What is Lung Cancer?
Lung cancer begins when abnormal cells grow and multiply in an uncontrolled way in lung tissue. Cancer that starts in the lungs is known as primary lung cancer. It can spread to other parts of the body such as the lymph nodes, brain, adrenal glands, liver and bones. If the primary cancer cells spread to form another tumour at new sites away from the primary, these new sites are called secondary cancers or metastases.
Lung cancer is the 5th most commonly diagnosed cancer, but accounts for the highest number of cancer related deaths, and more deaths than prostate and breast cancers combined. In 2021, it is estimated that 13,810 people will be diagnosed with lung cancer, with the peak age group for diagnosis 70-74 years (1).
While the highest risk factor for lung cancer is tobacco smoking, not all people diagnosed with lung cancer are smokers. Lung cancer patients report suffering stigma related to smoking that can have the following effects:
- thinking they ‘deserve’ their diagnosis;
- being too ashamed of their diagnosis or disheartened by statistics to seek treatment, or;
- having to constantly explain that they are not a smoker
There are other recognised risk factors for lung cancer including:
- exposure to radon, arsenic, cadmium, nickel, diesel fumes, asbestos or soot
- a family history of lung cancer
- second hand (passive) smoking
- history of lung diseases such as lung fibrosis or emphysema
- HIV infection
- older age
The most common symptoms of lung cancer are:
- a new or changed cough that doesn’t go away
- coughing up blood
- chest pain and/or shoulder pain or discomfort – the pain may be worse with coughing or deep breathing
- trouble breathing or shortness of breath
- hoarse voice
- unexplained weight loss
- loss of appetite
- tiredness or weakness
- persistent chest infection
Lung cancer is not the only condition that can cause these symptoms, but if you have any of these symptoms persistently, contact your doctor, even if you are not a smoker.
There are two main types of lung cancer:
- Non small cell lung cancer (NSCLC), which accounts for up to 85% of all lung cancers
- Small cell lung cancer (SCLC)
Once a lung cancer is confirmed, the next step is to determine the stage (extent of the cancer in the body). This is done with CT scans, PET scans and brain scans.
SCLC accounts for approx. 15% of all diagnoses and has two main stages
- Limited stage (LS-SCLC) with the cancer limited to one lung and possibly some lymph nodes
- Extensive stage (ES-SCLC) where the cancer has spread to the other lung, the fluid around the lungs, and potentially to other organs
NSCLC may be further classified as adenocarcinoma, squamous cell carcinoma, or large undifferentiated carcinoma depending on the cell type where the cancer is identified.
Following diagnostic tests, NSCLC will be staged to assist in determination of best treatment options. These can be broadly classified into:
- Stage I and II (early)
- Stage III (locally advanced)
- Stage IV (advanced)
In recent years, adenocarcinoma (sometimes referred to as non-squamous NSCLC) has been characterised on the basis of mutations or alterations in genes in the tumour (“oncogenes”), determined by specific testing. When these abnormalities are thought to be driving the cancer they may be targeted by drugs to block their action and control the cancer, as opposed to “passenger” mutations, where more generic therapy is used. Molecular testing for “driver” mutations is currently reimbursed by the PBS for the following pathways: EGFR, ALK and ROS-1, where targeted drugs are also funded.
Treatment for lung cancer will depend on the type of lung cancer you have, the stage of the cancer, how well you can breathe (your lung function) and your general health. Ideally your case will be reviewed and treatment options determined in a multidisciplinary team meeting (MDT) comprising the various specialities involved in lung cancer care. Generally, treatments comprise the following, although not all options will be offered to all patients based on the lung cancer diagnosis, and some options may be offered in combination.
- Surgery including removal of a lobe (lobectomy), wedge resection (part of the lobe is removed) and pneumonectomy (a whole lung is removed). Video-assisted thoracoscopic surgery (VATS) is increasingly being offered rather than open lobectomy.
- Radiotherapy or radiation therapy is the use of targeted radiation to kill or damage cancer cells. Radiotherapy may also be given as part of palliative care to reduce the symptoms of lung cancer and improve quality of life. Stereotactic ablative body radiation (SABR) or stereotactic body radiation therapy (SBRT) is a type of radiation therapy designed to give a very precise high dose of radiation therapy to small NSCLCs.
- Chemotherapy is the use of drugs to destroy cancer cells. It usually works by blocking the cancer cells from growing, dividing, and making more cells. Because cancer cells usually grow and divide faster than normal cells, chemotherapy has more of an effect on cancer cells. In lung cancer chemotherapy may be given:
- before surgery to try to shrink the cancer and make it easier to remove the cancer (neoadjuvant chemotherapy);
- before or in combination with radiation therapy to make radiation therapy more effective (chemoradiation);
- after surgery to reduce the risk of the cancer returning (adjuvant chemotherapy), or;
- when cancer is advanced – to reduce symptoms and improve quality of life (palliative chemotherapy).
- Immunotherapy, which refers mainly to modern immune checkpoint inhibitors, restores and recruits the patient’s own immune system to fight the lung cancer by releasing the ‘brakes’ that the tumour microenvironment can place on the immune response and restoring visibility of the tumour cell to attack by cells of the immune system.
- Targeted therapies (most often referring to oral tyrosine kinase inhibitors) are used in non-squamous NSCLC to target ‘driver’ mutations that are responsible for driving tumour growth. Patients on these treatments can live for many years, with milder and very manageable side effects.
- Resistance to therapy may still emerge but most targeted therapies have developed newer generation drugs that may overcome drug resistance.
NSCLC and SCLC are treated in different ways.
Generally, early stage SCLC is treated with chemotherapy and radiotherapy, whereas in extensive SCLC, palliative chemotherapy is the mainstay, with radiation therapy offered to control specific areas and to relieve symptoms. Immunotherapy has recently been included in treatment of extensive SCLC to improve disease control when added to standard upfront chemotherapy.
Early-stage NSCLC is considered curable and treatment options include surgery, and possibly chemotherapy after surgery to reduce recurrence. In patients that are not able to undergo surgery, radiotherapy has been shown to be an effective alternative.
Locally advanced NSCLC is usually treated with the intention to eliminate the cancer (referred to as ‘curative intent’), either with the combination of radiotherapy and chemotherapy, followed by immunotherapy, or chemotherapy followed by surgery, depending on the practice at the treating centre.
Advanced NSCLC is generally considered incurable, but treatment is used to control symptoms and quality of life (‘palliative treatment’) and to prolong life. The optimal treatment for a given patient is usually ‘personalised medicine’ taking into consideration the patient’s general health condition and fitness, the impact of the tumour on their symptoms and the biologic characteristics of the tumour, identified from the biopsy. Treatment options include chemotherapy alone or combined with immunotherapy, immunotherapy alone, radiotherapy, or targeted therapy for patients with ‘driver’ mutations in their tumour. When treatment is tailored to the molecular status of the tumour, it may also be called ‘precision medicine’.
In all diagnoses of lung cancer, clinical trials may offer expanded treatment options. Read more about clinical trials.
For an overview of what to expect during all stages of lung cancer care, visit Optimal Care Pathway for People with Lung Cancer Second Edition or the Cancer Council website.
The observed 5 year survival for lung cancer (the rate of survival at 5 years compared to all those diagnosed with lung cancer) in 2013-2017 was 17.8%, slightly higher for females, and slightly lower for males. In 2008-2012, the observed 5 year survival was just 13.2%, with the higher figures in 2013-2017 presumably reflecting the discovery of targeted treatments and immunotherapy (1).
Outcomes are better when lung cancer is diagnosed at an early stage, but more than 40% of lung cancers are diagnosed at Stage IV when the cancer has already metastasised (spread). Furthermore, this percentage of Stage IV lung cancer diagnoses is likely to be much higher, as almost 30% of lung cancer incidence in 2011 was unstaged (1).
In contrast approx. 12% of lung cancers are diagnosed at Stage I, where median 5 year survival is 68% (1).
Following the delivery of a comprehensive lung cancer screening enquiry report by Cancer Australia in 2020, the Australian Government has agreed to commence early scoping of lung cancer screening in Australia. It is expected that this program will target current and former heavy smokers aged 55-74 years (50-74 years in Aboriginal and Torres Strait Islander peoples), offering low dose CT scans every 2 years, and substantially increase the diagnosis of lung cancer at an earlier stage. More information on lung cancer screening can be found on the Cancer Australia website.
What is mesothelioma?
Mesothelioma is a cancer affecting the mesothelial cells which cover most internal organs. There are two main types of mesothelioma; pleural (occurring in the lining of the lungs) and peritoneal (occurring in the lining of the stomach), with malignant pleural mesothelioma accounting for 80-90% of all cases. Rarely, mesothelioma can affect the lining of the testis (tunica vaginalis) or heart (pericardium).
Australia has one of the highest incidences of mesothelioma in the world. In 2021, it is estimated that 868 new cases of mesothelioma will be diagnosed. The average age of diagnosis is 70-75 years.
Mesothelioma is caused by asbestos exposure but the cancer does not develop until 20-50 years after exposure. Many people who develop mesothelioma can identify how they were exposed to asbestos, but in some people, it is difficult to identify when or how asbestos exposure occurred.
The most common symptoms of pleural mesothelioma are:
shortness of breath
pain in the shoulder and upper arm
loss of appetite and/or weight loss
loss of energy
persistent cough or a change in a person’s usual cough
excessive sweating, especially at night.
Early signs of pleural mesothelioma are similar to other conditions and diseases, however, if you think you have been exposed to asbestos, talk to your doctor.
The main symptoms of peritoneal mesothelioma include:
swollen or painful abdomen
loss of appetite
nausea and/or vomiting
fever or night sweats
bowel or urinary problems
While the ‘stage’ of mesothelioma can be described, in practice, staging is less important in mesothelioma than in some other cancers. This is because the stage has less impact on treatment decisions and prognosis for mesothelioma than for many other cancers. The stages of pleural mesothelioma are:
- Stage 1: Early tumour growth occurs along the mesothelial lining of one lung.
- Stage 2: Cancer has spread to nearby lymph nodes.
- Stage 3: Tumours have invaded deeper tissues in nearby organs and distant lymph nodes.
- Stage 4: Metastasis is present, and tumours have formed at distant sites in the body.
Peritoneal mesothelioma is usually staged with the Peritoneal Cancer Index (PCI), a system that assigns a stage to many other abdominal cancers. The PCI determines a score based on tumour size in 13 different regions throughout the abdomen. PCI can only be determined after surgery.
Treatment for mesothelioma will depend on many factors including the type and location of the mesothelioma, symptoms, and the general health of the individual. Generally treatments comprise the following, although not all options will be offered to all patients, and some options may be offered in combination.
- Draining fluid out of the chest (pleural mesothelioma) or abdomen (peritoneal mesothelioma) to give symptom relief
- Other symptom control treatments including pain relief
- Immunotherapy, also referred to as immune checkpoint inhibitors, restores and recruits the patient’s own immune system to fight the cancer by releasing the ‘brakes’ that the tumour microenvironment can place on the immune response and restoring visibility of the tumour cell to the immune system. The goal of immunotherapy is to shrink the mesothelioma and prolong life, but it is not a curative treatment.
- Chemotherapy is the use of drugs to destroy cancer cells. It usually works by keeping the cancer cells from growing, dividing, and making more cells. Because cancer cells usually grow and divide faster than normal cells, chemotherapy has more of an effect on cancer cells. The goal of chemotherapy is to shrink the mesothelioma and prolong life, but it is not a curative treatment. Sometimes chemotherapy is combined with the drug bevacizumab, which may reduce blood vessel growth in cancers.
- Surgery – surgery may be used to reduce symptoms of fluid accumulation in mesothelioma (VATS pleurodesis). Less commonly, surgery is used to remove larger amounts of tumour (pleurectomy/decortication). The role of radical surgery to remove the entire affected lung and pleural (extrapleural pneumonectomy) in mesothelioma is controversial, but in a very small proportion of patients this may be considered and discussed.
- Radiotherapy or radiation therapy is the use of targeted radiation to kill or damage cancer cells. Radiotherapy for mesothelioma is most commonly used to reduce the symptoms of mesothelioma and improve quality of life. For example, radiotherapy may be used to a painful area or a chest wall lump.
In all diagnoses of mesothelioma, clinical trials may offer expanded treatment options. Read more about clinical trials.
There are several mesothelioma support organisations in Australia.
People with mesothelioma can survive a variable length of time, although most people will die of their disease. An individual prognosis estimate will take into account the histological subtype of the disease (epithelioid, sarcomatoid, biphasic or other), the extent of the disease, the age and other health issues of the person affected, and the types of treatments planned. Talk to your doctor for more detailed information on prognosis.
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