Lung Cancer: Diagnosis, Staging, and Treatment

Edward Omron MD, MPH, FCCPPulmonary Medicine

Saint Louise Regional HospitalGilroy, CA

What is the Function of the Lungs?• The lungs consist of five lobes, three

in the right lung and two in the left lung

• Most cells in the lung are epithelial cells, which line the breathing passages and produce mucus, which lubricates and protects the lungs

• The main function of the lungs is to allow oxygen from the air to enter the bloodstream for delivery to the rest of the body

What is Lung Cancer?

• The leading cause of cancer death among men and women

• Begins when cells in the lung grow out of control and form a tumor

• There are two main types of lung cancer: non-small cell and small cell

Epidemiology

• Lung Cancer is the most common cancer– In 2008, 1.4 million deaths worldwide– 1.61 million new cases– In the USA, lifetime risk for men is 8% and women

is 6%• Lung Cancer was rare before the advent of

cigarette smoking, first recognized in 1761.• For every 3.5 million cigarettes smoked, 1 lung

cancer death

What Are the Risk Factors for Lung Cancer?

• Tobacco and second-hand smoke • Asbestos • Radon, Radiation, Genetics, Chemicals• Most people who develop lung cancer today

have either stopped smoking years earlier or have never smoked

20 Year Lag Time between Smoking and Lung Cancer

Types of Lung Cancer

• The types of lung cancer are treated differently. The most common types are named for how the lung cancer cells look under a microscope.

• Most lung cancers (about 85 percent) are non-small cell lung cancers. This type spreads more slowly than small cell lung cancer.

• About 13 percent of lung cancers are small cell lung cancers. This type tends to spread quickly.

Lung Cancer

Lung Cancer

Pulmonary Nodule

Pulmonary Nodule

Squamous Cell Carcinoma Lungs

Small Cell Carcinoma Lungs

What Are the Symptoms of Lung Cancer?

• Fatigue (tiredness) • Cough • Shortness of breath • Chest pain • Loss of appetite • Coughing up phlegm • Hemoptysis (coughing up blood)• If cancer has spread, symptoms include bone pain,

difficulty breathing, abdominal pain, headache, weakness, and confusion

Diagnosis

• Physical Exam• Sputum Cytology• CXR• CT CHEST• Bronchoscopy

How is Lung Cancer Evaluated?

• The diagnosis must be confirmed with a biopsy and infectious or autoimmune causes need to be excluded

• The location(s) of all sites of cancer is determined by additional CT scans, PET (positron emission tomography) scans, and MRI (magnetic resonance imaging)

• It is important to find out if cancer started in the lung or somewhere else in the body. Cancer arising in other parts of the body can spread to the lung as well

Finding Lung Cancer Cells

• Thoracentesis• Bronchoscopy• Endobronchial Ultrasound• Mediastinoscopy• Thoracoscopy• CT Guided Biopsy

PET Scan of Lung Cancer

Bronchoscopy

Endobronchial Tumor By Bronchoscopy

Endobronchial Ultrasound Biopsy of Lymph Nodes

Mediastinoscopy For Lymph Node Biopsy

Thoracentesis

VATS vs Thoracotomy

Lung Cancer and Early Detection

• A low-dose helical computerized tomography (CT or CAT) scan is currently recommended for high risk individuals.

• Any person who is at increased risk due to smoking or asbestos exposure should discuss the benefits and limitations of a screening CT scan with his or her doctor

How is Lung Cancer Treated?

• Treatment depends on the stage and type of lung cancer

• Surgery

• Radiation therapy

• Chemotherapy (options include a combination of drugs)

• Targeted therapy

• Lung cancer is usually treated with a combination of therapies

Cancer Treatment: Surgery

• The tumor and the nearby lymph nodes in the chest are typically removed to offer the best chance for cure

• For non-small cell lung cancer, a lobectomy (removal of the entire lobe where the tumor is located), has shown to be most effective

• Surgery may not be possible in some patients

Cancer Treatment: Chemotherapy • Drugs used to kill cancer cells• EGFR genotyping for Adenocarcinoma• A combination of medications is often used • May be prescribed before or after surgery, or

before, during, or after radiation therapy• Can improve survival and lessen lung cancer

symptoms in all patients, even those with widespread lung cancer

Cancer Treatment: Radiation Therapy

• The use of high-energy x-rays or other particles to destroy cancer cells

• Side effects include fatigue, malaise (feeling unwell), loss of appetite, and skin irritation at the treatment site

• Radiation pneumonitis is the irritation and inflammation of the lung; occurs in 15% of patients

• It is important that the radiation treatments avoid the healthy parts of the lung

Lung Cancer Staging

• Staging is a way of describing a cancer, such as the size of the tumor and where it has spread

• Staging is the most important tool doctors have to determine a patient’s prognosis

• The type of treatment a person receives depends on

the stage of the cancer

• Staging is different for non-small cell lung cancer and small cell lung cancer

Staging

• CT scan• Bone Scan• PET scan• Bronchoscopy

Stage I Non-Small Cell Lung Cancer

• Cancer is found only in the lung

• Surgical removal recommended

• Radiation therapy and/or chemotherapy may also be used

Stage II Non-Small Cell Lung Cancer

• The cancer has spread to lymph nodes in the lung

• Treatment is surgery to remove the tumor and nearby lymph nodes

• Chemotherapy recommended; radiation therapy sometimes given after chemotherapy

Stage III Non-Small Cell Lung Cancer

• The cancer has spread to the lymph nodes located in the center of the chest, outside the lung

• Stage IIIA cancer has spread to lymph nodes in the chest, on the same side where the cancer originated

• Stage IIIB cancer has spread to lymph nodes on the opposite side of the chest, under the collarbone, or the pleura (lining of the chest cavity)

• Surgery or radiation therapy with chemotherapy recommended for stage IIIA

• Chemotherapy and sometimes radiation therapy recommended for stage IIIB

Stage IV Non-Small Cell Lung Cancer

• The cancer has spread to different lobes of the lung or to other organs, such as the brain, bones, and liver

• Stage IV non-small cell lung

cancer is treated with chemotherapy

Small Cell Lung Cancer–All Stages

• Patients with limited stage (confined to one area of the chest) small cell lung cancer are treated with simultaneous radiation therapy and chemotherapy

• Patients with extensive stage (not confined to one area of the chest) small cell lung cancer are treated with chemotherapy only

• Because small cell lung cancer can spread to the brain, preventative radiation therapy to the brain is routinely recommended to all patients whose tumors disappear following chemotherapy and radiation therapy

Five Year Survival Lung Cancer

Clinical Stage Non Small Cell Cancer Small Cell Cancer

1A 50% 38%

1B 47 21

2A 36 38

2B 26 18

3A 19 13

3B 7 9

4 2 1

Living With Lung Cancer

• Patients with lung cancer face the risk of cancer growing back or the development of a new lung cancer. All patients must follow up with their doctors for regular x-rays, scans, and check-ups

• Many people with lung cancer feel that they will not receive as much support or help from people around them because they believe others will think that their behavior caused the disease

• Doctors and other members of the health-care team can help patients and families cope with a diagnosis of lung cancer

• Patients can take comfort knowing that the advances being made in the diagnosis and treatment of lung cancer will provide more and more patients with a chance for cure

Resources

• http://www.cancer.gov/– NIH National Cancer Institute

• http://www.lungcanceralliance.org/get-help-and-support/practical-resources/– Lung Cancer Alliance

• http://www.cancer.org/– American Cancer Society