlotinib are all second-line therapies that may be considered in patients with a performance status of 0-2

Lung cancer only has a 5-year survival of 15.8%

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