Marianna Strakhan, MDAttending Physician

Department of Hematology/OncologyJacobi Medical Center

Bronx, NY

March 30, 2010

Incidence2nd most common type of malignancy in the U.S. among

both men and women

Most common form of cancer mortality in the U.S. in both men and women

In 2007 – approximately 215,000 new cases of Lung cancer were diagnosed in the U.S, with 162,000 deaths

Between 1990 and 2003 – incidence of lung cancer have remained stable in men, however in women, incidence increased by 60% (incidence in African american females being partially higher than white females). **Incidence increase is seen among large portion of never-smokers, healthy, and active women)

IncidenceAlthough deaths have begun decreasing in MEN

(likely due to decrease in smoking), mortality in WOMEN has reached a plateau

Almost ½ of all cancer deaths now occur in women

10 – 15% of lung cancer victims are non-smokers. Among that group, women are 2-3x more likely than men to get the disease

IncidenceMedian age of diagnosis is 66 y.o. in both women

and men.

More of the patients <50 y.o. at time of diagnosis were women

In women, 45% of all lung cancers were adenocarcinoma, followed by 22% small cell cancer, 21% squamous cell, rest as other subtypes(in men, squamous subtype is most common, followed by adeno, followed by small cell)

Risk Factors Cigarette smoking

- in the U.S, nearly 25% of women smoke- some studies suggest women have more difficulty quitting smoking than men– risk is increased 10 – 30 x than in non-smokers- smoking > or = 25 cig/day increases risk more than smoking less than 25 cig/day- age at onset of smoking- degree of inhalation correlates with risk of developing disease- Tar and nicotine content of cigarettes- use of unfiltered cigarettes- smoking cessation decreases risk significantly, with decline in risk starting > 5 years of abstinence.- after 15 years, risk is reduced by 80%. The longer one the person is not smoking, the lower the risk becomes – however risk still remains higher than in never smokers

2nd hand smoke - the longer the exposure the higher the risk - approximately 17% of all lung cancer in never smokers is due to second hand smoking during the person’s childhood and adolescence- risk doubles with 25 or > years of exposure- ban of smoking in restaurants/enclosed spaces decreases undesired exposure of non-smokers

Risk Factors Asbestos

Radon

Arsenic

Ionizing radiation

Polycyclic aromatic hydrocarbons

Nickel

Pulmonary Fibrosis

HIV infection

Family History

Beta Carotene (initially used for chemoprevention, noted to be associated with higher risk of lung cancer in smokers)

Race (African Americans and Hawaiians have higher risk of lung cancer incidence among persons who smoke <30 cig/day, no difference between the races among persons smoking >30 cig/day)

Risk Factors*Lung cancer in women is a biologically and geneticallydifferent disease than in men:

Genes that cause women to be more vulnerable to the harmful effects of tobacco smoke

Differences in how the chemicals in tobacco are metabolized (broken down) by the body

Changes to genes that control cell growth, which may result in the development of cancer

A decreased ability of the body to repair damaged DNA, as DNA damage can promote the development of cancer

Hormones, such as estrogen, which could directly or indirectly affect cancer growth

Signs and Symptoms Cough

Hemoptysis

Dyspnea

Chest Pain

Hoarseness (due to involvement of recurrent laryngeal nerve)

SVC syndrome (dilated neck veins, facial edema) – due to pressure on SVC by the tumor

Pancoast’s syndrome – pain in shoulder or arm, Horner’s syndrome (miosis, ptosis, anhidrosis), atrophy of hand muscles

Weight loss

Paraneoplastic syndromes -example: Hypercalcemia in Squamous cell ca

SIADH in Small Cell Ca

Thrombosis

Leucocytosis and thrombocytosis

SVC SyndromeEtiology:-result of compression of SVC by either malignancy (RUL mass) or thrombosis (mainly due to use of intravascular device)-most common etiology is lung cancer-may also be due to infections (TB, etc..) or hematological

malignancies such as lymphoma/leukemia

Signs/Symptoms:-symptoms may develop over weeks or longer-increased venous pressure leads to edema of head, neck and arms-headache-cyanosis-cough, dyspnea-dysphasia, stridor

SVC Syndrome

SVC Syndrome

SVC SyndromeDiagnosis-CXR (mediastinal widening, mediastinal mass)-CT neck/chest-ultrasound/doppler to r/o thrombosis of SVC

Treatment-Oxygen-elevation of the upper body-diuretics, fluid restriction-anticoagulation if thrombosis-biopsy – obtain pathology prior to treatment-*chemotherapy-radiation therapy-steroids (benefits unproven)-endovascular stents (if conventional therapy unsuccessful)

Prognosis-patients with malignant obstruction of SVC have Overall survival of <7

months

PathologyAdenocarcinoma (including bronchioloalveolar carcinoma) —

38%

Squamous cell carcinoma — 20%

Large cell carcinoma — 5%

Small cell carcinoma -13%

Other non-small cell carcinomas (not further classified) -18%

Other (mesothelioma, carcinoids)-6%

NSC Lung CancerAdenocarcinoma

-Bronchioloalveolar subtype (more common in never smokers and women)

Squamous cell Carcinoma -Centrally located-Often cavitates

Large Cell Carcinoma

*prognosis is similar among the subtypes

Staging – NSC Lung Cancer

Small Cell Lung CancerTypically centrally located

Comprises 13% of all lung cancers

Smoking is a major risk factor

s/s: cough, dyspnea, weight loss, chest pain

Approximately 70% present with metastatic disease at diagnosis

Frequent mets to liver, bone, bone marrow, brain

Overall prognosis is poor

Staging – Small Cell Lung CancerLimited Stage-disease confined to ipsilateral hemithorax-confined to a single radiotherapy port

Extensive Stage-evidence of disease outside of ipsilateral

hemithorax-disease which can not be covered by a single radiotherapy port

MesotheliomaRare type of cancer

Almost always caused by exposure to asbestos

Malignant cells develop in the mesothelium– the lining of the body’s organs (example: pleura)

There is no association between mesothelioma and smoking, although smoking greatly increases risk of asbestos induced cancer

ScreeningNO SCREENING TEST (CXR, CT, OR SPUTUM CYTOLOGY)

HAS BEEN SHOWN TO REDUCE MORTALITY FROM LUNG CANCER

DiagnosisHistory and Physical

Laboratory studies

Radiographic Imaging (CT, PET, bone scan)

Tissue sampling

Imaging

Imaging

Treatment Approach to treatment is multifactorial

Depends on: 1. type of cancer (Non-small cell including subtype or small cell)2. stage of disease3. patient’s age4. performance status5. patient’s smoking status6. patient’s preference

Options include:1. Surgery2. Radiation therapy3. Chemotherapy4. Combination of above

PharmacologyChemotherapy side –effects

Carboplatin – neuropathy, renal toxicity

Cisplatin – neuropathy, renal toxicity, renal wasting of electrolytes, hearing loss

Paclitaxel – neuropathy, allergic reactions to cremaphor (preservative), chest pain, fluid retention

Navelbine – neurotoxicity, cytopenias, fatigue

* all – cytopenias, nausea/vomiting, hair loss, fatigue

IPASS StudyEGFR inhibitor (Iressa in Europe, oral form -

Tarceva in U.S.)

Compared with standard chemotherapy (Carbo/Taxol)

Found that in women, Asian descent, non-smokers, with adenocarcinoma, with EGFR mutation – PFS >3x higher with EGFR inhibitor than with standard chemotherapy.

PrognosisNSC Lung Cancer:5 year overall survival:-Stage I – 50-60%-Stage IV – 1%-Stage IV disease median survival 9 months

Small Cell Lung Cancer:5 year overall survival:-Limited disease – 20%-Extensive disease - <1%

Prognosisstage specific survival rates are better in women

than in men in both NSC and small cell lung cancer

women who underwent surgical resection of disease had longer O.S. than men with same stage and surgery

THANK YOU