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 2 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 major 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 and former or current 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 than lifetime nonsmokers. 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 1 in 10 to 3 in 20 people with lung cancer have small cell lung cancer. It is also called oat cell cancer. It is almost only found in smokers. 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. They can help you understand more about this cancer.
Lung Cancer: Early Detection
Screening is the process of looking for cancer in people who don’t have symptoms. You may want to talk with your healthcare provider about yearly screening if you have an increased risk for lung cancer. Screening can sometimes find cancer early, when it's small, hasn't spread, and might be easier to treat.
Screening tests for lung cancer
Screening of the general population 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. Still, low-dose CT scans may help find lung cancer early in certain people at higher risk.
Low-dose CT (LDCT) scan
This test is also called a spiral CT scan. It uses X-rays to create detailed 3-D pictures of your lungs.
To have this test, you lie still on a narrow table as it passes through the center of the ring-shaped CT scanner. A CT scan is painless. No special preparation is needed before the scan. You may be asked to hold your breath a few times during the scan.
An LDCT 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 need more tests to be sure.
It’s not clear if LDCT scans can find cancer in people who aren't heavy smokers or who haven't smoked at all. It’s also not clear if the test can find cancer in people younger than age 55. So far, studies have only been done on heavy smokers ages 55 to 74.
LDCT 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. Or more invasive tests, such as biopsies or surgery may be done, even when a person doesn't have lung cancer. LDCT scans also use a small amount of radiation during each test.
Who should get lung cancer screening
Several expert groups have put out lung cancer screening guidelines. These include the U.S. Preventive Services Task Force (USPSTF), the American Society of Clinical Oncology, the American Cancer Society, and the National Comprehensive Cancer Network.
The guidelines vary a little among expert groups, so talk with your healthcare provider about your risk and personal situation. The USPSTF advises that people who smoke be screened every year with low-dose CT (LDCT). Or they should talk with their provider about yearly screening if they meet all of the following:
Are age 50 up to 80. (Check with your insurance plan, because some plans have age limits.)
Are current smokers or have quit in the last 15 years
Have a 20 pack-year history of smoking. A pack-year is 1 pack of cigarettes per day per year. So, 1 pack per day for 20 years or 2 packs per day for 10 years would be 20 pack-years.
The USPSTF says that screening can stop once a person has not smoked for 15 years or has a health problem that limits their life expectancy or their ability to have lung surgery.
Expert groups also recommend that screening be done at a center that has experience with screening. The center should also be able to offer tests and treatments that might be needed as a result of screening. Expert groups differ slightly in their advice, so talk with your provider about your risk and situation.
Talk with your healthcare provider
If you have a history of smoking, talk with your healthcare provider about whether yearly lung cancer screening might be right for you. It's important to think about your risk for lung cancer and whether 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 annual lung cancer screening.
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. You'll be asked about your health history, your symptoms, possible risk factors, and family history of disease. A physical exam will be done. You might need to:
Have a sputum cytology test . Each morning for 3 to 5 days in a row, you'll collect the mucus (sputum) that you cough up from your lungs. It's then sent to a lab and looked at under a microscope to see if there are cancer cells in it.
Have blood drawn. A needle might be used to take a small amount of blood from your hand or arm. Blood tests can show how well certain organs are working and give an idea of your overall health.
Get a chest X-ray. This is done to look for changes in your lungs, like tumors or fluid buildup.
Schedule other imaging tests. These are done to get a better picture of your lungs. A CT scan to get detailed pictures of the inside of your body is most often used.
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'll need to have a biopsy. This is when a 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 way a biopsy sample is taken out depends partly on where the tumor is and how big it is. Your healthcare provider may suggest 1 or more of the tests below to help do a biopsy and diagnose lung cancer.
After any kind of biopsy, the tissue samples are sent to a lab. They're looked at under a microscope and tested for cancer cells. It often takes up to a week for biopsy results to come back. Along with telling if you have lung cancer, a biopsy can often tell exactly what kind of lung cancer it is.
A lung biopsy can be done in many ways:
Thoracotomy or thoracoscopy
Each is briefly described below. Your healthcare provider can give you more details on the kind of biopsy you're going to have.
A pulmonologist often does this test. This healthcare provider specializes in lung diseases. The pulmonologist uses a long, thin, lighted tube called a bronchoscope to get a sample in this type of biopsy. The bronchoscope may be flexible or rigid. It's put in through your mouth or nose, through your breathing passages, and into your lungs. It has a tiny camera on the end so that your healthcare provider 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 healthcare provider is using a flexible bronchoscope, a numbing medicine (local anesthesia) is sprayed inside your nose or mouth. You may feel like fluid is running down your throat. It might make you cough or gag. This stops when the numbness kicks in. You may also have an IV (intravenous) line put into a vein in your hand or arm. It's used to give you medicine to help you relax. If your healthcare provider uses a rigid bronchoscope, you'll get general anesthesia through an IV. This means medicines are used so you sleep and don't feel pain during the test.
With either type of bronchoscopy, the healthcare provider might put a small amount of saltwater (saline) into your lung passageways. This liquid flushes the area and helps collect cells, fluids, and other materials in your airways. The collected material is then taken out through the bronchoscope and sent for testing. Your healthcare provider may also put tiny brushes, needles, or forceps (which are like tweezers) through the bronchoscope to collect cells from any suspicious-looking tissue. All 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.
This is also called needle aspiration or transthoracic needle aspiration. Your healthcare provider may use this test if the tumor can’t be reached with a bronchoscope. To do it, a thin, hollow needle is put through the skin of your chest and into the tumor to remove some tissue. Often an X-ray, ultrasound, or CT scan is done at the same time. This helps the healthcare provider see the tumor and guide the needle into it.
How it is done
A needle biopsy is often done by a healthcare provider called an interventional radiologist. An imaging scan is often used to help your healthcare provider see exactly where to get the cells that might be cancer. You might sit with your arms resting on a table or lie down. It depends on where the tumor is and the kind of imaging test used. Either way, it’s important that you don’t move.
You may get medicine to relax you and help you stay still. The healthcare provider uses a small needle to put numbing medicine in your skin. A tiny cut might be made in your skin to get the bigger biopsy needle in. You might feel pressure and a short, sharp pain when the needle touches your lung. The needle is then put into the tumor or abnormal tissue and a syringe is used to pull out cells. The needle is then taken out and pressure is put on the site until the bleeding stops. It's then covered with a bandage.
The healthcare provider sends the collected cells to a lab to be tested for cancer cells. Right after the biopsy, you'll get a chest X-ray. This is to make sure there are no problems, like a collapsed lung (pneumothorax). You may be able to drive yourself home after the test. But ask before the test is done to be sure this is OK.
This is also called a pleural fluid aspiration or a pleural tap. It might be done if fluid has built up around your lungs. It's used to see if the fluid contains cancer cells. A healthcare provider puts a thin, hollow needle through your skin to drain out the fluid. This test may be done to diagnose lung cancer. It's also used to drain fluid that's making it hard for you to breathe.
How it is done
You will lie on a bed or 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 numbing medicine into the skin over the part of your lung that has fluid in it. Then the healthcare provider puts 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. The fluid then drains out or is pulled into a syringe. It's sent to a lab to be checked for cancer. Ask your healthcare provider if you'll be able to drive yourself home after this test.
Thoracotomy or thoracoscopy
Thoracotomy and thoracoscopy are types of surgery done in an operating room. The surgeon opens up your chest to look for lung cancer. This is often done when the healthcare provider can’t make a clear diagnosis using any of the other methods. If possible, the surgeon takes out the entire tumor.
How it is done
You must be in the hospital for a thoracotomy. An IV (intravenous) line is put into a vein in your hand or arm. It's used to give you medicine that makes you sleep and not feel pain during the surgery. 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 medicine.
A thoracoscopy is much the same, but smaller cuts are used. It might be done to look at and take a biopsy from 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 so the surgeon can see inside your body. Long, thin tools are then put in through the other cuts to take out samples of any diseased tissue. Because the cuts are smaller, people often recover more quickly from this type of procedure.
Getting your test results
Ask your healthcare provider how long it will take to get your test results and how you'll get them. Will it be a phone call? Do you need to set up an appointment?
If lung cancer is found, your provider will talk with you about other tests you may need. Make sure you understand the results and what your next steps should be.