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What is lung cancer?
Cancer is the uncontrolled growth of cells within the body. Usually, all of our cells have a specific lifespan of days to years that is genetically programmed in our DNA. When our DNA becomes damaged, either through the aging process, exposure to toxins such as radiation or chemicals or through inherited genes, some cells do not die a natural death but continue to grow. As they do, they form new cells with the same genetic misinformation. These extra cells may form masses or tumours that can be either malignant or benign. A benign tumour is a tumour that does not invade the surrounding tissue or spread around the body and stays in one place. A malignant tumour can invade the surrounding tissue or spread via the blood or lymph networks and affects other cells and organs.
Approximately 6.5% or one in fifteen of the global population will develop some form of lung cancer during their lifetime. It is the most common cancer in the world, either as a primary site of cancer cell growth or as a destination for cancer cells produced in other parts of the body where it is known as metastatic lung cancer.
Most cases of lung cancer are first diagnosed after the development of a cough that simply does not go away, hoarseness, the appearance of blood in the sputum or unexplained weight loss or shortness of breath. Very early diagnosis usually happens during chest X-rays for other respiratory disorders such as pneumonia or the presence of cancerous cells in sputum samples. Other cases of early detection are found in those populations who suffer from chronic lung disorders such as COPD or cystic fibrosis. These groups usually visit their pulmonologist at regular intervals and are aware of the signs of lung cancer.
Screening programs for lung cancer are uncommon and it is usually up to the patient to ask. As the only recommended screening test is via a CT scan which emits low doses of radioactivity, these tests are only carried out on people with a history of heavy smoking who either continue to smoke or have given up in the past 15 years and are over 55 years of age. These criteria mean that many non-smokers are left out of the loop and with increasing numbers of patients having never smoked, current screening programs are insufficient. As regular CT scans can be damaging to your overall health, being aware of the early signs is important.
Women have a very slightly lower risk of developing lung cancer when compared to men, although these numbers are gradually rising. One in five women who develop lung cancer has never smoked, and this is true of one in every ten men. And it is not only second-hand smoke that increases risk for non-smokers – indoor coal fires for cooking and heating and some cooking fuels are known carcinogens. Another known risk factor is living in or working in environments with medium to high levels of pollution. And the presence of other cancer types in the body that form secondary tumours in the lungs also increase one’s chances of developing lung cancer.
Treatments for lung cancer prevent further growth, most commonly via chemotherapy, and often involve surgery.
Are there different types of lung cancer?
There are various forms of lung cancer and your medical notes may be difficult to understand. Most specific lung cancer types are based upon the features of their abnormal cells.
Primary lung cancer which starts in the lungs and is not secondary to other cancers are divided into two main groups known as small cell lung cancer (SCLC) and non small cell lung cancer (NSCLC). The latter of these is the most common group and consists of smaller groups: adenocarcinomas (ADC), squamous cell carcinomas (SCC), large cell carcinomas (LCC), large cell neuroendocrine carcinomas (LCNEC) and giant cell carcinomas. Small cell lung cancer is less common and usually the result of regular contact with cigarette smoke. Finally, combined small cell carcinoma (c-SCLC) is a tumour containing both small cell and non small cell components. All of these cancer cell types will be looked at in more detail below.
If you have cancer of the lung due to the metastasis of another cancer such as colon cancer, prostate cancer or breast cancer, your cancer will be named according to the primary source. Secondary lung cancer is not the result of mutations in lung cells but due to bowel, breast, prostate or any other type of cancer cell reaching the lungs and growing there. These cells do not become lung cells. This is why metastatic lung cancer is not dealt with in detail in this article.
Small cell lung cancer
Small cell lung cancers – previously referred to as oat cell cancers - are rarer than non small cell types but more aggressive and can grow quickly. They are also likely to metastasise to other areas of the body such as the liver, brain and bone if not caught in time. Most cases of SCLC are the result of smoking cigarettes or breathing in significant quantities of cigarette smoke produced by others, such as when living with a heavy smoker or working in an environment where smoking takes place.
This type of cancer usually starts in the centre of the chest at the bronchi and is difficult to treat.
Combined small cell lung cancer
Where other cancer cells that are different to small cells are present in a cancerous lesion of the lung, your diagnostic notes may feature the acronym c-SCLC. This type of cancer – combined small cell lung cancer - is often treated in the same way as small cell lung cancer but contains non small cell lung cancer types that may respond better to other therapies. It is therefore important that you have access to an experienced oncologist specialised in lung carcinomas. Remedazo works with a number of highly specialised oncological consultants.
Most of those with the combined cancer type are around 60 years of age and male and have a history of heavy smoking, just like those groups diagnosed with small cell lung cancer. However, this cancer type is also found in younger and older men and women with no history of smoking. The most frequent clinical symptoms of c-SCLC are coughing, trouble breathing and coughing up small or large quantities of blood. Tumours can start to grow anywhere in the lung and are more likely to be found further from the bronchi than small cell lung cancers.
Furthermore, c-SCLC tends to be detected at earlier stages than SCLC and does not metastasize as rapidly. It may respond better to surgery and radiotherapy but not as well to chemotherapy. Finally, very specific mutations in special cells known as epidermal growth factor receptors (EGFR) are not often found in small cell lung cancer types but prolific in non small cell lung cancer. This is important, as these mutations are not only treated differently but can also provide a means for blood sample detection at a much earlier stage.
Non small cell lung cancer
Non small cell lung cancer is the most common form of lung cancer in those who have never smoked. Non small cell lung carcinomas (the terms carcinoma and cancer are interchangeable) tend not to respond to chemotherapy as well as small cell lung cancers and the first line of treatment is therefore surgical. Surgical removal of a non small cell tumour without metastasis can be a curative therapy. Even though these cells are less sensitive to chemotherapy it is still given either before surgery to shrink the tumour (neoadjuvant therapy) or after surgery to kill off remaining cells (adjuvant therapy).
Adenocarcinoma (ADC)
The most common type of NSCLC, lung adenocarcinomas are often found on the outer surfaces of the lung and involve secretory cells such as those that produce mucus. Unlike most types of lung cancer, adenocarcinomas of the lung are more often found in women, many of whom are non-smokers. Because they grow slowly they are often detected at a later stage; any symptoms they produce are typical to lung cancer such as a cough that does not go away, blood in the sputum and unexplained weight loss.
Squamous cell carcinoma (SCC)
Squamous cell lung cancer begins in the thin, flat squamous cells of the airway lining, usually close to the central portion of the lung or a major airway. This type of non small cell cancer is more likely to be found in smokers or in those exposed to high levels of second hand smoke, certain chemicals such as asbestos and gases such as radon in the home or working environment. Symptoms at later stages are comparable to all types of lung cancer.
Large cell carcinoma (LCC)
Large cell carcinoma used to be confused with adenocarcinoma but better techniques now make it possible to distinguish cell types with more accuracy. This means that previous estimates of 10% of all lung cancers being due to LCC have now dropped to just 2%. Most people with LCC are men aged between 50 and 70 years of age who have smoked or still smoke. Treatment usually requires surgery as well as courses of chemotherapy and radiation.
Large cell neuroendocrine carcinoma (LCNEC)
This type of lung cancer is very rare. Usually found on the outer regions of the lungs, this cancer type is most often found in older men who smoke. This can be an aggressive cancer that often returns after treatment and is sometimes found together with other non small cell cancer cell types. Early stage treatments are surgery and chemotherapy. Later stage treatments primarily use chemotherapy, targeted therapy and immunotherapy to slow tumour growth.
Giant cell carcinoma
Giant cell carcinoma of the lung (GCCL), sometimes referred to as sarcomatoid carcinoma, is distinguishable by its large cells and rarely co-exists with other cancer cell types. It is extremely rare and most commonly found in middle aged to older men who are heavy smokers. In order to be diagnosed, surgical biopsy is required. Treatment is usually surgical in combination with radiation treatment, although this type of lung cancer is often detected after it has metastasized and is very aggressive. It does not respond well to chemotherapy. Recent studies show that targeted therapy can significantly lengthen survival in those who have certain growth factor mutations (EGFR mutations).
Lung cancer stages
Your medical notes may have listed a number of codes concerning your lung cancer diagnosis. Or perhaps you are waiting for further testing and prefer to be well-informed before receiving your results.
In the case of small cell lung cancer, there are only two clinically-defined stages. These are ‘limited’, where cancer is found in one lung and/or one or more regional lymph nodes on the same side of the chest and ‘extensive’, where cancer has spread throughout one lung, to the opposite lung, to the lymph nodes on the opposite side of the chest, to the pleura and pleura fluid, to the bone marrow or to the distant organs (metastasis). Because of its rapid growth, around 60% of people with SCLC are diagnosed in the extensive stage. Combined small cell lung cancer is usually slower growing and more likely to be detected in the limited stage than SCLC.
Non small cell lung cancers are staged using the universal TNM staging system according to tissue samples (biopsy) and imaging results.
T stands for tumour. T plus a letter or number describes the size (in centimetres) and location of a tumour. Where more than one tumour is present, the letter ‘m’ (multiple) is added. T letter and number systems for lung tumours are:
TX: It is not possible to evaluate the tumour due to a lack of data
T0: No evidence of a primary tumour
Tis: The carcinoma is restricted to a small area
T1: The tumour is local to the lung but not the bronchus and 3 cm or smaller
T1a(mi): A minimally invasive carcinoma
T1a: The tumour is local to the lung and 1 cm or smaller
T1b: The tumour is local to the lung and between 1 cm and 2 cm
T1c: The tumour is local to the lung and between 2 cm and 3 cm
T2: The tumour is local to the lung and larger than 3 cm
T2a: The tumour is local to the lung and between 3 cm and 4 cm
T2b: The tumour is local to the lung and between 4 cm and 5 cm
T3: The tumour has grown into the outer lining of the chest wall, pericardium or phrenic nerve but is not outside of these areas. The tumour is between 5 cm and 7 cm.
T4: The tumour has spread to areas beyond the chest wall (into the mediastinum, diaphragm, heart, large blood vessels, trachea or oesophagus) or a second tumour has been found in another lobe of the same lung or in the opposite lung. The primary tumour is greater than 7 cm.
N stands for nodes or lymph nodes and the following codes apply:
NX: Regional (nearby) lymph nodes cannot be evaluated due to lack of data
N0: No spread to regional lymph nodes
N1: Tumour has spread to regional lymph nodes
N2: Cancerous cells in lymph nodes of the mediastinum or trachea
N3: Cancerous cells in the lymph nodes on the opposite side of the chest to the primary tumour
Finally, M stands for metastasis. The following codes apply:
M0: There is no spread to distant lymph nodes or other organs
M1: Distant metastasis is present in distant lymph nodes and/or to other organs.
M1a: Cancer has spread to the other lung
M1b: Cancer has spread to 1 distant site
M1c: Cancer has spread into one or more other organs
Lung cancer metastasis (M1b to M1c) is most likely to affect the liver, bone marrow and/or brain.
Your medical notes may also contain reference to NSCLC stage I, 2, 3 or 4. These stages are based upon your TNM scores.
Stage 1 NSCLC is a curable lung cancer requiring surgery to remove the affected part of the lung. Chemotherapy is sometimes recommended for those in whom recurrence is possible. Stage two usually requires surgery and almost always chemotherapy. Stage 3 commonly requires at least three therapies – surgery, chemotherapy and radiation treatment. Finally, stage 4 NSCLC will include targeted and immunotherapies, as well as chemotherapy, perhaps with radiation treatment and surgery.
What are lung cancer symptoms?
If you are reading this page, you may have been diagnosed with lung cancer due to the presence of one or more symptoms. Symptoms usually occur once a tumour has grown enough to irritate the airways, possibly producing a persistent cough, shortness of breath, recurrent respiratory infections and blood in the sputum.
Later stages where cancerous cells in the lung spread to other organs produce further symptoms such as unexplained weight loss, loss of appetite, chest pain, fatigue and weakness.
If your lung cancer has been diagnosed before any symptoms appear, the chances are high that you are in the early stages of the disease. Coincidental discovery of lung cancer during X-rays for respiratory disorders, full body MRI scans arranged by those who prefer to keep tabs on their state of health in private clinics, and preoperative tests for other surgeries may indicate small, localised tumours that are curable.
Can I prevent lung cancer?
The simplest way to prevent lung cancer is to stop smoking or avoid areas where indoor smoking occurs. Similarly, care should be taken when exposed to certain chemicals such as asbestos through the use of specialised breathing equipment. If your work involves chemicals and you are not offered sufficient health and safety advice, take the time to look into any risks and follow the guidelines of companies that adhere to strict occupational health standards.
It is even possible to check your home for radon levels. If you live in an area of high pollution, moving to a greener area may lower risk. In addition, using an electrically powered car and keeping the vehicle windows closed when on busy highways can lower those pollutants responsible for some forms of lung cancer.
While certain dietary supplements are advertised as anti-cancer therapies, their actions as antioxidants are minimal. Reducing airborne pollutants is key to lowering the risk of developing any type of lung cancer, while remaining healthy through regular exercise and a varied diet low in processed foods means our bodies are able to respond more effectively when in the presence of toxins.
If you have integrated as many of the above as is realistically possible, the next step is to enable early detection should lung cancer develop. We do not recommend regular X-rays or CT scans as these use radioactivity which is itself harmful. Instead, arrange an MRI scan in a private clinic that uses harmless magnetic waves to produce detailed images. You will need to contact a clinic with specific hardware and software for lung tumour detection. MRI diagnosis is certainly not fail-safe as smaller tumours are difficult to detect; however, it does provide more peace of mind where screening programs are unavailable. Remedazo provides complete diagnostic packages for those who want more control over their personal holistic healthcare needs.
How is lung cancer diagnosed?
If you arrive at your general practitioner’s office complaining of a stubborn cough, weight loss and blood in your sputum, he or she should immediately refer you to an oncologist or pulmonologist. Either of these specialists will ask for multiple samples of your sputum to test for the presence of cancerous cells, arrange imaging tests (most commonly a CT scan) and ask questions about your lifestyle.
Blood tests rarely indicate lung cancer but might show whether other organs have been affected. While it is possible to visualise the lung with X-rays and CT scans, many pulmonologists prefer to use the technique known as bronchoscopy. This procedure usually administers a local anaesthetic sprayed into the throat to increase comfort, and perhaps sedation. The doctor inserts a thin, flexible tube with a light source and camera through the airway. If he or she finds any evidence of unusual growth in easy to access areas an immediate biopsy can be carried out. Tissue biopsies are the only way to confirm the presence of lung cancer but are only taken when there is a clinical suspicion of the disease.
Obtaining tissue from chest lymph nodes can be done using a thin, long needle under the guidance of ultrasound. This also requires the use of a bronchoscope so the specialist will use a local anaesthetic in the throat and perhaps sedation. This diagnostic method is called endobronchial ultrasound-guided transbronchial needle aspiration or EBUS-TBNA for short.
For those types of cancer that are primarily found on the outer regions of the lungs, an option may be transthoracic needle biopsy in combination with a chest CT. A thin needle is inserted through the chest wall and the area of suspicious cells aspirated to produce one or more samples for further testing. This sounds more painful that it is. A small amount of local anaesthetic to the skin is sufficient to make you comfortable.
A thoracentesis drains the fluid between the covering membranes of the lungs and tests the fluid for cancer cells. A thoracentesis is only recommended if you have fluid build-up in either lung. This test is done under a local anaesthetic.
Surgical biopsies are becoming more and more popular with surgeons as they offer an opportunity to search wider areas and not rely on tiny samples. There are three types of surgical procedure used to obtain larger samples. These are thoracoscopy, video-assisted thoracoscopic surgery (VATS) and mediastinoscopy. All require a general anaesthetic and a small incision. You will usually be able to go home the same day, depending on the site. Open lung biopsies (thoracotomy) are becoming less common due to the more recent technologies of video-assisted surgeries as they are much more invasive. While the majority of VATS procedures place a chest tube to drain fluids after surgery, hospital stays are short in comparison with open procedures.
Depending on the type of lung cancer that is diagnosed, further tests may be planned. These include blood tests together with CT, MRI or bone density scans that can indicate whether cancer cells have spread into other areas of the body.
All biopsy samples should also undergo biomarker testing. This new type of test gives more information about the cancer’s predicted behaviour to a range of treatments. It is a form of personalised medicine that prevents lung cancer patients from being treated as a single group. Biomarker tests look for mutations in certain cells that might improve or lower the effect of a certain therapy. It is then possible to use drugs to reduce or reverse abnormal responses. These drugs are known as targeted therapies.
For example, epidermal growth factor receptor (EGFR) analysis where a mutation in the genes that produce receptors on the cell surface allows tumours to continue to grow. In this case, EGFR inhibitor drugs can slow this growth or even shrink the tumour. If your biomarkers do not indicate an EGFR mutation, this therapy is not an option.
Other biomarkers include looking at protein patterns (proteomic testing), anaplastic lymphoma kinase (ALK) testing which is a mutation similar to EGFR that requires ALK inhibitors rather than EGFR inhibitors, and KRAS (named after the mutated gene) that can prevent the effectiveness of EGFR inhibitors in those with EGFR mutations. This is a very new field of medicine that is proving effective in a wide range of cancers, including lung cancer.
How is lung cancer treated?
The most common and recommended treatments for lung cancer are surgery and chemotherapy. Treatment type depends on your level of health, the location of the cancer, its stage, its cell type and the results of biomarkers. Surgery is a first-line treatment in most non small cell lung cancers up to and sometimes including stage 3. As small cell lung cancer is rarely diagnosed in early stages, you are less likely to be offered this option.
Segmentectomy and wedge resection
Small, localised tumours do not always require the removal of large areas of lung tissue. A wedge resection describes the removal of the tumour and a ring of the healthy tissue that surrounds it. A segmentectomy removes a larger quantity of lung tissue but less than that taken away during a lobectomy (see below). If you have an otherwise healthy lung, you may be advised to have a larger area of lung removed as this reduces the risk of recurrence.
Both procedures can be done using the minimally invasive surgical technique of video-assisted thoracoscopy (VATS). Rarely, a larger incision via a thoracotomy is necessary. All lung operations require a drain to be inserted at the end of the procedure to remove air and fluid from the lungs. This will remain in place for at least 24-hours. Hospital stays range between 2 and 5 days and you should expect some pain which is controlled via an epidural catheter or an intravenous catheter connected to a special pump that allows you to administer pain medication on an as and when basis.
Lobectomy
This procedure is carried out where cancer is found in a single lobe of either lung and can be an extremely effective, curative treatment. The right lung has three lobes and the left lung has two. This means that approximately one fifth of your total lung capacity will be removed. For this reason, a lobectomy has less long-term side effects in those with otherwise healthy lungs.
A lobectomy is now most commonly carried out with video assistance - the VATS lobectomy. Only three small incisions of up to 4 cm in length each are necessary. After this surgery you will have a chest tube to drain air and fluid from the site. There is always a chance that the VATS technique must become a thoracotomy, opening the thorax on one side of the body.
This procedure requires at least 3 days in hospital (5 days for a thoracotomy) and supplementary oxygen for the first 12 hours. The chest tube must remain in place for 24 – 48 hours. Because any surgery to the chest is painful due to the constant movement of the muscles we need to breath and the presence of many sensory nerve endings, this procedure also requires an epidural anaesthetic. You can then administer pain medication on an as and when basis according to your needs after surgery. You will also need physiotherapy after the procedure to help with breathing exercises. Recovery time for a VATS lobectomy is 2 – 4 weeks; for a thoracotomy up to 8 weeks.
Most recommendations ask that lung surgery patients only travel by air a number of weeks after surgery; however, after the chest tube is removed and there is no further evidence of air or fluid leakage, this mode of transport can be undertaken with much the same risks as ground transportation. Although cabin air pressure is different to that of the ground, you should be able to return home within 4 days after a VATS procedure or 7 days after a thoracotomy. Even so, travel can be uncomfortable and we recommend you avoid long journeys for at least 10 days after a lobectomy. Pain medication will need to be taken as usual and compression stockings worn. Long-haul flights should be split into shorter journeys wherever possible.
Pneumectomy
The removal of one lung is required for large tumours that are close to the middle of the chest. This procedure is done via a larger incision known as a thoracotomy of approximately 25 cm in length. In some circumstances, a VATS pneumectomy is possible. You can discuss your options during your Remedazo free Second Opinion. Thoracotomy incisions are notoriously painful and to make you comfortable after the operation you will be given an epidural or intravenous catheter which specifically serves to administer pain medication during your recovery period.
In a few cases, you may be informed of a procedure known as a sleeve resection. When tumours grow in the large airways it is possible to remove just one section of the airway and reattach the healthy ends to each other. This will allow higher postoperative lung function than a pneumectomy but the tumour must be limited to the larger bronchi.
As with all lung surgeries, a chest drain will be placed at the end of your operation to drain off air and fluids. This remains in place for 24 to 48 hours, perhaps longer. Physiotherapy is an important aspect of pneumectomy aftercare. You will be taught special breathing exercises and be shown how to use the least effort when repositioning and walking. Supplementary oxygen is administered for at least 24-hours after a pneumectomy.
Chemotherapy is usually necessary after a pneumectomy. Remedazo can cater for longer stays with or without family members and friends, catering for all hospital visits, transportation, catering, accommodation and home nursing care until you are ready to return home.
Nonsurgical treatments for lung cancer
Nonsurgical treatments are offered to those unable to undergo surgery due to low overall levels of health, to those at risk of recurrence after surgery or to those who need to keep metastatic lung cancer (secondary tumours) under control. These treatments include radiofrequency ablation of the tumour that destroys cancer cells using electrical current, and microwave ablation which uses needles that emit microwaves to produce localised heat. Target cells are accessed by way of needles under the guidance of medical imaging. Another option is cryotherapy where, instead of electricity, low temperatures are applied directly to a tumour to freeze and kill the cancerous cells. These procedures are carried out under a general anaesthetic.
Radiation therapy is used to kill off remaining cancer cells after surgery, as a first-line treatment in inoperable tumours and as a method of brain metastasis prevention known as prophylactic cranial irradiation.
Fractionated external beam radiation therapy (EBTR) may be given after lung surgery to prevent the growth of potentially remaining cancer cells. This therapy is given over the course of 3 to 7 weeks in low doses. More recently, stereotactic body radiation therapy (SBRT) has provided patients with a higher dose, shorter course of radiation therapy.
Post-surgical radiation therapy is used if it is unsure whether all cancer cells have been removed. For advanced cases of lung cancer, repeated radiation therapy can slow down tumour growth.
Radiotherapy therapy for lung cancer is composed of two main types – external beam radiation therapy (EBRT) and stereotactic body radiation. If cancer cells have spread to the bone tissue (bone metastasis), patients may be offered radiopharmaceuticals. These are injected drugs that contain radioactive substances and settle in areas of damaged bone. Here, they emit radiation that kills cancer cells. These drugs also relieve bone pain caused by metastasis and can extend life in stage IV lung cancer.
External beam radiation therapy focuses beams of radiation into the lung and requires short (10 to 30 minute) visits to the hospital 5 times a week for several weeks. Long-term stays with all transportation, support, accommodation and meals can be seamlessly arranged by the Remedazo team. EBRT is a painless treatment and recent technology now enables oncologists to be even more precise with dosage and range. Additional options such as three-dimensional conformal radiation therapy or 3D-CRT use computers to map the affected lung(s) and shape the radiation beams to avoid damaging non-cancerous tissues. The even more advanced intensity modulated radiation therapy (IMRT) machine moves around the patient, shapes the beams and adjusts radiation intensities. This may be done with built-in scanners (image guided radiation therapy or IGRT) or using a more rapid but not necessarily more effective technique called volumetric modulated arc therapy or VMAT. You will be able to discuss all of these alternatives with a Remedazo oncology specialist.
The side effects of radiation therapy often depend on its effects upon healthy tissues that are found close to the lungs such as major blood vessels and heart. In addition, radiation treatments can make you feel tired for weeks to months. At Remedazo, all associated information will be given upon or shortly after your consultation; you can then make an informed decision regarding the types of radiotherapy available to you.
Pharmaceutical treatments for lung cancer are used to increase the curative goals of surgery by killing off any remaining cells that may have been missed and to slow tumour growth. Chemotherapy is by far the most common non-surgical treatment used for all types of lung cancer cells before, after and in the absence of surgery; however, different cancer cell types do not all respond in the same way and combinations of drugs are necessary. More recently, targeted therapies are being used to attack specific cell types. These can have various effects as mentioned in the section of this article that talks about biomarkers. These can stop the formation of blood vessels that feed the tumour or slow down tumour growth by inhibiting growth-inducing proteins. Immunotherapy (or biologic therapy) increases the body’s natural immunity and help it to fight abnormal cells. Immunotherapy is often used in stage III and IV lung cancer. You will in all probability be offered a selection of therapies for your lung cancer which have been personalised to treat your specific cancer type and stage. Some women may be offered hormone therapy in the form of oestrogen and progesterone, although research into this treatment form is still in its infancy.
Why do I need lung cancer treatment?
Treatment is always necessary for any type of lung cancer to try to prevent cancerous cells from travelling to other organs via the many surrounding blood vessels and lymph nodes found in this part of the anatomy. Furthermore, when treated at an early stage, lung cancer can be cured. Even in more advanced stages, new therapies and procedures are continuously increasing longer-term survival.
How do I prepare for lung cancer treatment? What can I expect?
Pre-travel lung cancer preparation
Approximately 3 to 8 weeks before a lung cancer procedure you will be asked to supply the results of your blood, lung function and biomarker tests and copies of any diagnostic and imaging results (bronchoscopy, CT, MRI and/or PET). This means we can see how your lung cancer is progressing and help us to advise the best treatment options. We will also need any information regarding medication use, other illnesses or disorders and your overall state of health. It is important to get your lung function tested well before surgery and begin with breathing exercise to ensure your lungs are in the best possible condition before surgery. This will make your recovery shorter.
You will need to undergo an MRI or CT scan and possibly a bone scan – if these have not yet taken place - which will help us to see if cancer has spread to other organs. If lung cancer has spread or metastasised you will need to discuss various therapies.
Approximately 2 weeks before your lung cancer treatment you will need to ask your home doctor to take blood. Remedazo will inform you well beforehand which tests your doctor will need to take blood for. For surgical procedures, some blood-thinning medications will need to be temporarily stopped, others do not. Our or your own doctor will advise you what to do.
Lung cancer treatment in the hospital
Please scroll down to the appropriate section. The given information covers all available treatments for lung cancer at Remedazo. If you would like information on any treatment not covered by this section, please do not hesitate to contact us.
VATS procedures
VATS procedures require shorter hospital stays than thoracotomy techniques as the main muscles of the thorax remain intact. Only 3 to 5 small incisions are made on one side of the body. As the surgeon needs access to one lung, you will be placed on your side once you have been anaesthetised with the to be operated lung facing upwards.
The wedge, segment, lobe or entire lung must be taken out of the body via one of the small incisions. For larger sections, it is possible that one incision must be made larger. All VATS procedures have the potential to become a thoracotomy should access to the area of the tumour be limited. This is a rare occurrence but important to be aware of.
VATS wedge resection, segmentectomy, lobectomy and (where possible) pneumectomy all require a chest drain. The larger the area of tissue removed, the longer the drain remains in place. This time varies between 24 hours to 72 hours or more where air leaks persist.
As minimally invasive surgery, you will rarely need to spend a night in intensive care after a VATS unless other medical disorders make this a safer option. On average, a VATS hospital stay is 2 days. There is little postoperative pain and no need for an epidural anaesthetic.
Thoracotomy
The larger incision of the procedure known as a thoracotomy cuts through larger muscles and requires a longer recovery time and a higher level of pain control. As with all types of lung surgery a thoracotomy requires a full anaesthetic and a chest drain. Open surgeries require an incision of approximately 25 cm. In order to speed up your recovery, breathing and coughing exercises should be started well before surgery and you will be assisted by a trained physiotherapist on the surgical ward. Because of the higher pain level, your anaesthetist will place an epidural catheter before you are anaesthetised. If, due to back problems, this is not possible, a second intravenous catheter will be placed once you are anaesthetised specifically for postoperative patient-controlled pain medication via a special pump system.
Recovery from a thoracotomy requires time. You may need to spend 24 hours in a medium care facility after surgery and be prepared to stay for approximately 5 days. Radiation or chemotherapy is usually prescribed after surgery. Remedazo arranges longer stays to accommodate further treatment, accommodation, home nursing care, catering, transportation and follow ups.
You may usually fly home within 7 to 10 days after surgery, although you will need to wear compression stockings and perhaps split long-haul flights into shorter journeys.
General information about lung cancer surgery
All lung cancer surgeries require insertion of a chest drain through one incision to remove fluids and air from the operation site. This drain will remain in place for 24 to 72 hours after surgery. A urinary catheter may be placed after you are asleep in the case of thoracotomy but is removed within 24 hours.
For all types of lung cancer surgery, you will be admitted to your chosen clinic on the day of the procedure. Certain people such as those with a very high BMI, breathing difficulties, diabetes or other chronic illnesses usually benefit from spending the night before the operation in a hospital setting.
From midnight of the day before your surgery, you will be asked to refrain from eating. Undigested stomach contents can create serious complications during general anaesthesia. Smokers should stop smoking at least 24-hours before an operation as this improves oxygen levels throughout the body. Between midnight and six hours before anaesthesia you may only drink water or clear liquids. You are not permitted to eat, drink or smoke in the six hours preceding anaesthesia. Failure to comply may mean the anaesthesiologist and surgeon will be forced to postpone your procedure. This is purely for your own safety. It is possible to brush your teeth during this period but no water may be swallowed. In certain circumstances, medical staff will administer oral medications with a little water. This is administered under the advice of the anaesthesiologist and is therefore permitted.
Approximately thirty to ninety minutes before the planned procedure time you will be collected from your room and brought to the surgical department either in your bed, on a gurney, in a wheelchair or on foot.
Preoperative lung cancer surgery preparation requires:
An intravenous line
A blood pressure cuff placed on the upper arm
The completely painless placement of electrodes to the chest to measure heart activity
A finger or ear sensor to measure oxygen levels in the blood
An epidural catheter for thoracotomy
A general anaesthetic
An arterial catheter for some patients
A urinary catheter for thoracotomy (usually placed after you are asleep)
A double lumen endotracheal tube that allows the anaesthesiologist to perform single lung ventilation as the surgeon operates on the other lung
At the surgeon’s signal, you will be anaesthetised.
H5 What happens after lung cancer surgery? What can I expect?
You will be woken by the anaesthesiologist immediately after surgery and transported from the operating theatre to the recovery room. Here you will be carefully monitored. All patients remain in the recovery ward until they are fully responsive and any pain is well under control.
When the anaesthesiologist is satisfied you are fully awake and comfortable you will be brought to a surgical ward; some thoracotomy patients will be taken to the intensive care or medium care unit where they will remain for 24-hours before being transferred to a regular ward. Pain medication is given as standard for the first 24-hours and then upon request and according to your personal doctor’s prescription. Thoracotomy patients are able to administer medications themselves via an epidural or intravenous pain pump. Arterial lines are usually removed within 12-hours after surgery; those in medium care units retain the arterial line until transfer to a general surgical ward. The intravenous catheter will continue to administer fluids for at least 24 hours and your chest drain will be removed by a trained doctor within 1 - 4 days, depending on how well the wounds close. Urinary catheters are removed within 24-hours post-surgery.
The majority of VATS patients are out of bed within 8 hours of exiting the recovery room. For thoracotomy procedures this period of bedrest extends for 12 to 24 hours. Upon discharge from the hospital you will be transported to your accommodation and supported by your personal Remedazo team until you have safely and comfortably returned home or completed further treatment.
Long-term postoperative care includes the removal of stitches after 10 to 14 days. This can be done by your general practitioner at home if you are not attending further treatment sessions. You will need to take it easy for at least 2 weeks after a VATS procedure and up to 8 weeks after a thoracotomy.
H5 Benefits of lung cancer surgery
Lung cancer surgery aims to remove the tumour in its entirety and so has the potential to be a curative procedure. Surgery is nearly always recommended for the first 2 stages and rarely in cases of stage 4 metastatic lung cancer; the further cancer spreads the higher the chance you will need multiple non-surgical therapies. These are usually chemotherapy and radiotherapy. Neither VATS nor thoracotomy surgeries require significantly long stays in the hospital but need a few days of recovery time.
H5 Disadvantages of lung cancer surgery
Postoperative infection is always a risk with this type of surgery and patients are administered antibiotics as a preventive measure before surgery commences. The lungs are at risk of infection at any time, in particular during illness and after thoracic surgery. Your chosen clinic’s doctors and nurses are trained to recognise the symptoms of infection very early on. Other short-term risks include bleeding, adverse reactions to the anaesthesia, blood clots, an urge to urinate in the presence of a urinary catheter, and breathing problems.
Long-term complications include shortness of breath and the need for oxygen supplementation depending on the amount of lung that is removed. Scar tissue formation may increase your risk of lung obstruction and respiratory infection. We recommend you visit your local pulmonologist early on so he or she can keep an eye on your progress.
Lung radiation therapy
Radiotherapy may be given before surgery in order to shrink a larger tumour (neo-adjuvant radiotherapy), after surgery to reduce the risk of the cancer recurring (adjuvant therapy) or as a palliative measure for advanced primary and secondary lung tumours to help control uncomfortable symptoms.
Radiotherapy as a stand-alone cancer therapy is rare. Fractionated external beam radiation therapy (EBTR) may be given prevent the growth of potentially remaining cancer cells. This therapy is given over the course of 3 to 7 weeks in low doses. More recently, stereotactic body radiation therapy (SBRT) has provided patients with a higher dose, shorter course of radiation therapy. Radiotherapy options are described in more details in the Nonsurgical Therapy section of this article.
Lung chemotherapy
Lung cancer is often treated with surgery and commonly in combination with chemotherapy. Chemotherapy for lung cancer may be given to treat cancer that has or may spread to other areas of the body, to cancer types with the potential to return, and also to kill any cancer cells left behind after surgery. It is also administered to those with small cell lung cancer as a first-line therapy and in cases where surgery is not an option due to tumour position or patient health. Chemotherapy drugs are often given in combinations of two or more types and in accordance with your level of health. Chemotherapy drugs may also be adjusted if your cancer has what is known as a driver mutation, determined via biomarker testing. This shows how important it is to approach a specialised oncologist who is experienced in the latest methods of lung cancer care.
Chemotherapy drugs are administered intravenously via a portacath, PICC line or central venous catheter. Each treatment lasts for 4 to 6 cycles. A cycle consists of chemotherapy and a rest period of 3 to 4 weeks. This means that a complete cycle may last anywhere between 12 to 24 weeks. After a first cycle, further tests will show whether the cancer is gone, reduced, controlled, unaffected or re-emerging. Only then is it possible to know if another cycle is required.
Ask Remedazo for more information regarding longer-term stays where all of your physical, psychological and emotional needs are catered for during this stressful time. Alternatively, we can arrange similar accommodation and familiar, trusted team members for regular returns to your clinic of choice and cater for your accompanying family members or friends. Naturally, your care will be overseen by a consulting oncologist with in-depth knowledge of the latest drug combinations and treatments for all types of lung cancer. We also help you to access skilled thoracic surgeons equipped with top staff, the best equipment and high quality materials whenyou require surgery.
Lung cancer immunotherapy
Checkpoint inhibitors allow your immune system to respond to the presence of specific cancer cells and attack them. Often, this response is absent during tumour growth. It has been shown that some lung cancers respond well to immunotherapy treatment but this certainly does not apply to all. Ask about immunotherapy options during your free Second Opinion.
Drugs such as pembrolizumab and the combination therapy of nivolumab and atezolizumab block the activity of a protein that prevents your immune cells from recognizing and attacking inflamed tissues and cancer cells. These intravenous treatments require at least a 2-hour stay in a clinical setting every two to three weeks and have been shown to increase survival times in metastasised small and non small cell lung cancers within 2 months of treatment; however, immunotherapy is rarely offered before other types of therapy have been administered. The usual first-line treatment for metastatic lung cancer without surgery is chemotherapy plus targeted therapy.
The side effects of immunotherapy are many and can be serious. Those offered this type of treatment are given in-depth information regarding side effects and the detection of their early signs. Remedazo can put you in touch with one of our specialist oncologists to discuss your eligibility for immunotherapy based upon your personal medical history.
Lung cancer targeted therapy
Targeted therapies are receiving more and more interest in scientific communities and are often described as a breakthrough in the race to cure cancer. Finally, we are working towards highly personalised medical treatments based upon our genetic information and that of abnormal cells inside us. It is an exciting time for scientists who are discovering further areas in which drugs can control, slow, temporarily halt and even permanently stop cancer growth.
Vascular endothelial growth factor inhibitors (VEGF inhibitors) in combination with checkpoint inhibitors (immunotherapy) have been proven to be effective in the treatment of metastatic lung cancer; however, not every type of lung cancer responds in the same way to either inhibitory drugs or immunotherapy due to our differing genetic makeup. VEGF inhibitors are drugs that prevent the growth of a tumour’s blood supply network and are often combined with early treatment modalities such as chemotherapy and even surgery. When used together with immunotherapy treatment, VEGF inhibitors may extend survival and reduce discomfort in cases of inoperable metastasised lung cancer.
Kinase inhibitors stop specific proteins that increase cell signalling, growth and multiplication, and do not affect the blood supply as is the case with VEGF inhibitors. Cancer cells are cells that signal, grow and multiply at abnormally high rates. These proteins (kinases) are produced by specific genes and inhibitory drugs can stop kinases from functioning. This means that rapid tumour growth in cancer patients with mutations can be controlled through specific inhibitors. If you are being treated with ALK, EGFR, ROS1, BRAF V600E or NTRK1 inhibitor drugs, you are taking one of the current ranges of approved kinase inhibitors.
Lung cancer alternatives
It is possible that you have been given a choice of one or more alternative treatments or have not yet made an appointment for your free e-consult and are simply browsing the possibilities.
The accepted and current lung cancer treatment alternatives have been described in the necessary detail above. Complementary and alternative lung cancer remedies are unproven and should not take the place of accepted treatment courses. Stem cell transplants for lung cancer are, as yet, insufficiently researched to judge their efficiency and today’s scientists are concentrating more on the targeted and immunotherapies highlighted above.
Of course, there is no alternative for professional medical advice. Please call us to arrange your free e-consult and the opportunity to speak personally with specialist pulmonologists, thoracic surgeons and oncologists to determine the best treatment type for you. You can discuss all lung cancer treatment alternatives with them, ask for second or third opinions, and take the first step towards your personalised Remedazo holistic care package.
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