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LUNG CANCER
Lung cancer is having a malignant tumor in the lungs especially in the cells lining air passages.
Primary tumor-related signs and symptoms are cough, dyspnea, hemoptysis, and chest discomfort.
Signs and symptoms due to intrathoracic spread may involve the nerves (hoarseness, dyspnea, muscle wasting of upper limb, Horner's syndrome), chest wall and pleura (chest pain, dyspnea) and vascular structures (facial swelling, dilated neck veins, cardiac tamponade) & viscera (dsyphagia).
The signs and symptoms due to metastatic spread are bone pain with or without pleuritic pain, neurologic symptoms, limb weakness, unsteady gait, cervical lymphadenopathy, and skin nodules.

Principles of Therapy for Small Cell Lung Cancer (SCLC)

  • Adjuvant chemotherapy is advised in patients who underwent successful surgical resection
  • Lobectomy & mediastinal lymph node dissection is recommended for limited disease small cell lung cancer (LD SCLC) patients with clinical stage T1-2, N0
    • Patients without node involvement should be given systemic therapy
    • Concurrent systemic therapy & mediastinal radiotherapy is recommended for patients with node involvement
  • Surgery for patients with limited disease small cell lung cancer (LD SCLC) in excess of clinical stage T1-2, N0 is not recommended
    • For patients with PS 0-2, radiotherapy is recommended to be given concurrently with systemic therapy, but is to be given sequentially in patients with PS 3-4 due to SCLC
    • For SCLC patients with PS 3-4 due to comorbidities, treatment should be individualized
  • For asymptomatic extensive disease small cell lung cancer (ED SCLC) patients without localized symptomatic sites or brain metastasis with PS 0-2 or PS 3-4 due to SCLC, combination systemic therapy with supportive therapy is recommended
    • For SCLC patients with PS 3-4 due to comorbidities, treatment should be individualized & supportive care should be provided
  • Systemic therapy with or without radiotherapy to symptomatic sites is recommended for extensive disease small cell lung cancer (ED SCLC) patients with superior vena cava syndrome, lobar obstruction, or bone metastases
    • If spinal cord compression is present, radiotherapy prior to systemic therapy is preferred
  • Systemic therapy followed by whole brain radiotherapy is recommended for asymptomatic extensive disease small cell lung cancer (ED SCLC) patients with brain metastasis 
  • Symptomatic extensive disease small cell lung cancer (ED SCLC) patients with brain metastasis may be given whole brain radiotherapy prior to initiation of systemic therapy unless immediate need for systemic therapy arises

Palliative Care for Lung Cancer

  • Identify all patients who may benefit from palliative care & specialist referral should be done immediately

Pain

  • Mild-moderate pain
    • Treat with Acetaminophen or nonsteroidal anti-inflammatory drug
    • May consider titrating short-acting opioid if pain control with NSAIDs/Acetaminophen is inadequate, may consider increasing the dose, or switching to combination therapies containing opioids
  • Severe pain
    • Treat with opioids
      • Meperidine is not used if pain medication will be given continuously; may cause dysphoria, agitation or seizure
      • May give medication for constipation prophylactically if opioid is used
    • Tricyclic antidepressants, anticonvulsants & neuropathic agents may be given to enhance the effect of pain medications
  • Bone pain secondary to cancer metastasis
    • Radiotherapy is recommended for pain relief
    • Bisphosphonates (eg Pamidronate, Zoledronic acid) are advised together with radiotherapy
      • Effectively relieve bone pain, treat hypercalcemia of malignancy & delay onset of bone disease progression
    • Denosumab, a receptor activator of nuclear factor kappa-B ligand (RANKL) inhibitor, demonstrated pain relief in patients with pain secondary to bone metastases

Dyspnea, Cough & Compression Symptoms

  • Opioid & non-opioid antitussives may be given to the patient to reduce coughing
    • External beam radiotherapy is also an option
  • Symptom relief by administration of opioids may be considered for dyspneic patients
    • May consider adding benzodiazepines if dyspnea is associated with anxiety 
  • Radiotherapy & stents may be considered in patients if there are breathlessness & hemoptysis due to the endobronchial tumor
  • Relief of pleural effusion should be done primarily by thoracentesis
    • Recurrent pleural effusions should be managed with chest tube drainage & pleurodesis

Superior Vena Cava (SVC) Obstruction

  • Chemotherapy is recommended for patients with symptomatic SVC obstruction secondary to small cell lung cancer (SCLC)
  • Stent insertion &/or radiotherapy are recommended for patients with symptomatic SVC obstruction secondary to non-small cell lung cancer (NSCLC) & small-cell lung cancer (SCLC) who do not respond to chemotherapy

Osseous Structural Impairment

  • Orthopedic stabilization should be done prior to radiotherapy for patients at high risk for fracture due to osseous structural impairment
    • Preferred therapy for spinal cord compression & fractures compared to surgery

Brain Metastases

  • Corticosteroids may be given to relieve headache, seizures & sensorimotor deficits
  • Resection of isolated brain metastasis may be considered in nos-small cell lung cancer (NSCLC) patients after complete tumor resection & with no metastasis found on other sites
    • Whole brain radiotherapy should follow removal of isolated single brain metastasis
  • Stereotactic radiotherapy may be considered in patients with single brain metastasis
    • Given alone, after surgical resection, or with whole brain radiotherapy

Depression

  • Should always be assessed & managed
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