Review: Managing Lung Cancer in Patients With Interstitial Lung Disease

The risk of lung cancer is increased in patients with interstitial lung disease (ILD), regardless of the ILD subtype. Lung cancer treatment can prolong survival, but patients with ILD are at increased risk of adverse effects from all treatment modalities.

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Angela J. Frank, MD, MPH, and Sydney Montesi, MD, clinician-researchers in the Division of Pulmonary and Critical Care Medicine at Massachusetts General Hospital, Ibiayi Dagogo-Jack, MD, thoracic oncologist in the Mass General Cancer Center, and colleagues recently reviewed considerations for the diagnosis and management of lung cancer in patients with ILD. In The Oncologist, they also give practical suggestions about closely monitoring for ILD progression during lung cancer treatment.

The Problems

The authors first give details about the following problems:

• Diagnosis—There are no ILD-specific guidelines for lung cancer screening
• Outcomes—Survival is worse for patients with lung cancer and ILD than in those who have lung cancer without ILD, even when controlling for cancer stage; survival is also shorter in patients with lung cancer who have interstitial lung abnormalities (ILA) incidentally detected on CT
• Systemic therapy—Chemotherapy, certain targeted therapies, and immunotherapies can induce pneumonitis or acute exacerbations of ILD
• Radiation therapy—The risk of pneumonitis is a particularly significant concern in patients with pre-existing ILD; whether proton beam therapy reduces that risk is under investigation
• Surgery—Lung resection is associated with an increased risk of postoperative complications, acute exacerbations, and worse survival in patients with ILD
• Percutaneous ablation—Acute exacerbations of ILD are also a concern with image-guided thermal ablation

Practical Considerations

The authors provide pragmatic guidance to physicians:

• On initial CT imaging of lung cancer, pay attention to findings that suggest ILD—ground-glass opacities, reticular markings, traction bronchiectasis, or honeycombing
• Patients with lung cancer who are suspected of also having ILD should undergo pulmonary evaluation because a diagnosis of the ILD subtype may clarify the risks and benefits of various lung cancer treatments
• If possible before treatment is initiated, patients with lung cancer and ILD should undergo pulmonary function tests (PFTs), including spirometry, lung volumes, and diffusing capacity of the lung for carbon monoxide, as the severity of lung function impairment may inform what management options are available
• Patients with lung cancer and ILD should have a multidisciplinary team, including a pulmonologist, to discuss their case regularly before and throughout therapy so treatment plans can be changed efficiently, especially if pneumonitis develops
• During treatment, periodically measure PFTs (to assess for interval changes that signify ILD progression), and oxygen levels at rest and with exertion (to assess the need for supplemental oxygen or adjustment to existing supplemental oxygen flow rates, especially if dyspnea is worsening)
• Early referral to palliative care may be beneficial for patients with lung cancer and ILD since lung cancer treatment may exacerbate pre-existing respiratory symptoms

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