Lung cancer is the number one killer among cancers worldwide. The World Health Organization says lung cancer causes about 1.69 million deaths annually. Tobacco smoking is the main risk factor for the disease. Often, people with lung cancer do not have symptoms, so it can be quite advanced before it is found. The earlier it is found, the better the chance of survival.
What is lung cancer?
Lung cancer is cancer that begins in the lungs, usually in the cells lining air passages. Cancer cells, unlike normal cells, divide and multiply uncontrollably. This abnormal growth of cancer cells in the lungs can form a solid tumor. If unchecked, lung cancer continues to grow and can spread (metastasize) to other parts of the body.
The American Cancer Society estimates that approximately 154,000 deaths will be caused by lung cancer and 234,030 people will be diagnosed with lung cancer in the US in 2018. In the UK lung cancer kills around 36,000 a year and in 2014 accounted for 22% of all cancer deaths. You can learn more about lung cancer in your country by using the Global Lung Cancer Coalition’s e-atlas.
Only cancers that begin in the lungs are called “lung cancer”, though a number of other cancers commonly spread to the lungs.
The two main types of lung cancer are non-small cell lung cancer (NSCLC) and small-cell lung cancer. NSCLC is further divided into subtypes, the most common of which are:
• Squamous cell carcinoma
• Large cell carcinoma
There are also other less common subtypes of lung cancer.
About eight out of ten lung cancers are NSCLC, and around half of those are adenocarcinoma. Small-cell lung cancers tend to grow and spread more rapidly and cause symptoms sooner than NSCLC. Treatments for small-cell lung cancer usually differ from those for NSCLC.
Symptoms of lung Cancer
Many people with lung cancer do not have any symptoms. The symptoms people do get with lung cancer can also be caused by many other conditions. You should talk to your doctor if you have any of the following:
- Blood when you cough or spit
- Recurring respiratory infections
- Enduring cough that is new or different
- Ache or pain in shoulder, back or chest
- Trouble breathing
- Hoarseness or wheezing
- Exhaustion, weakness or loss of appetite
Other symptoms of lung cancer may include:
- Swelling in the neck and face
- Difficulty swallowing
- Weight loss
“I didn’t realize a fit 31-year-old could have it, having never smoked”– response in HealthUnlocked lung cancer survey, 2017
Diagnosis of lung cancer
If lung cancer is suspected based on symptoms or other factors, such as a history of smoking, imaging tests may be used to help see if there might be a tumor in the lungs. Chest X-rays and CT (computed tomography) scans are imaging tests that might be used. But only tests on tissue or fluid from or around the lung can be used to definitively diagnose lung cancer.
Many different procedures are used to take samples of tissue. The removal of tissue from the body is known as a biopsy. Ways that tissue or fluid is obtained to diagnose lung cancer include:
- Bronchoscopy, a procedure in which a doctor puts a small, flexible camera into the airway to look for tumors. The bronchoscope may have tools to remove for testing a small sample of the tumor or nearby lymph nodes, which are part of the body’s defense against infection.
- Fine needle aspiration or core needle biopsy, in which a doctor known as an interventional radiologist removes a sample of the lung tumor for testing.
- Thoracentesis, where fluid is removed from the space between the lung and the wall of the chest.
The tissue or fluid samples obtained by biopsy are then looked at under a microscope to see if they are cancer.
A sample used to diagnose lung cancer might also be used to determine the specific subtype. Even more detailed tumor testing can be done. These tests are sometimes called molecular testing or biomarker testing, and may involve:
• Looking for changes (mutations) in the DNA of the tumor
• Looking at levels of specific proteins in the tumor
Tumor testing is important to determine the best treatment for someone with lung cancer. Different subtypes respond differently to available treatments. For example, some patients may be prescribed drugs that target a specific mutation found in their tumor.
Screening for lung cancer
Screening looks for cancer (or conditions that may lead to cancer) in people who do not have cancer symptoms. The idea is to find cancer early, when the disease may be easier to treat and could be curable. CT scanning is the currently recommended screening test for lung cancer. CT screening is painless and quick, usually taking just a few minutes. If cancer is suspected based on the scan, a biopsy is used to confirm a diagnosis.
The US Preventive Services Task Force recommends annual lung cancer screening for those aged 55 to 80 with a history of smoking. In the UK, the NHS is planning to extend screening after a 2017 pilot scheme among people aged 55-74. It found cancer in 3% of those tested and four out of five of the cancers detected were early stage, giving the best chance of successful treatment.
Causes of lung cancer
Smoking is the number one risk factor for lung cancer. In the US, exposure to naturally occurring radon gas is the second leading risk factor; in the UK it is estimated that radon is responsible for 3% of lung cancer deaths.
Other risk factors include exposure to:
• Second-hand smoke
• Air pollution
• Diesel exhaust
• Certain metals (arsenic, chromium)
• Some organic chemicals
Family history and genetic factors may also play a role in the development of lung cancer.
Effects of lung cancer
Lung cancer and its treatments can have a profound impact on your physical, social, and emotional well-being. People with lung cancer should talk to their healthcare team to get help in managing the effects. Treatments that help manage the symptoms of your cancer commonly cause side effects, but these can also be treated. Care known as supportive care or palliative care is designed to manage symptoms and address psychological, social, or spiritual concerns. Patients with advanced cancer may be referred to a palliative care specialist soon after diagnosis, as palliative care is not only for “end of life” but can help you live more comfortably.
Some level of distress is normal with a diagnosis of cancer, but healthcare professionals can assess patients for anxiety and depression, both of which can be treated. Psychosocial support and counselling can help patients and their families better cope with a diagnosis of lung cancer.
The financial burden of cancer and its treatments is another issue for patients and their loved ones. Forced unemployment and loss of income can contribute to loss of self-esteem, anxiety, and other emotions. In the US, government assistance programs, patient advocacy organizations, and pharmaceutical company programs may help pay for expenses related to cancer, including costs of the treatments and travel to receive treatment, as well as general living expenses. In the UK, NHS treatment is free and there is a range of benefits people with lung cancer may be able to claim. You can find out more about UK benefits and financial support on the Macmillan website.
“There is a general stigma towards lung cancer as opposed to breast or prostate cancer … people treat you differently”– response in HealthUnlocked lung cancer survey, 2017
People with lung cancer may also face stigma that can have many negative consequences. They may avoid or delay seeking treatment, not talk about the illness, and have little social support. There’s also less research funding compared to other major cancers. This stigma is largely centered on the role of smoking in lung cancer, which can lead to feelings of guilt and shame by patients, as well as apathy and blame by the general public. The poor prognosis for lung cancer contributes to negative views of the disease.
Stages of lung cancer
Staging lung cancer is important in determining the best treatment options. The early stages have the best chance for a cure. Unfortunately, most lung cancers are not diagnosed until it is in the late stages of the disease and has often spread to other parts of the body.
Lung cancer is staged using a system called the TNM classification in which T stands for primary tumor, N stands for regional lymph nodes, and M stands for distant metastasis, or spread. Briefly, the stages for NSCLC are:
Stage I: Stage I tumors are smaller than 5 cm and have not spread to any lymph nodes or other organs. These tumors may be able to be removed surgically. Radiation therapy may also be used to treat these tumors.
Stage II: These lung cancers may be larger than those of stage I (ie, up to 7 cm), and/or may have spread to lymph nodes, and/or may have begun to invade other parts of the chest. These tumors are usually suitable for surgery.
Stage III: Stage III tumors have not spread to other organs (ie, outside the lungs). Subcategories within stage III NSCLC are used to more fully characterize tumor size and spread to lymph nodes. Often, stage III tumors are unable to be removed surgically. People with stage III disease are assessed individually for surgery, which may be performed after chemotherapy and/or radiation (radiotherapy).
Stage IV: Stage IV lung cancer has spread to other areas of the body. Common sites of metastasis sites include the brain, bones, adrenal glands (which release hormones), and liver. Although stage IV cancers are generally not curable, treatments aim to help patients live longer and improve quality of life.
In the past, small-cell lung cancer was classed using two stages, limited and extensive. However, recommendations by the International Association for the Study of Lung Cancer (IASLC) indicate that TNM staging should also be applied to small-cell lung cancer.
Treatment of lung cancer
Surgery, radiation (radiotherapy), chemotherapy, targeted therapies, and immunotherapy are the main treatments for lung cancer. Various factors help determine treatment options for each individual. The sorts of things taken into account include the type of cancer, stage, location of the tumor, presence of specific mutations, and the patient’s overall health.
There are also clinical trials people with lung cancer may be able to join. You might benefit from treatments being developed and will be helping others by taking part in research. You can find details of clinical trials at the US National Cancer Institute or through the UK Clinical Trials Gateway
Surgery, or having an operation, is the physical removal of the tumor and any nearby lymph nodes that may contain cancer cells. Ideally, a thoracic surgeon, an expert in lung cancer surgery, should perform this operation. Advances in surgical techniques include less invasive procedures, such as video-assisted thoracic surgery (VATS) or robotic-assisted thoracic surgery (RATS).
Radiation therapy (also called radiotherapy) is the use of X-rays or other high-energy beams (such as protons) to damage cancer cells and stop them from growing or multiplying. Radiation is directed to the tumor and the surrounding area. The radiation kills tumor cells and normal cells in the area. Radiation treatment might be used to treat a tumor in the lung or to address lung cancer that has spread to other areas of the body, such as the brain or bone. Newer techniques allow higher doses of radiation to be precisely focused on the tumor, avoiding healthy tissue. Stereotactic Body Radiation Therapy (SBRT) or Stereotactic Ablative Radiotherapy (SABR) are examples of highly focused radiation techniques that might be used to treat lung cancer.
Chemotherapy drugs are medicines that kill or stop the growth of cancer cells throughout the body. Unlike surgery and radiation, which are used to treat disease locally, chemotherapy is “systemic”; it can affect cancer cells (as well as normal cells) throughout the body.
Many types of abnormalities or mutations in the DNA of lung cancer cells have been identified. Drugs that specifically target these mutations have been developed. By targeting specific mutations of cancer cells, these drugs can stop or limit the growth and spread of cancer. These drugs are also called “molecular targeted therapies” or “precision medicines” because they precisely target the mutation that is causing the cancer. Tumor testing to check for mutations is key to determining the best treatment options for an individual patient.
Immunotherapy is a way to treat lung cancer that is different from chemotherapy or targeted therapies. Immunotherapies are designed to make use of your body’s own immune system to fight cancer. Some immunotherapies work by targeting proteins involved in the immune system. Tumor testing to check for the amount of a protein called PD-L1 might be used to help decide if immunotherapy is a good choice for a particular person.
Side effects of treatments
Lung cancer treatments can cause a variety of side effects – including things like hair loss, tiredness, feeling sick, losing your appetite, having trouble swallowing and more. You should tell your cancer treatment team about any side effects. In most cases, these can be controlled with medication or other treatment so you feel better and can continue with your daily activities. Because immunotherapy can sometimes cause the immune system to become too active, you and your healthcare team should discuss specific side effects that you’d need to report.
Living with lung cancer
Lung cancer can affect you in many ways – physically, emotionally and socially – but there’s a lot you can do to ensure you keep as well as possible and continue to enjoy life.
Learn about your illness – Knowing as much as you can about your particular lung cancer will help you become your own advocate. Making decisions about treatments was the biggest clinical worry among lung cancer patients in a survey on HealthUnlocked in 2017. With deeper knowledge, you’ll be more able to make balanced decisions about treatment options your doctors suggest and about other things you can do to help yourself.
Quit smoking – First, if you have lung cancer and you smoke, stop. Of all the things you can do, this is just about the most important. People who keep smoking after diagnosis have worse symptoms, more pain and poorer outcomes.
Ask questions – Always ask for explanation if you aren’t clear about anything your doctors or nurses say. Some people find it helps to have someone with them at appointments to remind them of things or take notes.
Exercise and diet – Regular exercise can help ease your symptoms and improve your general fitness, which in turn can help fend off infections and improve your mental wellbeing. How much exercise you do will depend on your circumstances, but even something as simple as a daily walk is better than nothing. Along with exercise, it’s important to maintain a healthy weight, ensure you eat a well-balanced diet and get enough sleep.
Medicines – Take any prescribed medication as directed. If you want to take over-the-counter medicines, supplements or other remedies alongside your prescribed drugs, check with your doctor first – some medicines interfere with one another, making them less effective or causing unwanted side effects.
Pain – Many people with lung cancer have little or no pain. If you are in pain, don’t suffer in silence – tell your healthcare team. There are very effective pain control measures that will help you cope.
Relationships – Any serious condition such as lung cancer can strain close relationships, interfere with your sex life, limit social activities and make you feel ‘down’ or ‘blue’. Your partner or others close to you will also have worries. If you can, be honest about how you feel and discuss any issues openly. This can help reduce anxiety and stress, for you and for them. Try to stay connected with your community and keep doing the things you enjoy.
Accept help – Take emotional support and practical help from wherever it’s available – family and friends, medical staff, support organizations and others with lung cancer. You aren’t alone in living with lung cancer and talking with others who have it can be a great source of advice and comfort.
“As family and friends have been fantastic this has made it easy for my husband and I to ask for help”– response in HealthUnlocked lung cancer survey, 2017
Some people find it helpful to connect with and talk to other people with lung cancer. Local support groups offer the opportunity for patients and people caring for them to meet others face-to-face. Online forums and communities are other ways to find support and let you ask questions and join discussions.
Your healthcare team may be able to suggest local groups you could join and most big cancer support organizations can direct you to networks of groups and help you find one near you.
In the US, if you need someone to talk to, call the Lung Cancer Research Foundation Support Line at 844-835-4325.
In the UK, you can call the Roy Castle Lung Cancer Foundation helpline on 0800 358 7200 (Mon-Fri, 9am-5pm)
There are many online communities for people with lung cancer. You could start by visiting the Lung Cancer Research Foundation/Free to Breathe online community at HealthUnlocked
Find more information on lung cancer
The US Lung Cancer Research Foundation (which merged with Free to Breathe in 2017) provides a comprehensive education portfolio on lung cancer. All materials are free and can either be downloaded from the website or you can have them mailed to you.
The UK-based Roy Castle Foundation provides information online and in a range of booklets you can download.
Other organizations with information on lung cancer include:
- World Health Organization
- National Cancer Institute
- American Cancer Society
- Cancer Research UK
- NHS Choices
Main resources consulted in preparing this information
All sources mentioned here were accessed during February 2018.