SLIDE 1: Management of Lung Cancer
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Introduction:
Cindy Card
Medical Oncologist at TBCC in Thoracic and Endocrine Oncology
Pleasure to be talking to you today
o 3 things that I have done to help you understand cancer
o Intro to Onc primer
o Hand-out to accompany this talk with additional details and resources, including
links to guidelines, referrals and pt resources
o regardless of which field you go into, you will have patients with cancer so
o My hope for today is that you will come out of this lecture with some
understanding of how we manage lung cancer, but more importantly why we do
this
o The patient is the focus, and whatever we can do to help whether that be a
treatment for cure or a treatment to palliate, then we need to be able to be there to
provide that care
Key points that will covered in today’s talk
o Lung cancer is not one disease  not only in terms of pathology but also in the way it
behaves and can be managed
o Lung cancer is a disease that is perceived by patients, health care professionals (including
many doctors) and even society in a different way than most diseases. There is often a sense
that this was self-inflicted and is a diagnosis that carries a lot of shame.
o Lastly, I will spend some time reviewing the management of lung cancer
o I will do this by presenting 2 cases… or even better stories… of patients that are
currently under my care
SLIDE 2:
Disclosure of Conflict of Interest  None
SLIDE 3: What does lung cancer look like? – CT image
 How it looks
 How to diagnose it
 That it is “BAD”
SLIDE 4: What does lung cancer look like? – Cigarette
It is true that smoking is the #1 cause of lung cancer with about 80% of NSCLC seen in
current/former smokers, and ~99% of SCLC seen in smokers (highest correlations to smoking
of any cancer, FYI)
It is normal to feel guilty when first diagnosed with lung cancer if you have smoked. And the
comments from people around them probably doesn’t help. I have had many patients who have
told me that the first thing anyone asks them when they hear they have lung cancer is “did you
smoke?”
Studies have shown that people who have smoked and develop lung cancer experience higher
levels of guilt, shame, anxiety and depression than those with other forms of cancer, even if
they are/were smokers.
The danger of lung cancer smoker’s guilt can go even beyond the emotional toll it takes. Due
to the stigma, people often hide their diagnosis, fearing that they will be judged as causing their
disease. Others don’t seek medical attention as they feel they deserve the problems that they
have because they smoked.
One study even suggested a higher mortality rate in those who experience this guilt.
Why couldn’t it have been breast cancer?
Even non-smokers feel shame and guilt at their diagnosis. I had a woman a few weeks ago say
to me “Why couldn’t it have been breast cancer” when we met for the first time to discuss her
diagnosis of stage IV NSCLC. She felt that people did not believe that she never smoked,
including many physicians that she had encountered over the few months leading up to her
initial cancer centre consult. The physician who told her of her diagnosis started the
conversation by stating that “she should make peace with herself” which made her feel like she
must have done something to deserve this.
Nobody is perfect. Some of us don’t smoke, but that doesn’t mean we don’t drive too fast at
times, eat unhealthy food, stay our in the sun too long, or bask in sedentary behaviors that are
risk factors just the same.
SLIDE 5: What does lung cancer look like? – People
Lung Cancer is not one disease
I know that you have had lectures during this course by respirologists and surgeons, where you
learned that they are 2 types of lung cancer: Small Cell Lung Cancer and Non Small Cell Lung
Cancer. If it were 7-8 years ago, that would really be all we would need to know from
pathology in order to make decisions about management
Today we have a far greater understanding of lung cancer. We still need to know if it is a
SCLC vs NSCLC. But with NSCLC, it is also important for us to know if it is a Squamous cell
or a Non-Squamous cell. This is because the chemotherapy drugs that we use, and in what
order do we use them depends on this differentiation. Within Non-squamous cell, there are
certain subtypes that also may change our management.
For example, a patient with a Non-squamous cell which is EGFR mutation positive would
likely receive a targeted agent called an EGFR tyrosine kinase inhibitor. These newer chemo
drugs are better tolerated than the traditional chemotherapy with higher response rates and
longer duration of response.
Another example is Large Cell Neuroendocrine Lung Cancer. Although technically this falls
under the NSCLC type, its behavior and response to treatment is much more like SCLC, and
many oncologists will treat at Lg cell NET like a SCLC
It is also important to note that just as there are no two people who are the same in this world,
there are no two cancers that are the same. You may have 2 patients with the same diagnosis,
same stage, same age and yet the way their cancers are managed will vary based on their
personal experiences, on their desires and views and also on their social and spiritual
environment. So although I provided a sort of algorithm for the management of lung cancer,
this is only a general guide and there is a lot of “Art” in medicine and in oncology that guides
specific decisions.
Slide 6: Case #1
 I’ll call him Tony
 57 year old man; executive in Oil and Gas with premium medical plan including bi-annual
CT Scan
 Healthy and active with no concerns
 <10 pack year history of smoking having quit in late 20’s
 Goes for his annual medical
Slide 7: CT Scan
Slide 8: Referred to TOP clinic
Slide 9: Algorithm for Lung Cancer
 Investigations:
 Bronch/EBUS
 PFT’s
 Felt likely to be a Stage 2 NSCLC given CT findings
 Other tests ordered to complete w/u
Slide 10: Adenocarcinoma
Slide 11: Bone Scan
 Solitary area of metastatic disease in ribs
Slide 12: Tony
 Devastated
 2nd opinion in US
 Incurable
 Tx intent is palliative
 Referred to TBCC
Slide 13: Mgmt of Stage IV NSCLC
 Symptom focus
 Adeno
o EGFR testing +
Obviously, as a medical oncologist, this is the main way that I treat cancer. Chemotherapy is
basically any medication used to stop/shrink cancer – whether that be with the intent to cure or
to control (aka palliate) Traditional chemotherapy is considered to be cytotoxic – ie cell killing.
While a lot of the newer agents are being called ‘targeted therapies’ (even though many still do
kill cells) and typically target a specific abnormality in a person’s cancer.
In NSCLC, the role of chemotherapy depends very much on the stage:
o In resected early stage NSCLC, chemotherapy is used adjuvantly to increase the chance for
cure in patients with node positive disease and/or a large primary tumor
o In locally advanced NSCLC, chemotherapy is used as a radiosensitizer when radical dose
radiation is given with curative intent
o In incurable NSCLC, chemotherapy has a palliative role. This is where it is important to
know the subtype, EGFR mutation status, and likely other mutations will be assessed in the
future when other targeted agents become available
Radiation is a focused treatment which plays a variety of roles in the management of lung
cancer
Regardless of the stage or treatment course, it is imperative to make sure that a patient is having
their symptoms cared for in the best possible manner. This may include management of
physical symptoms such as pain, nausea, cough, dyspnea. This also includes spiritual and
psychological support, as well as financial support. You cannot underestimate the effect of not
being able to work and the stress that results from this. So that would include filling out
insurance forms and advocating for the patient to the best of your ability.
Slide 14: Targeted therapies
Afatinib
- EGFR +
Slide 15: Karen
Slide 16/17: CXR
Slide 18: CT
Slide 19: Karen
Slide 20: Pathology
Slide 21: Staging
Slide 22: Mgmt of SCLC
Slide 23: Chemo and radiation
Slide 24: post tx scans for Karen
Slide 25: Thank you and Questions