Download British Journal of Cancer

Lung Cancer
Elin Roddy, Lead Clinician for Lung
Cancer at SaTH
[email protected]
@elinlowri
Overview
• Some depressing statistics
• Some possible reasons for the depressing
statistics
• Brief overview of diagnosis and treatment
of lung cancer, explaining why we
sometimes take so long
• Discussion around potential improvements
Age-Standardised Ten-Year Survival for Common Cancers in Males and Females, England and Wales, 2010-2011
Mesothelioma 2008 - 2012
Reasons why lung cancer survival is
still variable and poor?
•
•
•
•
Late presentation
Deprivation (not just smoking, but mainly)
Lack of advocacy & research
Stigma
• Access to staff,diagnostics and treatment
Late presentation
• Late symptoms due to anatomy
• Poor differentiation of symptoms by patients
• Primary care gate-keeping?
• Early diagnosis campaigns not a panacea
Symptoms in patients who turn out
to have lung cancer
Red flags are not always reliable
but……NICE says
•
•
•
•
•
•
•
•
Any haemoptysis
Three weeks of unexplained clubbing or…..
Cough
Breathlessness
Chest or shoulder pain
Weight loss
Hoarseness
Chest signs
• Or just because smokes and tired? Unclear. But probably.
• Don’t wait for antibiotics to work
What about the radiation?
What about the cost?
We (you) do well in terms of routes of referral
for lung cancer – very few ‘emergencies’
Is there an ideal percentage?
% Total of 2ww Referrals with confirmed Ca
25.0%
20.0%
19.3%
18.2%
15.9%
15.0%
10.0%
5.0%
0.0%
2011
2012
2013
Lung cancer rates by deprivation quintile
Lung Cancer (C33-C34): 2006-2010
European Age-Standardised Incidence Rates by Deprivation Quintile, England
Smoking prevalence 22.8% vs. 19.5% national average vs. 30% highest
Advocacy, stigma, research
• Linked to deprivation and smoking
• ‘It’s all my own fault’
• Deserving vs. undeserving cancers
• Research spend per annum in the UK:
Breast - £41million (£3500 per death)
Leukaemia - £32million (£7000 per death)
Lung - £15million (£400 per death)
Diagnosis and Staging
•
•
•
•
Accurate diagnosis AND staging is important
CT should be before bronchoscopy
Most patients should have histology obtained
Nodal staging with EBUS is becoming
important
• ‘Radical’ treatment should be preceded by
PET
• ‘Open and close rates’ should be <5%
TNM staging –
T1 NO MO good, T4 N3 M1b bad
At diagnosis
20%
10%
1 yr survival
80%
70%
25%
50%
45%
<20%
Diagnostics
Treatment
• Surgery is preferred radical option
• ‘Resectable’ versus ‘operable’
• Radical RT (or SBRT) should be considered even if
patient not fit for surgery (‘operable’)
• Performance status at diagnosis is crucial:
Grade
Explanation of activity
0
Fully active, able to carry on all pre-disease performance without restriction
1
Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or
sedentary nature, e.g., light house work, office work
2
Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more
than 50% of waking hours
3
Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours
4
Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair
5
Dead
Things that affect PS
•
•
•
•
•
Nutrition
Pain
Continued smoking
Low mood
Physical activity
Surgery
Radiotherapy
• Radiotherapy – can be curative, good for pain, brain
mets or in combination with chemo
• Radical, long course palliative, single fraction
• Side effects – skin redness, hair loss, fatigue
• Spinal cord and lung damage concerns with higher
doses but IMRT reduces risk
• Previous RT (eg for breast) may affect current dose
Chemotherapy
•
•
•
•
Neo-adjuvant
Adjuvant
Palliative – first-line, second-line, maintenance
Biologic treatments – gefitinib, erlotinib – oral,
fewer side-effects – need receptor testing
•
•
•
•
Incremental gains
Histological diagnosis more & more important
In the future – a panel of receptors tested?
Treatment more likely with CNS support
-
Comparison LUCADA headline
data 2013 (2012)
Number
of pts
% MDT
discussi
on
RXW
256
(245)
RL4
%CT
before
bronch
% seen
by CNS
CNS
present at
diagnosis
Histo
diagnosis
% Active
treatment
Surgery
(all
cases)
%
receiving
radiother
apy
% small
cell
receiving
chemo
96.1
80.9
(96.3) (85.8)
74.2
(81.2)
44.5
(75.9)
73.8
(77.1)
59
(60)
18.8
(20)
33.2
(35)
64.2
(58.6)
237
(228)
100
(100)
100
(91.5)
97
(96.5)
94.1
(95.6)
74
(70.6)
56.1
(57)
15.6
23.2
74.2
(23.2) (18.9) (68.4)
RTH
317
98.1
100
85.8
82.6
90.9
71.6
29.7
18.6
76.0
RVR
181
76.2
92.5
76.2
40.9
73.5
59.7
8.3
19.3
56.8
Learning points
• Smoking and deprivation influence incidence, treatment
and outcomes
• Improving early diagnosis is complex
• X ray early
• Aim to maintain PS - including smoking cessation
• Surgery preferred treatment option
• Accurate staging can be complex and time-consuming
• Chemo is improving, individualised
• Improving specialist nurse support improves outcomes
• Inverse care law – perhaps equal resource not the
answer?
References
• British Journal of Cancer (2015) 112, 207–216.
doi:10.1038/bjc.2014.596 – evaluation of the early diagnosis
campaign
• http://www.bbc.co.uk/news/business-22310825 - Robert
Peston on funding
• http://www.rcgp.org.uk/clinical/clinicalresources/~/media/Files/CIRC/Cancer/ImprovingCancerDiag
nosis
• The Patient Paradox by Margaret McCartney
• http://www.apho.org.uk/resource/item.aspx?RID=142221 –
Health Profile for T&W
• http://www.hscic.gov.uk/catalogue/PUB12719/clin-audi-suppprog-lung-nlca-2013-rep.pdf