What is the diagnosis and treatment of lung carcinoma (lung cancer)?

From the Guidelines

Lung cancer treatment should prioritize a multidisciplinary approach, with consideration of the cancer type, stage, and patient health, as outlined in the most recent guidelines, such as the 2022 ASCO guideline for stage III non-small-cell lung cancer 1. When managing lung cancer, it is essential to consider the heterogeneity of the disease, particularly in stage III non-small-cell lung cancer, where treatment options vary significantly among clinicians and institutions.

• The diagnosis and treatment of lung cancer should be individualized, taking into account patient factors, radiologic characteristics, and local experience, as recommended by the NCCN Guidelines for NSCLC 1.
• Early detection and prompt treatment are crucial, as the five-year survival rate varies widely from 60% for localized disease to 6% for metastatic cancer, emphasizing the importance of regular screenings for high-risk individuals, particularly smokers aged 50-80 with a 20+ pack-year history.
• Treatment options for lung cancer typically involve surgery, chemotherapy, radiation therapy, targeted therapy, or immunotherapy, with the choice of treatment depending on the cancer type, stage, and patient health, as discussed in the current WHO guidelines and the critical role of immunohistochemical markers in the subclassification of non-small cell lung carcinoma (NSCLC) 1.
• Prevention focuses on avoiding tobacco, limiting exposure to carcinogens, maintaining a healthy lifestyle, and getting regular check-ups, which can help reduce the risk of developing lung cancer.
• The most recent and highest quality study, the 2022 ASCO guideline for stage III non-small-cell lung cancer 1, provides evidence-based guidance on the common clinical dilemmas that clinicians may have while evaluating a patient with suspected or known stage III NSCLC, and should be prioritized when making treatment decisions.

From the FDA Drug Label

INDICATIONS AND USAGE KEYTRUDA is a programmed death receptor-1 (PD-1)-blocking antibody indicated: Non-Small Cell Lung Cancer (NSCLC) in combination with pemetrexed and platinum chemotherapy, as first-line treatment of patients with metastatic nonsquamous NSCLC, with no EGFR or ALK genomic tumor aberrations. (1.2) in combination with carboplatin and either paclitaxel or paclitaxel protein-bound, as first-line treatment of patients with metastatic squamous NSCLC. (1. 2) as a single agent for the first-line treatment of patients with NSCLC expressing PD-L1 [Tumor Proportion Score (TPS) ≥1%] as determined by an FDA-approved test, with no EGFR or ALK genomic tumor aberrations, and is: Stage III where patients are not candidates for surgical resection or definitive chemoradiation, or metastatic. (1.2. 1) as a single agent for the treatment of patients with metastatic NSCLC whose tumors express PD-L1 (TPS ≥1%) as determined by an FDA-approved test, with disease progression on or after platinum-containing chemotherapy. Patients with EGFR or ALK genomic tumor aberrations should have disease progression on FDA-approved therapy for these aberrations prior to receiving KEYTRUDA. (1.2. 1) for the treatment of patients with resectable (tumors ≥4 cm or node positive) NSCLC in combination with platinum-containing chemotherapy as neoadjuvant treatment, and then continued as a single agent as adjuvant treatment after surgery. (1. 2) as a single agent, for adjuvant treatment following resection and platinum-based chemotherapy for adult patients with Stage IB (T2a ≥4 cm), II, or IIIA NSCLC. (1.2)

Lung Cancer Treatment Options

• Pembrolizumab (KEYTRUDA): is indicated for the treatment of patients with non-small cell lung cancer (NSCLC) in various settings, including first-line treatment, adjuvant treatment, and treatment of metastatic disease.
• Nivolumab (OPDIVO): is also indicated for the treatment of patients with NSCLC, including resectable NSCLC, metastatic NSCLC, and NSCLC with PD-L1 expression. Key Considerations
• PD-L1 expression is an important factor in determining treatment eligibility for both pembrolizumab and nivolumab.
• Patients with EGFR or ALK genomic tumor aberrations should have disease progression on FDA-approved therapy for these aberrations prior to receiving pembrolizumab or nivolumab. 2 3

From the Research

Lung Cancer Overview

• Lung cancer is the most common type of cancer and the leading cause of cancer deaths in the United States for both men and women 4.
• It is classified histologically into small cell and non-small cell lung cancers 5.
• The most common symptoms of lung cancer are cough, dyspnea, hemoptysis, and systemic symptoms such as weight loss and anorexia 5, 6.

Diagnosis and Evaluation

• The diagnostic evaluation of lung cancer has three simultaneous steps: tissue diagnosis, staging, and functional evaluation, all of which affect treatment planning and determination of prognosis 5.
• A standardized evaluation, relying on symptoms, signs, and routinely available laboratory tests, can serve as a useful screen for metastatic disease 7, 8.
• Imaging plays an important role in the staging evaluation of the patient, and radiologists need to be aware of the differences in what each specialist needs from imaging to provide appropriate treatment 4.

Treatment and Screening

• Treatment options for lung cancer vary based on staging, histology, immunotherapy biomarker testing, and patient health status 6.
• Treatments include surgical resection, immunotherapy, chemotherapy, and/or radiotherapy 6.
• The U.S. Preventive Services Task Force recommends annual lung cancer screening using low-dose computed tomography starting at 50 years of age in patients with a 20 pack-year history 6.
• Family physicians should focus on primary prevention of lung cancer by encouraging tobacco cessation and early recognition by screening at-risk individuals and following guidelines for pulmonary nodules 6.