To kick off our PCCM Friday School block, Dr. Bazhenova, a lung cancer medical oncologist and the UCSD hem/onc program director, joined us for noon report to discuss Lung Cancer. She did a great review of everything from lung cancer incidence to work-up and treatment. Highlights below!
Risk Factors: Tobacco smoke, asbestos, radon, arsenic, polycyclic aromatic hydrocarbons, and ionizing radiation. Of note, 20% of lung cancers are in non-smokers.
Epidemiology: Peak ages 50-69 y/o. 2% before age of 40.
A large percentage of patients present with metastatic disease, because pain receptors do not exist in lung parenchyma, and we can’t directly visualize or palpate the lung!
Incidence by Histology:
- Non-small cell lung cancer – 80%
- Adenocarcinoma 40%
- Squamous cell carcinoma – 30%
- Large cell carcinoma – 10%
- Small cell lung cancer – 20%
Clinical Presentation: 70% of patients have symptoms at presentation including cough, hemoptysis, pain, weakness, SOB, weight loss, hoarseness, headache, nausea, and vomiting.
Diagnostic Evaluation: Two things we need to determine are the stage and histology.
- Imaging: CT scan of chest and abdomen and pelvis, PET scan or bone scan, PFT’s if patient is less than stage IV, MRI brain in SCLC even if symptomatic
- Biopsy: Make sure to review the imaging yourself to help you determine the best route for biopsy. Options include an EBUS by interventional pulmonology, a transthoracic biopsy by IR, and a bone biopsy (less preferred).
Treatment of Non-Small Cell Lung Cancer: Depends on stage of disease.
- I-II: Surgery, if possible, followed by adjuvant chemotherapy.
- If surgery is not an option, XRT
- In Stage I, there is no need for chemo/XRT after surgery!
- IIIA: Surgery is not usually considered upfront – use combination of chemotherapy and radiation alone
- Most controversial stage
- IIIB: Surgery is not an option – treat with chemotherapy/XRT
- IV: Systemic chemotherapy – radiation reserved for local control
- Stage IV diagnosis is not in itself an indication for hospice
- Evaluate for an oncogenic driver and PD-L1 expression
Management of stage IV non-small cell lung cancer depends on the presence of an oncogenic driver and PD-L1 expression.
You can download the slide deck here:
Thank you so much, Dr. Bazhenova, for this great talk!