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Outcomes of lung cancer

CXR of lung cancer obstructing the air entry into the right lung (right panel - red arrowed) and after (left panel) therapy - good response to therapy.
CXR of lung cancer obstructing the air entry into the right lung (right panel - red arrowed) and after (left panel) therapy - good response to therapy.
Of the 20% of patients who undergo curative resection, regrettably only 25-30% of these are alive at five years due to local/chest relapse in a quarter of this number and further afield/metastatic spread in three quarters. Of course, within this group are better outcome patients; thus, a patient with a true, early and small stage 1 tumour has a greater than 50% chance of being alive and disease free at this time point, but regrettably such patients account for only 5% of the population of patients presenting with this diagnosis.


Patients with squamous cancers have a marginally better outlook, stage for stage, than those with adenocarcinomas.


Unfortunately, the majority of patients with lung cancer relapse, and the sites of relapse vary between individuals. Sometimes the relapse is in the original site and, once again, may present with coughing up of blood or imminent collapse of a lung due to tumour obstructing the bronchial tree. In these situations, radiotherapy is needed to relieve the problem.


Where the patient has had previous radiotherapy,, this may be problematic as it is not always safe to repeat the course, although with modern planning methods (IMRT, tomotherapy)to reduce the re-treatment dose to critically sensitive structures such as the thoracic spinal cord, it is more feasible than in previous times.


However, the possibility of intraluminal brachytherapy should also be considered in these situations. In this technique, sealed radioactive sources are implanted, down a bronchoscope, to a localised area within the bronchial tree to deliver a highly focal; re-treatment radiation dose to this region. By the inverse square law (the law that says that if you are in a ship at sea and you treble your distance from a lighthouse, then the intensity of the lighthouse beam reduces to one ninth) the intense re-treatment dose is confined to the local tumour recurrence. Considerable success has been achieved with brachytherapy in this situation, moreso than laser therapy down a bronchoscope, which is an alternative method which has been tried.


For disease relapse outside the chest, chemotherapy makes the most sense and is recommended for all those fit enough to withstand a course. However, particular relapse situations may require more individual attention. For example, painful bone relapses may be most simply and effectively treated by a short course of radiotherapy directed just to the metastasis within the bone.


A spine metastasis causing pain is similarly treated by local radiotherapy as is brain metastatic relapse. If a bone metastasis is threatening to cause a fracture of a long bone such as the femur (the thigh bone) then an orthopaedic operation to stabilise the bone prior to radiation is required.


In general terms, when a patient with lung cancer has relapsed, particularly with metastatic relapse, then the patient is incurable and has an outlook for life measured in months. This being the case, so it is the strategy of the doctors looking after such a patient to concentrate on the patients’ comfort rather than striving to give every last agent that might prolong life a little but detract from its quality, due to treatment toxicity, in the process. Therefore, chemotherapy will be used carefully bearing in mind both the patient’s tolerance of the drug regime and the regression of the tumour equally. Tyrosine kinase inhibitor (TKI) therapy is much better tolerated than chemotherapy and may be indicated in these patients.Otherwise, therapy is palliative (i.e. entirely directed at alleviating symptoms).


Furthermore, where a patient has liver metastases that have resisted chemotherapy and has a life expectancy of weeks or a month or so only, then the development of brain metastases would usually not be an indication for brain radiotherapy.


Sadly, this disease usually ends in death and palliative care teams such as the MacMillan palliative care nursing teams who practice home nursing care and work in conjunction with the hospice movement are important professionals in the last months of life for many lung cancer patients.

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