Lung%20cancer Treatment

• Adjuvant chemotherapy is advised in patients who underwent successful surgical resection
• Lobectomy and mediastinal lymph node dissection or sampling is recommended for limited disease small cell lung cancer (LD SCLC) patients with clinical stage I-IIA (T1-2, N0, M0)
  • Patients without node involvement should be given systemic therapy
  • Adjuvant systemic therapy with or without sequential or concurrent mediastinal radiotherapy is recommended for patients with N1 node involvement
  • Adjuvant systemic therapy with sequential or concurrent mediastinal radiotherapy is recommended for patients with N2 node involvement
• Surgery for patients with 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
  • Systemic therapy with or without radiotherapy given concurrently or sequentially is recommended for 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 metastases 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 and supportive care should be provided
• Systemic therapy with or without radiotherapy to symptomatic sites is recommended for ED SCLC patients with superior vena cava syndrome, lobar obstruction, or bone metastases
  • If at high risk for fracture secondary to osseous structural impairment, palliative EBRT with orthopedic stabilization should be considered
  • If spinal cord compression is present, radiotherapy prior to systemic therapy is preferred
• Systemic therapy followed by whole brain radiotherapy after completed induction systemic therapy is recommended for asymptomatic ED SCLC patients with brain metastasis 
• Symptomatic 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
• Enrollment in a clinical trial should be considered in patients who are unresponsive to initial or adjuvant systemic therapy

• Identify all patients who may benefit from palliative care and 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 and 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 and 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

Cachexia/Anorexia

• Appetite stimulants may help improve the quality of life of patients with months to days' life expectancy
• Consider consultation with a nutritionist for appropriate calorie supplementation

Dyspnea, Cough and Compression Symptoms

• Opioid and non-opioid antitussives (eg Morphine, Fentanyl, Oxycodone) 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 
• Excessive secretions can be managed using Scopolamine, Atropine, Hyoscyamine or Glycopyrrolate 
• Radiotherapy and stents may be considered in patients if there are breathlessness and 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, or indwelling pleural catheter
• Use of supplemental O₂ and noninvasive mechanical ventilation may be considered

Superior Vena Cava (SVC) Obstruction

• Chemotherapy is recommended for patients with symptomatic SVC obstruction secondary to SCLC
• Stent insertion and/or radiotherapy are recommended for patients with symptomatic SVC obstruction secondary to NSCLC and 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 and fractures compared to surgery

Brain Metastases

• Corticosteroids may be given to relieve headache, seizures and sensorimotor deficits
• Resection of isolated brain metastasis may be considered in NSCLC patients after complete tumor resection and 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 and managed