Patient information: Lung cancer risks, symptoms, and diagnosis (Beyond the Basics)
- Karl W Thomas, MD
Karl W Thomas, MD
- Professor of Medicine, Division of Pulmonary and Critical Care Medicine
- University of Iowa Carver College of Medicine
Lung cancer is a serious health problem that affects many people and their families. Lung cancer is the leading cause of cancer death in the United States. Cigarette smoke causes most lung cancers, but there are many other factors related to occupation, home, and family that increase the risk for lung cancer.
When a person develops lung cancer, tests are done to determine the type of lung cancer and if it has spread. When a cancer spreads, this is called metastasis. The size of the tumor and whether or not it is found in lymph nodes or other places in the body is measured on a scale called the cancer stage. The stage is an important feature used to help choose the best treatments.
This article will first review the risks for developing lung cancer. The different types of lung cancer will also be reviewed. Next, this article will describe the signs and symptoms of lung cancer and the medical testing for patients who have lung cancer. Finally, this article will review the process of measuring the cancer’s size and locations to determine the stage.
The treatment of lung cancer is discussed separately.
More detailed information about lung cancer is available by subscription. (See 'Professional level information' below.)
RISKS FOR LUNG CANCER
The total risk of lung cancer in any one person is related to whether or not they have used tobacco, if they have had other toxic exposures at home or work, as well as their inherited predisposition to developing cancer. While many patients have only one risk factor, there are significant numbers of patients with more than one risk. Unfortunately, there are some patients for whom the cause of cancer is unknown.
Smoking — Cigarette smoking is the most common risk factor for lung cancer. As an example, smoking is estimated to cause 80 to 85 percent of all lung cancers in the United States. A smoker's risk of developing lung cancer is 10 to 30 times greater than that of a nonsmoker. All forms of tobacco and smoking, including pipes, cigars, and chewing tobacco, may cause cancers of the mouth, throat, and lungs. The risk of lung cancer increases with the number of cigarettes smoked per day and the number of years of smoking. The quantity of cigarette smoking is usually summarized by the number of packs of cigarettes smoked per day multiplied by the number of years smoked. For example, a person who smoked one pack per day for 20 years would be said to have 20 pack-years of smoking exposure.
Quitting smoking can reduce the risk for lung cancer regardless of how many years a person has smoked. The risk of cancer remains high for several years after quitting smoking, but the risk does go down within 5 to 10 years after quitting. A former smoker's risk of lung cancer is never as low as a nonsmoker's risk.
Secondhand smoke — Secondhand smoke, sometimes called passive smoking or sidestream smoke, can be hazardous to adults and children. Secondhand smoke contains the same toxic substances as directly inhaled smoke. Secondhand smoke is an important cause of both lung cancer and heart disease deaths. Secondhand smoke is also a risk factor for respiratory problems such as bronchitis, sinus problems, and ear infections in both adults and children.
Radiation in the home — Radon in homes and workplaces is recognized as an important risk factor for lung cancer. Radon is a radioactive gas that occurs naturally in the ground. Radon leaks out of the ground and into houses or buildings where it is then inhaled. You cannot see or smell radon. This is why a special test of the air in the building is used to measure if radon is present. For more information about radon and testing recommendations, there are resources on the internet such as the United States Environmental Protection Agency (http://www.epa.gov/radon/), as well as many other state-based guides. Buildings that have elevated radon levels should have radon mitigation to vent the radon outside or to seal the building against radon entry.
Occupational and environmental factors — Substances at work or in the environment can increase a person's risk of developing lung cancer. In parts of the world where fuels such as wood or coal are widely used for indoor cooking and heating, these may be important contributors to the risk of lung cancer. Other important factors include asbestos, arsenic, radiation, and some chemicals. Dusts and fumes from nickel, chromium, and other metals used to create alloys in metal-working industries may also increase the risk of lung cancer.
Age and lung cancer — The risk of developing lung cancer increases with age. Lung cancer can occur in young people, although it is unusual in people younger than 40 years old. After age 40, the risk for developing lung cancer slowly increases every year.
Family and genetic risk — Some people have a genetic predisposition to lung cancer. Anyone with a first-degree relative (parent, brother, sister) with lung cancer has a slightly higher risk of developing lung cancer themselves.
SCREENING FOR LUNG CANCER
The most important steps to reduce the risks from lung cancer are to avoid smoking, assess and mitigate radon in the home, and use appropriate protection in workplaces that have hazardous or dangerous substances. For those individuals who have a high risk of lung cancer because of how much they have smoked, screening with low-dose computed tomography may be recommended. (See "Patient information: Lung cancer prevention and screening (Beyond the Basics)".)
LUNG CANCER SYMPTOMS
Most people with lung cancer have one or more symptoms. However, the symptoms of lung cancer may be the same as symptoms of other more common problems. If you are concerned about your symptoms, talk to your doctor or nurse.
The most common symptoms of lung cancer include:
●Cough – Lung cancer can cause a new cough or a change in a chronic cough. (See "Patient information: Chronic cough in adults (Beyond the Basics)".)
●Blood in sputum – This is called hemoptysis, and this requires medical evaluation if it occurs.
●Shortness of breath
●Wheezing, a whistling sound when you breathe
●Chest pain can develop and may be dull, sharp, or stabbing
●Headache and swelling of the face, arms, or neck
●Arm, shoulder, and neck pain can be caused by a tumor in the top of the lungs (called a Pancoast tumor). Other symptoms can include weakening of the hand muscles (due to pressure on the nerve that stimulates the arm), a droopy eyelid, and blurred vision.
INITIAL TESTING AND DIAGNOSIS
If you have symptoms that suggest lung cancer, your doctor will perform an examination. If your findings are still concerning, more tests, including blood work and x-rays or scans will then be ordered.
If the chest x-ray or computed tomography (CT) scan shows an abnormal growth that could be a tumor, additional testing is performed to make a diagnosis. Usually, a small piece will need to be removed from the chest and examined with a microscope. This procedure is called a biopsy. Importantly, the decision to perform a biopsy does not mean that cancer is present. Biopsies are routinely performed to check for both cancer as well as many other diseases.
A biopsy can be done in one of several ways:
●Bronchoscopy is a procedure where a flexible tube with a camera and other small instruments is inserted through your mouth or nose and then into the windpipe (called the trachea). This procedure is described in detail separately. (See "Patient information: Flexible bronchoscopy (Beyond the Basics)".)
●Endobronchial ultrasound bronchoscopy or EBUS is a technique that combines flexible bronchoscopy with ultrasound to first see lymph nodes in the chest and then to take biopsies from enlarged lymph nodes.
●CT-guided fine needle biopsy is performed by locating the tumor with a CT scan and inserting a thin needle through the skin to remove a tiny sample of tissue.
●Needle aspiration is performed by inserting a needle into lumps or lymph nodes that can be felt under the skin or seen with an ultrasound.
●Thoracentesis is insertion of a needle and small catheter into fluid collections in the chest to remove the fluid and look at it with a microscope.
●Surgery may be needed to remove the tumor entirely if it is small or if other biopsy procedures have not made a definitive diagnosis. The most common surgical procedures are mediastinoscopy, which is used to biopsy lymph nodes in the center of the chest; video-assisted thoracoscopic surgery (VATS), which is a less invasive way to biopsy lung tissue; and thoracotomy, which is a larger surgery to remove larger portions of lung tissue or tumors.
ADVANCED TESTING IN LUNG CANCER
In addition to looking at the tumor with a microscope, some lung cancers may also be tested for abnormal proteins called biomarkers or for mutations in their DNA. If present, these biomarkers or genetic mutations may be used to determine the best treatment options. Common biomarkers in lung cancer include EGFR mutations, ALK translocations, and ROS1 translocations. This is a rapidly changing area of lung cancer research, and the list of biomarkers and targeted treatment options is rapidly changing.
TYPES OF LUNG CANCER
There are many different kinds of lung cancer based on how they look under a microscope. However, there are two main categories used to determine the best treatment approach:
●Small cell lung cancer is found in about 10 to 15 percent of patients.
●Non-small cell lung cancer (often abbreviated NSCLC) includes most other types of lung cancer and is found in the remaining 85 to 90 percent of patients. There are subcategories of NSCLC, the most common of which are adenocarcinoma, squamous cell carcinoma, and large cell carcinoma.
The reason that small cell cancer is separated from non-small cell cancers is that small cell cancers grow and metastasize differently. Small cell cancer tends to be more aggressive and can spread quickly. Small and non-small cancers have different treatment regimens for surgery, radiation, and chemotherapy.
STAGING NON-SMALL CELL LUNG CANCER
Once lung cancer is diagnosed, the next step is to carefully measure the size of the tumor, determine its exact location, and look for evidence that it has spread. This process is called staging. Determining the stage of a lung cancer can be complicated because many different tests and procedures are used when determining the stage. The factors used to assign stage to non-small cell cancer are:
●The size and location of the tumor
●Whether the tumor has invaded lymph nodes and tissues inside the chest
●Whether the tumor has spread to places outside the chest (for example, lung cancer can spread [metastasize] to places like the bones, liver, adrenal glands, or elsewhere)
Non-small cell lung cancer stages range from I to IV. In general, the lower numbers (stages I and II) suggest that the tumor is smaller and has not spread far. By comparison, the higher numbers (stage III and IV) suggest that the tumor is larger or has metastasized.
●Stage I – The tumor is smaller than or equal to 3 cm in maximum diameter and has not spread to any other tissues or lymph nodes (figure 1). (See "Patient information: Non-small cell lung cancer treatment; stage I to III cancer (Beyond the Basics)".)
●Stage II – Stage II means that the tumor is either between 3 and 7 cm in size, or it has spread to the lymph nodes, or it has invaded the tissues surrounding the lung, or it has started to invade the large bronchial tubes (figure 2). (See "Patient information: Non-small cell lung cancer treatment; stage I to III cancer (Beyond the Basics)".)
●Stage IIIA – Stage IIIA disease means that the tumor can be bigger than 7 cm, or has spread to the lymph nodes in the center of the chest (called the mediastinum), or has spread to the rib cage, heart, swallowing tube (called the esophagus), or to the trachea (figure 3).
●Stage IIIB – Stage IIIB disease means that the tumor has spread to lymph nodes on the other side of the mediastinum or to the lymph nodes above or behind the clavicle (collar bone). Stage IIIB also includes large tumors that have spread to the rib cage, heart, swallowing tube (called the esophagus), or to the trachea when there is involvement of the mediastinal lymph nodes (figure 4).
●Stage IV – Stage IV means that the cancer has spread outside of the chest or to the opposite side of the chest (figure 5). In addition, stage IV could mean that the cancer has caused fluid to collect around the lung or heart (called a malignant effusion). (See "Patient information: Non-small cell lung cancer treatment; stage IV cancer (Beyond the Basics)".)
In general, lower-stage cancers require different kinds of treatment than do higher-stage cancers. Furthermore, the overall health, goals, and preferences of the lung cancer patient are very important in determining the best treatment options. Early-stage lung cancers are generally managed with surgery to remove the tumor and surrounding lung. However, patients who cannot have surgery or who prefer not to have surgery may be treated with focused radiation therapy with or without chemotherapy. Stage III lung cancers are usually not treated with surgery, and the treatment options for patients with these tumors include chemotherapy and radiation therapy in combination. When the cancer has spread outside of the chest (stage IV), chemotherapy, targeted radiation therapy, and other treatments to minimize pain or anxiety may have a role in controlling the disease and its symptoms. Finally, participation in research studies of new cancer treatments may be considered by some patients, particularly those who have had testing for biomarkers and genetic mutations.
All patients should consider goals of care and what quality of life means to them. Alternative treatment approaches for patients with advanced-stage cancer include palliative care and treatments designed to control symptoms. These approaches may improve quality of life and often achieve good survival times and acceptable quality of life.
STAGING SMALL CELL LUNG CANCER
Technical staging for small cell cancer is exactly the same as for non-small cell cancer. However, treatment options are usually determined by a much more simple system. This is because small cell lung cancer has different growth patterns and a different prognosis. Small cell lung cancer is typically categorized as either "limited" or "extensive" disease. This system helps to determine which treatment will be most effective.
●Limited disease – This refers to small cell lung cancers that are confined to one side of the chest and lymph nodes.
●Extensive disease – This refers to small cell lung cancer that has spread to the opposite side of the chest or has metastasized (spread) to distant locations outside the chest.
The treatment and prognosis of small cell lung cancer (SCLC) depends upon whether disease is limited or extensive. This is discussed in detail in a separate topic review. (See "Patient information: Small cell lung cancer treatment (Beyond the Basics)".)
Progress in treating lung cancer requires better treatments. A clinical trial is a carefully controlled way to study the effectiveness of new treatments or new combinations of known therapies. Clinical trials are conducted around the world. Ask for more information about clinical trials, or read about clinical trials at:
Videos addressing common questions about clinical trials are available from the American Society of Clinical Oncology (http://www.cancer.net/pre-act).
WHERE TO GET MORE INFORMATION
Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient information: Lung cancer (The Basics)
Patient information: Non-small cell lung cancer (The Basics)
Patient information: Small cell lung cancer (The Basics)
Patient information: Lung cancer screening (The Basics)
Patient information: Asbestos exposure (The Basics)
Patient information: Multiple pulmonary nodules (The Basics)
Patient information: Single pulmonary nodule (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient information: Non-small cell lung cancer treatment; stage I to III cancer (Beyond the Basics)
Patient information: Non-small cell lung cancer treatment; stage IV cancer (Beyond the Basics)
Patient information: Small cell lung cancer treatment (Beyond the Basics)
Patient information: Chronic cough in adults (Beyond the Basics)
Patient information: Flexible bronchoscopy (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Overview of the risk factors, pathology, and clinical manifestations of lung cancer
Cigarette smoking and other possible risk factors for lung cancer
Screening for lung cancer
Overview of the initial evaluation, treatment and prognosis of lung cancer
Pathology of lung malignancies
Pathobiology and staging of small cell carcinoma of the lung
Imaging of non-small cell lung cancer
Preoperative evaluation for lung resection
Management of stage I and stage II non-small cell lung cancer
Management of stage III non-small cell lung cancer
Overview of the treatment of advanced non-small cell lung cancer
Personalized, genotype-directed therapy for advanced non-small cell lung cancer
Extensive stage small cell lung cancer: Initial management
The following organizations also provide reliable health information.
●National Cancer Institute
●American Society of Clinical Oncology
- Pretreatment evaluation of non-small-cell lung cancer. The American Thoracic Society and The European Respiratory Society. Am J Respir Crit Care Med 1997; 156:320.
- Alberg AJ, Brock MV, Ford JG, et al. Epidemiology of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143:e1S.
- Silvestri GA, Gonzalez AV, Jantz MA, et al. Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143:e211S.
- Detterbeck FC, Postmus PE, Tanoue LT. The stage classification of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143:e191S.
- Nana-Sinkam SP, Powell CA. Molecular biology of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143:e30S.
- Detterbeck FC, Mazzone PJ, Naidich DP, Bach PB. Screening for lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143:e78S.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.