26 HOW TO TREAT : LUNG CANCER
26 HOW TO TREAT : LUNG CANCER
16 JUNE 2023 ausdoc . com . au
Figure 8 . PET scans for staging .
Figure 8A . Initial scan .
Figure 8B . Following three months of treatment , a restaging PET scan shows an almost complete response to therapy .
Figure 9 . Scanning for disease .
Figure 9A . CT chest scan confirms a lung nodule in the posterior segment of the left lower lobe .
Figure 9B . MRI brain confirms the presence of new brain metastases after two years of stable disease . breath or weight loss . Lisa has a history of gastro-oesophageal reflux disease , sciatica and benign colonic polyps . She and her partner live independently at home , and Lisa is a lifelong non-smoker .
A chest X-ray shows evidence of a cavitating lung lesion . A CT confirms a 3cm lung nodule in the posterior segment of the left lower lobe ( see figure 9A ). There is also a small liver metastasis , which is confirmed on PET scan .
Lisa is admitted for further investigation , with a CT-guided biopsy confirming adenocarcinoma consistent
1 . Which THREE statements regarding lung cancer are correct ? a Lung cancer accounts for the highest number of cancer-related deaths for both men and women . b The pathway to diagnosis in primary care can be complex . c Outcomes for lung cancer are still relatively poor . d The more common lung cancer symptoms , such as cough and breathlessness , are specific .
2 . Which ONE is the largest single cause of lung cancer ? a Occupational exposure
( for example , asbestos ). b HIV infection . c Tobacco smoking . d Air pollution .
3 . Which TWO statements regarding lung cancer are correct ? a Aboriginal and Torres Strait Islander people are twice as likely to be diagnosed with and die from lung cancer . b There is increasing concern that e-cigarette use or “ vaping ” may also increase lung cancer risk . c There is no evidence long-term cannabis smoking increases the risk of lung cancer in young adults . d Lung cancer is not seen in those who have never smoked .
4 . Which THREE statements regarding the pathophysiology with lung cancer . On detailed molecular testing , she is found to have an EGFR Exon 19 deletion .
She is started on erlotinib ( an EGFR targeting TKI ) and continues on this for about two years , with stable disease .
Two years after diagnosis , Lisa presents to ED with new sensory changes to the face and right hand . MRI brain confirms a new brain metastases ( see figure 9B ). In addition , the primary lung mass is enlarging , with multiple new sites of disease in the lungs and ribs .
A further biopsy is taken , which confirms the presence of a T790M
How to Treat Quiz .
and pathogenesis of lung cancer are correct ? a Histopathological classification is based on cellular and molecular subtypes and forms an important part of diagnosing and managing lung cancers . b Most lung cancers are SCLC . c The genetic and epigenetic pathways involved in the formation of lung cancer differ between smokers and never-smokers . d Targeted agents are available for use in patients with an oncogene driver , depending on the clinical setting .
5 . Which TWO are features of SCLC ? a Frequently associated with a wide range of paraneoplastic syndromes . b Typically appears as a large peripheral mass . c The most common form is adenocarcinoma . d Characterised by rapid doubling time and early development of widespread metastatic disease .
6 . Which ONE is not a common symptom in lung cancer ? mutation ( conferring resistance to the original TKI erlotinib ). Lisa ’ s medication is changed to osimertinib . Imaging performed three months after the medication change shows significant improvement in the appearance of her known metastatic disease .
CONCLUSION
LUNG cancer in Australia is characterised by high prevalence , high morbidity and poor survival . It imposes a considerable disease burden , both through years of life lost as well as direct management costs . The GP is
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a Cough ( new or changed ). b Haematemesis . c Shortness of breath . d Persistent or recurrent chest infection .
7 . Which THREE are GP investigations when lung cancer is suspected ? a A thorough medical history . b Urgent chest X-ray for unexplained , persistent symptoms and signs . c Sputum cytology ( only occasionally ). d Referral to a specialist linked to a lung cancer multidisciplinary team .
8 . Which TWO statements regarding the survival and screening of lung cancer are correct ? a The survival rate for lung cancer is poor compared with most other cancers . b Diagnosis in Australians usually occurs before the cancer has spread . c There is mounting recognition of the effectiveness of targeted lung cancer screening of asymptomatic people . d The survival rate is less than 50 % for Stage I at diagnoses .
EARN CPD OR PDP POINTS
• Read this article and take the quiz via ausdoc . com . au / how-to-treat
• Each article has been allocated one hour by the RACGP and ACRRM .
• RACGP points are uploaded every six weeks and ACRRM points quarterly . pivotal at diagnosis and in the continuum of care of the patient , as the community centre of the multidisciplinary care team , integrating specialist and palliative care .
There is currently great interest in better understanding the pathway to diagnosis and developing interventions to help improve outcomes both in terms of early diagnosis and improved treatment .
Lung cancer is not considered a single disease , with advances in understanding the molecular biology of lung cancer transforming the
LUNG CANCER
9 . Which THREE statements regarding the management of lung cancer are correct ? a SABR is the preferred treatment for early-stage localised lung cancers . b Depending on the pathology and stage , treatment is either curative or to improve quality of life and / or longevity . c Surgical lobectomy remains the preferred treatment for medically fit patients with operable early-stage NSCLC . d Localised SCLC may be managed with chemoradiotherapy .
10 . Which THREE statements regarding the management of lung cancer are correct ? a ICIs and oncogene-directed targeted therapies offer a molecular-based personalised approach for patients with metastatic NSCLC . b ICIs are specifically indicated in those with a severe or poorly controlled immune / autoimmune condition . c Current best practice for patients with extensivestage SCLC disease involves platinum-based chemotherapy combined with immunotherapy . d Patients with lung cancer and their families will need psychological support to help cope with their diagnosis and treatment . personalised care of many patients , but if lung cancer continues to be diagnosed at a late stage , improvements in survival will be limited . Optimal management of lung cancer has become increasingly complex , despite new diagnostic tools and novel treatments helping improve outcomes . Additional challenges include other factors , such as the importance of patient-centred healthcare and the need for advances to be translated to routine clinical practice .
RESOURCES
Guidelines and information for health professionals
• Cancer Australia . Lung Cancer : Guidance for GPs bit . ly / 3LUquBF
• Cancer Council Australia — Clinical practice guidelines for the prevention and diagnosis of lung cancer bit . ly / 3JMNbFk
— Clinical practice guidelines for the treatment of lung cancer bit . ly / 42K8U9C
— Optimal Care Pathways bit . ly / 3LWMFXP
• Cancer Council Victoria and Department of Health Victoria . Optimal care pathway for people with lung cancer , 2021 ( 2nd ed ), Cancer Council Victoria , Melbourne bit . ly / 3TPBemH
• ESMO Clinical Practice Guidelines ( Europe ). Lung and chest tumours bit . ly / 3ZoHgf7
• NCCN Clinical Practice Guidelines ( US ) — Non-small cell lung cancer
Version : 3.2023 bit . ly / 3OcJ2OQ
— Small cell lung cancer Version : 3.2023 bit . ly / 3nYHKfq
• NICE Guidelines ( UK ). Lung cancer : diagnosis and management ( NG122 ) bit . ly / 2V5Ao6o
Patient information
• Cancer Council NSW . Understanding Lung Cancer : A guide for people with cancer , their families and friends bit . ly / 3o43uqs
• NCCN Guidelines for Patients . Non-Small Cell Lung cancer bit . ly / 3FVmY66
References Available on request from howtotreat @ adg . com . au