Lung Cancer

Lung cancer is the number one cancer killer among both men and women, accounting for one-third of all cancer-related deaths in the United States. While the number of men who get lung cancer has dropped slightly in recent years, the number of women who get lung cancer has steadily grown. For about 40 years, breast cancer was the leading cause of death in women until lung cancer replaced it in 1987.

The two types of lung cancer are small cell and non-small cell. Each type of lung cancer behaves differently and is evaluated and treated differently.

Small cell lung cancer, which includes oat cell carcinoma, is more aggressive and usually more advanced by the time it is diagnosed. Treatment usually involves chemotherapy and radiation.

Non-small cell lung cancer includes adenocarcinoma, squamous cell and large cell cancer. Surgery is the primary option for early stages of this type. Overall, between 20 and 80% of non-small cell lung cancer can be cured by surgery, depending on the size of the tumor and whether the cancer has spread to other parts of the body.

Risk Factors

Smoking. A total of 90% of lung cancers are related to smoking. The risk of lung cancer is 30 times greater in smokers than in non-smokers, correlating with the total exposure to cigarettes (referred to as pack-years or packs smoked per day multiplied by the number of years of smoking). One in seven people who smoke at least two packs per day will die of lung cancer. Cigar and pipe smoke double the risk of developing lung cancer. Between 5,000 to 10,000 Americans develop lung cancer every year from secondhand smoke.
Exposure to air pollution, radiation, asbestos and industrial chemicals like arsenic, nickel and chromium increases the risk of lung cancer. Asbestos alone increases the risk of getting lung cancer four times. The combination of asbestos and smoking increase the risk 90 times. Asbestos exposure is also associated with mesothelioma, a type of cancer that starts in the lining of the chest.

Signs and Symptoms

Lung cancer may appear as a mass on the chest X-ray of a patient with no symptoms, but most patients have symptoms when diagnosed. Symptoms may include:

A new cough, a bloody cough or a change in an existing cough
Pneumonia
Rib, shoulder or bone pain
Hoarseness
Loss of appetite and weight
Facial swelling
Headaches

Evaluation

Chest X-ray and CT scan. The X-ray gives a good picture of the chest cavity, but a CT scan is also done because it shows the lung mass, lymph nodes and the rest of the chest cavity in greater detail. These help evaluate the extent of a lung mass and suggest the likelihood of cancer, but they do not confirm the diagnosis of lung cancer. Confirmation requires a biopsy.
MRI (magnetic resonance imaging) test. This tool may be part of the evaluation for a lung mass; however, it does not visualize the lung well.
PET (positron emission tomography) scan. This relatively new nuclear medicine technique may be helpful in evaluating and staging a lung mass. If a lung mass "lights up" on the PET scan, it usually indicates lung cancer. If the mass does not light up, cancer is not likely to be present. The test also evaluates the entire body to determine whether cancer has spread to lymph nodes or other areas of the body.

Diagnosis

Although evaluation tests may suggest the presence of cancer, a biopsy is needed to confirm the diagnosis. In a biopsy, a piece of tissue is examined under the microscope to look for the presence of cancer. A biopsy may be done in several ways, including:

Sputum sample. Sputum cytology will diagnose 75% of tumors located in the bronchi (windpipes) but only 25% of tumors located at the edge of the lung. A negative response to this test alone is no guarantee that cancer is not present.
Needle biopsy. The radiologist anesthetizes the skin and inserts a needle through the chest, usually with the assistance of a CT scan to direct the needle into the lung mass. This method diagnoses 60 to 90% of lung cancers, depending on size and location. Even under the best circumstance, a needle biopsy sometimes fails to diagnose some lung cancers. Therefore, even if the test reports no cancerous cells, there is no guarantee the lung mass is cancer free.
Flexible bronchoscopy. The bronchoscope is a hollow tube that is inserted into the windpipe through the mouth or nose. This may be done with a light sedative or under a general anesthetic. If a tumor is seen in the windpipe, a biopsy is taken. Most lung cancers are not visible with the bronchoscope because they are located at the edge rather than in a central part of the lung.
Cervical mediastinoscopy. Performed under general anesthesia in the operating room, a one-inch incision in the neck allows the surgeon to follow the windpipe into the chest and remove lymph nodes. This can be done on an outpatient basis. This test can diagnose lung cancer and indicate the extent of the tumor and direction that treatment should take.
Surgical biopsy. This requires hospital admission and a general anesthetic. The biopsy can often be done with three small (half-inch) incisions in a procedure called thoracoscopy or video-assisted thoracoscopic surgery (VATS). A camera is placed in one of the incisions, and surgical instruments are used in the other incisions. The lung mass is removed and examined by the pathologist. If cancer is found, then a complete cancer operation is done while the patient is still asleep.

For more information about video-assisted thoracoscopic surgery, visit the Cedars-Sinai Center for Chest Diseases Web pages.

Stages (Small Cell Lung Cancer)

About 25% of all lung cancer is small cell cancer. Stages include limited disease (confined to the chest) or extensive disease (spread outside the chest). The prognosis is better for limited-stage small cell cancer. Generally, patients are treated with chemotherapy and radiation. Surgery is rarely done because by the time this cancer has been diagnosed it has usually spread to other parts of the body, even if tests do not prove it.

Stages (Non-Small Cell Lung Cancer)

The four stages of non-small cell lung cancer are:

Stage I (confined to the lung)
Stage II (lung cancer has spread to lymph nodes near the tumor and within the lung)
Stage III (confined to the chest, but much more extensive involvement )
Stage IV (cancer has spread to other parts of the body, such as the brain, liver or bones)

The staging system is important to determine prognosis and treatment. The patient's medical history and physical condition are evaluated as part of the staging process, and pulmonary function tests are given to see if the patient has enough lung capacity to undergo surgery safely. Other tests, such as bone or brain scans, may be needed to see if the tumor has spread to other parts of the body.

Treatment

Cedars-Sinai offers state-of-the-art treatment for all stages of lung cancer, including new treatments resulting from research studies. Because lung cancer affects other functions of the body, specialists from different fields of medicine approach patient cases as a team. Our surgeons, pulmonary specialists, oncologists and radiation therapy specialists consult together to create the best treatment plan for each patient. All staff members are dedicated to creating the most compassionate and caring treatment environment possible.

As with all cancers, lung cancer may be treated with surgery, chemotherapy or radiation treatments. The treatment depends on the type and extent of the cancer.

Surgery

Drs. Robert McKenna and Clark Fuller of Cedars-Sinai's Center for Chest Diseases perform most lung cancer surgeries through minimally invasive incisions and video technology. Cedars-Sinai is one of the few institutions in the world capable of offering this innovative lung cancer surgery. Unlike traditional invasive rib-spreading operations, patients experience less pain, shorter hospital stays and faster recovery.

Surgery offers the best chance of a cure for lung cancer and is the treatment of choice for early stage, non-small-cell lung cancer. It is not effective for more advanced staged cancers. Surgery is performed when the tumor appears to be confined to the lung and the operation can be accomplished safely. A variety of surgical procedures can be employed to remove the cancer and lymph nodes from the chest.

Patients undergoing lung cancer surgery are generally admitted to the hospital for three to seven days. The operation is performed under general anesthesia. During the operation, drainage tubes are placed into the chest cavity and connected to a collection system. The tubes are removed several days after surgery. Because the most common risk is pneumonia, patients are out of bed and walking the day after surgery.

Chemotherapy

During chemotherapy drugs are injected into the veins to shrink a tumor by killing cancer cells. Chemotherapy may be used to shrink a cancer prior to surgery, prevent recurrence of cancer after surgery or for patients whose extensive cancer is inoperable. There are many different chemotherapy drugs, and their side effects vary. Chemotherapy alone does not cure non-small cell lung cancer, but it is the primary treatment for small cell lung cancer.

Radiation Therapy

Radiation therapy involves X-ray treatments that are given daily for several weeks. Treatments take only a few minutes. Like chemotherapy, radiation may be given prior to surgery, after surgery or instead of surgery. Usually, minimal side effects include a tired feeling, sunburn, esophagitis and nausea. Although radiation may cure lung cancer, only 5 to 10% of patients who receive this therapy are considered cured.