2012/13 - HKTS / ACCP 2012 Public Education Activity - Lung Cancer Eduction Events
Lung Cancer Education Series
From September 2012 onwards, the HKTS / ACCP (HK and Macau Chapter) has devised a series of public education activities on Lung Cancer. Having obtained the full support of the both HKTS and ACCP (HK and Macau Chapter) Councils, the following Key Messages were conveyed to the public through a series of radio program and news media columns as listed here.
Key Messages
1. Epidemiology
1.1 Lung Cancer New Cases in 2009 in HK=4,365 (2848 males, 1517 females; M:F 1.9:1).
1.2 Ranked number one among all cancers in HK (for both sexes). Lung cancer is the commonest cancer in men and the third commonest in women, after breast cancer and colorectal cancer.
1.3 Lung Cancer accounted for 16.8% of new cancer cases.
1.4 Estimates of the relative risk of lung cancer in the long-term smoker compared with the lifetime nonsmoker vary from 10- to 30-fold.
1.5 Worldwide, lung cancer in never smokers comprises an estimated 15 to 20 percent of cases in men and over 50 percent in women. There are major geographic differences, particularly in Asia, where 60 to 80 percent of women with the disease are never smokers. The incidence of small cell lung cancer in never smokers is exceedingly small.
1.6 Data from HKU published in 2003: Smoking was the most important risk factor associated with lung cancer but the attributable risk (AR) was estimated to be 45.8% in men and 6.2% in women. Among women, exposure to environmental tobacco smoke (ETS) at work and /at home and lack of education, were independent risk factors for lung cancer with adjusted odds ratio (OR) 3.60, (95% confidence interval (CI) 1.52-/8.51) and OR 2.41 (95% CI 1.27-/4.55), respectively.
1.7 Mortality
In 2009:(mortality ranked first among all cancers in both genders):
Death registered Relative frequency among the top 10 cancers deaths Crude mortality rate (per 100,000)
All 3692 28.8 52.7
Male 2465 32.1 74.8
Female 1227 23.8 33.1
1.8 Environmental toxins — Environmental factors have been associated with an increased risk for developing lung cancer. These include exposure to second-hand smoke, asbestos, radon, metals (arsenic, chromium, and nickel), ionizing radiation, and polycyclic aromatic hydrocarbons.
1.9 Pulmonary fibrosis — Several studies have shown that the risk for lung cancer is increased about sevenfold patients with pulmonary fibrosis. This increased risk appears to be independent of smoking.
1.10 Genetic factors — Genetic factors can affect both the risk for and prognosis from lung cancer. Although the genetic basis of lung cancer is still being elucidated, there is a clearly established familial risk.
2 Symptoms, Diagnosis and Investigations
2.1 Symptoms are usually non-specific to lung cancer and can be late findings already.
2.2 Radiological (providing images) and tissue (providing the cells) diagnosis are both important
2.3 Respiratory physicians carry out a variety of endoscopic procedures to obtain tissue diagnosis.
2.4 Bronchoscopy, Autofluoresent bronchoscopy, Endobronchial ultrasound (EBUS) and Pleuroscopy are performed by respiratory physicians
2.5 EBUS (氣管鏡超聲波) and Pleuroscopy (內科胸腔鏡) are relatively new endoscopic procedures that enable the diagnosis and staging of lung cancer to be carried out under local anaesthesia (局部麻醉) in a minimally-invasive (微創) manner (vs. the previous procedures that require surgical operations under general anaesthesia)
2.6 Image (ultrasound or CT-guided) biopsy through chest wall can also enable tissue diagnosis
2.7 CT scan and PET scan are common and complementary radiological diagnostic tools.
2.8 Staging is useful for the treatment planning and prognosis. Staging is determined by the size, location and extent of the tumour, as well as the presence of lymph node and distant metastases.
3 Screening, Prevention and Prognosis
3.1 Cigarette smoking is responsible for almost 90% of lung cancer
3.2 The best way to prevent lung cancer is never start or to quit smoking
3.3 Low dose CT as a screening tool was found to be useful in a US study for those people who are at high risk:
• Current or former smokers, aged 55-74 years
• A smoking history of at least 30 pack-years
• No history of lung cancer
3.4 CXR alone was not recommended for Lung cancer screening
3.5 Low dose CT screening should NOT be recommended for everyone
3.6 Pitfalls of screening by LDCT
• False positive
• Anxiety, invasive procedures
• In NLST study, nearly ¼ patients have positive results and >95% positive results were false positive
• Radiation exposure (0.5-1.5mSv for low dose CT)
• High TB prevalence in HK
• Lack of local study and uncertain cost effectiveness of screening in HK
3.7 5 year survival rates for clinical stages:
• IA 50%
• II 26-36%
• III 7-19%
• IV 2%
4 Treatment (1)
4.1 What is personalized treatment for advanced stage lung cancer?
To tailor make treatment according to the characteristics of tumors.
Most lung tumors are adenocarcinomas (70%), among squamous cell, large cell and small cell lung cancer. Among lung adenocarcinomas, EGFR mutations could be present in up to 50% among Asian patients with lung cancer. For tumors with EGFR mutations, good response to EGFR-TKI treatment is obtained in 70% of patients. Patients who are EGFR-wildtype should consider alternative options like systemic chemotherapy
4.2 What are the different therapeutic targets in advanced stage lung cancer?
The most common EGFR mutations occurs at Exons 18 – 21, with deletion 19 and L858R at exon 21 marking the tumor’s favourable response to EGFR-TKI treatment. Other types of EGFR mutations like T790M at exon 20 means resistance to EGFR-TKI treatment.
The presence of EGFR mutation is usually exclusive to the presence of other cancer driver mutations
One example is the ALK rearrangement, present on human chromosome 2, which is found in up to 7% of tumors in the Asian population. The presence of such ALK gene rearrangement is known to give good response to treatment with Crizotinib.
4.3 What’s the benefit of targeting the right target in advanced stage lung cancer?
Treatment with EGFR-TKI for EGFR mutated tumors prolongs the median progression free survival period of up to 19 months compared to conventional chemotherapy, which is usually 5 – 9 months
4.4 Tissue is the issue, so repeat biopsy or fluid specimens could be indicated.
5 Treatment (2)
5.1 Why do some patients need chemotherapy after surgery for early stage lung cancer? Is surgery supposedly curative?
• Cancer cells have the tendency to spread even in early development/stages
• Current scanning is not 100% accurate in picking up small number of cancer cells hidden in our body
• Chance of disease recurrence >30% even for early stage lung cancer after surgery
• Stage II or III lung cancer after surgery may benefit from post-operative chemotherapy (platinum-based) with improvement of 5-year survival by 5%
5.2 How to choose between chemotherapy and targeted therapy? What are the factors for decision-making?
• With known biomarkers in tumours (e.g. EGFR mutations) specific targeted therapy
• Without known biomarkers in tumours chemotherapy
• Chemotherapy can only be given to those with relatively good performance state
• Most important factor is to have enough tumour tissues when getting biopsies during diagnosis, which facilitate mutation testing
5.3 Can I have chemo + oral drugs together?
• Combination of chemotherapy with EGFR targeted therapy (oral drugs) at the same time has been shown to be of no benefit over chemotherapy alone for patients with lung cancer
RTHK Programs
Date Topic Speaker
23 Oct, 2012 Epidemiology Dr Fanny KO
30 Oct, 2012 Symptoms and Diagnosis/Investigations Dr Johnny CHAN
13 Nov, 2012 Lung Cancer Treatment I Dr David LAM
20 Nov, 2012 Lung Cancer Treatment II Dr James HO
Featured articles in Eastweek (東周刊):
11.12.2012 Drs Fanny Ko and Johnny Chan
18.12.2012 Drs James Ho and David Lam
8.1.2013 Drs Angus Lo and Johnny Chan
16.1.2013 Drs James Ho and David Lam
The outlines are given below and the text version will be uploaded to the Newsletter website.
香港胸肺學會肺癌專輯大綱
媒體：東周刊
出版日期：2012年12月及2013年1月，共4集
第一集：早期肺癌患者的故事(上)——有關成因、檢查及病徵
- 個案經歷：有吸煙史的年長患者因身體檢查發現肺部有陰影
- 醫學資料：吸煙與肺癌的關係+ importance of smoking cessation
- 醫學資料：吸煙患者常有長期咳嗽，容易與肺癌病徵混淆，早前肺癌病徵不明顯+有沒有早期察覺肺癌的方法(low dose CT screening)
- 個案經歷：患者需要再進行其他檢查才能確診是否患上肺癌
- 醫學資料：患者需要進行的檢查，包括各種掃描、各種氣管內窺鏡及抽取活組織的應用以達到確診及staging目的
第二集：早期肺癌患者的故事(下)——早期肺癌患者治療篇
- 個案經歷：患者需要進行手術切除腫瘤
- 醫學資料：Staging of lung cancer and its bearing on prognosis and treatment option; 肺癌的手術治療及微創手術; who is eligible?
- 個案經歷：患者再需要接受電療及化療
- 醫學資料：indications and the process of neoadjuvant and adjuvant chemo/irradiation; 術後電療及化療的應用、療效及副作用
第三集：晚期肺癌患者的故事(上)——晚期肺癌患者求診篇
- 個案經歷：沒有吸煙病史的年輕女性患上因肺積水求診, 結果最後診斷為腺癌
- 醫學資料：年輕女性及非吸煙肺癌患者的增加趨勢; non-smoking etiology of lung cancer; the epidemiology of Hong Kong and the rest of the world
- 醫學資料：及晚期肺癌病徵的多樣化; such as bone pain, shortness of breath, other paraneoplastic and metastatic symptoms; pleural effusion is associated with a late stage already
- 個案經歷：患者抽取活組織檢驗(抽肺水化驗, 超聲波, 肺膜組織化驗及內科胸腔鏡) 及確定EGFR status ; 各種掃描例如電腦掃描, PET 等
- 醫學資料：活檢組織可用作分析肺癌的腫瘤，而造影檢查則幫助評計癌細胞的擴散程度
第四集：晚期肺癌患者的故事(下) ——晚期肺癌患者治療篇
- 個案經歷：患者帶有EGFR基因突變
- 醫學資料：帶有EGFR基因突變可選擇的治療方案，及其療效和副作用
- 醫學資料：沒有EGFR基因突變可選擇的治療方案，及其療效和副作用
- 個案經歷：患者病情復發
- 醫學資料：肺癌患者完成治療後的覆診方案，減少復發的治療及復發治療
Health columns in The Sun Daily:
10.12.2012 Advanced lung cancer treatment (Dr James Ho)
17.12.2012 The use of endoscopy in taking biopsy (Dr Johnny Chan)
24.12.2012 The use of Autofluorescence Bronchoscopy in carcinoma in situ (Dr David Lam)
31.12.2012 The relationship between smoking and lung cancer (Dr Angus Lo)
7.1.2013 The non-smoker lung cancer patient (Dr Fanny Ko)
This series of activities on Lung Cancer has not yet concluded at the time of this reporting in the Newsletter and more articles are expected in due course.
