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Frankly Speaking About Lung Cancer

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					  Frankly Speaking About Lung Cancer




  The Wellness Community
  provides a free program of
 emotional support, education
and hope for people with cancer
     and their loved ones.


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  Frankly Speaking About Lung Cancer



The Wellness Community
Patient Active Concept
 “Cancer patients who participate in their
     fight for recovery along with their
  healthcare team will improve the quality
    of their lives and may enhance the
           possibility of recovery.”


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    Frankly Speaking About Lung Cancer



The Wellness Community
• national non-profit organization
• 21 locations nationwide + 2 international
• over 12,000 support group sessions
• 138,000 visits each year
• Research, publications
• The Virtual Wellness Community


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      The Wellness Community Programs

• Weekly patient support      • Nutritional education
  groups                      • Stress reduction
• Weekly family support         programs (Tai Chi,
  groups                        Yoga, etc.)
• Diagnosis specific          • Exercise programs
  networking groups           • Children‟s programs
• Bereavement groups          • Resource library
• Educational programs        • Social activities

           All programs are free of charge!

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Frankly Speaking About Lung Cancer




  “What You Need to
Know About Lung Cancer
   & Its Treatment”



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      Frankly Speaking About Lung Cancer



Powerful facts:
• 177,000 cases annually
• Lung cancer is the #1 cause of cancer-
  related deaths by far in the U.S.
  …more than breast, prostate, and colon
  cancer combined.

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     Frankly Speaking About Lung Cancer



Risk Factors:
• Smoking (90% of all cases)
• Second-hand smoke (25% of non-smoker
  cases)
• Occupational/environmental



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     Frankly Speaking About Lung Cancer


Non-Small Cell Lung Cancer (NSCLC)
Comprises 85% of all lung cancers
Types of NSCLC:
  – Adenocarcinoma (most common)
  – Squamous cell
  – Bronchoalveolar Carcinoma
  – Large Cell Carcinoma
  – Adenosquamous

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      Frankly Speaking About Lung Cancer



Small Cell Lung Cancer (SCLC)
•   Comprises 15-20% of all lung cancers
•   Spreads more aggressively than NSCLC
•   Is more responsive to chemotherapy
•   Frequently found in smokers or former
    smokers



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    Frankly Speaking About Lung Cancer


Stages of Non-Small Cell Lung Cancer
– Stage I     confined to lung tissue alone
– Stage II    lung tissue and lymph nodes in
              lung
– Stage III   lung tissue and lymph nodes
              outside of the lung
– Stage IV    distant spread (liver, adrenal
              glands, bone, brain, other sites)


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  Frankly Speaking About Lung Cancer




LUNG CANCER STAGING (TNM)
 T= Primary tumor size (T1-T4)
 N= Lymph node involvement (N1-N3)
 M= Distant metastasis (M0-M1)




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       Frankly Speaking About Lung Cancer


Treatment of Stage I NSCLC
•   Evaluate for surgery
•   Surgery alone is the standard of care
•   Pathologic stage I: 67% cure
•   Clinical trials are evaluating the value of
    adjuvant (after surgery) therapy




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        Frankly Speaking About Lung Cancer


Treatment of Stage II NSCLC
•   Evaluate for type of surgery
•   Surgery alone is the standard of care
•   Pathologic stage II: 40-50% cure
•   Clinical trials are evaluating the value of
    adjuvant (after surgery) therapy



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          Frankly Speaking About Lung Cancer

‘Theoretical’ Advantages of Combining Different Types
   of Cancer Therapies
•   Chemotherapy:
    Controls micro-metastases that may be responsible
    for systemic recurrence after “successful” surgery

    Acts synergistically with XRT to downstage NSCLC
    and make tumor-free margin surgery more likely

•   Radiation Therapy
     “Sterilizes” surgical margins making local recurrence
    less likely
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        Frankly Speaking About Lung Cancer


Summary: Treatment Stage I & II NSCLC
•   Surgery is the standard of care
•   Neoadjuvant (given before surgery) therapy is
    promising
•   Adjuvant (given after surgery) chemotherapy
    or radiation therapy show no improvement




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      Frankly Speaking About Lung Cancer


Stage III Non-Small Cell Lung Cancer
•   2 types: Stage IIIA and Stage IIIB
•   Radiation alone was the standard care
    until 1990‟s
•   Chemotherapy + radiation is the new
    standard based on results of clinical trials
•   Newer radiation techniques minimize side
    effects of treatment


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      Frankly Speaking About Lung Cancer


Treatment of Stage III NSCLC
• Chemo + radiation = standard of care
• Role of surgery is undefined
• Unanswered questions:
  -Which chemo is best? How does one decide?
  -When & how should chemotherapy be given?
  -When & how should radiation be given?


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     Frankly Speaking About Lung Cancer


Stage III A Non-Small Cell Lung Cancer
•  Bulky vs. minimal disease
•  Chemotherapy + radiation
•  Commonly used chemotherapy drugs:
  – Platinum-based
  – Non-platinum based
• Role of surgery undefined


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        Frankly Speaking About Lung Cancer


Stage III B Non-Small Cell Lung Cancer
•    Pleural effusion affects treatment plan
•    Chemotherapy + radiation or radiation alone
•    Commonly used chemotherapy drugs:
    – Platinum-based
    – Non-platinum based



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       Frankly Speaking About Lung Cancer


Treatment of Stage IIIB-IV NSCLC
Reduce Chemotherapy Toxicity
• Recent study: Combination of 2 drugs provide
  same benefit as 3, but with fewer side effects:
  –Less nausea/vomiting
  –Less hair loss
  –Less nerve damage
  –Lower risk of infection
• Gemcitabine + vinorelbine slightly less toxicity
  but equivalent response
              (Cancer, Vol. 95, No. 6, 2002)

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      Frankly Speaking About Lung Cancer


Stage IV NSCLC

NCI Recommended First-Line Chemotherapy:
 –   gemcitabine + cisplatin
 –   paclitaxel + carboplatin or cisplatin
 –   vinorelbine + cisplatin
 –   docetaxel + cisplatin
 –   Other drug combinations


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       Frankly Speaking About Lung Cancer


Treatment of Recurrent NSCLC
Challenges of decision-making
• General health status of the patient
• Several treatment options with equivalent results
  but widely varying side effects
• Balancing quality of life with side effects
• Patient‟s goals and wishes


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     Frankly Speaking About Lung Cancer


Treatment of Recurrent NSCLC
NCI Recommended treatment options:
• Chemotherapy
  – vinorelbine + cisplatin
  – paclitaxel +cisplatin or carboplatin
  – gemcitabine + cisplatin
  – docetaxel + cisplatin
  – Other drug combinations

•   Palliative radiation therapy to relieve
    symptoms
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          Frankly Speaking About Lung Cancer


Treatment of Small Cell Lung Cancer
•    Limited stage: chemo+ xrt =standard of care
    – etoposide + cisplatin + radiation
    – cisplatin + irinotecan

•    Extensive stage: first-line chemotherapy
    – etoposide (VP-16) + cisplatin (or carboplatin)+
       radiation
    – cisplatin + irinotecan
    – CAV, CAE in clinical trials
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        Frankly Speaking About Lung Cancer

Treatment of Recurrent Small Cell Lung Cancer
• Possible Chemotherapy Agents:
      – topotecan (Hycamtin): only FDA-approved drug for
        recurrent disease
      – oral etoposide (VP-16)
      – paclitaxel (Taxol)
      – irinotecan/CPT-11 (Camptosar)
      – CAV
      – others in clinical trials
•   Palliative radiation to relieve symptoms

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       Frankly Speaking About Lung Cancer


Newer Strategies: Targeted Therapy
•   Chemotherapy targets general features of
    cells, including both cancer cells and normal
    cells
•   Normal cells usually recover, while cancer
    cells may not
•   However, chemotherapy is associated with
    side effects


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    Frankly Speaking About Lung Cancer


Examples of Lung Cancer Targeted Therapy
in Development
   • Epidermal        • PDGF-r
     Growth Factor    • Cox-2
     Receptors
                      • Ras inhibitors
   • Angiogenesis
                      • Raf inhibitors
   • Antisense
                      • Map kinase
   • Protein Kinase C
                      • Others
   • C-kit

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    Frankly Speaking About Lung Cancer



Epidermal Growth Factor Receptors
•   Iressa (AstraZeneca)
•   Tarceva (Genentech)
•   Erbitux (Imclone, BMS)
•   Many others in development



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          Frankly Speaking About Lung Cancer


Angiogenesis Inhibitors
•       “Angio”=blood vessel, “Genesis”=formation
        or beginning
•       Many agents being tested to inhibit this
        process:
    –    Anti-VEGF
    –    Thalidomide
    –    Angiostatin/Endostatin
    –    Anti-VEGF tyrosine kinase inhibitors
    – Others
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    Frankly Speaking About Lung Cancer


Antisense Drugs
Affinitac (Lilly)
•   Antisense drug to protein kinase C
•   Phase II studies completed combining
    with chemotherapy
•   Evaluating effectiveness in recurrent lung
    cancer
•   Phase III trials underway comparing
    chemotherapy + drug

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Frankly Speaking About Lung Cancer




  “What You Need to
Know About Lung Cancer
   & Its Treatment”

 Questions and Discussion


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 Frankly Speaking About Lung Cancer




PATIENT ACTIVE BREAK




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   Frankly Speaking About Lung Cancer



“Issues to Discuss With Your Doctor
  When Making Decisions About Lung
           Cancer Treatment:
     A Patient Active Approach”




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     Frankly Speaking About Lung Cancer



Making decisions about cancer treatment
  is a complex and sometimes
  overwhelming experience.

You have choices. But you need to be
  informed & you need to evaluate
  many aspects of your care.


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      Frankly Speaking About Lung Cancer



What is the goal of my cancer therapy?

 – Is it prolongation of life?
 – Is to control symptoms?
 – Is it palliation?


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     Frankly Speaking About Lung Cancer



What is a clinical trial and would one be a
  reasonable treatment option for me?

What are the risks and benefits?




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       Frankly Speaking About Lung Cancer


Clinical Trial Definitions
  – Phase I-new drug/treatment well-tested in the
    lab now testing toxicity in people
  – Phase II-new drug/treatment has given good
    preliminary results-test feasibility
  – Phase III-compares new drug/treatment vs
    standard of care



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      Frankly Speaking About Lung Cancer



What are the risks of treatment?

What are the risks of no treatment?

Should I seek a second opinion?


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       Frankly Speaking About Lung Cancer


Are there some treatments that have
   equal benefit, but fewer or different
   side effects?

Can we discuss which side effects I would
  be most concerned about having or
  preventing?

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      Frankly Speaking About Lung Cancer

How do we balance my quality of life with
  my need for effective treatment?

How will we know that the treatment is
  working?

What can I expect to happen to me as the
  cancer progresses?

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      Frankly Speaking About Lung Cancer


Can I continue to work or maintain my
  other daily activities during treatment?

•   If I have pain, what should I do?
•   Nausea & vomiting?
•   Fatigue?
•   Risk of infection?

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       Frankly Speaking About Lung Cancer



Why do some people who smoke get lung
  cancer while others don‟t?

Why did I get lung cancer if I never
  smoked?



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    Frankly Speaking About Lung Cancer




What kind of supportive resources are
  available to me and my family?

What can I expect from an emotional
  perspective?


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      Frankly Speaking About Lung Cancer



Questions to Ask Yourself:
What can I do to be a stronger partner
  with my physician & health care team?

What is my goal of therapy and have I
  expressed that to my physician?


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       Frankly Speaking About Lung Cancer

Am I ready and willing to participate fully
  and actively in my treatment plan?

Do I know what the potential side effects
  of therapy are and how best to prevent
  or manage them?

Have I communicated with my physician
  what „quality of life‟ means to me?
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      Frankly Speaking About Lung Cancer



How will I (and my family) address the
  emotional issues of living with lung
  cancer?

Is a support group right for me (and/or my
    family)?


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      Frankly Speaking About Lung Cancer


Making decisions about lung cancer and its
  treatment is never easy.

By being informed & partnering with your
   physician & health care team, you can
   improve the quality of your life and may
   enhance the possibility of your recovery.


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    Frankly Speaking About Lung Cancer



Making Decisions About Lung Cancer
              Treatment

      Questions and Discussion




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