This information has been prepared to help you understand more about lung cancer.
Many people feel understandably shocked and upset when they are told they have lung cancer. This information is intended to help you understand the diagnosis and treatment of this type of cancer.
We cannot advise you about the best treatment for you. You need to discuss this with your doctors. However, we hope this information will answer some of your questions and help you think about the questions you want to ask your doctors or other health carers.
The lungs are the organs in your body used for respiration (breathing). The lungs look like two large, spongy cones. Each lung is made up of sections called lobes – the left lung has two lobes and the right lung has three. The lungs rest on the diaphragm, which is a wide, thin muscle that helps with breathing.
A number of structures lie between the lungs and include:
- the heart and large blood vessels
- the windpipe (trachea)
- the tube that carries food from mouth to stomach (oesophagus)
- lymph nodes (also known as lymph glands).
The lungs are covered by a thin sheet of tissue called the pleura, which is about the thickness of plastic cling wrap. Its inner layer (the visceral layer) is attached to the lungs and its outer layer (the parietal layer) lines the chest wall and diaphragm. Between the two layers is the pleural cavity (also called pleural space), which normally contains a small volume of fluid. This fluid allows the two layers of pleura to slide against each other so your lungs can move smoothly against the chest wall as you breathe.
How the lungs work
Air enters through the nose or mouth. From there, it travels down the windpipe into the right or left bronchi (airways in each lung). The bronchi branch into smaller tubes, called secondary bronchi and bronchioles.
At the end of the bronchioles, there are tiny air sacs called alveoli. Alveoli pass oxygen into the bloodstream through a network of capillaries. Blood flows between the thin walls of the air sacs. This allows oxygen to move from the air into the blood, and carbon dioxide (a waste product from the body) to move from blood to air, to be breathed out.
Lung cancer explained
Lung cancer is a malignant tumour in the tissue of one or both of the lungs.
There are many different types of lung cancer, which are classified according to the type of cell affected. The two main types are:
Small cell lung cancer (SCLC) – Makes up about 15% of lung cancers. SCLC tends to start in the middle of the lungs, and it usually spreads early. It is strongly linked with cigarette smoking. Surgery is not often used for this type of tumour — it’s usually treated with drugs (chemotherapy) combined with radiotherapy. Cancers are named for the way the cells appear when viewed under a microscope. Types include:
- small cell carcinoma
- mixed small cell/large cell carcinoma
Non-small cell lung cancer (NSCLC) – Makes up about 80% of lung cancers. NSCLC is classified as:
- squamous cell carcinoma (it mainly affects the cells that line the tubes into the lungs (bronchi)
- adenocarcinoma (affecting smaller airways)
- large cell carcinoma (large round cells under the microscope).
Mesothelioma – A rare type of cancer that affects the covering of the lung (the pleura). It is often caused by exposure to asbestos. It is a rare cancer, but Australia has the highest incidence in the world (40 cases/million people). It is very different to lung cancer.
How common is it?
Around 3,000 (1,950 males, 1,050 females) are diagnosed with lung cancer in NSW each year.
Lung cancer is the third most common cancer in men and the fourth most common cancer in women.
Lung cancer is one of the few types of cancer that has a number of known and proven risk factors.
Smoking – About one in ten smokers develop lung cancer but studies show that exposure to smoke causes up to nine out of 10 cases of lung cancer in men and about seven out of ten cases in women. Breathing in someone else’s tobacco smoke (passive or secondhand smoking) can cause lung cancer. Non-smokers who have been frequently exposed to secondhand smoke have a 20-30% higher risk of developing lung cancer than non-smokers who have not been exposed. People who have never smoked and have not been around secondhand smoke have a 0.5% risk of getting lung cancer.
If I am a smoker, have I caused my cancer?
Most people started smoking when they were young, at a time when they were unconcerned with, or unaware of health risks. Smoking is addictive and this is the main reason smokers continue to smoke even if they have tried to quit. Your health care team understands this and will consider it when caring for you. They won’t regard you poorly because you are (or were) a smoker.
Quitting smoking will improve your chances of responding to treatment. You must stop smoking before you have an operation. If you need help quitting, speak to your doctor, nurses or contact the Quitline on 13 18 48.
Exposure to asbestos – Although the use of asbestos has been banned nationally since 2003, it may still be in some older buildings. People who are exposed to asbestos have a greater risk of getting cancer. Some people are exposed to asbestos at work or during home renovations. People who have been exposed to asbestos and been a smoker are at even greater risk.
Exposure to other elements – Contact with the processing of steel, nickel, chrome and coal gas may also be a risk factor. Exposure to radiation and other air pollution, such as diesel fumes, also increases the risk of lung cancer.
The main symptoms of lung cancer are:
- a new dry cough or change in a chronic cough
- chest pain or breathlessness
- repeated bouts of pneumonia or bronchitis
- coughing or spitting up blood.
Lung cancer is often discovered when it is advanced. A person may have experienced symptoms such as fatigue, weight loss, hoarseness or wheezing, difficulty swallowing, or abdominal and joint pain.
Having one or more of these symptoms doesn’t necessarily mean you have lung cancer, so speak to your doctor if you are concerned about your symptoms.
How is lung cancer diagnosed?
If lung cancer is suspected, a number of tests will be done to help make a diagnosis.
Some of these tests can also show if cancer has spread to other parts of the body. Not every person will have all the tests described in this booklet. Your doctors will determine the best tests for you.
An x-ray of the chest can show tumours as small as 1 cm wide. Occasionally a tumour is found on a chest x-ray that has been taken for other reasons. X-rays are painless and effective in identifying tumours, but sometimes small, hidden tumours don’t show up on the x-ray.
A computerised tomography (CT) scan is a special type of x-ray that gives a three-dimensional picture of the organs and other structures (including any tumour) in your body.
CT scans are usually done at a hospital or a radiology service. They help identify smaller tumours than those found by x-rays, assess whether lymph nodes in the chest are enlarged, and determine whether the cancer may have spread to other parts of the body.
A CT scan usually takes less than 10 minutes. You will be asked to lie flat on a table while the CT scanner, which is large and round like a doughnut, rotates around you. Before the scan, a dye may be injected into a vein, probably in your arm. This will make the scanner’s pictures clearer.
You will be asked not to eat or drink for a while before your scan. A CT scan is painless and takes about 10 minutes. Most people are able to go home as soon as their scan is done.
A positron emission tomography (PET) scan is a specialised imaging test that is available in only some hospitals.
The PET scan is useful in diagnosing lung tumours where a biopsy is not possible. It is also very helpful in staging lung cancer, and finding cancer that might have spread to other body organs, such as the lymph nodes, bones, brain, liver and adrenal glands.
You will be injected with a radioactive glucose solution. It takes 30-90 minutes for the fluid to go through your body, then you will have a body scan. The scan shows ‘hot spots’ in the body where there are active cells, like cancer cells. All activity does not necessarily mean cancer. The scan will be carefully evaluated by a PET specialist.
Tissue sampling test
The sputum cytology test is an examination of sputum (liquid phlegm coughed up from lungs) under a microscope to check for abnormal cells. You can collect sputum samples by coughing deeply to bring up sputum from your lungs. You can do this at home, storing the sample in the fridge before taking it to the doctor or pathology collection centre.
If a tumour can be seen in your airway during a bronchoscopy, a biopsy might be taken. A sample of tissue from your lungs is examined under the microscope.
A fine-needle aspiration biopsy is done when tumours are accessible (in the outer parts of the lung). Not every tumour can be safely sampled this way.
A local anaesthetic is injected into the skin and, under the guidance of an x-ray machine, a needle is inserted through the chest wall and into the tumour. A small piece of tumour can usually be removed with the needle.
The procedure is done in a hospital or radiology department. You will be observed afterwards because the lung is at risk of being punctured during this procedure.
A fine needle biopsy is less likely to be offered when the tumour is close to the heart or major blood vessels, or if the patient has a lung condition such as emphysema.
Tests to look at growth
Bronchoscopy allows the doctor to look directly into your bronchi (airways). The bronchoscope can only look at the larger airways, so if the tumour is in the outer part of the lung, it may not be seen. You will be given sedation, and a local anaesthetic will be sprayed on the back of your throat to numb it. The doctor will insert a flexible tube called a bronchoscope through your nose or mouth and down your windpipe (trachea). The bronchoscope may feel uncomfortable, but it shouldn’t feel painful.
During the bronchoscopy, the doctor will take a tissue sample (biopsy). If the tumour is near your main respiratory tract, the cells can be sampled using a technique called brushing and washing. ‘Washing’ means that a small amount of fluid is injected into the lung and withdrawn for further examination, while ‘brushing’ involves the use of a brush-like tool to remove some cells from the bronchi.
An endobronchial ultrasound (EBUS) is a type of bronchoscopy procedure that allows a doctor to examine the airways (bronchi) and take tissue samples through the airways and windpipe (trachea). Samples may also be taken from an adjacent tumour, or from a lymph node.
The doctor will use a bronchoscope with a small ultrasound probe on the end. The bronchoscope will be put down your throat into your trachea. The ultrasound probe uses soundwaves to create a picture of the body which will show and allow the doctor to measure the size and position of the tumour. After an EBUS, you may have a sore throat or cough up a small amount of blood. Tell your medical team how you are feeling so they can monitor you.
A mediastinoscopy is a procedure that allows a surgeon to examine lymph nodes at the centre of your chest (and remove a sample, if necessary).
A rigid tube is inserted through a small cut in the front of your neck and passed down the outside of your trachea. The surgeon will inspect the area between the lungs (mediastinum) and remove some tissue. This is usually a day procedure but some people need to stay overnight in hospital.
A thoracoscopy or thoracotomy is an operation performed under a general anaesthetic. It is usually done if other tests fail to provide a diagnosis. Your surgeon will do this test to take a tissue sample (biopsy) or remove the tumour.
This operation can be done in two ways. The surgeon may be able to make one or two small cuts in your chest and insert a camera and surgical instrument called a thoracoscope. If this isn’t possible, the surgeon will open the chest cavity through a larger cut on your back. You will stay in hospital for a few days, wake up with a drain coming from your side and will then need time to recover from the procedure.
You may also have blood and breathing tests.
If surgery is being planned, it is important to check that you are fit to have an operation, particularly that your breathing capacity is good enough. Some people who smoke develop a condition called emphysema, in which the alveoli of the lungs are enlarged and damaged. They may have reduced breathing capacity.
Staging of lung cancer
Staging describes the size of a tumour and if it has spread from its original location. Staging the cancer helps determine what treatment is required.
Small cell lung cancer has often spread outside the chest when it is diagnosed. It is staged in two ways:
- Limited disease – when the tumour can be detected in only one lung and nearby lymph glands.
- Extensive disease – the tumour has spread outside one lung or to other parts of the body.
Staging non-small cell lung cancer is more complex. The following is a simplified guide to staging this condition:
- Stage 1 – Tumours are only in one lobe of the lung.
- Stage 2 – A tumour in the lung with limited spread to nearby lymph nodes, or a tumour that has grown into the chest wall.
- Stage 3A – Tumours have spread to lymph nodes in the centre of the chest (the mediastinum).
- Stage 3B – Tumours have spread more extensively to lymph nodes in the mediastinum, or have become attached to major blood vessels or the trachea (windpipe).
- Stage 4 – The cancer cells have spread to distant parts of the body. Lung cancer sometimes spreads to the bones, the liver and to the adrenal glands (the glands that sit on top of the kidneys and regulate stress response).
Prognosis means the expected outcome of a disease.
You will need to discuss your prognosis with your doctor, but it is not possible for any doctor to give you a 100% accurate prognosis. It will be important to complete any tests to assess the stage of the tumour and then to observe how quickly it grows and how well you respond to treatment.
As in most types of cancer, the results of treatment are best when the cancer is found and treated early. People operated on in the early stages of lung cancer have the best chance of cure.
Which health professionals will I see?
Your GP will arrange the first tests to check out your symptoms.
If these tests do not rule out cancer, you will generally be referred to a lung specialist. This specialist will arrange further tests and advise you about treatment options.
You should expect to be cared for by a team of health professionals associated with a treatment centre that can diagnose and treat your lung cancer.
Other health professionals you may see include:
- respiratory physician – usually responsible for investigating symptoms, making a diagnosis, assessing how far the cancer has spread (staging the disease), and helping you optimise your lung function
- thoracic (chest) surgeon – responsible for some biopsies and removing tumours using surgery
- medical oncologist – responsible for chemotherapy and following treatment options
- radiation oncologist – prescribes and coordinates course of radiotherapy
- nurses and clinical care coordinators – support and assist you through all stages of your treatment
- dietician – recommends the best diet to follow while you are in treatment and recovery
- social worker, physiotherapist and occupational therapist – advise you on support services and help you get back to normal activities.
Your choice of treatment will depend on the stage of the cancer, your breathing capacity and ongoing general health, and your wishes.
Types of lung cancer and treatment options
Small cell lung cancer – is usually treated with chemotherapy. Some people with cancer in one lung (limited disease) will have radiotherapy to the chest and brain (known as preventive or prophylactic radiotherapy). Because it usually spreads early, surgery is not often used for this type of cancer.
Non-small cell lung cancer is best treated with surgery if possible, otherwise a combination of radiotherapy and chemotherapy. The choice of treatment will depend on the stage of your cancer, your general health, whether you are fit enough to have an anaesthetic and operation, and whether your lungs are working well enough.
The aim of treatment is to keep you as well and symptom-free as possible, even if your cancer cannot be cured.
Surgical removal of the tumour offers the best chance of cure for patients who have early-stage disease. The surgeon will assess three important factors when deciding if surgery is an option:
- Whether the cancer has spread beyond the lungs.
- Your health (apart from the cancer) – whether or not you will withstand a major operation
- Your breathing capacity – if it is sufficient.
Types of surgery:
Patients must cease smoking for a minimum of four weeks before any surgery will be performed.
There are three main types of surgery:
Lobectomy – a lobe of the lung is removed.
Wedge resection – part of the lung (but not the lobe) is removed.
Pneumonectomy – a lung is removed.
In some patients who have breathing difficulties before the operation, less of the lung is removed. Your doctor will advise which type of surgery is best for you.
Chemotherapy is treatment with anti-cancer (cytotoxic) drugs to stop the cancer cells from growing and multiplying. The aim of chemotherapy is to kill cancer cells while doing the least possible damage to your normal cells.
Chemotherapy is commonly given to patients whose cancer is large or has spread outside the lungs. It may be given:
- before surgery, to try to shrink the cancer and make the operation easier
- before radiotherapy or during radiotherapy (chemoradiation), to increase the chance of the radiotherapy working
- after surgery, to reduce the chances of the cancer coming back
- as palliative treatment, to reduce symptoms, improve your quality
Generally, chemotherapy is given through a drip (intravenously) — a plastic tube called a catheter is inserted into a vein in your arm or hand. Less commonly, chemotherapy is given in tablet form.
Chemotherapy is given in cycles. Each cycle lasts about three weeks. During this time you might have treatment for 3-5 days, depending on the drugs needed to treat you.
New research has discovered that the growth of some lung cancers depends on the presence of damaged genes (mutations) in the cancer. These mutations are not inherited or passed on to your children. The cause of the mutations is unknown as some are more common in non-smokers. A number of drugs have been developed which ‘switch off’ these mutations and arrest the growth of the cancer. Because these drugs target specific mutations within the cancer, they are known as ‘targeted’ therapies. As a result, they have fewer side effects compared with traditional chemotherapy, since their effects are largely restricted to the cancer cells.
Two of the mutations for which targeted therapies are available are the EGFR and ALK mutations. If your doctor suspects that your cancer may be due to a mutation, he will ask the laboratory to analyse the cancer tissue to see if one is present. If a mutation is found, this will guide your doctor in the choice of targeted therapy for your particular cancer, which is often referred to as ‘personalised medicine’.
Other examples of targeted therapies are drugs which attack the cancer’s blood supply and so starve the cancer (anti-angiogenesis drugs), and drugs which block the signals which make the cancer grow.
You may be asked if you want to participate in a clinical trial to receive targeted therapy. Talk to your doctor for more information about new drug trials.
Radiotherapy treats cancer by using x-rays to kill or damage cancer cells. Radiotherapy may be used to cure lung cancer that is confined to the chest. It is used instead of surgery if the tumour is too large for an operation or if your general health or lung function make surgery an unsafe option for you. Radiotherapy can also be used to treat cancer that has spread to the lymph nodes. This may stop the cancer from spreading further or from returning later. It is often given together with chemotherapy if the intention is to cure the cancer.
It can also be used:
- to treat an early stage small peripheral (on the outer portions of the lung rather than deep inside) lung cancer, where the patient is not fit for an operation or cannot abstain from smoking
- after surgery to treat sites where lymph nodes were taken as an attempt to reduce the chances of the cancer coming back
- to treat cancer that has spread to other organs such as the brain or bones
- as palliative treatment, to reduce symptoms, improve your quality of life or extend your life.
To plan radiotherapy treatment, your doctor will take an x-ray, CT or PET scan of the treatment area. To ensure that the same area is treated each time, the radiation therapist will make a few small marks on your skin.
During treatment, you will lie on a treatment table. A machine that delivers the radiation will be positioned around you. The treatment session itself will take about 10-15 minutes. Radiotherapy treatment is painless and the person giving you the treatment will make you as comfortable as possible.
Thoracentesis (pleural tap)
When fluid builds up in the pleural space (the area between the lung and the chest wall), symptoms like breathlessness, tiredness, lethargy and pain sometimes occur.
To relieve the symptoms, fluid can be removed by inserting a hollow needle between the ribs into the pleural space, and draining some or all of the fluid. This will take about 30-60 minutes. A pleural tap is performed under a local anaesthetic and it is usually done on an outpatient basis. Some of this fluid will be sent to pathology for examination.
If fluid in your chest is drained (by pleural tap procedure) and it comes back, it may be necessary to have another thoracenteis. If the fluid recurs again, a thoracic surgeon may perform a procedure called a pleurodesis. This is usually done with a key-hole type surgical approach (video-assisted thoracoscopic surgery or VATS).
In pleurodesis, you will have talcum powder instilled into the pleural space (between the lung and chest wall). The powder will inflame the membranes and make them stick together. This closes the space between the pleura, preventing the fluid from coming back. It is ideal to have this procedure performed by a thoracic surgeon under a general anaesthetic. You will have a hospital stay of two or three days.
Indwelling pleural drains
Some patients are not fit for surgery, and fluid is not adequately controlled with local pleurodesis, so they are offered an indwelling pleural catheter. This is a drainage tube that is inserted into the pleural space (by a cardiothoracic surgeon or experienced interventional radiologist) for the purpose of draining fluid when the fluid accumulates and causes troublesome symptoms like breathlessness. The tube remains in the body, capped off and secured under a dressing on the skin until needed for draining. It is connected to and drained into a company bottle when symptoms build up. In time, pleurodesis may occur and the drain may be removed but most people live the rest of their life with the drain. The drain can be managed by the patient, a confident carer, or the community nurse service.
Palliative treatment aims to improve the quality of life of people with cancer and their families by relieving symptoms of illness, particularly pain, without trying to cure the disease. It is available for all people who have cancer symptoms, whatever their stage of treatment.
Treatment can include radiotherapy, chemotherapy and pain-relieving medications.
Palliative treatment is particularly helpful and important for people with advanced cancer.