After long interval, I want to discuss a topic not unfamiliar in health post or public education material. The topic on ADVANCED Lung cancer. (晚期肺癌)
The diagnosis of cancer is very important to patient's life. There is no permission of any degree of error whatsoever. In addition to the verdict of malignant disease, the
type and stage of the cancer and the approach of staging or treatment must be communicated in skilful and easy to understand manner. The avoidance of pessimism
(悲观主义) must be balanced with honest and candid approach.
For lung cancer, it is quite common to find out that patient with this disease falls into late stage group. The handling of such patients demand skill and empathy.
More crucial, it is the time for physician to spend with the patient indirecly convey the sense of "captain ordering vessel abandonment" in its worst scenario.
Patients, especially the young and working group, would seldom recieve the message in positive way.
Nowadays, as spoken by one eminent local oncologist, the development of orally administered target enzyme blocker drug for anti- lung cancer treatment
(Tyrosin kinase inhibitor, or TKI in short) is a miles stone in the treatment of all cancers. Compared to the invention of penicillin (Fleming in nineteenth century)
discovery of insulin synthesis, the invention of exogenous corticosteroid (Cushing in early twentithed century) , the accidental notice of anti-tuberculosis chemotherapy
(Streptomycin, in parenteral form), the use of first TKI gefitonib (Iressa R 易瑞沙) in advanced lung cancer brought hope to only small group of patients with lung cancer.
But the concept of personalised treatment of all cancer has revolutionized the entire medical community,
It is rather a change of personal treatment concept that has significant impact on entire medical community that the pursuit of genetic marker for most diseases has the
implication of treatment.
For example, the association of chromosomal abnormality with retinoblastoma, the use of target therapy in iv form for Gastrointestinal Stromal cancer (GIST), the use of
propanolol for the treatment of facial or other childhood haemangioma, the screening for congenital hypothyroidism and familial polyposis. All these discoveries are not
applicable to all form of diseases but the spirit has strong repercussion on medical knowledge advancement. It is in fact a change of paradigm. (though a cliche陳詞濫調)
but very true)
The diagnosis of advanced lung cancer is usually based on PET scan (正電子斷層掃描) or advanced symptoms such as pleural effusion, hoarseness of voice
or palpable lymphadenopathy or multiple lesions in X ray/CT scan. With the need for tissue for genetic study, the requirement for tissue confirmation and
genetic marker study is mandatory irrespective what stage of disease or patients' status are.
Using efficient DNA extraction and/or amplification technique, even a small amount of tissue or cells are sufficient for EGFR receptor study. Sometimes, the shredded
cells in pleural effusion specimen or TBNA (transbronchial needle aspiration biopsy) is enough for marker study. Another study for the ALK- receptor study is more
expansive and less easily available (in both Universities' lab.). Radiological guided biopsy can generate core of tissue (with 20 G or 18 G needle) which is even better.
For TBNA , if performed by endobronchial ultrasound, the accuracy is very acceptable and risk-free. The endobronchial ultrasound is now widely available in all HA
hospitals and most private hospitals.
However, the aspirated cells are still less abundant than mediastinoscopic biopsy and both procedures should be complementary and not mutually exclusive
to lung cancer patients.
Finally, the handling of message to patients and their familes must be careful and consistent. It is best dealt with by patient 's primary care physicians. So the consulting
Oncologist can spare the effort of bad news breaking. Clinical oncologists can concentrate on various form of treatment and pros and cons of chemotherapy.
With oral TKI, target drug therapy is main stay for advanced lung cancer treatment.
For the rest of patients who did not have EGFR +ve addenocarcinoma, induction and maintenance of chemotherapy with Premetrexed or other drugs are well
tolerated and beneficial to young and fit patient.
I welcome all question on advanced lung cancer diagnostic procedure, such as CT guided Fine needle biopsy or core needle biopsy, Video assisted thoracoscopic,
Pleural effusion biopsy and eradication, Endobronchial ultrasound TBNA, Endoscopic Ultrasound FNAC and mediastinoscopy and Ultrasound guided neck or chest wall
biopsy. My clinic no is 3160 8865.
My clinic in Mongkok (3160 8847) and in Central (3543 1814).