A guide for journalists on Non-Small Cell Lung cancer

Lung cancer
A guide for journalists on Non-Small Cell
Lung Cancer (NSCLC) and its treatment
Contents
Overview
Section 1 Lung Cancer
Section 2 Epidemiology
Section 3 Treatment
References
Contents
Contents2
Overview3
Section 1: Lung Cancer4
i. Types of lung cancer
4
ii. Causes and risk factors
5
iii. Symptoms and diagnosis
6
iv. Staging
7
v. Prognosis
8
Section 2: Epidemiology9
i. Incidence & mortality
10
Section 2: Treatment11
i. Surgery
11
ii. Radiotherapy
11
iii. Chemotherapy
11
iv. Biological (targeted) therapy
11
References12
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Contents
Overview
Section 1 Lung Cancer
Section 2 Epidemiology
Section 3 Treatment
References
Overview
Lung cancer is the leading cause of cancer death
globally. It kills more people than breast, colorectal and
prostate cancers combined.1 Each year 1.38 million
people die as a result of the disease, equating to more
than 3,000 deaths a day worldwide, or two deaths
every minute.1,2
Five year survival rates for lung cancer
are poor when compared to other high
incidence cancers. For example, the five
year survival rate for patients with breast
cancer is up to 89%;3 for lung cancer
patients, that figure is only around 15%.4
There are two main types of lung cancer;
non-small cell lung cancer (NSCLC) and
small cell lung cancer (SCLC). NSCLC is
the most commonly diagnosed type of lung
cancer, accounting for approximately 85%
of all cases.5
The early signs and symptoms of lung
cancer are non-specific and as a
consequence the majority of cases are
diagnosed at an advanced stage, making
successful treatment more difficult and
survival outcomes poor.5
Traditionally, treatment options have
included surgery (for patients with earlier
stage disease), radiation therapy and
chemotherapy, alone or in combination.
More recently, new treatment options,
including biological therapies, have become
available and are helping to improve
outcomes and survival for patients.
This guide provides an overview of lung
cancer, including its incidence, risk factors,
symptoms, diagnosis and treatment options.
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Contents
Overview
Section 1 Lung Cancer
Section 2 Epidemiology
Section 3 Treatment
References
Section 1
Lung cancer
i. Types of lung cancer?
Figure 1 Typical location of the most common types of non small cell lung cancer
Lung cancer arises from the uncontrolled
growth (proliferation) of abnormal cells
inside the lung. There are two main forms
of the disease, non-small cell lung cancer
(NSCLC) and small cell lung cancer (SCLC).
NSCLC is the most common form of lung
cancer, accounting for approximately
85% of all cases.5 It grows and spreads
more slowly than small cell lung cancer.
Early stage disease is associated with few
specific symptoms; therefore approximately
70% of cases are not diagnosed until the
disease is at an advanced stage when the
chances for cure or significant patient
benefit are limited.6
NSCLC comprises a number of different
types of lung cancer, which are grouped
as ‘squamous’ or ‘non-squamous’. Nonsquamous NSCLC includes further subtypes such as adenocarcinoma and large
cell carcinoma.7
Squamous Cell Carcinoma
TRACHEA
• Develops from cells that line the airways
• Often found near the centre of the lung in one
• of the main airways (the left or right bronchus)
• Associated with smoking
Adenocarcinoma
LYMPH
NODES
BRONCHI
• The most common type of NSCLC
• Develops from a particular type of cell which
• produces mucous (phlegm), which lines the airways.
• Often found in the periphery (outer areas) of the lungs
Large Cell Carcinoma
LUNG LOBE
• Cells appear large and round when viewed under a microscope.
• Grows quickly and can develop in any part of the lung
SCLC is highly aggressive and is
predominantly caused by smoking. It
metastasises (spreads around the body)
early in the disease process and accounts
for approximately 15% of all lung cancers.5
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Contents
Overview
Section 1 Lung Cancer
ii. Causes and risk factors
Smoking The most common cause of
lung cancer is cigarette smoking which
is associated with at least 80% of all
diagnoses.8 The risk of lung cancer
amongst smokers is at least ten times
higher than that of non-smokers. This
risk is reduced among ex-smokers, but
a small excess risk may remain for exsmokers throughout their lives.8 There is
also a causal link between lung cancer and
use of cigars, tobacco pipes, water pipes
and smoking of other tobacco products.9
Evidence also exists of a link between lung
cancer risk and passive smoking (estimated
to be 20%).9
Whilst smoking is the single biggest cause
of lung cancer, people who have never
smoked also develop the disease. Risk
factors include:
Section 2 Epidemiology
Section 3 Treatment
Ionising radiation Exposure to ionising
radiation increases the risk of lung cancer.
10
Atomic bomb survivors and patients treated
with radiotherapy for some rheumatic
diseases or Hodgkin’s lymphoma are at
moderately increased risk of developing
lung cancer.8
Occupational risks There is an increased
risk of lung cancer amongst workers
employed in certain industries and
occupations which involve high-risk agents.
The most significant of these are asbestos
and combustion fumes. In industrialised
countries, occupational risks account for
approximately 5-10% of lung cancers.9
Underground miners exposed to radioactive
radon and its decay products have also
been found to be at an increased risk of
developing lung cancer.12
References
Environment Extensive evidence suggests
that lung cancer rates are higher in cities
than in rural settings. This is likely to be
caused by urban air pollution, although
it may also involve other factors, such
as tobacco smoking and occupational
exposures.8
Diseases as risk factors for lung cancer
Patients with pulmonary tuberculosis are at
increased risk of lung cancer, as are those
with chronic bronchitis and emphysema.11
Indoor air pollution Indoor air pollution
may be responsible for the increased risk
of lung cancer that exists for non-smoking
women in certain regions of China and
other Asian countries. This risk is highest
for women living in poorly ventilated
homes where coal, wood or other solid
fuels are regularly burnt. Fumes from
high-temperature cooking using unrefined
vegetable oils such as rapeseed oil have
also been associated with an increased risk
of developing lung cancer.8 There is also a
link between high concentrations of radon
gas decay particles and lung cancer in
some countries.8 This gas is emitted from
natural sources and can accumulate in
buildings, especially in confined areas such
as attics and basements.10
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Contents
Overview
Section 1 Lung Cancer
iii. Symptoms and diagnosis
Section 2 Epidemiology
Section 3 Treatment
Persistent cough
Common symptoms of NSCLC are
mostly non-specific and may initially
be disregarded by the patient. As a
consequence many patients go to their
doctor when the disease is at an advanced
stage when symptoms become more
troublesome and persist. Symptoms to
A change in a persistent cough
watch out for include:
Fatigue
Shortness of breath
Coughing up phlegm (sputum) with
signs of blood
Aches or pains when breathing or
coughing
Loss of appetite
Loss of weight
References
Diagnosis allows confirmation of the
disease. Analysis of cancerous cell tissue
(histology) is particularly important in
obtaining an accurate diagnosis. There are
a variety of tests available to diagnose lung
cancer.5
Cytology: A sample of sputum is taken
to confirm the diagnosis and type of
lung cancer.
Bronchoscopy: A visual examination
of the trachea and internal parts of
the lungs. Specimens of tissue may be
taken from inside the lungs to gather
cells for analysis.
Needle biopsy: Alongside a CT scan
this procedure is used to obtain cells
for analysis.
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Contents
Overview
Section 1 Lung Cancer
iv. Staging
Staging reflects how advanced the cancer
is and whether it has spread to other parts
of the body. It helps to identify the most
appropriate treatment options for the
patient.
Staging determines how extensive
(advanced) the cancer is.8 There are a
variety of tests available to stage lung
cancer.5
Radiological/nuclear medicine
X-rays: detect a localised mass in the lungs
or enlarged lymph nodes in the chest.
Section 2 Epidemiology
Section 3 Treatment
Magnetic resonance imaging (MRI)
scan: uses a magnetic field to create
an image of the chest to determine the
location and extent of cancer spread.
Bone scan: allows detection of spread to
the bone.
Other tests
Abnormal blood chemistry tests: may
suggest the presence of metastases in
bone or the liver.
References
Table 1 Staging of NSCLC
StageClassification
Early stage Stage I
disease
Stage II
The cancer is present only in one part of the lung.
Cancer has spread to the nearby lymph nodes or nearby tissues, such as the chest wall.
Later stage Stage IIIThe cancer has spread more extensively within the chest
and, generally to the major lymph nodes.
Stage IVCancer has spread to other parts of the body, such as the
liver or bones.
With early stage disease there is the chance
of a cure if the tumour can be successfully
surgically removed. Late stage disease has a
worse prognosis than earlier stage disease.
Computed tomography (CT) scan:
a computer assisted technique which
produces cross-sectional images of the
body to confirm the size and location of a
mass as well as possible spread to other
organs.
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Contents
Overview
Section 1 Lung Cancer
Prognosis
Section 2 Epidemiology
Section 3 Treatment
References
Figure 2 Lung cancer average 5 year survival rates depending on stage at diagnosis
Cancer statistics often use an ‘overall
5-year survival rate’ to give a better idea of
the longer term outlook for people with a
particular cancer. Five year survival rates
for lung cancer are poor when compared to
other high incidence cancers. For example,
the five year survival rate for patients with
breast cancer is up to 89%.3 For lung cancer
patients that figure is only around 15%.4
Average 5 year survival rates at Stage I NSCLC: 58%
Average 5 year survival rates at Stage IV NSCLC: 7.5%
Cancer Research UK: http://www.cancerhelp.org.uk/type/lung-cancer/treatment/statistics-and-outlook-for-lung-cancer#nonsmall
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Contents
Overview
Section 1 Lung Cancer
Section 2 Epidemiology
Section 3 Treatment
References
Section 2
Epidemiology
i. Incidence & mortality
Lung cancer is the most common type of
cancer worldwide (accounting for 16.5%
of all cancers), and is responsible for
the greatest number of cancer deaths
worldwide.
Worldwide
• 1.6 million new cases of lung cancer are
diagnosed every year.1
• It is the most common cancer in men,
and the third most common cancer
in women in both developed and
developing countries.8
• Lung cancer is the leading cause of
cancer mortality and is responsible for
1.38 million deaths each year.1
• Each day, more than 3,000 people die
from lung cancer worldwide, equal to two
deaths every minute.2
• Almost half of the diagnosed cases
of lung cancer occur in developing
countries (49.9%), with the incidence
generally being lower in women (globally,
12.1 per 100,000 women compared to
35.5 per 100,000 in men).
2000 where it accounts for an average of
20.3% of all cancer deaths.8
Figure 3 Lung cancer incidence by region
North America
Central & South America
1.38
Europe
million deaths
from lung cancer
every year
1.6
Asia
Africa
million new
cases of lung
cancer every year
Australia & New Zealand
85%
Accounts for 28.4% of all
cancer deaths in North America
of cases are
non-small cell
lung cancer
Accounts for an average of 20.3%
of all cancer deaths in Europe
28.4%
20.3%
16.3%
Accounts for an average of
11.6% of all cancer deaths
in South and Central America
11.6%
Accounts for an
average of 9%
of cancer deaths
in Southern and
Northern Africa
Accounts for an average
of 16.3% of all cancer
deaths in Eastern, South
Eastern, South Central
and Western Asia
9%
Accounts for an average of 22.4%
of all cancer deaths in Australia,
New Zealand and Micronesia
22.4%
Parkin MD et al. Global Cancer Statistics, 2002. CA Cancer J Clin 2005; 55:74-108
Allen J et al. Neoadjuvant Chemotherapy in Stage III NSCLC J Natl Compr Canc Netw. 2008 6 (3):285-93
Garcia M, et al. Global Cancer Facts & Figures 2007. Atlanta, GA: American Cancer Society, 2007
*Developed countries defined as Europe, Japan,
Australia, New Zealand and North America.
Developing countries defined as Africa, Latin
America and the Caribbean, Asia, Micronesia,
Polynesia and Melanesia
Europe Lung cancer is the leading cause of
cancer related death in Europe, accounting
for 18.9% of all cancer deaths in Western
Europe and 21.1% of all cancer deaths in
Northern Europe.8 Approximately 375,000
cases were attributed to lung cancer in
The average estimated age-standardised
incidence per 100,000 population was 71.8
for men and 21.7 for women, across the
European Union (25-member states), in
2006.8
North America and Canada Lung cancer
is the most common cause of cancer death
in North America, accounting for 28.4%
of all cancer deaths, and is the third most
common type of new cancer cases (14.5%)
in this region. North America has one of
the highest lung cancer incidence rates for
men and women with approximately 1.75
million new cancer cases and deaths in
2007.8
South and Central America Lung cancer
is the most common cause of cancer death
in South and Central America (accounting
for 12% and 11.6% of all cancer deaths,
respectively).8
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Contents
Overview
Section 1 Lung Cancer
Asia Lung cancer is the most common
cancer diagnosed in South Eastern Asia
(accounting for 13.3% of all cancer deaths)
and the second most common cancer
diagnosed in Eastern and Western Asia
(diagnosed in 17.1% and 12.8% of all
cancer cases, respectively).8 It is also the
leading cause of cancer death in Eastern,
Western and South Eastern Asia accounting
for 20.9%, 18.1% and 17.8% of all cancer
deaths, respectively), and the second
most common cause of cancer death
among South Central Asian populations
(accounting for 8.2% of all cancer deaths).8
China and Japan in particular have a high
incidence and death rate by comparison to
the rest of the world.
Africa Lung cancer is the third most
common type of cancer (6.9%), as well as
the third most common cause of cancer
death (at 8.5%) in Northern Africa. It is the
second most common cause of cancer
death in Southern Africa, at 9.5%.8
Section 2 Epidemiology
Section 3 Treatment
References
Figure 4 Incidence and mortality of some of the most common cancers worldwide
Lung
1,092
515
427
948
1,384
Breast
458
571
663
Colorectum
320
288
348
640
Stomach
273
463
226
523
Liver
217
478
899
Prostate
258
1000,000
500,000
500,000
Male
Incidence and mortality of some of
the most common cancers worldwide
Adapted from GLOBOCAN 2008
1000,000
Female
Incidence
Incidence
Mortality
Mortality
Australia Lung cancer is the most common
cause of cancer deaths in Australia and
New Zealand (19.6%), and in Micronesia
(25.2%).8
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Contents
Overview
Section 1 Lung Cancer
Section 2 Epidemiology
Section 3 Treatment
References
Section 3
Treatment
Treatment options vary depending on the
type and stage of the cancer in addition to
its size, position in the lung, whether it has
spread to other parts of the body and the
overall physical health of the patient.
In general the treatment options for
NSCLC are:
i. Surgery
Patients with early stage, localised NSCLC
may be successfully treated using surgery.
Up to 70% of patients survive for at least
five years after diagnosis if treated at this
stage, with a proportion of these patients
being cured.
ii. Radiotherapy
For patients whose cancer cannot be
operated on, radiotherapy may be offered
alone or in combination with chemotherapy.
In addition, radiotherapy also has a well
established role in providing control and
relief of the symptoms of lung cancer.
iii. Chemotherapy
The majority of cases of NSCLC cases
diagnosed at an advanced stage1 when
the cancer has already spread to another
part of the body and can no longer be
successfully removed by surgery. In
these cases chemotherapy is often used
to treat patients. The most common
chemotherapies used in NSCLC are based
on a platinum-containing regimen in
combination with a second therapeutic
agent. Patients usually receive treatment
in a number of defined “cycles” as the
incremental benefit of giving continuous
chemotherapy does not outweigh the
cumulative toxicities experienced.
First-line treatment refers to the initial
therapy a patient receives for advanced
disease.
Treatment until progression/
maintenance therapy describes treatment
given immediately following first-line
treatment, when the tumour has not
progressed.
Second line treatment that patients
receive after a first-line treatment, following
disease progression.
iv. Biological (targeted) therapy
This is a relatively a new approach to
cancer treatment that target specific
biological processes often essential to
tumour growth. Biological therapy can
include monoclonal antibodies, vaccines
and gene therapies. As biological therapies
precisely target cancer-specific processes,
they may potentially be more effective
than other types of treatment (such as
chemotherapy and radiotherapy) and less
toxic to non-cancerous, healthy cells.12
Several types of biological therapy exist
for the treatment of advanced non-small
cell lung cancer. These are either given as
monotherapy or in conjunction with other
therapies at various stages of advanced
disease (in accordance with their approved
label).
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Contents
Overview
Section 1 Lung Cancer
Section 2 Epidemiology
Section 3 Treatment
References
References
1
GLOBOCAN 2008 facts about lung cancer mortality rate at http://globocan.iarc.fr/factsheet.asp.
Accessed 15.05.12
2
1.38 million deaths per year / 365 days – 3,771 deaths per day / 24 hours = 157 deaths per hour / 60
minutes = 2.61 deaths per minute
3 American Cancer Society. Breast Cancer Facts and Figures 2009-2010. Atlanta. American Cancer
Society Inc.
4
Lung cancer 5 year survival rates at http://lung-cancer.emedtv.com/lung-cancer/lung-cancer-surviv
al-rate-p2.html. Accessed 11.05.11
5
Barzi A and Pennell NA. Targeting angiogenesis in non-small cell lung cancer: agents in practice
and clinical development. EJCMO (2010). 2(1):31-42
6
Schiller JH, et al. Comparison of four chemotherapy regimens for advanced non-small-cell lung
cancer. NEJM (2002). 346(2):92-98
7
Cancer Research UK: About Lung Cancer at http://www.cancerhelp.org.uk/type/lung-cancer/about/.
Accessed 11.05.11
8
WHO World Cancer Report 2008. Edited by Peter Boyle and Bernard Levin. Lung cancer, 12.
Chapter 5.10
9
I ARC (2004). Tobacco smoke. In: IARC Monographs on the Evaluation of Carcinogenic Risks to
13. Humans, Volume 83, Tobacco smoke and involuntary smoking Lyon, France: International
Agency for Research on Cancer. 51-1187
10 US Environmental Protection Agency. A Citizen’s Guide to Radon. http://www.epa.gov/radon/pdfs/
citizensguide.pdf Accessed 22.02.10
11 Boffetta P and Trichopoulos D (2008). Biomarkers in cancer epidemiology. In: Adami HO, Hunter
DJ, 17. Trichopoulos D, eds., Textbook of cancer epidemiology. Oxford: Oxford University Press
109 – 126
12 National Cancer Institute. Targeted cancer therapies. Last accessed April 2011 at http://www.
cancer.gov/cancertopics/factsheet/Therapy/targeted
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