Transcript Oncology Pathways - Cheshire & Merseyside Strategic

Oncology Pathways
Lung CNG 2009
Intro
• Oncology overview
• Presentation and investigation
• Oncology Management strategies
– Stage review
– Follow up
• Management of toxicity
• research
Themes
• Early diagnosis
• Patient selection
• Pt centred care
– Investigation and treatment
– local
– Expertise
• Future progress
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
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Diagnostic (EBUS)
Pathways: Mesothelioma
radiotherapy
Research
• Future Research
– Huge potential
– Need for greater collaboration
Approach to management
Prevention/Screening
Early
Stage I/II
Surgery
radiotherapy
Cure
Locally Advanced
Stage III
ChemoRadiotherapy
concurrent
Advanced
Stage IIIB/IV
Chemotherapy
Sequential
QOL
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
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
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
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
Palliative Chemotherapy
‘Benefits’
PS 0
No wt loss
Benefit
PS 3
Toxicity
Physical
?Cost
psychological
?Convenience
true
perceived (pt,
doctor, nurse, relative)
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)
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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)
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 2nd line
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
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
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
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
Novel Toxicities
& MDT working
• Erlotinib
– Rash
– diarrhoea
• Bevacizumab
– Bleeding
– Hypertension
– perforation
• Sunitinib
– Hand foot syndrome
– Arrythmia & QT interval
MCCN Trials Portfolio
Prevention/Screening
Early
Stage I/II
Locally Advanced
Stage III
MAGRIT
Surgery
LLP
?Screening
ET Trial
Fragmatic
Lilly
Lungstar
ChemoRadiotherapy
Advanced
Stage IIIB/IV
Chemotherapy
SOCCAR
radiotherapy
concurrent
NovaRex
Sequential
START
QUARTZ
SCORAD
Transitions
Breathlessness
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
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