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Introduction to:
Lung Cancer
Lorraine Martelli-Reid
RN(EC),MN, NP-Adult Lung Disease Site Team
Juravinski Cancer Centre
Objectives
 To understand the clinical presentation, risk
factors and prognostic factors in relation to the
management of patients with Lung Cancer
 To understand the diagnostics and staging of the
diagnosis of Lung Cancer
 To understand the standard
treatments in relation to the
management of patients with
Lung Cancer
Lung Cancer Statistics
 In 2008, an estimated 23,900 Canadians will be diagnosed
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with lung cancer and 20,200 will die of it.
Lung cancer is the leading cause of cancer deaths in both
men and women
Lung cancer is the 2nd most common type diagnosed in
both men and women
One in 12 men is expected to develop lung cancer during
their lifetime and one in 13 will die of it. One in 16 women
is expected to develop lung cancer during their lifetime and
one in 18 is expected to die of it.
Lung cancer incidence and death rates continue to climb
among women while decreasing among men.
Risk Factors
 Smoking
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Risk declines after 5
years of non-smoking
Passive smoking: an
increase in RR of lung
cancer ~25%
Environmental
exposure: 2 - 3% of all
lung cancer cases
85% of lung cancer
deaths can be attributed
to smoking
Higher incidence among
those of African descent
Risk Factors Cont’d
 Occupational exposure
 arsenic, asbestos, ether, chromium, nickel,
polycyclic aromatic compounds, radon, vinyl
chloride
 Geography
 Clustering among men along coastal areas
(industry and asbestos exposures)
 Indurstry: crude petroleum, coal, tars, combustion
products, wood dust
 Diet: Possible protective effect from a diet rich in
fresh fruit and vegetables. 2 RCTs show no benefit
from alpha-tocopherol and harm from
beta-carotene.
 Possible genetic predisposition
Prevention, Screening & Early
Detection
 85% of lung cancers are caused by smoking and thus can be
prevented


Decrease the number of new smokers
Help present smokers quit
 <10% those with heavy asbestos exposure will
develop mesothelioma, but 80% of those with pleural
mesothelioma had heavy asbestos exposure
 There is currently no evidence that screening decreases the cost
of lung cancer nor decreases mortality rates
 Early detection is difficult since presenting
symptoms are common to other health
problems
Most Common
Signs & Symptoms at Diagnosis
Cough
Weight Loss
Anorexia
Weakness
Dyspnea
max
min
%
Chest Pain
Hemoptysis
Fever
Anemia
0
20
40
60
80
Signs of Tumor Spread
 Regional Tumor Spread  Metastases or
Superior Vena Cava
Syndrome (SVC)
 Hoarseness from
laryngeal nerve
paralysis
 Horner’s syndrome
 Pancoast syndrome
 Pleural effusion
 Pericardial effusion
and tamponade

Paraneoplastic Syndromes
 Spread to liver, bone,
adrenals, brain
 Syndrome of
Inappropriate
Antidiuretic Hormone
secretion (SIADH)
 Cachexia

Hypertrophic
osteoarthropathy (HPOA)
Diagnostics & Staging
 CXR
 CT scan of chest:
 If mediastinal lymph nodes are ≥ 1.5 cm, then sensitivity is 6070%, specificity is 70% → mediastinoscopy
 Bronchoscopy for tissue diagnosis
 EGFR and ALK mutation testing if stage 4 non-squamous NSCLC
 Mediastinoscopy to assess the level of lymph node involvement
(not always needed)
 Positron Emission Tomography (PET) current indications in
Lung Cancer
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Solitary pulmonary nodule-unable to obtain tissue diagnosis
NSCLC-where curative surgical resection is being considered
Stage III NSCLC- potentially curative combined chemo/rads
Limited Stage SCLC- for evaluation, staging & potentially
curative chemo/rads
PET as a Diagnostic Tool
Diagnostics & Staging
 Thorough history and physical assessment
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Smoking history: #pack years
Co-existing health problems
Change in usual symptoms
Symptoms or findings of metastatic disease
Performance status, weight loss
 CBC and Chemistries

Hb (anemia), creat (kidney functioning), Na (SIADH),
Ca, liver function tests, alk phos
 Pulmonary function tests

Needed prior to surgery or radiation
 Bonescan, MRI brain and abdominal imaging
(liver and adrenals) *if patient had a PET don’t need bonescan
Histology of Lung Cancer
 Small Cell
 Non-Small Cell
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Squamous
Adenocarcinoma
Large Cell
Other
20-25%
70-90%
25%
40%
10%
25%
 Mesothelioma not considered a true lung cancer
 Small Cell is declining
 Increased frequency of Adenocarcinoma in recent
years
TNM Classification for NSCLC
 T1:Tumour ≤ 3 cm, surrounded by lung or visceral pleura,
not more proximal than the lobar bronchus
 T1a:Tumour ≤ 2 cm
 T1b:Tumour > 2 but ≤ 3 cm
 T2: Tumour > 3 but ≤ 7 cm, or tumour with any of the
following: invades visceral pleura, involves main bronchus ≥
2 cm distal to the carina, atelectasis/obstructive pneumonia
extending to hilum but not involving the entire lung
 T2a:Tumour > 2 but ≤ 5 cm
 T2b:Tumour > 5 but ≤ 7 cm
TNM Classification Cont’d
 T3: Tumour > 7 cm;
 or directly invading chest wall, diaphragm, phrenic nerve,
mediastinal pleura, or parietal pericardium;
 or tumour in the main bronchus < 2 cm distal to the carina;
 or atelectasis/obstructive pneumonititis of entire lung;
 or separate tumour nodules in the same lobe
 T4: Tumour of any size with invasion of heart, great
vessels, trachea, recurrent laryngeal nerve, esophagus,
vertebral body, or carina;
 or separate tumour nodules in a different ipsilateral lobe
TNM Classification Cont’d
 N0: Regional lymph nodes not involved
 N1: Ipsilateral peribronchial or hilar lymph nodes,
Intrapulmonary lymph nodes by direct extension
(stations 10-14)
 N2: Ipsilateral mediastinal and/or subcarinal lymph
nodes (stations 5-9)
 N3: Contralateral mediastinal, contralateral hilar,
ipsilateral or contralateral scalene or
supraclavicular lymph nodes (stations 2-4)
 M0: No distant metastases
 M1: Distant metastases present
Non-Small Cell Lung Cancer
Stage 1
Stage 1A
(T1aN0M0 or T1bN0M0)
Stage 1B
(T2aN0M0)
Non-Small Cell Lung Cancer
Stage II
Stage IIA
Stage IIB
(T2bN0M0 or T2aN1M0)
(T2bN1M0 or T3N0M0)
(N1=stations 10-14)
Non-Small Cell Lung Cancer
Stage III
Stage IIIA
or
Stage IIIB
(T4N0M0, T3/T4N1M0, T2/3N2M0)
(any TN3M0 or T4N2M0)
N2=stations 2-9, ipsilateral
N3=stations 1-9, contralateral
Non-Small Cell Lung Cancer
Stage IV
Stage IV (any T any N M1)
Tumor has spread to other lung or beyond the chest
Lymph node
station #’s and
names
Non-Small Cell Lung Cancer
Treatment Options and Prognosis
Stage
Treatment
Survival at 5 years
Stage
1A/1B
Surgical Resection
1A ~ 67%
1B ~ 57%
Stage
2A
2B
Surgery alone vs
Surgery + Adjuvant Chemo
Stage
3A
Surgery alone vs surgery + Adjuvant chemo
21% ↑ 29%
Neoadjuvant chemo/rads + surgery
21% ↑ 25%-45%
Radiation alone vs Concurrent chemo/rads
15% ↑ 30% (at 3 yrs)
Stage 3B
Radiation alone vs. Concurrent chemo/rads
10% ↑ 20% (at 3 years)
Stage 4
No treatment vs Chemotherapy or
Radiation (symptoms)
15% ↑ 24% (at 1 year)
45% ↑
35% ↑
10- 60%
15% 50%
Chemotherapy for NSCLC
 In addition to diagnostics and staging ones
performance status ECOG and % weight loss
determine fitness for chemotherapy
 Cisplatin is the most active drug in NSCLC and SCLC
 Cisplatin doublet therapy is the first treatment of choice
when weight loss is ≤ 5% and ECOG=0/1
 Cisplatin is usually combined with Etoposide,
Gemcitabine
 Carboplatin can be substituted for cisplatin in the
presence of impaired kidney functioning but is inferior
 Other drugs: paclitaxel, docetaxel
Radiation for NSCLC
 Best responses are achieved when disease is
treated to 60Gy daily over 6-7 weeks continuously
 Brachytherapy: High-dose rate (HDR)
endobronchial brachytherapy is selected with
airway obstruction and ≥moderate hemoptysis
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Seeds are placed close to the tumor and radiation is
delivered over a few minutes to the area with little
injury to adjacent tissue
Delivered 1-2 weeks apart usually 2-3 sessions
until symptoms are relieved
Treatment for Resected NSCLC
Stages IIA, IIB, IIIA
Cycle 1 Mon Tues Wed Thurs Fri Sat
Day 1
Day 8
Day 15
CV
CV
Repeat X 4
V
Day 22
V
 Cisplatin (C) Day 1 and Day 8 each cycle
 Vinorelbine (V) Day 1, 8, 15, 22 each cycle
 Day 1 & Day 8 = clinic visit, lab, 5 hrs
 Day 15 & Day 22 = lab, 1 ½ hrs
 Ondansetron post chemo X 5 doses days 1& 8
 Dexamethasone post chemo X 4 doses days 1 & 8
 Constipation prophylaxis first 14 days each cycle
Treatment for Stage IV NSCLC
 First line recommendation: The combination of a platinum
agent with either vinorelbine, gemcitabine, paclitaxel

For non-squamous histology-If an EGFR mutation is detected
then erlotinib is recommended
 The decision to use a particular regimen should be influenced
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by the clinical setting and the toxicity of the regimen chosen
3 drugs are not better than 2 drugs
There is disagreement regarding the
optimum treatment for those >70 yrs.
There is conflicting evidence regarding
the use of non-platinum doublets
Carboplatin substituted for Cisplatin is
not as effective, but is less toxic
Other Treatments
 Targeting epidermal growth factor receptors
(EGFR)
EGFR gene is frequently expressed in NSCLC
 Mutations present that encode for tyrosine
kinase
 Occur more frequently in adenocarcinoma,
women, Asians and patients who have never
smoked
 EGFR, ALK, KRAS, and EML4-ALK genes
 Erlotinib=Tarceva
 Gefitinib=Iressa
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Side Effects + Monitoring
 For resected early stage NSCLC on
adjuvant chemotherapy
 Fatigue
 Anemia
 Post-thoracotomy pain
 Peripheral neuropathy
 Depression
Side Effects + Monitoring
 For Stage III receiving concurrent cisplatin
+ etoposide + radiation
 Esophagitis
 Fatigue
 Post treatment radiation pneumonitis
Onset 2-6 months post treatment
 Acute onset of cough/SOB
 CXR demonstrates pneumonitis
 Treat with prednisone +/- antibiotics
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Side Effects and Monitoring
 For Tarceva: Most Common
75% rash
 Acne-like and a strong reason for
discontinuation
 Rash management protocols
 54% diarrhea
 52% fatigue + anorexia
 41% dyspnea
 33% nausea + cough
 23% vomiting
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Small Cell Lung Cancer
 Limited Stage: involves one lung,
mediastinum, ipsilateral supraclavicular
fossa and can be encompassed by one
radiation treatment field
 Extensive Stage: disease spread beyond the
chest or malignant pleural/pericardial
effusion
Small Cell Lung Cancer
Treatment Options and Prognosis
Stage
Treatment
Prognosis
at 5 years
Limited
Stage
Concurrent
chemo/rads +
prophylactic
cranial
radiation
NO Surgery
20-25%
Extensive
Palliative
Chemotherapy
Stage
5%
SCLC Treatments
 For Limited Stage:
 Cisplatin
+ Etoposide concurrently with
radiation to chest (45Gy)
 If CR after 4 cycles will proceed to 6
cycles
 Followed by PCI
 For Extensive Stage:
 Cisplatin + Etoposide
 Other chemo drugs possible
Side Effects + Monitoring
 Delayed effects of PCI
 Onset
can be 2-5 yrs post treatment
 Cerebral atrophy
 Dementia
 Confusion
 Personality changes
Mesothelioma
 Mesotheliomas arise from the serosal lining outside of the
lungs within the chest or outside the bowel within the
abdomen.
 About 100 new cases of malignant mesothelioma appear in
Canada each year
 Malignant mesothelioma is usually not curable; overall
survival is approximately 1 year
 Etiology/Risks
 Crocidolite (Cape blue asbestos), the main cancer causing form
of asbestos, is associated with over 90% of pleural and
peritoneal mesotheliomas
 asbestos industry; dockyard workers, especially if they
dismantle asbestos-insulated steam piping; those who handle
and manufacture asbestos compounds; insulators and steam
fitters; and those in demolition and construction industries
Mesothelioma
 Symptoms are due to tumor growth and invasion
of surrounding tissues:
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pleural effusion, ascites, or pericardial effusion
Chest pain may be caused by invasion of the chest
wall
Pleural effusion causes collapse of adjacent lung and
shortness of breath
fever, night sweats and weight loss
 Treatment
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% of patients may have a temporary shrinkage of the
disease with currently available drugs.
Chemotherapy with pemetrexed
Mesothelioma Staging
 Stage I: Disease confined within the capsule of the parietal
pleura (i.e., ipsilateral pleura, lung, pericardium, and
diaphragm).
 Stage II: All of stage I with positive intrathoracic (N1 or
N2) lymph nodes.
 Stage III: Local extension of disease into the following
areas, e.g., chest wall or mediastinum, heart or
through the diaphragm or peritoneum, with or without
extrathoracic or contralateral (N3) lymph node
involvement.
 Stage IV: Distant metastatic disease.
Treatment
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Surgery is rare unless there is only one plaque and
a lobe of lung can be removed
% of patients may have a temporary shrinkage of
the disease with currently available drugs.
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Chemotherapy with cisplatin + pemetrexed (Alimta)*
has an improved median survival of 13.3 months vs.
10 months with cisplatin alone
Cisplatin has also been combined with gemcitabine,
vinorelbine or vinorelbine, but with no survival
advantage
* Alimta only covered by Workers Compensation if asbestos
exposure occurred in Canada