L C P

LUNG CANCER
POPULATION STATUS &
TREATMENT OPTIONS
By: Sweety Narang, RTT
&
Gurpreet Sandhu, RTT
OVERVIEW
Statistics on Lung Cancer – Incidence &
Mortality
Functions of the Lung
Etiology & Risk Factors
Classification/Pathology of Lung Cancer
Stages of Lung Cancer
Treatment Options
1.
2.
3.
4.
5.
6.
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7.
Surgery
Chemotherapy
Radiation Therapy
Other treatment options
Survival Rates
SOME STATISTICS ON LUNG CANCER
Lung cancer is the leading cause of cancer death
in Canada for both men (28%) and women (27%)
 In 2011, there were approximately 2,500 deaths
from lung cancer in B.C.
 In 2011, there were more than 20,000 deaths
from lung cancer in Canada.
 Every 30 seconds, someone, somewhere in the
world dies of lung cancer
 In 2012 lung cancer will kill more people worldwide than breast, prostate and colon cancer
combined

INCIDENCE
ASIR For Selected Cancers
(Including Lung) – Canadian
Males – 1980-2009
ASIR For Selected Cancers
(Including Lung) – Canadian
Females – 1980-2009
In men and women combined, lung cancer is the second most common
cancer (14%)
MORTALITY
ASMR For Selected Cancers
(Including Lung) – Canadian
Males – 1980-2009
ASMR For Selected Cancers
(Including Lung) – Canadian
Females – 1980-2009
• Lung cancer remains the leading cause of cancer death in both men
(28%) and women (27%)
• In 1950, the male/female ratio was approx 6:1; however, an increase in
female incidence has now produced a ratio approaching 1:1
WHAT IS THE FUNCTION OF THE LUNGS?
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The lungs consist of five
lobes, three in the right
lung and two in the left
lung
Most cells in the lung are
epithelial cells, which line
the breathing passages
and produce mucus, which
lubricates and protects
the lungs
The main function of the
lungs is to allow oxygen
from the air to enter the
bloodstream for delivery
to the rest of the body
ROUTES OF SPREAD
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Direct: as the mass increases, it may grow into
surrounding structures called local extension
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Lymphatic: regional extension through lymph nodes
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Most likely to extend to contralateral lung, ribs, heart,
esophagus, and vertebral column
The diaphragm, esophagus, pleural cavity, and heart are
all in intimate relationship to the lungs
Hematogenous: circulatory system plays a major
role in the distant spread of disease

Common sites of metastasis: liver, brain, bones, adrenal
glands, kidneys, and contralateral lung
ETIOLOGY/RISK FACTORS
 Tabacco
exposure (including secondary)
 Occupational
exposure – fumes from coal
tar, nickel, chromium, arsenic and
exposure to various radioactive materials
 Pollution
 Genetic
factors
EARLY DETECTION

No tests are recommended for screening the
general population

Estimates show ~75% of the natural history of the
disease has occurred at the time of first radiographic
appearance.
A low-dose helical CT scan is currently being
studied
 B.C. Cancer Agency currently has a project called
Lung Health Study
 Any person who is at increased risk due to
smoking or asbestos exposure should discuss the
benefits and limitations of a screening CT scan
with his/her doctor
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CLINICAL PRESENTATION
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Fatigue
Cough
Dyspnea (shortness of breath) and/or orthopnea
Chest pain
Loss of appetite
Coughing of phlegm
Hemoptysis (coughing up blood)
Dysphagia (difficulty swallowing)
Superior Vena Cava Syndrome
Paraneoplastic Syndrome
Metastatic disease, symptoms include bone pain,
difficulty breathing, abdominal pain, headache,
weakness, and confusion
CLASSIFICATION
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Non-small cell lung cancer (NSCLC)
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Small cell lung cancer (SCLC)
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Adenocarcinoma, squamous cell carcinoma, large cell
carcinoma
Classified on its own due to its particular natural
history and treatment
Mesothelioma
Affects both visceral & parietal pleura, rare,
aggressive, fatal in 80% of cases
 ~400 cases/year in Canada
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PATHOLOGY
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Squamous cell
carcinoma: usually
associated with tobacco
consumption
Second most common
form of primary
pulmonary malignancy
(~30%)
 Slight male
predominance
 Often located centrally
and involve a mainstem
or lobar bronchus
 Commonly starts in the
bronchi and may not
spread as rapidly as
other lung cancers
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PATHOLOGY
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Adenocarcinoma
Most common
histologic cancer type,
accounts for ~35-40%
of all lung cancers
 Less frequently
associated with
tobacco consumption
 Occur most often in
woman
 Most arise in
periphery of lung
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PATHOLOGY

Small cell carcinoma and large cell carcinoma
each represent approximately 20% of the
remaining lesions
SCLC tend to occur more centrally and large cell
lesions appear more peripherally
 SCLC is prone to early spread, and fewer than 10% of
these patients have diagnoses of limited stage
disease.
 SCLC can create its own hormones, which alter body
chemistry (paraneoplastic syndrome)
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SMALL CELL CARCINOMA
STAGES OF LUNG CANCER.
NSCLC are assigned a stage from I to IV
 Stage I – the cancer is small and only in one
area of the lung (localised)
 Stage II and III – the cancer is larger and
may have grown into the surrounding tissues
and/or contra lateral lung and there may be
cancer cells in the lymph nodes (locally
advanced)
 Stage IV – the cancer has spread to another
part of the body (secondary or metastatic
cancer)
STAGES OF NSCLC
STAGES OF LUNG CANCER
SCLC are staged using a two-tiered system
Limited-stage (LS): cancerous cells affecting
only one lung and lymph nodes on the same
side
 Extensive-stage (ES): the malignant cells
spreading to both the lungs and lymph nodes
extend even further to other organs
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FACTORS AFFECTING TREATMENT
PLANNING
 Pathology
 Location
of lung cancer
and extent of the tumor (Stage of
disease)
 Patient’s
general health
TREATMENT OPTIONS
 Surgery
: for limited-stage (stage I or
sometimes stage II)
 Chemotherapy
 Radiation
Therapy
SURGERY
Wedge Resection
Lobectomy
SURGERY
Sleeve Resection
Pneumonectomy
CHEMOTHERAPY
Refers to administration of drugs (oral or
intravenous) that stop the growth of cancer cells
by killing them or preventing them from dividing
 May be given alone or adjuvant to surgery or
concurrent with radiation therapy
 Both NSCLC and SCLC treated with
chemotherapy
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Treatment of choice for most SCLC
Platinum-based drugs have been most effective
in treatment of lung cancer
RADIATION THERAPY (RT)
May be employed as a treatment for both NSCLC
and SCLC
 Uses high-energy x-rays or other types of
radiation to kill dividing cancer cells
 May be curative, palliative, or adjuvant in
combination with surgery and/or chemotherapy
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Delivered 5 days/week over 6 or more weeks for
curative and usually 5-10 treatments for palliation
Delivered externally (XRT) or internally
(brachytherapy)
WHY RADIATION THERAPY?
Pre-operative: decrease the size of the tumor and
make surgery more effective
 Post-operative: treat any microscopic disease that
might remain in the area after surgery
 Alone with no surgery: small tumor, location of
tumor doesn’t allow for surgery, or in patients
that are not fit for surgery due to other
comorbidities (age, health status, etc.)
 Palliation: to relieve symptoms such as pain,
shortness of breath, etc.
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Includes whole brain radiation for spread of SCLC
EXTERNAL BEAM RADIATION THERAPY
(EBRT)
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A linear
accelerator
(LINAC), used
for EBRT
It delivers highenergy x-ray
treatments
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Custom design
treatment plans
in order to spare
as much
surrounding
normal tissue as
possible
RT TREATMENT TECHNIQUES
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Parallel-opposed pair
(POP)
Simplest fields used in
treatment of lung cancer
 2 fields 180° apart
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Anterior and posterior
parallel-opposed fields
Field size depends on
location of tumor and
adjacent structures
Usually used for large
tumors and/or palliation
RT TREATMENT TECHNIQUES
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3-D conformal RT
Multiple field combination
with alterations in
weighting, shaping, and
tissue compensation
 Requires use of computed
tomography (CT) simulation
for treatment planning
 Goal is to direct RT
specifically to tumor and
spare surrounding tissues
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Care must be taken to
calculate doses to adjacent
critical structures
RT TREATMENT TECHNIQUES
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Intensity-modulated RT
(IMRT)
Directs radiation at tumor and
varies the intensity of the beam
with conformance and accuracy,
thereby escalating dose to tumor
volume and reducing the dose to
normal tissue
 Intensity adjusted with aid of
MLC moving in/out of the
beam portal under precise
computer guidance.
 Allows for simultaneous
treatment of multiple tumors
with different doses of radiation,
while sparing healthy tissue
 Fewer side effects
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IMRT VS. 3D CONFORMAL
FOLLOW-UP SCANS
RT TREATMENT TECHNIQUES
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Stereotactic Body Radiotherapy
(SBRT)
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SBRT delivers precisely-targeted
(highly conformal) radiation at a much
higher dose than traditional RT, while
sparing healthy tissue
 sharp dose gradient outside tumor
and into surrounding tissues
Uses special patient positioning &
image guidance (with cone beam CT)
Typically used in patients with small
tumors (early stage) who are unable to
tolerate surgery due to age, co
morbidities, location of tumor, etc.
Typical Dose of 24-60Gy/3-5fractions
with a minimal break of 40 hours
between fractions
SBRT
90%
PROBABILITY
Potentially more
effective in tumor
killing by delivering a
few, very large doses
of radiation, from
which cells will have
limited ability to
recover from.
 Tight targets and
rapid dose fall-off

tumor control
toxicity
10%
DOSE OF RADIATION
IMPROVED SURVIVAL RATES WITH SBRT
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Every year about 8 -10,000 patients are diagnosed with earlystage lung cancer who, for medical reasons, are unable to
undergo surgery as an initial treatment for their cancer.
Often they are treated with standard EBRT, which is
delivered in 20-30 treatments, but local tumor control rates
using this approach have ranged from 30-40%.
SBRT is effective in controlling the primary tumour of nearly
100% of patients with medically inoperable early-stage
NSCLC who are still alive three years after treatment,
according to early findings of a North American clinical trial
(Journal of the American Medical Association)
According to the lead investigator of a RTOG 0236 trial, the
study's control rate is more than double the published rate of
primary tumour control for similar patients who received
conventional RT
PROPHYLACTIC CRANIAL
IRRADIATION (PCI)
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SCLC often spreads to
the brain
Used to treat
micrometastasis that
are not yet detectable
with CT or MRI scans
and has not yet
produced symptoms
RT TREATMENT TECHNIQUES
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High Dose Rate (HDR)
Brachytherapy
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Used to treat tumors located in
the major bronchi (the
breathing passages) or tumors
located medially causing
tracheal or esophageal
obstruction
 May be used to help treat a
blockage of large airways and
relieve symptoms
Due to its short treatment
distance, minimal dose given to
sensitive nearby tissues such as
heart and spinal cord
Also used to treat recurrent
endobronchial tumors, where
surgery and EBRT are no longer
options
OTHER TREATMENT OPTIONS
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Targeted Therapy
Uses monoclonal antibodies to identify and attack
specific cancer cells without harming normal cells
 May be used to treat NSCLC that has relapsed or
recurred
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Usually given only after chemotherapy treatments have
failed and the cancer is no longer responding
Given by infusion
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May be used alone or to carry other drugs, toxins, or
radioactive materials directly to cancer cells
OTHER TREATMENT OPTIONS
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Laser Therapy: uses intense narrow beams of
light to cut and destroy tissue (cancer cells)
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Can be used to open airways when they are blocked
by a tumor
Photodynamic Therapy: also known
photochemotherapy or photoradiation therapy
Injection of drugs that are sensitive to light
(photosensitizing drugs)
 Drugs become active and kill cancer cells when light
from laser hits the cells (brought in by fiberoptic
tubes)
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Cancer cells die during the 24-48hours period after drug is
activated
Rarely used in B.C.
OTHER TREATMENT OPTIONS
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Cryosurgery: is a treatment that uses an
instrument to freeze and destroy abnormal
tissue, such as carcinoma in situ
Electrocautery: is a treatment that uses a
probe or needle heated by an electric current to
destroy abnormal tissue
Watchful Waiting: is closely monitoring a
patient’s condition without giving any treatment
until symptoms appear or change. This may be
done in certain rare cases of NSCLC
SURVIVAL RATES
Non-small cell lung
cancer
Small cell lung cancer
Stage
5 –year
survival
(percentage)
Stage
5 –year
survival
(percentage)
I
70%
10%
II
55%
Limited Stage
(LS)
I – II (no
surgery; RT
alone)
20%
Extensive
Stage (ES)
6-10 months
III
10-15%
IV
3-6 months
Pleural Mesothelioma:
• 4-18month survival after initial
diagnosis
• 5-year survival: 10%
WORK CITED
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Damjanov, I. 2006. Pathology for the Health Professions, 3rd ed.
Elsevier Inc, PA, USA.
B.C. Cancer Agency. “Lung”
<http://www.bccancer.bc.ca/PPI/TypesofCancer/Lung/default.htm
>
Canadian Cancer Society. “What is lung cancer?”
<http://www.cancer.ca/British%20ColumbiaYukon/About%20cancer/Types%20of%20cancer/What%20is%20lu
ng%20cancer.aspx?sc_lang=en&r=1>
Canadian Medical Association Journal. 2008. “Canadian cancer
statistics at a glance: mesothelioma.”
<http://www.cmaj.ca/content/178/6/677.full
Cox, J. & Ang, K. 2003. Radiation Oncology: Rationale,
Technique, Results, 8th Ed. Mosby Inc, PA, USA.
Fischer B, Lassen U, Mortensen J, et al. Preoperative staging of
lung cancer with combined PET-CT. N Engl J Med.
2009;361(1):32-39.
WORK CITED
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Lawrence TS, Ten Haken RK, Giaccia A. Principles of Radiation
Oncology. In: DeVita VT Jr., Lawrence TS, Rosenberg SA, editors.
Cancer: Principles and Practice of Oncology. 8th ed. Philadelphia:
Lippincott Williams and Wilkins, 2008.
Lung Cancer Symptoms & Treatment Options. 2009. “Lung
Cancer Statistics.” <http://lungcancersymptoms.ca/lung-cancerstatistics-canada/>
MedicineNet.com. 2012. “Lung Cancer.”
<http://www.medicinenet.com/lung_cancer/page6.htm>
National Cancer Institute. Small Cell Lung Cancer Treatment
(PDQ). Health Professional Version. 07/01/09. http:
//www.cancer.gov/cancertopics/pdq/treatment/smallcelllung/health
professional.
Pleural Mesothelioma.com. 2011. Mesothelioma Statistics and
Facts. <http://www.pleuralmesothelioma.com/cancer/statisticsfacts.php>
WORK CITED
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Scott WJ, Howington J, Feigenberg S, Movsas B, Pisters K.
Treatment of non-small cell lung cancer stage I and stage
II: ACCP evidence-based clinical practice guidelines (2nd
edition). Chest. 2007;132:234S-242S
Small Cell Lung Cancer Life Expectancy. 2012.
<http://www.buzzle.com/articles/small-cell-lung-cancer-lifeexpectancy.html>
Targeting the epidermal growth factor receptor in nonsmall cell lung cancer) cells: the effect of combining RNA
interference with Tyrosine Kinase inhibitors or Cetuximab
Gang Chen, Peter Kronenberger, Erik Teugels, Ijeoma
Adaku Umelo and Jacques De Grève
BMC Medicine (in press)
Timmerman RD, et al "Stereotactic body radiation therapy
for medically inoperable early stage lung cancer patients:
Analysis of RTOG 0236" ASTRO 2009; Abstract 5.
Washington, C. & Leaver, D. 2004. Principles and Practices
of Radiation Therapy, 2nd Ed. Mosby Inc. PA, USA.
QUESTIONS
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