Lung Cancer Treatment in India - Are you aware that it

is the leading cause of cancer death in the world?

The high incidence of lung cancer and the poor survival rate

make lung cancer a very important public health problem, and

the leading cause of cancer death in the world. Most patients

have locally advanced lung cancer at the time of diagnosis. As

per the Madras Metropolitan Tumor Registry (MMTR) Chennai,

in 2006-2008, cancer of the lung was the most common among

males, and was ranked among the top ten in females.

It constituted 10.9 percent and 3.3 per cent of all cancers among

males and females respectively. The peak incidence occurred in

the age group of 65-69 years among both sexes.

Risk factors

•Cigarette smoking is the single highest cause of the lung cancer

epidemic

•Other contributing factors are asbestos, arsenic, chromium,

nickel, and radon in the work environment

•Other environmental factors such as passive smoking and air

pollution

•Molecular changes that commonly occur in lung cancer are

mutations of tumour suppressor genes p16, p53, and H, K, N-ras

family of oncogenes

•Studies have shown that individuals with a higher dietary intake

of fruits or vegetables have a lower risk of lung cancer.

Lung cancers are classified into:

Non-Small Cell Carcinoma (NSCLC) that includes

squamous cell carcinoma, adenocarcinoma, large cell

carcinoma and their subtypes (80 per cent) Small Cell

Carcinoma (SCLC) (20 percent) There are other rare types

of lung cancers that can occur apart from these

Types

Prognostics

1. Well differentiated squamous cell carcinomas and non mucinous bronchiloalveolar

carcinomas have favourable prognosis.

2. Poor prognostic factors include: higher tumour size and extent, regional nodal

involvement, absence or presence of distant metastasis, weight loss of more than 10 per

cent, age less than 40 years, tumour size more than 3 cm, Iymphovascular invasion, and

mutation of the tumour suppressor gene p53.

Spread

Spread can occur along bronchus into lung parenchyma, to mediastinum or pleura

causing pleural effusion. Diaphragm and chest wall involvement are not

uncommon. 50 per cent have nodal metastasis at resection. Distant spread

commonly involves adrenals to 50 per cent, liver to 30 percent, apart from brain,

bone opposite lung, pericardium and kidneys.

Common Symptoms

Cough, weight loss, chest pain, shortness of breath, blood in the sputum, superior

vena cava syndrome, ulnar nerve and Horner's syndrome (Pancoast tumour) are

common symptoms of lung cancer.

Screening for lung cancer

At present, screening for early detection of lung cancer is not recommended, probably

because of the failure of early studies to demonstrate any mortality reduction from lung

cancer evaluation based on sputum cytology and/or chest radiography. With the

introduction of helical computerised tomography, a new imaging modality that can

detect nodules as small as a few millimetres, the potential benefits of lung cancer

screening is being re-examined.

Imaging in lung cancer

•Chest radiography remains the basic modality for the detection of lung cancer.

•Computerised tomography (CT) provides information about the primary lesion,

thoracic lymph nodes, pleura, chestwall and upper abdomen. It is the standard

imaging modality for staging lung cancer.

• Magnetic resonance imaging (MRI) appears to be superior to CT in detecting

mediastinal, chest wall tumour invasion into the pericardium, heart and great vessels,

brachial plexus, vertebral body and spinal canal.

• Positron emission tomography (PET) is a molecular imaging modality that detects

metabolic changes in tumour cells. PET improves the rate of detection of the extent of

primary tumour, draining nodes and distant metastases thereby improving the staging

accuracy in patients with NSCLC that can have a significant impact on clinical

management.

Other diagnostic modalities

•Clinical and radiological findings should guide the diagnostic approach, depending

on the size and location of the tumour, the presence of metastatic disease, and the

clinical status of the patient. Diagnostic and staging work is taken up concomitantly.

•Sputum cytology, flexible bronchoscopy for biopsies, brushings and washings, CT

guided transthoracic needle aspiration, oesophageal endoscopic ultrasound guided

fine needle aspiration/trucut biopsy of the mediastinal nodes, anterior

mediastinoscopy to assess lymph nodes, are the aids used to establish the

histopathological diagnosis. Distant metastatic sites need to be documented with

microscopic diagnosis.

Management

•Surgery is the preferred modality of primary management for resectable NSCLC.

•Based on initial stage and postoperative histopathological report, patients will be

planned for adjuvant radiation therapy with or without chemotherapy, or

chemotherapy with or without radiation therapy.

•For medically inoperable and unresectable tumours chemoradiation therapy is the

preferred line of management.

•With the rapid technological explosion in diagnostic imaging and radiation delivery

techniques, radiation oncologists are now able to deliver external beam radiation

therapy with high precision using Image Guided Intensity Modulated Radiation

Therapy (IG IMRT), Stereotactic Body , Radio surge with real time positional

management respiratory gating system delivering significantly higher doses to the

tumour and minimum dose to the surrounding normal lung and other critical

structures like the opposite lung, heart, spinal cord, oesophagus, and breast,

resulting in increased cure rates and lesser side effects respectively.

Management

•Radiation along with chemotherapy has a role in palliation of symptoms due to

recurrent, advancing and metastatic cancer.

•Newer targeted therapy compounds have resulted in progression-free and overall

survival advantage in NSCLC.

•For SCLC, chemoradiation therapy is the preferred choice of treatment, except in T1-

2 NO MO where surgery followed by chemotherapy is the standard of care.

•The by and large outcome for patients with lung cancer may not be gratifying at

present. But with improved surgical techniques, newer anti-cancer drugs, and modern

radiation therapy delivery techniques, we are able to confer superior progression-free

and overall survival period ensuring a good quality of life for our patients. Lung

cancer surgery hospitals in India attracts many international patients because of

availability of very good treatment facilities, good success rate and very low cost of

treatment.

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