RISK FACTORS: Smoking (attributable in 87% of cases), Passive - second hand smoke exposure, Chronic obstructive pulmonary disease (COPD), Preexisting lung disease (pulmonary fibrosis), Environmental; occupational exposure, Asbestos expo.
ABOUT 90% OF MALE & 80% OF FEMALE LUNG CANCER DEATHS ARE ATTRIBUTABLE TO CIGARETTE SMOKING
RISK FACTORS:
. Smoking (attributable in 87% of cases)
. Passive - second hand smoke exposure
. Chronic obstructive pulmonary disease (COPD)
. Preexisting lung disease (pulmonary fi brosis)
. Environmental; occupational exposure
. Asbestos exposure
. Ionizing radiation
. Atmospheric pollution
. Gases: halogen ethers, radon, mustard gas, aromatic hydrocarbons
. Metals: inorganic arsenic, chromium, nickel
. Possibly HIV (adenocarcinoma)
APPROPRIATE HEALTH CARE
. Depends on tumor cell type and stage of disease at diagnosis
. Treatment options for NSCLC include:
. Surgical resection
. Chemotherapy
. Radiation therapy
. Treatment options of SCLC include:
. Chemotherapy
. Radiation therapy
GENERAL MEASURES
. Relief of symptoms
. Pain relief as needed
. Discussions with patient and family about wishes for end-of-life care
SURGICAL MEASURES Resection for non-small cell cancer, when possible, stage I and II and some stage III. Resection of isolated, distant metastases has been achieved and may improve survival. Functional evaluation performed prior to surgery.
DRUG(S) OF CHOICE
. NSCLC, chemotherapy. Indicated only in patients with a good functional status.
. Cisplatin (Platinol) and cisplatin-based regimens are standard although response rates with cisplatin alone are <20% in stage IIIB/IV disease with a 3 year survival rate of 8%. Combination regimens can improve survival an average of 2 months with a 5-year survival rate improved by about 10% in stage III disease.
. Etoposide (Toposar) benefi cial in combination with cisplatin and radiation (becoming standard)
. Newer agents include paclitaxel (Taxol), docetaxel (Taxotere), vinorelbine (Navelbine), gemcitabine (Gemzar) and irinotecan (Camptosar) either alone or as radiation sensitizers have led to response rates up to 40% in non-small cell tumors
. SCLC, chemotherapy. Excellent response, including complete remissions possible.
. Palliative measures
. Analgesics: hydrocodone, morphine, fentanyl (Duragesic)
. Dyspnea: oxygen, nebulized morphine, benzodiazepines [e.g., lorazepam (Ativan) 1-2 mg po, SL, SC, or pr q2-6 h]
PATIENT MONITORING
. Surgically resectable
. First year each 3 months
. Second year each 6 months
. Third though fi fth year once a year
. Surgically unresectable
. As necessary for palliation
. Consider early hospice referral
. Follow up CT scans as indicated
PREVENTION/AVOIDANCE
. Despite numerous studies, no cost effective screening measure has been found for lung cancer. Therefore,
prevention via aggressive smoking cessation counseling and therapy is the cornerstone of patient
management. 20-30% risk reduction within 5 years of cessation.
. Stop smoking; avoid second hand smoke exposure
. Avoid radon exposure
. Avoid occupational exposure to asbestos, metals
. Consider prophylaxis with retinoid, such as beta-carotene or antioxidants such as vitamin A or E
POSSIBLE COMPLICATIONS
. Development of metastatic disease to brain, bones and liver
. Local recurrence of disease
. Postsurgical complications
. Side effects of chemotherapy or radiation
. Dysphagia (radiation-induced, fungal)
. Infections
. Bleeding
. Radiation pneumonitis
. Superior vena cava syndrome
. Atelectasis
. Spinal cord compression
. Pulmonary abscess
. Horner syndrome
. Hypercalcemia (ectopic parathyroid hormone)
. Syndrome of inappropriate antidiuretic hormone (SIADH)
. Hypercoagulable state
. Terminal restlessness (anorexia, dyspnea)
EXPECTED COURSE/PROGNOSIS
. Overall survival rate is 15%
. Stage I, 50% survival status postresection of squamous, adenocarcinoma or large cell
. Stage II, 33% survival status postresection for squamous and 20% for adenocarcinoma or large cell
. Stage IIIa, 15% survival status postresection for squamous
. Note: Presurgical staging is less accurate so survival figures are lower
. If nonresectable, prognosis is poor with mean survival of 8-14 months