Download PDF

www.lungcancer.org

ABOUT LUNG CANCER

Lung cancer is the uncontrolled growth of abnormal cells in one or both lungs. These abnormal cells do not carry out
the functions of normal cells and do not develop into healthy lung tissue. As they grow, the abnormal cells can form
tumors and impede the function of the lung, which is to provide oxygen to the body via the blood.
There are different types of lung cancer and each type is treated differently.

The Genetic Basis of Lung Cancer

All cells in the body contain the genetic material called deoxyribonucleic acid (DNA). Every time a mature cell divides
into two daughter cells, it replicates its DNA exactly. The daughter cells are clones of the original cell, identical in
every way. It is in this way that our bodies continually replenish themselves. Old cells die off and the next generation
takes their place.

A cancer begins with an error, or mutation, in a cell’s DNA. DNA mutations can be caused by the normal aging
process or through environmental factors, such as cigarette smoke or breathing in asbestos.

Researchers have found that it takes a series of genetic changes to create a lung cancer cell. Before becoming
fully cancerous, cells can be precancerous, which means they have some irregularities (mutations) but still function
as lung cells. However, precancerous changes may signify progression toward cancer. When a cell with a genetic
mutation divides, it passes along its abnormal genes to the two daughter cells, which then divide into four cells with
errors in their DNA and so on. Once a cell has a genetic mutation, it may develop more. With each new mutation, the
cell becomes more irregular and may not be as effective in carrying out their function in lung tissue. At a later stage of
disease, some cells can migrate away from the main tumor and start growing in other parts of the body. These sites
are called metastases.

Lung Cancer Statistics

When you read about statistics, it is always important to remember that they are compiled from populations, or
groups, of people. They do not represent individual experiences.

Lung cancer is one of the most common cancers. In 2007, lung cancer will account for approximately 15% of all
cancer diagnoses and 29% of all cancer deaths. It is the second most diagnosed cancer in men and women (after
prostate and breast, respectively), but it is the number one cause of death from cancer each year in both men and
women. Because lung cancer can take years to develop, it is mostly found in older people. The average age of a
person receiving a lung cancer diagnosis is 69 years.

Overall, lung cancer affects men more than women, but that gap is closing. In 2007, an estimated 114,760 men and
an estimated 98,620 women will be diagnosed with lung cancer and an estimated 89,510 men and an estimated
70,880 women will die from lung cancer.

Cigarette smoking is the cause of most lung cancers, but there are other factors, too. Exposure
to asbestos, radon, environmental factors, or secondhand smoke can cause lung cancer. Sometimes, a person
develops lung cancer and doctors do not know why. There are often internal factors (inherited or from our genes) as
well as external or environmental factors (from outside of our bodies) involved in the development of any type of
cancer.

Lung cancer is the subject of a great amount of research. Promising areas of research include the study
of chemopreventive agents and research into targeted therapies, both of which show potential to halt the
progression of the development of a cancer cell. However, lung cancer does not receive as much attention, both in
funding and in public awareness, compared to other types of cancers that are not as common. Advocates for lung
cancer research are working hard to raise awareness of this imbalance. Here are some organizations that work to
support people with lung cancer by raising awareness of the disease and offering information and services to patients
and families.

• Lung Cancer Alliance www.lungcanceralliance.org
• Cancer.Net www.cancer.net
• National Lung Cancer Partnership www.nationallungcancerpartnership.org

TYPES OF LUNG CANCER

There are two main types of lung cancer, non-small cell lung cancer and small cell lung cancer. These names refer to
how the cancers look under a microscope to a pathologist.

Most cancers are non-small cell. There are subtypes of non-small cell lung cancer. Because different types of lung
cancer are treated differently, your oncologist will determine exactly what treatment is best for you.
Remember, no matter what type or what stage of lung cancer you have, there are treatment options.

Non Small Cell Lung Cancer- (NSCLC)

NSCLC accounts for about 80% of lung cancers. There are different types of NSCLC, including

• Squamous cell carcinoma (also called epidermoid carcinoma). This is the most common type of NSCLC. It
  forms in the lining of the bronchial tubes and is the most common type of lung cancer in men.
• Adenocarcinoma. This cancer is found in the glands of the lungs that produce mucus. This is the most
  common type of lung cancer in women and also among people who have not smoked.
• Bronchioalveolar carcinoma. This is a rare subset of adenocarcinoma. It forms near the lungs’ air sacs.
  Recent clinical research has shown that this type of cancer responds more effectively to the newer targeted
  therapies.
• Large-cell undifferentiated carcinoma. This cancer forms near the surface, or outer edges, of the lungs. It
  can grow rapidly.

Small Cell Lung Cancer-(SCLC)

• SCLC accounts for about 20% of all lung cancers. Although the cells are small, they multiply quickly and
  form large tumors that can spread throughout the body. Smoking is almost always the cause of SCLC.

LUNG CANCER SYMPTOMS

Everyone should be aware of how his or her body normally feels and report any abnormal feelings to their doctor.
Often, these unusual feelings can be attributed to other causes, such as bronchitis. But a doctor should check
anything that is worrisome.

The signs and symptoms of lung cancer can take years to develop and they may not appear until the disease is
advanced.

Some symptoms of lung cancer that are in the chest:

• Coughing, especially if it persists or becomes intense
• Pain in the chest, shoulder, or back unrelated to pain from coughing
• A change in color or volume of sputum
• Shortness of breath
• Changes in the voice or being hoarse
• Harsh sounds with each breath (stridor)
• Recurrent lung problems, such as bronchitis or pneumonia
• Coughing up phlegm or mucus, especially if it is tinged with blood
• Coughing up blood
  If the original lung cancer has spread, a person may feel symptoms in other places in the body. Common places for
  lung cancer to spread include other parts of the lungs, lymph nodes, bones, brain, liver, and adrenal glands.
  Some symptoms of lung cancer that may occur elsewhere in the body:
  • Loss of appetite or unexplained weight loss
  • Fatigue
  • Headaches, bone or joint pain
  • Bone fractures not related to accidental injury
  • Neurological symptoms, such as unsteady gait or memory loss
  • Neck or facial swelling
  • General weakness
  • Bleeding
  • Blood clots

SCREENING & EARLY DETECTION

The goal of a screening program is to find cancer at an early stage when there are fewer symptoms. Treatment at
early stages of cancer can lead to more treatment options, less invasive surgery, and a higher survival rate. For
example, in recent years, the five-year survival rate of persons whose cancers were diagnosed when they were still
localized (had not spread) was almost 50%. This drops to 2% for persons whose cancers were diagnosed after their
cancers had spread distantly. Even though early detection can save lives, there is currently no approved screening
test for lung cancer that has been proven to improve survival or detect localized disease. There are studies
underway, though, to find appropriate screening tools.

Early detection of lung cancer is critical for improving survival of this disease because only 15% of lung cancers are
found when they are localized. Since there are few or no symptoms in the early stages of the disease, the majority of
lung cancers are diagnosed in the late stages of the disease. Symptoms of later-stage disease may include a
persistent cough, sputum streaked with blood, chest pain, voice change, and recurrent pneumonia or bronchitis.
Testing people who are known to be at high risk for developing lung cancer may help find tumors at an earlier stage
when they are small and more easily treated. People at high risk include men and women

• Aged 60 years and older who currently smoke or have a history of smoking
• With previous lung tumors
• With chronic obstructive pulmonary disease (COPD)

Possible screening techniques for lung cancer include

• Microscopic analysis of cells in sputum
• Fiberoptic examination of bronchial passages (bronchoscopy)
• Low-dose spiral computed tomography (CT) scans
• Evaluation of molecular markers in sputum

Efforts are underway to find effective ways to screen for lung cancer. The National Lung Screening Trial is a clinical
trial to assess whether screening individuals at high risk for lung cancer with spiral computerized tomography
(CT) or standardchest x-ray can reduce lung cancer deaths. Even though this clinical trial is fully enrolled and is not
accepting any new patients, any person who is at increased risk of developing lung cancer should consult their doctor
to discuss screening with a low-dose helical CT scan even though this screening is somewhat controversial.

Although spiral CT scans can detect tumors in the earliest stages of disease, there is debate among the medical
community about whether this earlier detection ultimately saves lives. Some experts are concerned that screening will
lead to over diagnosis, or the detection of cancers that would not have caused symptoms prior to the patient dying of
other causes. Additionally, the procedures, such as needle biopsies, that are required to investigate irregularities on
the scans can be quite invasive and have their own risks, such as collapsing a lung. False positives (the test shows
something on the patient’s lung even though it may not be cancer) can be common because the test can mistake scar
tissue or a benign lump for cancer. Other medical experts feel the benefits of early detection of lung cancer outweigh
the uncertainty of false positives.

LUNG CANCER STAGING

When lung cancer is diagnosed, the pathologist will assign a type (non-small cell lung cancer or small cell lung
cancer) and a stage to the cancer. The stage is a formal classification that signifies the extent of the cancer and will
determine the type of treatment your oncologist recommends. It is important to note that staging is used solely to
determine the most appropriate treatment and does not indicate prognosis.

A lower stage number signifies a less advanced cancer. For example, a stage I cancer is an early stage cancer and
most likely will not have spread from its place of origin. A stage IV cancer indicates an advanced stage cancer and
may appear in the lung or other areas of the body (metastasis).

Lung cancers are divided into two types, non-small cell lung cancer and small cell lung cancer, depending on their
cellular characteristics. The staging is different for the two types. Generally, the stage number assigned to the cancer
includes characteristics for the tumor (its size, if it has spread), the lymph nodes (if the tumor has spread to them, and
to which ones), and if the tumor has metastasized to distant organs. You may see this referred to as the TNM system,
for Tumor, Nodes, and Metastases. The American Society of Clinical Oncology explains the system of staging and
provides illustrations.

Prognosis

It is important to remember that there are treatments available for lung cancer, no matter what stage the cancer is.
Treatment decisions will vary based upon the status of the individual patient and may also be influenced by the
patient’s strength, general health, co-existing illnesses and ability to tolerate certain treatments.
Staging of non-small cell lung cancer: The overall staging for NSCLC uses I through IV, with I being the earliest
stage and IV being the latest. Evaluation of the tumor, lymph nodes, and metastases are included in the overall
stage.

• Stage I: The earliest stage of lung cancer. The tumor is found only in one lung and has not spread to any
  lymph nodes.
• Stage II: The tumor has spread to lymph nodes that are contained within the surrounding lung.
• Stage IIIa: The tumor has spread to the lymph nodes outside of the lung, to those the tracheal area,
  including the chest wall and diaphragm on the same side as the cancer started.
• Stage IIIb: The tumor has spread to the lymph nodes on the opposite lung or in the neck.
• Stage IV: The tumor has spread to other parts of the lungs or distantly throughout the body.
  Staging of small cell lung cancer: Small cell lung cancer is classified as either limited stage or extensive stage.
• Limited stage: the tumor is found in one lung and in nearby lymph nodes.
• Extensive: the tumor has spread beyond one lung or to other organs.

LUNG CANCER TREATMENT

People respond in different ways when they learn they have been diagnosed with cancer. Some people want to learn
all they can about their disease, while others try not to think too much about it. Most health care professionals want
you to be an active partner with them in making decisions. They know that you will better be able to cope with the
challenges of treatment if you have a sense of control over the process. This section is intended to supply you with
the basic information on lung cancer treatment. If you would like to learn more, additional resources are included at
the end of this section. One thing to keep in mind: even though there are common approaches to lung cancer
treatment, the treatment plan for each patient is individually designed for the patient by his or her physician.

Types of Treatment

After a patient receives a lung cancer diagnosis, the physician and the patient will choose the most appropriate
treatment option, based on the type and stage of the patient’s cancer and the patient’s overall health. The oncologist
will also consider what symptoms the patient is having, the patient’s ability to carry on normal daily activities and need
for bed rest, and the patient’s opinion about quality of life. All of these are important considerations in choosing the
best treatments. The main treatment options are surgery, radiation, and chemotherapy. New treatments are also
showing promise.

SURGERY

Because surgery actually removes a tumor and nearby lymph nodes, it offers the greatest chance for significant
survival for some types of lung cancer. This is especially true for the early stage (I, II) cancers that have not spread to
other parts of the body. Some patients may undergo surgery during the course of their diagnosis and treatment.
Surgery may be the first step in treating lung cancer or it may be considered after chemotherapy and radiation.
A thoracic surgeon is specially trained to perform lung cancer surgery. During surgery, the surgeon will remove the
tumor and a surrounding margin of tissue. This margin will be evaluated under a microscope to see if it contains any
cancer cells. A “negative margin” means that no cancer is found in the tissue surrounding the tumor. A “positive
margin” may require the surgeon to remove more of the lung tissue until a clear margin can be identified.

TYPES OF SURGERY

Curative surgery: The removal of a tumor when it appears to be confined to one area, which means an
early stage cancer. This type of surgery aims to completely remove the cancerous tumor, and may include remove a
wedge, a lobe, or an entire lung.

• Palliative surgery: The goal of this surgery is to make the patient more comfortable, e.g., laser surgery for
  the removal of an obstruction or opening of an airway.

SIDE EFFECTS

As with any type of treatment, there are certain side effects associated with surgery. These side effects may occur
during or after the procedure and will vary depending on the type of surgery.
After surgery, potential side effects include:

• Pain. One of the most common side effects associated with surgery. Some surgery for lung cancer requires
  cutting through the ribs and/or cutting a nerve. This can take several months to heal. A patient should be honest with
  his or her health care team about pain because there are many options to alleviate it. CancerCare has developed a booklet titled Controlling Cancer Pain: What You Need to Know to Get Relief
  that addresses this issue.
• Infection. Infections at the site of the wound and inside the body are another possible side effect. Antibiotics
  give by a doctor are able to treat most infections.

CHEMOTHERAPY

Chemotherapy uses strong chemicals or drugs to kill cancer cells, stop their reproduction, or slow their growth.
There are many types of chemotherapy drugs, and they may be given in combination with each other, and also in
combination with surgery and radiation. A medical oncologist prescribes, but it may be given by an oncology nurse.
Even though chemotherapy drugs may be administered intravenously, or taken orally in tablet, capsule, or liquid form,
most chemotherapy for lung cancer is given intravenously. Chemotherapy is called systemic therapy, because it
treats the entire body, or system. Chemotherapy can kill cancer cells that have metastasized from the original tumor
because it travels through the blood system to all parts of the body.

The amount of chemotherapy a patient receives depends on the type of cancer, the drugs, and the patient’s overall
response to treatment. This therapy may be given daily, weekly, or monthly, and can continue for months or possibly
years. Some drugs may be given in cycles, with rest periods between treatments to allow the body to recover.
Chemotherapy may be referred to as adjuvant therapy, because it is given in addition to surgery or radiation. When it
is used as adjuvant therapy, it is intended to reduce the risk of a recurrence by traveling throughout the body and
killing whatever cancer cells remain after surgery. Neo-adjuvant therapy is chemotherapy that is given prior to any
surgery. The goal of neo-adjuvant therapy is to shrink the lung tumor so that it can more successfully be removed.

SIDE EFFECTS

Chemotherapeutic drugs affect normal cells, too. Particularly, cells that are rapidly dividing will take up chemotherapy
and die. Examples of these include cells lining the gastrointestinal tract, those in the bone marrow, and those making
up hair follicles. The most common side effects from chemotherapy, such as nausea and vomiting, a weakened
immune system, and hair loss are due to these normal cells being damaged during chemotherapy. Fortunately,
almost all side effects from chemotherapy are temporary and gradually disappear after treatment is finished.
It is important to know side effects of chemotherapy vary depending on the type of chemotherapy and how the patient
responds. Some drugs are known to have more side effects than others. Your doctor will be able to explain the
different drugs, their side effects, and why different drugs are recommended for different uses. Patients should
discuss any side effects with their doctors because there are many medicines available to help alleviate them. Some
common side effects of chemotherapy include:

• Nausea and vomiting. Chemotherapy may cause nausea and vomiting, but there are medications that may
  help with these issues. Even though eating may be difficult if the patient has nausea and vomiting, it is important to
  eat frequent, small meals to maintain strength. Eating and drinking slowly and avoiding fatty foods may help. After
  eating, it is important to not lie down flat for at least two hours, as this may worsen symptoms.
• Hair loss. Hair loss can occur on all parts of the body. Hair may fall out completely or may thin. Usually, hair
  grows back after treatment is completed.
• Fatigue. Chemotherapy affects the bone marrow and the body’s ability to make red blood cells, which may
  temporarily cause anemia. Anemia can make patients feel weak and tired. Getting more sleep at night and resting
  during the day can help with fatigue. Eating foods rich in iron and regular exercise can also help.
• Infections. Chemotherapy’s effects on bone marrow may also lower the number of white blood cells, which
  help fight infection. To prevent infection, patients should avoid exposure to people who have a cold, flu, or other
  contagious disease. Frequent hand washing helps minimize infections.
• Bleeding. Chemotherapy can affect other blood cells called platelets, which may lead to easier bruising or
  bleeding. Patients should alert their doctors if bleeding occurs.
• Mouth sores. Because the lining of the mouth contains cells that are susceptible to chemotherapy, a person
  may develop sores there during therapy. Because mouth sores are painful, a patient experiencing them may avoid
  eating. A dietician or oncology nurse will have ideas about how to get appropriate nutrition through beverages, such
  as liquid supplements and homemade smoothies, and through soothing foods, such as yogurt or puddings.
• Loss of appetite. Whether due to nausea or vomiting or some other reason, many patients undergoing
  chemotherapy report losing their appetites. Eating small meals of healthful foods can help and patients should keep
  in mind the importance of staying strong through good nutrition. Liquid supplements that contain vitamins and
  minerals can help maintain nutrition and avoid weight loss.
• Diarrhea. Chemotherapy may cause diarrhea because it affects the cells lining the gastrointestinal tract.
  There are medicines available to help with this side effect. Patients should alert their doctors if diarrhea continues.
  There are many resources available to learn more about chemotherapy and its side effects. Here are a few that might
  be helpful to you.
• CancerCare’s Connect® booklet Understanding and Managing Chemotherapy Side Effects
• The National Cancer Institute’s Coping with Cancer Side Effects
• The National Comprehensive Cancer Network’s Types of Treatment for Lung Cancer

RADIATION

Radiation therapy (also called radiotherapy) may be effective for the treatment of lung cancer. It uses high-energy
rays, similar to X-rays, but stronger, to kill or shrink cancer cells. Usually, lung cancers are treated from an external
source of energy. However research is underway to study the use of implanted radioactive seeds into or near the
lung cancer. This type of radiotherapy, called brachytherapy, has been successfully used in the treatment of prostate
cancer.

Radiation oncologists are the physicians who administer radiation. Radiation-delivery machines are designed to focus
the radiation in precise locations in the body for exact periods of time. This precision reduces the risk of damage to
normal tissue surrounding the tumor. However, even with such advances and the use of shields to protect the parts of
the body that do not require treatment, some healthy cells will be damaged by the radiation.

Radiation therapy is usually spaced over a number of weeks or months because the doses needed to kill cancer cells
cannot be given all at once. The number of treatments a patient receives depends on the type and extent of the
tumor, as well as the radiation dosage and how the patient is affected by the treatment.

SIDE EFFECTS

Depending on the specific regimen for each patient, side effects from radiation therapy may vary. However, a few
common side effects include:

• Fatigue. Fatigue is the most common side effect of radiation. A patient undergoing radiation therapy should
  rest as much as possible at night and limit their activities during the day.
• Eating problems. Nausea may occur with radiation, as can loss of appetite. Some medications are
  available to help with nausea and some patients find it useful to eat frequent, small meals throughout the day.
• Hair loss. Hair loss may occur on the part of the body undergoing radiation.
• Skin reactions. The skin in the treatment area may become dry, irritated, and sensitive, and should be
  treated gently. In some cases, the skin may resemble skin that has been sunburned and it may peel. The affected
  area should be kept out of direct sunlight for at least a year after treatment.

NEW TREATMENTS

Recently, there has been an increase in new treatment advances for lung cancer. Some of these advances are still
undergoing research in clinical trials, while others have been approved and are being used for treatment of patients.

The following are some of these new treatments.

• Chemotherapy regimens: Different combinations of existing chemotherapy drugs are being explored.
  Oncologists are constantly refining the way lung cancer is treated. Clinical trials often test new combinations of drugs
  to see if they will work better than what is currently the standard of care. CancerCareoffers a podcast, Advances in
  the Treatment of Lung Cancer that explains some of the new combinations of therapies that have been announced at
  medical conferences.
• Targeted therapies: These therapies, which include monoclonal antibodies, anti-angiogenesis drugs, and
  growth factor inhibitors, are designed to treat only the cancer cells, thus sparing normal cells from damage. Many
  targeted therapies are being researched, and some are in active use.
  • Monoclonal antibodies: these bioengineered molecules contain one part that can home in on the
    cancer cells coupled with another part that may contain a drug or radiation. Therefore, when the monoclonal
    antibodies are administered, they travel to the site of the cancer and release their drug or radiation. Monoclonal
    antibodies are designed to target only cancer cells, thus reducing side effects.
  • Anti-angiogenesis agents: Angiogenesis is the process that tumors use to make new blood
    supplies, which enable the tumors to grow. Drugs that counteract this ability are called anti-angiogenesis agents.
    They are a very promising area of cancer therapy.
  • Growth factor inhibitors: Cancer cells can grow so quickly because they often manufacture
    substances, called growth factors, that encourage their own growth. Specially designed drugs have been created that
    block the effects of the growth factors, which means the cancer cells can no longer grow.
• Photodynamic therapy: The use of light (photo) to shine on cancer tissue and activate drugs is another
  promising area of research.
• Lung cancer vaccines: Vaccines use the body’s immune system to fight diseases by engineering cancer
  cells so that they are no longer cancerous, but still contain components that the immune system will recognize as
  foreign. The theory is that by introducing small amounts of the vaccine, the body’s immune system will mount a
  defense against it. Unlike childhood vaccinations, cancer vaccines are promising not to prevent the primary
  occurrence of cancer, but to treat cancer that already exists.
• Gene therapy: As scientists learn more about how the genetic changes in cancer cells, they are working to
  design ways to correct those changes. The area of gene therapy, in which normal copies of damaged genes are
  inserted into cells, has much promise, but is still largely experimental.