Lung Cancer (Non-Small Cell) Overview - PDF

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Lung Cancer (Non-Small Cell) Overview The information that follows is an overview of this type of cancer. It is based on the more detailed information in our document Lung Cancer (Non-Small Cell). This
Lung Cancer (Non-Small Cell) Overview The information that follows is an overview of this type of cancer. It is based on the more detailed information in our document Lung Cancer (Non-Small Cell). This document and other information can be obtained by calling or visiting our website What is non-small cell lung cancer? Note: This document covers only the non-small cell type of lung cancer. The treatment for the 2 main types of lung cancer (small cell and non-small cell) is very different. Some of the information for one type will not apply to the other type. If you are not sure which type of lung cancer you have, it is very important to ask your doctor so you can be sure you get the right information. Lung cancer is a cancer starts in the lungs. In order to understand lung cancer, it helps to know something about the structure of the lungs and how they work. The lungs The lungs are 2 sponge-like organs found in the chest. Each lung is divided into sections called lobes. The right lung has 3 lobes, while the left lung has 2 lobes. The left lung is smaller because the heart takes up more room on that side of the body. When you breathe in, air enters through your mouth and nose and goes into your lungs through the windpipe (trachea). The trachea divides into tubes called the bronchi, which enter the lungs and divide into smaller branches. These divide into even smaller branches called bronchioles. At the end of the bronchioles are tiny air sacs known as alveoli. Many tiny blood vessels run through the alveoli. They absorb oxygen from the air you breathe in and pass carbon dioxide from the body into the alveoli to be breathed out when you exhale. Taking in oxygen and getting rid of carbon dioxide are your lungs main functions. The thin lining around the lungs, called the pleura, helps to protect the lungs and allows them to move during breathing. Below the lungs, a thin muscle called the diaphragm separates the chest from the belly (abdomen). When you breathe, the diaphragm moves up and down, forcing air in and out of the lungs. Start and spread of lung cancer Lung cancers are thought to start as areas of pre-cancerous changes in the lung. These changes are not a mass or tumor. They can t be seen on an x-ray and they don t cause symptoms. Over time, pre-cancers may go on to become true cancer. The cells divide to make new cells and a tumor may form. In time, the tumor becomes large enough to show up on an x-ray. At some point, cancer cells can break away and spread to other parts of the body in a process called metastasis. Lung cancer can be a life-threatening disease because it often spreads in this way before it is found. The lymph system One of the ways lung cancer can spread is through the lymph system. Lymph vessels are like veins, but they carry lymph instead of blood. Lymph is a clear fluid that contains tissue waste products and cells that fight infection. Lung cancer cells can enter lymph vessels and begin to grow in lymph nodes (small collections of immune cells) around the bronchi and in the area between the lungs. Once lung cancer cells have reached the lymph nodes, they are more likely to have spread to other organs of the body. The stage (extent) of the cancer and decisions about treatment are based in part on whether or not the cancer has spread to the nearby lymph nodes. This is covered in Staging for non-small cell lung cancer. Types of lung cancer There are 2 main types of lung cancer and they are treated differently. Small cell lung cancer (SCLC) Non-small cell lung cancer (NSCLC) (If the cancer has features of both types, it is called mixed small cell/non-small cell cancer. This is not common.) The information here only covers non-small cell lung cancer. Small cell lung cancer is covered in Lung Cancer (Small Cell) Overview. Non-small cell lung cancer (NSCLC) About 9 out of 10 cases of all lung cancers are the non-small cell type. Based on how the cells look under the microscope, NSCLC is usually one of 3 sub-types: Squamous cell carcinoma Adenocarcinoma Large cell (undifferentiated) carcinoma Other types of lung cancer Along with the 2 main types of lung cancer, other cancers can be found in the lungs, too. Cancers that start in other places can spread to the lungs. Sometimes tumors that aren t cancer are found in the lungs, as well. Keep in mind that cancer that starts in other organs (such as the breast, pancreas, kidney, or skin) can sometimes spread (metastasize) to the lungs, but these are not lung cancers. For example, cancer that starts in the kidney and spreads to the lungs is still kidney cancer, not lung cancer. Treatment for these cancers that have spread to the lungs depends on where the cancer started. What are the risk factors for non-small cell lung cancer? A risk factor is anything that affects a person s chance of getting a disease such as cancer. Different cancers have different risk factors. Some risk factors, like smoking, can be changed. Others, like a person s age or family history, can t be changed. But having a risk factor, or even many risk factors, does not mean that you will get the disease. And some people who get the disease may have few or no known risk factors. Even if a person with lung cancer has a risk factor, it is often very hard to know how much it may have contributed to the cancer. Several risk factors can make you more likely to develop lung cancer: Smoking tobacco including cigarettes, cigars, and pipes Secondhand smoke (breathing in the smoke of others) Radon Asbestos Air pollution Radiation therapy to treat cancers in the chest Arsenic in drinking water Certain workplace exposures Having had lung cancer before Having a family member with lung cancer For more information about these factors and how they increase the risk of lung cancer, see the section about risk factors in Lung Cancer (Non Small Cell). Can non-small cell lung cancer be prevented? Some people who get lung cancer do not have any clear risk factors. Although we know how to prevent most lung cancers, at this time we don t know how to prevent all of them. The best way to reduce your risk of lung cancer is not to smoke. You should also avoid breathing in other people s smoke. If you smoke, stopping can help lower your risk of getting lung cancer. If you stop smoking before a cancer starts, your damaged lungs gradually repair themselves. No matter what your age or how long you ve smoked, quitting may lower your risk of lung cancer and help you live longer. If you would like help quitting smoking, see our Guide to Quitting Smoking or call us at Radon is also a cause of lung cancer. You can lower your exposure by having your home tested and treated, if needed. To learn more, see Radon. Protecting yourself from cancer-causing chemicals at work and elsewhere can also be helpful. When people work where these chemicals are common, exposure should be kept as low as possible. A good diet with lots of fruits and vegetables may also help reduce your risk of lung cancer. Can non-small cell lung cancer be found early? It is often hard to find lung cancer early. Most people with early lung cancer do not have any symptoms, so only a small number of lung cancers are found at an early stage. When lung cancer is found early, it is often because of tests that were being done for something else. Screening for lung cancer Screening is the use of tests or exams to find a disease like cancer in people who don t have any symptoms of that disease. Doctors have looked for many years for a test that could find lung cancer early and help patients live longer. In recent years, a large clinical trial, known as the National Lung Screening Trial (NLST), found that in some people at high risk of lung cancer (due to their history of smoking), a screening test known as a low-dose CT (LDCT) scan could lower the chance of dying from lung cancer. Still, screening with LDCT scans also has some downsides. One drawback is that this test also finds a lot of things that turn out not to be cancer but that still need to be tested to be sure. LDCTs also expose people to a small amount of radiation with each test. These factors, and others, need to be taken into account by people and their doctors who are thinking about whether screening with LDCT scans is right for them. Based on the results of the NLST, the American Cancer Society has developing screening guidelines for lung cancer. People who are at higher risk for lung cancer, such as current or former smokers, might want to discuss these guidelines with their doctor to see if screening might be right for them. For more details about the American Cancer Society s lung cancer screening guidelines, see Lung Cancer Prevention and Early Detection. Signs and symptoms of lung cancer Most lung cancers do not cause symptoms until they have spread, but you should report any of the following problems to a doctor right away. Often these problems are caused by something other than cancer, but if lung cancer is found, getting treatment right away might mean treatment would work better. The most common symptoms of lung cancer are: A cough that does not go away or gets worse Chest pain, often made worse by deep breathing, coughing, or laughing Hoarseness Weight loss and loss of appetite Coughing up blood or rust-colored sputum (spit or phlegm) Shortness of breath Feeling tired or weak Infections such as bronchitis and pneumonia that don t go away or keep coming back New onset of wheezing When lung cancer spreads to other parts of the body, it may cause: Bone pain (like pain in the back or the hips) Weakness or numbness of the arms or legs Headache, dizziness, balance problems, or seizures Jaundice (yellow coloring of the skin and eyes) Lumps near the surface of the body, caused by cancer spreading to the skin or to lymph nodes in the neck or above the collarbone Some lung cancers can cause a group of very specific symptoms. These are often described as syndromes. Horner syndrome Cancers of the top part of the lungs (sometimes called Pancoast tumors) can damage a nerve that passes from the upper chest into your neck. This can cause severe shoulder pain. Sometimes these tumors also cause a group of symptoms called Horner syndrome: Drooping or weakness of one eyelid Having a smaller pupil (dark part in the center of the eye) in the same eye Reduced or absent sweating on the same side of the face Conditions other than lung cancer can also cause Horner syndrome. Superior vena cava syndrome The superior vena cava (SVC) is a large vein that carries blood from the head and arms back to the heart. It passes next to the upper part of the right lung and the lymph nodes inside the chest. Tumors in this area may press on the SVC, which can cause swelling in the face, neck, arms, and upper chest. It can also cause headaches, dizziness, and a change in consciousness if it affects the brain. While SVC syndrome can develop slowly over time, in some cases it can become life-threatening, and needs to be treated right away. Paraneoplastic syndromes Some lung cancers can make hormone-like substances that enter the bloodstream and cause problems with other tissues and organs, even though the cancer has not spread to those tissues or organs. These problems are called paraneoplastic syndromes. Sometimes these syndromes can be the first symptoms of lung cancer. Because the symptoms affect other organs, patients and their doctors at first may suspect that something other than lung cancer is causing them. The most common paraneoplastic syndromes caused by non-small cell lung cancer are: High blood calcium levels, which can cause frequent urination, thirst, constipation, nausea, vomiting, belly pain, weakness, fatigue, dizziness, confusion, and other nervous system problems Too much growth of certain bones, like those in the finger tips, which is often painful Blood clots Breast growth in men Most of the symptoms listed here are more likely to be caused by something other than lung cancer. Still, if you have any of these problems, you should see a doctor right away. How is non-small cell lung cancer diagnosed? If you have symptoms of lung cancer, you should go to your doctor. After asking questions about your health and doing a physical exam, your doctor might want to do some tests if he or she thinks you might have lung cancer: Imaging tests There are a number of different tests that can make pictures of the inside of your body. These can be used to find lung cancer, to see if it has spread, to find out whether treatment is working, or to spot a cancer that has come back after treatment. Chest x-ray A plain x-ray of your chest is often the first test your doctor will do to look for any spots on the lungs. If the x-ray is normal, you most likely do not have lung cancer. If anything does not look normal the doctor may order more tests. CT scan (computed tomography) A CT (or CAT) scan is a special kind of x-ray test that can show a detailed picture of a slice of your body. A CT scan is more likely to show a lung tumor than a routine chest x-ray. It can also give the doctor precise information about the size, shape, and place of a tumor, or help find enlarged lymph nodes that might contain cancer. CT scans are used to find tumors in the adrenal glands, liver, brain, and other organs, too. A CT scan can also be used to guide a biopsy needle (see below) right into a place that might have cancer. To have this done, you stay on the CT scanning table while the doctor moves a biopsy needle through the skin and into the mass. A biopsy sample is then removed and looked at under a microscope. MRI scan (magnetic resonance imaging) Like CT scans, MRI scans give detailed pictures of soft tissues in the body. But MRI scans use radio waves and strong magnets instead of x-rays. MRI scans are useful in looking for the spread of lung cancer to the brain or spinal cord. MRI scans take longer than x-rays often up to an hour. Also, you have to be placed inside a tube-like machine, which upsets some people. Special open MRI machines can sometimes help with this if needed. PET scan (positron emission tomography) For a PET scan, a form of radioactive sugar is injected into the blood. Cancer cells in the body absorb large amounts of the sugar. A special camera can then spot the radioactivity. If you appear to have early stage lung cancer, this test can help show if the cancer has spread to nearby lymph nodes or other areas, which can help determine if surgery may be an option for you. This test can also help tell whether an abnormal area on a chest x-ray or CT scan might be cancer. Special machines combine a CT and a PET scan to even better pinpoint tumors. This is called a PET/CT and is the most common form of PET used for patients with lung cancer. Bone scan A bone scan can help show if a cancer has spread to the bones. For this test, a small amount of radioactive substance is put into your vein. The amount used is very low. This substance builds up in areas of bone that may not be normal because of cancer. These will show up on the scan as hot spots. While these areas may suggest the spread of cancer, other problems can also cause hot spots. PET scans, which are often done in people with non-small cell lung cancer, can usually show the spread of cancer to bones, so bone scans aren t needed very often. Bone scans are done mainly when other test results aren t clear. Tests to diagnose lung cancer The actual diagnosis of non-small cell lung cancer is made by looking at lung cells under a microscope. The cells can be taken from lung secretions (sputum or phlegm), removed from the lung (known as a biopsy), or found in fluid removed from the area around the lung. The choice of which tests to use depends on the situation. Sputum cytology In this test, a sample of mucus you cough up from the lungs (called sputum or phlegm) is looked at under a microscope to see if cancer cells are present. This test is more likely to help find cancers that start in the big airways of the lung. Needle biopsy For this test, a long, hollow needle is used to remove a sample of cells from the area that may be cancer. If the area is in the outer part of the lungs, the biopsy needle can be inserted through the skin on the chest wall. An imaging test (like a CT scan) is used to guide the needle to the right spot. The sample is looked at in the lab to see if there are cancer cells in it. A needle biopsy may also be done during a bronchoscopy (see below) to take samples of lymph nodes between the lungs. Thoracentesis If fluid has built up around the lungs, this test can be done to check whether it is caused by cancer or by some other medical problem, such as heart failure or an infection. First, the skin is numbed and then a hollow needle is placed between the ribs to drain the fluid. The fluid is checked for cancer cells. Samples from biopsies or other tests are sent to a lab. There, a doctor looks at the samples under a microscope to find out if they contain cancer and if so, what type of cancer it is. Special tests may be needed to help classify the cancer. Cancers from other organs can spread to the lungs. It s very important to find out where the cancer started, because treatment is different for different types of cancer. The results of these tests are described in a pathology report, which is usually available within about a week. If you have any questions about your pathology results or any tests, talk to your doctor. For more information on understanding your pathology report, see the Lung Pathology section of our website. Tests to look for cancer spread in the chest Bronchoscopy A lighted, flexible tube (called a bronchoscope) is passed through the mouth or nose and into the larger airways of the lungs. The mouth and throat are sprayed first with a numbing medicine. You may also be given medicine through an intravenous (IV) line to make you feel relaxed. This test can help the doctor see tumors, or it can be used to take samples of tissue or fluids to see if cancer cells are present. Endobronchial ultrasound Ultrasound is a test that uses sound waves to make pictures of the inside of your body. For endobronchial ultrasound, a bronchoscope is fitted with an ultrasound device at its tip and is passed down into the windpipe to look at nearby lymph nodes and other structures in the chest. If enlarged lymph nodes are seen on the ultrasound, a hollow needle can be passed through the bronchoscope and guided into the area to take biopsy samples. The samples are then looked at under a microscope to see if cancer cells are present. Endoscopic esophageal ultrasound This test is much like an endobronchial ultrasound, except that an endoscope (a lighted, flexible tube) is passed down the throat and into the esophagus (the swallowing tube that connects the mouth to the stomach). This test is done with numbing medicine and drugs to make you sleepy (light sedation). The esophagus lies just behind the windpipe. Ultrasound images taken from inside the esophagus can help find large lymph nodes inside the chest that might contain lung cancer. If enlarged lymph nodes are seen on the ultrasound, a hollow needle can be passed through the endoscope to get biopsy samples of them. The samples are then looked at under a microscope to see if they contain cancer cells. Mediastinoscopy and mediastinotomy Both of these tests let the doctor look at and take samples of the structures in the area between the lungs (called the mediastinum). These tests are done in an operating room while you are in a deep sleep (under general anesthesia). The main difference between them is that a mediastinotomy involves a slightly larger cut (incision), a little lower down on the chest. Thoracoscopy This test can be done to find out if cancer has spread to the spaces between the lungs and the chest wall, or to the linings of these spaces. It can also be used to sample tumors on the outer parts of the lungs. It is done in an o
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