OHO-14(227-248) 11/18/02 8:16 AM Page 240 PRINCIPLES OF PALLIATIVE CARE 240 Supporting cancer patients Introduction For cancer patients, the trauma of diagnosis, protracted and some- times toxic curative treatments, possible disease relapse, with progres- sion to incurable and increas ingly disabling or terminal disease, provokes intense, often distressing emotional and psyc hological reactions. These may include: (cid:2) Fear (cid:2) Anxiety (cid:2) Anger (cid:2) Confusion (cid:2) Sense of loss (cid:2) Alienation (cid:2) Sadness/depression The cancer no t only impacts on the patient personally, but also on family, friends, their work, and \201nances. Up to one-third of cancer patients suffer signi \201cant psychological morbidi ty. Appropriate support interventions can help alleviate much of their distress. Palliative care is synonymous with good supportive care, at every stage of a cancer illness . Palliative care ameliorates all distressing symptoms, whether physical, psychological, so cial, or spiritual in an integrated approach, as essential in achieving the best of quality of life for patients and families. For patients with a terminal diagnosis, it strives to e nable them to live as actively as possible until death, while offering support of the famil y during the patient \200\231s illness and in their own bereavement. Detecting patients in need of support All patients bene \201t from support but assessment of the following can identify patients at particular risk: (cid:2) Degree of physical disab ility Internal resources of the patient (cid:2) (cid:2) Past history of functioning (cid:2) Social supports \200\224family (marital status, living arrangements, number of family members in the immediate geographical area and their capacity and willingness to provide support), friends, community/church links (cid:2) Hist ory of substance abuse OHO-14(227-248) 11/18/02 8:16 AM Page 241 SUPPORTING CANCER PATIENTS 241 Use a standardized measure of psychological morbidity and quality of life such as: (cid:2) Hospital Anxiety and Depression Scale (HADS) (cid:2) Functional Assessment of Cancer Therap y (FACT) (cid:2) Functional Living Index \200\223Cancer (FLIC) (cid:2) Cancer Rehabilitatio n Evaluation Systems (CARES) (cid:2) European Organization for Research and Treatment Quali ty of Life Questionnaire (EORTC QLQ-C30) (cid:2) The Schedule for Evaluation of Individualized Quality of Life (SEIQoL) \200\224allo ws patients to nominate the aspects of life they consider important in the evaluation of Qo L, and they are scored on these Providing support We can all offer support to cancer patients. Cancer patients tell us that they need to \201nd meaning and hope in the midst of deterioration, dis- tress, and desp air. Our challenge is to \201nd the balance in providing hope and alleviating fears throu ghout the cancer journey. Communication Effective communication is the cornerstone of good supportive care. Patients should be able to participate in decisions about their care, allowing them to retain some c ontrol over their lives. Doctors are not legally or ethically obliged to provide treatments that are futile or pro- long life (and sometimes the distress of dying) at all costs. Comp etent patients are entitled to refuse life-prolonging or life-sustaining treat- ments. Pote ntial con \202ict about such decisions can be avoided by good communication. Patients need honest, compassionately delivered information. Poor communication and breaking of bad news are consistently mentioned by patients and fami lies as a cause of stress and dissatisfac- tion. Good communication builds trust, reduces u ncertainty, and allows appropriate adjustment (practical and emotional) by patient and fami ly, thus reducing psychological morbidity. Breaking bad news is not a single, isolated even t. The process is ongoing and recurring, involving telling the diagnosis, updating the pati ent and family on changes and, possibly, preparing them for death. Breaking bad news \200\224a ten-step approach This approach can be used as a general framew ork and adapted for speci \201c situations. Remember, a patient has a right but not a duty to hear bad news. 1. Preparation: (know the facts; arrange the meeting; \201nd out who the patient wants present). OHO-14(227-248) 11/18/02 8:16 AM Page 242 PRINCIPLES OF PALLIATIVE CARE 242 2. Establish what the patient already knows (both doctors and family generally underestimat e the level of patient \200\231s knowledge). 3. Establish whether the patient wants more information. 4. Allow denial (denial is a defen se and a way of coping). Allow the patient to control the amount of information. 5. Give a warning shot (allows patient time to consider their own reactions and whether the y feel able to ask for more information). 6. Explain (if requested \200\224be clear and sim ple; avoid harsh state- ments; avoid medical jargon; check understanding; be as opti- misti c as possible). 7. Listen to concerns (avoid premature reassurance or excessive explanations). 8. Encourage ventilation of feelings (the key phases, as it conveys empathy). 9. Summarize and make a plan (reduces confusion and uncertainty; fosters hope). 10 Offer availability (communicating bad news is an ongoing process). Formal counseling/psychological therapies Some patients will need more formalized support \200\224trained counsel- lors, social workers, hospital chaplains may provide this. Cogniti ve \200\223 behavioral and brief psychotherapeutic interventions are effective for more sig ni \201cant levels of anxiety or depression e.g. adjuvant psy- chological therapy. Psychiatric interventions When psychological interventions are inadequate, psychotropic med ication may help. Drug therapy bene \201t 20 \200\22325% of cancer patients suffering sign i \201cant anxiety and depression. Support groups and information services These can help to reduce the sense of alienation an d isolation some- times associated with cancer. They facilitate the sharing of experi- ence s, the ventilation of feelings in a supportive environment, and the exchange of information about the physical, psychological, and social consequences of cancer and its treatment (e. g. Bristol Cancer Help Center, Cancer BACUP, Cancerlink). Support in death Often it is the actual mode of death that patients fear rather than the fa ct of dying e.g. \200\230What will it be like? \200\231 or \200\230I \200\231m afraid of dying in agony \200\231. Patients need reassurance that any physical distress can be allevi ated and that death is normally peaceful. Issues of spirituality may be important for indiv idual patients and religious ritual should be facili- tated where possible. Doctors need to be sensitive to psychological dis- tress (a sense of hopelessness, despair, meaninglessnes s; questions OHO-14(227-248) 11/18/02 8:16 AM Page 243 SUPPORTING CANCER PATIENTS 243 such as \200\230why me? \200\231) as it often masks intractable, distressing, physical sym ptoms (e.g. pain). During \201nal hours, patients should never be left alone to feel isolated or abandoned. Families need to be involved, and this includes children; they need to be kept updated on c hanges and encouraged to be present. Good care of a patient \200\231s family will reduce th e likelihood of complicated bereavement. If the family can \200\231t be there, a member of staff should sit with the patient. Staff stress Supporting cancer patients is stressful to the health professionals involved. Staff also need support structures (including training in communication skills, as well as direct supportive measures such as counseling and relaxation therapies). OHO-14(227-248) 11/18/02 8:16 AM Page 244 PRINCIPLES OF PALLIATIVE CARE 244 The \200\230holistic \200\231 approach to cancer The holistic approach is typi \201ed by the emphasis placed on the role of \200\230mind, body, and spirit \200\231 in health and illness management, either by the individual themse lves or by those caring for them. In cancer medicine this approach is implemented in three settings: (cid:2) Psychosocial care given within hospitals, hospices, voluntary sector supp ort groups, or within the community via health visitors, social workers, or the Church. (cid:2) The palliative care setting, where there is increasing use of comple- mentary thera pies, particularly by nurses, for symptom control, comfort, and support. (cid:2) The patient self-help movement, where a mixture of self-help approaches, complement ary and alternative therapies, nutrition, and psychological approaches are used with the ai m of improving health, well-being, and treatment outcome. The holistic model The purist model is health-based in which individuals and therapists wor k in partnership to achieve the best levels of health, energy, and emotional and spiritual well-being, whether as a preventive measure or to promote health in the presence of illness . The holistic model is integrative, with the states of mind, body, and spirit inextricably linked \200\224an individual \200\231s spirit or will to live, mental state, level of stre ss, self-expression, lifestyle, and emotional state are all seen as relevant in terms of th e illness and potential to improve health. The physical state, in terms of nutrition, \201tness, energy levels and oxygena- tion are also given key attention. The holistic approach for individuals who are seeking to improve their health is ideally divided into two phases: (cid:2) Therapeutic (cid:2) Self-help Duri ng the therapeutic phase, help is sought from: (cid:2) Holistic doctors and nurses for medi cal counseling, needs and lifestyle assessment, symptom control with stress reduction and n atural remedies (herbal and homeopathic), and speci \201c nutri- tional advice. (cid:2) Counseling, psychotherapy, and group work aimed at promoting emotional expression, for examination of lifestyle, stress, and self- stressing attitudes, for re-orientation and rehabilitation of individ- uals towards more authentic and meaningful personal values and OHO-14(227-248) 11/18/02 8:16 AM Page 245 THE \200\230HOLISTIC \200\231 APPROACH TO CANCER 245 Complementary therapy Nutrition Creative self- expression Alternative therapy Personal growth and self-development Self-help approaches Exercise Counseling and psychotherapy Lifestyle, stress, and attitudinal evaluation Spiritual healing Support groups Components of the holistic approach. goals, and for learning self-help techniques of visualization, medi- tation, and relaxation . (cid:2) Nutritional approaches based on replacing high-fat, high-protein, high-salt, high-s ugar, highly-processed Western diets with a whole- food, vegan, preferably organic diet, su pplemented with anti- oxidant vitamins and minerals (A, (cid:3)-as carotene, C, and E, plus the minerals selenium and zinc). Nutritional changes should be super- vised by quali \201 ed nutritional therapists to avoid weight loss and an inappropriate diet. (cid:2) Complementary therapies which include acupuncture, shiatsu, and homeopathy (which m ay increase energy levels and improve well-being and symptom control) and body work, such a s massage and aromatherapy (which can reduce fear, tension, isolation, and the alienation f elt by cancer patients towards their diseased or dis \201gured bodies). (cid:2) Spiritual healing which lifts underlying energy, improves coping, is calming, and has emotional and spiritual bene \201ts. (cid:2) Support groups aimed at giving encouragement, social contact, and support. (cid:2) Alternative cancer therapies that are reputed to have \200\230anti-cancer \200\231 activity, and in this sense are more like allopathic medicines than holistic, health-based therapies. These fall into the categories of: OHO-14(227-248) 11/18/02 8:16 AM Page 246 PRINCIPLES OF PALLIATIVE CARE 246 \200\224Herbal remedies e.g. Rene Caisse herbs (Essiac), Iscador (mistle- toe therapy), or Carnivora (Venus \202ytrap). \200\224Metabolic approaches, which may be immuno-stimulant. \200\224Dietary approaches, which are based on fasting to \200\230detoxify \200\231 the body, followed by \200\230sup er nutrition \200\231 with very pure, plant-based juice, raw food, or other \200\230spring cleaning \200\231 diets. \200\224Alternative remedies e.g. shark \200\231s cartilage, that has some anti- angiogenesis activity. \200\224Hormonal therapies aimed at inhibiting tumor growth e.g. melatonin, somatostatin, and bromocryptine \200\230cocktails \200\231. Self-help approaches A point will come when, through the application of holistic therapies, the patient feels suf \201ciently strong to embark upon self-help approaches. It is impor tant not to encourage patients to take up self- help approaches before they are strong enou gh to do so, because if they are unable to implement this advice they will blame themselves and feel they have failed. Key self-help strategies include: (cid:2) Mind/body approaches aimed at calming the mind and inducing states of well-being and happiness (e.g. regular pra ctice of relax- ation and meditation). Visualization promotes a positive mental state using pictures or words, in an attempt to affect disease outcome and morale. Visualization is di vided into guided ima- gery, where therapists guide individuals or groups with the sequen- tial use of pleasant visual images into happier states of mind, or personal imaging, where a cancer patient creates images of their cancer being destroyed or images of themselves as completely recovered. (cid:2) Holistic forms of exercise such as yoga, tai chi, or chi gong, which again promote emotional, physical, and spiritual well- being. (cid:2) Healthy eating, where once the patient has been taught and guided through dietary c hanges, healthy eating can be incorporated into their lifestyle. (cid:2) Creative self-expression, in which patients are encouraged to live a more balanced, expressive life with more emphasis on recreation, self-expression, and the ful \201lment of personal goals and ambitions. Psychological approaches These overlap with interventions undertaken in traditional cancer centers and typically involve: (cid:2) Counseling and psychotherapy (cid:2) Support groups (cid:2) Use of creative therapies OHO-14(227-248) 11/18/02 8:16 AM Page 247 THE \200\230HOLISTIC \200\231 APPROACH TO CANCER 247 Bene \201ts of the holistic approach Individual patients report signi \201cant bene \201 ts from the use of these approaches including: (cid:2) Reduction in fear, anxiety, isolatio n (cid:2) A sense of control, involvement, and partnership with health care professionals Improvement in physical state, energy levels, and sleep Improved symptom cont rol and tolerance of treatment Improved quality of life (cid:2) (cid:2) (cid:2) Use of the holistic approach During the 1990s, studies showed that up to 35% of cancer pati ents were using complementary therapies, and up to 75% would use them if they were availabl e on the NHS. Currently, use of complementary therapies within palliative care has become a ccepted, but mainly within the passive/dependent context of patient care. The current chall enge in oncology is whether the model of holistic self-help can be incorporated into the sp ectrum of options available within con- ventional healthcare settings, or whether at the ve ry least information about, and access to such resources are made routinely available to pa tients. OHO-14(227-248) 11/18/02 8:16 AM Page 248 PRINCIPLES OF PALLIATIVE CARE 248 Further reading Kaye, P. (1995) Breaking bad news \200\223 a ten-step approach. EPL Publications, Northampton. Zech, D.F.I., Grond, S., Lynon, J., et al. (1995) Validation of World Health Organization Guidelines for cancer pain relief: a 10-year prospective study. Pain 63, 65 \200\22376. McQuay, H. and Moore, A. (1998) An evidence-based resource for pain relief. Oxford University Press. Oxford Textbook of Palliative Medicine. Twycross, R. (1996) Sympto m management in advanced cancer. Radcliffe Medical Press, Oxford. OHO-15(249-258) 11/16/02 12:20 PM Page 249 Chapter 15 Psychosocial aspects of cancer Distress 251 Decision making 252 Dealing with uncertainty 253 Discomfort, dis \201gurement , and disability 254 Disruption to lifestyle 255 Dependence on others 256 Deleterious impac t on quality of life 257 Summary 258 OHO-15(249-258) 11/16/02 12:20 PM Page 250 PSYCHOSOCIAL ASPECTS OF CANCER 250 Cancer and its treatment impose a severe threat to a patient \200\231s sense of well-being and quality of life. People tend to overestimate the numbers of deaths, underestimate cure rates, and see cancer as the single most alarming disease. OHO-15(249-258) 11/16/02 12:20 PM Page 251 DISTRESS 251 Distress A cancer diagnosis provokes considerable psychological, social, and sexual dif \201culties for most people. Estimations vary, depending on the measurement used, but 20 \200\22335% o f patients, irrespective of disease site or stage, experience psychological problems which merit inter- vention with anxiolytics and antidepressants or referral to a liaison psychiat rist or oncology counselor. There are several studies showing that oncologists are not very good at detecting psychiatr ic morbidity among their patients. In a study examining the ability of doctors to identify distress when patients were being given con \201rmation of a cancer diagnosis or recurrenc e, only one out of six senior oncologists behaved above chance level. Recent meta-analysis of 62 randomized trials of psycho-educational interventions with adult cancer patients demo nstrated positive effect, suggesting that such interventions should be an integral part of cancer services, not just an optional extra. OHO-15(249-258) 11/16/02 12:20 PM Page 252 PSYCHOSOCIAL ASPECTS OF CANCER 252 Decision making Once the diagnosis has been con \201rmed, decisions about treatment must be made. Innumera ble studies show that patients are manifestly unhappy with much of the communication that t akes place at this time. Too many leave their consultations uncertain of the precise diagno sis and prognosis, unclear about the likely therapeutic bene \201ts of treatments, and wan ting more information than is usually pro- vided. A study of women with breast cancer showe d those who were unsatis \201ed with the information given at this time failed to adjust t o the fact of their cancer and its treatment. They suffered twice as much anxiety and depre ssion up to three years post-diagnosis than women who felt well-informed. Research has shown that the number of patients who genuinely pre- fer to have little inform ation and leave everything up to the doctor is less than 5%. The large number of calls from patients and their fami- lies to charitable information services such as Cancer BACUP, att est to the dif \201culties some have in getting suf \201cient, understandable infor- mati on to enable them to make decisions and give informed consent to treatment. There has been some confusion about patients \200\231 preference for more information and t heir desire to participate in decision making. Surveys have shown that lay populations with out cancer believe that they would wish to play an active role in decision making if they t hem- selves were to get cancer but that patients with cancer usually desire a more passive role or an offer of joint decision making. In a study of women with breast cancer, perceive d adequacy of the information given, and not merely being offered choice of treatment, in \202uenced psychological distress. OHO-15(249-258) 11/16/02 12:20 PM Page 253 DEALING WITH UNCERTAINTY 253 Dealing with uncertainty Uncertainty in any situation is one of the most dif \201cult problems for the psyche to be ar. It is a state in which most patients with cancer remain from the time that they discove r sinister symptoms and undergo diagnostic tests until they complete treatment. Doctors are also faced with a dilemma when trying to offer reassurance to an anxious patient and be ho nest about an enigmatic disease which has an uncertain outcome. This can be especially prob lematic when dis- cussing clinical trials where uncertainty about the ef \201cacy of treat - ment is inherent and must be discussed in order to gain informed consent. Some doctors \201nd it useful to attend specialist courses in communication to learn ways of dealing wit h these issues more appropriately. OHO-15(249-258) 11/16/02 12:20 PM Page 254 PSYCHOSOCIAL ASPECTS OF CANCER 254 Discomfort, dis \201gurement, and disability Treatments for cancer are unpleasant and cause considerable distress. Surgery can be mutila ting and may cause losses of function, body image, self-esteem, and libido. Radiotherapy ca n induce: (cid:2) Anxiety and depression (cid:2) Nausea and vomiting (cid:2) Fatigue (cid:2 ) Skin irritation Chemotherapy probably has the worst reputation for side-effects, in parti cular: (cid:2) Alopecia (cid:2) Sore mouth (cid:2) Neurotoxicity (cid:2) Cardiotoxicity (ci d:2) Nausea and vomiting The advent of the 5HT3 antagonists in the past decade has made man y toxic treatments more tolerable, but clinicians should be aware of the need to prevent em esis occurring at the beginning of treatment to avoid classically conditioned responses dev eloping. One study of patients successfully treated for lymphoma showed that they continued to experience nausea and vomiting in response to any stimuli asso- ciated with the hospita l many years after the cessation of treatment. OHO-15(249-258) 11/16/02 12:20 PM Page 255 DISRUPTION TO LIFESTYLE 255 Disruption to lifestyle Cancer treatment inevitably means a considerable disruption to a patient \200\231s life. So me manage to continue working through their radio- therapy and chemotherapy, but others req uire lengthy periods of hospitalization with its associated effects on social, family, sexu al, and occupational functioning. After initial therapy, even if this has been successful, the months and years of follow-up visits and tests can con- tinue to make it dif \201cult for patients to ever see themselves in the same way as they did prior to diagnosis. Individ uals may describe them- selves as living \200\230under the sword of Damocles \200\231, nev er sure when the disease will reappear, anxiously monitoring aches and pains as signs of re currence. Paradoxically, it is when treatment ends that patients may be more in need of support and h elp from a trained counselor in re-appraising their lives and coping with survivorship. OHO-15(249-258) 11/16/02 12:20 PM Page 256 PSYCHOSOCIAL ASPECTS OF CANCER 256 Dependence on others The advanced technology of modern cancer treatment, as well as its potential dangers, rende rs patients extremely vulnerable and depen- dent on others. For many this loss of control i s overwhelming and contributes signi \201cantly to psychological distress. This is especia lly true for adolescents who may already be struggling with the challenges of establishing their own identity. Helping these people and their families cope with the stresses of treat ment for a life-threatening disease at such a crucial time in their development is a vital part of their care if normal social, intellectual, and personal growth is to be achieved. OHO-15(249-258) 11/16/02 12:20 PM Page 257 DELETERIOUS IMPACT ON QUALITY OF LIFE 257 Deleterious impact on quality of life Although many cancers can be cured and the survival rate in some cancers is good, psycholog ical, social, sexual, and physical dysfunction caused by both the diagnosis and treatment e xerts a deleterious impact on the quality of most patients \200\231 lives. The range of pos sible treatments may have very similar outcomes in terms of response and survival but can p roduce very different effects on psychosocial well-being. Monitoring quality of life is now more frequent in clinical trials but has failed to be use d routinely in clinical assessment. Some groups are attempting to rectify this by introduci ng user-friendly touch screens that provide clinicians with a \200\230print out \200\231 o f current and past scores, together with normal ranges which are adjusted for age and disea se state. Data derived from studies of quality of life can help the doctor and patient in management decisions and identify those patients who might pro \201t from psychosocial interventions. Generic tests are avail- able and valid and reliable tests exist for the measurement of qu ality of life in relation to most of the common cancer sites. OHO-15(249-258) 11/16/02 12:20 PM Page 258 PSYCHOSOCIAL ASPECTS OF CANCER 258 Summary For many, the diagnosis of cancer is a major emotional catastrophe; for others, it is yet o ne dif \201culty to overcome in the midst of other social iniquities and disadvantages. So me may see their cancer as a challenge, offering an opportunity to completely reappraise at titudes to relationships, work, and life in general. Many people display extra- ordinary co urage, resilience, and fortitude during the course of their illness, while others \201nd that it exposes or magni \201es the limits of their ability to cope. The doctor can do muc h to prevent or ameliorate their burden by good communication and preparedness to discuss p sychosocial concerns. OHO-16(259-294) 11/18/02 8:16 AM Page 259 Part 4 Speci \201c types of cancer 16 Thoracic cancer 261 17 Breast cancer 295 18 Colorectal cancer 323 19 Anal cancer 339 20 Upper gastrointestinal cancer 349 21 Endocrine cancer 375 22 Genitourinary cancer 389 23 Gy necological cancer 417 24 Head and neck cancer 443 25 Tumors of the central nervous system 469 26 Skin cancer 481 27 Hematological emergencies 489 28 Bone and soft tissue malignancie s 515 29 Cancer of unknown primary site 531 30 Paraneoplastic syndromes 543 31 AIDS-related malignancies 559 OHO-16(259-294) 11/18/02 8:16 AM Page 260 This page intentionally left blank OHO-16(259-294) 11/18/02 8:16 AM Page 261 Chapter 16 Thoracic cancer Lung cancer 262 Non-small cell lung cancer 264 NSCLC \200\224surgery 268 NSCLC \200\224radi ation therapy 272 NSCLC \200\224chemotherapy 274 Small cell lung cancer \200\224radiotherap y 278 SSCLC \200\224chemotherapy 282 Mesothelioma 286 Thymic tumors 290 Further reading 294 OHO-16(259-294) 11/18/02 8:16 AM Page 262 THORACIC CANCER 262 Lung cancer Epidemiology Lung cancer is now the most frequent cause of cancer mortality in both men and women in the UK and US. Its incidence is continuing to rise worldwide, in particular in de veloping countries, where smoking is increasing. It is estimated that 80% of cancer deaths are due to smoking. The risk of lung cancer relat es to the number of cigarettes smoked, the number of years of smoking, early age of startin g to smoke, and the type of cigarette (greater risk with un \201ltered and high- nicotine) . While health education has had some success in reducing tobacco consumption in men, smoking in women and adolescents is increasing. Much less frequent causes of lung cancer are exposure to: (cid:2) Asbestos (cid:2) Radon (cid:2) Polycyclic aromatic hydrocarbons (cid:2) Nickel (cid :2) Chromate Inorganic arsenicals (cid:2) Pathology There is evidence that lung cancers may arise in pluripotent stem cells in the br onchial epithelium, and this would certainly offer an explana- tion for the mixed histology that is fairly commonly seen. The WHO pathological classi \201cation is: A Squamous cell carcinoma (30%) B Small cell carcinoma (20%) C Adenocarcinoma (40%): 1 acinar 2 papillary 3 bronchoalveolar 4 mucinous D Large cell carcinoma E Mixed For the purposes of management, lung cancers are grouped as non- small cell (NSCLC) or smal l cell (SCLC), but within the former certain OHO-16(259-294) 11/18/02 8:16 AM Page 263 LUNG CANCER 263 patterns of disease do relate to histological subtype. For example, squamous cancers typica lly arise in proximal segmental bronchi and grow slowly, disseminating relatively late in t heir course. Adeno- carcinomas are often peripheral in origin and even small resectable les ions carry a risk of occult metastases. However the risk of dissemination is greatest in SCLC, where it is estimated that >90% of p atients have either overt or occult metastases at presentation. These aggressive tumors mos t frequently arise in large airways but can rarely present as a small peripheral nodule. So me have suggested that the latter presentation is in fact indicative of a different patholo gy with an inherently better prognosis. OHO-16(259-294) 11/18/02 8:16 AM Page 264 THORACIC CANCER 264 Non-small cell lung cancer Introduction Surgical removal of non-small cell bronchogenic carcinoma continues to offer b est possibility of a cure. Consequently, each patient should be considered where possible f or surgical treatment, although advanced stage and signi \201cant co-morbidity will preclu de this option in many patients. The aim of surgical treatment is cure; in patients where t his is not possible suitable alternative treatments should be considered. Before embarking on surgery all cases should undergo careful and detailed pre-operative assessment to establish: (cid:2) Histological proof of disease (cid: 2) Staging of disease (cid:2) Fitness for surgery Histological/cytological proof of non-small cell lung cancer Pre-operative proof of maligna ncy is possible in the majority of patients suffering from lung cancer. Main methods of dia gnosis continue to be: (cid:2) Sputum cytology (cid:2) Bronchoscopy with biopsy (cid:2) Bro nchial brushings (cid:2) Washings These methods have a high yield of positive diagnosis, particularly in more centrally place d bronchogenic tumors. In more peripherally situated tumors percutaneous \201ne-needle as piration for cytology or trucut-needle biopsy performed under \202uoroscopic screening or guided by CT are preferred. In a few patients pre-operative proof of malignancy may not be pos- sible and surgery may b e offered on radiological evidence (a mass lesion that has grown on sequential imaging). Staging of disease (cid:2) Bronchoscopy (cid:2) CT \200\224 chest and abdomen \200\224 size of tumor \200\224 site OHO-16(259-294) 11/18/02 8:16 AM Page 265 NON-SMALL CELL LUNG CANCER 265 \200\224 relationship to chest wall, \201ssures, mediastinal struc- tures, diaphragm \200\224 lymph nodes >1 cm suggestive of tumor (cid:2) Mediastinoscopy (cid:2) Thoracoscopy (cid:2) Mediastinotomy (cid:2) Pleural aspirat ion, pleural biopsy (cid:2) Nodes may be enlarged due to reactive change (cid:2) CT liver a nd adrenals for metastases (cid:2) Bone scan and brain scan \200\224only if symptoms Fitness for surgery In patients undergoing surgery for non-small cell lung cancer, pre- ope rative assessment is vital. Age alone should not be considered a contraindication to lung r esection. Patient \200\231s performance status can be a useful indicator of ability to with stand major lung resection. Weight loss is an indicator of poor prognosis in lung cancer. Table 16.1 TNM staging of lung cancer T1 Tumor 3 cm or less in diameter, surrounded by lung or visceral pleura, distal to the main b ronchus T2 Tumor >3 cm diameter; or involving main bronchus 2 cm or more distal to carina; or invading visceral pleura; or associated with atelectasis which extends to the hilum but does not in volve the whole lung T3 Tumor invading chest wall, diaphragm, mediastinal pleura, or pericardium; or tumor in main bronchus <2 cm distal to carina; or atelectasis of the whole lung T4 Tumor invading mediastinum, heart, great vessels, trachea, esophagus, vertebra, or carina; or intralobar tumor nodules; or malignant pleural effusion N0 No regional node metastases N1 Ipsilateral peribronchial or hilar node involvement N2 Ipsilateral mediastinal or subcarinal nodes N3 Contra-lateral mediastinal nodes; scalene; or supraclavicular nodes Stage grouping I T1 \200\2232 N0 II T1 \200\2232 N1; or T3 N0 IIIa T1 \200\2232 N2; or T3 N1 \200\2232 IIIb T4 any N M0; or any N3 M0 IV Any M1 OHO-16(259-294) 11/18/02 8:16 AM Page 266 THORACIC CANCER 266 Pulmonary function tests are essential \200\224as well as demonstrating adequate respirator y reserve they are useful in post-operative management. Other investigations include hemato logical and biochemical screening to exclude signi \201cant co-morbidity and electrocardio gram, with or without an exercise test. OHO-16(259-294) 11/18/02 8:16 AM Page 267 This page intentionally left blank OHO-16(259-294) 11/18/02 8:16 AM Page 268 THORACIC CANCER 268 NSCLC \200\224surgery Thoracotomy and major lung resection continue to carry signi \201cant morbidity and mortal ity. Surgery for lung cancer should be carried out in a unit with the appropriate level of experience and expertise. Unnecessary delay may result in a previously operable lung tumor becoming inoperable by progression of disease. In the majority of patients, general anesthe sia with use of double lumen endotracheal tube is desirable to allow one-lung anesthesia du ring thoracotomy. Surgical resection The essential procedures involved include: (cid:2) Lobectomy (cid:2) Bi- lobectomy (cid:2) Pneumonectomy Segmental or wedge resection is generally not advisable because of the risk of incomplete r esection due to the presence of satellite tumor foci within the surrounding lung. In a few patients with poor lung function, segmental or wedge resection may be appropriate. In addition to the removal of all primary tumor with clear mar- gins, regional lymph node s ampling is essential to guide the planning of any adjuvant therapy. In cases where histolog ical proof of malig- nancy is not available pre-operatively, every effort should be made to obtain histology at operation by frozen section before resection is undertaken. In a minority of cases where the tumor is sited at the origin of the upper lobe bronchus, a nd is essentially con \201ned to it, an upper lob- ectomy with sleeve resection of the mai n bronchus, followed by recon- struction by end-to-end anastomosis, will be possible, thus preserving the remainder of functioning lung. Involvement of the chest wall (T3) or pericardium, including the phrenic nerve, in the abse nce of signi \201cant mediastinal lymph node involvement, does not necessarily constitute inoperability. Resection of the involved chest wall should be considered. A signi \201cant portion of pericardium can be removed en bloc in patients with pericardial involvement. Si milarly removal of an involved section of the dia- phragm is technically feasible. Post-operative management Patients should be nursed in an intensive care or high-dependency unit with adequate monitoring of: OHO-16(259-294) 11/18/02 8:16 AM Page 269 NSCLC \200\224SURGERY 269 (cid:2) ECG (cid:2) Pulse rate (cid:2) Blood pressure (cid:2) Central venous pressure (cid: 2) Respiratory rate (cid:2) Oxygen saturation Adequate pain control is essential following thoracotomy and can be provided by thoracic epidural anesthesia, intravenous opiates admini stered by patient-controlled analgesia (PCA), intercostal nerve block prior to wound closur e, or opiates administered by intermittent intra-muscular injection. Oxygen therapy is required in the early post-operative stage, pre- ferably through a nebuli zer, and in patients with signi \201cant airways \200\231 obstruction, a bronchodilator sh ould be added. Regular chest physio- therapy is essential. Post-operative complications Early (within days) (cid:2) Hemorrhage (particularly when there has been widespread pleural adhesions) that may result in a substantial haemothorax (cid:2) Respiratory failure due to drug-induced respir atory depression, pneumothorax with or without surgical emphysema, and retained bronchial s ecretions leading to signi \201cant atelectasis (cid:2) Prolonged air leak following lobectomy (cid:2) Cardiac arrhythmias, particularly at rial \201brillation (cid:2) Chest infection (cid:2) Wound infection (cid:2) Broncho-pleur al \201stula (particularly on the right following pneumonectomy) (cid:2) Empyema Late (within weeks to months) (cid:2) Post-thoracotomy pain (cid:2) Late broncho-pleural \201stula with empyema (cid:2) Tumor recurrence Results of lung resection Post-operative mortality rate should be less than 3% following lo bec- tomy and less than 5% following pneumonectomy. Five-year survival is in \202uenced by a number of factors, the most important of which is pathological staging, post-resection ( see Table 16.2). Overall \201ve-year OHO-16(259-294) 11/18/02 8:16 AM Page 270 THORACIC CANCER 270 Table 16.2 Five-year survival by stage Stage Five-year survival I 60 \200\22380% II 25 \200\22340% IIIa 10 \200\22330% IIIb and IV <5% survival for patients undergoing resection may be as high as 40%, approaching 70% in cases without nodal involvement (N0). However, when mediastinal nodes are involved (N2) only 15% of patients will survive \201ve years. OHO-16(259-294) 11/18/02 8:16 AM Page 271 NSCLC \200\224SURGERY 271 OHO-16(259-294) 11/18/02 8:16 AM Page 272 THORACIC CANCER 272 NSCLC \200\224radiation therapy Introduction Radical radiotherapy is indicated for patients with stage I \200\223II NSCLC w ho are un \201t for surgery, or have good performance status and stage III disease which c an be encompassed in a radical volume. Patients with inoperable non-small cell lung cancer (NSCLC) have a 20 \200\22330% chance of surviving two years if \201t for radical radiotherapy and a similar chance of surviving one year if not. No randomized trial has examined the role of radical radiotherapy in these outcomes. Dose and fractionation The standard international dose is 60 Gy in 30 fractions over 6 week s. Attempts to increase dose by hyperfractionation without acceleration have not shown any bene \201t. CHART, delivering 54 Gy in 36 fractions over 12 days has afforded a 9% surviva l advantage at two years com- pared with standard therapy. No trial has compared these regi mes with shorter 3 \200\2234 week schedules (e.g. 50 \200\22355 Gy in 20 fractions), which remain popular in the UK. CHART is logistically dif \201cult to deliver because of weekend treat- ment; its modi \201cation to exclude weekends, CHARTWEL, delivers 60 Gy in 40 fractions over 17 days. Modi \201cation has not yet been compared to other schedules. Treatment volume No randomized trials have examined what volume should be irradiated. The s tandard in most of the world is the primary tumor and hilar and mediastinal lymph nodes, wi th a 1 \200\2232 cm margin. Retrospective compar- isons have not demonstrated any advantage over volumes encompassing tumor and involved lymph nodes only. In dose escalation studies with conformal therapy, adjuvant nodal irradiation constrains the radiation dose delivered to the primary tumor. Omitting uninvolved nodal groups does not appear to increase local re lapse rate. Chemo-radiation The Non-Small Cell Lung Cancer Collaborative Group (1995)1 over- view sugge sted a 2% increase in 5-year survival when cisplatin-based chemotherapy is added to radical radiotherapy. The RTOG 88-08 study reinforces these conclusions, with a 4-year survival ad vantage of 5% with combined therapy. Chemotherapy delivered synchronously with radiotherapy has not yet been shown to increase s urvival in randomized trials and certainly OHO-16(259-294) 11/18/02 8:16 AM Page 273 NSCLC \200\224RADIATION THERAPY 273