Lung cancer

Lung cancer
Background:
• 5 year survival 12-14%
• Subtypes: NSCLC (85%)
• SCLC (15%)
o Subtypes determined treatment option
Risk factors:
o Smoking (duration and quantify), Pack years = pack (20/day) x years
o Age
o Asbestos
o Others (less common): silica, radiation (medical, ranium), cadmium
(electroplasters), arsenic (copper smelter), nickel, beryllium (ceramics,
electronics, mining), chromium, and diesel exhaust fumes.
Screening:
o No proven effect
o Investigate symptomatic patient
Prevention:
Primary:
o Avoid active and passive smoking (increased risk for non smoker) (stop
smoking is beneficial at any age)
o All smokers: smoking cessation advice.
o Ask (about smoking at every opportunity)
o Assess (willingness to quit)
o Advice (all smokers to stop)
o Assist (smoker to stop) Refer to Quitline 13 Quit (13 7848)
o Arrange (follow up)

Secondary:
• No proven chemoprevention agents. Avoid supplemental beta-carotene as it
increases risk.
Clinical:
• Common presentations:
• Solitary pulmonary nodule/coin lesion
o More likely to be malignant if >3cm, speculated, irregular enlarging
• Symptoms:
o Unresolved chest infection
o Haemoptysis
o New or changed cough or wheeze
o Chest pain
o Dyspnoea
o Unexplained weight loss
o Metastases (pathological fracture)
o Other eg. Paraneoplastic, constitutional symptoms.

• Initial investigations:
• CXR
• Sputum culture (x3) – cannot rule out disease if negative
• Chest CT – spiral not HRCT (including upper abdomen for staging)
• Referral:
• Suspected cases
• Tissue diagnosis where possible
• Fibreoptic bronchoscopy (FOB): proximal or endobronchial lesions
• +/- transbronchial biopsy
• FNA: peripheral lesions, risk of pneumothorax requiring intercostals catheter,
bleeding
• Pleural tap: for effusions.

Initial management:
• Breaking bad news: in a quiet private place
• Allow enough uninterrupted time in the initial meeting
• Assess the individual’s understanding
• Provide information simply and honestly
• Encourage individuals to express their feelings
• Respond to individual’s feelings with empathy
• Give a broad time-frame for the prognosis
• Avoid the notion that nothing can be done
• Arrange a time to review the situation
• Discuss treatment options
• Offer assistance to tell others
• Provide information about support services
• Provide written information
• Offer a tape recording of the session
Quality of life:
• Discuss the potential impact of tests and treatments on quality of life for patient
and carers
Staging of disease:
• Determines treatment options
• Staging system differ:
o NSCLC – TNM stage
o SCLC – Limited (localized to 1 hemithorax) or extensive
• Staging test options:
o Chest CT:
 For staging tumour and hilar/mediastinal nodes
 Usually includes upper abdomen (liver and adrenals)
o CT head (with contrast)
 NSCLC – for symptoms or abnormal signs
o Bone scan:
 NSCLC – symptoms, abnormal clinical findings, lab tests

o Flluoro-deoxy glucose (FDG) positron emission tomography (PET)
scan:
 Highly sensitive and specific for lung cancer
 Assess SPNs when bronchoscopy/ FNA unsuitable
 Helps stage NSCLC (appropriate staging will avoid fruitless
surgery)
o As SCLC staging and treatment is different, staging tests can stop if
extensive disease confirmed.
Specific management principles:
 Share decision making with patient and carers
 Address psychosocial issues
 Ensure patient’s questions are answered
 Evaluate prognostic factors:
o TNM stage, performance status, and weight loss are prognostic factors in
NSCLC.
o Performance status guides treatment suitability.
Treatment options (see appendix)
Supportive care and quality of life:

Treatment shown to improve QOL even if not curative:

o Dyspnoea: breathing retraining; coping and adaptive strategies
o Morphine – nebulised/systemic
o Oxygen as indicated
o Treat cause: pleural effusion (drainage +/-pleurodesis eg talc insufflation); large
airway obstruction: stents, lawer, radiotherapy/brachytherapy
o Cough: nebulised lignocaine, oral opioids.
o Chest pain: palliative radiotherapy, analgesia including opioids.
o Haemoptysis: Palliative radiotherapy.
o Bone pain: palliative radiotherapy, analgesia (opioids, +/- cisphosphonates), +/-
fixation (consult orthopaedic surgeon)
o Anxiety/depression:
o Psychological support and counseling
o Medications (anxiolytics, antidepressants)
o Agitations: midazolam
o Address medication side-effects:
o Drowsiness eg. Morphine – titrate, co-analgesia
o Constipation: Laxatives, aperients, hydration.

Appendix:

NSCLC
Stage Optimal Rx If not suitable for optimal
Rx, treat depending on
symptoms and
performance status
I and II Surgical resection o Observation if no
symptoms.
o Good performance
status: radical
radiotherapy +/-
chemotherapy.
o Poor performance
status: palliative
management
III A o Induction chemotherapy o Observation if
followed by: surgery asymptomatic
+/- mediastinal o Palliative
radiotherapy radiotherapy/chemother
o Radical combination apy
chemoradiotherapy

III B Radical combination
chemoradiotherapy
IV o Chemotherapy and o Supportive care alone
palliative o Palliative radiotherapy
radiotherapy for
specific sites of
disease (brain, bone
pain)
o Some patients have
solitary brain
metastases may be
suitable for surgical
excision.

SCLC

Stage Optimal Rx If not suitable for optimal
Rx
Limited Platinum based Palliative chemotherapy +/-
chemotherapy (4-6 cycles) radiotherapy
combined with thoracic
radiotherapy concomitant
with first or second cycle
Prophylactic cranial
irradiation for complete
responders.
Extensive Combination chemotherapy Symptom control
(4-6 cycles)
Prophylactic cranial
irradiation for complete
responders.

Lung cancer

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