Lung Cancer Guidelines - CMS
ANTI-EMETICPractice GuidelinesPage 1 of 10ONC – Anti-Emetic – Practice GuidelinesCopyright 2005 Oncology Network Consultants is an affiliate of Texas Oncology P.A. All rights reserved. These guidelines and this illustration may not bereproduced in any form without the express written permission of Oncology Network Consultants.
Guidelines LegendClinical StateDo BoxDiagnostic AssessmentStageTreatmentReference to another algorithmNOTE:Algorithm’s number sequence within the parenthesis ( ) are defined as such:First number represents the guideline treatment; second number represents the directional step; an asterisk* represents additionalnotes listed on the following page(s).Page 2 of 10ONC – Anti-Emetic – Practice GuidelinesCopyright 2005 Oncology Network Consultants is an affiliate of Texas Oncology P.A. All rights reserved. These guidelines and this illustration may not bereproduced in any form without the express written permission of Oncology Network Consultants.
Anti-EmeticTreatment ntial(1.2)LowLevel I, II(1.3)MildLevel III(1.4)Moderate/HighLevel IV, V(1.5)Review eIV/PO /- prnAnti-emetics(1.6)Coverage forPO meds(1.9)Access toin officePO meds(1.13)YES5-HT3RA10-20mgmDexamethasone PO(1.17)No coveragefor PO meds(1.10)NO5-HT3RA10-20mgmDexamethasone IV(1.14)Review InsuranceContractCoverage(1.8)Coverage forPO meds(1.11)Access toin officePO meds(1.15)No coveragefor PO meds(1.12)NO5-HT3RA10-20mgmDexamethasone IV(1.16)YES5-HT3RA10-20mgmDexamethasone PO(1.18)Page 3 of 10ONC – Anti-Emetic – Practice GuidelinesCopyright 2005 Oncology Network Consultants is an affiliate of Texas Oncology P.A. All rights reserved. These guidelines and this illustration may not bereproduced in any form without the express written permission of Oncology Network Consultants.
Anti-Emetic Protocol (AEP) for ChemotherapyPatient’s Name:Physician’s Name:Check all appropriate boxes (Level:)Emetogenic Potential:I, IIAnti-Emetic Regimen:Low to MinimalLevel:Emetogenic Potential:IIIAnti-Emetic Regimen:MildOREmetogenic Potential:IV, VNOTE:Routine:PRN:Routine:Dolasetron 100mgm POKytril 2mgm PO(FOR PO SEE NOTE BELOW)Dolasetron 100 mgm IVKytril 1mgm IVDexamethasone 10mg IVDexamethasone 20mg IVDexamethasone 10mg PODexamethasone 20mg POCompazine spansule 15mg POORLevel:PRN:Compazine 10mg IVCompazine spansule 15mg PODexamethasone 10mg IVDexamethasone 20mg IVDexamethasone 10mg PODexamethasone 20mg POAnti-Emetic Regimen:PRN:Routine:Moderate/HighDolasetron 100mgm POORKytril 2mgm PO(FOR PO SEE NOTE BELOW)Dolasetron 1.8mgm/kg IVORKytril 1mgm IVDexamethasone 10mg IVDexamethasone 20mg IVDexamethasone 10mg PODexamethasone 20mg POCompazine spansule 15mg PON.B. - For administration of oral Dolasetron the following two (2) conditions must apply:1)Insurance covers in office administration of PO anti-emetics; and2)The drug is available in the office.If either condition does not apply, the IV drug is ordered.PRN Anti-Emetics:Compazine 10mg IV q4-6hLorazepam 1mg Iv q4-6hDroperidol 1-2mg IV q4h (refractory nausea)Delayed Anti-Emetic Regimen:Dexamethasone 8mg PO bid x 2 days, then 4mg bid x 2 days, plusMetoclopramide 20mg PO qid x 2 days, plus Diphenhydramine 25 -50mg PO prn dystoniaCompazine spansule 15 - 30mg PO bidPhysician’s signatureDatePage 4 of 10ONC – Anti-Emetic – Practice GuidelinesCopyright 2005 Oncology Network Consultants is an affiliate of Texas Oncology P.A. All rights reserved. These guidelines and this illustration may not bereproduced in any form without the express written permission of Oncology Network Consultants.
Anti-Emetic Protocol (AEP) Guidelines for AdultsAcute Anti-Emetic Regimens:Grade:VAcute Emetic Potential:HighAnti-Emetic Regimen:5-HT3RA (dolesetron, granisetron or ondansetron) 10-20mg Dexamethasone IV/POOR5-HT3RA (dolesetron, granisetron or ondansetron) 10-20mg Dexamethasone PO(see note)Grade:IVAcute Emetic Potential:ModerateAnti-Emetic Regimen:5-HT3RA (dolesetron, granisetron or ondansetron) 10-20mg Dexamethasone IV/POOR5HT3RA (dolesetron, granisetron or ondansetron) 10-20mg Dexamethasone POGrade:IIIAcute Emetic Potential:MildAnti-Emetic Regimen:5-HT3RA (dolesetron, granisetron or ondansetron) 10-20mg Dexamethasone IV/POOR5-HT3RA (dolesetron, granisetron or ondansetron) 10-20mg Dexamethasone PO(see note)Grade:IIAcute Emetic Potential:LowAnti-Emetic Regimen:Dexamethasone 10-20mg IV/POGrade:IAcute Emetic Potential:MinimalAnti-Emetic Regimen:PRN anti-emetics onlyNOTE:Not all providers reimburse for oral anti-emetics given in the office. Check algorithm and insurance coverage before giving PO regimen.Delayed Anti-Emetic Regimen:To begin the morning of the day following chemotherapy which may require delayed anti-emetic regimen. Dexamethasone 8mg PO bid x 2 days, taper to 4mg bid x 2 days;PLUS Prochlorperazine 15mg spansule PO bid x 2 days plus Diphendydramine 50mg PO q 4hrs prn restlessness;OR Dexamethasone 8mg PO bid x 2 days, taper to 4mg bid x 2 days;PLUS Metoclopramide 30mg PO qid x 2 days plus Diphenhydramine 25-50mg PO q 4hrs prn restlessness.PRN Anti-Emetics:All patients (Grade I-V) should have PRN anti-emetics ordered. Patients receiving Grade I chemotherapy regimens require PRN antiemetics only: Lorazepam 1-3mg PO/IV every 4-6 hours prn;Prochlorperazine spansule 15mg PO bid prn; ORMetoclopramide 30mg PO every 4 hours prn, plus Diphenhydramine 50mg PO prn dystonia reactions or restlessness.NOTE:Patients should receive Dexamethasone concurrently with Serotonin antagonists when possible. For leukemia, lymphoma, multiple myeloma, and bonemarrow transplant patients, refer to individual protocols for Dexamethasone use. Patients may not tolerate Metoclopramide or Prochlorperazine for delayedemesis regimens, however, Dexamethasone is strongly recommended.Page 5 of 10ONC – Anti-Emetic – Practice GuidelinesCopyright 2005 Oncology Network Consultants is an affiliate of Texas Oncology P.A. All rights reserved. These guidelines and this illustration may not bereproduced in any form without the express written permission of Oncology Network Consultants.
Anti-Emetic Protocol (AEP) Guidelines for AdultsEmetogenic potential of individual chemotherapy agents:Grade:VAcute Emetic Potential:HighBusulfan2Carboplatin 1000mg/m2Carmustine 200mg/m2Cisplatin 70mg/m2Cyclophosphamide 1000mg/mCytarabine 1000mg/m2Dacarbazine 500mg/mDactinomycin2Ifosfamide 3g/m2Lomustine 60mg/mGrade:IVAcute Emetic Potential:2ModerateAmifostine (Ethyol) 200mg/m2Carboplatin 300-1000mg/m2Carmustine 200mg/m2Cisplatin 70mg/m2Cyclophosphamide 750-1000mg/m2Cytarabine 250-1000mg/m2Dacarbazine 500mg/mDaunorubicin 75mg/m2Doxorubicin 45mg/mEloxatinEpirubicin (Ellenece)Idarubicin2Ifosfamide 1200-3000mg/m2Lomustine 60mg/mGrade:IIIAcute Emetic Potential:MildAldesleukinAltretamine2Amifostine (Ethyol) 200mg/mArsenic toxicide (Trisenox)2Carboplatin 300mg/mCyclophosphamide 750mg/m2Cytarabine 20-250mg/mDenileukin (Ontak)2Doxorubicin 20-45mg/mEtoposideGrade:IIAcute Emetic Potential:LowAlemtuzumab (Campath)Bleomycin2Cytarabine 20mg/m2Docetaxel 60-100 mg/m2Doxorubicin 20mg/mDoxil (liposomal doxorubicin)5FU 1000mg/m2Fludarabine 30mg/m2Gemcitabine 1000mg/m2Hydroxyurea 1000-6000mg/m2Irinotecan 125 mg/m2Methotrexate 250mg/mMitomycin2Mitoxantrone 10-14mg/mPeg Interferon-alpha(PEG-Intron)2Topotecan 1.5mg/mGrade:IAcute Emetic bineCyclophosphamide (po)Floxuridine25FU 1000mg/mFulvestrant (Faslodex)GoserelinInterferonIrbitumomab nTrastuzumab (Herceptin)Valrubicin rethamine2Melphalan 140mg/mStreptozocinThiotepa2Methotrexate 1000mg/mPentostatinPlicamycin (Mitramycin)2Procarbazine 100mg/mVelcade22Gemtuzumab (Mylotarg)2Ifosfamide 1200mg/m2Methotrexate 250mg/mMitotaneDetermination of Emetogenic Potential of Chemotherapy Combination Regimens:1. Combining two (2) antineoplastic agents from Class II and above increases the emetogenic potential of the combination (one) 1 class higher thanthe most emetogenic agent in the combination. (Example: Low Mild Moderate; Mild Moderate High; Low Moderate High)2.Combine three (3) agents from Class III and above raises the emetogenic level 2 classes higher than the most emetogenic agent in thecombination. (Example: Mild Mild Mild High)3.Combining three (3) agents where two (2) are from Class II, follow rule #1. (Example: Low Low Mild Moderate)4.The addition of any number of agents from Class I does not change the calculated class.5.When in doubt, raise to a higher class.Physician’s signatureSource: Hesketh P, et al. Support Care Cancer 1995; 3:340DatePage 6 of 10ONC – Anti-Emetic – Practice GuidelinesCopyright 2005 Oncology Network Consultants is an affiliate of Texas Oncology P.A. All rights reserved. These guidelines and this illustration may not bereproduced in any form without the express written permission of Oncology Network Consultants.
High risk fordelayed emesis(2.1)*Anti-EmeticTreatment AlgorithmDelayed er 5-HT3RA Emend Decadron(2.5)*YES5-HT3 RA Decadron routine delayed emesisregimen. Considerpalonosetron in refractorycases.(2.6)*Page 7 of 10ONC – Anti-Emetic – Practice GuidelinesCopyright 2005 Oncology Network Consultants is an affiliate of Texas Oncology P.A. All rights reserved. These guidelines and this illustration may not bereproduced in any form without the express written permission of Oncology Network Consultants.
Anti-Emetic Practice Guidelines - NOTESAE-2:2.1Although not perfect, 5-HT3RA receptor antagonists (RAs) represented a significant steptowards emesis control in cancer chemotherapy. However, delayed emesis has continued tobe a problem. There are those with high risk for delayed emesis. Risk factors include acuteemesis with chemotherapy, delayed emesis with previous chemotherapy, lack of alcohol use,female sex, previous history of morning or motion sickness. Using platinum containingchemotherapy as maximal emetogenesis, slightly over 50% of patients will have control ofdelayed emesis with standard AEP recommendations that is a 5-HT3 RA on day 1 andDecadron and metoclopramide on days 2-5. A new neurokinin-1 antagonist, aprepitant(Emend), when added to a 5-HT3 RA has improved control to 70 % through day 5. Inaddition, a longer acting 5-HT3 RA has been approved for use, palonosetron (Aloxi). This isnot approved for delayed emesis prevention for platinum containing regimens but mayimprove delayed emesis control with moderately emetogenic regimens. Even with these newdrugs, a significant obstacle to emesis control is standardizing the approach using thecombination of drugs shown to lead to the best outcomes.2.2Aprepitant has been studied in regimens with 70 mgm/m2 cisplatin.2.5Aprepitant enhances the effects of Decadron so that a maximum of 8mgm daily isrecommended with aprepitant on days 2 and 3. The role of palonosetron in this situation isunproven. Aprepitant is an oral preparation and will not be covered as part of chemotherapy.For Medicare patients it may be an out-of-pocket expense.2.6Control of acute emesis in moderately emetogenic chemotherapy (MEC) is 80-85% with5-HT3RA plus a minimum of 8 mgm of decadron. With a regimen of decadron andmetoclopramide the control rate for delayed emesis is 55-65%. (Roila F, Basurto C, BosnjakG et al). Palonosetron has been shown to have a better control rate for delayed emesis forMEC when compared to a typical 5-HT3 RA only, without the use of decadron. (RubensteinEB, Gralla RJ, Einsenberg P et al). When trials of typical 5-HT3 RA with decadron plus adelayed regimen are compared to the palonosetron trials, the results are similar. It has notbeen shown that palonosetron leads to better control than current regimens. A trial ofpalonosetron with decadron would be appropriate in those who have failed standard AEPrecommendations. Adding Emend to standard non-platinum containing regimens withdelayed emesis refractory to usual measures is also reasonable.Page 8 of 10ONC – Anti-Emetic – Practice GuidelinesCopyright 2005 Oncology Network Consultants is an affiliate of Texas Oncology P.A. All rights reserved. These guidelines and this illustration may not bereproduced in any form without the express written permission of Oncology Network Consultants.
Anti-EmeticRadiation TreatmentAE-3ConcurrentChemo/XRT(3.1)YESUse AEP forchemo agents(3.2)NONOUpper GI tract orTBI(3.3)No routine antiemetic needed(3.4)YESAdd prophylacticGranisetron 2mgmPO on each day ofXRT(3.5)Page 9 of 10ONC – Anti-Emetic – Practice GuidelinesCopyright 2005 Oncology Network Consultants is an affiliate of Texas Oncology P.A. All rights reserved. These guidelines and this illustration may not bereproduced in any form without the express written permission of Oncology Network Consultants.
REFERENCESFor Anti-EmeticRoila F, Basurto C, Bosnjak G, et al. Optimal dose of dexamethasone inn preventing acuteemesis induced by highly-moderately emetogenic chemotherapy: a randomized, doubleblind, dose-finding study Proc Am Soc Clinic Onc 2003; 22:729 Abst 2930.Rubenstein EB, Gralla RJ, Einsenberg P, et al. Paolnosetron compared with ondansetron ordolestron for prevention of acute and delayed chemotherapy-induced nausea and vomiting:combined results of two phase III trials. Proc Am Soc Clinic Onc 2003; 22:729 abst 2932.***Page 10 of 10ONC – Anti-Emetic – Practice GuidelinesCopyright 2005 Oncology Network Consultants is an affiliate of Texas Oncology P.A. All rights reserved. These guidelines and this illustration may not bereproduced in any form without the express written permission of Oncology Network Consultants.
reproduced in any form without the express written permission of Oncology Network Consultants. Anti-Emetic Treatment Algorithm Delayed Emesis Platinum Regimen (2.2)* Consider 5-HT3RA Emend Decadron (2.5)* Non-platinum Moderate/High Emesis Potential (2.4) YES NO 5-HT 3 RA Decadron routine delayed emesis
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