Overview
There are two main types of lung cancer. However, all forms of lung cancer are caused by smoking or exposure to other people’s cigarette smoke.
The risk of developing lung cancer decreases gradually after an individual stops smoking, but the risk of developing other smoking related diseases falls much more quickly.
Lung cancer is the third most common cancer across Europe and the leading cause of cancer deaths in Europe.
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Key Figures
| Total number of new cancer cases in Europe (2006) |
3.2 million |
| Total numvber of cancer deaths in Europe (2006) |
1.7 million |
| Number of new lung cancer cases in Europe (2006) |
386,300 |
|
(292,200 men) |
|
(94,100 women) |
|
271,600(EEA) |
|
265,600(EU25) |
| Number of lung cancer deaths in Europe (2006) |
334,800 |
| |
(253,300men) |
|
(81,500 women) |
|
241,000 (EEA) |
|
236,000 (EU25) |
Lung cancer is the third most common cancer across Europe (only breast and rectal cancers are more common). However, it is the leading cause of cancer deaths in Europe.
Lung cancer is approximately three times more common in men than women. However, the number of women developing lung cancer is increasing as more women take up smoking.
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Cancer Types
Non-small cell and small cell lung cancer are the two main types of lung cancer.
Non-small cell lung cancer, which makes up around 80% of lung cancers, can be divided into different types (although it can sometimes be difficult to tell these types apart even when samples are examined under a microscope). The three types of non-small cell cancer are:
Small cell lung cancers (SCLC) - about 15% of all lung cancers, are made up as the name suggests of small round cells.
Mesothelioma is another type of cancer that affects the covering of the lungs (the pleura). It is relatively rare and usually occurs in people who have been exposed to asbestos.
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Causes of Lung Cancer
Smoking – including passive as well as active smoking and smoking cannabis as well as tobacco.
If an individual stops smoking, the risk of developing lung cancer falls. After about fifteen years, the risk of that individual developing lung cancer falls back to that of a non-smoker. (The risk of developing other diseases associated with smoking falls off much more quickly).
Some people seem more likely to develop lung cancer due to genetic factors but no responsible genes have yet been identified.
Mesothelioma is a rare cancer of the membrane (the pleura) that covers the lungs and is specifically linked with exposure to asbestos fibres.
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Prevention of Lung Cancer
- Stopping smoking
- Avoiding exposure to other people’s cigarette smoke (passive smoking)
- Avoiding exposure to asbestos (mesothelioma)
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Common Symptoms
- coughing up blood
- a persistent cough
- shortness of breath
- wheezing
- a hoarse voice
- chest and shoulder pain
- tiredness
- weight loss
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Diagnostic Tests
- Chest X-rays never provide a definitive diagnosis but they may show that there is an abnormality in the lung which requires further investigation.
- Sputum examination – Cancer cells can often be identified in a sputum sample.
- Computerised Tomography (CT scan) is a type of X-ray that shows the shape of the body organs in cross section, allowing localisation of any abnormalities present.
- Positron Emission Tomography (PET scan) uses small amounts of radioactive material to detect cancer and other diseases in the body.
- Bronchoscopy – a thin flexible telescope is used to look directly into the lungs and take both photographs and biopsies.
- Lung biopsy – a sample of lung tissue is obtained for examination under a microscope by passing a needle through the skin into the part of the lung where something abnormal has been found on an X-ray.
- Mediastinoscopy – a test to look directly at the centre of the chest and take biopsies.
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Treatment
Surgery
Non-small cell lung cancers that have not spread to nearby lymph nodes in the centre of the chest or to other parts of the body can be treated using surgery.
As small cell lung cancers (SCLC) are rarely found in just one place surgery is not usually a good option.
Surgery to remove all or part of a lung involves opening the thorax via a long incision between the ribs on the side of the chest wall (a thoracotomy) whilst avoiding important structures such as the heart and the spinal cord. The ribs are then spread apart to allow access to the chest cavity. A small piece of rib may also be removed and one of the nerves running underneath that rib may be cut to make it easier for the surgeon to take out the lung cancer.
Before surgery, lung function tests (possibly including a lung scan) are usually done to ensure that the patient is a good candidate for surgery. The tests will determine whether or not after removal of all or part of a lung, lung function will be adequate. They can also be used to identify risk factors that may indicate potential cardiac complications.
Once the chest has been opened, lung tissue can be removed.
A wedge resection or segmentectomy is the removal of a small wedge-shaped piece of lung that contains the lung cancer and a small area of healthy tissue. The advantage of removing just a small amount of lung is that it has the least effect on remaining lung function. However, there is a disadvantage, which is that there is a higher risk of the cancer recurring.
A lobectomy is the removal of an entire lobe of the lung that contains the cancer. Provided that the patient has good lung function the removal of one lobe will not cause breathlessness after surgery.
A pneumonectomy is the removal of the entire lung containing the cancer. It greatly reduces the patient’s lung function.
During surgery, the lung collapses down because air has been let into the pleural space. Because of this, the lung must be reinflated after surgery and to do this a chest drain is left in place. This drains fluid and blood out of the chest cavity and the lung then refills with air.
This sort of surgery requires patients to stay in the hospital after the procedure for at least a few days. The chest will be painful while the wound heals – moving, coughing, deep breathing and sneezing may be particularly painful to begin with. This pain may persist for several weeks and sometimes months after surgery.
Chest drains are used after surgery to drain blood and air into a container that measures the amount of fluid drained. The drain exits the chest wall and skin through small cuts. The chest drain is removed when the drainage from the chest has stopped and no air is leaking from the wound (usually after a few days).
Physiotherapy helps improve a patient’s lung function after surgery as well as moving phlegm off the chest, thus preventing infection.
Potential side-effects of surgery include:
- bleeding in the chest
- chest and wound infections
- an air leak in the lung that does not seal
- continuing pain in the chest wall (particularly if a nerve was cut during surgery)
Radiotherapy
External beam radiotherapy uses high energy X-ray beams, generated from machines, to kill cancer cells and is given as a series of short regular treatments over a period of several weeks. Treatments for reducing symptoms (palliative treatments), are commonly completed in a few visits and in less than 2 weeks.
There are a number of ways of delivering radiotherapy. Most use radiation sources outside the body generated by a liner accelerator (Linac).
From the patient’s perspective treatment involves lying on a couch underneath a linear accelerator, which looks a bit like a large X-ray machine. The linear accelerator is a source of powerful X-rays. Electrons produced in the machine are accelerated in a straight line, hitting a metal target within the machine. This produces high energy X-rays, which are then focussed into a beam that can be used for treatment.
The X-ray beam itself comes out of a gantry which rotates around the patient. Scanning machines are used to ensure that the radiation is correctly targeted before each treatment and lasers are used to check that the patient is in the proper position. The linear accelerator can deliver radiotherapy from any angle by rotating the gantry and moving the treatment bed.
The shape of the radiation beam used to treat the cancer is shaped to the cancer itself, using an attachment called a multi-leaf collimator. A number of metal sheets are used to block the beams from reaching areas where there is no cancer, but allowing the radiation beams to target the area of the cancer. This means that high doses of radiation are given where they are needed whilst at the same time protecting healthy surrounding tissues and thus reducing side effects.
Radiographers position the patient’s couch so that the target area is under the head of the Linac. The patient then has to lie as still as possible while the machine is switched on.
Treatments are usually short, lasting about ten minutes.
The treatment plan will depend on the reasons for giving radiotherapy which may be either to control symptoms or to cure the cancer.
Radiotherapy to control symptoms may involve just one treatment, several treatments or daily treatments for up to 3 weeks.
Radiotherapy to cure lung cancer (radical radiotherapy) may require as many as 36 treatments. Some plans involve three radiotherapy treatments every day for about 12 days, including weekends. This is known as CHART (Continuous Hyperfractionated Accelerated RadioTherapy). Alternatively, treatment can be given every weekday over 4-7 weeks.
Side Effects of Radiotherapy
Most patients treated with radiotherapy find that they tire easily after their first few radiation treatments. Fatigue tends to increase as treatment progresses and may become severe, seriously affecting normal daily activities. Fatigue gradually improves after radiotherapy is completed. Rest coupled with as much activity as the patient can reasonably manage is the best way of dealing with this fatigue.
Skin irritation is usual after a few weeks of radiotherapy with patients experiencing red, dry, tender and itchy skin. This can become quite severe during a long course of treatment. It is helped by keeping the skin clean and moisturised but not by using perfumes, cosmetics or deodorants. Using a sunscreen is important if the affected area is exposed to sunlight. Hair loss can occur on the chest wall which may be temporary or permanent. Loss of appetite is common and patients may require dietetic advice.
Oesophagitis is common after radiotherapy for lung cancer and can be severe. Oesophagitis makes it difficult to swallow and some patients lose weight as a result. However, it usually settles within three weeks of completing treatment and can be helped by antacids and soothing liquids. Most patients regain lost weight.
Radiation pneumonitis can develop three to nine months after radiotherapy, causing coughing, shortness of breath and fever. It usually gets better without specific treatment and leaves no lasting effects.
Stereotactic RadioTherapy (SRT)
A new form of high-precision radiotherapy available in specialized centres. SRT provides radiotherapy focused on the whole tumour with very little effect on surrounding normal tissues. This allows very high doses of radiation to be given in 3-8 treatment sessions or fractions over a two week period, which is of great advantage to the patient.
Concurrent chemotherapy and radiotherapy
When given at the same time, the combined effect of radiotherapy and chemotherapy together is more effective in treating lung cancer than when given separately. It is particularly useful for patients for whom surgery is inappropriate or carries high risks.
Endobronchial laser treatments
Specific symptoms such as breathlessness caused by obstruction of the trachea (windpipe) or one of the main airways can be relieved using laser beams.
Lasers are powerful light beams that can be used to destroy lung cancers that are blocking the larger airways, causing symptoms like wheezing and breathlessness.
Brachytherapy
Brachytherapy delivers radiotherapy directly to the cancer site by putting a radiation source in or beside the tumour. Damage to healthy lung tissue is minimised. Brachytherapy is effective in stopping bleeding from tumours and opening up blocked areas of the lung. However, in many centres, laser treatments are now used instead.
Chemotherapy
Small cell lung cancer usually responds well to cisplatin and etoposide, but other combinations are also used across Europe.
Chemotherapy is not routinely used for non-metastatic forms of non small cell lung cancer, as these tumours are not very sensitive to chemotherapy, so surgery and/or radiotherapy are the main treatments.
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Prognosis
The prognosis for patients with lung cancer varies according to the type of cancer, how advanced the cancer is and how well it responds to treatment, so general statements about the prognosis of lung cancer are necessarily vague.
Overall, 20% of patients with lung cancer will live for at least 1 year after diagnosis; 6% will live for at least 5 years; and about 5% will live for at least 10 years.
These figures are an average of all types of lung cancer presenting at all stages of the disease. As with most cancers, the earlier the diagnosis is made the better the prognosis. The prognosis for patients who can be treated with surgery tends to be better with 20% living 5 years or more.
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Key Trends
In many countries the numbers of young people who smoke continues to rise.
The use of surgery as a treatment for lung cancer is declining, and the use of non-surgical techniques is increasing.
PET scans are providing more accurate identification of patients with limited disease who are more suitable for aggressive treatments.
SRT seems to provide very good local tumour control in very early-stage non-small cell lung cancer, but no long term data are available yet.
From the patient's perspective, SRT is very convenient as it is an outpatient treatment and patients can generally resume their normal activities directly following treatment.
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Potential Developments
Genomics may help in determining which patients are best suited to particular treatments, so avoiding giving the toxic side effects of treatment to patients where overall the treatment is unlikely to succeed.
New so-called ‘molecular targeted agents’ have been shown to improve survival in advanced stages of lung cancer. These include monoclonal antibodies and small molecules which target cell growth pathways, and are currently being investigated for their ability to enhance the effectiveness of radiotherapy as well.
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