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	Non-Small Cell Lung Cancer Thierry M. Jahan, MD, Alan B. Glassberg, MD, Patricia Cornett, MD, Daphne Haas-Kogan, MD, Peter Anastassiou, MD, Sabrina Selim, MD and David Jablons, MD

Lung cancer is the second most common cancer and the number-one cause of cancer death in both men and women in the U.S. This is especially unfortunate because it is one of the most preventable cancers caused, for the most part, by tobacco use.

There are two general types of lung cancer-small cell and non-small cell. The non-small cell variety is much more common, accounting for 80 percent of all lung cancer cases. There has been modest improvement in the survival rate over the past two decades. The slow rate of improvement is due to the fact that we lack a satisfactory, widely applicable, screening test that could increase our ability to detect lung cancer at an early stage, when it has the best chance of being cured and the fact that lung cancer is a biologically aggressive cancer.

Types There are at least four distinct types of non small cell lung cancer adenocarcinoma, squamous cell, large cell and bronchoalveolar carcinoma the treatment is generally similar.

• Squamous cell (epidermoid) carcinoma of the lung is the microscopic type most frequently related to smoking.
• Adenocarcinoma of the lung accounts for over 50 percent of all lung cancer cases in the United States. It is more common in women and is still the most frequent type seen in non-smokers.
• Large cell carcinoma, especially those with neuroendocrine features, is commonly associated with spread of the tumor to the brain.

How It Spreads Non-small cell cancer can spread through the lymphatic system and through the blood. It can directly invade also to involve the center of the chest (mediastinum), the lining of the chest, the ribs or, if it is in the top part of the lung, the nerves and blood vessels leading into the arm. When non-small cell lung cancer enters the bloodstream, it can spread to distant sites such as the liver, bones, brain and other places in the lung.

Increased Risk Factors

• Cigarette smokers.
• The male to female ratio remains 4 to 1
• Workers exposed to industrial substances such as asbestos, nickel, chromium, cadmium, uranium, radon compounds and chloromethyl ether, especially those who smoke.
• Prior early stage lung cancer or head and neck cancer

Staging Once a diagnosis of a malignant tumor is made, further studies are done to establish the stage of disease. The stage helps to determine the prognosis and to guide the selection of treatment.

Stage is based on a combination of clinical findings (physical examination, chest x-ray and lab studies) and pathologic findings (biopsy).

Stage	Signs and Symptoms	Diagnostic Tests	Common Treatments	Survival
I The tumor can be removed surgically and has not spread to involve lymph nodes	New or changing cough Pink/bloody sputum Hoarseness Shortness of breath Increased sputum Recurrent lung infections Weight loss Fatigue	Blood and other tests: Sputum examination for malignant cells. Biopsy or fine needle aspiration	Surgery: This involves removing a lobe of the lung or resection of a tumor in the center of the lung. Techniques have improved significantly will low risks Radiation therapy: For patients who cannot tolerate surgery, limited radiation may be used with smaller survival benefit	5 year: 50-80%
II The tumor has spread to the hilar lymph nodes or the dust wall, mediastinum or diaphragm	The above (I) plus: Swelling of arm or face	Physical examination: Lymph node enlargement in neck or above collarbone PET scan to stage the mediastinum Mediastinoscopy with biopsy	Surgery: This is the standard treatment Chemotherapy: Combined with surgery, this improves the outcome for locally advanced disease. Radiation therapy: Patients unable to withstand surgery may benefit	5 year: 30-50%
III Divided into stages IIIA (able to be removed) and IIIB (unable to be removed). Both show involvement of lymph nodes in the center of the chest	Same as above (I)	Physical examination: Same as above plus decreased breath sounds or dullness when chest is tapped indicating fluid in the lung	These tumors are treated mainly with radiation and chemotherapy, surgery or both, depending on clinical circumstances	5 year: IIIA 10-30% IIIB 5-20%
IV The cancer has spread to distant sites	Same as above(I) plus the following if the tumor has spread: Severe headaches Double vision Pain in bones, chest, abdomen, neck or arms	Physical examination: same as above plus enlarged liver or other abdominal mass Bone scan or bone biopsy CT scan of liver or adrenal glands liver biopsy PET, CT or MRI scans of the brain	Chemotherapy: Platinum drug combined with Taxol, Taxotere, Gemzar or Navelbine appear to be more effective than simple palliative care. Additionally, they may relieve symptoms and reduce tumor size	5 year: less than 5%

Supportive Therapy The importance of supportive therapy in the treatment of lung cancer cannot be overemphasized.

Quite clearly, malnutrition results in a bad outcome in patients with lung cancer. Patients must be served a palatable meal and attempts must be made to work with patients to determine food likes and dislikes.
Pain control is of critical importance, and the tools to achieve control are available even for the most advanced cases. These include the use of pain-relieving (analgesic) drugs such as non-steroidal anti-inflammatory agents, mild narcotics, strong narcotics, continuous narcotics and narcotics delivered into the spinal canal (epidural). Pain control can generally be achieved without interfering with mental competence. Nausea can be controlled with a variety of drugs
Physical therapy will help maintain muscle strength to keep life as normal as possible.

Important Questions to Ask

What is the stage of my disease and what is my prognosis?
How sick will I be on chemotherapy and what can be done to control the side effects?
If chemotherapy cannot cure my cancer, why should I expose myself to its side effects and toxicities?
What is the chance that I will die from this tumor? How much time am I likely to have?
Are there investigational protocols for which I may be eligible?

Reference
Everyone's Guide to Cancer Therapy by Malin Dollinger, Ernest H. Rosenbaum, Margaret Tempero and Sean Mulvihill. Andrews McMeel. 4th edition, 2002

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