Lung Cancer and Palliative Care

Lung Cancer and Palliative Care

– Dr. Prabhat S. Malik, New Delhi

Lung cancer is the most common cause of cancer-related mortality worldwide. It is considered as the ‘disease of smokers’; however lung cancer in non-smokers is being recognized as an increasingly prominent public health issue in recent times. Though screening with low dose CT scan is recommended in high-risk population, it’s applicability in Indian contexts is questionable in view of the high false positivity due to a tuberculosis endemicity. Most patients present in advanced stages and the prognosis has been dismal. Lung cancers are generally associated with a high symptom burden and a poor quality of life. Conventionally, lung cancer is treated with surgery in early stage, with chemo-radiotherapy in locally advanced stage and with systemic therapy in metastatic setting.

Over the years, our understanding of disease biology has evolved. Newer molecular targets and driver mutations have been identified which play a major role in disease pathogenesis that can be addressed with therapeutic interventions. These advancements have led to a complete shift in the treatment paradigm and outlook of this deadly disease. Incorporating targeted treatments and immunotherapeutic approaches over the past decade, have significantly improved the survival rates, even at advanced stages.

Currently, more than 2/3^rd of lung adenocarcinomas and about a third of squamous cell carcinomas can be characterized based on the mutation profile. Mutations in epidermal growth factor receptors (EGFR) best illustrate the success story of targeted therapy. EGFR mutations strongly predict the efficacy of inhibitors of EGFR with response rates higher than 70%, median progression free survival ranging from 9-19 months and median overall survival of 24-36 months are seen in multiple studies. Similarly, several other therapeutic targets like ALK, ROS1, BRAF, MET, RET, Her-2, NTRK and KRAS have been identified and treated with appropriate targeted treatments.

Another breakthrough in the field of lung cancer treatment is the development of immune checkpoint inhibitors. These molecules block the checkpoints used by the cancer cells to evade host immune surveillance, particularly the PD1-PDL1 axis and CTLA4 receptor. These drugs have been shown to produce durable responses even in advanced or metastatic disease.

Despite initial success of these targeted therapeutic options, most patients with advanced lung cancer eventually face resistance development and disease progression. Timely integration of palliative care in the course of illness have been found to be associated with better quality of life, a better understanding of the disease and treatment goals, a better end of life care and eventually better survival. Lung cancer management is a perfect example of multidisciplinary team approach which involves a good co-ordination between medical, surgical and radiation oncologists, molecular pathologist, intervention radiologists and the palliative care team.

Clinical Vignette: An 82 year old lady presented with gradually worsening shortness of breath. Post evaluation, she was found to have massive left pleural effusion. Pleural fluid cytology revealed the presence of malignant cells. Though the patient’s son was a doctor himself, the family was concerned about the diagnosis and the limitations of therapeutic options due to her old age and frailty. The patient was then evaluated and counselled by the palliative care team. A pigtail catheter drainage of the pleural effusion was done to relive her dyspnoea. Pleural fluid was sent for cell block preparation and subsequent pathological and molecular testing. After drainage of pleural fluid and lung expansion, chemical pleurodesis was performed. Cell block evaluation revealed presence of adenocarcinoma and EGFR mutation (exon 19 deletion). She was started on EGFR inhibitor erlotinib by the medical oncology team. She tolerated the treatment very well without much toxicities. She continued to remain active and at home with a good quality of life, while taking only one oral pill every day. Her disease progressed after 16 months and she subsequently succumbed due to the disease with a very dignified end of life care.

This was a classic example of how practicing a multidisciplinary team approach in the management of advance lung cancer ensures the provision of good quality of life and better survival outcomes.