Lung Cancer: Overview

This in-depth overview is designed to help you find your footing and provide you with the most important information you need to know about lung cancer, with insights and advice from the top thoracic surgeons, radiation oncologists, and medical oncologists across the country. SurvivorNet has developed this user-friendly overview to provide you with access to the best doctors at the leading institutions!

Do I Need Screening?

The reason lung cancer can be so deadly is that it's often caught at a late stage, when it's more difficult to treat. When doctors can catch this cancer at an early stage, survival vastly improves. The U.S. Preventive Services Task Force recommends lung cancer screening with the same level of importance as mammograms for breast cancer.

Many lung cancers are found incidentally on tests done for other reasons. Right now, screening is recommended for people who meet all of the following criteria:

  • You are or were a heavy smoker (who smoked a minimum of 20 pack years)
  • You currently smoke or quit within the last 15 years
  • You are between 50 and 80 years old

Talk to your doctor about getting a low-dose CT scan (LDCT) if you are at high risk because you were or are a heavy smoker and you're between the ages of 50 and 80. Unlike diagnostic CT scans, LDCT scans use a smaller amount of radiation. Also get evaluated if you have symptoms like a cough that doesn't go away or chest pain.

What Are the Symptoms of Lung Cancer?

Lung cancer often doesn't cause symptoms until it has already spread outside the lungs, according to SurvivorNet's experts. Your doctor may suspect lung cancer after seeing a shadow on a routine chest X-ray that requires further evaluation.

One of the most worrisome parts of lung cancer is its lack of symptoms until the cancer has already spread, says SurvivorNet medical advisor, Dr. Joseph Friedberg 

Some people with lung cancer do have symptoms like these:

  • A cough that doesn't go away, that gets worse, or that brings up bloody phlegm
  • Shortness of breath
  • Fatigue
  • Chest pain
  • Hoarse voice
  • Appetite loss
  • Weight loss

Mention symptoms like these to your doctor, who will ask questions to get a better picture of what is happening inside your body. If your symptoms suggest lung cancer, you'll likely need to have more tests.


Getting a Diagnosis

It's often a pulmonologist or lung specialist who makes the initial lung cancer diagnosis by evaluating symptoms such as coughing and shortness of breath, and analyzing a subsequent lung biopsy, according to SurvivorNet’s experts.

Thoracic oncologist Dr. Leena Gandhi talks you through what to expect during a lung cancer diagnosis

Once a lung cancer diagnosis is confirmed, it’s important to find out whether the cancer has spread. The next step is typically a meeting with a medical oncologist and/or several other specialists — including a thoracic surgeon and a radiation oncologist — to determine the stage and extent of the cancer.  This important process may include scans of the chest, abdomen, pelvis, and brain to see if the cancer has started to spread outside of the lung. Sometimes doctors will order CT scans of the chest, abdomen and pelvis. In other scenarios your treating team may order a PET scan. If your team wants to see if cancer has spread to the brain this is done with an MRI. Your doctors will order all of these tests to determine what stage your lung cancer is and this process is known as cancer staging. It is extremely important to know what stage of cancer you have as this will help determine what treatment is best for you.

Biomarker testing is also important after a lung cancer diagnosis.  This diagnostic work up includes PDL1 testing and genetic testing. This process tests the tumor tissue for abnormalities in its DNA and levels of specific proteins in the tumor. If doctors can determine what makes the tumor grow, they can match you with the best targeted therapies that can slow tumor growth. PDL1 testing helps to gauge whether a patient would benefit from immunotherapy.

After you have had your staging completed most patients with lung cancer will have their case presented in a multidisciplinary tumor conference where many doctors from several specialties are present to provide recommendations. If your doctor discusses this with you it is normal procedure and ensures that all the correct doctors can provide recommendations.

Dana-Farber Cancer Institute thoracic oncologist, Dr. Geoffrey Oxnard, explains how doctors stage lung cancer

Lung Cancer Staging

Lung cancer, like all cancers is staged into four main groups based upon the tumor size and location, if any lymph nodes are involved, and if the cancer has spread outside of the lung to other parts of the body. Although lung cancer is staged into four main stages there are several substages within each category that your physician may discuss with you. In general, the four stages of lung cancer are:

  • Stage I- The tumor is less than or equal to 4cm in size and is limited to a single spot of the lung. In Stage I lung cancer there are no lymph nodes involved and the cancer has not spread outside of the lung. Stage I is further divided into Stage IA1, Stage 1A2, Stage 1A3, and Stage 1B depending on the size of the tumor.
  • Stage II- The tumor is > 4cm and less than or equal to 7cm and no lymph nodes are involved OR the tumor is less than or equal to 5cm and there are certain lymph nodes in the chest involved (known as N1). In Stage II lung cancer the cancer has not spread outside of the lungs. Stage II is further divided into Stage IIA and Stage IIB.
  • Stage III- The tumor is > 7cm and no lymph nodes are involved or only certain lymph nodes (N1) OR the tumor is less than or equal to 7cm in size and more advance lymph nodes (N2) are involved OR  the tumor is >5cm or less than or equal to 7cm and certain lymph nodes are involved (N1). Also, any size tumor with very advanced lymph nodes (N3) involved is Stage III. In Stage III lung cancer the cancer has not spread outside of the lung. Stage III is further divided into Stage IIIA, Stage IIIB, and Stage IIIC.
  • Stage IV- In stage IV lung cancer the cancer has spread outside of the lung and is known as metastatic cancer.

We know that staging is complicated and can be difficult to understand. We have presented a summary of the four lung cancer stages. For more information on your lung cancer please discuss this with your doctors. We encourage all patients to ask their doctor what stage there cancer is and what this means for treatment.


Lung Cancer Treatment Options

After a lung cancer diagnosis, you will need to discuss a few things with your doctor, such as the stage of the disease, your treatment options, and how long you have to consider these options, say our experts. Take your time in making a decision, and don't be afraid to get a second opinion.

Lung cancer is no longer a death sentence, but it's important to understand your treatment options, says thoracic surgeon, Dr. Raja Flores 

Treatment varies depending on which type and stage of cancer you have. If the cancer is local — meaning just in the lungs — surgery may be an option. But if it has spread to the lymph nodes, a combination of radiation with chemotherapy, followed by immunotherapy, may be the best option. Once the cancer has spread outside of the lungs, chemotherapy and/or targeted drugs are used to control its growth as much as possible.

Treating Stage I Lung Cancer

Stage I lung cancer means that your cancer is only in your lungs and has not started to spread to your lymph nodes. Surgery to remove the cancer is considered the gold standard for this stage. Although there are subdivisions of stage I lung cancer, everyone who can have surgery should have surgery to remove their tumor. Some doctors or centers may discuss using a targeted drug after surgery depending on specific aspects unique to your tumor.

For anyone who can't have surgery because of underlying health conditions, the current standard of care is stereotactic body radiation therapy (SBRT), which directs extremely high doses of radiation to the tumor. SBRT minimizes the radiation dose to nearby structures, reducing the risk of damage to healthy organs.

Treating Stage II Lung Cancer

Stage II lung cancer means that your cancer is still in your lung, but it has spread to at least one lymph node. Surgery to remove a lobe of the lung (lobectomy) and the affected lymph node(s) is the first-line treatment. As with stage I lung cancer, there are subdivisions of stage II lung cancer, but these often don’t affect the initial treatment decision. Surgery is the gold standard treatment for stage II lung cancer, regardless of what subdivision you have. In some cases, surgery to remove the whole lung (pneumonectomy) may be necessary.

Chemotherapy plus immunotherapy may also be recommended to shrink the tumor before surgery and reduce chances of recurrence after surgery. Some doctors may discuss using a targeted drug after surgery depending on specific aspects unique to your tumor.  Surgery could be followed by additional chemo and immunotherapy. In people with stage II disease who are unable to have surgery, meeting with a radiation oncologist is a very important step, because the tumor may be able to effectively be treated with radiation or chemoradiation, a combination of chemotherapy and radiation.

Stage IIIA, IIIB, and IIIC Lung Cancer Treatment

The decision to proceed with surgery for stage IIIA lung cancer is not always black and white, and it's an area where doctors sometimes disagree.

Stage III lung cancers can fall into a gray zone. Whether surgery is a good option depends on where the tumor is located, says radiation oncologist, Dr. Keith Cengel.

In stage IIIA, surgery can play a role, depending on where the cancer is, how close it is to other structures, and how many lymph nodes are affected. Chemotherapy plus immunotherapy may also be an option before surgery to shrink the tumor and destroy any errant cancer cells. In scenarios where surgery is not ideal, patients are treated with radiation therapy, which is often given together with chemotherapy. Many of those who are treated with radiation and chemotherapy will receive immunotherapy, as well.

In stage IIIB, cancer has spread to the lymph nodes on the opposite side of the chest, or it has invaded another area, such as the veins feeding the heart. This stage is most often treated with radiation therapy and chemotherapy, followed by immunotherapy. Like with stage IIIA disease, radiation serves as the backbone of treatment for patients with stage IIIB disease, and chemotherapy is often given to enhance the effects of radiation. Patients who tolerate chemotherapy and radiation therapy well are also considered for immunotherapy.

In stage IIIC, the primary tumor is large and the cancer has spread to lymph nodes on the opposite side of the chest, or it has invaded other structures, such as the veins feeding the heart.  As with stage IIIA and stage IIIB cancers, radiation therapy is the mainstay of treatment. Chemotherapy is also used to enhance the effect of radiation therapy. Patients who respond to treatment may also receive immunotherapy.

Treating Late-Stage Lung Cancer

More treatments are available for late-stage lung cancer than ever before, explains Dr. Raja Flores

Stage IV means that your cancer has spread to other organs, which may include your brain, liver and/or bones. The goal of therapy is to treat the entire body to destroy every last remnant of the cancer. In the past, chemotherapy was considered the treatment standard for stage IV lung cancer, but times have changed.

More types of treatment are available for stage IV lung cancer today than ever before. Treatment for late-stage lung cancer may include a combination of surgery, chemotherapy, or radiation. Immunotherapy has also yielded good results.

Your doctor will discuss all of your treatment options with you, and you can evaluate them together. The treatments currently available for late-stage lung cancer can help you to live longer and make you feel better by relieving symptoms.

Dr. Brendon Stiles explains how targeted therapies can be used for advanced lung cancer.

Reaching the end of your treatment is a major milestone in your cancer journey. Regard it with a great sense of accomplishment, but still be wary. The likelihood of cancer recurrence is highest in the first five years after your initial treatment. That's why your doctor will do regular follow-ups and carefully review your test results and any symptoms you may develop during the first several years. The longer you live without any traces of cancer, the lower your chance of a recurrence.

After your remission, you may have anxiety about routine follow-up scans and tests. Know the drill, follow the guidelines, and listen to your body, is the guidance from SurvivorNet's medical advisors.


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