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The Christie NHS Foundation Trust
Palliative treatments for lung cancer:
What can the oncologist do?
Neil Bayman
Consultant Clinical Oncologist
The Christie NHS Foundation Trust
GM Cancer Palliative Care and Lung Cancer Education Event
Manchester, 31st January 2017
The Christie NHS Foundation Trust
Most patients present with stage 4
disease
NLCA 2014
The Christie NHS Foundation Trust
• Radiotherapy
• Systemic therapy
Palliative treatments for lung cancer:
What can the oncologist do?
The Christie NHS Foundation Trust
Palliative Radiotherapy
The Christie NHS Foundation Trust
The Christie NHS Foundation Trust
Case Study
• 63 yr old man
• Stage 4 NSCLC
• WHO PS 1
• Pain in right hip
• Mobile
• No neurological signs
What next?
The Christie NHS Foundation Trust
The Christie NHS Foundation Trust
The Christie NHS Foundation Trust
The Christie NHS Foundation Trust
The Christie NHS Foundation Trust
Radiotherapy for bone pain
• Systematic review 25 randomised trials, > 5500
patients
• Response rate
Any reduction in pain = 60%
Complete response = 23%
Overall and complete response rates 73% and 29% respectively
when excluding patients not assessed at follow-up
Chow, Clin Oncol (R Coll Radiol) 2012
The Christie NHS Foundation Trust
Systematic review of single vs multiple fraction
radiotherapy for bone metastases
n Single
fraction
Multiple
fractions
OR (95% CI)
Overall
response
5617 60% 61% 0.98 (0.95-
1.02)
Complete
response
5263 23% 24% 0.97 (0.89-
1.06)
Re-irradiation 4632 20% 8% 2.60 (1.92-
3.47)
Pathological
fracture
4279 3.3% 3% 1.10 (0.65-
1.86)
Spinal cord
compression
2886 2.8% 1.9% 1.44 (0.90-
2.30)
Chow, Clin Oncol (R Coll Radiol) 2012
Response rate assessments ranged from 3 weeks to 3 months
The Christie NHS Foundation Trust
Pain flare occurs in up to 40% patient following radiotherapy for
bone pain Hird IJROP 2009
Dexamethasone (8mg d1-5) reduces risk of pain flare
Chow, Lancet Oncol 2015
The Christie NHS Foundation Trust
Guidelines
Royal College of Radiologists
For the initial therapy of pain from bone
metastases, a single fraction of 8 Gy is
recommended (Grade A)
RCR Radiotherapy Dose-Fractionation 2016
The Christie NHS Foundation Trust
Palliative RT for bone pain in last 3
months of life: Worthwhile or Futile?
Prospective, population-based Canadian study
• Response rates
• 70% at 1 month
• 63% at 2 months Dennis, Clin Oncol (R Coll Radiol) 2011
Dutch bone metastases study
• 76% response rate overall
• 54-65% response rate in those dying < 3 months
Meeuse, Cancer 2010
The Christie NHS Foundation Trust
Palliative Radiotherapy Audit
Christie
• 14 day mortality after RT = 5%
• 30 day mortality after RT = 18%
The Christie NHS Foundation Trust
Palliative Radiotherapy Audit
Christie
The Christie NHS Foundation Trust
Metastatic Spinal Cord Compression
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Metastatic Spinal Cord Compression
(MSCC)
• > 4000 cases per year in UK
• Extradural compression or invasion from adjacent
metastatic vertebra
• Oncological emergency treated with surgery or
radiotherapy
Reversible
Venous obstruction
and oedema
Irreversible
Direct compression
• arterial compression
• axonal fracture
• neuropraxia
MSCC
Pain
Immobility
Loss of sphincter control
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Tokuhashi
Score
• Validated score to
predict prognosis
after diagnosis
MSCC
• Surgical selection
tool
• Lung cancer poor
prognostic factor
The Christie NHS Foundation Trust
Metastatic Spinal Cord Compression:
NICE guidance
1.5.1. Radiotherapy for painful spinal metastases
• Offer patients with spinal metastases causing non-mechanical spinal pain 8 Gy single fraction palliative radiotherapy even if they are completely paralysed.
• Patients with asymptomatic spinal metastases should not be offered radiotherapy with the intention of preventing MSCC except as part of a randomised controlled trial.
The Christie NHS Foundation Trust
Metastatic Spinal Cord Compression:
NICE guidance
1.5.5 Radiotherapy for the definitive treatment of MSCC
• Urgent access (within 24 hours) to radiotherapy 7 days a week
• Offer a fractionated rather than a single fraction regimen to patients with a good prognosis.
• Routine fractionated radiotherapy to all patients after surgery
• Offer urgent radiotherapy (within 24 hours) to all patients with MSCC who are not suitable for spinal surgery unless:
• they have had complete tetraplegia or paraplegia for more than 24 hours and their pain is well controlled; or
• their overall prognosis is judged to be too poor.
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SCORAD III
• Phase III RCT
• Eligibility
• MSCC
• Prognosis > 8 weeks
• Histological diagnosis
of malignancy
• Primary outcome
• Ambulation at 8 weeks
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Palliative Radiotherapy for Brain
Metastases
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The Christie NHS Foundation Trust
Median survival
(weeks)
Whole brain RT 9.2
Supportive care 8.5
No difference in
QALY or OS
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The Christie NHS Foundation Trust
Palliative thoracic radiotherapy
Erridge et al. Clin Oncol (R Coll Radiol) 2005
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Systemic Therapy
The Christie NHS Foundation Trust
The Christie NHS Foundation Trust
The Christie NHS Foundation Trust
Case Study
• 60 year old lady
• Vietnamese
• Never smoked
• No co-morbidities
• Keen ballroom dancer
• PS2
• Fatigue
• Cough
• Dyspnoea
• Weight Loss
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The Christie NHS Foundation Trust
Where is it?
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What is it?
The Christie NHS Foundation Trust
Case 2
What is it?
• Adenocarcinoma
• EGFR mutation
• Started 1st line Gefitinib (tyrosine kinase inhibitor)
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1st line Iressa vs chemotherapy in NSCLC
with EGFR mutation N Engl J Med 2010;362:2380-8
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October November
December January
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Case
• Symptoms resolved after 1st cycle
• Toxicity - Mild skin reaction (acneform rash over face
and dry skin)
• Restarted ballroom dancing
• Spent time visiting relatives and travelling with her
husband in SE Asia.
……with several boxes of gefitinib.
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Prevention of Skeletal Related
Events (SRE)
• Bisphosphonates • Zolendronic acid (4mg every 3w for 9 months) reduced risk of
skeletal related events compared to placebo
• Increased time to first SRE
• NNT to prevent SRE at 9 months = 14 Rosen JCO 2003
• Denosumab • Non-inferior to ZA in delaying time to first SLE
Henry JCO 2011
• Improved OS compared to ZA on exploratory analysis (8.9 vs 7.7
months; hazard ratio [HR] 0.80, p=0.01) Scagliotti JTO 2012
Palliation of bone pain???
The Christie NHS Foundation Trust
Take home messages
• Radiotherapy
• Very effective treatment for cancer induced bone pain and
heamoptysis
• Metastatic spinal cord compression is an oncological emergency
• Does not improve QALY for patients with brain metastases
(?young/good PS/controlled extracranial disease)
• Systemic therapy
• Can improve survival and offer holistic symptom relief
• Tissue for histological and molecular analysis is essential
The Christie NHS Foundation Trust