Lung Cancer

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In 2018, there were 48,698 new lung cancer cases among Indian males and 19,097 new cases among Indian female. Lung cancer has a high mortality rate of 63,475 deaths reported across India in 2018 due to lung cancer.

TYPES OF GASTRIC CANCER

  • Small Cell & Non-small cell lung cancer: Non-small cell lung cancer is a form of lung cancer that originates from lung tissue whereas, Small cell lung cancer almost always begins in the bronchi (the tubes or airways in the centre of the chest transporting air to the lungs). Small lung cancer occurs almost exclusively in smokers and is less common than non-small cell lung cancer.
  • Non-small cell lung cancer includes several subtypes such as squamous cell carcinoma, adenocarcinoma and large cell carcinoma. Adenocarcinoma (40% of all lung cancers; develop from mucus-producing cells) Squamous cell carcinoma (25–30% of all lung cancers; develop in cells lining the airways and is usually caused due to smoking), Large cell or undifferentiated carcinoma (10–15% of all lung cancers consists; named from the way cells appear under a microscope).

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STAGING OF GASTRIC CANCER

If you are diagnosed with lung cancer, your doctor will run more tests to determine the extent (stage) of your cancer. The stage of your lung cancer is based on the size and spread of the tumour and helps the clinical team decide which treatments are optimum.

Non-Small Cell Cancer Staging

    • Occult Cancer: The main tumour can’t be assessed or cancer cells are seen in a sample of sputum but the cancer isn’t found with other tests
    • Stage 0: Tumour is restricted only in the top layers of cells in the air passages, but it has not invaded deeper into the lung tissues, to the lymph nodes, or to distant parts of the body.
    • Stage I: Stage IA (The tumour is between 1 and 3 cm across, it has not reached the membranes that surround the lungs with no spread to lymph nodes or distant sites in the body), Stage IB (The tumour is between 3-4 cm across, has grown into a main bronchus, has grown into the membranes surrounding the lungs or is partially clogging the airways with no spread to lymph nodes or distant sites in the body).
    • Stage II: It is divided into two subtypes. Stage IIA (The tumour is 4-5 cm, has grown into a main bronchus, has grown into the membranes surrounding the lungs or the tumour is partially clogging the airways with no spread to lymph nodes or distant sites in the body). Stage IIB (The tumour is less than 3 cm across, has not grown into the membranes that surround the lungs, and does not affect the main branches of the bronchi. It has spread to lymph nodes within or around the lung on the same side as the cancer. The cancer has not spread to distant parts of the body OR the tumour is 5-7 cm across, has grown into the inner lining of the chest wall, the phrenic nerve, or membranes of the sac surrounding the heart (parietal pericardium) or has two or more separate tumour nodules in the same lobe of a lung)
    • Stage III: It is divided into three subtypes. Stage IIIA (The tumour is less than 3 cm, 3-5cm or greater than 7cm across, may or may not have grown into the membranes that surround the lungs, may or may not affect the main branches of the bronchi. The lymph nodes around the point where the windpipe splits into the left and right bronchi are affected on the same side as the main lung tumour but the cancer has not spread to distant parts of the body) Stage IIIB (The tumour is less than 3 cm, 3-5cm or greater than 7cm across, may or may not affect the bronchi, has spread to the lymph nodes, may or may not partially clog the airway and may or may not have spread to the other tissue in the chest.) Stage IIIC (The tumour has one or more of the following features greater than 5 cm has grown into the chest wall, the inner lining of the chest wall, affects the phrenic nerve, or the sac surrounding the heart, There are 2 or more separate tumour nodules in the same lobe of the lung, has spread to lymph nodes but has not spread to distant parts of the body).
    • Stage IV: It has two subtypes. Stage IVA (The cancer can be any size, may or may not have grown into nearby structures and lymph nodes. In addition, any of the following: spread to the other lung, cancer cells are found in the fluid around the lung or in the fluid around the heart or has spread as has spread as a single tumour outside of the chest to the liver, bones, or brain), Stage IVB (The cancer can be any size and may or may not have grown into nearby structures, may or may not have reached nearby lymph nodes and has spread to more than one tumour outside the chest, to other organs such as the liver, bones, or brain).
  • Small Cell Cancer staging
      • Stage 0: Also known as in-situ cancer wherein the cancer has not grown into nearby tissues or spread outside the lung
      • Stage I: The tumour is small and has not spread to any lymph nodes. It is divided into two sub-stages based on the size: Stage IA (3cm or less in size) Stage IB (3 cm to 4 cm across)
      • Stage II: It is divided into 2 sub-stages: Stage IIA (the tumour is between 4 to 5cm and has not spread to the nearby lymph nodes) Stage IIB l(tumour is 5 cm or less and has spread to the lymph nodes OR is more than 5 cm wide that has not spread to the lymph nodes)
      • Stage III: It is classified in to three subtypes
      • Stage IV: The lung cancer has spread to more than one area in the other lung, the fluid surrounding the lung or the heart, or distant parts of the body through the bloodstream. Once cancer cells get into the blood, the cancer can spread anywhere in the body. Stage IV is divided into 2 substages: Stage IVA (cancer has spread within the chest and/or has spread to one area outside of the chest) Stage IVB (cancer has spread outside of the chest to more than 1 place in 1 organ or to more than 1 organ).

Sources: Globocan; MedicineNet ; European Society of Medical Oncology (ESMO); Cancer India; American Cancer Society; Mayo Clinic; Cancer.Net

DIAGNOSTIC TESTS FOR LUNG CANCER

  • Clinical History & Examination: The doctor will ask for symptoms such as persistent cough, coughing blood, repeated chest infection, chest or shoulder pain, breathlessness, hoarseness of the voice, weight loss and wheezing. A examination will also be done to examine the chest, lymph nodes in your neck. The doctor may also ask for blood tests such as Complete blood count to measure the number of white blood cells, red blood cells and platelets to get information on the patients overall health. Other tests such as alkaline phosphatase (ALP), calcium or phosphorus, liver function tests are used to gauge whether the cancer has spread to organs such as the liver and bones.
  • Pulmonary Function Tests: Pulmonary function tests are used to measure how well the lungs are working. There are a number of tests such as spirometry (measures how much air can be breathed in and out of the lungs), plethysmography (measures how much air is taken in to the lungs after a deep breath and how much air is left in the lungs after forcefully breathing out), lung diffusion test (measures how well oxygen moves from the lungs into the bloodstream).
  • Imaging tests: X-ray - An image of the lungs may reveal abnormalities such as a mass or a nodule. CT scan: A CT scan is useful to detect small lesions in the lungs that may be missed on X-ray. MRI: MRI scans are useful for staging of the cancer. Certain diagnostic tests may be used to detect the spread of the disease to other organs such as positron emission tomography (PET) and bone scans.
  • Tissue sample or Biopsy: A sample of abnormal cells may be removed in a procedure called a biopsy by procedures such as bronchoscopy (a lighted tube that's passed down the throat and into the lungs) mediastinoscopy (an incision is made at the base of the neck and surgical tools are inserted behind your breastbone to take tissue samples from lymph nodes;) and needle biopsy (X-ray or CT images are used to guide a needle through the chest wall and into the lung tissue). Thoracoscopy is another minimally invasive procedure to examine the outer lining and the surface of the lungs and collect samples in the case a suspicious area is noted. Oesophageal ultrasound-guided sampling (EUS) is a technique used to confirm the spread of cancer to nearby lymph nodes if suggested based on radiological scans.
  • Cytology:  (or cytopathology) is the examination of cancerous cells that spontaneously detach from the tumour. These samples are obtained by Bronchoscopy (Bronchial washings with a mild salt solution in the airways), Thoracentesis/pleural drainage (Pleural effusion is the abnormal collection of fluid between the thin layers that surround the lung. The fluid is collected using a fine needle) and Pericardiocentesis/pericardial (Pericardial effusion is an abnormal collection of fluid between the layers that surround the heart  and which is drained using a fine syringe).  

TREATMENT OF LUNG CANCER

  • Surgery: The objective of the surgeons is to remove all the cancer in the lung or in advanced cases to remove a part of the tumour that leads to symptoms affecting the quality of life. There are various procedures that may be implemented: Wedge resection (the procedure involves the removal of a small section of lung containing the tumor and a margin of healthy tissue), Segmental resection (removes a larger portion of lung, but not an entire lobe which is a subpart of the lung), Lobectomy (remove the entire lobe of the lung) and Pneumonectomy (removal of an entire lung). In larger tumours it may be recommended to receive chemotherapy or radiation therapy before surgery in order to shrink the tumour. Advancements in lung cancer surgery include minimally invasive surgery and video-assisted thoracoscopic surgery (VATS), which reduce the amount of time spent in the hospital post-surgery but are indicated only in specific conditions. Side effects: Pain, air leak, pneumonia, infection.
  • Radiotherapy: Radiation therapy uses high-powered energy beams to kill cancer cells. In patients with advanced lung cancer restricted to the lungs, radiation may be used before surgery or after surgery and is often combined with chemotherapy treatments. If patients in whom surgery isn't an option, combined chemotherapy and radiation therapy may be the primary choice of treatment. Side effects: Skin damage, blisters, difficulty swallowing, heartburn or indigestion, radiation pneumonitis (an inflammation leading to cough, fever and fullness of chest).
  • Stereotactic body radiotherapy: It is also known as radiosurgery. It is an intense radiation treatment that aims beams of radiation at the cancer. It may be an option for patients with small lung cancers who can't undergo surgery and in patients in whom the cancer has spread to other parts of the body.
  • Chemotherapy: Chemotherapy uses drugs to kill cancer cells and is given through a vein or taken orally. A combination of drugs usually is given in a series of treatments over a period of weeks or months. It is often used before surgery to shrink the tumour or after surgery to kill any cancer cells that may remain. It can be used alone or combined with radiation therapy. Side effects: Depending on the agent used these may differ but common side effects include anemia, fatigue, nausea, lowered immunity, anorexia, nerve damage, increased risk of bleeding, loss of hair, mouth ulcers, swelling of legs, nausea, vomiting, muscle pain etc.
  • Targeted drug treatments: These agents block specific chemicals and pathways present within cancer cells, causing them to die. These agents are most commonly reserved for people with advanced or recurrent cancer. Side effects: Depending on the agent used these may differ but common side effects include: decreased appetite, diarrhoea, nose bleeds, nausea, rash, acne, dry skin, itchiness, vomiting, constipation, muscle and joint pain, swelling of legs, hypertension , lowered immunity, anorexia, nerve damage, increased risk of bleeding etc.
  • Immunotherapy: Immunotherapy uses the body’s immune system to fight cancer. Immunotherapy interferes with the process of blocking the immune system that is used by some cancer cells. Patients whose tumours express high levels of a specific PD-L1 protein based on molecular testing using a tumour biopsy may receive first-line immunotherapy with a specific agent called pembrolizumab. Side effects: Depending on the agent used, these may differ but common side effects include: Back pain, cough, decreased appetite, diarrhoea, rash, difficulty in breathing etc.
  • Photodynamic therapy: Photodynamic therapy is also called PDT and is a form of treatment that kills cancer cells by using a combination of a light sensitising drug followed by a very bright light. It is used in patients in whom the cancer is too advanced or the patient is not healthy enough to undergo aggressive therapy. PDT can shrink the tumour and relieve symptoms in these patients. Side effects: Light sensitivity, skin rashes, blisters, body soreness etc.
  • Palliative care: People with lung cancer experience symptoms of the cancer, as well as side effects of the various types of treatment. Palliative care specialists work to minimize these symptoms and improve the patient’s quality of life as well as reduce the anxiety and depression involved with the cancer diagnosis.

Sources: American Cancer Society; European Society for Medical Oncology (ESMO); Canadian Cancer Society; Mayo Clinic;Cancer Research UK

MULTI-DISCIPLINARY TEAM (MDT): Unlike most other diseases, cancer treatment requires an integrated approach from several specialists, each with their own expertise. This team of specialists who would work together on your cancer, is referred to as the Multi-Disciplinary Team (MDT). Many global organisations have recognized the importance of a MDT for cancer treatment, as it improves coordinated care to you, as a patient. Your MDT would include specialists from the following:

      • Medical Oncologists: Specialists that decide the agent to be administered for chemotherapy
      • Pathologists: Specialists that examine the sputum and biopsy samples under the microscope and report specific abnormalities that can guide management of the cancer
      • Pulmonologists: Lung specialists that treat all conditions pertaining to the lungs
      • Radiation oncologists: Specialists that decide the course for radiotherapy
      • Radiologists: Specialists that read CT scans, MRI scans, X rays etc
      • Thoracic Surgeons: Surgeons that specialise in operating on conditions pertaining to the region in the thorax (within the ribcage, specifically pertaining to the lungs)
      • Palliative Care Specialists: These are specialists who specialize in palliative care or pain management.

TUMOR BOARD: A tumor board is a meeting where a Multi-Disciplinary Team discusses cancer cases and share knowledge. The board’s goal is to determine the best possible cancer treatment and care plan for an individual patient. Having fresh perspectives from other doctors makes it much easier to come up with that plan.

In some hospitals, all cancer cases are discussed at the Tumor Board, while in other hospitals the Tumor Board focuses on cases where a doctor seeks inputs from other specialists on the patient's case. It’s OK to ask your doctor if or why your case was discussed at a tumor board. Or if it wasn’t, why not? In some cases, a patient’s treatment plan is very straightforward using standard treatment guidelines, and the doctor may feel a tumor board review isn’t needed. However, you can request that one be done.

SUPPORT GROUPS: These are offline or online groups that connect patients suffering from cancer. Do find out about a support group around you. The hospital where you are being treated may have a support group that you could join.

Sources:  Mayo Clinic; Cancer.Net

Choosing your oncologist and hospital is a very important decision, we recommend you make the time to research your options. We profile hospitals and doctors based on range of services they offer for lung cancer treatment, use our search tools to guide your choice of medical provider. You may also call us for any assistance during selection and booking.

If you’ve been diagnosed with cancer, you need to find an oncologist to begin your treatment. An oncologist is a doctor who specializes in treating cancer. For lung cancer, you can start by visiting a medical oncologist or a radiation oncologist. Choose someone you are not only confident about but also comfortable with.

TIPS TO FIND AN ONCOLOGIST 

    1. Look for Specialists: Look for doctors who treat your specific type of cancer - lung cancer. You may need to work with more than one type of oncologists – surgical, medical or radiation oncologists.
    2. Gather Feedback: Discuss with friends and family, especially those who’ve taken similar treatment before. Online communities are a quick way to get feedback from others who’ve experienced your type of cancer before.
    3. Check the doctor’s credentials: Find out if the doctor has received any advanced training. There may be super-specialists available for lung cancers, who have received dedicated training on treating lung If doctor’s credentials are not available easily, you have the right to ask for it from the doctor directly.
    4. Review doctor’s experience: Check how long the doctor has been practicing after completion of formal oncology education. How many patients with your type of cancer – lung cancer – does the doctor see every year? In case of surgeons, studies have proven that higher volumes of surgeries lead to better outcomes. Organ-specific surgeons are also available in some hospitals, they have advance training and experience in operating cancers in specific organs.
    5. Find out hospital affiliations: Which hospitals does the doctor practice in? The availability of a multiple types of doctors at the hospital where you get treated is important. Find out what support staff is available at the hospital e.g. dietitian, counselor, home healthcare facilities etc.

TIPS TO FIND A HOSPITAL 

    1. Lookout for hospitals with lot of experts: Look for hospitals that offer a multi-disciplinary approach to lung cancer treatment. This means each you receive inputs from many cancer experts. You will be helped by specialists including surgeons, medical oncologists, radiation oncologists, oncology nurses and other supporting staff. Does the hospital have Tumor Board reviews – how often are they conducted and will your case be discussed there if you wish?
    2. Work with a major cancer hospital, even if it is far: Most experts in high-volume centers are willing to work with your local doctors. Usually, part of the treatment (for example, surgery) can be executed in the major center and the post-surgery treatment is executed locally.
    3. Research hospital’s Lung Cancer volumes: How many cases of lung cancer cases are treated in the hospital every year? High volume centers with multiple specialists available for lung cancers may have better expertise and specialized medical infrastructure required.
    4. Consider Clinical Trials Availability: Ask whether the doctor or hospital has access to clinical trials and if you are eligible for any. Clinical trials are research studies that test new ways to treat cancer that you can be involved with. By being involved, you can help improve treatments and outcomes for future patients.
    5. Insurance Acceptance: Check if the hospital accepts your insurance. Check if the hospital has a desk that can assist you with claims.

Sources: Rogel Cancer Center; Cancer.Net

Section: Cancer Basics

How do Cancer cells behave differently from healthy ones?

Source: TEDed

Staging of Small cell Lung Cancer

Source: Nucleus Medical Media

Staging of Non-small cell Lung Cancer

Source: Nucleus Medical Media

Coping with your Lung Cancer Diagnosis

Source: American Lung Association

Section: Tests for Lung Cancer

Tests: Bronchoscopy, Needle biopsy

Source: American Lung Association

Test for Lung function - Spirometry

Source: Nucleus Medical Media

Lung Biopsy (Transthoracic Needle Biopsy)

Source: Nucleus Medical Media

Learn about Lung Biopsies

Source: ACCPChest

CT Scan

Source: Nucleus Medical Media

PET CT Scan

Source: Blausen Medical

MRI Scan

Source: Blausen Medical

How does gamma scan work?

Source: ZRN

Lung Cancer Tumor Testing - Genetic tests

Source: American Lung Association

Section: Treatments for Lung Cancer

Lung cancer surgery - What to expect

Source: American Lung Association

Treatments: Surgery, Radiation, Chemotherapy, Targeted Therapy

Source: Nucleus Medical Media

Lung Cancer Chemotherapy: What to expect

Source: American Lung Association

How does Chemotherapy work?

Source: Nucleus Medical Media

Radiation Therapy for Lung Caner

Source: American Lung Association

Radiation Therapy: What to expect

Source: Accelerated Education Program

What is cancer radiotherapy?

Source: Cancer Research UK

What is Radiation Sickness

Source: Blausen Medical

Who is Eligible for Targeted and Immune Therapies?

Source: American Lung Association

Palliative Care - The Extra Layer of Support

Source: American Lung Association

What is Palliative Care

Source: Get Palliative Care

What are Clinical Trials?

Source: Cancer Research UK

Section: Useful Patient Resources

NCCN Guide for Early Lung Cancer Patients
Non-small cell lung cancer
NCCN Guide for Metastatic Lung Cancer Patients
Non-small cell lung cancer