Lung Cancer Awareness Month

Lung cancer is cancer that starts in the windpipe (trachea), the main airway (bronchus) or the lung tissue. These are part of the body system we use to breathe – the respiratory system. It is made up of the

  • Nose and mouth
  • Windpipe (trachea)
  • Airways to each lung (the right main bronchus and left main bronchus)
  • The lungs

Cancer that started in the lung
If your cancer started in the lung, it is a primary lung cancer. There are several different types and these are divided into two main groups: small cell lung cancer (SCLC) and non small cell lung cancer (NSCLC).

Small cell lung cancer
About 12 out of every 100 lung cancers diagnosed are this type (12%). Small cell lung cancer is called this because under the microscope the cancer cells look small and are mostly filled with the nucleus (the control centre of cells). It is also called oat cell cancer.

This type of cancer is usually caused by smoking. It is very rare for someone who has never smoked to develop it. Small cell lung cancer often spreads quite early on and so your doctors may recommend chemotherapy treatment rather than surgery.

Non small cell lung cancer

There are three common types of non small cell lung cancer. These are grouped together because they behave in a similar way and respond to treatment in a different way to small cell lung cancer. They make up about 87 out of 100 lung cancers in the UK (87%). The three types are adenocarcinoma, squamous cell carcinoma, and large cell carcinoma.

Adenocarcinoma
This is the most common type of primary lung cancer. It develops from mucus making cells in the lining of the airways. It is often found in the outer areas of the lungs. There are different sub types of adenocarcinoma of the lung. Bronchiolo alveolar carcinoma (BAC) is one of these sub types.

Squamous cell cancer
Squamous cell lung cancer develops from the flat, surface covering cells in the airways. It is often found near the centre of the lung in one of the main airways (the left or right bronchus). This type of cancer is often due to smoking. The number of people developing squamous cell lung cancer is going down in the UK.

Large cell carcinoma
This is so called because the cells look large and rounded under a microscope. This type of lung cancer tends to grow quite quickly.

Unknown type
Occasionally it is not possible to work out which type of non small cell lung cancer you have. It may not be possible to tell if only a few cells are taken during a biopsy. It can also be difficult if the cells are very undeveloped. Undeveloped cancer cells are known as undifferentiated cells. So your doctor will say that you have undifferentiated non small cell lung cancer. This will not usually make any difference to your treatment, because most non small cell lung cancers are treated in the same way.

If you have had cancer elsewhere in your body and it has spread to another part of the body, this is a secondary cancer. Quite a few different types of cancer can spread to the lung, including breast cancer and bowel cancer. If you are diagnosed with cancer in the lung and have already had another type of cancer, check with your doctor whether the cancer started in the lung or has spread into the lung.
The choice of cancer treatment depends on where a cancer started. When cancer spreads to the lung from the breast, the cells are breast cancer cells, not lung cancer cells. So they respond to breast cancer treatments. And cancer that has spread from the bowel should respond to bowel cancer treatments.
So, if you have secondary cancer you need to look at the section about where the cancer started. For example, if you had breast cancer that has spread to the lungs, then you need to look at the section about breast cancer. It is important to know which type of cancer you have so that you can find the right information.symptoms
General symptoms of lung cancer may include

  • Having a cough most of the time
  • A change in a cough you have had for a long time
  • Being short of breath
  • Coughing up phlegm (sputum) with signs of blood in it
  • An ache or pain in the chest or shoulder
  • Loss of appetite
  • Tiredness (fatigue)
  • Losing weight

less common symptoms may include

  • A hoarse voice
  • Difficulty swallowing
  • Changes in the shape of your fingers and nails called finger clubbing
  • Swelling of the face caused by a blockage of a main blood vessel (superior vena cava obstruction)
  • Swelling in the neck caused by enlarged lymph nodes
  • A raised platelet count (thrombocytosis)
  • Pain or discomfort under your ribs on your right side (from cancer cells in the liver)
  • Shortness of breath caused by fluid around the lungs (called a pleural effusion)

Diagnosing

Seeing your GP
Usually you begin by seeing your GP who will ask you about your general health and will examine you. They may ask you to breathe into a small device called a spirometer. The machine measures the amount of air you breathe in and out and also measures how quickly you breathe. They call this test spirometry.

Your GP will refer you to hospital for any X-rays or other tests you may need. You will usually be asked to go for a chest X-ray to check for anything that looks abnormal in your lungs.

image: http://www.cancerresearchuk.org/prod_consump/groups/cr_common/@cah/@gen/documents/image/crukmig_1000img-12178.jpg

Picture of chest X-rayYou may have some routine blood tests. Your GP may also ask you to give some samples of phlegm. They may send them to the hospital for you or may ask you to take them to the hospital. At the hospital the laboratory staff will examine the samples for cancer cells.

You can find out about having a blood test.

At the hospital
When you go to the hospital, the doctor will ask about your medical history and your symptoms. They will then probably arrange for you to have some tests, which may include any of the following.

CT scan

This is a scan that takes X-rays through sections of the body. The scanner feeds the pictures into a computer and they form a detailed image of the inside of your body.

You might have a CT scan done before having a bronchoscopy or biopsy. The scan can show the area where the cancer is. You will have an injection of dye before the scan to help show up any abnormal areas.

We have detailed information about having a CT scan.

Looking inside the airways (bronchoscopy)

A bronchoscopy looks at the inside of the airways. Your doctor puts a narrow, flexible tube called a bronchoscope down your throat and into the airway. The tube has a light at the tip and an eye piece so that the doctor can see inside.

image: http://www.cancerresearchuk.org/prod_consump/groups/cr_common/@cah/@gen/documents/image/bronchoscopy-diagram.jpg

Diagram-showing-a-bronchoscopyYou usually have this test as an outpatient, or day case, under local anaesthetic. This means you are awake for the test, but your throat is numbed. If you are very anxious about having the test let your doctor know at least a week in advance. They may be able to arrange for you to have a general anaesthetic or an injection of a sedative into a vein. If you have an anaesthetic or sedative, you may need to stay in hospital overnight. This depends on the time of day you have the test and on your general health.

If you are going to have sedation or a general anaesthetic, your doctor will ask you not to eat or drink anything on the morning of the test. When you arrive at the outpatient department, a nurse may ask you to change into a gown or you may be able to stay in your own clothes. Then your nurse will show you into the test room. Once you are lying on the couch, you will have a sedative to help you relax. Just before the test, the doctor sprays a local anaesthetic onto the back of your throat.

The doctor puts a long, thin, flexible tube called a bronchoscope either down your nose, or into your mouth and down the airway. This will be a bit uncomfortable, but it doesn’t last long. The doctor then looks for anything abnormal and can take tissue samples (biopsies) for testing. They can take photographs of the inside of your airways if necessary.

After the bronchoscopy, you will not be able to eat or drink anything until the local anaesthetic has worn off. Your throat will be too numb to swallow safely at first. The numbness usually passes off after about an hour. You should not drive until the day after the test because of the sedative. Someone should collect you from the hospital and make sure that you get home safely. You may have a sore throat for a couple of days after the test because of the tube, but it will soon go.

Endobronchial ultrasound

Doctors call this test an EBUS. It is like having a bronchoscopy with an ultrasound. An ultrasound can show structures in the body using sound waves. You may have EBUS under a general anaesthetic or may have medicine to make you drowsy.

The doctor gently passes a small bronchoscope into your mouth and down into the windpipe (trachea). It can pass into the smaller airway passages. The probe at the end of the tube creates ultrasound pictures of the lung tissue and nearby lymph glands. So it can help to show the size of the tumour and whether the cancer has spread into any lymph nodes.

The doctor can pass a hollow needle down the tube to take an ultrasound guided biopsy of any lung tissue that looks abnormal. They call this a trans bronchial needle aspiration (TBNA). This test usually takes less than half an hour.

Biopsy through the skin
This type of biopsy is called a percutaneous lung biopsy. The doctor puts a thin needle through the skin and muscle of your chest to take samples of cells from the lung tumour. The area of the test depends on the position of the abnormal cells.

The test can be uncomfortable. The actual biopsy only takes a few minutes but getting ready may take between 30 minutes and an hour.

You usually have this test in the X-ray department, ultrasound department, or a special procedures room. You have a local anaesthetic injection into the area where the needle is to be put in. The doctor will ask you to hold your breath for a moment while they put the needle through the skin into the lung. Once the needle is in, the doctor uses X-ray, CT scan or ultrasound to make sure the tip is in the tumour. The doctor then sucks out a sample of cells with a syringe. They send the cells to the laboratory for examination under a microscope.

After a biopsy through the skin your nurse will monitor you closely for a few hours. You may need to stay in hospital overnight. There is a small risk that the lung may collapse after the biopsy (pneumothorax). Let your nurse know if you suddenly feel breathless or dizzy.

Surgical biopsy
If it is difficult to get enough tissue using a biopsy through the skin, your doctor may do an open lung biopsy under general anaesthetic in a similar way to mediastinoscopy. Or you may have keyhole surgery (thoracoscopy) to get a biopsy.

Neck lymph node biopsy

If a CT scan has shown changes in the lymph nodes in your neck, your doctor may need to take a sample of cells from the lymph nodes. This checks whether any cancer cells have spread into the nodes.

You have a local anaesthetic injection into the skin over the lymph nodes. The doctor then puts a thin needle through the skin. They may use ultrasound to make sure the tip is in the right place. The doctor then sucks out a sample of cells from the lymph node with a syringe. They send the cells to the laboratory for examination under a microscope.

You can usually go home soon after this test.

Getting the results
Your doctor will ask you to go back to the hospital when your test results have come through. But this is bound to take a little time, even if only a few days. This is a very anxious time for most people. You may have contact details for a lung cancer specialist nurse. You can contact them for information if you need to.

The main treatments

Treatment depends on the type of lung cancer you have. The treatment for non small cell lung cancer is different from the treatment for small cell lung cancer.

Small cell lung cancer is mostly treated with chemotherapy. Surgery is only suitable if there is no sign that the cancer has spread to the lymph glands in the centre of the chest (the mediastinal lymph glands). This is rare with small cell lung cancer. It has usually spread at the time of diagnosis. So chemotherapy is usually the main treatment. You may also have radiotherapy to treat this type of lung cancer. There is information below about the treatment of small cell lung cancer by stage.

Non small cell lung cancer can be treated with surgery, chemotherapy, radiotherapy or a combination of these, depending on the stage when the cancer is diagnosed. Some people with advanced lung cancer may have biological therapy. There is information below about the treatment of non small cell cancer by stage.

How treatment is planned

Your cancer specialist looks at a number of factors that help them to plan your treatment. These include

  • The type of lung cancer you have
  • Where the cancer is within the lung
  • Your general health
  • Whether the cancer has spread (the stage)
  • Results of blood tests and scans
  • Your own wishes

You may find that other people you meet are having different treatment from you. This may be because they have a different type of lung cancer. Or it may be that some of the other factors listed above are different. Don’t be afraid to ask your doctor or specialist nurse any questions you have about your treatment.

Surgery, radiotherapy and chemotherapy are all used to treat lung cancer. They can each be used alone or together. Your doctor will plan the best treatment for you. Some people with advanced non small cell lung cancer may have biological therapy.

Treatment by stage for small cell lung cancer

If you have early stage small cell lung cancer you are most likely to have chemotherapy and then radiotherapy to the lung. People who are fairly fit may have chemotherapy and radiotherapy at the same time (chemoradiation). It is quite common for this type of cancer to spread to the brain. So doctors often recommend radiotherapy to the brain for people whose lung cancer shrinks with chemotherapy treatment. You usually have radiotherapy to the brain at the end of the chemotherapy treatment. It aims to try to kill any cancer cells that may have already spread to the brain but are too small to show up on scans. Doctors call this prophylactic cranial irradiation or PCI.

For very early stage small cell lung cancer that has not spread to the lymph nodes in the centre of the chest (the mediastinal lymph nodes), you may have surgery to remove the part of the lung containing the tumour (a lobectomy). The surgery is followed by chemotherapy and sometimes radiotherapy. But usually the cancer has already spread at the time of diagnosis and surgery is not then possible.

If you have small cell cancer that has spread to lymph nodes or other areas of the body you may have chemotherapy, radiotherapy or treatment to relieve symptoms. If chemotherapy works well to shrink the lung tumour down and you are fairly fit you may also have radiotherapy to the brain to kill any cancer cells that may have already spread there.

Treatment by stage for non small cell lung cancer
Stage 1

Stage 1 non small cell lung cancer is uncommon. You normally have surgery to remove part of the lung (a lobectomy) or all of the lung (a pneumonectomy). If you can’t have an operation for other health reasons, your doctor may suggest targeted radiotherapy instead to try to cure the cancer. Another option for small tumours if you cannot have surgery is radio frequency ablation (RFA).

Stage 2
For stage 2 non small cell lung cancer, you may be offered surgery. Depending on the position of the tumour, your surgeon may remove part of the lung (a lobectomy) or all of the lung (a pneumonectomy). If the cancer is completely removed, your specialist may suggest chemotherapy. The chemotherapy aims to lower the risk of the cancer coming back. Doctors call this adjuvant chemotherapy. It is important that your doctor talks to you beforehand about the benefits and side effects of chemotherapy. If the surgeon could not remove all of the tumour you may have radiotherapy afterwards.

If you can’t have surgery due to other health concerns, your doctor may offer radiotherapy or combined radiotherapy and chemotherapy (chemoradiation). This treatment aims to try to get rid of the cancer completely.

Stage 3
For stage 3 non small cell lung cancer you may be able to have surgery, depending on where the cancer is in the lung. You may need to have the whole lung removed (a pneumonectomy). If the surgeon completely removes the cancer, you may then have chemotherapy to try to lower the risk of the cancer coming back. If the surgeon finds cancer cells in the lymph nodes during the surgery they are likely to advise you to have chemotherapy and possibly radiotherapy after the operation.

If you can’t have surgery due to other health concerns, your doctor may offer radiotherapy or combined radiotherapy and chemotherapy (chemoradiation). This treatment aims to try to get rid of the cancer completely.

If your scans showed that there are cancer cells in the middle area of the chest (the mediastinum), your doctor may suggest radiotherapy instead of surgery. The cancer may be too close to your heart to operate safely. Or your doctor may advise that you have a course of chemotherapy followed by radiotherapy. Some people who are fairly fit and have small tumours have radiotherapy at the same time as chemotherapy (concomitant chemoradiotherapy). Concomitant chemoradiotherapy causes more side effects than the treatments given alone. So you need to be well enough to cope with the increased side effects.

If scans show signs of cancer in the lymph nodes on the opposite side of your chest, surgery is not possible. But you may have a course of chemotherapy. After the chemotherapy you might need further treatment with radiotherapy. If you are fairly fit you may have radiotherapy at the same time as chemotherapy.

Stage 4
Treatment for stage 4 non small cell lung cancer aims to control the cancer for as long as possible and to shrink the tumour down to reduce symptoms. Many trials have used chemotherapy in this situation and we know that it can help people to live longer as well as relieving symptoms.

People whose cancer cells have particular proteins (receptors) may have treatment with biological therapy drugs called erlotinib (Tarceva), gefitinib (Iressa) or crizotinib (Xalkori).

If you have had chemotherapy and it is no longer controlling the cancer, you may have further chemotherapy if you are well enough. If your cancer has EGFR receptors your doctor may offer erlotinib treatment. Or you may choose to have no further active treatment but to control your symptoms with medicines.

You may have radiotherapy to control symptoms such as pain or a cough. As well as radiotherapy, other treatments can relieve a blockage and reduce symptoms if you have a tumour in one of the main airways (the left or right bronchus). These treatments include

  • Internal radiotherapy (brachytherapy)
  • Laser treatment
  • Freezing the tumour (cryotherapy)
  • Using a rigid tube (a stent) to keep the airway open
  • Light therapy (photodynamic therapy – PDT)

There is detailed information about treatments to relieve an airway blockage in the advanced lung cancer treatment section.

Being cared for by a multidisciplinary team

NHS guidelines state that everyone diagnosed with lung cancer should be under the care of a multi disciplinary team (MDT). This is a team of health professionals who work together to discuss your case and how best to manage your treatment and care. The team includes

  • Specialist surgeons
  • Doctors who specialise in using drugs to treat cancer (medical oncologists)
  • Doctors who specialise in chest conditions
  • Doctors who specialist in symptom control
  • Doctors who specialist in radiotherapy and chemotherapy treatment (clinical oncologists)
  • Specialist lung cancer nurses
  • Doctors specialising in diagnosis from tissue specimens (histopathologists)
  • Physiotherapists
  • Occupational therapists
  • Psychologists
  • Social workers
  • Dieticians
  • Other health professionals or specialists
Discussing things with your doctor

An appointment where you are given your diagnosis and told about your treatment options is very important. You are likely to be shocked and might find it hard to take in information or make decisions. When you go to see the doctor it often helps to write down a list of questions you want to ask. There may be more than 1 treatment option that is suitable for you.

It’s important that you feel OK about the treatment your specialist recommends. Most people feel more comfortable about this if they understand why a particular treatment decision has been made. Doctors expect patients to want to ask questions and they appreciate that you need things explained in a way you can understand. It is important that your doctor fully explains all options to you and their benefits and possible problems.

Your doctor won’t give any treatment without your permission (consent). In some situations you may feel that you don’t want to have treatment, for example if the treatment has only a small chance of helping you and may cause bad side effects. Your doctor can explain what will happen if you don’t have the treatment and they will go along with your wishes.

 

 

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