2011 Cancer Annual Report L U NG CANCER STUDY

Fighting Cancer Together.

N S C LLung C Non–Small Cell CancerD Diagnosis andT Treatment Overview Lung cancer is the leading cause of cancer death among both men and women in the United States (Table 1). More people die of lung cancer than of colon, breast, and prostate cancers combined. Lung cancer accounts for about 28% of all cancer deaths with most patients presenting with locoregionally advanced or metastatic disease resulting in poor response rates and overall survival. Table 1. 2010 Estimated Lung Cancer Incidence and Mortality U.S and Louisiana, 2010, ACS United States

Louisiana

Incidence Overall Female Male

222,520 105,770 116,750

3,320 / /

Mortality Overall Female Male

157,220 71, 080 88,220

3,550 / /

/

Only overall Louisiana data available

The primary risk factor for lung cancer is smoking which accounts for more than 85% of all lung cancer related deaths. The risk for lung cancer increases with the number of cigarettes smoked per day and with the number of years spent smoking. Exposed nonsmokers also have an increased relative risk of developing lung cancer. Even when patients don’t’ smoke, breathing in secondhand smoke can increase the risk of developing lung cancer. A non-smoker who lives with a smoker has about a 20% to 30% greater risk of developing lung cancer. Workers who have been exposed to tobacco smoke in the workplace are also more likely to get lung cancer. Secondhand smoke is thought to cause more than 3,000 deaths from lung cancer each year, a reason the American Cancer Society (ACS) has worked tirelessly to enact laws to protect workers and those within out state. Physicians and staff associated with STPH and MBP have aided in those efforts. Other risks include radon, a naturally occurring radioactive gas that results from the breakdown of uranium in soil and rocks. It cannot be seen, tasted, or smelled. According to the U.S. Environmental Protection Agency (EPA), radon is the second leading cause of lung cancer, and is the leading cause among non-smokers. Asbestos, a mineral compound that breaks into small airborne particles, is a known carcinogen that increases the risk of lung cancer in people exposed to airborne particles, especially those who smoke. In recent years, government regulations have greatly reduced the use

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of asbestos in commercial and industrial products. It is still present in many homes and commercial buildings but is not usually considered harmful as long as it is not released into the air by deterioration, demolition, or renovation. By the time lung cancer is clinically evident (i.e., symptoms such as cough or chest pain are present) it is usually at an advanced stage. Small, early stage lung cancers are typically asymptomatic. Cough is the most common complaint, but is a nonspecific finding. Hemoptysis (coughing up of blood) is always worth investigation in individuals at risk for lung cancer. Chest pain or discomfort may also be present but is, again, nonspecific. Dyspnea (breathlessness) as well as wheezing may also be reported due to blockage of major airways by tumor. Advanced stage cancers can also present with hoarseness due to impingement upon the laryngeal nerves, which control the vocal cords, as well as facial swelling due to impingement upon the large vein (superior vena cava), which drains blood from the head and neck areas. Metastatic disease is common and presents with symptoms such as bone pain, fractures, seizures and arrhythmias due to metastases to the bones, central nervous system and pericardium. Local invasion of the spine and brachial plexus (nerve bundle controlling the arms) are also possible presenting with nerve deficits corresponding to the site of invasion. Prevention and Screening Since over 85% of all lung cancer cases are caused by voluntary or “involuntary” second hand smoke, the best way to reduce the risk of lung cancer is not to smoke and to avoid breathing in other people’s smoke. Active and passive “second hand” smoke both cause lung cancer, and there is a causal relationship between smoking , lung cancer, and other cancers such as oral, laryngeal, pharyngeal, and cervical cancers (http:// www.cdc.gov/tobacco/datastatistics/sgr/2004/pdfs/ executivesummary.pdf.) Physicians should encourage tobacco cessation, especially in those diagnosed with cancer. People who stop smoking before age 50 cut their risk of dying in the next 15 years in half compared with those who continue to smoke. Programs that use behavioral modification combined with medications that promote tobacco cessation can be very beneficial to patients. STPH/MBP provide such cessation classes throughout the year (898.4581) or patients may be referred to the American Cancer Society Quitline (1-800-227-2345) or website (www.cancer.org).

2010 STPH and MBP Cancer Annual Report

Classification and Prognostic Factors Lung cancer is divided into 2 major classes based on its biology, therapy and prognosis (World Health Organization). Non-Small Cell Lung Cancer (NSCLC) accounts for more than 85% of all lung cancer cases and includes 2 major types: (1) non-squamous carcinoma (including adenocarcinoma, large cell carcinoma, other cell types); and (2) squamous cell (epidermoid) carcinoma. Adenocarcinoma frequently occurs in nonsmokers and is the most common type of lung cancer seen in the United States. Table 2. Comparison of Demographic Data (%) Between ACoS Approved Community Cancer Programs and MBP/STPH in Patients Diagnosed 2000-2007 with Non-Small Cell Lung Cancer1 NCDB n=135,579 (%)

MBP/STPH n=344 (%)

Female Male

43% 57%

41% 59%

30-39 40-49 50-59 60-69 70-79 80-89 90+

1% 5% 15% 29% 35% 15% 1%

<1% 6% 18% 25% 31% 19% 1%

White Black Hispanic Other/Unknown2

87% 8% 2% 2%

85% 13% 1% 1%

Not Insured Private Insurance Managed Care Medicaid Medicare Medicare w/Supplement Veterans affairs TRICARE/Military

3% 10% 17% 5% 23% 40% <1% 1%

1% 1% 32% 6% 21% 37% 1% 2%

Sex

Age At Diagnosis

Race

Insurance

Although no prognostic factors are required for staging of NSCLC, clinically significant factors include pleural/ elastic invasion (based on H & E and elastic stains) and separate tumor nodules. Other prognostic factors that are predictive of survival include:

•• Good prognostic factors early stage disease at

diagnosis, good performance status, no more than 5% weight loss, and female gender,

•• Factors with significant value include biologic factors, such as mutations of the tumor suppressor gene (p53) or activation of proto-oncogene K-ras, and

•• Factors with little prognostic significance include age and histologic subtype.

The STPH/MBP NSCLC Experience The STPH/MBP Cancer Committee compared patterns of treatment and outcomes (survival) of patients with NCCLC at STPH/MBP (344 cases) with data submitted from all approved community hospital cancer program across the United States (135,579) into the National Cancer Data Base (NCDB) during the years 2000 through 2007. (Table 2) demonstrates no significant variations in sex, age, sex or race between the groups though a slightly higher percentage of managed care was noted in the STPH/MBP group. Although non-small cell lung cancer can be seen across a broad age range, the majority of cases are typically diagnosed between the sixth and seventh decades as is reflected in STPH/MBP data. Non-small cell lung cancer is typically more common in men than in women with a reported male to female ratio of more than 3:1, a ratio not reflected in STPH/MBP data.

May not equal 100% due to rounding errors; only comparable data presented. NCDB data represents all reported cases from approved Community Hospital Cancer Programs in all states. 2 Includes Native American, Asian/Pacific Islands, other races or unknown 1

2010 STPH and MBP Cancer Annual Report

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Table 3. Comparison of Stage,Tumor Types and Treatment (%) Between ACoS Approved Community Cancer Programs and MBP/STPH in Patients Diagnosed 2000-2007 with Non-Small Cell Lung Cancer1 NCDB n=135,579 (%)

MBP/STPH n=344 (%)

I II III IV OC UNK

20% 7% 26% 36% <1% 11%

19% 10% 33% 33% <1% 4%

Large Cell Carcinoma Non-Small Cell Carcinoma Squamous Cell Carcinoma, NOS Adenocarcinoma, NOS Bronchio-Alveolar Adenocarcinoma Other Specified types

5% 22% 27% 33% 3% 10%

6% 29% 26% 25% 2% 11%

14% 12% 3% 22% 13% 3% 14% 19%

12% 14% 6% 23% 8% 1% 17% 18%

AJCC Stage

Histology

Treatment Surgery Only Radiation Only Surgery/Chemotherapy Radiation/Chemotherapy Chemotherapy Only Surgery/Radiation/Chemotherapy Other Specified Therapy No 1st Course of Therapy 1

May not equal 100% due to rounding errors; only comparable data presented. NCDB data represents all reported cases from approved Community Hospital Cancer Programs in all states.

Table 4. Observed Non-Small Cell Lung Cancer Survival Rate Comparisons (%) Between All Approved Community Hospital Cancer Programs, Approved Cancer Programs in Louisiana, & STPH/MBP NCDB Comm Hosp Only 1998-2002 AJCC Stage % All Stages 0 I II III IV

NCDB State of LA 1998-2002 %

NCDB STPH/MBP (%) 1998-2002 %

14.8 25.7 39.2 21.4 8.8 2.4

14.4 / 40.4 24.1 8.1 3.4

12.5 / / / 14.3 0

(n=43049) 477 programs

(n=5899) 66 programs

(n=103) 1 program

/ Insufficient cases to stratify by stage AJCC: American Joint Commission on Cancer

All NCDB Approved Community Hospital Cancer Programs All NCDB Approved Cancer Programs in Louisiana MBP/STPH Approved Cancer Program

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No significant variations were noted in AJCC stage at diagnosis, histology types, or treatment patterns (Table 3). Although not shown in table format, treatment patterns were also compared with the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines (v. 2.2010). Early stage NSCLC represents a minority of cases and is often curable with surgery with or without adjuvant chemotherapy. Radiation therapy, surgery and chemotherapy have been used in combination or alone in locally advanced cases. Most NSCLC patients present with distant metastasis where chemotherapy is most often utilized. No variations were noted in STPH/ MBP treatment patterns when compared with NCCN treatment guidelines. Observed survival rates were also compared between STPH/MBP, other approved cancer programs in the state of Louisiana and other NCDB community hospital cancer programs. Again, no major variances noted in overall 5 year survival rates (Table 4). Results were in fact consistent with SEER data that observed a 15% 5-year survival rate after diagnosis for all lung cancer patients (http://seer.cancer.gov/statfacts/html/lungb.html). Discussion In 2010, the American Joint Commission (AJCC) published the AJCC Staging Manual, 7th edition which included several changes specific to the staging of lung cancers (Table 5). Included in the majority of staging forms, including lung cancer, is a section to document that clinical staging and NCCN (or other) treatment guidelines were used in treatment planning. Prognostic (site-specific) factors are also included for many cancer sites, although none are required for the staging of lung cancer. Also included is discussion and suggested documentation regarding nodal sampling which is known to impact staging, treatment decisions, and prognosis. â&#x20AC;&#x153;There is no evidence based guideline regarding the number of lymph nodes to be removed at surgery for adequate staging. However, adequate N staging is generally considered to include sampling or dissection of lymph nodes from stations 2R, 4R, 7, 10R and 11R for right sided tumors and stations 5, 6, 7, 10L and 11L for left sided tumors. Station 9 lymph nodes should also be evaluated for lower lobe tumors. The more peripheral lymph nodes at stations 12-14 are usually evaluated by the pathologist in lobectomy or pneumonectomy specimens. There is evidence to support the recommendation that histological examination of hilar and mediastinal lymphenectomy specimen(s) will ordinarily include 6 or more lymph nodes/station Three of these nodes/station should be mediastinal, including the sub-carinal nodes and 3 from N1 nodesâ&#x20AC;? (AJCC, 2010).

2010 STPH and MBP Cancer Annual Report

Cutting-edge technology is helping STPH physicians more effectively diagnose earlier stage lung cancers and then aid in treatment planning. In 2010, STPH became the only Northshore facility utilizing electromagnetic navigation bronchoscopy (ENB), which uses globalpositioning-system-like technology to examine lesions in the lung’s distant edges. This technology helps pulmonologists to examine lymph nodes and lung lesions too small for viewing with standard equipment. In contrast to traditional bronchoscopy, ENB allows examination of 100 percent of the lungs and can be used to take samples from lesions too small for testing with a traditional bronchoscope. Needle biopsy through the patient’s chest, a procedure that carries a high risk for a collapsed lung is avoided. Treatment plans can be implemented faster than ever before and markers can be placed on lesions by special catheters to allow for surgical removal or image-guided radiation therapy that pinpoints tumors without impacting healthy tissue. Lung cancers are typically diagnosed in later stage, limiting treatment options and survival. Because it allows cancers to be diagnosed at earlier stages, ENB can improve life expectancy and quality of life for patients. For more information on this technology, Contact the STPH Endoscopy Department at 898.4412.

Table 5. Lung Cancer: AJCC Cancer Staging Manual

Summary of Changes From the Sixth Edition to the Seventh Edition This staging system is now recommended for the classification of both non-small cell and small-cell lung carcinomas and for carcinoid tumors of the lung. The T classifications have been redefined: • T1 has been subclassified into T1a (less then/ equal to 2 cm in size) and T1b (greater than 2-3 cm). • T2 has been classified into T2a (greater than 3-5 cm) and T2b (greater than 5-7cm). • T2 (greater than 7 cm) has been classified as T3. • Multiple tumor nodules in the same lobe have been reclassified from T4 to T3. • Mutliple tumor nodules in the same lung but a different lobe have been reclassified from M1 to T4. No changes have been made to the N classification. However, a new international lymph node map defining the anatomical boundaries for lymph node stations has been developed. The M classifications have been redefined: • M1 has been subdivided into M1a and M1b. • Malignant pleural and pericardial effusions have been reclassified from T4 to M1a. • Separate tumor nodules in the contralateral lung are considered M1a. • M1b designates distant metastases. Carcinoid tumors are included. Sarcomas and other rare tumors are not included. American Joint Commission on Cancer, 7th edition, page 253, 2010.

For more information about tobacco cessation classes, contact 898-4581. References: National Cancer Data Base (NCDB), American College of Surgeons Commission on Cancer, 2010. NCCN Practice Guidelines on Oncology for Non Small Cell Lung Cancer-v.2.2010. Cancer Facts and Figures, 2010, American Cancer Society. AJCC Cancer Staging Manual, 7th edition. American Joint Commission on Cancer, 2010. Aggarwal, C, Somaiah, N, Simon, G.R. Biomarkers with Predictive and Prognostic Function in Non-Small Cell Lung Cancer: Ready for Prime Time? Journal National Comprehensive Cancer Network 2010; 8 (7): 822-832.

2010 STPH and MBP Cancer Annual Report

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1202 South Tyler Street Covington, LA 70433 www.stph.org

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