Lung Cancer

Lung cancer is the second most common cancer in both men and women in the United States. The two main types of lung cancer are non-small cell lung cancer and small cell lung cancer. They differ in the look and biology of the cancer cells, and how they spread and respond to treatment. Mesothelioma is another cancer that can start in the lungs but is not lung cancer.

A risk factor is something that increases your chances of developing a disease. 

Common signs and symptoms of lung cancer include:

• Chest pain
• Cough that worsens or does not go away
• Coughing up blood or mucus
• Fatigue
• Hoarseness
• Loss of appetite
• Shortness of breath 
• Unexplained weight loss

The goal of screening is to look for disease in people who do not yet have symptoms. Lung cancer screening (in the form of a CT scan) is recommended for people at high risk. It has been shown to reduce deaths from lung cancer. The U.S. Services Task Force recommends screening for: 

• People ages 50-80 who have a history of smoking more than 20 pack years: A pack year is based on the number of cigarettes and the years of smoking. For example, 20 pack years could be one pack per day for 20 years or two packs per day for 10 years. People who currently smoke and those who have quit within the last 15 years may be eligible. 
• People who have had lung cancer already: If you had lung cancer once, you have a greater chance of getting a second lung cancer. It is a good idea to have yearly scans after you have completed treatment. 

If you think you may be at risk for lung cancer, find a screening program that follows these guidelines and uses low-dose CT scans. Remember, the goal of lung cancer screening is to find cancer earlier. People who have never smoked or smoked fewer than 30 pack years can still get lung cancer. Doctors do not recommend routine screening for these groups. Talk to your doctor if you feel that you have an increased risk for lung cancer and are not eligible for screening under current guidelines.

The process of finding out if you have lung cancer and learning as much as possible about it is called diagnosis and staging. A complete diagnosis usually takes more than one doctor’s visit. It may involve scans, blood tests, and a biopsy. Your doctor will work with a team to figure out if you have cancer, the type and subtype, and if and where it has spread.

• Diagnosis = Is there lung cancer? What type of lung cancer?
• Staging = Has the lung cancer spread? If it has spread, where?

Tools for diagnosis

Your health care team will want a detailed medical history if they suspect lung cancer. They will then run tests to learn as much as they can about your lung cancer. This process may include:

Physical exam – The exam will include questions about your medical history and any symptoms, such as cough, pain, or shortness of breath. Your doctor will listen to your breathing, check for swollen lymph nodes in or near the neck or collarbones, and feel your liver and stomach area for swelling or masses.

Imaging (scans) – Scans provide a picture of the lungs and other areas. They are used to look for tumors or abnormal cells. They help determine the extent or spread of the cancer. Common ones include:

• Chest x-ray – This is likely to be used first but does not provide as clear a picture as other scans.
• CT scan and MRI – CT (computed tomography) and MRI (magnetic resonance imaging) use computers to produce detailed, 3-D images. These images help diagnose lung cancer by determining the size, shape, and location of a tumor.
• PET scan – PET (positron emission tomography) uses a sugar substance and special camera to see if and where cancer has spread.

Samples of tissue, blood, or mucus – A sample of tissue or fluid will be needed to confirm cancer and identify its type and stage. There are many ways to obtain a sample. Common ones include:

• Needle biopsy - A small piece of tissue is removed and looked at under a microscope. This may be taken from the lung or a part of the body where the cancer has spread.
• Sputum cytology - A sample of sputum (mucus produced by a cough) is collected and looked at under a microscope.
• Thoracentesis - If there is fluid build-up around the lungs (called pleural effusion), a doctor can use a needle to remove some of the fluid. This can help you breathe better by expanding your lungs. A sample of the fluid can be sent to a lab to be tested for cancer cells.
• Bronchoscopy - A bronchoscope (a thin, lighted tube) is used to view the airways into the lungs and to collect tissue samples. Local anesthesia and mild sedation are generally used.
• Navigational bronchoscopy - This new technology uses a bronchoscope to provide a 3-D virtual “roadmap.” It is used to biopsy hard-to-reach parts of the lungs.
• Liquid biopsy - This new technology helps detect tumor DNA in your blood. It is still being studied and is best not used alone (without other types of biopsy) because it is not as sensitive as other types of biopsies.

The team also will consider your “performance status.” This status describes how well you can function. It includes your ability to take care of yourself and do daily activities. This is used to help determine your treatment options.

Your doctor will recommend the treatment type and approach based on your cancer’s stage.

A complete lung cancer diagnosis also may include tests of the blood, tumor tissue, or cough mucous for biomarkers. Biomarkers are features of your tumor cells that can be measured. The results of these tests will guide treatment planning. A positive biomarker test may mean more treatment options.

All patients with advanced or recurrent non-small cell lung cancer (NSCLC) should ask their health care team to be tested for biomarkers. People with earlier stage non-small cell lung cancer should talk to their health care team about getting tested for the biomarker “EGFR” before they start treatment. Many people with earlier stage non-small cell lung cancer and any stage small cell lung cancer get biomarker testing to qualify for clinical trials. Be sure to ask your doctor whether there might be a clinical trial that is right for you.

Questions to ask about biomarker testing:

• Was my tissue sent for biomarker (molecular) testing?
• Have you tested my tumor for EGFR, ALK, BRAF, ROS1, NTRK, MET, RET, KRAS and PD-L1? What about others that are being studied in lung cancer, such as HER2 and MEK1?
• How long will it take for all results to be returned?
• How will you use the information to recommend a treatment plan?
• Does my insurance pay for biomarker testing? If not, is there any financial assistance available for paying for biomarker testing?
• What do my results of these tests mean for my treatment?

Learning about the treatments used for your type of lung cancer will help you and your healthcare team make shared decisions. Standard treatment for lung cancer often involves a combination of approaches, together or in sequence.

Be sure to ask about clinical trials. Clinical trials are research studies to test new treatments or learn how to use existing treatments better. Today’s standard treatments were developed in yesterday’s clinical trials. Today’s clinical trials may become tomorrow’s standard of care. Trials are generally available for each stage and type of lung cancer, although every individual may not be eligible for a given trial.

Key Things to Know

• No one receives a placebo or “sugar pill” in place of appropriate treatments.
• Clinical trials for lung cancer test new treatments, new combinations of treatments, or better ways of using existing treatments.
• A doctor experienced in treating lung cancer should be able to recommend specific trials.
• The U.S. Food and Drug Administration (FDA) and local review boards oversee all U.S. clinical trials to keep patients safe.
• If you join a clinical trial, you can leave at any time.
• Every doctor does not have the same trials.
• Often, the trial pays the costs of the drug being studied. Then, your health insurance and your copay cover “standard” treatment costs. Be sure to ask about the costs to you.
• There are phase I, II, and III clinical trials; make sure you understand the goals of a clinical trial you join.
• Some clinical trials may make you ineligible for a future trial or treatment, so make sure to ask questions about this. See the resources below for help finding clinical trials that might be right for you.

Resources to Help Search for Clinical Trials

• Cancer Support Community’s Clinical Trials Resources or call 888-793-9355 
• GO2 for Lung Cancer's LungMATCH Program (a clinical trial matching resource) or call 800-298-2436
• LUNGevity Foundation Clinical Trial Finder
• National Cancer Institute or call 800-422-6237 

Coping With Stigma/blame/shame

Cancer can cause feelings of guilt or shame. You may feel like others blame you for developing cancer. You may blame yourself. You may be upset with yourself because you “should have stopped smoking, exercised more, lost weight, drank less alcohol, gone to the doctor more, or gotten that preventive screening sooner. You may see these thoughts as coming from your friends, family, or health care team.

In some cases, there may be a stigma associated with the kind of cancer you have. Stigma occurs when a group has negative or unfair beliefs about something. Stigma, or perceived stigma, can be isolating and interfere with your ability to take the steps you need to move forward. If you feel blame, shame, or stigma, it is important to remember:

• The causes of cancer are still largely unknown.
• Having a risk factor does not mean that you will get a disease. It is impossible to know who will get cancer, or when.
• Cancer can grow very quickly. Even people who stay on top of health care are sometimes diagnosed with late stage cancers.
• Most importantly, no one deserves cancer. And everyone with cancer deserves high-quality health care and support.
• Forgive yourself and focus on what you need to do now. If these thoughts become overwhelming, look for support in the form of a support group or counselor.

It is important to talk with your doctor about possible side effects before you begin treatment. Everyone reacts differently to treatment and being prepared helps whether you experience problems or not.

Common side effects can include:

• Fatigue 
• Infection, bleeding and anemia (chemotherapy can lower blood counts)
• Stomach problems (nausea, vomiting, diarrhea or constipation)
• Changes in appearance, including hair loss
• Pain and discomfort 
• Changes in sexual functioning and effects on fertility

Potentially serious side effects of chemotherapy may include lowered white blood cell counts, which increase the risk of infection, and problems with heart function. If you now have or ever have had heart problems, be sure to tell your doctor to prevent complications.

Difficulty Breathing

It is common for people with lung cancer to have breathing problems. Trouble breathing can decrease energy and cause fatigue. Breathing can become uncomfortable. You may feel like you can’t get enough air into your lungs. It can be a scary sensation. Breathlessness or breathing problems have many possible causes. They include tumors or blood clots in the lung or airways, an infection, certain chemotherapy drugs, fluid around the lungs or heart, a condition called radiation fibrosis, or feelings of stress or anxiety.

Sometimes, lifestyle changes can help with breathing problems. In other cases, medical treatment may be needed.

• Call your doctor right away if you have a feeling of tightness in your chest, pain, fever, or trouble breathing.
• Ask your doctor about oxygen therapy, corticosteroid therapy, and pulmonary rehabilitation to relieve breathing problems.
• If you use an inhaler, be sure to do so exactly as your doctor prescribed. If inhalers are not used consistently over time, they will not relieve symptoms.
• Sometimes having a fan in the room or having a cooler room temperature helps if you are having difficulty breathing.

Inflammation of the Lungs

Some treatments can cause inflammation of your lungs. This is a rare side effect but it can be fatal. Call your healthcare team if you have a worsening cough, chest pain, or shortness of breath while taking a targeted therapy or immunotherapy. The problem can reverse itself by stopping treatment — temporarily or permanently — or using steroids.

Palliative (Supportive) Care

Palliative care is a specialized medical care focused on relieving the symptoms and stress of a serious illness. It is not treatment for the lung cancer itself. It is appropriate at any age and at any stage. You can get it along with curative treatment. The goal is to improve quality of life for both the patient and the family.

Palliative care is provided by a specially-trained team of doctors, nurses, and other specialists. They work together with a patient's medical team to provide an extra layer of support.