LUNG CANCER OVERVIEW

LUNG CANCER OVERVIEW

Non–Small Cell Lung Cancer

  • Constitutes 80% to 85% of new cases of lung cancer in North America.
  • Most frequent histologies: adenocarcinoma, squamous cell carcinoma, and large cell carcinoma.
  • Leading cause of cancer-related death in the United States for both men and women; represents one of the most preventable forms of cancer death.
  • Tobacco use causes 80% of lung cancer deaths.
  • Low-dose computed tomography (CT) scan in high-risk individuals is associated with high sensitivity but low specificity for detection of early stage disease.
  • Screening remains controversial.
  • History and physical examination, routine hematologic and biochemical testing.
  • Imaging studies:
    • CT scan (with contrast) evaluating lungs, mediastinum, liver, and adrenals
    • Positron emission tomography (PET) scan
    • If patient has locally advanced or metastatic disease, add magnetic resonance imaging (MRI) of brain
    • If PET is not available, add bone scan
  • Bronchoscopy and/or CT-guided and/or ultrasound-guided biopsy.
  • If disease is clinically more advanced, use the least invasive biopsy procedure and sample to confirm advanced disease.
  • Mediastinal node evaluation:
    • If disease is in early stage (I or II) and PET of mediastinum is negative, proceed directly to surgery. If PET is positive, proceed to biopsy via endobronchial ultrasound (EBUS), or endoscopic ultrasound (EUS), or mediastinoscopy, depending on node location.
  • Stage I disease:
    • Surgery is often curative.
    • Role of preoperative or postoperative chemotherapy is unclear. Often recommended in patients with stage IB tumors ≥4
    • Stereotactic body radiotherapy in selected cases.
  • Stage II disease:
    • Surgery is often curative.
    • Postoperative chemotherapy prolongs survival in patients with a good performance status.
    • Stereotactic body radiotherapy in selected cases.
  • Stage IIIA disease:
    • Postoperative chemotherapy useful in resected IIIA in patients with a good performance status.
    • Role of preoperative chemotherapy ± radiotherapy for stage IIIA is unknown except for Pancoast tumors where it is recommended.
    • Concurrent chemotherapy combined with radiation therapy in patients with a good performance status.
  • Stage IIIB disease:
    • Concurrent chemotherapy combined with radiation is superior to radiation alone; increased toxicity limits this approach in frail patients.
    • Clinical trials of new approaches should be a high priority.
  • Stage IV disease:
    • Primary chemotherapy with platinum-based doublet improves the quality and quantity of life.
    • All tumors should be sent for molecular testing.
    • Targeted therapy with epidermal growth factor receptor tyrosine kinase inhibitors (EGFR TKI) as first-line therapy in patients with known EGFR mutations.
    • No advantage for triplet therapy.
    • Non–platinum-based therapy is appropriate in selected patients.
    • Single-agent therapy reserved for select populations.
    • There is a clear need for more clinical trials at this stage.
  • Second- or third-line therapy
    • Further treatment with any of several agents is appropriate with progression after chemotherapy if patient sustains a good performance status; docetaxel, pemetrexed, erlotinib, and crizotinib are all U.S. Food and Drug Administration (FDA)-approved.
    • Local recurrence after surgery can be treated with combined chemotherapy and radiation after complete restaging.

Small Cell Lung Cancer

  • Accounts for approximately 15% of new cases of lung cancer each year in United States; incidence is decreasing.
  • Subtypes include small cell carcinoma and combined small cell carcinoma (most often combined with squamous cell carcinoma, adenocarcinoma or large cell carcinoma).
  • History and physical examination, routine histologic and biochemical testing.
  • Imaging:
    • CT scan (with contrast) evaluating lungs, mediastinum, liver, and adrenals.
    • PET useful with clinically early stage disease.
    • Brain evaluation (MRI preferred).
    • If there are signs or symptoms of bone involvement, a bone scan or PET scan is recommended.
    • Mediastinal node evaluation is not required unless as a convenient site for biopsy.
    • If peripheral smear or hemogram is abnormal, a bone marrow biopsy may be obtained if no other site of metastatic disease has been confirmed.
  • Limited disease:
    • Concurrent etoposide plus cisplatin and radiation to the intrathoracic disease.
    • Prophylactic cranial irradiation in complete (or near complete) responders.
  • Extensive disease:
    • Etoposide (or irinotecan) plus cisplatin or carboplatin.
    • No evidence a third agent or dose intensification improves outcome.
    • Research studies are a clear priority given the lack of progress in this arena.
    • Prophylactic cranial irradiation in complete (or near complete) responders.
    • Consider consolidative radiotherapy (RT) to primary in complete responders.
  • Recurrent disease:
    • Second-line therapy useful mainly in patents who have experienced a longer treatment-free interval and a good performance status.
    • Topotecan FDA-approved; however, any of several chemotherapy agents offer short-term benefit.
    • Research protocols are a preferred choice for patients with disease recurrence.

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