Non-Small Cell Lung Cancer

Clinical Description 

Lung cancer is the leading cause of cancer death for both men and women. There will be approximately 220,500 new cases of lung cancer this year and 150,000 deaths. The average lifetime risk of development of lung cancer, for both smokers and nonsmokers, is 1 in 13 for men and 1 in 16 for women.

There are several types of lung cancer, with two main categories, small cell and non-small cell. Non-small cell cancer tends to grow more slowly than small cell and accounts for 85-90% of all lung cancers. There are three subtypes: adenocarcinoma, squamous cell carcinoma and large cell carcinoma. Adenocarcinoma accounts for approximately 40% of all lung cancers and tends to be located in the outer portions of the lung. Squamous cell carcinoma is closely linked to smoking and accounts for approximately 25-30% of all lung cancer. Squamous cell is often found in the middle portions of the lung, close to a bronchus. Large cell is the least common, representing approximately 10-15% of all lung cancers. It can be found in any part of the lung and tends to grow and spread quickly. 

Symptoms of Non-Small Cell Lung Cancer 
  • Cough: The cough can be new or there can be a change in the nature of a chronic cough. Coughing up blood (hemoptysis) can also be a symptom of lung cancer.
  • Shortness of breath
  • Wheezing
  • Chest pain
  • Hoarseness
  • Weight loss, decreased appetite
  • Fatigue or generalized weakness
  • Headache associated with swelling of the face, arms or neck
  • Arm, shoulder and neck pain can be caused by lung cancer if the tumor is in the top of the lungs. This can cause weakness in the muscles of the hand, a droopy eyelid and blurred vision. 
Risk Factors of Non-Small Cell Lung Cancer

  • Lung cancer increases with age; it can occur in persons younger than 40 years but it is rare. Genetic predispositions for lung cancer do exist. Having a first-degree relative with lung cancer will increase an individual’s risk of developing lung cancer
  • Cigarette smoking is a significant risk factor for the development of lung cancer. It is linked to 85% of all lung cancers. The risk increases as the number of cigarettes and the years smoked increase. The risk of lung cancer stays elevated after quitting and begins to decline 5-10 years after stopping. A smoker’s risk is never as low as a non-smoker’s risk.
  • Environmental factors have been associated with lung cancer. These include tobacco smoke, arsenic, asbestos, radiation and dust or fumes from metals including nickel and chromium. Radon is an important risk factor that can be found in the home. It is odorless and tasteless, so home testing is important. Diesel exhaust and air pollution both result in an increased risk for development of lung cancer. 
  • A history of previous radiation to the chest also results in an increased risk of lung cancer development.

How Non-Small Cell Lung Cancer is Diagnosed 

If an individual has symptoms that suggest lung cancer, the care provider will complete a thorough history and physical and obtain a chest x-ray. If the chest x-ray is abnormal then often a computed tomography (CT) scan is obtained. If the CT scan reveals a suspicious mass then tissue will be needed to confirm the diagnosis. Tissue can be obtained in a variety of ways including bronchoscopy, CT guided biopsy or even surgery.

There are a variety of other imaging studies that might be used to further evaluate the primary lesion and to look for distant spread. Some of these modalities include magnetic resonance imaging (MRI), positron emission tomography (PET) scan, and bone scan. 

Treatment Options for Non-Small Cell Lung Cancer at Tufts Medical Center 

Treatment of non-small cell lung cancer depends on the stage of the disease. Stages range from I to IV with stage I being less advanced and stage IV being more advanced. Stages I through III are referred to as localized disease, while stage IV is referred to as advanced disease.

Options for treatment include surgery, radiation, chemotherapy and newer more specifically targeted agents. Surgery is frequently used to treat early stage non-small cell lung cancer. Some patients may be offered chemotherapy or chemotherapy and radiation following their surgery based on the characteristics of their tumor and involvement of lymph nodes. In some patients, either due to other medical issues or underlying lung disease, surgery is not a safe option. Stereotactic body radiotherapy, or SBRT, is an alternative treatment that has the ability to cure patients with early stage lung cancer. 

If cancer is found within the mediastinal lymph nodes, the ones that are found in the middle of the chest, patients most often receive chemotherapy and radiation. In addition, some of these patients have surgery following a course of chemotherapy or a combination of chemotherapy and radiation. When surgery can be done, this offers the best chance of curing non-small cell lung cancer.

A minority of patients with NSCLC have tumors that have mutations in certain tyrosine kinases, including epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK). These patients may respond well to drugs (tyrosine kinase inhibitors or TKIs) that inhibit the particular kinase, such as erlotinib (Tarceva) or crizotinib. Genetic testing of the tumor specimen can sometimes help guide the choice of TKI therapy.

Patients with advanced disease may be offered palliative systemic treatment with chemotherapy and targeted agents. A short course of focused radiation can often help alleviate symptoms such as pain, shortness of breath or swelling caused by the cancer. All of our patients are provided with supportive care for effective pain management, maintenance of good nutrition, and emotional support.