Lung Cancer in IPF Patients Best Treated on ‘Do No Harm’ Basis, Commentary Argues

The management of patients with idiopathic pulmonary fibrosis (IPF) and lung cancer should follow the premise “first, do no harm,” researchers argue in the journal The Lancet Respiratory Medicine.

Their commentary, “Patients with IPF and lung cancer: diagnosis and management,” spotlights the fact that — despite lung cancer being five times more common in IPF patients than in the general population — no guidelines exist on how to manage these people.

Studies that might enable clinicians to better diagnose and treat them are also scarce.

The group, led by researchers from the National and Kapodistrian University of Athens, argues that this lack suggests that invasive diagnostic methods may do more harm than good.

Surgery in IPF patients comes with a high risk of disease exacerbation, and biopsies and lung resections by surgeons can result in complications, they said.

To improve the likelihood of better outcomes, the team recommends that all IPF patients undergo yearly high-resolution chest CT scans to detect tumor growth as soon as possible. If suspected tumor lesions are noted, further diagnostic procedures should follow an individual plan, based on a patient’s health status and preference.

While noninvasive or minimally invasive diagnostic methods can be used if a lesion appears small, larger lesions should not be diagnosed further. Rather, a discussion of treatment options should begin.

Most chemotherapies give rise to increased lung toxicity in IPF patients, and studies suggest that conventional radiotherapy can be detrimental as well. Newer options, such as proton beam therapy or immunotherapies, including checkpoint inhibitors, may be better treatment approaches for specific patients.

But, so far, there is little data supporting how such approaches work in this patient group.

The researchers also suggest that IPF patients not stop their antifibrotic treatment if they receive anticancer medications. The few studies that exist on the topic appear to show that the benefits of antifibrotics outweigh the risks.

Interestingly, nintedanib (an approved IPF therapy, marketed as Ofev) was initially developed and approved for the treatment of non-small-cell lung cancer (NSCLC), while preoperative treatment with pirfenidone (another IPF approved therapy, marketed as Esbriet) was shown to reduce IPF exacerbations upon cancer surgery.

These data suggest that both these drugs seem to be safe in treating lung cancer patients with IPF.

Many IPF patients who develop cancer are older. Since standard cancer treatments may make these patients worse, it is important to consider if palliative care and antifibrotic treatments may be the best option, the researchers wrote. While having no impact on survival, they may improve patients’ quality of life, the team concluded.