LUNG CANCER Date of Publication: Jan

Disease/Medical Condition

1 LUNG CANCER Date of Publication: Jan. 23, 2019

(includes “non-small cell lung cancer” (NSCLC), which encompasses ‘adenocarcinoma2’, ‘squamous cell carcinoma3’, ‘large cell carcinoma’, and ‘large cell neuroendocrine tumours’, as well as “small cell lung cancer” (SCLC), which encompasses ‘small cell neuroendocrine tumours’]

Note: The therapeutic modalities of chemotherapy and radiation therapy are addressed in detail in separate fact sheets.

Is the initiation of non-invasive dental hygiene procedures* contra-indicated? Unlikely, but depends on severity of disease, severity of complications arising from treatment (e.g., bisphosphonate-associated osteonecrosis of the jaw [BRONJ]), and procedure being contemplated.

■ Is medical consult advised? — Yes, if the patient/client is about to undergo, or is undergoing, radiation therapy. — Yes, if the patient/client is undergoing chemotherapy and has, or is suspected to have, certain oral conditions or systemic manifestations. — Yes, if the patient/client is taking a bisphosphonate (either orally or by injection). — Yes, if the patient/client appears debilitated. — Yes, prior to dental hygiene procedures, if interstitial brachytherapy4 has taken place within the past two months in a patient/client undergoing prostate, breast, or lung cancer treatment and you, the dental hygienist, are, or may be, pregnant. In such a circumstance, input should be sought from a radiation oncologist regarding radiation safety precautions.

Is the initiation of invasive dental hygiene procedures contra-indicated?**

— Yes, if the patient/client is undergoing radiation therapy and/or chemotherapy. — Yes, if the patient/client has BRONJ (as can be the case in advanced lung cancer, depending on treatment). ■ Is medical consult advised? ...... See above. Additionally, pre- and post-radiotherapy/ chemotherapy medical and/or dental consultation is often warranted. ■ Is medical clearance required? — Yes, if the patient/client is undergoing radiotherapy and/or chemotherapy. — Yes, if BRONJ exists or is suspected. — Yes, if patient/client is being treated with medications associated with immunosuppression +/- increased risk of infection (e.g., corticosteroids are used as part of some regimens in the treatment or palliation of lung cancer). ■ Is antibiotic prophylaxis required? ...... Possibly, for some patients/clients undergoing radiotherapy and/or chemotherapy according to blood indices and/or delivery mechanism (e.g., in-dwelling central venous catheters or ports). Also, persons who have had radiation to the chest are at increased risk of valvular heart disease, and they may be candidates for prophylaxis. ■ Is postponing treatment advised? — Possibly, depending on blood indices (which indicate degree of immunosuppression and/or thrombocytopenia) in patients/ clients undergoing radiotherapy or chemotherapy. Elective invasive procedures should be deferred until after radiation- or chemo-induced immunosuppression ceases. — Potentially, if BRONJ exists, informed by medical/dental consultation. Ideally, all necessary invasive dental and dental hygiene treatments should be performed before administration of injectable bisphosphonate drugs. — Potentially, if interstitial brachytherapy has taken place within the past two months in a patient/client and you, the dental hygienist, are, or may be, pregnant.

1 Cancerous cells are characterized by uncontrolled growth, abnormal structure, and the ability to move into other parts of the body (invasiveness and metastasis). 2 Adenocarcinoma is a cancer that begins in the glandular structures of epithelial tissue. 3 Carcinoma is a cancer that begins in the epithelial tissue that lines or covers body organs or the skin. 4 Interstitial brachytherapy is “permanent” radioactive seed implantation within cancerous tissue.

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Disease/Medical Condition

LUNG CANCER

Oral management implications

■ Refer also to Radiation Therapy, Chemotherapy, Xerostomia, and BRONJ fact sheets, as applicable. ■ Jawbone metastasis may be the first sign of malignancy, including lung cancer. If undiagnosed metastatic cancer of the jaw (or elsewhere in the oral cavity) is suspected, prompt medical referral is indicated for work-up to identify the primary site and to stage the degree of metastatic involvement (i.e., solitary jaw lesion or, more commonly, a clinical sign of disseminated skeletal disease). ■ To reduce the risk of tooth damage secondary to bronchoscopy5, tooth and gum health (including fillings) should ideally be optimized prior to such intervention. ■ Oral assessment before, during, and after active chemotherapy and radiotherapy is important. Coordination of care between the oncology and oral health teams is essential for patient/client safety. ■ Patients/clients with lung cancer may be short of breath and require supplemental oxygen. ■ Post-operatively, dental hygiene appointments should be kept short. This is particularly important for patients/clients with lung cancer, because dyspnea (severe shortness of breath) may result from lung resection. Dyspnea may also occur after radiotherapy due to acute radiation pneumonitis6 and/or after later onset of radiation-induced pulmonary fibrosis. ■ Smoking cessation should be encouraged if the patient/client still smokes7. However, the dental hygienist should be careful not to be judgmental of patients/clients who smoke. Smokers and former smokers who develop lung cancer are subject to societal stigmatization, which should not be perpetuated in the dental hygiene office.

Oral manifestations

■ Refer also to Radiation Therapy, Chemotherapy, Xerostomia, and BRONJ fact sheets for details regarding cancer treatment- related dry mouth, caries, mouth sores, gingival bleeding, dysgeusia (unpleasant taste), infections, periodontitis, tooth decay, and osteonecrosis. ■ The leading cause of lung cancer — smoking — increases the likelihood of periodontal disease. ■ Lung surgery or bronchoscopy may involve manipulation of instruments around the anterior teeth. This can cause inadvertent damage. ■ While cancer metastases to the mandible and maxilla are unusual, about 1% of all malignant neoplasms do metastasize to the jaws8. About 80% of these metastases affect the mandible9, 14% affect the maxilla, and 5% affect both jaws. In men, metastases of the jaws most commonly result from lung cancer, whereas in women the most common cause is breast cancer. ■ Persons more likely to be affected by metastatic cancer to the jaws are in the older age brackets, which reflects the higher prevalence of malignancy in this population. The prognosis for patients/clients with metastatic carcinoma of the jaws is poor, with 5-year survival rates in the 10% range. ■ Most metastatic jaw lesions involve one oral site, with only a few occurring in 2 or 3 sites.

5 Bronchoscopy is insertion of a flexible fibreoptic scope down the bronchus into the lung. In addition to visualization, it can be used to obtain tissue biopsies for diagnostic purposes. 6 Pneumonitis is inflammation of lung tissue. 7 The Canadian Cancer Society, facilitated by Government of Ontario funding, offers a free, confidential Smokers’ Helpline for smokers in Ontario via 1-877-513-5333. Smokers’ Helpline Online is available at www.smokershelpline.ca. 8 The mechanism of spread to the jaws is usually hematogenous (i.e., via the blood stream) from the primary neoplasm or from lung metastases. 9 The premolar region, the angle, and the body of the mandible are most commonly affected by metastatic disease.

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Disease/Medical Condition

LUNG CANCER

Oral manifestations (cont’d)

■ Bone pain, tooth ache, loosening of teeth, bone (and hence jaw) swelling, lip or chin paresthesia, gingival mass, trismus, and pathologic fracture may result from metastatic jaw lesions. Radiographically, most metastases appear as poorly marginated, radiolucent, osteolytic defects. However, bone metastases of lung cancer, depending on type, may be osteolytic or osteoblastic, in which case fairly well circumscribed radiodense (i.e., radiopaque) lesions may be seen. ■ More rarely, metastatic deposits occur in the gingiva (especially the attached gingiva, with hyperplastic or reactive lesions initially resembling the clinical appearance of pyogenic granuloma10 and periodontal abscess. Metastatic lesions in other areas of the oral soft tissues tend to manifest as submucosal masses, particularly in the tongue, with very occasional presentation as ulcers. The lung is the most common primary site for cancers that metastasize to the oral soft tissues. ■ Oral metastases can grow rapidly, causing pain, difficulty in chewing, dysphagia, disfigurement, and intermittent bleeding. ■ Bisphosphonate-related osteonecrosis of the jaw may occur secondary to medications used to manage metastatic cancer affecting the bones. Osteonecrosis may also be caused by metastatic disease itself.

Related signs and symptoms

■ Refer also to Radiation Therapy and Chemotherapy fact sheets. ■ Excluding non-melanoma skin cancer, lung cancer (LC) accounts for 14% of all newly diagnosed cases of cancer in Canada. It is the most common cause of cancer death in Ontario (and Canada). Annually, about 10,600 persons — slightly more males than females — are diagnosed in Ontario (28,600 in Canada), and 7,100 (21,100) die from the disease. The 5-year net survival rate is low at 17%, because by the time it causes overt signs/symptoms, LC has usually spread to other parts of the body or is locally too advanced for treatment to work11. ■ Non-small cell lung cancer makes up 80% to 85% of all cases of lung cancer. The major risk factor is smoking (often accompanied by stigmata and other sequelae of smoking, such as chronic obstructive pulmonary disease). However, lung cancer can also occur in never-smokers, where it is among the leading causes of cancer-related mortality. ■ Presenting signs for tumours that grow locally include cough, change in nature of chronic cough, wheezing, and dyspnea (shortness of breath) on exertion. ■ LC that invades adjacent structures can produce chest pain, haemoptysis (coughing up of blood), or produce syndromes from disruption of nerves in the chest and neck12 or cutaneous, endocrine, or neurologic manifestations. Pancoast syndrome13 is characterized by severe pain in the shoulder region radiating toward the axilla and scapula, with later extension along the ulnar aspect of arm to the hand. Paraneoplastic syndromes include hypercalcemia (which manifests as weakness, lack of coordination, changes in mental function, high blood pressure, and nausea/vomiting) and hypertrophic osteoarthropathy (which manifests as increased, and sometimes painful, growth of bones, particularly those in the fingertips; finger clubbing; and pain and swelling of bones and joints). ■ Metastases to the bone, brain, liver, and adrenal gland produce features associated with malfunction of these organs, as well as lymphadenopathy (e.g., enlarged nodes in the neck or above the clavicle).

10 Pyogenic granuloma is a benign, vascular “overgrowth” lesion that occurs on the mucosa or skin due to irritation, physical trauma, or hormonal factors. 11 As of June 2017, Cancer Care Ontario has introduced a pilot screening program for persons at high risk of getting lung cancer. Offered in a few hospitals across Ontario (Ottawa, Sudbury, and Oshawa), this pilot uses low-dose computed tomography (LDCT) screening, and the results will inform planning for a possible province-wide lung cancer screening program. 12 For example, Horner’s syndrome results from interruption of the sympathetic nerve supply to the eye. It is characterized by the classic triad of unilateral miosis (constricted pupil), partial ptosis (drooping eyelid), and facial anhidrosis (loss of sweating). 13 Pancoast syndrome is caused by malignancy in the apex of the lung, which leads to destructive lesions of the thoracic inlet.

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Disease/Medical Condition

LUNG CANCER

Related signs and symptoms (cont’d)

■ With advanced disease, patients/clients experience loss of appetite, weight loss, fatigue, and weakness. ■ For patients/clients with LC, depending on individual circumstances, treatment options might include one or more of: surgical resection; radiation therapy (external beam and/or brachytherapy14); and chemotherapy.

References and sources of more detailed information

■ Farbicka P, Nowicki A. Palliative care in patients with lung cancer. Contemporary Oncology. 2013;17(3):238-245. doi:10.5114/wo.2013.35033. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3934061/ ■ Ming X, Feng Y, Yang C, Wang W, Wang P, Deng J. Radiation-induced heart disease in lung cancer radiotherapy: A dosimetric update. Xie. M, ed. Medicine. 2016;95(41):e5051. doi:10.1097/MD.0000000000005051. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5072944/ ■ Kumar G, Manjunatha B. Metastatic tumors to the jaws and oral cavity. Journal of Oral and Maxillofacial Pathology. 2013;17 (1):71-75. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3687193/ ■ Heindel W, Gübitz R, Vieth V, Weckesser M, Schober O, Schäfers M. The Diagnostic Imaging of Bone Metastases. Deutsches Ärzteblatt International. 2014;111(44):741-747. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4239579/?report=classic ■ O’Sullivan GJ, Carty FL, Cronin CG. Imaging of bone metastasis: An update. World Journal of Radiology. 2015;7(8):202-211. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4553252/ ■ Lung Cancer Canada http://www.lungcancercanada.ca/LungCancerCanada/media/Documents/cancer-_dentaltreatment.pdf http://www.lungcancercanada.ca/LungCancerCanada/media/Documents/Faces-of-Lung-Cancer-Report-2016.pdf ■ Canadian Cancer Society http://www.cancer.ca/en/cancer-information/cancer-type/lung/signs-and-symptoms/? region=on&gclid=CJy0n7XC_NQCFQO2wAodmlUJwQ http://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/radiation-therapy/brachytherapy/?region=on http://www.cancer.ca/~/media/cancer.ca/CW/cancer%20information/cancer%20101/Canadian%20cancer%20statistics/ Canadian-Cancer-Statistics-2017-EN.pdf?la=en ■ Cancer Care Ontario https://www.cancercare.on.ca/cms/one.aspx?objectId=333743&contextId=1377 (Lung Cancer Screening Pilot for People at High Risk) ■ Lung Cancer Alliance http://www.lungcanceralliance.org/get-information/types-of-lung-cancer.html ■ Lungcancer.org (CancerCare) https://www.lungcancer.org/find_information/publications/269-the_importance_of_dental_health

14 Endobronchial brachytherapy for lung cancer is usually given as a single, high dose or radiation in a very short period of time. After the radiation is administered, the catheter with the radioactive material is removed from the bronchus. By contrast, interstitial brachytherapy for lung cancer is more invasive, and it involves “permanent” radioactive seed implantation in a tumour.

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Disease/Medical Condition

LUNG CANCER

References and sources of more detailed information (cont’d)

■ WebMD http://www.webmd.com/lung-cancer/lung-cancer-oral-health#1 ■ Cancer Network www.cancernetwork.com/printpdf/173868 (Brachytherapy for Carcinoma of the Lung) ■ Medscape http://emedicine.medscape.com/article/284011-overview (Pancoast Syndrome) ■ Cancer Research UK http://www.cancerresearchuk.org/about-cancer/cancer-in-general/treatment/radiotherapy/side-effects/chest- radiotherapy/breathlessness ■ Darby M (ed.) and Walsh M (ed.). Dental Hygiene: Theory and Practice (4th edition). St. Louis: Elsevier Saunders; 2015. ■ Ibsen OAC and Phelan JA. Oral Pathology For The Dental Hygienist (6th edition). St. Louis: Elsevier Saunders; 2014. ■ Regezi JA, Sciubba JJ, and Jordan RCK. Oral Pathology: Clinical Pathologic Correlations (6th edition). St. Louis: Elsevier Saunders; 2012. ■ Little JW, Falace Da, Miller CS and Rhodus NL. Dental Management of the Medically Compromised Patient (8th edition). St. Louis: Elsevier Mosby; 2013.

* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc. ** Ontario Regulation 501/07 made under Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.

Date: December 4, 2017