Penn Medicine's Abramson Cancer Center and the Joan Karnell 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.
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.
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.
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.
There are two other types of lung carcinoid tumors and their differences can be seen under a microscope.
Carcinoid tumors are sometimes also classified by where they form in the lung.
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 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:
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.
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.
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.
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:
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:
When lung cancer spreads to distant organs, it may cause:
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.
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.
The TNM staging system for lung carcinoid tumors and non-small cell lung is used to describe the:
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.
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 Joan Karnell Cancer Center. 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:
Penn's lung cancer team has established a national reputation with a number of noteworthy attributes including:
The program focuses on:
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.
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.
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.
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.
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.
At Penn, pathologists look at cells under a microscope to determine if they are cancerous.
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.
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.
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 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:
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.
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:
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.
For treatment purposes, some doctors prefer the two-stage system that divides small cell lung cancers into limited stage and extensive stage.
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).
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.
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.
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.
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.
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.
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.
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.
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.
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 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.
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.
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 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.
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 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.
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 uses drugs to attack cancer cells, slowing or stopping their ability to grow and multiply. Chemotherapy is usually given:
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 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 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:
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.
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:
A complete listing of lung cancer clinical trials is available on the Abramson Cancer Center website.
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.
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 Joan Karnell 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:
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 offer a full range of home health care needs by partnering three top-level home health care services under one roof:
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 Joan Karnell 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.
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:
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.
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 Joan Karnell 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.
Penn offers cancer patients support programs and groups to enhance their survivorship care plans.
The Abramson Cancer Center and Joan Karnell 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.
During her week at college orientation at Columbia University in late August 2008, Annalisa Meier, an outgoing, self-reliant teenager, first noticed that she wasn't feeling well. She began having vivid nightmares and experienced an onslaught of headaches. In her first regular class, September 2, 2008, her jaw began twitching uncontrollably. After class, Annalisa made her way back to her dorm room and called her Mother, Pilar. While on the phone with her Mother, Annalisa fell to the floor and lost consciousness. When Annalisa regained consciousness, she called Pilar again, who "talked her" across campus to the Columbia University's Medical Center.
Watch Focus on Lung Cancer Conference - Get information on the latest advances in lung cancer risk, prevention, diagnosis, treatment, symptom management and psychosocial issues.
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