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Patricia Rivera



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    MTE26 - New Paradigms in Symptom Management in Lung Cancer (Ticketed Session) (ID 836)

    • Event: WCLC 2018
    • Type: Meet the Expert Session
    • Track: Treatment in the Real World - Support, Survivorship, Systems Research
    • Presentations: 1
    • Moderators:
    • Coordinates: 9/26/2018, 07:00 - 08:00, Room 206 AC
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      MTE26.01 - Treatment of Cancer Related Symptoms (ID 11592)

      07:00 - 07:30  |  Presenting Author(s): Patricia Rivera

      • Abstract
      • Presentation
      • Slides

      Abstract

      The majority of patients with lung cancer are diagnosed with advanced disease where the 5-year survival rate remains low. Improving survival, quality of life (QOL) and control of symptoms are pivotal goals for health care professionals caring for patients with lung cancer. Several studies have shown that symptom burden and distress are higher among patients with lung cancer 1,2. Despite advances in treatment of advanced lung cancer including targeted oral therapies which have resulted in improved survival and QOL3, and early palliative care intervention which results in improvement in symptom control and quality of life4, a recent study showed persistent significant symptom burden, distress and unmet needs in patients with advanced lung cancer5. The most common symptom in lung cancer is fatigue, reported in about 40% of patients, followed by pain (30%)5. Organ specific symptoms and complications include cough and dyspnea (20%), airway obstruction, hemoptysis, pleural effusions and tracheoesophageal fistula5,6. Providers caring for lung cancer patients need to be aware of common symptoms and interventions available, particularly non-drug interventions, and work together in multidisciplinary teams to ensure lung cancer patients are receiving the best therapeutic and non-therapeutic interventions in their cancer care in order to improve survival and QOL.

      Interventions:

      -Fatigue:

      Cancer-related fatigue, sometimes referred as cancer fatigue syndrome may be related to both the disease process and treatments, including surgery, chemotherapy and radiation therapy. Other factors that may contribute to fatigue include anemia, dyspnea, decreased nutrition, decreased exercise, pain, depression, and insomnia.Pulmonary rehabilitation (PH)/physiotherapy, shown to be very effective in patients with COPD, is an underappreciated intervention in patients with lung cancer due to lack of randomized data and low rates of referral (<25%). Although limited, existing, evidence supports PH/physiotherapy in lung cancer patients before and after surgery and that in patients receiving therapy other than surgery, may result in both ability to maintain and improve physical function, muscle strength and quality of life 7,8.

      -Pain:

      Acute and chronic pain in the lung cancer patient may be multifactorial and influenced by physical, psychosocial and spiritual factors6. Pain-assessment tools and targeted imaging as required are as first essential steps in evaluating a patient’s pain symptom6. Healthcare providers should understand the WHO analgesic ladder which recommends use of analgesics (acetaminophen and NSAIDs) for mild pain, addition of weaker opioids (codeine or dihydrocodeine) for mild to moderate pain and stronger opioids (morphine, hydromorphone, oxycodone)for severe pain6. Psychologic factors contribute to increased pain and suffering among cancer patients and non-drug interventions including hypnosis, cognitive behavioral coping mechanisms, meditation and relaxation exercises have been shown to reduce pain in patients and long term survivors9.

      -Dyspnea:

      The symptom of dyspnea is complex , often multifactorial and results in worsening QOL in patients with lung cancer. Dyspnea may be due underlying COPD or cardiac disease, complications of the tumor such as airway obstruction or pleural effusion, and side effects of treatment such as anemia, muscle fatigue, infection, pneumonitis and decreased nutrition. Careful and thorough assessment is paramount in order to manage dyspnea effectively.

      -Airway Obstruction:

      Patients with symptomatic endobronchial and extrinsic airway obstruction can benefit significantly from therapeutic bronchoscopy. Therapeutic bronchoscopic interventions, often used in combination, include debulking of airway tumors mechanically, using laser, electrocautery, cryotherapy, argon plasma coagulation. Balloon dilatation and insertion of silicone or metallic airway stents may be performed to treat extrinsic stenosis or endobronchial strictures due to radiation and covered metallic airway stents are effective in the management of tracheoesophageal fistulas6.

      -Hemoptysis:

      Hemoptysis, occurring in about 7-10% of lung cancer patients, is most commonly due to endobronchial tumor involvement. Rare causes include airway-vascular fistula formation, tumor necrosis with cavity formation, and complications from treatment (bevacizumab). Hemoptysis can be minor or severe/massive, the later defined as more than 200 mL of blood in a 24-hour period and commonly requires intervention. Securing the airway with a single-lumen endotracheal tube is paramount. Bronchoscopy is an excellent tool for both diagnosis and therapeutic intervention when endobronchial disease is found as the cause of the hemoptysis and includes laser, electrocautery, and argon plasma coagulation. External beam radiation therapy may also be used for endobronchial tumors causing hemoptysis6. When hemoptysis is due to parenchymal lesion such cavitary lung lesions due to cancer or due to complications of therapy, external bean radiation therapy or bronchial artery embolization is recommended.

      References:

      1. Cooley ME. Symptoms in adults with lung cancer. A systematic research review. J Pain Symptom Manage 2000;19:137-53

      2. Graves KD, Arnold SM, Love CL, et al. Distress screening in a multidisciplinary lung cancer clinic : prevalence and predictors of clinically significant distress. Lung Cancer 2007; 55:215-24

      3. Rolfo C, Passiglia F, Ostrowski M, et al. Improvement in Lung Cancer Outcomes With Targeted Therapies: An Update for Family Physicians. J Am Board Int Med 2015;28:123-33

      4. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small cell lung cancer. N Engl J Med 2010;363:733-42

      5. Sung MR, Patel MV, Djalalov S, et al. Evolution of Symptom Burden of Advanced Lung Cancer Over a Decade. Clinical Lung Cancer 2017;3:264-80

      6. Simoff MJ, Lally B, Slade MG, et al. Symptom Management in Patients With Lung Cancer. Diagnosis and management of Lung Cancer, 3rded: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2013; 143(5) (Suppl):e455S-e497S

      7. Granger CL. Physiotherapy management of lung cancer. Journal of Physiotherapy 2016; 62:60-67

      8. Holland AE, Wadell K, Spruit MA. How to adapt the pulmonary rehabilitation programme to patients with chronic respiratory disease other than COPD. Eur Respir Rev 2013; 22:405-13

      9.Ayrjla KL, Jensen MP, Mendoza ME, et al. Psychological and Behavioral Approaches to Cancer Pain Management. J Clin Oncol 2014; 32:1703-11

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    P1.05 - Interventional Diagnostics/Pulmonology (Not CME Accredited Session) (ID 937)

    • Event: WCLC 2018
    • Type: Poster Viewing in the Exhibit Hall
    • Track:
    • Presentations: 1
    • Moderators:
    • Coordinates: 9/24/2018, 16:45 - 18:00, Exhibit Hall
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      P1.05-01 - Incidence and Clinical Relevance of NSCLC Lymph Node Micro-Metastasis Detected by Staging EBUS-TBNA (ID 13829)

      16:45 - 18:00  |  Author(s): Patricia Rivera

      • Abstract

      Background

      Appropriate staging of non-small cell lung cancer (NSCLC) patients is crucial to provide accurate prognostic information and select appropriate treatment. Several publications have reported an approximate 20% incidence of occult micro-metastasis (MM) in surgically resected lymph nodes (LN) pathologically interpreted as negative by hematoxylin and eosin staining (H&E). Detection of MM was associated with worsened survival. The majority of NSCLC lymph node staging is now conducted using endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). The purpose of this study is to determine the frequency of detection of occult MM in EBUS-TBNA specimens and to evaluate the impact of the presence of MM on progression-free and overall survival.

      a9ded1e5ce5d75814730bb4caaf49419 Method

      All patients undergoing EBUS-TBNA for NSCLC lymph node staging at our institution between September 2013 and October 2017 were eligible for inclusion. Patients were identified using provider-maintained case lists, operating or procedure room electronic schedules, and tumor board patient presentations. Patients were excluded if a definitive diagnosis of NSCLC was not obtained within 3 months of the EBUS-TBNA examination or if distant metastatic disease was present at the time of diagnosis. Patient cell blocks from the EBUS-TBNA procedure were evaluated by a cytopathologist using H&E staining according to standard guidelines. Patients with N2 or N3 disease on routine cytopathology examination were excluded. Cell blocks from the included patients were sectioned into five 5 mm sections spaced at least 10 mm apart and immunohistochemistry for pan-cytokeratin was performed. The resulting slides were then reviewed for evidence of MM by a blinded cytopathologist.

      4c3880bb027f159e801041b1021e88e8 Result

      Of 887 patients screened, 44 patients were identified fitting inclusion criteria with sufficient additional tissue for testing. The mean age and smoking history were 68 ± 10 years and 45 pack-year history, respectively. The patients were majority male (61%) and Caucasian (75%). Fifty-two percent of patients were stage 1 at the time of diagnosis, 34% were stage 2, and 14% were stage 3a. Three patients (6.8%) were found to have pan-cytokeratin positive MMs. All 3 MMs detected were at N2 LN stations. The presence of MMs was associated with significantly decreased progression-free (median 210 vs. 1293 days, p=0.0099) and overall survival (median 238 vs. 1120 days, p=0.0357).

      8eea62084ca7e541d918e823422bd82e Conclusion

      LN micro-metastases can be detected during EBUS-TBNA staging examinations and are associated with poor clinical outcomes. If prospectively confirmed in a larger study, these results have significant implications for EBUS-TBNA specimen analyses and the current NSCLC staging paradigm.

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