1. Oncology Pathways Lung CNG 2009

2. Intro Oncology overview Presentation and investigation Oncology Management strategies – Stage review – Follow up Management of toxicity research

3. Themes Early diagnosis Patient selection Pt centred care – Investigation and treatment – local – Expertise Future progress

4. MCCN Lung Cancer Overview Presentation and outcomes – Advanced disease – Poor prognosis (23% 1yr survival) – Comparable outcomes cf pt selection (NWCIS 2008) Devolved care – MDT & pt centred care – Chemotherapy – Satellite radiotherapy Specialised care – Diagnostic (EBUS) – Pathways: Mesothelioma – radiotherapy – Research Future Research – Huge potential – Need for greater collaboration

5. Approach to management Prevention/Screening Early Stage I/II Locally Advanced Stage III Advanced Stage IIIB/IV Surgery radiotherapy ChemoRadiotherapy concurrentSequential Chemotherapy Cure QOL

6. Investigation PET –CT – Improved staging but – More likely to upstage – False positive rates and treatment delay Histology – Standard of care for all ? – Move towards individualised management but – May not influence management (poor PS) – May delay treatment decision and palliative care

7. Histology Small Cell Carcinoma AdenoCarcinoma ERCC1 (DNA repair) – Platinum-resistance – ~50% of samples EGFR expression EGFR mutations – Rosell et al, Sept 2009 – 16% of 2100 samples – Predicted by Female, adeno, never-smokers

8. Rapid Access Instinctively correct for pt care and reassurance ? evidence for early diagnosis – CCO SCLC audit 2002-2008 Outstanding issues – Logistics and clinic design – Patient information and informed consent

9. Advanced Disease Stage IIIB and IV bulky LN disease, effusion, distant metastases Median survival 7-10 mths Chemotherapy 3-4 cycles standard of care (platinum-doublets) Important but modest gains in good PS 0-1 patients (NICE Guidance, 2005) Significant population of borderline cases (PS 2) Emphasis on patient centred care and QOL Clinical Trials

10. Palliative Chemotherapy ‘Benefits’ BenefitToxicity Physical psychological true perceived (pt, doctor, nurse, relative) ?Cost ?Convenience PS 0 No wt loss PS 3

11. Recent Advances Erlotinib (BR21, 2005) – Second/third line general population 2month OS – Maintenance (SATURN): 4weeks OS gain Bevacizumab (Sandler, 2006) – 2month benefit – Fatal pulmonary haemorrhage Cetuximab (FLEX Study, 2009) – 4 week benefit in EGFR expressing tumours Cisplatin-Premetrexed (2009) – Subset analysis in AdenoCa/Large Cell. – 2month survival benefit – Maintenance (JMEN, 2009) benefit Gefitinib (IPASS Study, 2009) – Benefit in First line EGFR mutations (60% of samples tested) – Selected advanced Adeno, Non-smokers – Gefitinib vs carboT – PFS benefit. OS 18.6mths (no difference)

12. NICE Guidance First Line – Cisplatin Premetrexed (TA181 Sept 09) – Bevacizumab (Withdrawn) – Cetuximab (Ongoing, Rejected EMEA) – Gefitinib 2010 – Erlotinib 2010 Second line – Erlotinib (TA162 Nov 08) – Alternative to Taxotere in 2 nd line

13. Locally Advanced Stages IIIA-B Variable course dependent on T & LN staging Median survival 14-16mths Comorbidity issues Progress Radiotherapy Planning – Hypofractionation, CHART, Stereotactic, IMRT ChemoRadiotherapy Sequencing – Concurrent 16 vs 13mths

14. Resection Adjuvant therapy – Delivery of post op chemotherapy in high risk disease (micro metastases) – T2N1 disease (?large 1B) – Cisplatin-based 2.5-4.1% Absolute benefit – Low numbers (10% resection, PET) – Comorbidity Trials – MAGRIT (adjuvant vaccination) – 25% NSCLC MAGE 3 expression (poor prognostic feature) – Supportive Phase II data

15. Follow up Second Line therapy – Taxotere (7.5 VS 4.6mths) – Erlotinib Aims/endpoints – Reassurance – Data collection – Identification of recurrence – No impact on survival ? Maintenance trials – No agreed standard FU

16. toxicities Pt selection – Toxicity linked to PS and comorbidity – Early mortality 25/15% in Poor PS SCLC/NSCLC NCEPOD 2008. – SACT ‘For better, for worse’ – Examples of poor management, pt selection – failings in acute care (35% good) NCAG & Acute Oncology – Every hospital with A&E should have Acute Oncology Team consisting of Oncology, Nurse Specialists and Admin support – MCCN leading with AOT’s in place 01/04/10

17. Novel Toxicities & MDT working Erlotinib – Rash – diarrhoea Bevacizumab – Bleeding – Hypertension – perforation Sunitinib – Hand foot syndrome – Arrythmia & QT interval

18. MCCN Trials Portfolio Prevention/Screening Early Stage I/II Locally Advanced Stage III Advanced Stage IIIB/IV Surgery radiotherapy ChemoRadiotherapy concurrentSequential Chemotherapy LLP ?Screening MAGRIT SOCCAR START ET Trial Fragmatic Lilly Lungstar NovaRex Transitions Breathlessness QUARTZ SCORAD

19. Barriers To Research National – Bureaucracy and Research Governance – Eligibility Criteria (PS, comorbidity) Local Time constraints Medical Preference (eg QUARTZ) Patient inconvenience (eg BTOG) Competition for funds (Industry) ? Concept of local versus subspecialist care in lung cancer research

20. conclusions Majority of patients continue to present with advanced, poor PS and comorbidity MCCN compares favourably nationally and internationally when comparing Good PS Emphasis on local delivery of Patient-centred care Patient selection essential at all points Need for collaboration and subspecialist care