Lung Cancer in 2011Lung Cancer in 2011

Dr. Natasha Leighl, MD MMSc FRCPCDr. Natasha Leighl, MD MMSc FRCPCMedical Oncologist, Princess Margaret Medical Oncologist, Princess Margaret

HospitalHospitalAssistant Professor, Medicine, University of Assistant Professor, Medicine, University of

TorontoToronto

Lung Cancer: a growing problemLung Cancer: a growing problem

• One of the most common cancers in Canadians, and the One of the most common cancers in Canadians, and the leading cause of cancer deaths (27%)leading cause of cancer deaths (27%)

• 1.4 million new cases per year, 1.2 million deaths1.4 million new cases per year, 1.2 million deaths

• Most present with advanced disease, severe symptomsMost present with advanced disease, severe symptoms

• North American incidence falling in men, rising in womenNorth American incidence falling in men, rising in women

• Peak incidence in 70sPeak incidence in 70s

• Most ex-smokers, about 30% smokers, 15% Most ex-smokers, about 30% smokers, 15% nonsmokersnonsmokers

Estimated new cases in Canada, Estimated new cases in Canada, 20112011

0 5000 10000 15000 20000

Lung

Breast

Colon

Prostate

Canadian Cancer Statistics 2011Canadian Cancer Statistics 2011

25,50025,500

22,20022,200

23,60023,600

25,30025,300

Estimated cancer deaths, Canada Estimated cancer deaths, Canada 20112011

0 5000 10000 15000 20000 25000 30000

Lung

Breast

Colon

Prostate

Canadian Cancer Statistics 2011Canadian Cancer Statistics 2011

4,100 4,100 95%95%

8,900 8,900 61%61%

5,100 5,100 87%87%

20,600 20,600 18%18%

5 yr OS5 yr OS

Cancer Research Dollars

Research FundingResearch Funding

• 7% of Canadian research dollars go to 7% of Canadian research dollars go to lung cancer, less than 1% of donations lung cancer, less than 1% of donations

• Breast cancer support, services Breast cancer support, services outnumber lung cancer by more than 10 outnumber lung cancer by more than 10 to 1to 1

• Approximately $23,000 research dollars Approximately $23,000 research dollars spent per breast cancer patient, spent per breast cancer patient, compared to $1,800 per lung cancer compared to $1,800 per lung cancer patientpatient

Causes of Lung CancerCauses of Lung Cancer

• SMOKING!!!! (87%)SMOKING!!!! (87%)

• Occupational exposureOccupational exposure– Asbestos, arsenic, nickel, petroleumAsbestos, arsenic, nickel, petroleum– Radon, RadiationRadon, Radiation

• Passive smokingPassive smoking

• AgeAge

• ? Genetic predisposition? Genetic predisposition

• ?Environmental exposures-air pollution?Environmental exposures-air pollution

Lung Cancer TypesLung Cancer Types

35%25%

10%

15% 15%Small CellAdenocarcinomaSquamous CellLarge CellMixed/Other

15% Small Cell 15% Small Cell

85% Non-small Cell 85% Non-small Cell (NSCLC)(NSCLC)

Bronchial Bronchial PluripotentiPluripotenti

al Stem al Stem CellCell

Histological Types of Lung Cancer

00

2525

5050

7575

Per

cen

tP

erce

nt

1962-19681962-1968 1972-19781972-1978 1963-1988 NCI1963-1988 NCI

Gazdar and Linnoila, Seminars Oncol 1988; 15(3): 215

Squamous cell

Adenocarcinoma

BACLarge cell

Other

T stageT stage

T1 - T1 - 3 cm, 3 cm, not in main not in main bronchusbronchus

T stageT stage

T1 - T1 - 3 cm, 3 cm, not in main not in main bronchusbronchusT2 - >3 T2 - >3 (<7)(<7)cm,cm,2cm 2cm from carina, from carina, inv’n visceral inv’n visceral pleura, subtotal pleura, subtotal atelectasisatelectasis

T stageT stage

T1 - T1 - 3 cm, 3 cm, not in main not in main bronchusbronchusT2 - >3 T2 - >3 (<7)cm,(<7)cm,2 cm 2 cm from carina, inv’n from carina, inv’n visceral pleura, visceral pleura, subtotal subtotal atelectasisatelectasisT3 – T3 – >7 cm>7 cm, , invade chest wall, invade chest wall, diaphragm, med diaphragm, med pleura, parietal pleura, parietal pericard, total pericard, total atelect, atelect, satellite satellite nodules same nodules same lobelobe

T stageT stage

T1 - 3 cm, not in main bronchusT2 - >3 (<7)cm,2 cm from carina, invn visceral pleura, subtotal atelectasisT3 – >7cm, invade chest wall, diaphragm, med pleura, parietal pericard, total atelect, satellite nod same lobe

N stageN stage

N1 – ipsilateral peribronchial, pulmonary nodes

N stageN stage

N1 – ipsilateral peribronchial, pulmonary nodesN2 – ipsilateral mediastinal, subcarinal nodes

N stageN stage

N1 – ipsilateral peribronchial, pulmonary nodesN2 – ipsilateral mediastinal, subcarinal nodesN3 – contralateral med, hilar, any scalene, supraclav nodes

M StageM Stage

M1a – nodule in M1a – nodule in contralateral contralateral lung, malignant lung, malignant effusioneffusion

M1bM1b – distant – distant metsmets

Common Sites:Common Sites:LiverLiverBoneBoneBrainBrainAdrenalsAdrenalsPleura, Pleura, Pericardium, Pericardium, Other LungOther Lung

Survival by Pathologic Stage

Changes to Staging - 2009• Current system implemented in 2009

• Key changes from 1996 system:– Tumors more than 7 cm moving from T2 to T3

– Changing classification of same lobe satellite nodules from T4 to T3

– Changing ipsilateral lung but different lobe metastases from M1 to T4, and contralateral lung nodules from M1 to “M1a”

– Changing malignant effusions from T4 to M1a

Old Clinical Stage

Current Clinical Stage

Old Pathologic stage

Current Pathologic

Stage

What tests do you need?What tests do you need?• DiagnosisDiagnosis

– Bronchoscopy (>90%) / mediastinoscopy (node), Bronchoscopy (>90%) / mediastinoscopy (node), endobronchial ultrasound (with nodal biopsy, EBUS)endobronchial ultrasound (with nodal biopsy, EBUS)

– Needle aspirate or biopsy (>95%), sputum x 3(80% v Needle aspirate or biopsy (>95%), sputum x 3(80% v 20%)20%)

– Video-Assisted Thoracoscopic Surgery (VATS)Video-Assisted Thoracoscopic Surgery (VATS)– Thoracentesis (pleural effusion)Thoracentesis (pleural effusion)

• StagingStaging– Chest X-ray / CT Scan (Chest + Upper Abdomen)Chest X-ray / CT Scan (Chest + Upper Abdomen)– Mediastinoscopy (assess node involvement), EBUSMediastinoscopy (assess node involvement), EBUS– Blood counts, chemistryBlood counts, chemistry– Bone scan (if indicated)Bone scan (if indicated)– CT / MRI brain (if indicated)CT / MRI brain (if indicated)– FDG PET for SPN, resectable, Stage III NSCLC in OntarioFDG PET for SPN, resectable, Stage III NSCLC in Ontario

PET for NSCLC

PET image courtesy of Dr Nevin Murray, BC Cancer Agency

PET in NSCLC• Solitary Pulmonary Nodules

– FNA or biopsy best approach

– Meta-analyses (no RCTs):– Sensitivity 96-97%, Specificity 78-86% – False negatives in low grade tumours

(e.g. BAC, GGOs)– False positives in inflammatory conditions

– So if biopsy not possible, PET uptake + - intervene. If negative, follow (CT q3m x 2 y)

PET in NSCLC• Staging of Primary Lung Cancer

– 11 systematic reviews, 3 RCTs, 22 other studies– Standard staging +/- PET

• 51% relative reduction in futile thoracotomies in one trial; no difference in 2nd trial

– PET vs. Standard Staging• Shorter time to diagnosis (14 days vs. 23)• Fewer mediastinoscopies, invasive tests to stage med

– Indicated in addition to standard staging for resectable and stage 3 NSCLC

– In early stage patients upstaged by PET (up to 15%), should verify results to confirm true positive

PET in SCLC

• Limited evidence in SCLC• PET accuracy in staging 83-99%

(limited versus extensive stage disease)

• Better to map out primary tumour and involved nodes, less sensitive for metastatic disease

• May be helpful tool in radiation planning