Lung Cancer, Non Small Cell

Treatment and Diagnosis:

Finding Lung Cancer Cells

Types of Lung Cancer

If you have a symptom that suggests lung cancer, your doctor must find out whether it's from cancer or something else. Your doctor may ask about your personal and family medical history. Your doctor may order blood tests, and you may have one or more of the following tests:

• Physical exam: Your doctor checks for general signs of health, listens to your breathing, and checks for fluid in the lungs. Your doctor may feel for swollen lymph nodes and a swollen liver.
• Chest x-ray: X-ray pictures of your chest may show tumors or abnormal fluid.
• CT scan: Doctors often use CT scans to take pictures of tissue inside the chest. An x-ray machine linked to a computer takes several pictures. For a spiral CT scan, the CT scanner rotates around you as you lie on a table. The table passes through the center of the scanner. The pictures may show a tumor, abnormal fluid, or swollen lymph nodes.

Finding Lung Cancer Cells

The only sure way to know if lung cancer is present is for a pathologist to check samples of cells or tissue. The pathologist studies the sample under a microscope and performs other tests. There are many ways to collect samples.

Your doctor may order one or more of the following tests to collect samples:

• Sputum cytology: Thick fluid (sputum) is coughed up from the lungs. The lab checks samples of sputum for cancer cells.
• Thoracentesis: The doctor uses a long needle to remove fluid (pleural fluid) from the chest. The lab checks the fluid for cancer cells.
• Bronchoscopy: The doctor inserts a thin, lighted tube (a bronchoscope) through the nose or mouth into the lung. This allows an exam of the lungs and the air passages that lead to them. The doctor may take a sample of cells with a needle, brush, or other tool. The doctor also may wash the area with water to collect cells in the water.
• Fine-needle aspiration: The doctor uses a thin needle to remove tissue or fluid from the lung or lymph node. Sometimes the doctor uses a CT scan or other imaging method to guide the needle to a lung tumor or lymph node.
• Thoracoscopy: The surgeon makes several small incisions in your chest and back. The surgeon looks at the lungs and nearby tissues with a thin, lighted tube. If an abnormal area is seen, a biopsy to check for cancer cells may be needed.
• Thoracotomy: The surgeon opens the chest with a long incision. Lymph nodes and other tissue may be removed.
• Mediastinoscopy: The surgeon makes an incision at the top of the breastbone. A thin, lighted tube is used to see inside the chest. The surgeon may take tissue and lymph node samples.

Types of Lung Cancer

The pathologist checks the sputum, pleural fluid, tissue, or other samples for cancer cells. If cancer is found, the pathologist reports the type. The types of lung cancer are treated differently. The most common types are named for how the lung cancer cells look under a microscope:

• Small cell lung cancer: About 13 percent of lung cancers are small cell lung cancers. This type tends to spread quickly.
• Non-small cell lung cancer: Most lung cancers (about 87 percent) are non-small cell lung cancers. This type spreads more slowly than small cell lung cancer.

Staging

Stages of Small Cell Lung Cancer

Stages of Non-Small Cell Lung Cancer

To plan the best treatment, your doctor needs to know the type of lung cancer and the extent (stage) of the disease. Staging is a careful attempt to find out whether the cancer has spread, and if so, to what parts of the body. Lung cancer spreads most often to the lymph nodes, brain, bones, liver, and adrenal glands.

When cancer spreads from its original place to another part of the body, the new tumor has the same kind of cancer cells and the same name as the original cancer. For example, if lung cancer spreads to the liver, the cancer cells in the liver are actually lung cancer cells. The disease is metastatic lung cancer, not liver cancer. For that reason, it's treated as lung cancer, not liver cancer. Doctors call the new tumor "distant" or metastatic disease.

Staging may involve blood tests and other tests:

• CT scan: CT scans may show cancer that has spread to your liver, adrenal glands, brain, or other organs. You may receive contrast material by mouth and by injection into your arm or hand. The contrast material helps these tissues show up more clearly. If a tumor shows up on the CT scan, your doctor may order a biopsy to look for lung cancer cells.
• Bone scan: A bone scan may show cancer that has spread to your bones. You receive an injection of a small amount of a radioactive substance. It travels through your blood and collects in your bones. A machine called a scanner detects and measures the radiation. The scanner makes pictures of your bones on a computer screen or on film.
• MRI: Your doctor may order MRI pictures of your brain, bones, or other tissues. MRI uses a powerful magnet linked to a computer. It makes detailed pictures of tissue on a computer screen or film.
• PET scan: Your doctor uses a PET scan to find cancer that has spread. You receive an injection of a small amount of radioactive sugar. A machine makes computerized pictures of the sugar being used by cells in the body. Cancer cells use sugar faster than normal cells, and areas with cancer look brighter on the pictures.

Stages of Small Cell Lung Cancer

Doctors describe small cell lung cancer using two stages:

• Limited stage: Cancer is found only in one lung and its nearby tissues.
• Extensive stage: Cancer is found in tissues of the chest outside of the lung in which it began. Or cancer is found in distant organs.

The treatment options are different for limited and extensive stage small cell lung cancer. See the Treatment section for information about treatment choices.

Stages of Non-Small Cell Lung Cancer

Doctors describe non-small cell lung cancer based on the size of the lung tumor and whether cancer has spread to the lymph nodes or other tissues:

• Occult stage: Lung cancer cells are found in sputum or in a sample of water collected during bronchoscopy, but a tumor cannot be seen in the lung.
• Stage 0: Cancer cells are found only in the innermost lining of the lung. The tumor has not grown through this lining. A Stage 0 tumor is also called carcinoma in situ. The tumor is not an invasive cancer.
• Stage IA: The lung tumor is an invasive cancer. It has grown through the innermost lining of the lung into deeper lung tissue. The tumor is no more than 3 centimeters across (less than 1 ¼ inches). It is surrounded by normal tissue and the tumor does not invade the bronchus. Cancer cells are not found in nearby lymph nodes.
• Stage IB: The tumor is larger or has grown deeper, but cancer cells are not found in nearby lymph nodes. The lung tumor is one of the following (see the picture of the main bronchus and pleura):
  • The tumor is more than 3 centimeters across.
  • It has grown into the main bronchus.
  • It has grown through the lung into the pleura.
• Stage IIA: The lung tumor is no more than 3 centimeters across. Cancer cells are found in nearby lymph nodes.
• Stage IIB: The tumor is one of the following:
  • Cancer cells are not found in nearby lymph nodes, but the tumor has invaded the chest wall, diaphragm, pleura, main bronchus, or tissue that surrounds the heart (see the picture of the diaphragm).
  • Cancer cells are found in nearby lymph nodes, and one of the following:
    • The tumor is more than 3 centimeters across.
    • It has grown into the main bronchus.
    • It has grown through the lung into the pleura.
• Stage IIIA: The tumor may be any size. Cancer cells are found in the lymph nodes near the lungs and bronchi, and in the lymph nodes between the lungs but on the same side of the chest as the lung tumor.
• Stage IIIB: The tumor may be any size. Cancer cells are found on the opposite side of the chest from the lung tumor or in the neck. The tumor may have invaded nearby organs, such as the heart, esophagus, or trachea. More than one malignant growth may be found within the same lobe of the lung. The doctor may find cancer cells in the pleural fluid.
• Stage IV: Malignant growths may be found in more than one lobe of the same lung or in the other lung. Or cancer cells may be found in other parts of the body, such as the brain, adrenal gland, liver, or bone.

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Treatment

• Surgery
• Radiation Therapy
• Chemotherapy
• Targeted Therapy

Your doctor may refer you to a specialist who has experience treating lung cancer, or you may ask for a referral. You may have a team of specialists. Specialists who treat lung cancer include thoracic (chest) surgeons, thoracic surgical oncologists, medical oncologists, and radiation oncologists. Your health care team may also include a pulmonologist (a lung specialist), a respiratory therapist, an oncology nurse, and a registered dietitian.

Lung cancer is hard to control with current treatments. For that reason, many doctors encourage patients with this disease to consider taking part in a clinical trial. Clinical trials are an important option for people with all stages of lung cancer. See "The Promise of Cancer Research."

The choice of treatment depends mainly on the type of lung cancer and its stage. People with lung cancer may have surgery, chemotherapy, radiation therapy, targeted therapy, or a combination of treatments.

People with limited stage small cell lung cancer usually have radiation therapy and chemotherapy. For a very small lung tumor, a person may have surgery and chemotherapy. Most people with extensive stage small cell lung cancer are treated with chemotherapy only.

People with non-small cell lung cancer may have surgery, chemotherapy, radiation therapy, or a combination of treatments. The treatment choices are different for each stage. Some people with advanced cancer receive targeted therapy.

Cancer treatment is either local therapy or systemic therapy:

• Local therapy: Surgery and radiation therapy are local therapies. They remove or destroy cancer in the chest. When lung cancer has spread to other parts of the body, local therapy may be used to control the disease in those specific areas. For example, lung cancer that spreads to the brain may be controlled with radiation therapy to the head.
• Systemic therapy: Chemotherapy and targeted therapy are systemic therapies. The drugs enter the bloodstream and destroy or control cancer throughout the body.

Your doctor can describe your treatment choices and the expected results. You may want to know about side effects and how treatment may change your normal activities. Because cancer treatments often damage healthy cells and tissues, side effects are common. Side effects depend mainly on the type and extent of the treatment. Side effects may not be the same for each person, and they may change from one treatment session to the next. Before treatment starts, your health care team will explain possible side effects and suggest ways to help you manage them.

You and your doctor can work together to develop a treatment plan that meets your medical and personal needs.

Surgery

Surgery for lung cancer removes the tissue that contains the tumor. The surgeon also removes nearby lymph nodes.

The surgeon removes part or all of the lung:

• A small part of the lung (wedge resection or segmentectomy): The surgeon removes the tumor and a small part of the lung.
• A lobe of the lung (lobectomy or sleeve lobectomy): The surgeon removes a lobe of the lung. This is the most common surgery for lung cancer.
• All of the lung (pneumonectomy): The surgeon removes the entire lung.

After lung surgery, air and fluid collect in the chest. A chest tube allows the fluid to drain. Also, a nurse or respiratory therapist will teach you coughing and breathing exercises. You'll need to do the exercises several times a day.

The time it takes to heal after surgery is different for everyone. Your hospital stay may be a week or longer. It may be several weeks before you return to normal activities.

Medicine can help control your pain after surgery. Before surgery, you should discuss the plan for pain relief with your doctor or nurse. After surgery, your doctor can adjust the plan if you need more pain relief.

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Radiation Therapy

Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. It affects cells only in the treated area.

You may receive external radiation. This is the most common type of radiation therapy for lung cancer. The radiation comes from a large machine outside your body. Most people go to a hospital or clinic for treatment. Treatments are usually 5 days a week for several weeks.

Another type of radiation therapy is internal radiation (Brach therapy). Internal radiation is seldom used for people with lung cancer. The radiation comes from a seed, wire, or another device put inside your body.

The side effects depend mainly on the type of radiation therapy, the dose of radiation, and the part of your body that is treated. External radiation therapy to the chest may harm the esophagus, causing problems with swallowing. You may also feel very tired. In addition, your skin in the treated area may become red, dry, and tender. After internal radiation therapy, a person may cough up small amounts of blood.

Chemotherapy

Chemotherapy uses anticancer drugs to kill cancer cells. The drugs enter the bloodstream and can affect cancer cells all over the body.

Usually, more than one drug is given. Anticancer drugs for lung cancer are usually given through a vein (intravenous). Some anticancer drugs can be taken by mouth.

Chemotherapy is given in cycles. You have a rest period after each treatment period. The length of the rest period and the number of cycles depend on the anticancer drugs used.

You may have your treatment in a clinic, at the doctor's office, or at home. Some people may need to stay in the hospital for treatment.

The side effects depend mainly on which drugs are given and how much. The drugs can harm normal cells that divide rapidly:

• Blood cells: When chemotherapy lowers your levels of healthy blood cells, you're more likely to get infections, bruise or bleed easily, and feel very weak and tired. Your health care team gives you blood tests to check for low levels of blood cells. If the levels are low, there are medicines that can help your body make new blood cells.
• Cells in hair roots: Chemotherapy may cause hair loss. Your hair will grow back after treatment ends, but it may be somewhat different in color and texture.
• Cells that line the digestive tract: Chemotherapy can cause poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. Ask your health care team about treatments that help with these problems.

Some drugs for lung cancer can cause hearing loss, joint pain, and tingling or numbness in your hands and feet. These side effects usually go away after treatment ends.

When radiation therapy and chemotherapy are given at the same time, the side effects may be worse.

Targeted Therapy

Targeted therapy uses drugs to block the growth and spread of cancer cells. The drugs enter the bloodstream and can affect cancer cells all over the body. Some people with non-small cell lung cancer that has spread receive targeted therapy.

There are two kinds of targeted therapy for lung cancer:

• One kind is given through a vein (intravenous) at the doctor's office, hospital, or clinic. It's given at the same time as chemotherapy. The side effects may include bleeding, coughing up blood, a rash, high blood pressure, abdominal pain, vomiting, or diarrhea.
• Another kind of targeted therapy is taken by mouth. It isn't given with chemotherapy. The side effects may include rash, diarrhea, and shortness of breath.

During treatment, your health care team will watch for signs of problems. Side effects usually go away after treatment ends.

Second Opinion

Before starting treatment, you might want a second opinion about your diagnosis and treatment plan. Many insurance companies cover a second opinion if you or your doctor requests it.

It may take some time and effort to gather your medical records and see another doctor. In most cases, a brief delay in starting treatment will not make treatment less effective. To make sure, you should discuss this delay with your doctor. Sometimes people with lung cancer need treatment right away. For example, a doctor may advise a person with small cell lung cancer not to delay treatment more than a week or two.

There are many ways to find a doctor for a second opinion. You can ask your doctor, a local or state medical society, a nearby hospital, or a medical school for names of specialists. Also, your nearest cancer center can tell you about doctors who work there.

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