Division of Thoracic and Cardiovascular Surgery

Lung Cancer: What I need to know about my cancer.

Lung Cancer is currently the number one cause of cancer death in both men and women in the United States. More people die each year of lung cancer than of colon, breast and prostate cancer combined. It is estimated that 184,000 new cases of lung cancer diagnosed will be diagnosed this year and approximately 168,000 patients will die of this type of cancer. Despite this early-stage lung cancer can be effectively treated with surgical resection achieving good 5-year survival rates of 70% for stage (cancer has not yet begun to spread) and 50% for stage II (limited spread within the lung itself) lung cancers. In addition, new protocols are in place to add chemotherapy and radiation to help improve these outcomes.

What is Lung Cancer?

Lung cancer is an abnormal growth of cells in the lung. This usually starts from a single cell that has undergone a change that allows it to grow and spread in an uncontrolled fashion. Lung cancers can arise from a variety of different types of cells in the lung, thus leading to different types of lung cancers.

The most common types include small cell and non-small cell lung cancers. There are many types of non-small cell cancers, including squamous cell carcinoma, adenocarcinoma, bronchoalveolar carcinoma, large cell carcinoma and carcinoid tumors. They may be discovered at different stages. Depending on the type and stage of lung cancer one has, surgery, chemotherapy, radiation therapy, or some combination of the three treatments, may be recommended as part of treatment.

Some patients may become confused about lung cancer. Not every cancer that is in the lung is a lung cancer. Lung cancer is a type of cancer that starts in the lung first. Some patients with other types of cancer may have their cancer spread to the lung. Although this is also cancer and it is in the lung, it is not lung cancer. This is metastatic disease (spread from another type of cancer).

How Does One Get Lung Cancer?

Lung cancer is most commonly associated with smoking. However, certain people may have a genetic predisposition to cancer. Even if you do not smoke, you may be exposed to smoke through your environment. Several workplace substances have also been associated with an increased risk for lung cancer, including arsenic, asbestos, beryllium, silica, radon, etc. Also, patients who do not have normal lungs but have chronic bronchitis or emphysema are at increased risk of developing lung cancer.

What Tests Should I have if I am suspected of having Lung Cancer?

Lung cancer is most often suspected on either chest x-ray or a chest computed tomography scan (CT or “CAT” scan). The findings of a suspicious nodule or mass often need to be confirmed with a sample of tissue. This piece of tissue can be obtained from a bronchoscopy (a flexible tube with a light and camera on the end (the bronchoscope) which is passed into the windpipe), a fine-needle biopsy (usually done by a radiologist using CT scans), or by a surgical biopsy. One may have additional testing, but these tests are not always required. Other common tests include a full body positron emission tomography (PET) scan, a magnetic resonance imaging (MRI) of the brain, a bone scan and blood work. If you are not sure what tests are appropriate for you, ask you doctor.

How is Lung Cancer Treated?

The answer to this question depends on a number of factors; the type of lung cancer, the stage, and the overall condition of the patient. Your Doctor will need to perform some tests which will help determine these factors before a treatment plan for is made you. If you are otherwise healthy, and the cancer is not too advanced, surgery is usually the single best treatment available for lung cancer.

What treatment is right for me?

The type of treatment that is right for you depends on the stage of the lung cancer and cell type. This is an extremely complex discussion. Prior to deciding on what is best for you, you should make sure that you understand the details of the specific treatments as well as the potential risks and benefits to those treatments.

How does my doctor know what stage my cancer is in?

It is absolutely essential to accurately stage lung cancer before commencing treatment.

Staging lung cancer is based on the tumor’s size/location, the involvement of lymph node spread and whether there is spread to other parts of the lung or to distant organs. Several tests will need to be performed to help determine your stage. Staging requires searching for distant spread and for local extent. Head scans (CT or MRI), bone scans, PET scans, and chest CT scans are used to evaluate possible spread to brain, bones, liver and adrenal glands. PET scans can evaluate distant disease or, to a lesser extent nodal disease.

What is a Bronchoscopy?

A bronchoscopy is a procedure using a bronchoscope or flexible camera, placed into your airway to view the bronchial tree. This may be used to make a diagnosis or it is done for specific therapy. Surgeons commonly perform this procedure on patients after the have received general anesthesia so that the surgeon can look at a patient's airways to confirm expectations prior to surgery.

What is a Mediastinoscopy?

The most accurate way to evaluate local spread to lymph nodes in the middle of the chest (mediastinum) is by a small surgical procedure called mediastinoscopy. Your surgeon will make a small incision at the base of your neck just above your breast bone under general anesthesia. Then a mediastinoscope is placed through the incision along side your trachea, and the lymph nodes that surround your trachea are biopsied. This procedure however should be performed by an expert in the field. If an incomplete procedure is done, the chance of accurate staging and the subsequent treatment plan may be altered.This is important because the appropriate treatment of lung cancer depends upon how advanced is the cancer stage.The information your doctor gets from the scans, bronchoscopy, mediastinoscopy and other tests should give an accurate picture of you clinical cancer stage. This will allow your doctors to tailor your treatment plan appropriately. Early cancers are best treated with surgery (sometimes followed by chemotherapy), while intermediate cancers (those that involve lymph nodes in mediastinum (middle of the chest) are best treated with a combination of chemotherapy and/or radiotherapy prior to surgery. Metastatic (advanced) cancer is cancer that has spread from the lung to other sites. Patients that have single metastases to their brain or adrenal glands can undergo resection of both, all other patients with metastatic or advanced cancer are best treated with chemotherapy alone.

Lung Cancer Staging System

What operation is performed for Lung Cancer?

The standard surgical treatment for lung cancer is based upon the anatomy of the lungs, which are divided into three lobes on the right, and two lobes on the left. The typical surgery performed is to remove the entire lobe of the lung with contains the tumor (a lobectomy). Occasionally a pneumonectomy (removal of an entire lung) or more complex procedures may be required to adequately treat your cancer. Once the portion of the lung with the tumor has been removed, the surgeon removes the lymph nodes that receive drainage from the lung. The lymph nodes are examined to determine if the tumor has spread to them; this information will affect the staging of the tumor and hence the prognosis of your disease.

Most often, surgeons perform either a posterolateral thoracotomy (an incision from the back around towards the front that goes between the ribs) or a smaller muscle-sparing incision to remove a lung cancer. However, other approaches may be possible such as a minimally invasive video-assisted operation. If you are about to undergo surgery for lung cancer it is important to ask your surgeon about these approaches and what is best for you.

After the surgery has been completed, the surgeon will insert one or two chest tubes (drains). These will allow air and fluid to drain out of the chest in the days after the procedure. Once the drainage has decreased, the surgeon will remove the drain. Next, the epidural catheter which was used to give local anesthesia will be removed. Most patients go home after four or five days in the hospital. While in the hospital, it is important to work on deep breathing and coughing. As with any procedure, there are risks associated with every type of operation. Before having any surgery, make sure you have discussed the potential risks and benefits of your operation with your surgeon.

How much of my lung can be removed safely?

Most of us have enough lung tissue that if we had an operation to remove one whole lung, or a portion of one lung, we could still breathe. However, some patients who undergo lung surgery do not necessarily have normal lung function. Therefore, the amount of the lung that can be removed can be a complicated question. Surgeons usually answer this question with a number of tests including some of the following: pulmonary function studies, ventilation perfusion scan, and a six-minute walk test. With this information, your surgeon may be able to calculate how much lung tissue you can afford to do without, if necessary. Most people who have lung surgery do not need to be on oxygen for the rest of their life; however, most patients are placed on it temporarily around the time of their operation.

Do I have to have Chemotherapy or Radiation Therapy?

Lung cancer is often best treated by multimodality therapy, that is, before or after surgery, your surgeon may also ask for consultations with a medical oncologist (chemotherapy doctor) and/or a radiation oncologist (radiation therapy doctor). The smallest and earliest tumors need only surgery, thus while the other doctors may see you, they will not need to give any therapy to you and you will only need observation. Some patients have tumors which are slightly larger or more advanced, and even though the surgeon can remove all visible traces of tumor, there is still a risk of microscopic deposits of disease being left behind, so chemotherapy or radiation therapy may be offered in those patients. This is called adjuvant therapy, and it is offered to reduce the risk of a recurrence. Even if a cancerous tumor recurs, it may be possible to remove the recurrence with surgery. Chemotherapy and radiation therapy are usually used when there are too many tumor deposits, or the tumor cannot be safely removed because of where it is located. Radiation therapy is often used alone or with chemotherapy when the tumor cannot be completely removed because of where it is located.

Chemotherapy uses drugs to fight the cancer, given either by vein (“IV injection”) or by mouth; your doctor will describe these drugs, how they are given, and potential side effects and ways to avoid or treat the side effects. Not all chemotherapy drugs may make you nauseated or lose your hair, but some do. If you do lose your hair, you should get it back. Medical oncologists try very hard to avoid making patients sicker with the therapy. Your medical oncologist will talk with you about which drug or drugs are best for you, and your treatment alternatives. Chemotherapy is almost always given as an outpatient, and one of the goals is to preserve your lifestyle as much as possible, so you will be encouraged to be as active and continue your usual routine as much as possible. Chemotherapy is usually administered for several months.

Radiation therapy is similar to taking a bunch of chest x-rays. You will first undergo a “simulation” which is to have another CT scan which the radiation therapist uses to aim the radiation beams as precisely as possible to miss vital structures if possible. This “treatment planning” takes about a week, and then you can begin your therapy. The therapy itself is also usually given as an outpatient; it is given Monday through Friday for about six straight weeks, and each session takes only a few minutes. Once you have received radiation therapy to any part of the body, you cannot receive any more radiation therapy to the same spot, though you can receive radiation therapy to another part of the body, if you need it. Radiation therapy will make you lose your hair, but only where the beam is aimed. It takes longer for the hair to grow back and it is usually thinner after radiation therapy. You may receive a combination of radiation and chemotherapy, where the radiation therapy is given daily during the week, and the chemotherapy is given either weekly or every several weeks. The major side effect of radiation therapy to your chest, with or without chemotherapy, is heartburn due to a sunburn-like reaction to your esophagus (the tube that leads from the mouth to the stomach). If you get this reaction, you would start to notice it towards the last couple weeks of your therapy, it gets more intense through the end of your therapy and then resolves over then next several weeks after the therapy ends.

Both chemotherapy and radiation therapy will make you tired toward the end of your therapy, and while the fatigue will go away it may take weeks or months before you feel normal again.

If I have Lung Cancer, What is my prognosis?

The prognosis for patients with lung cancer depends very much on the cell type of the cancer and the stage. Some people will have an excellent prognosis, such as those diagnosed early staged cancers and others will not have a favorable prognosis. However, you should understand that when your physicians are talking about a prognosis, they can only predict the risks of a group of people with your disease, with the same characteristics as yours. There is no way to tell precisely what will happen to you. But the information is still helpful to allow you to make the appropriate plans and decisions about your treatment. What is also important for you to know is that you will be treated with the best possible treatment options for your given cancer.

If I have Lung Cancer, what about a clinical trial?

Your physicians are going to offer you the best possible care for your disease, no matter what stage it is. This is called the “standard of care”. Your physicians are also looking at ways to improve the overall outcome for patients with lung cancer and other diseases, by improving the quality of life and, if possible, the overall survival. They do this by conducting clinical trials, and offering participation to patients. Some of the studies are conducted only in one or a few centers, and some may be conducted in multiple countries. In general, these studies are evaluating new therapies in an effort to see if improvements can be made on the standard of care. You may be offered a clinical trial, but it is not required that you participate in order to obtain the best possible care. If you do participate, there are no guarantees that you in particular will benefit from the therapy. However, it is hoped that important information about your disease may be obtained which may help your doctors to learn more about how to better treat patients with your disease.

More information on Lung Cancer from the UNM School of Medicine Cancer Research and Treatment Center.