Lung cancer, sometimes also called bronchogenic carcinoma or bronchial carcinoma, is a serious disease affecting many Pakistanis and their families. It manifests itself as an uncontrolled proliferation of cells in the lung tissue. It is the third most common type of cancer and the fourth leading cause of cancer deaths in Pakistan.
According to Global Cancer Observatory, newly diagnosed patients with lung cancer accounted for ~5% of the total volume of all newly diagnosed cancers in 2022. In absolute numbers, this is 9,464 new patients (7,571 in men and 1,893in women). In the same year, 8,307 people died of lung cancer in Pakistan, which represents 7% of all cancer deaths.
Lung cancer is a complex disease that can occur in several different forms. Recognizing and determining the type and stage of lung cancer is important for planning treatment and assessing the patient's prognosis. Lung cancer is divided into two basic subtypes based on histological findings (examination of tissue under a microscope).
NSCLC is the most common form of lung cancer, accounting for about 85% of all cases. There are three main subtypes of NSCLC:
- Adenocarcinoma: Adenocarcinoma is the most common type of NSCLC, accounting for about 40% of all lung cancers. This type of cancer develops from the glandular epithelium of cells that secrete mucus and is most often diagnosed in former smokers or non-smokers.
- Squamous cell carcinoma: Squamous cell carcinoma, sometimes called squamous cell carcinoma, accounts for more than 30% of NSCLC cases. This type of cancer develops in the flat layers of cells that line the inner surface of the lungs.
- Large cell carcinoma: Large cell carcinoma is a rarer type of NSCLC, occurring in about 10-15% of cases. This type of cancer is characterized by large, irregular cells that grow and spread quickly.
Non-small cell lung cancer is divided into four stages:
- Stage I: In this stage, the tumor is small and confined to the lungs. The tumor is 3 cm or less in diameter and has not spread to surrounding tissues or lymph nodes. The prognosis at this stage is the best, and if possible, surgery is performed to remove the tumor.
- Stage II: In stage II, the tumor is larger than 3 cm but still located in one lung. However, a nearby lymph node may be affected. Treatment for stage II includes surgery followed by chemotherapy, possibly in combination with radiotherapy.
- Stage III: At this stage, cancer has spread to surrounding tissues and multiple lymph nodes around the lung. Stage III is further divided into IIIA, IIIB, and IIIC based on the extent of the tumor spread. Treatment includes surgery and a combination of chemotherapy and radiation therapy, sometimes with targeted therapy or immunotherapy.
- Stage IV: This is the final stage, when lung cancer has spread to distant organs (metastasized), such as the liver, bones, brain, or both lungs or lymph nodes. Treatment for stage IV focuses on relieving symptoms and improving quality of life. Chemotherapy, targeted therapy, and immunotherapy may be used.
Small cell lung cancer accounts for about 15% of all lung cancers. This type of cancer is more aggressive than NSCLC and spreads quickly to other parts of the body. SCLC is associated with smoking and is often diagnosed at an advanced stage.
Small cell lung cancer is divided according to the extent of the tumor and the presence of metastases, i.e. the spread of the tumor to areas other than where it originally originated:
- Limited stage: In this stage, the tumor is confined to one side of the chest and may involve only one or more nodes near the primary tumor. Limited stage is generally more treatable because the tumor is localized and affects a smaller area of the body. Treatment includes surgery and a combination of chemotherapy and radiation therapy.
- Extensive stage: An extensive stage tumor has spread beyond one lung (metastasized), may involve contralateral nodes (nodes on the opposite side of the chest), or may be present in other organs, such as the liver, bones, or brain. Extensive stage SCLC is more difficult to treat because cancer is spread throughout the body. Treatment includes chemotherapy and, in some cases, may be supplemented with radiation therapy or immunotherapy.
Recognizing the type of lung cancer is important for determining the most effective treatment plan. It is important to remember that treatment and prognosis may vary from person to person. Each case of lung cancer is unique, and doctors consider a variety of factors when choosing the most appropriate treatment. This approach is called personalized medicine, and there are currently specific personalized diagnostic and treatment approaches that aim to select a treatment tailored to the patient.
Symptoms of lung cancer can manifest themselves in various ways and are often confused with other respiratory problems. The most common symptoms include chronic cough, change in the color or consistency of expectorated mucus, shortness of breath, chest pain, hoarseness or loss of voice, or repeated respiratory tract infections. The course, especially in the early stages, can also often be asymptomatic, or the clinical symptoms are non-specific or appear late, as clinical symptoms of metastases. Here are the key symptoms you should look out for:
• Cough: A persistent cough that gets worse or doesn't go away after a few weeks could be a sign of lung cancer. If the cough is accompanied by coughing up blood (hemoptysis), it requires immediate medical attention.
• Breathing difficulties: Shortness of breath or a feeling of lack of air can be caused by a tumor that blocks or narrows the airways, or by a tumor that causes fluid to build up in the lungs (pleural effusion).
• Chest pain: Chest pain, especially when breathing or coughing, can be a sign of lung cancer. The pain may be caused by the spread of the tumor to surrounding tissues, bones, or nerves.
• Weight loss and fatigue: Unintentional weight loss and persistent fatigue can be symptoms of many diseases, including lung cancer.
• Voice changes: The vocal cords can be affected by the tumor, causing hoarseness or voice changes. This symptom should not be ignored, especially if it lasts more than a few weeks.
It is important to emphasize that while the above symptoms are the most common, other symptoms may also occur. These symptoms can also be caused by less serious conditions; however, if you notice any of them, you should consult your healthcare professional as soon as possible so they can conduct a thorough examination and begin treatment if needed.
Prevention and early diagnosis are key factors for successful treatment of lung cancer. Therefore, it is important to regularly monitor your health, undergo preventive examinations and be aware of risk factors such as smoking, exposure to carcinogenic substances such as asbestos or radon, and a family history of various types of cancer, especially lung cancer. If necessary, do not hesitate to contact your general practitioner, who will provide you with further information and support.
Detecting lung cancer early plays a pivotal role in improving outcomes, empowering healthcare providers to offer timely interventions and optimize patient care.
A medical history is an important part of the diagnostic process, which involves gathering information about the patient's current symptoms, their family's medical history, and risk factors for lung cancer, such as smoking, asbestos, or radon exposure. This provides valuable information for the physician to determine an appropriate diagnostic strategy.
A physical examination involves a careful examination of the patient's body. This may include listening to the patient's breathing with a stethoscope and examining the lymph nodes for swelling.
Lung function testing allows doctors to assess lung function and detect any abnormalities that could indicate lung disease. The test is covered by public health insurance, is indicated by a pulmonologist, and is performed in a specialized workplace that has the necessary equipment to perform the test.
Spirometry is a basic test used to assess lung function. This test measures the volume of air a patient can inhale and exhale, and the speed at which air can flow in and out of the lungs. Spirometry is important for determining whether a patient has obstructive or restrictive lung disease.
Another method of lung function testing is body plethysmography, which measures changes in lung volume in response to changes in alveolar pressure. Body plethysmography provides more accurate information about lung volume than spirometry and can be used to diagnose restrictive lung diseases.
A bronchodilator test measures the volume of air a person can inhale and exhale before and after taking a bronchodilator medication. This can help determine whether the airway obstruction is reversible, as is typical of asthma, or irreversible, as may be associated with lung cancer or other chronic lung diseases.
The six-minute walk test (6MWT) has become an important tool in the diagnosis of lung cancer in recent years, as it can detect reduced lung function and related problems. This test, which is performed under the supervision of a specialist, involves the patient walking as fast as possible for six minutes without stopping or slowing down. During the test, the patient's distance, heart rate and breathing are monitored. The results of the 6MWT can provide doctors with important information about the health of their lungs and the patient's overall condition. The test is safe, simple and non-invasive.
These examinations are most often indicated by the treating pulmonologist or pneumo-oncologist and are performed in specialized clinics, where the patient comes with a request from the referring physician.
A chest X-ray is the most commonly used method for detecting suspected lung cancer. This method provides a two-dimensional image of the chest, allowing doctors to quickly and easily detect the presence of irregularities in the lungs, such as tumors, inflammation, or fluid retention.
Procedure: During an X-ray examination, the patient stands or lies next to the X-ray machine while a healthcare professional operates the device and takes images of the chest.
Preparing for the exam: A chest X-ray does not require any special preparation, but it is important to tell the doctor about your pregnancy.
Computed tomography (CT) is an advanced imaging technique that creates detailed three-dimensional images of the lungs and chest. The test is performed to obtain more detailed information about suspicious tumors or other irregularities that have been detected on a chest X-ray. CT can also help with planning treatment, monitoring the effectiveness of treatment, and detecting disease recurrence.
Procedure: During a CT scan, the patient lies on a special bed that moves into the CT machine. The machine takes a series of images from different angles, which are then processed by a computer into a three-dimensional image. The scan takes approximately 10 to 20 minutes.
Preparing for the exam: Patients should follow their doctor's instructions regarding preparation for a CT scan, which may include dietary measures such as not eating or drinking for several hours before the procedure and temporarily stopping certain medications.
Magnetic resonance imaging (MRI) is a noninvasive imaging technique that uses a strong magnetic field and radiofrequency pulses to image organs and structures in the body. MRI provides high-contrast images without the use of ionizing radiation, which is especially beneficial for sensitive groups such as pregnant women or younger patients. MRI can be used to evaluate lung tumors and surrounding tissues that are not clearly visible on CT scans, or to monitor changes during treatment.
Examination procedure: The patient is informed before the examination and signs an informed consent. The examination itself lasts 30 to 60 minutes, during which the patient lies completely still on the examination table. A radiofrequency coil is initially placed on the part of the body being examined. In indicated cases, a cannula is inserted into the vein for intravenous administration of contrast medium. The patient is then inserted into the magnetic resonance tunnel. This is a relatively narrow space with a diameter of about 60 cm, which may be uncomfortable for some patients. The MRI tunnel is illuminated and air-conditioned. The patient is connected to the radiological assistant at all times via a microphone. The patient has a signaling balloon in his hand in case of complications. To dampen the significant noise caused by the operation of the magnetic resonance, the patient wears headphones during the examination.
Preparation for the examination: Magnetic resonance imaging without contrast medium does not require any special preparation. It is necessary to fast for at least 3 hours before the contrast examination. There is no need to limit fluids, water or unsweetened tea is ideal. The patient takes medications as usual. Before the examination, the patient removes clothing and all metal objects. The patient should come to the head examination without makeup, because makeup may contain small metal particles.
Positron emission tomography (PET) is a highly sensitive imaging technique that detects metabolic activity in the body. A PET scan can help doctors identify cancer cells based on their increased glucose metabolism. A PET scan is often used to assess the extent and stage of lung cancer, plan treatment, and monitor the effectiveness of treatment. It can also help doctors distinguish between active tumors and scarring or inflammation.
Procedure: During a PET scan, the patient is injected with a radioactive contrast agent. The patient then lies on a bed that moves into the PET machine. The machine detects the radiation emitted by the radioactive contrast agent and displays areas of increased metabolic activity.
Preparation for the examination: Avoid exercise and heavy physical activity 2 days before, and especially on the day of the examination (e.g. long walks or carrying heavy objects). Do not eat or drink anything other than unsweetened water 6 hours before the examination. The restrictions also apply to chewing gum or menthol candies and mineral waters with flavor and sugar. If you are being treated for diabetes, an increased blood sugar level may adversely affect the quality of the examination or, in the case of high blood sugar levels, may also make it impossible to perform it. The use of oral antidiabetic drugs (PAD - "diabetes tablets") based on metformin should be discontinued for 48 hours before and 48 hours after the PET/CT examination, after consultation with the referring physician or diabetologist. In general, the treatment of most diseases does not change before the examination, so continue to take all medications.
Laboratory tests are another important part of diagnosing lung cancer. These tests help doctors gain important information about the biological aspects of tumors and determine the most appropriate treatment plan. The most commonly used laboratory tests in diagnosing lung cancer include:
Blood tests can provide information about a patient's overall health, such as levels of red and white blood cells, platelets, and liver and kidney function. These tests may also include measurements of certain tumor markers.
Biopsy is a process in which a tissue sample (called a biopsy specimen) is removed from a living organism for morphological examination. Examination of a biopsy specimen allows confirming or clarifying a clinical diagnosis and determining a number of tissue characteristics that are important for deciding on the optimal treatment. In cancer, examination of a biopsy specimen is absolutely necessary.
Cytology involves microscopic analysis of cells obtained from body fluids, such as a pleural effusion (a collection of fluid in the pleural space that exceeds the physiological amount, which is approximately 10 ml) or a bronchial lavage (a diagnostic procedure in which a doctor "washes out" a specific area of the lung). This examination can detect the presence of cancer cells and provide information about the type of cancer.
Genomic testing is performed on samples of tumor tissue to detect genomic mutations or changes that may be associated with the growth and spread of lung cancer. These tests can help determine the most effective treatment strategies and identify patients who might benefit from targeted therapy. Ask your doctor if your tumor sample will be tested for genomic changes with comprehensive genomic profiling. This is not a common practice, but it is possible to pay for the test. Ask your doctor if this test is relevant for you.
Invasive methods involve procedures that are performed directly on tissues or organs of the body to obtain samples for laboratory testing. These methods are often necessary to confirm a diagnosis of lung cancer and determine the stage of the disease. Commonly used invasive methods include:
Bronchoscopy is a diagnostic and therapeutic procedure that allows doctors to directly view the airways and lung tissue. It is often performed to examine irregularities found on chest X-rays or CT scans. It can also be used to obtain tissue samples (biopsies) for laboratory analysis, remove foreign bodies, or unblock blocked airways.
Procedure: Bronchoscopy is usually performed on an outpatient basis and takes about 10-30 minutes. You will be under local anesthesia or sedation during the procedure to keep you comfortable. Your doctor will insert a bronchoscope, a thin, flexible instrument equipped with a light and camera, through your mouth or nose and gradually advance it into your airways. Your doctor can examine your airways and lung tissue and may perform a biopsy or other therapeutic procedures.
Preparing for the exam: Before a bronchoscopy, the patient can expect dietary precautions, such as not eating or drinking for several hours before the procedure and temporarily stopping certain medications. It is important to inform the doctor about any allergies or health problems that could affect the safety or effectiveness of the procedure.
Mediastinoscopy is an invasive diagnostic method that allows doctors to obtain tissue samples from mediastinal nodes for more detailed laboratory analysis.
Procedure: A mediastinoscopy involves giving you general anesthesia, then your doctor makes an incision in your neck or chest and inserts an endoscope with a camera and instruments into your chest. During the procedure, which usually takes 30 minutes, your doctor examines the mediastinum and takes tissue samples. The results of laboratory tests on the samples are usually available within a few days to weeks. After a mediastinoscopy, you will recover in a recovery room, and your doctor will provide instructions for wound care and pain medication.
Preparing for the exam: Before a mediastinoscopy, the patient can expect to fast (not eat or drink) for several hours before the procedure and temporarily stop taking certain medications. It is important to inform the doctor about any allergies or health problems that could affect the safety or effectiveness of the procedure.
Preventing lung cancer is essential to reducing your risk of developing this serious disease. You can help reduce your risk of developing cancer by following these tips:
• Quit smoking: In addition to improving your overall health, quitting smoking is the most effective way to reduce your risk of lung cancer. Smoking is a major risk factor for developing this disease. Consider participating in a smoking cessation program or talk to your doctor about available treatment options.
• Avoid secondhand smoke: Secondhand smoke, or breathing in smoke from cigarettes, vaporizers, e-cigarettes, or water pipes that other people are smoking near you, can also increase your risk of lung cancer. Avoid places where people smoke.
• Healthy lifestyle: Following a healthy lifestyle, including a balanced diet rich in fruits and vegetables, regular exercise, and maintaining a healthy body weight, can reduce the risk of lung cancer. Limiting alcohol consumption also has a major impact on good health with a strong immune system.
• Reducing exposure to carcinogens: Certain substances, such as asbestos, radon, cadmium, and benzene, can increase the risk of lung cancer.
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