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Case history

image A 71-year-old man presented with increasing shortness of breath, productive cough, lethargy, weight loss and haemoptysis. CT was suggestive of stage IV lung cancer (T4N3M1a), and bronchial biopsies confirmed squamous cell carcinoma. Past medical history included peripheral vascular disease, hypertension and chronic obstructive pulmonary disease (COPD). His medications included: salbutamol inhaler (as required), simvastatin, clopidogrel, bisoprolol, amlodipine and ramipril. He had been a lifelong smoker (60 pack-year history) and drank 24 units alcohol/week. He lived with his son in a first floor flat and mobilized independently with a stick.

A Barthel Index of activities of daily living (ADL) was used to assess his functional ability and revealed he needed assistance with bathing and using stairs. He also reported intermittent dizziness on standing and two falls (one associated with syncope) in the last 6 months. His lying BP was 130/90 mmHg, with a BP of 105/65 mmHg at 1 min, which improved to 120/75 mmHg at 3 min. His ECG showed sinus rhythm with a rate of 70 bpm and no ischaemic change. He was urgently referred to a falls clinic.

In view of metastatic non-small-cell lung carcinoma (NSCLC) he was offered palliative chemotherapy and opted for treatment to preserve his quality of life. Because of his respiratory and vascular comorbidities he received carboplatin AUC 5 and gemcitabine 1000 mg/m2 with prophylactic antibiotics. He experienced severe nausea and required a dose reduction. He completed four cycles with no further complications and achieved partial response. Nine months later he progressed locally and proceeded to second-line chemotherapy with docetaxel 60 mg/m2, with partial response. He progressed 4 months later with liver metastases and at this point his performance status (PS) had deteriorated significantly and he was offered best supportive care (BSC) by his community palliative team. He died at home approximately 18 months after the initial diagnosis.

What is the goal of cancer treatment for this patient?

What is the evidence base for treatment options in metastatic NSCLC?

What is the evidence base for treatment options in this patient?

How should this patient be optimized prior to starting cancer treatment?

What is the goal of cancer treatment for this patient?

The treatment aim in metastatic NSCLC is to control symptoms, preserve functional status and prolong survival. The patient wanted to stay at home with his son and was willing to accept additional support. With appropriate tailored chemotherapy he achieved 18 months' survival with a good quality of life.

What is the evidence base for treatment options in metastatic NSCLC?

Treatment decisions should be directed by a multidisciplinary cancer team and will depend on histology, molecular pathology, age, PS, comorbidities and patient preference. Four cycles of platinum-based doublet chemotherapy are recommended for patients with PS 0–2. In the presence of EGFR mutation, tyrosine kinase inhibitors (TKIs) should be offered as first-line agents in patients with PS 0-3. Second-line ...

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