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Lung cancer is the second most common cancer in the UK and the leading
cause of cancer death in both men and women. It accounts for over 20
per cent of cancer deaths.
The prognosis of lung cancer is poor and this
is in large part because of late diagnosis, with the disease often being
advanced and incurable by the time patients seek medical advice. As with
other solid tumours, chance of curative treatment is improved if the
disease is detected and treated at an early stage.
To tie in with November’s Lung
Cancer Awareness Month, the Royal
Pharmaceutical Society in association with The Pharmaceutical Journal has
produced practice guidance (PDF 610K)
that highlights how community pharmacists can help with earlier detection
of lung cancer.
A key message is that pharmacists are in a good position
to identify
patients with suspicious symptoms.
One difficulty with lung cancer is that early symptoms are often non-specific.
The advice to pharmacists is to refer if the patient has persistent
symptoms, particularly if the patient is from a high-risk group (see
Panel below).
When to refer
Pharmacists should be suspicious if a patient has any of the following:
• A cough that does not go away after two to three weeks
• Worsening of a long-standing cough
• Persistent chest infections
• Coughing blood
• Unexplained persistent breathlessness
• Unexplained persistent tiredness or lack of energy
• Unexplained persistent weight loss
• Persistent chest and / or shoulder pain |
For
patients, the message of the awareness campaign is not to delay if they
have symptoms. They are being advised: “These symptoms may
not be serious, in which case you have got nothing to lose by getting
them checked out. If they are serious you have got everything to gain — diagnosis
at an early stage could save your life.”
Michael Peake, consultant in respiratory medicine at
Glenfield Hospital Leicester, and the Cancer Services Collaborative national
clinical lead
for lung cancer, believes that pharmacists can help to empower patients. “I
am convinced that a significant proportion of patients who don’t
like to pester the doctor could be picked up by pharmacists and persuaded
to go to the GP,” he says.
Dr Peake adds: “Twenty years ago
women with a breast lump did not want to bother the doctor but now women
are very proactive. We want the same situation with lung cancer. Patients
should be encouraged to go to the GP and ask if they need a chest X ray.”
One recent study among patients diagnosed with lung cancer found that
symptoms had been present for many months before advice was sought. Symptoms
were not in the main interpreted as serious by patients and so were not
acted on. They were attributed to everyday causes, such as “getting
older”.1
Lung Cancer Awareness Month
Lung
Cancer Awareness Month, now in its fifth year, is designed to
raise awareness of the disease and the importance of early diagnosis.
The awareness month was pioneered by Macmillan Cancer Support
and the Roy Castle Lung Cancer Foundation.
A multidisciplinary
working
group has now been convened by the Department of Health to bring
together the major stakeholders, including health professionals and
charities, to help raise the profile of the campaign.
The group sees
pharmacists as having an important role in helping to raise awareness.
The
UK Lung Cancer Coalition says: “Often patients will share
worries with a pharmacist or ask for their advice, and so pharmacists
can be an important conduit for ensuring that patients with symptoms
that could suggest lung cancer are directed to GP services.”
Posters
and leaflets about lung cancer have been made available for pharmacy
display. |
The UK Lung Cancer Coalition,
an organisation involved in Lung
Cancer Awareness Month, notes that one reason for delay is the continued
stigma associated with lung cancer, with many smokers feeling guilt that
they
have brought illness on themselves.
Reducing delays in access to specialist care is also vital to improving
outcome, an issue covered in the National Institute for Health and Clinical
Excellence referral guidelines for suspected cancer.
Although prognosis for patients with lung cancer is still poor, Dr Peake
says that studies are beginning to show modest improvement in survival
in UK specialist centres.
“One-year survival in Leicester has almost
doubled from 15 to 30 per cent, and we think that five-year survival
has improved from 5 per cent in the early 1990s to 9 per cent now,” he
says.
This improvement is related to system redesign, with quicker diagnosis
and access to multidisciplinary specialist teams. “I think we could
double five-year survival nationally without any new treatments, just
by applying what we know,” he says. Trends in lung cancer
Until the late 1990s, lung cancer was the most common cancer among
the UK population. It has now been overtaken by breast cancer but still
accounts for one in seven new cancer cases. In nearly all areas of
the UK, lung cancer is now a more common cause of death in women
than
breast cancer.
In men, mortality from lung cancer has been falling continuously,
from 107 deaths per 100,000 in 1971 to 53 deaths per 100,000 in 2005,
reflecting
the fall in smoking. In contrast, female lung cancer mortality rates
increased from 18 per 100,000 in 1971 to 30 per 100,000 in 2005.2
Smoking causes around 88 per cent of cases of lung cancer, and some
of the others will be caused by passive smoking. For pharmacists, advice
on smoking cessation is a key intervention to help reduce deaths from
lung cancer. There is good evidence that stopping at just about any
age
has a significant impact on risk. Sex differences in lung cancer
Sebastian Kaulitzki/Dreamstime.com
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Recent research has suggested possible differences between the sexes
in lung cancer.
There is evidence that women may be more susceptible than men to the
damaging effect of cigarette smoke on the lungs, and have a higher risk
of lung cancer than men with the same history of smoking.
Conversely,
a higher proportion of female lung cancer patients are never smokers:
15–20 per cent of lung cancers in women occur in never smokers
compared with 10 per cent in men.
Why women might have greater susceptibility to lung cancer is not known,
and not all the evidence points this way. However, at this year’s
American Society of Clinical
Oncology conference, Heather Wakelee,
from Stanford University, suggested that it might be related to hormonal
factors
or differences in DNA repair mechanisms.
Small cell lung cancer used to be more common in men than women but it
is now equally common in both sexes. This cancer is almost entirely smoking-related.
Adenocarcinoma (a type of non-small cell lung cancer) is more common
in women than men; it is also the most common type of lung cancer in
never-smokers. Interestingly, some 50 per cent of female adenocarcinomas
have oestrogen receptors on the tumour cell surface. “A large trial
needs to be done with tamoxifen in women with oestrogen-receptor positive
adenocarcinoma,” Dr Peake says.
Studies have also suggested sex differences in response to the newer
targeted cytotoxic drugs. For example, in the major phase III trial of
erlotinib, a tyrosine kinase inhibitor, there was a trend to longer survival
in women.
A new form of paclitaxel currently under development may work better
in women. Paclitaxel poliglumex is an inactive conjugate that is metabolised
to active paclitaxel in tumour cells (the idea being to reduce toxicity
to normal cells) and it has been suggested that this activation may be
enhanced by premenopausal levels of circulating oestrogen.
It is too early to know whether a patient’s sex might eventually
guide therapy choices in lung cancer but more studies are being done
to investigate the possible sex differences in response to treatment. Young people
Lung cancer cases in women may have plateaued now, but experts believe
that today’s smoking habits in young people may be storing up
problems for the future. Current cancer mortality trends reflect smoking
habits of 20 years ago.
“My guess is that we may see an epidemic
again in young women who are smoking now. Around 28 per cent of women
under 30 still smoke. They do not seem to have got the message,” says
Dr Peake.
In a recent survey of schoolchildren in England, 9 per cent of 11-
to 15-year-olds said that they smoked regularly (at least one cigarette
a week) — this is the same level as in 2003 and a reduction from
13 per cent in 1998. However, 20 per cent of 15-year-olds were regular
smokers. Girls were more likely to smoke than boys.3
Similarly, among 16- to 19-year-olds, smoking prevalence tends to be
higher in women than men.4
In the schoolchildren survey, a high proportion of regular smokers saw
themselves as dependent on the habit. Many said they would like to give
up and some had tried nicotine replacement therapy.3 Increased risk for early smokers?
People who begin to smoke at a young age are less likely to give up
than those who start later. A report published earlier this year by the
British Medical Association5 highlights research showing that people
who start smoking before age 16 are more than twice as likely to continue
smoking than those who begin later in life, and are likely to smoke
more heavily than those who begin to smoke later.
Lung cancer risk is related to the amount smoked per day and the duration
of smoking, with duration being the most important factor. So, clearly,
smokers who start young and continue to smoke are at higher risk. But
it may not just be a dose effect. There is also some evidence that younger
age of starting smoking may be a risk factor for lung cancer independently
of the amount or duration of smoking.
The jury is still out on this. Some experts take the view that the worse
outcome in those who start smoking at a young age is purely a function
of how long they have smoked. Others believe there is more to it and
that in young people the cells lining the airways are more susceptible
to DNA damage from carcinogens in tobacco.
“The lungs are still
maturing until age 14–15 and cell turnover is high. So we would
expect carcinogens to have a disproportionate effect at that age,” Dr
Peake says.
Pharmacy-led oral chemotherapy
lung cancer clinic
Increasing use of oral chemotherapy is offering opportunities
for greater pharmacist involvement in the care of patients with
lung cancer. At North Tyneside General Hospital, pharmacist Steve
Williamson runs a pharmacy-led oral chemotherapy clinic for patients
with advanced non-small cell lung cancer.
The clinic is for patients prescribed oral vinorelbine. “This
is a first-line chemotherapy for patients with poor performance
status who are not fit enough to tolerate standard two-drug intravenous
chemotherapy regimens,” says Mr Williamson, consultant pharmacist
in cancer services. “This tends to be older, frailer patients,” he
says.
Mr Williamson runs a weekly clinic on the ward and generally sees
two to three patients in each clinic. Most patients are receiving
vinorelbine single agent therapy; a few are taking oral vinorelbine
as part of a vinorelbine/cisplatin regimen. Vinorelbine is given
once a week for two weeks, followed by a two-week break, for four
cycles.
Patients come into the clinic for each dose. Before dispensing
the tablets, Mr Williamson arranges blood tests on the ward. If
the results are satisfactory, he assesses the patient’s fitness
for chemotherapy, checking against common toxicity criteria.
Patient group directions are used to supply treatments for chemotherapy-associated
problems, such as gastrointestinal problems (constipation is common
with vinorelbine), mouth problems, or nausea/vomiting, and he counsels
about mouth care and other issues. He is now training to be an
independent prescriber.
“I manage to run the clinic quite
successfully using PGDs, but being an independent prescriber will
give more freedom, allowing use of a non-standard course of a medicine
to relieve symptoms and will enable me to make dose adjustments
to a patient’s chemotherapy if, say, the blood counts are
borderline.”
Treatment is palliative but can improve symptoms and delay disease
progression.
Mr Williamson highlights the job satisfaction in this clinical
role. “I am able to build up a relationship with the patient,
becoming their key worker during their chemotherapy and helping
to sort out problems relating to their treatment.”
He adds: “We are committed to trying to improve patient safety.
Oral chemotherapy is an area of high risk so is an area to target
our clinical expertise.” He emphasises that patients on oral
chemotherapy should be monitored and counselled exactly the same
as those receiving IV chemotherapy.
“Oral vinorelbine is
less aggressive than alternate first-line treatments for NSCLC
but this is because it is given as a single agent rather than because
it is an oral therapy.”
Vinorelbine is currently the only oral cytotoxic used for lung
cancer at the hospital but others may be available soon. Mr Williamson
also plans to extend the clinic to include patients taking oral
chemotherapy for colorectal cancer. |
References
1. Corner J, Hopkinson J, Fitzsimmons D et al. Is late diagnosis of lung
cancer inevitable? Interview study of patients’ recollections of
symptoms before diagnosis. Thorax 2005;60:314–9
2. Cancer Research UK. UK
lung cancer and smoking statistics (accessed
19 October 2007)
3. National Centre for Social Research. Smoking,
drinking and drug use among young people in England in 2006
(accessed 19 October 2007)
4. Office for National Statistics. General Household Survey, 2005. Smoking
and drinking among adults 2005. London: ONS; 2006.
5. British Medical Association. Breaking the cycle of children’s
exposure to tobacco smoke. London: BMA; 2007. |
The
Pharmaceutical Journal