Current Diagnostic and Treatment Algorithm for Lung Cancer
Lung cancer is the leading cause of cancer deaths worldwide. According to information from Robert Koch Institute, about 64,000 patients were diagnosed with lung cancer in 2014 in Germany alone (1). The prognosis of lung cancer is generally poor with an estimated relative 5 years survival rate of 15 % for males and 20% for females (1). The two major forms of lung cancer are non–small-cell lung cancer (about 85% of all lung cancers) and small-cell lung cancer (about 15%). Despite advances in early detection and standard treatment, non–small-cell lung cancer is often diagnosed at an advanced stage and has a poor prognosis.
Advances in the diagnosis and treatment of lung cancer have had a major impact on the management of this malignancy. In lung tumor care, doctors from different specialties often work together to create a patient’s overall treatment plan that combines different types of treatment. The personalized care plan is the cornerstone of the successful treatment of cancers in Germany. Each patient receives an individualized treatment plan depending on their tumour type and its stage of progression. In order to do that, the identification of tumour histology and staging of the tumour is of fundamental importance for the successful planning of treatment options. This is a key factor in German Health Advisors’ daily work.
For each patient with a tumour, we attempt to initially fulfill these two aspects in collaboration with our patients and local colleagues. We then discuss the case with the specialists, or, at the multidisciplinary tumour boards at our partner clinics in Germany. If any problems arise, we communicate this to our patients and try to find solutions. This usually happens when we get incorrect or incomplete pathology or radiology reports (discussed in details below).
Initial Staging and Risk Assessment
The staging for overseas patients is usually not complete when they contact us for a second opinion and/or any subsequent treatment recommendations. The system employed by German Health Advisors, however, allows for the completion of this stage while the patients are in their homeland. It is not necessary to come to Germany for cancer staging. You will be informed if there are any obstacles in the staging process. For the staging of lung cancer, please bear in mind the following:
- Family history, physical examination, blood count and differential, tumor markers, liver and renal function tests (see the request form for German Health Advisors). This will usually be carried out by our local colleagues and documented in the form of a doctor’s letter.
- Pathology of lung cancer. Sputum cytology is a quick and inexpensive test, however, it is not always accurate. The false-positive rate is low (1%), but false-negatives can occur in as many as 40% of tests. Therefore, a biopsy is needed for a definitive diagnosis. A biopsy can be taken in a number of ways, including bronchoscopy, mediastinoscopy and CT-guided needle biopsy to collect suspicious cells. If it is already done, please, keep this report to send it to us later on. In some cases, when our specialists are not satisfied with the quality of a pathology report, we will contact you with a recommendation for further steps. You may have to send us the frozen/paraffin embedded tissue samples for further histology investigation at one of German Health Advisors’ partner laboratories in Germany.
- The following imaging tests might be required to diagnose lung cancer: X-rays, CT-Scan, and PET scan.You can send the DICOM files of CT scans using German Health Advisors’ secure data transfer system. Our experience shows that the quality of radiology images might not be good enough to correctly stage the cancer. In such cases, we will contact you in order to work towards a solution. It is of great importance for us to have high-quality radiology images from our local colleagues. This greatly assists in defining the diagnostic and treatment plan in a timely fashion and helps to avoid unnecessary expenses.
- Bone scan or positron emission tomography (PET), ideally coupled with CT, can be used for detection of bone metastasis. PET-CT is currently limited by its high cost and will not be covered by insurance. However, in some countries, such radiology tests are less expensive. You can obtain MRI or/and FDG-PET scanning and send the results using German Health Advisors’ secure data transfer system. Such results would be greatly advantageous in assisting the staging
Treatment of Lung Cancer
In our partner clinics in Germany, usually, a multidisciplinary team of specialists discusses each case to define the best treatment strategy for the patients. Below we list the main current treatment options:
- The aim of the surgical treatment is to remove the lung cancer and a margin of healthy tissue. In order to remove lung cancer, the following procedures can be employed: Wedge resection, Segmental resection, Lobectomy and Pneumonectomy
- Radiation therapy uses high-powered energy beams from sources such as X-rays and protons. For people with locally advanced lung cancer, radiation may be used before surgery or after surgery. It's often combined with chemotherapy treatments.
- Chemotherapy for lung cancer is usually given after surgery to kill any cancer cells that may remain. It can be used alone or combined with radiation therapy. Sometimes chemotherapy may be used before surgery as well, with the goal of shrinking the cancer before an operation.
- Stereotactic radiosurgery is generally used for people who cannot have surgery because of age, lung disease, or heart disease. The treatment machine directs beams of high-dose radiation directly to the area in the lung that needs to be treated.
- Targeted drug therapy.Drugs that target specific malfunctions that allow cancer cells to grow are available to people with lung cancer, such as angiogenesis (i.e. Avastin,Cyramza etc.) or EGFR inhibitors (i.e. Tarceva Gilotrif etc.).
- Immunotherapy. Some patients with advanced colon cancer have a chance to benefit from immunotherapy with antibodies such as pembrolizumab (Keytruda). Pembrolizumab is considered a standard first-line option for patients with advanced NSCLC and PD-L1 expression 50% who do not otherwise have contraindications to use of immunotherapy, such as severe autoimmune disease or organ transplantation (2).
- Proton beam therapy. One of the newest radiation therapies is proton beam therapy can benefit children, young adults, and those with cancers located close to critical organs and body structures.
Follow-Up After Treatment of Lung Cancer
Due to the aggressive nature of this disease, generally close follow-up will be followed. The German Health Advisors’ partner clinics will normally schedule follow-ups in this manner:
- The first follow-up control is usually scheduled two or three months after the treatment. Further follow-up controls will be done every three to six months for the first 2 years. These controls usually include assessment of treatment effect and CT- Scan.
- Two years after the treatment, the follow-up controls may be conducted less often
The patients, who got their treatments in Germany, usually do not need to come for the follow-up controls to Germany. German Health Advisors will provide you with follow-up care through its Telemedicine platform.
Keywords: colorectal cancer, rectal cancer, cytoreductive surgery, HIPEC, targeted therapy,
1. Lungenkrebs (Bronchialkarzinom). Source: https://www.krebsdaten.de
2. ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol (2018) 29 (suppl 4): iv192–iv237