Lung cancer or bronchogenic carcinoma refers to tumors originating in the lung parenchyma or within bronchi. It is one of the leading causes of cancer-related deaths in the United States. Since 1987, lung cancer is responsible for more deaths in women than breast cancer. It is estimated that there are 225,000 new cases of lung cancer in the United States annually and approximately 160,000 die because of lung cancer. It is interesting to note that at the beginning of the 20th century, lung cancer was a relatively rare disease. Its dramatic rise in later decades is mostly attributable to the increase in smoking among both males and females.
Smoking is the most common cause of lung cancer. It is estimated that 90% of the cases of lung cancer are attributable to smoking. The risk is highest in males who smoke. The risk is further compounded with exposure to other carcinogens, such as asbestos. There is no correlation between lung cancer and the number of packs smoked per year due to the complex interplay between smoking and environmental and genetic factors. The risk of lung cancer by passive smoking increases by 20% to 30%. Other factors include radiation for non-lung cancer treatment, especially non-Hodgkins lymphoma and breast cancer. Exposure to metals, such as chromium, nickel, and arsenic, and polycyclic aromatic hydrocarbons also is associated with lung cancer. Lung diseases like idiopathic pulmonary fibrosis increase risk of lung cancer independent of smoking.
Lung cancer is the most commonly diagnosed cancer worldwide, accounting for 12.4% of all cancers diagnosed. It also is responsible for the most cancer-related deaths, 17.6%. Historically, the lung cancer epidemic seems to involve the developed world only. Recent data suggest that the incidence of lung cancer is dramatically rising with nearly half of new cases, 49.9%, diagnosed in the under-developed world. In the United States, mortality is high in men compared to women. Overall, there is no difference between blacks and whites, but age-adjusted mortality is higher in black males than their white counterparts. No such distinction exists between black and white women.
The pathophysiology of lung cancer is very complex and incompletely understood. It is hypothesized that repeated exposure to carcinogens, cigarette smoke in-particular, leads to dysplasia of lung epithelium. If the exposure continues, it leads to genetic mutations and affects protein synthesis. This, in turn, disrupts the cell cycle and promotes carcinogenesis. The most common genetic mutations responsible for lung cancer development are MYC, BCL2, and p53 for small cell lung cancer (SCLC) and EGFR, KRAS, and p16 for non-small cell lung cancer (NSCLC).
The broad divisions of SCLC and NSCLC represent more than 95% of all lung cancers.
Small Cell Lung Cancer
Histologically, SCLC is characterized by small cells with scant cytoplasm and no distinct nucleoli. The WHO (World Health Organization) classifies SCLC into three cell subtypes: oat cell, intermediate cell, and combined cell (SCLC with NSCLC component, squamous, or adenocarcinoma).
SCLC is almost usually with smoking. It has a higher doubling time and metastasizes early; therefore, it is always considered a systemic disease at diagnosis. The central nervous system, liver, and bone are the most common sites. Certain tumor markers help differentiate SCLC from NSCLC. The most commonly tested tumor markers are thyroid transcription factor-1, CD56, synaptophysin, and chromogranin. Characteristically, NSCLC is associated with a paraneoplastic syndrome which could be the presenting feature of the disease
Non-Small Cell Lung Cancer
Five Types of NSCLC
- Squamous cell carcinoma is characterized by the presence of intercellular bridges and keratinization. These NSCLCs are associated with smoking and occur predominantly in men. Squamous cell cancers can present as Pancoast tumor and hypercalcemia. Pancoast tumor is the tumor in the superior sulcus of the lung. The brain is the most common site of recurrence postsurgery in cases of Pancoast tumor.
- Adenocarcinoma is the most common histologic subtype of NSCLC. It is also the most common cancer in women and non-smokers. Classic histochemical markers include Napsin A, Cytokeratin-7, and thyroid transcription factor-1. Lung adenocarcinoma is further subdivided into acinar, papillary and mixed subtypes.
- Adenosquamous carcinoma comprises 0.4 % to 4% of diagnosed NSCLC. It is defined as having more than 10% mixed glandular and squamous components. It has a poorer prognosis than either squamous and adenocarcinomas. Molecular testing is recommended for these cancers.
- Large cell carcinoma lacks the differentiation of a small cell and glandular or squamous cells.
- Carcinoid tumors include two subtypes: typical and atypical. Typical carcinoid carries relatively better prognosis and is only occasionally associated with carcinoid syndrome.
- Apart from this, there is anecdotal evidence of rare and unusual forms of non-small cell lung cancer which includes but are not limited to giant cell carcinoma of the lung and sarcomatoid carcinoma of the lung.
Multiple compounds have been implicated as the cause of lung cancer. In reality, it is hard to establish a causal relationship due to a battery of other confounding factors, such as the difference in the quantity of exposure time, smoking status.
Among the chemicals considered responsible, asbestos is the only one that has a clear causal relationship with the development of lung cancer.
Asbestos and Lung Cancer
The risk depends on exposure time and type of asbestos. Amphibole fibers confer a much higher risk of lung cancer than chrysotile fibers. The risk increases considerably with concurrent smoking. In non-smokers who are exposed to asbestos, there is a six-fold increase in the risk of lung cancer; whereas, in smokers, this risk is 16-fold if a minimum of 20 cigarettes smoked per day and nine-fold increase with less than 20 cigarettes per day. Other compounds that may increase the risk of lung cancer include radon, nickel, cadmium, chromium, silica, and arsenic.
History and Physical
No specific signs and symptoms exist for lung cancer. Most patients already have advanced disease at the time of presentation. Lung cancer symptoms occur due to local effects of the tumor, such as cough due to bronchial compression by the tumor, due to distant metastasis, stroke-like symptoms secondary to brain metastasis, paraneoplastic syndrome, and kidney stones due to persistent hypercalcemia. Specifically:
- A cough, dyspnea, and hemoptysis are the common presenting symptoms.
- A cough is the most common symptom, accounting for 50% to 75% of cases. It is sensitive but not specific. Squamous cell and small cell cancers usually cause a cough early due to the involvement of the central airways.
- Dyspnea or shortness of breath represents lung cancer in 25% to 40% of cases.
- Hemoptysis is an important symptom in anyone with a history of smoking. Although bronchitis is the most common cause of hemoptysis, 20% to 50% of patients with underlying lung cancer present with hemoptysis.
- Rarely, patients present with shoulder pain, Horner syndrome, and hand muscles atrophy. This constellation of symptoms is called Pancoast syndrome. It is due to lung cancers arising in the superior sulcus.
Lung cancer is the leading cause of death in both men and women. NSCLC accounts for 85% of diagnosed cases of lung cancer in the United States. The overall goal is a timely diagnosis and accurate staging. As per the American College of Chest Physicians (ACCP) guidelines, the initial evaluation should be complete within 6 weeks in patients with tolerable symptoms and no complications. Only 26% and 8% of cancers are diagnosed at stages I and II, whereas 28% and 38% are diagnosed at stages III and IV respectively. Therefore, curative surgery is an option for a minority of patients.
Lung cancer evaluation can be divided in 2 ways:
- Radiological staging
- Invasive staging
Goals of Initial Evaluation
- Clinical extent and stage of the disease
- Optimal target site and modality of 1st tissue biopsy
- Specific histologic subtypes
- Presence of co-morbidities, para-neoplastic syndromes
- Patient values and preferences regarding therapy
Every patient suspected of having lung cancer should undergo the following tests:
- Contrast-enhanced CT chest with extension to upper abdomen up to the level of adrenal glands
- Imaging with PET or PET-CT directed at sites of potential metastasis when symptoms or focal findings are present or when chest CT shows evidence of advanced disease
Intravenous (IV) contrast enhancement is preferable as it may distinguish mediastinal invasion of the primary tumor or metastatic lymph nodes from vascular structures.
The major advantage of CT is that it provides an accurate anatomic definition of the tumor within the thorax which helps clinicians to decide the optimal biopsy site.
CT can also identify the following:
- Tumor-related atelectasis
- Post obstructive pneumonitis
- Intra- or extrathoracic metastatic disease
- Co-existing lung disease
The main objective of a CT scan is to identify the extent of the tumor, its anatomical location, and the lymph node involvement. TNM staging relies heavily on lymph node involvement. Therefore, most of the societies in Europe and the United States agree to regard a lymph node of 1 centimeter or more in the short axis to be considered as highly suspicious for malignancy. Lymph nodes can be enlarged secondary to acute inflammation, such as with congestive heart failure exacerbation or recent viral infection. The overall sensitivity and specificity of CT scan to identify malignancy are 55% and 81% respectively. Hence, CT is not a good test for lung cancer staging.
The American College of Chest Physicians (ACCP) has proposed grouping patients based on tumor extent and lymph node involvement. Although CT is not the right staging tool, it helps the clinician select the site for tissue biopsy. In other words, based on these groups, further staging via non-invasive or invasive methods is planned.
- Patients with bulky tumor encircling/invading mediastinal structures such that remote lymph nodes cannot be distinguished from the primary tumor.
- Mediastinal invasion is implied, therefore, no need for LN sampling. Tissue diagnosis suffices.
- Patients with discrete lymph node enlargement greater than 1 centimeter such that an isolated lymph node can be distinguished from the primary tumor
- Lymph node sampling is required for pathologic confirmation before curative intent therapy.
- Patients with a central tumor and elevated risk of nodal disease despite normal-sized nodes, such as high risk for N2/3 disease.
- Lymph node sampling is needed even if CT/PET negative due to a high risk of N2/N3 disease.
- Patients with low risk of N2/3 involvement or distant metastatic disease, such as peripheral T1 tumors.
- Invasive testing is not done routinely except if suspicion of N1 disease is high or patient is not a candidate for surgery but going for Stereotactic Body Radiation Therapy (SBRT).
PET scanning allows in vivo determination of metabolic and pathologic processes. It provides limited anatomic resolution but does provide information on the metabolic activity of the primary tumor, mediastinal involvement, and potential distant metastases. The new integrated PET/CT scanners have eliminated the problem of unclear anatomy.
The primary advantage of PET scanning is that it has reduced the number of futile thoracotomies by accurately identifying metastasis and thus excluding curative surgery as an option.
PET scan is also helpful in excluding recurrent tumors after initial therapy. It also can identify recurrence versus metabolic changes post radiation therapy. False positives occur in patients with active infection and inflammation with increased glycolysis. In cases of recent lymph node sampling, a PET scan may be falsely positive. False-negative PET scans occur when there are impaired blood flow and low metabolic activity, such as with carcinoid and some adenocarcinomas, and smaller lymph nodes.
PET scan has a sensitivity of 80% and specificity of 88%, which is higher than CT but not sufficient to stage lung cancer on its own. Therefore, the ACCP recommends that, except for group A disease, a positive PET does not obviate the need for lymph node sampling.
After CT and PET scans, the next step is to obtain tissue or pathologic confirmation of malignancy, confirm staging, and histological differentiation of cancer. One of the following procedures achieves this.
- Bronchoscopic Endobronchial Ultrasound-Transbronchial Needle Aspiration (TBNA)
- Thoracoscopy or video-assisted thoracoscopy(VATS)
CT guided a transthoracic biopsy is an option for peripheral lesions with a low risk of pneumothorax. Certain older procedures, such as Chamberlain procedure, is sometimes required.
- Convex Probe-Endobronchial Ultrasound guided (EBUS)-TBNA
- Radial Probe-EBUS-TBNA
- Navigation Bronchoscopy
This is a bronchoscopic technique in which a miniature convex ultrasound of 7.5 MHZ is attached to the tip of the bronchoscope. It provides direct visualization of structures in the mediastinum or lung parenchyma through the bronchial wall. A biopsy is performed in real time. It mainly is used to sample the mediastinal and hilar lymph nodes. The image can be frozen and measured, and there is also Doppler available to identify blood vessels. It is the procedure of choice for this purpose. CP-EBUS is also the procedure of choice postinduction chemotherapy before surgery to confirm complete remission. CP-EBUS can be used to sample upper and lower paratracheal nodes as well as stations 10, 11 and 12. Stations 3, 5, and 6 are not accessible via CP-EBUS.
Instead of a convex probe, there is a miniature (20 to 30 MHz) probe. The advantages are that smaller lesions or lesions that are more peripheral can be reached, and it provides a 360-degree view of lung parenchyma. A real-time biopsy cannot be performed.
The concept is to construct a navigational map of airways using either CT scan or electromagnetic field. After the map is constructed, the software creates the path to reach the location of the nodule. The bronchoscopist can create the pathway, and the software then navigates the bronchoscopist to the biopsy site.
Endoscopic ultrasonography (EUS) is becoming an increasingly useful tool for the diagnosis and staging of lung cancer. It can sample lymph nodes through the esophageal wall and provides a real-time sampling of stations 2, 4, 7, 8, and 9. The latter 2 stations cannot be sampled by Endobronchial ultrasound (EBUS). It has the same sensitivity and specificity of EUS, 89%, and 100% respectively. There is also a growing trend to combine EBUS and EUS as a minimally invasive technique for lung cancer staging.
Mediastinoscopy was formerly the gold standard for lung cancer diagnosis and staging. Now it is mainly used to sample lymph nodes after negative needle technique and when the patient is still at high risk for cancer due to lymph node size or FDG uptake on PET scan. Most commonly, para-tracheal lymph nodes are sampled. Alternatively, an anterior mediastinoscopy (Chamberlain procedure) can be performed to access subaortic and para-aortic nodes, stations 5 and 6 respectively. Mediastinoscopy has a sensitivity of 78% and specificity of 100%. Like all surgical procedures, mediastinoscopy has some risks. General anesthesia is required, and the procedure carries a mortality risk of 0.08%.
Traditionally, thoracoscopy was performed by dividing the ribs and opening the chest cavity. Like laparoscopic surgery, it has largely replaced open abdominal surgeries. Video-assisted thoracoscopy surgery (VATS) has replaced thoracoscopy. It is used to treat a number of chest wall, pleural, pulmonary, and mediastinal conditions. Mediastinal lymph node sampling, as well as full dissection during lung resection for cancer, can be performed with VATS. A newer version of VATS is called RATS (robotic-assisted thoracoscopy). There are no trials comparing VATS and RATS for mediastinal lymph node biopsy.
- Superior vena cava syndrome in emergency medicine
Lung Cancer Staging
After the diagnosis of lung cancer, the most crucial step is to stage the disease because the state dictates treatment options, morbidity, and survival. It is of paramount importance that this is done with utmost vigilance. Staging is primarily done for NSCLC using the TNM classification. SCLC also can be staged in the same way, but a much more straightforward approach is used for limited disease and extensive disease.
Tumor, node, metastasis staging of non-small cell lung cancer
Tumor (T), node (N), and metastasis (M) is an internationally accepted way of staging NSCLC. It is comprehensive in defining tumor size and extent, location, and distant spread which helps clinicians draw meaningful conclusions regarding the best treatment, avoid unnecessary surgeries and provide a timely referral to palliative care if the cure is not an option. The most recent TNM classification is the eighth edition, and it is effective in the United States from January 1, 2018. Outside the United States, it was accepted on January 1, 2017, by Union of International Cancer Control (UICC).
For the eighth edition, Ithe International Association of the Study of Lung Cancer (IASLC) studied and analyzed data from 16 countries including approximately 95,000 patients from 1999 to 2010.
A primary tumor is divided into 5 categories, and each category is then further subdivided depending on the size, location and invasion of surrounding structures by the tumor.
- No primary tumor
- T Carcinoma in situ
T1 (less than 3 cm)
- T1mi: minimally invasive tumor
- T1a: superficial tumor confined to central airways (tracheal or bronchial wall)
- T1a: Less than 1 cm
- T1b: Greater than 1 cm but less than 2cm
- T1C: Greater than 2 cm but less than 3cm
- T2: Greater than 3 cm but less than 5 cm
- T2a: Greater than 3 cm but less than 4cm
- T2b: Greater than 4 cm but less than 5cm
- Also considered a T2 tumor if involving main bronchus but not carina, visceral pleura or causes atelectasis to the hilum
- T3: Greater than 5 cm but less than 7 cm)
- T3 Inv: invasion of the chest wall, pericardium or phrenic nerve
- T3 Satell: separate tumor nodules in the same lobe
- Also considered T3 tumor if involving the pericardium, phrenic nerve, chest wall or separate tumor nodules in the same lobe
- T4: Greater than 7 cm)
- T4inv: Invading above structures
- T4Ipsi nod: Nodules in an ipsilateral lobe
Also considered T4 tumor if involving heart, esophagus, trachea, carina, mediastinum, great vessels, recurrent laryngeal nerve, spine or tumor nodules in the different ipsilateral lobe. Invasion of Diaphragm is now considered a T4 tumor as compared to a T3 tumor in the seventh edition of TNM classification25.
Thoracic Lymph Nodes
Lung cancer staging also depends upon the extension of cancer to the lymph nodes corresponding to the primary tumor as well as the opposite hemithorax. It is extremely important to rule out lymph node metastasis before attempting curative surgery. Lung resection in itself carries high morbidity and mortality, therefore, should not be attempted if a cure is not possible.
Historically, thoracic lymph nodes were first classified in the 1960s by Naruke. This map was accepted by North America, Europe, and Japan. Later, in the 1980s and early 90s, further refinements were made in response to better imaging and invasive testing improvements. Hence, two lymph node maps gained popularity in North America.
- American thoracic society (ATS-Map)
- American Joint Committee on Cancer (AJCC). This was an adaptation of the Naruke map.
In 1996, the differences in the above 2 were resolved in the form of Mountain-Dressler modification, MD-ATS Map. It was accepted in North America but only sporadically in Europe.
The International Association of Study of Lung Cancer (IASLC) attempted to resolve the differences between the MD-ATS map and the Naruke map. The IASLC lymph node map is now the most widely accepted lymph node classification system utilized all over the world.
Thoracic lymph nodes can be divided into mediastinal or N2 and hilar or N1 lymph nodes. N2 nodes are more important because they differentiate in cancer stages and, therefore, treatment options.
Much care has been taking in defining the N2 nodes in all the lymph node maps. We will attempt to explain the classification under the broad headings of Mediastinal and Hilar groups and then further explain the individual mediastinal stations as per IASLC map.
Mediastinal Lymph Nodes
They are subdivided into the following groups or stations:
- Supraclavicular nodes, station 1
- Superior mediastinal nodes, station 2 to 4
- Aortic nodes, station 3
- Inferior mediastinal lymph nodes, station 4
Supraclavicular Nodes (Station 1)
It includes lower cervical, supraclavicular and sternal notch nodes. Lymph nodes are further divided into 1R and 1L corresponding to right and left the side of the body respectively. The distinction between 1R and 1L is an imaginary midline of trachea serves as the boundary. Below station 1, the left tracheal border is considered the boundary is differentiating between right and left-sided lymph nodes.
Superior Mediastinal Lymph Nodes (Station 2 to 4)
These lymph nodes occupy the superior mediastinum, hence, named accordingly. They are further subdivided into the following groups:
Upperparatracheall (station 2R and 2L)
- 2R nodes extend to the left lateral border of the trachea.
From the upper border of manubrium to the intersection of the caudal margin of the innominate (left brachiocephalic) vein with the trachea.
- 2L nodes extend from the upper border of manubrium to the superior border of the aortic arch. 2L nodes are located to the left of the left lateral border of the trachea
Pre-vascular (station 3A)
These nodes are not adjacent to the trachea like the nodes in station 2, but they are anterior to the vessels
Pre-vertebral (station 3P)
Nodes not adjacent to the trachea like the nodes in station 2, but behind the esophagus, which is pre-vertebral
Lower para-tracheal (station 4R and 4L)
- 4R nodes extend from the intersection of the caudal margin of the innominate (left brachiocephalic) vein with the trachea to the lower border of the azygos vein. 4R nodes extend from the right to the left lateral border of the trachea.
- 4L nodes extend from the upper margin of the aortic arch to the upper rim of the left main pulmonary artery
Aortic Lymph Nodes (5 and 6)
This group includes:
Sub-aortic nodes (station 5)
These nodes are located lateral to the aorta and pulmonary trunk in the so-called AP window
Para-aortic node (station 6)
These are ascending aorta or phrenic nodes lying anterior and lateral to the ascending aorta and the aortic arch
Inferior Mediastinal Lymph Nodes (Station 7 to 9)
This group includes sub-carinal and para-esophageal nodes:
Sub-carinal nodes (station 7)
They extend in a triangular fashion from the division of carina superiorly to the lower border of the bronchus intermedius on the right and the upper border of the lower lobe bronchus on the left.
Para-esophageal nodes (station 8)
These nodes are situated adjacent to the right and left the side of the esophageal wall. Both, station 7 and eight are located below the carina.
Pulmonary Ligament (station 9) They are located within the pulmonary ligaments extending from inferior pulmonary vein up to the diaphragm.
Hilar Lymph Nodes (Station 10 to 14)
These are all N1 nodes. These include nodes adjacent to the main stem bronchus and hilar vessels. On the right, they extend from the lower rim of the azygos vein to the interlobar region. On the left from the upper rim of the pulmonary artery to the inter-lobar region.
Lymph Node Classification (N)
N0: No lymph node involvement
N1: Involvement of ipsilateral hilar nodes
- N1a: single station N1 nodes
- N1b: multiple-station N1 nodes
N2: Involvement of mediastinal nodes
- N2a1: Single station N2 nodes without N1 involvement (skip metastasis)
- N2a2: Single station N2 nodes with N1 involvement
- N2b: Multiple station N2 involvement
N3: Involvement of contralateral mediastinal or hilar lymph nodes
- M0: No distant metastasis
- M1a: Malignant pleural / pericardial effusion or nodules
- M1b: Single extra-thoracic metastasis
- M2: Multiple extra-thoracic metastases
Tumor Node Metastasis Staging of Lung Cancer
Occult cancer: TX N0 M0
Primary cancer not found. No lymph node or distant metastasis.
- T1a / T1b / T1c N 1 M 0
- T2a / T2b N 1 M 0
- T3 N 0 M 0
- T1a / T2b / T2c N 2 M 0
- T2a / T2b N2 M 0
- T3 N 1 M 0
- T4 N 0 / N 1 M0
- T1a / T1b / T1c N 3 M 0
- T2a / T2b N 3 M0
- T3 N 2 M 0
- T4 N 2 M 0
Staging for all Small Cell Lung Cancer
- SCLC staging can be done using the TNM system, but since SCLC is considered a systemic disease, a much more straightforward classification has been used successfully since the 1950s. There is a growing body of evidence that TNM rating may be better in defining SCLC, but there is consensus on this approach yet.
- SCLC is classified as LS-SCLC and ES-SCLC small cell based on the Veterans Affairs Lung study group (VALSG) classification.
- LS-SCLC is confined to the ipsilateral hemithorax, and local lymph nodes, both mediastinal and hilar and supraclavicular nodes can be included in a single tolerable radiotherapy port (corresponding to TNM stages I through IIIB).
- ES-SCLC has tumor beyond the boundaries of limited disease including distant metastases, malignant pericardial, or pleural effusions, and contralateral supraclavicular and contralateral hilar involvement.
Pearls and Other Issues
Palliative Care in Lung Cancer
All therapeutic options, surgery, chemotherapy, and radiation have a role in managing pain and other symptoms in terminal lung cancer patients.
Surgery results in better outcomes in patients with at least three months expected survival and good performance status. Surgical procedures for palliation includes tumor bypass procedures, partial resection of the tumor, and removal of metastasis. Surgical intervention may be beneficial in patients with lung cancer if there is airway obstruction, hemoptysis, pleural or pericardial exudate, or metastases to the brain or bone. Almost 30% of lung cancer patients experience central airway occlusion, and bronchoscopic laser destruction followed by stent placement provides immediate relief in such patients.
Chemotherapy helps alleviate symptoms of pain and cough and may prolong survival.
Palliative radiation provides symptomatic relief in 41% to 95% of lung cancer patients. Almost 60% of lung cancer patients, regardless of type and stage, receive radiation treatments during their course of illness. Radiation plays a crucial role in alleviating symptoms of pain due to metastasis, particularly brain and bone metastasis. Endoscopic treatment, such as brachytherapy, helps control symptoms due to airway narrowing.
Enhancing Healthcare Team Outcomes
Despite all the advances, the outcomes for lung cancer remain abysmal. The key reason is that most patients are diagnosed with advanced-stage disease. To improve outcomes, an interprofessional team approach with close communication between the members may perhaps lead to earlier diagnosis and treatment.
The majority of patients with lung cancer are first seen by the primary care provider, nurse practitioner or internist. These clinicians need to have a high suspicion of lung cancer in smokers and others with occupational exposures and order the appropriate imaging tests ASAP. Referral to a thoracic surgeon should be done on a timely basis.
The definitive diagnosis and management of lung cancer is done by the thoracic surgeon with collaboration with the radiologist and pathologist.
After surgery, the patients are usually monitored by nurses for oxygenation, ventilation, and pain. Since many of these patients are smokers, they also have other comorbidities like heart disease and peripheral vascular disease, which often presents with symptoms in the post-operative period. Thus, nurses have to be extra vigilant for physical abnormalities and communicate with the surgeon.
After surgery, patients need prolonged rehabilitation. Some may need chemotherapy and radiation, and hence the oncology nurse should educate the patients on the procedures and protocols. The pharmacist should educate the patient on the chemotherapeutic drugs, their benefits, and adverse effects. Oncology board-certified pharmacists can consult with the oncologist on the regimens for chemotherapy, and the alternatives based on patient response.
Lung cancer is not curable and all clinicians should urge patients to quit smoking; screening may be useful in selective patients.
Due to high incidence and mortality, there has been a worldwide interest in developing a screening program for lung cancer. A landmark study, the National Lung Screening Trial, showed an overall decrease in mortality of 6.7%. Currently, lung cancer screening is offered to men and women who are 55 years or older who have smoked 30 pack-years or more or have quit smoking less than 15 years ago. It is done every year until the minimum age of 74 years.
Lung cancer screening uses a low-dose helical CT scan of the chest which takes less than 25 seconds. A major drawback of screening is the detection of benign lesions, resulting in a relatively high number of unnecessary biopsies, surgeries, or continued radiological follow-up. The key is for the interprofessional team to communicate and determine the best course of action. A great many patients have advanced-stage lung cancer and a pain nurse and the hospice team should be involved in the care.