24 HOW TO TREAT : LUNG CANCER
24 HOW TO TREAT : LUNG CANCER
16 JUNE 2023 ausdoc . com . au
Source : Cancer Australia 202019 This information is reproduced with permission from Cancer Australia .
Figure 6 . Investigating symptoms and signs of lung cancer . ( For the full recommendations , the evidence underpinning the guide and reference list , visit canceraustralia . gov . au ).
being evaluated preoperatively . The place of these approaches in the treatment algorithm of early NSCLC awaits additional trial data and PBS approval .
Locally advanced disease
Treatment options for locally advanced NSCLC ( Stage III ) include neoadjuvant chemotherapy +/ - an immune checkpoint inhibitor ( ICI ), then surgery or surgery followed by adjuvant ( postoperative ) chemotherapy +/ - an ICI or targeted therapy , or chemotherapy and radiotherapy combined in inoperable disease . Immunotherapy with an ICI ( durvalumab ) after chemoradiotherapy is now considered standard of care . 27
Localised SCLC ( limited stage ) is managed with chemotherapy combined with radiotherapy
19 , 25
.
Metastatic disease
Considerable changes have occurred in the management of metastatic NSCLC with the development of highly effective agents , including ICIs and oncogene-directed targeted therapies offering a molecular-based personalised approach .
Traditionally , treatment involved combination chemotherapy . However , with the development of ICIs , combination chemoimmunotherapy has moved into the first-line setting for patients without an identified oncogene . ICIs , more commonly known as ‘ immunotherapy ’, are a group of drugs that use the immune system to help fight cancer . ICIs help the immune system recognise and attack cancer cells . Because of the activation of the immune system
Box 4 . GP investigations when lung cancer is suspected
• A thorough medical history .
• Urgent chest X-ray for unexplained , persistent symptoms and signs ( lasting more than three weeks , or earlier in patients with known risk factors / more than one symptom or sign ).
• If the chest X-ray is normal and symptoms persist , then repeat the chest X-ray six weeks later ( chest X-rays have a false-negative rate of at least 22 %). 22
• CT scan ( with contrast unless contraindicated ) if there is a strong clinical suspicion of lung cancer , within two weeks of the patient presenting with symptoms .
• At the same time as the CT scan , refer to a specialist linked to a lung cancer multidisciplinary team .
Box 5 . Diagnosis and staging of lung cancer
• Diagnosis can be made through :* — Additional imaging . — Bronchoscopy . — Ultrasound-guided biopsy . — CT or ultrasound-guided biopsy or aspiration . — Excisional biopsy or biopsy of a metastasis . — Sputum cytology ( only occasionally ).
* For early-stage lung cancer , diagnosis is usually made with small biopsies such as CT-guided FNA or EBUS FNA . For more advanced disease where systemic therapy will be required , sufficient tissue to enable molecular profiling is required , such as CT-guided core biopsy or EBUS-FNA .
• Staging involves : — CT scans of the chest and upper abdomen . — Imaging of the brain in most cases . — 18F-FDG PET-CT scans where curative treatment is being considered . — Surgical assessment # where curative treatment is being considered .
#
It is important to carry out a ‘ physiologic workup ’ in operable patients to assess fitness and suitability for surgery .
Source : Cancer Council Victoria and Department of Health Victoria 2021 19
that occurs with the use of ICIs , they are generally not used in people who have severe or poorly controlled immune / autoimmune conditions . 31 PD-L1 tissue propensity score
( TPS , %) is generally provided as part of the diagnostic report . ICIs combined with chemotherapy provide benefits independent of PD-L1 TPS . However , single agent ICIs aremore
Box 6 . Summary of population , risk assessment and screening elements from proposed national lung cancer screening program
• Screening program population cohort Current or former smoker ( ever-smokers ): — General population aged 55-74 years . — Aboriginal and Torres Strait Islander people aged 50-74 years .
• Risk assessment — Australian validated PLCOm2012 risk prediction tool ( individual is eligible for the screening intervention if PLCOm2012 score is 1.51 % or greater )*. — Risk assessment to be undertaken by an authorised health professional .
• Screening eligible population — Self-referral ( seen advertising or is concerned ). — Facilitated entry ( recommended by health professional ). — Opportunistic entry ( recommended during a routine medical consultation ). — Organised entry ( invitation from a health service / authorised health professional as a result of a record review ).
• Screening intervention and infrastructure — Low-dose computed tomography ( LDCT ) with volumetric analysis at two-yearly intervals . — Public and private fixed and mobile CT scanners .
* The PLCOm2012 ( Prostate , Lung , Colorectal and Ovarian cancer ) model is currently the only risk prediction model validated in an Australian population and considered the most feasible risk assessment tool for a national LDCT screening program in Australia .
Source : Cancer Australia 2020 22
effective than monotherapy in patients with PD-L1 TPS 50 or more . Generally , tumour response is greater with higher PD-L1 TPS , but patients with low or 0 PD-L1 TPS may also respond . 31 , 32 For those with an underlying oncogenic driver , targeted therapy with the relevant tyrosine kinase inhibitor is the treatment of choice . The most common oncogenic drivers are EGFR and anaplastic lymphoma kinase ( ALK ) mutations 25 ( see table 2 ). There are less common oncogenic drivers with targeted therapies available or in development ( ROS1 , RET , BRAF , KRAS , NTRK ), including MET exon 14 skipping alterations , for which tepotinib has recently been registered as a treatment in Australia and listed on the PBS . 1 , 33
Small cell lung cancer
SCLC has generally been considered a systemic disease because of its propensity for widespread metastases at diagnosis . Staging for treatment