NICE guidelines for the treatment of Lung Cancer

Michael-John Devlin (F2)

Aims

• Background

• Discuss the treatment options for SCLC and NSCLC as recommended by NICE

• Identify which treatments are appropriate for which patients

• Cases

• The most common cancer

• Lifetime risk ♀ = 5% ♂ = 7%

• Most common cause of cancer related deaths 35,000/annum

• 5 year survival rate 8% – 1970’s survival rate was 4%– NI better prognosis than rest of UK at 9%

• 1 year survival ~ 37%– Median survival 203 day

TNMStage TNM

0 Carcinoma in situ

1A T1A NO MO

T1B NO MO

1B T2A NO MO

2A T2B NO MO, T1A N1 MO,

T1B N1 M0, T2A N1 MO

2B T2B NI MO,

T3 NO MO

3AT1A NO MO, T1B N2 M0, T2A N2 M0, T2B N0 MO, T3 N1

M0, T3 N2 M0, T4 N0 M0, T4 N1 MO

3BT1A N3 MO, T1B N3 M0, T2A N3 M0, T2B N3 M0,T3 N3

M0, T4 N2 MO, T4 N3 MO

4 Any T, N with M1

WHO/ECOG Performance Status

Grade Description

0 Fully active, able to carry on all pre-disease performance without restriction

1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work

2 Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours

3 Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours

4 Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair

5Dead

Smoking Cessation

NSCLC

• Surgery

• Surgery and Chemotherapy

• Radiotherapy

• Radiotherapy and Chemotherapy

• Chemotherapy

• Other

SURGERY

Lobectomy (either open or thorascopic)

Segmentectomy

Wedge Resection

Bi-lobectomy

Pneumonectomy

Bronchoangioplasic

• Hilar and mediastinal lymph node sampling/ en bloc resection for all patients undergoing surgery with curative intent

• T3 NSCLC surgery should involve complete resection of tumour either extrapleural or en bloc chest wall resection

Work-Up For Surgery

• Perioperative Mortality• CV Function

– NO if <30days post MI– Optimise cardiac treatment including prophylaxis for

cornary disease– Cardiology Imput if needed

• Lung Function– FEV1 = Normal/Good Exercise Tolerance– FEV1/TLCO <30% OK IF they accept risk of dyspnoea– If they’re high risk can assess with shuttle walk or

segment counting

Chemotherapy and Surgery

• OFFER it if they have a good performance status (WHO 0,1) and T1-3 N1-2 M0

• CONSIDER if they have a good performance status and T2-3 N0 M0 with tumours >4cm

Radiotherapy

• Indicated in patients who are:– Stage 1, 2 or 3– Good performance status– Disease can be encompassed in the radiotherapy

volume without undue risk to normal tissue

• CHART Continuous Hyperfractionared Accelerated RadioTherapy

• Stage 1 and 2 who are medically inoperable but suitable for radical radiotherapy

• Stage 3a or 3b who are not medically fit for (or simply don’t want to have) chemoradiotherapy

• 32/33 # of 64-66 Gr in 6 ½ weeks

• 20 # of 55 Gr in 4 weeks

ChemoRadioTherapy

• Offered to stage 2 or 3 who are not suitable for surgery

Chemotherapy

• Stage 3 or 4 NSCLC with good performance status

• Dual therapy with:• 3rd generation drug: docetaxel, gemcitabine, paclitaxel• Platinum drug

• If unable to tolerate platinum: single 3rd generation agent

• Locally advanced relapse: docetaxel monotherapy

Other

• Gefitinib• First line treatment for locally advanced or metastatic NSCLC

• +ve for EGFR-TK mutation AND manufacturer provides it at fixed price

• Pemetrexed• First line with cisplatin for locally advanced or metastatic

• Adenocarcinoma or large cell

• Erlotinib• Alternative to docataxel

SCLC

Limited StageT1-4 N0-3 M0

Extensive StageT1-4 N0-3 M1a/b

Chemotherapy

ChemoRadiotherapy

Surgery

Chemotherapy ±

Radiotherapy

Topotecan

Limited Stage

• Chemotherapy• Offer 4-6 weeks of Cisplatin based chemotherapy

• Chemoradiotherapy• Limited stage with good preformance status that can be

encompassed in a radical thoracic RTx volume.

• Surgery• Consider in patients with early stage T1-2a NO MO

Extensive Stage

• Chemotherapy• Platinum based to a maximum of 6 cycles• Radiotherapy can be considered if complete response at

distal sites and a partial response within the thorax• Relapse

• Topotecan• Oral but not intravenous• Relapsed SCLC where:

– Treatment with first agent is inappropriate

– CAV are contraindicated

Cranial Irradiation

• 10# of 25Gy

• WHO ≤ 2 and whose disease has not progressed on first line treatment

Case One

Brenda

Aged 56

Cough and Haemoptysis

Otherwise well. Independent.

CT: 4cm lesion with ipsilateral node

Tissue Confirmation: NSCLC

• NSCLC

• T2 N1 M0 = Stage 2a

• WHO = 0

• Lobectomy and node clearance

• 6 weeks of post-operative chemotherapy

• Still alive at One Year

Case Two• Frank

• 70• T2DM, IHD, CABG, Osteoarthritis• Has carers x3 daily, spending most

of time in his chair• Confusion• CTB metastatic disease• CT shows >7cm lesion with

contralateral mediastinal nodes• Tissue Confirmation: SCLC

• Extensive Stage SCLC• T3 N3 M1• WHO = 3• Multiple Co-Morbidities

• Assessed for ? 6 cycles of platinum chemo +/- radiotherapy depending on response

• Felt not appropriate for this gentleman and a palliative approach was adopted.

• Frank was deceased at One Year