About Lung Cancer

About Lung Cancer

Penn Medicine's Abramson Cancer Center and the Abramson Cancer Center at Pennsylvania Hospital offer hope to patients facing lung cancer. Early and accurate diagnosis and the full range of treatment options available at Penn give patients with lung cancer the best chance of being cured.

Penn's Lung Cancer Program features a comprehensive team of thoracic surgeons, pulmonologists, nurses, respiratory therapists, rehabilitation specialists, medical oncologists, radiation oncologists, and pathologists. Each provides comprehensive expertise in treating lung cancer. These specialists incorporate surgery, radiation, chemotherapy and immunotherapy to deliver integrated medicine for complex management of lung cancer.

In addition, Penn researchers are on the forefront of testing new surgical procedures, applying new drug therapies and developing the protocols for proton therapy and other radiation therapies that incorporate cutting edge technology and are changing the way lung cancer is treated.

Types of Lung Cancer

Types of Lung Cancer

  • Small cell lung cancer
  • Non-small cell lung cancer
  • Lung carcinoid or neuroendocrine tumors
  • Mesothelioma

Lungs

Small Cell Lung Cancer (SCLC)

Small cell lung cancer, often called oat cell carcinoma and small cell undifferentiated carcinoma, makes up about 10 to 15 percent of all lung cancers.

This cancer often starts in the bronchi near the center of the chest. Although the cancer cells are small, they can divide quickly, form large tumors, and spread to lymph nodes and other organs throughout the body.

Because of these traits, surgery is rarely an option for treating small cell lung cancer and never the only treatment given. Chemotherapy, which targets cancer cells throughout the body, is an important part of treatment for all small cell lung cancers. When disease is limited to the chest, doctors often use radiation and chemotherapy together. In addition, these cells can often hide out in the brain despite successful treatment to the chest. Physicians often employ prophylactic cranial irradiation (PCI) as a precaution to prevent recurrence in the brain.

Non-small Cell Lung Cancer (NSCLC)

The most common types of lung cancer are three main sub-types of NSCLC. The cells in these sub-types differ in size, shape, and chemical make-up. Treatment for NSCLC may include surgery to remove tumors or part of the lung.

  • Adenocarcinoma: Accounts for about 40 percent of lung cancers. It is usually found in the outer part of the lung and often, though not always, occurs in people who smoke or have smoked. It is also the most common type of lung cancer seen in non-smokers; it is more common in women than in men; and it is more likely to occur in younger people than other types of lung cancer.
  • Large-cell (undifferentiated) carcinoma: About 10 to 15 percent of lung cancers are this type. It can start in any part of the lung. It tends to grow and spread quickly, making it more difficult to treat.
  • Squamous cell carcinoma: About 25 to 30 percent of all lung cancers are squamous cell carcinoma. Its development is linked to smoking and it tends to be found in the middle of the lungs, near a bronchus (airway).

Lung Carcinoid or Neuroendocrine Tumors

Carcinoid tumors start from cells from the neuroendocrine system, they are like nerve cells in some ways and like hormone-making endocrine cells in other ways. Neuroendocrine cells do not form an actual gland, but are scattered throughout the chest and abdomen.

Lung neuroendocrine cells sometimes grow out of control and form tumors. These are known as neuroendocrine tumors (NETs) or neuroendocrine cancers. NETs can develop anywhere in the body.

Other carcinoid tumors

There are two other types of lung carcinoid tumors and their differences can be seen under a microscope.

  • Typical carcinoids grow slowly and only rarely spread beyond the lungs. Nearly 90 percent of lung carcinoids are typical carcinoids. They are usually without symptoms, but can sometimes block a bronchial tube and trigger asthma symptoms.
  • Atypical carcinoids grow a little faster and are somewhat more likely to spread to other organs. Seen under a microscope, they have more cells in the process of dividing and look more like a fast-growing tumor. They are much less common than typical carcinoids.

Carcinoid tumors are sometimes also classified by where they form in the lung.

  • Central carcinoids form in the walls of large airways near the center of the lungs. Most lung carcinoid tumors are central carcinoids, and nearly all of these are also typical carcinoids.
  • Peripheral carcinoids develop in the narrower airways toward the edges of the lungs. Most peripheral carcinoids are also typical carcinoids.

Very little is known about what causes lung carcinoid tumors. They probably develop from tiny clusters of neuroendocrine cells in the lung airways called carcinoid tumorlets. Researchers still do not understand how carcinoid tumorlets develop from lung neuroendocrine cells or why tumorlets sometimes grow to become carcinoid tumors, and why others materialize, but never grow.

Mesothelioma

Mesothelioma is a rare type of malignancy that affects the lining (mesothelium) around the organs in the chest and abdomen. These cells protect organs by making a special fluid that lubricates the surfaces, allowing the lungs and other organs to move during breathing.

The mesothelium has different names in different parts of the body:

  • In the chest it is called the pleura.
  • In the belly it is called the peritoneum.
  • In the space around the heart it is called the pericardium.

There are several different subtypes of mesothelioma, including epithelioid, sarcomatoid, biphasic and desmoplastic. Epithelioid is the most common, comprising 70 to 80 percent of cases. Mesothelioma is most often attributed to exposure to airborne asbestos particles and occurs in both men and women. Asbestos is a group of naturally occurring fibrous minerals used as a fire retardant, but generally is no longer used in insulation or brake materials. The latency period between exposure and the development of mesothelioma can be as much as 40 to 50 years.

Watch a short video about mesothelioma treatment at Penn Medicine.

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Lung Cancer Risk and Prevention

Lung Cancer Risk and Prevention

A risk factor is anything that affects a person's chance of getting cancer. Different cancers have different risk factors. Some risk factors, like smoking, can be controlled to help prevent cancer. Others, like a person's age or family history, can't be changed.

Risk Factors for Lung Cancer

Having a risk factor, or even several risk factors, does not mean that someone will develop cancer. And some people who get the disease may not have had any known risk factors. It is often very hard to know how much that risk factor may have contributed to the cancer. For every risk factor listed, the risk is much higher for people who smoke.

  • Tobacco smoke: Smoking is by far the leading risk factor for lung cancer. Tobacco smoke causes nearly nine out of 10 cases of lung cancer. The longer a person has been smoking and the more packs per day smoked, the greater the risk. If a person stops smoking before lung cancer develops, the lung tissue slowly repairs itself. Stopping smoking at any age can lower the risk of lung cancer. People who don't smoke but who breathe the smoke of others may also be at a higher risk for lung cancer.
  • Radon: Radon is a radioactive gas released by the normal breakdown of uranium in soil and rocks. It is found at higher levels in the soil in some parts of the United States. Radon can't be seen, tasted or smelled. It can build up indoors and create a possible risk for cancer. The lung cancer risk from radon is much lower than that from tobacco smoke.
  • Asbestos: People who work with asbestos have a higher risk of getting lung cancer. If they also smoke, the risk is greatly increased. Those exposed to asbestos, regardless of smoking status, have a greater risk of developing mesothelioma.
  • Carcinogens found in some workplaces:
    • Radioactive ores, such as uranium
    • Inhaled chemicals or minerals like arsenic, beryllium, cadmium, vinyl chloride, nickel compounds, chromium compounds, coal products, mustard gas and chloromethyl ethers
    • Diesel exhaust
  • Chest radiation: People who have had radiation therapy to the chest to treat other cancers are at higher risk for lung cancer, although the actual risk is still quite low. However, women who have radiation to the breast after a lumpectomy for breast cancer do not appear to have a higher risk of lung cancer.
  • Arsenic: High levels of arsenic in drinking water may increase the risk of lung cancer.
  • Personal and family history: People who have had lung cancer have a higher risk of getting another lung cancer. Brothers, sisters and children of people who have had lung cancer have a slightly higher risk themselves, especially if the family member developed cancer at a young age.
  • Certain vitamins: Studies have found that smokers who took beta carotene supplements actually had an increased risk of lung cancer, especially if they smoked.
  • Air pollution: Air pollution may slightly increase the risk of lung cancer, but the risk is still far less than that caused by smoking.
  • Gender, race/ethnicity and age: Lung carcinoids occur more often in women than in men; in whites than in African Americans, Asian Americans, or Hispanics/Latinos; and are usually found in people about 60 years old (slightly younger than the average age for other types of lung cancer). Carcinoids can occur in people of almost any age, and although rare they are sometimes found in children.

Preventing Lung Cancer

Avoiding certain risk factors can reduce the chance of developing lung cancer, but there is no known way to prevent all cases.

The number one thing people can do to reduce their risk of developing lung cancer is not to smoke and to avoid secondhand smoke. Penn offers a Comprehensive Smoking Treatment Program for people who need help to quit smoking.

Other steps that people can take to help reduce the risk for developing lung cancer include:

  • Testing and treating their home for radon.
  • Protecting themselves from cancer-causing chemicals at work.
  • Maintaining a good diet with lots of fruits and vegetables.

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Lung Cancer Symptoms

Lung Cancer Symptoms

Most lung cancers do not cause symptoms until they have grown locally or spread. Any of the following problems should be reported to a doctor. Often these symptoms are caused by something other than cancer, but if lung cancer is found, getting treatment right away can help prevent it from spreading and/or increase the chances of it being cured. The most common symptoms of lung cancer are:

  • A cough that does not go away
  • Chest pain, often made worse by deep breathing, coughing or laughing
  • Hoarseness
  • Weight loss and loss of appetite
  • Coughing up bloody or rust-colored sputum
  • Shortness of breath
  • Fatigue
  • Recurring respiratory infections, such as bronchitis and pneumonia
  • Wheezing that did not previously exist

When lung cancer spreads to distant organs, it may cause:

  • Bone pain
  • Abdominal pain or chest pain
  • Weakness or numbness of the arms or legs
  • Headache, dizziness, or seizure
  • Jaundice (yellowing) of the skin and eyes
  • Lumps near the surface of the skin, caused by cancer spreading to the skin or to lymph nodes in the neck or above the collarbone

In addition mesothelioma may cause pain in the chest due to an accumulation of fluid in the pleura, or lining around the lungs. If mesothelioma has spread beyond the chest to other parts of the body, symptoms may include pain, trouble swallowing, or swelling of the neck or face.

Some lung cancers can cause a group of symptoms called syndromes. Most of these symptoms are likely to be caused by something other than lung cancer, but should be checked by a doctor.

  • Horner syndrome: Cancers in the top part of the lungs may damage the nerve that passes from the upper chest into the neck, causing:
    • Severe shoulder pain
    • Drooping or weakness of the eyelid and a smaller pupil in the same eye
    • Reduced or absent sweating on the same side of the face
  • Superior vena cava syndrome: The superior vena cava is a large vein that carries blood from the head and arms back to the heart. It passes alongside the upper part of the right lung and the lymph nodes inside the chest. Tumors in this area may push on the superior vena cava causing the blood to back up in the veins. The result can be swelling in the face, neck, arms, and upper chest, and headaches, dizziness, and a change in mental function if it affects the brain.
  • Paraneoplastic syndromes: Some lung cancers make hormone-like substances that enter the bloodstream and cause problems with organs and tissues even though the cancer has not spread to those areas. For instance, squamous cell carcinoma can make abnormal levels of parathyroid-like hormone (PTH) leading to elevated calcium levels. Small cell lung cancer can elaborate abnormal amounts of anti-diuretic hormone (ADH), which can cause the sodium level to drop. These paraneoplastic syndromes are sometimes the first symptoms of lung cancer.
  • Carcinoid syndrome: Rarely, lung carcinoid tumors release enough hormone-like substances into the bloodstream to cause symptoms. Stress, heavy exercise, and drinking alcohol can bring on these symptoms or make them worse. Symptoms include:
    • Facial flushing
    • Severe diarrhea
    • Wheezing
    • Rapid heartbeat
  • Cushing syndrome: In rare cases, lung carcinoid tumors may produce something called ACTH. This substance causes the adrenal glands to make too much cortisol and other hormones, causing weight gain, weakness, high blood sugar (or even diabetes), and increased body and facial hair. This can be seen with small cell lung cancer.

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Staging Lung Cancer

Staging Lung Cancer

Staging is the process of finding out if and how far lung cancer has spread. The treatment plan and prognosis depend on the stage of the cancer. A staging system is a standard way for doctors to describe how large a cancer is and how far it has spread. The stage is based on the results of the physical exam, biopsies, and imaging tests.

TNM Staging System

The TNM staging system for lung carcinoid tumors and non-small cell lung is used to describe the:

  • Tumor
  • Nodes (lymph nodes)
  • Metastasis (if the cancer has spread)

Staging Small Cell Lung Cancer

Small cell lung cancer may also be staged as limited versus extensive. In the limited stage, the cancer is only in one lung and perhaps in lymph nodes on the same side of the chest, an area that is small enough to be treated with radiation.

If the cancer has spread to the other lung, to lymph nodes on the other side of the chest, or to distant organs, it is called extensive. Many doctors also consider cancer that has spread to the fluid around the lung as extensive stage.

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The Penn Difference

The Penn Difference

Patients under the care of Penn's Lung Cancer Program benefit from a multidisciplinary team of specialists and the resources of the Abramson Cancer Center and Abramson Cancer Center at Pennsylvania Hospital. Internationally recognized specialists in pulmonology, oncology, radiation therapy and thoracic surgery are supported by a robust care who are committed to providing the most advanced treatment options, including:

  • Lung-sparing surgery and other surgical options
  • Radiation therapy including new technologies involving proton beams, Gamma Knife® and CyberKnife®.
  • Chemotherapy and biological therapies
  • Clinical trials

Penn's lung cancer team has established a national reputation with a number of noteworthy attributes including:

  • Thoracic surgeons, radiation oncologists, medical oncologists, pulmonologists and radiologists who specialize in treating lung cancer working together as a team to manage patient care.
  • Dedicated thoracic radiologists who focus entirely on images of the chest and lungs, whose experience and expertise helps them to detect lung cancer at early stages when it is most treatable.
  • A multidisciplinary lung nodule program that determines the best course of treatment or surveillance for all tumors, including benign lung nodules.
  • Supportive care including psychosocial counseling and palliative care.

The program focuses on:

  • Clinical care: Developing treatment strategies that can significantly extend and improve the life of patients.
  • Research: Scientists from basic, translational and clinical research collaborate to understand the causes of lung cancer and translate their findings into improved therapies.
  • Education: Training the physicians, surgeons and researchers of tomorrow has been a part of Penn's tradition for nearly 250 years.
  • Patient support: Cancer support programs provide nutrition counseling, emotional and spiritual support, physical and occupational therapy.
  • Psychological/caregiver support: Therapists at Penn provide support for patients and their caregiver including family therapy, individual therapy sessions, relaxation training and assessment of needs.

At Penn, patients with lung cancer and their families receive the support and education they need to understand the diagnosis as well as the vast resources available to them throughout Penn Medicine. In most cases, consultations with all physicians and team members are scheduled on the same day for the convenience of patients and their families.

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Lung Cancer Diagnosis

Penn Medicine's Lung Cancer Program at the Abramson Cancer Center offers hope to patients facing lung cancer. The early and accurate diagnosis and full range of immediate options available at Penn give patients with lung cancer the best chance of being cured.

Early diagnosis of lung cancer can be difficult. The early stages of lung cancer do not usually produce any symptoms, so only a small number of lung cancers are found early. When lung cancer is found early, it is often because of tests that were being done for something else.

Lung Cancer Screening

Lung Cancer Screening

Screening is the use of tests or exams to find a disease like cancer in people who don't have any symptoms. Because lung cancer often spreads beyond the lungs before it causes symptoms, a screening test that finds lung cancer early could save many lives.

In the past, no lung cancer screening test had been shown to lower the risk of dying from this disease. Studies involving spiral CT (or helical CT) have shown some promise in finding early lung cancers in heavy smokers and former smokers. So far, major medical groups have not recommended routine screening tests for all people or even for people at increased risk, such as smokers.

People who smoke, who smoked in the past, or who have been exposed to secondhand smoke, as well as those who have worked around materials that increase the risk for lung cancer need to be aware of their lung cancer risk. They should talk to their doctors about their chances of getting lung cancer and the pros and cons of lung cancer screening.

For those who decide in favor of testing, the physicians in Penn Medicine's Lung Cancer Program are experienced in lung scanning and the latest screening techniques for people at high risk.

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Lung Cancer Diagnostic Tools

Lung Cancer Diagnostic Tools

If patients have any signs or symptoms that suggest they might have a lung tumor, their physician takes a complete medical history, including family history, and checks for symptoms and possible risk factors.

A physical exam provides information about general health, possible signs of lung cancer and other health problems. During the physical exam the doctor pays close attention to the chest and lungs.

If symptoms and/or the results of the physical exam suggest a lung tumor might be present, imaging tests, lab tests and other procedures may be performed to confirm the diagnosis.

Imaging Tests

There are a number of different tests that take pictures of the chest and lungs. Some of these are used to find lung cancer, to see if it has spread, to find out whether treatment is working, or to spot a cancer that has come back after treatment.

  • Chest X-ray: Often the first test performed to look for any spots on the lungs is a traditional X-ray of the chest. If anything on the X-ray looks abnormal, the doctor may order more tests.
  • CT scan (computed tomography): A CT scan uses X-rays to produce detailed cross-sectional pictures of your body. The CT scanner takes many pictures as it moves around the body, and a computer combines these pictures into a detailed picture of a slice of the body. A CT scan can provide exact information about the size, shape and location of a tumor. It can also help find swollen lymph nodes that might contain cancer. CT scans are also used to find tumors in other organs that might be the spread of lung cancer. A CT scan can be used to:
    • Spot very small lung tumors and help determine the exact location and extent of the tumors.
    • Stage cancer (determining the extent of its spread). For example, CT scans of the abdomen can show if the cancer has spread to the liver or other organs. This can help to determine if surgery is a good treatment option.
    • Guide a biopsy needle precisely into a suspected tumor or metastasis.
  • Spiral CT: Studies involving spiral CT (or helical CT) have shown some promise in finding early lung cancers in heavy smokers and former smokers. Spiral CT gives rotates around the body as the patient passes through the scanner. It provides more detailed pictures than a chest X-ray and is better at finding small changes in the lungs. The National Lung Screening Trial (NLST) is a large study that compared spiral CT scans to chest X-rays in people at high risk of lung cancer to see if these scans could help lower the risk of dying from lung cancer. People in the study were current or former heavy smokers between the ages of 55 and 74, who were followed for several years. Early results from the study, announced in November 2010, found that people who received spiral CT had a 20 percent lower chance of dying from lung cancer than those who got chest X-rays.
  • MRI scan (magnetic resonance imaging): Like CT scans, MRI scans give detailed pictures of soft tissues in the body. MRI scans use radio waves and strong magnets instead of X-rays. MRI scans take longer than X-rays, but are useful in finding lung cancer that has spread to the brain or spinal cord.
  • PET scan (positron emission tomography) and PET/CT scan: For a PET scan, a form of radioactive sugar is injected into the blood. Cancer cells in the body take in large amounts of the sugar and a special camera takes images of the radioactivity. This test is useful for seeing if the cancer has spread to the lymph nodes or other parts of the body. It is also helpful in telling whether a spot on a chest X-ray is cancerous. Radiologists at Penn combine PET and CT scan to even better pinpoint tumors.

Blood and Tissue Tests

At Penn, pathologists look at cells under a microscope to determine if they are cancerous.

  • Sputum cytology: A sample of mucus, or phlegm, is looked at under a microscope to see if cancer cells are present.
  • Fine needle biopsy (FNA): A long, thin needle is put into the place in the lung that might be cancer to remove a sample of cells. The sample is looked at in the lab to see whether there are cancer cells. An FNA biopsy may also be done to take samples of lymph nodes around the trachea and the bronchial tubes. If the results are unclear, a larger needle may be used to remove a slightly bigger piece of lung tissue. This is known as a core needle biopsy.
  • Bronchoscopy: A lighted, flexible tube called a bronchoscope is passed through the mouth or nose and into the larger airways of the lungs. This scope can help physicians see tumors, or it can be used to take samples of tissue or fluids to determine if cancer cells are present.
  • Endobronchial ultrasound: A bronchoscope fitted with an ultrasound device at its tip is passed down into the windpipe to look at nearby lymph nodes and other structures in the chest. A hollow needle can be passed through the bronchoscope and guided by ultrasound to take biopsy samples.
  • Endoscopic esophageal ultrasound (EUS): This test is much like an endobronchial ultrasound, except an endoscope is passed down the throat and into the esophagus. Ultrasound images taken from inside the esophagus can help find large lymph nodes inside the chest that might contain lung cancer, and a hollow needle can be passed through the endoscope to get biopsy samples of them.
  • Mediastinoscopy and mediastinotomy: Both of these tests are performed in an operating room. They allow the doctor can look at and take samples of the structures in the area between the lungs, called the mediastinum.
  • Thoracentesis: A hollow needle is placed between the ribs to drain fluid from the chest to check for cancer cells.
  • Thoracoscopy: A thin, lighted tube connected to a video camera and screen is inserted into the chest to look at the space between the lungs and the chest wall. By doing this, the doctor can see any cancer deposits on the lung or the lining of the chest wall and take out small pieces of tissue to be looked at under the microscope. Thoracoscopy can also be used to sample lymph nodes and fluid and to tell whether a tumor is growing into nearby tissues or organs.
  • Bone marrow aspiration and biopsy: These two tests are usually done at the same time. A thin, hollow needle is inserted into the hip bone to remove a small amount of fluid from the marrow. A larger needle is then used to remove a small piece of the hip bone and some marrow. Both samples are checked for cancer cells. This is done mostly to help find if small cell lung cancer has spread to the bones.
  • Blood and urine tests: Blood and urine tests are not used to find lung cancer, but they are done to get a sense of a person's overall health. Because carcinoid tumors can secrete hormone-like chemicals into the blood, a tumor can sometimes be detected by simple blood or urine tests.

Pulmonary Function Test

Pulmonary function tests (PFTs) are often done after lung cancer has been found. These tests show how well the lungs are working. PFTs can give the surgeon an idea of how much lung can be removed or whether surgery is a good option at all.

Biopsy

Even if imaging tests such as a chest X-ray or CT scan find a mass, it is often hard for doctors to tell if the mass is a carcinoid tumor, another type of lung cancer, or an area of infection. In many cases, the only way to know for sure is to perform a biopsy, in which cells from the tumor are removed and examined under a microscope.

  • Bronchoscopic biopsy: A long, thin, flexible, fiber-optic tube is inserted through the windpipe, and into the lungs to look at the lining of the lung's main airways. A small sample of cells can be removed through the tube. No surgical incision or hospital stay is needed, and patients are ready to return home within hours.
  • Endobronchial ultrasonography (EBUS): If a CT scan shows enlarged lymph nodes on either side of the trachea or in the area just below where the trachea divides, this minimally invasive approach can be used. EBUS uses a special bronchoscope that has a small balloon on the end. This balloon gives off sound waves and collects information about the waves that bounce back. Under ultrasound guidance, a needle is inserted into the lymph nodes and cells removed to be examined under the microscope.
  • Needle biopsy: Tumors away from the large airways are often sampled by needle biopsy. A long, hollow needle is passed between the ribs and into the lung. CT scan images are used to guide the needle into the tumor so that a small sample can be removed and looked at under the microscope. This procedure is also done without a surgical incision or overnight hospital stay.
  • Surgical biopsy: In some cases, bronchoscopic biopsy or needle biopsy don't remove enough tissue to identify the type of tumor, so a surgical biopsy is performed. Different types of operations may be used, including:
    • Thoracotomy: An incision is made in the chest wall between the ribs to get to the lungs and to the space between the lungs and the chest wall. If doctors strongly suspect a carcinoid or some other type of lung cancer they may do a thoracotomy and remove the entire tumor without first doing a biopsy.
    • Thoracoscopy: This procedure is less invasive than a thoracotomy and is also used to look at the space between the lungs and the chest wall. In the operating room, doctors insert a thin, lighted scope with a small video camera on the end through a small cut made in the chest wall to look at the space between the lungs and the chest wall. Using the scope, the doctors can see potential areas of cancer and remove small pieces of tissue to look at under the microscope.
    • Mediastinoscopy: If imaging tests such as a CT scan suggest that the cancer may have spread to the lymph nodes between the lungs, a small cut is made in the front of the neck above the breastbone (sternum) and a thin, hollow, lighted tube is inserted behind the sternum. Special instruments can be passed through this tube to take tissue samples from the lymph nodes along the windpipe and the major bronchial tube areas.

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Staging Lung Cancer

Staging Lung Cancer

Staging is a way of describing a cancer, such as where it is located, if or where it has spread, and if it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the stage of mesothelioma, so staging may not be complete until all the tests are finished.

The stage of a cancer does not change over time, even if the cancer progresses. A cancer that comes back or spreads is still referred to by the stage it was given when it was first found and diagnosed, only information about the current extent of the cancer is added. A person keeps the same diagnosis stage, but more information is added to the diagnosis to explain the current disease status.

Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's chance of recovery.

The TNM Staging System

The system used to describe the growth and spread of non-small cell lung cancer is the American Joint Committee on Cancer (AJCC) TNM staging system. The TNM system is based on three key pieces of information:

  • T indicates the size of the main (primary) tumor and whether it has grown into nearby areas.
  • N describes the spread of cancer to nearby (regional) lymph nodes. Cancer often spreads to the lymph nodes before going to other parts of the body.
  • M indicates whether the cancer has spread or metastasized to other organs of the body. (The most common sites are the brain, bones, adrenal glands, liver, kidneys, and the other lung.)

Numbers or letters appear after T, N, and M to provide more details about each of these factors. The numbers zero through four indicate increasing severity, and X means the information is not available.

The TNM staging system is complex and can be difficult to understand. Patients and their families are encouraged to ask the care team for an explanation of their cancer staging.

Stage Grouping

Once the T, N, and M categories have been assigned, this information is combined to assign an overall stage grouping. The staging diagnosis depends on the type of cancer and the staging system the doctor is using, but in general there are four stages of lung cancer:

  • Stage I: The tumor is localized, meaning it is restricted to the area where it originated.
  • Stage II: The tumor has spread or metastasized to lymph nodes in the chest.
  • Stage III: The tumor has metastasized into the chest wall, mediastinum (area of the chest between the lungs), heart, diaphragm, or abdominal lining.
  • Stage IV: The tumor has metastasized to distant organs or tissues.

Some stages are subdivided into A and B. The stages identify cancers that have a similar prognosis and thus are treated in a similar way. Patients with lower stage numbers tend to have a better prognosis.

Limited and Extensive Stage for Small Cell Lung Cancer

For treatment purposes, some doctors prefer the two-stage system that divides small cell lung cancers into limited stage and extensive stage.

  • Limitedstage usually means that the cancer is only in one lung and perhaps lymph nodes on the same side of the chest. The cancer is typically confined to an area that is small enough to be treated with radiation therapy.
  • Extensive stage is used to describe cancers that have spread to the other lung, to lymph nodes on the other side of the chest, or to distant organs. Many doctors consider small cell lung cancer that has spread to the fluid around the lung to be extensive stage as well. About two out of three people with small cell lung cancer have extensive disease when their cancer is first found.

Small cell lung cancer is often staged in this way because it helps separate patients who may be able to get local treatments such as surgery and/or radiation therapy to try to cure the cancer (limited stage) from those for whom these treatments aren't likely to be helpful (extensive stage).

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Treating Lung Cancer at Penn

The lung cancer specialists at Penn Medicine develop personalized treatment plans designed to give every patient the best possible outcome. Like all of programs at Penn's Abramson Cancer Center, the lung cancer program is focused on patient-centered care and meeting the unique needs of every patient and family.

Treatment options for lung cancer include surgery, radiation therapy and systemic treatment including both chemotherapy and targeted agents, as well as combined approaches utilizing a combination of some or all of these therapies have shown promise in extending survival of some patients with early disease.

Penn's treatment options for lung cancer include:

Each of these treatment options is explained in detail below.

Surgery

Surgery

Penn Medicine's lung cancer surgeons treat a large number of patients and are experienced in performing every type of cancer surgery, from minimally invasive procedures to traditional open surgery. As specialists in lung cancer surgery, they can determine the appropriate surgical option for every patient.

Lung cancer surgery is rarely used as the main treatment in lung cancer. In most, but not all cases, the surgery is followed by chemotherapy, biologic therapy, radiation therapy or a combination of treatments. These approaches are generally reserved for patients with larger tumors (> 4 cm) or tumors with lymph node involvement.

Several different types of operations are used to treat lung cancer. The type of surgery depends on the size and location of the tumor. Penn thoracic surgeons are now performed many lung cancer procedures robotically.

Lobectomy

A lobectomy is a type of lung cancer surgery in which one lobe of a lung is removed. The right lung has three lobes, and the left lung has two lobes. It is most commonly performed for non-small cell lung cancers in which the tumor is confined to a single lobe. It is less invasive and conserves more lung function that a pneumonectomy.

Pneumonectomy

A pneumonectomy is the surgical removal of a lung. It is performed on patients with non-small cell lung cancer where the cancer is limited to the lung. The size and location of the cancer within the lung also plays an important factor. Several lung function/respiratory tests are performed prior to surgery.

Segmentectomy or Wedge Resection

A wedge resection is a type of lung cancer surgery in which the tumor and a small amount of surrounding tissue is removed. It is usually performed for very small lung cancers.

Sleeve Resection

A small number of people with lung cancer may have a sleeve resection, in which the affected section of the bronchus, or large airway, is removed along with any surrounding cancer in the lobe of the lung. It is usually performed if the cancer is in the central area of the lung and is growing into one of the main airways.

Video-assisted Thoracic Surgery (VATS)

VATS is a minimally invasive surgical procedure in which the surgeon makes several small incisions in the chest. A tiny camera is inserted through one of the openings so the surgeon can see the lung and the tumor. Long instruments are passed though the other small holes to remove the tumor.

Other types of surgery may be used to help relieve the symptoms of the cancer.

  • Laser surgery can be used to open an airway blockage that may be causing pneumonia or shortness of breath.
  • Metal or plastic tubes called stents may be placed in the airways to help keep them open.
  • Small tubes may be placed in the chest to drain fluid that collects in the pleural space between the chest wall and the lungs, and makes it hard to breathe. One such catheter is called a pleurex.

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Radiation Therapy

Radiation Therapy

Penn Radiation Oncology has an international reputation for providing radiation therapy for patients with lung cancer. Radiation oncologists work side-by-side with their surgical and medical oncology colleagues to conduct clinical trials to advance the treatment of lung cancer.

In addition, patients being treated for at Penn Medicine have access to the Roberts Proton Therapy Center, one of the largest and most advanced facilities in the world with one of the most sophisticated weapons against cancer. Penn is one of the few academic medical centers using proton therapy with chemotherapy and biologic therapy to treat lung cancer prior to surgery.

Radiation may be recommended before lung cancer surgery to shrink a tumor, making it easier for the surgeon to remove. Radiation may be used after surgery if there are worrisome risk factors that make it likely for a tumor to come back in the chest. Sometimes radiation is used instead of surgery if the lung cancer team feels surgery is too dangerous for the patient, or if a tumor is too extensive to be removed with surgery.

Conformal Radiation Therapy (CRT)

In conformal radiation, a special computer uses CT imaging scans to create 3-D maps of the location of the cancer in the lung. The system permits the delivery of radiation from several directions, and the beams can then be shaped, or conformed, to match the shape of the cancer. Conformal radiation therapy limits radiation exposure to nearby healthy tissue as well as the tissue in the beam's path.

CyberKnife®

CyberKnife is a non-invasive alternative to surgery for the treatment of both cancerous and non-cancerous tumors anywhere in the body, including the lung. The treatment delivers beams of high dose radiation to tumors, all converging with extreme accuracy.

Image-guided Radiation Therapy (IGRT)

IGRT uses frequent imaging during a course of radiation therapy to improve the precision and accuracy of the delivery the radiation treatment. The linear accelerators are equipped with imaging technology that takes pictures of the tumor immediately before or even during the time radiation is delivered.

Specialized computer software compares these images of the tumor to the images taken during the simulation to establish the treatment plan. Necessary adjustments can then be made to the patient's position and/or the radiation beams to more precisely target radiation at the cancer and avoid the healthy surrounding tissue.

Intensity-modulated Radiation Therapy (IMRT)

IMRT uses 3-D computed tomography (CT) images of the patient along with computerized dose calculations. It allows for the radiation dose to conform more precisely to the actual three-dimensional shape of the tumor by controlling, or modulating, the intensity of the radiation beam. The therapy allows higher radiation doses to be delivered to regions within the tumor while minimizing the dose to the surrounding area.

Proton Therapy

Proton therapy is external beam radiotherapy in which protons are directed at a tumor. The radiation dose that is given through protons is very precise, and limits the exposure of normal tissues. This allows the radiation dose delivered to the tumor to be increased beyond conventional radiation doses. The result is a better chance for curing cancer with fewer harmful side effects.

Unlike X-rays, protons can be manipulated to release most of their energy only when they reach their target. With more energy reaching the cancerous cells, more damage is administered by each burst of radiation and sensitive, healthy lung tissue is better protected from the effects of radiation.

Photodynamic Therapy (PDT)

Penn was the first health system in the Philadelphia area to begin researching the use of photodynamic therapy (PDT) to treat cancer. Also known as photoradiation therapy, phototherapy, or photochemotherapy, PDT brings together light-sensitive medication with low-level beams of light to destroy cancer cells.

Research has shown that certain chemicals, known as photosensitizing agents, can kill cancer cells when they are exposed to a particular type of light. PDT uses light-sensitive medication, called a photosensitizing agent, together with low-level beams of light to destroy cancer cells. The laser light used in PDT is directed through a fiber-optic strand placed close to the cancer cells.

For treating lung cancer, the fiber-optic strand is directed through a bronchoscope into the lungs. It is primarily used as a treatment for mesothelioma.

Stereotactic Radiosurgery (SBRT)

Stereotactic radiosurgery uses a large dose of radiation to focally destroy tumor tissue. The dose and area receiving the radiation are coordinated very precisely. Penn radiation oncologists use stereotactic radiosurgery to treat lung cancer diagnosed in the early stages. CyberKnife® and Gamma Knife® are two forms of SBRT.

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Chemotherapy and Biologic Therapies

Chemotherapy and Biologic Therapies

Penn medical oncologists administer systemic treatments, usually in the form of chemotherapy as well as newer targeted agents, and coordinate the complex care required for patients with lung cancer. Penn’s recent advanced in biologic therapies allow the lung cancer team to personalize the treatment for every patient.

To ensure that patients get treatment options from all disciplines and that care is optimized, they meet weekly with other members of Penn Medicine’s multidisciplinary lung cancer program to review patient cases and discuss treatment plans in detail.

Chemotherapy

Chemotherapy uses drugs to attack cancer cells, slowing or stopping their ability to grow and multiply. Chemotherapy is usually given:

  • Orally: Pills or capsules taken by mouth
  • Intravenously (IV): Injection into a vein
  • Intramuscularly (IM): Injection into a muscle
  • Subcutaneously: Injection under the skin

Chemotherapy is not a one-size-fits-all cancer treatment. The wide range of cancer-fighting drugs attack different types of cancer cells at varying stages of cell development. Penn medical oncologists are experts at determining which drug or combination of drugs will be the most effective in treating specific types of lung cancer. For example, the use of pemetrexed, one of the most active forms of chemotherapy, is restricted to patients with adenocarcinoma of the lung. In addition, Penn medical oncologists and the oncology nursing staff have developed protocols for reducing or minimizing the side effects of treatment.

Targeted Molecular Therapies

Targeted molecular therapy at Penn Medicine is a type of personalized medical therapy designed to treat cancer by interrupting unique molecular abnormalities that drive cancer growth. Targeted therapies are drugs that are designed to interfere with a specific biochemical pathway that is central to the development, growth and spread of that particular cancer.

Because not every type of lung cancer develops in the same way in every person, targeted molecular therapy is personalized to the individual. In some cancers the molecular targets are known, but in others these targets are still being identified. Identifying the molecular requires working closely with pathologists to carefully analyze the patient’s cancer pathology.

Two specific targets discovered in the past five years have changed the therapeutic landscape. ALK (+) tumors are highly responsive to a newly approved agent called crizotinib. EGFR mutation (+) tumors are very sensitive to erlotinib. Both of these agents are taken orally and neither is associated with the side effects typically seen with chemotherapy.

Penn oncologists in collaboration with molecular pathologists are devoted to discovering new biomarkers that can help drive treatment of lung cancer.

Immunotherapy and Vaccine Therapy

Immunotherapy and vaccine therapy are investigational therapies that have shown promise in repairing, stimulating or enhancing the immune system's responses. The body's immune system helps to prevent disease, but it can also play a role in preventing cancer from developing or spreading. The goal of immunotherapy is to enhance the body's natural defenses and its ability to fight cancer.

Immunotherapy often has fewer side effects than conventional cancer treatments because it uses the body's own immune system to:

  • Target specific cancer cells, thereby potentially avoiding damage to normal cells.
  • Make cancer cells easier for the immune system to recognize and destroy.
  • Prevent or slow tumor growth and spread of cancer cells.

Vaccine therapy is a type of immunotherapy that uses vaccines to teach the body’s immune system to attack and destroy cancer cells. The immune system does not naturally recognize cancer cells as being foreign so it does not mount an immune response against the tumor. Cancer vaccines stimulate the immune system to recognize and attack the cancer cells.

Cancer vaccines treat cancers that have already developed. They are intended to delay or stop cancer cell growth, shrink tumors, prevent cancer from coming back and eliminate cancer cells that have not been killed by other forms of treatment. Vaccines are sometimes made with cells from the patient's own tumor that are modified and given back to the patient to stop, destroy or delay the cancer.

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Clinical Trials

Clinical Trials

More people are surviving cancer than ever before, and new advances provide hope that even greater discoveries lie ahead. Patients who choose Penn’s Lung Cancer Program for care have access to the latest research and clinical trials in planning their treatment.

Through research and clinical trials:

  • Diagnosing cancer has become more precise.
  • Radiation and surgical techniques have advanced.
  • Medications are more successful.
  • Combinations of medical, surgical and radiation therapy are improving our effectiveness and enhancing outcomes.
  • Strategies to address the late effects of cancer and its treatment are improving quality of life.

A complete listing of lung cancer clinical trials is available on the Abramson Cancer Center website.

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Other Treatments

Other Treatments

In addition to standard treatments and clinical trials, patients at Penn Medicine may wish to add additional therapies and treatments such as massage therapy, acupuncture and art therapy. These therapies do not have curative intent, and are designed to complement standard treatments, not take their place. They are meant to improve quality of life and well being during the cancer process.

Integrative Medicine and Wellness Programs

At Penn Medicine, integrative medicine and wellness services can supplement traditional cancer treatments such as chemotherapy, surgery and radiation therapy. While conventional medicine plays a critical role in eradicating cancer, integrative medicine and wellness programs offer patients ways to enhance the quality of their lives, minimize or reduce the side effects of cancer and cancer treatment, and promote healing and recovery.

Cancer specialists at Penn Medicine are knowledgeable and supportive of complementary cancer treatments. The cancer team works with patients and families to integrate these supportive programs into the overall care plan, while ensuring the safety and health of patients.

The Abramson Cancer Center's range of integrative supportive services is designed to help patients cope with the cancer experience and improve their overall sense of well-being. Services include:

The Abramson Cancer Center at Pennsylvania Hospital offers a variety of supportive care programs for patients and families, from diagnosis through survivorship. These programs are available at no cost to the patients treated at Pennsylvania Hospital, and some are open to patients treated elsewhere. These services include social work counseling, nutrition counseling, psychological counseling and spiritual counseling.

The Cancer Appetite and Rehabilitation Clinic (CARE Clinic) focuses on patients experiencing loss of appetite and weight. ;This multidisciplinary clinic includes clinicians from medicine, nursing, physical therapy, nutrition and speech/swallowing therapy.

The Supportive Care Clinic helps to manage cancer-related symptoms, and focuses on goals of care discussions between patients, families and clinicians.

Also integrative support programs include:

Support groups and educational programs are available at Pennsylvania Hospital and the Abramson Cancer Center throughout the year.

Palliative Care

Palliative care provides medical and non-medical interventions to ease the symptoms of cancer and its treatment. Palliative care includes physical, emotional and spiritual care that can enhance the quality of life for cancer patients.

Palliative care can be used to complement traditional cancer therapies, to treat symptoms or to improve quality of life when curative therapies are no longer an option.

Palliative care is an approach to patient care that can be integrated with curative therapies at any point from diagnosis to survivorship or end-of-life care.

Palliative care services include chemotherapy, radiation therapy and surgery as well as psychological counseling, pain management, spiritual counseling, nutrition counseling, music therapy, mindfulness-based stress reduction, art therapy and support groups for patients and families. The goals of palliative care are to enhance the quality of life for cancer patients and their families, and provide emotional and spiritual support to enhance personal growth.

Palliative care services are offered at Pennsylvania Hospital, and at the Hospital of the University of Pennsylvania.

Penn Home Care and Hospice Services

Penn Home Care and Hospice Services offer a full range of home health care needs by partnering three top-level home health care services under one roof:

Penn Home Care and Hospice Services offer an array of specialized therapies and medications for patients with cancer and cancer-related conditions.

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Lung Cancer Survivorship

There are more than 12 million cancer survivors living today as a result of advances in cancer treatment. However, cancer treatments can result in physical, emotional and financial complications long after the therapy is complete. Survivorship programs at Penn’s Abramson Cancer Center and the Abramson Cancer Center at Pennsylvania Hospital are a distinct phase of lung cancer care and are designed to help patients' transition from their cancer treatment routine to a post-cancer care lifestyle.

Personalized Survivorship Care

Personalized Survivorship Care

At the end of treatment, lung cancer patients should schedule a survivorship visit with their oncologist and nurse practitioner. At this time, patients are provided with a summary of the treatment received as well as a plan for follow-up care and a schedule for routine testing.

Penn cancer providers work one-on-one with patients to develop survivorship care plans. Since every cancer and every patient are unique, the plans are tailored to the patients.

The survivorship care plan includes information on:

  • Potential long-term or late side effects of cancer treatment, the symptoms and treatment.
  • Recommendations for cancer screening for disease recurrence or new cancers.
  • Psychosocial effects, including relationships and sexuality.
  • Follow-up visits.

A survivorship care plan encourages patients to review the information with their healthcare team and become active participants in their follow-up care.

Penn also offers lung cancer patients a number of support programs and groups to enhance their survivorship care plans.

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Survivorship Programs at Penn

Survivorship Programs at Penn

Penn Medicine's Living Well After Cancer™ Program is a nationally recognized program that focuses on issues facing cancer survivors. In 2007, the Abramson Cancer Center was designated a LIVESTRONG ™ Survivorship Center of Excellence Network. The Abramson Cancer Center is only one of eight LIVESTRONG centers in the United States, and is the only LIVESTRONG Survivorship Center of Excellence in the Philadelphia region. The program focuses on survivorship, a distinct phase of care.

Prescription for Living: The Cancer Survivorship Program at the Abramson Cancer Center at Pennsylvania Hospital, provides patients with a summary of important information about specific cancer diagnoses and treatments, as well as follow-up information and steps to take towards recovery, supportive care and education to help patients adjust to their lives as cancer survivors.

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Continued Support

Continued Support

Penn offers cancer patients support programs and groups to enhance their survivorship care plans.

The Abramson Cancer Center and Abramson Cancer Center at Pennsylvania Hospital provide materials and host a wide range of activities that provide education and support to address key areas of concern including survivorship for cancer patients and their loved ones.

Focus On: Lung Cancer is a day-long conference that addresses issues for patients with lung cancer, as well as their loved ones. It occurs annually.

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Survivor Stories

Andrew Vartanian

Immediately after being told by his primary care physician that the Abramson Cancer Center is one of the best cancer institutions in the country, Andrew Vartanian made his first appointment.




Spotlight

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