Lung Cancer

The team at Saint Luke’s Cancer Institute has deep experience in treating both early stage and complex cases of lung cancer.

Lung Cancer: Introduction

What is cancer?

Cancer is when cells in the body change and grow out of control. Your body is made up of tiny building blocks called cells. Normal cells grow when your body needs them, and die when your body does not need them any longer.

Cancer is made up of abnormal cells that grow even though your body doesn't need them. In most cancers, the abnormal cells grow to form a lump or mass called a tumor. If cancer cells are in the body long enough, they can grow into (invade) nearby areas. They can even spread to other parts of the body (metastasis).

What is lung cancer?

Lung cancer is cancer that starts in the cells that make up the lungs. Many other types of cancer, such as breast or kidney, can spread (metastasize) to the lungs. When this happens, the cancer is not called lung cancer. This is because cancer is named for--and treatment is based on--the site of the original tumor. For example, if breast cancer spreads to the lungs, it will be treated as metastatic breast cancer, not lung cancer.

Understanding the lungs

The lungs are sponge-like organs in your chest. Their job is to bring oxygen into the body and to get rid of carbon dioxide. When you breathe air in, it goes into your lungs through your windpipe (trachea). The trachea divides into tubes called bronchi, which enter the lungs. These divide into smaller branches called bronchioles. At the end of the bronchioles are tiny air sacs called alveoli. The alveoli move oxygen from the air into your blood. They take carbon dioxide out of the blood. This leaves your body when you breathe out (exhale).

Your right lung is divided into 3 sections (lobes). Your left lung has 2 lobes.

What are the types of lung cancer?

Lung cancer is divided into two main types: non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). These types grow and spread differently. They are often treated in different ways.

Non-small cell lung cancer (NSCLC)

About 85% to 90% of lung cancers are non-small cell. This cancer has 3 types. They are grouped by the kind of lung cell the cancer started in and by how the cells look under a microscope. They have slight differences among them. But they tend to have a similar outlook (prognosis) and are generally treated the same way:

  • Adenocarcinoma. This is the most common type of NSCLC. It's the most common type of lung cancer in nonsmokers. But it's found more often in smokers or former smokers. It tends to grow in the outer edges of the lungs. It usually grows more slowly than other types of lung cancer. 

  • Squamous cell carcinoma (epidermoid carcinoma). This type of NSCLC develops more often in smokers or former smokers. These cancers tend to start in the middle part of the lungs near the main airways (the bronchi).

  • Large cell carcinoma. This is the least common type of NSCLC. It tends to quickly grow and spread to other organs. This can make it harder to treat.

Small cell lung cancer (SCLC)

Only about 10% to 15% of people with lung cancer have small cell lung cancer. It is also called oat cell cancer. It grows and spreads more quickly than non-small cell lung cancer. It often spreads to other parts of the body at an early stage.

How lung cancer spreads

Lung cancer, like all cancers, can act differently in each person, depending on the kind of lung cancer it is and the stage it is in. But when lung cancer spreads outside the lungs, it often goes to the same places.

The first place lung cancer usually spreads to is the lymph nodes in the center of the chest. These lymph nodes are called mediastinal lymph nodes. Lung cancer may also spread to the lymph nodes in the lower neck. In its later stages, lung cancer may spread (metastasize) to distant parts of the body, like the liver, brain, or bones.

Talk with your healthcare provider

If you have questions about lung cancer, talk with your healthcare provider. He or she can help you understand more about this cancer. 

Early Detection

Lung Cancer: Early Detection

Screening is the process of looking for cancer in people who don’t have symptoms. Your healthcare provider may recommend screening if you have an increased risk for lung cancer. Screening can sometimes find cancer early, when it is likely to be easier to treat.

Screening tests for lung cancer

In general, screening is not done for lung cancer. This is because studies have not found that tests such as X-rays or looking for cancer cells in coughed-up mucus (sputum cytology) actually save lives. But the following test may help find lung cancer early.

Low-dose CT (LDCT) scan

This test is also called a spiral CT scan. It uses X-rays to create detailed pictures of your lungs. To have the test, you lie still on a table as it passes through the center of the CT scanner. A CT scan is painless and noninvasive. It does not need any special preparation. You may be asked to hold your breath one or more times during the scan. A CT scan can show some abnormal areas that a chest X-ray might miss. But these areas often turn out not to be cancer. You may still need more invasive tests to be sure.

It’s not clear if spiral CT scans can find cancer in people who are not heavy smokers or who have not smoked at all. It’s also not clear if the test can find cancer in people younger than age 55. Studies of the spiral CT scan have only been on heavy smokers who were 55 to 74 years old.

Spiral CT scans also have some downsides. They find many abnormalities that turn out not to be cancer but that still need more testing to be sure. This can make people feel anxious. It may also mean unneeded tests such as more CT scans. And it might mean more invasive tests such as biopsies or surgery, even when a person doesn't have lung cancer. Spiral CT scans also use a small amount of radiation during each test.

What expert groups recommend

Several groups have issued lung cancer screening guidelines. The groups include the U.S. Preventive Services Task Force, the American Society of Clinical Oncology, the American Cancer Society, and the National Comprehensive Cancer Network. The guidelines vary slightly among groups. But in general, they recommend that people be screened or talk with their healthcare provider about screening if they:

  • Are 55 to 74, or slightly older. Check with your insurance plan, because some plans may extend the age limit to 77 or even 80.

  • Are current or former smokers. Former means quitting within the last 15 years.

  • Have at least a 30 pack-year history of smoking.

  • Are in good enough health to be helped by screening. This means that if an early lung cancer is found on screening, they would be able to survive lung surgery to remove it.

These groups also generally recommend that screening should be done at a center that has experience with screening. The center should also be able to offer with tests and treatments that might be needed as a result of screening.

Talk with your healthcare provider

If you have risk factors for lung cancer, such as a history of smoking, talk with your healthcare provider about whether lung cancer screening might be right for you. It's important to think about your risk for lung cancer and whether the screening could help you. You should also think about the limits of screening and the risks that might come along with testing. 

 Another thing to talk about is cost. Not all insurance plans pay for lung cancer screening.

Diagnosis

Lung Cancer: Diagnosis

How is lung cancer diagnosed?

If your healthcare provider thinks you may have lung cancer, you will need certain exams and tests to be sure. Diagnosing lung cancer starts with your healthcare provider asking you questions. He or she will ask you about your health history, your symptoms, possible risk factors, and family history of disease. Your provider will also give you a physical exam. He or she might also:

  • Do a sputum cytology test . For this test, each morning for 3 to 5 days in a row, you collect the mucus (sputum) that you cough up from your lungs. The sputum is then looked at under a microscope to see if there are cancer cells in it. Not all types of lung cancer show up in this test.

  • Schedule an X-ray of your chest. This is done to look for masses in your lungs.

  • Arrange for other imaging tests. This helps to get a better picture of your lungs. This may include a CT scan or an MRI to get detailed pictures of the inside of your body.

Any of these tests might suggest that you have lung cancer. But if imaging tests show a change, such as a mass or fluid, you will need to have a biopsy. This is when the healthcare provider takes out a tiny piece of the change or some of the fluid (called a sample) for testing. A biopsy is almost always needed to diagnose lung cancer.

What kind of biopsy might I need?

The method used to get a biopsy sample is determined partly by where the tumor is and how large it is. Your doctor may suggest that you have one or more of the tests below to help diagnose lung cancer.

After any kind of biopsy, the biopsy samples are looked at under a microscope and tested for cancer cells. It often takes several days for biopsy results to come back. Along with telling if you have lung cancer, a biopsy can often tell what kind of lung cancer it is.

A lung biopsy can be done in several ways:

  • Bronchoscopy

  • Needle biopsy

  • Thoracentesis

  • Thoracotomy or thoracoscopy 

Each is described below.

Bronchoscopy

A doctor called a pulmonologist often does this test. This is a doctor who specializes in lung diseases. To get a sample in this type of biopsy, a long, thin, lighted tube called a bronchoscope is used. The bronchoscope may be flexible or rigid. It goes through your mouth or nose, through your breathing passages, and into your lungs. It has a tiny camera on the end so that your doctor can see inside your lungs to get the sample from the right place.

How it is done

This procedure often takes about an hour. If your doctor is using a flexible bronchoscope, a local numbing medicine (anesthesia) is sprayed inside your nose or mouth. You may feel as if fluid is running down your throat. It may make you cough or gag. That feeling will stop when the numbness kicks in. You may also have an IV (intravenous) line with medicine to help you relax. If your doctor uses a rigid bronchoscope, you will get general anesthesia so you sleep during the test.

With either type of bronchoscopy, your doctor might put a small amount saltwater solution (saline) into the lung passageways. This liquid flushes the area and helps collect cells, fluids, and other materials in your airways. It's then taken out through the bronchoscope for testing. Your doctor may also put tiny brushes, needles, or forceps (which are like tweezers) through the bronchoscope to collect cells from any suspicious-looking areas. All of the collected samples are sent to a lab and checked for cancer.

As the numbing medicine wears off, your throat may feel scratchy. You won’t be able to eat for a few hours. You'll need to have someone drive you home. Some people want to rest the day after the biopsy. So you may want to take the day off from your normal activities.

Needle biopsy

This is also called needle aspiration or transthoracic needle aspiration. Your doctor may use this test if your tumor can’t be reached easily with a bronchoscope. The doctor puts a thin, hollow needle through the skin of your chest and into the tumor to remove some tissue. Often an X-ray or CT scan is done at the same time. That helps the doctor see the tumor and guide the needle to it. 

How it is done

This procedure is often done by a doctor called an interventional radiologist. You may have a chest X-ray or a chest CT scan to help your doctor see exactly where to get the cells that might be cancer. If you're getting an X-ray, you'll sit with your arms resting on a table. If you're getting a CT scan, you will lie down. In either case, it’s important that you don’t move. You may get medicine to relax you and help you stay still. The doctor uses a small needle to put in medicine that numbs your skin. To get the bigger biopsy needle in, the doctor may need to make a very small cut in your skin. You will feel pressure and a short, sharp pain when the needle touches your lung. The needle goes into the tumor or abnormal tissue and is used to pull out cells. The needle is then removed and pressure is put on the site until the bleeding stops. It's then covered with a bandage.

The doctor sends the collected cells to a lab to be checked for cancer. Right after the biopsy, you'll get a chest X-ray. This is to make sure there are no problems, such as a collapsed lung (pneumothorax). You may be able to drive yourself home after the test. But ask to be sure that this is OK.

Thoracentesis

This is also called a pleural fluid aspiration or a pleural tap. If you have fluid around your lungs, this test can be used to see if the fluid contains cancer cells. To get the fluid, the doctor puts a hollow needle into the skin between your ribs to drain out the fluid. This test may be done to diagnose lung cancer. Or it can be used to drain fluid that's making it hard for you to breathe.

How it is done

You will lie on a bed. Or you may sit on the edge of a bed or a chair and rest your head and arms on a table. A small needle is used to put medicine into the skin on your chest or back to numb the area. Then the doctor outs in the thoracentesis needle. It goes in above a rib and into the space between the lining of the outside of your lungs and your chest wall (called the pleural space). You may feel pressure. Your doctor sends the collected fluid to a lab to be checked for cancer. Ask your doctor if you'll be able to drive yourself home after the test.

Thoracotomy or thoracoscopy 

A thoracotomy is a type of surgery. It's done in an operating room. The surgeon opens up your chest to look for lung cancer. This is often done when the doctor can’t make a clear diagnosis using any of the other methods. If possible, the surgeon removes the entire tumor during a thoracotomy.    

How it is done

You must be in the hospital for a thoracotomy. On the day of your surgery, you get medicine so you will sleep through the surgery. You won’t feel anything. The surgeon cuts between your ribs to reach your lungs and look for diseased tissue. Some or all of the diseased tissue is taken out and sent to a lab to be checked for cancer. When you wake up, you'll have a tube in your chest to drain air, fluid, and blood. You may need to stay in the hospital for a couple of days. During that time, you will get pain .

A thoracoscopy is much the same, but smaller cuts are used. The surgeon can do this to look at and take a biopsy of the outer surface or the linings of the lungs and other nearby structures. Like a thoracotomy, you get medicine so that you sleep during the surgery. But instead of making one long cut, the surgeon makes a few small cuts in the chest wall. A long, thin tool with a small camera on the end is put in through one of the cuts to let the surgeon see inside your body. Special tools are put in through the other cuts to take out samples of any abnormal areas. Because the cuts are smaller, people often recover more quickly from this type of procedure.

Getting your test results

When your healthcare provider has your biopsy results, he or she will contact you. Your provider will talk with you about other tests you may need if lung cancer is found. Make sure you understand the results and what follow-up you need.   

News

MEDIA COVERAGE: Saint Luke's signs cancer trial agreement with hospital with National Cancer Institute designation
Saint Luke’s Health System has signed an agreement with Washington University’s Alvin J. Siteman Cancer Center that will give its patients access to National Cancer Institute trials for new treatments.