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Lung cancer

About Lung Cancer
Lung cancer is the disease that develops when cells of the lung start to divide and grow out of control. When it starts from the Lung is called primary cancer and when starts from another part of the body and spread to the lung (secondary cancer). Lung cancer can also spread to other parts of the body such as nearby lymph nodes, brain, liver and bones.
Lungs
Lungs are sponge like organs located inside chest wall. Normally every person has two lungs, one on right hand side and one on the left side. Right lung is divided into three sections called lobes while left lung is divided into two sections. Left lung has two lobes because heart has occupied some space.
During the process of breathing, when you inhale air enters through nose or mouth, then it travels through trachea into the lungs. Trachea (windpipe) is two tubes called bronchi (one is called bronchus). Air enters the lung through bronchi, whereby these bronchi further divides into small tubules called bronchioles. At the end of bronchioles, there are air sacs called alveoli (alveolus in singular form).
At alveolus is where gas exchange occurs, whereby oxygen gas from inhaled air enters into blood stream to the rest of the body, while carbon dioxide is removed from blood into the lungs then removed from the body through exhalation process.That is main function of lungs in the body.
Lungs are covered by fibrous sheet of tissues called pleural membranes (pleura). Pleural membranes protects lungs against chest wall during breathing process. The gap between the pleura is called the pleural space.

Types of lung cancer
There are mainly two types of lung cancer.
• Small cell lung cancer (SCLC).
• Non-small cell lung cancer (NSCLC)
These types are simply differentiated by the way they appear under microscope during diagnosis. Also the way these cancers are treated is different.
Non-small cell lung cancer is divided into three types depending on the cells involved. These subtypes of Non-small cell lung cancerincludes,
• Adenocarcinoma. Adenocarcinoma starts from mucus producing cells of the lungs and is commonly found on the outer part of the lungs. This type of NSCLC tend to grow slower than other types of lung cancer, hence the chance of detection before spread to other parts of the body is high.
• Squamous cell carcinomas (epidermoid). This type of cancer starts in the squamous cells that line the airways of the lung. Normally they are found at the central part of lungs near the bronchus.
• Large cell undifferentiated carcinomas. These are NSCLC that are not clearly squamous or adenocarcinoma. These cancers grow fast and spread quickly. This can be found at any part of the lung. Although it is not lung cancer, but when dealing with lung cancer, there is another cancer known as mesothelioma. Mesothelioma is a type of cancer that affects the covering of the lung (the pleura). This cancer is different to lung cancer and it is divided into two main types; pleural and peritoneal. In most cases, exposure to asbestos is the only known cause of pleural mesothelioma.

Risk factors of lung cancer
When it comes to cancer, anything that increases your probability of developing cancer is called a risk factor. Risk factors only influence development of cancer but it does not directly cause cancer. Sometimes people with risk factors do not develop the disease while those with no risk factors do develop the disease. Knowing risk factors will help you live your life making some better healthy choices to reduce the risk. The risk factors of lung cancer include the following;
• Tobacco smoking. Tobacco smoking is one of the leading cause of lung cancer in various places in the world including Tanzania. Tobacco smoke contains harmful substances that increase your risk of developing lung cancer. In this case of tobacco smoking, there are those who breathe in tobacco smoke coming from others. They are called secondhand smokers.
• Exposure to asbestos. Asbestos is a high heat-resistant fibrous silicate mineral able to be woven into fabrics. It used in brake linings and making fire-resistant and insulating materials. Exposure to this chemical especially to those working in textile, mills and mines, increases the risk of developing lung cancer.
• Personal history of lung cancer. If you have been diagnosed with lung cancer before, your risk of developing lung cancer for the second time is slightly high compared to those with no history of the disease.
• Family history of the disease. Being in a family with lung cancer history to one of your family members, increases your chance of developing lung cancer. This is due to the possibility of having the same genetic defect that contributed to development of lung cancer to your family member.
• Previous radiation exposure. For those with the history of radiation therapy of another cancer to their chest such as radiotherapy of breast cancer and lymphoma, have slightly raised chance of developing lung cancer that result from previous lungs exposure to radiations.
• Air pollution. This mostly affect those living in heavy traffic roads. Although smoke from air pollution increase risk of lung cancer to people near the area, but its effect is for less compared to tobacco smoke.
• Radon exposure. Radon is a radioactive noble gas resulting from radioactive decay of uranium. People living in areas where there is uranium mines have higher risk of developing lung cancer due to exposure to radon.

Prevention
Since the exact cause of lung cancer is not known, there is no way of preventing lung cancer completely, but there are some ways that will help you lower the risk of developing lung cancer. These include the following;
• Stopping and avoiding tobacco smoking. Since tobacco smoking is one of the leading cause of lung cancer, then stopping smoking and avoiding to start smoking will lower your risk of developing lung cancer.
• Controlling air pollution. Enforcing some initiatives to reduce air pollution will help in reducing lung cancer cases in the society.
• Wearing protective gear and following safety procedures at work. For those working in industries where chance of contacting asbestos is high, should wear protective gears while working with asbestos.
• Avoiding radon exposure. To those living in areas with uranium, it is better if they could reside to other distant place from the mines. This will help in reducing the risk of developing the disease.

Screening and early detection of lung cancer
Screening is the process of running some tests to someone with no symptoms of the disease to check for presence or absence of the disease. For some other cancers, screening has proven to be helpful in improving lives of people as through screening, they were able to detect cancer while it was still early.
Early detection of cancer is very crucial in determining outcome of treatment. But for lung cancer it is not the case as symptoms of lung cancer do not always appear at an early stage of the disease and if symptoms do appear, most of the times they are confused with the symptoms of other health conditions of lungs, such as infection and pneumonia.
Currently there is no recommended screening test to those at an average risk of developing lung cancer because of the risks of the test and economic factors (it is expensive). But for those at high risk of developing the disease, there is low dose CT scan (LDCT) test. This test is different to normal CT scan test used for diagnosis of the disease, this test uses low radiation dose.LDCT has proven helpful in detecting lung cancer hence improved their treatment outcome although it is no recommended to those at average risk.

Signs and symptoms of lung cancer
Most cases of lung cancer start showing signs and symptoms at late stage of the disease although some cases can show symptoms at early stage of the disease. So visiting the doctor upon experiencing signs and symptoms is strongly advised. Among the signs and symptoms of lung cancer include the following;
• Coughing or spitting up blood
• Fever
• Coughing that do not go away or keep coming back
• Weight loss
• Shortness of breath
• Persistent lung infections like pneumonia and bronchitis
• Loss of appetite
• Feeling chest pain
• Feeling weak

Diagnosis
Doctors use many tests to find or diagnose cancer. The tests also help doctors to know if the disease started spreading or not. There are many tests used in diagnosis of lung cancer, but not every patient will require all the diagnostic tests available.
Doctor will perform diagnostic test by considering different factors including your signs and symptoms, results of previous tests, general health and size, location and type of cancer suspected. Among the diagnostic procedures for lung cancer include the following;
• Medical history.Although this is usually done as first procedure when you visit your doctor, but it is also one of the diagnostic procedure as from your medical history, doctors will be able to narrow your diagnostic procedure depending on the result of your medical history.
• Chest x-ray. Plain x-ray picture will enable your doctors to check for presence or absence of any abnormal features in your lungs.
• CT scan.Computed tomography is the test that uses x-rays to produce images of internal structures of the body in three dimension mode. Computer will combine these images to form a cross sectional image of your body parts. In this case CT scan of abdomen is mostly used. This may reveal size, position of tumor and if nearby organs and blood vessels are involved. Special dye may be used in order to produce a clear picture.
• MRI scan.Magnetic resonance imaging is the test that uses radio waves and strong magnetic field to produce image of internal parts of the body. Just like CT scan, MRI can provide size, position of tumor and if nearby tissues and blood vessels are involved. MRI can sometimes give detail if tumor is benign or malignant. Also in this test special dye called contrast (gadolinium) is given to help in producing clearer picture.
• PET scan. Positron emission tomography scan is a specialized imaging test, which is available at most major hospitals. It is usedto stage lung cancer, usually after the diagnosisis confirmed.
Before the scan, a small amount of radioactive sugar solutionwill be injected into a vein, usually in your arm. Since cancer cells are growing very fast, they will absorb more radioactive sugar than normal cells, and by using special camera doctors will be able to differentiate between cancer cells and normal cells.
• Bone scan. . Bone scan is very useful in diagnosis of osteosarcoma as it can give information about the whole skeleton. Special radioactive substance is injected into veins. This radioactive substance (tracer) has the property of being absorbed more at the area of a damaged bone than normal bone. Special camera will be used to detect the area with more absorption of this substance. But this doesn`t prove absorption is caused by cancer or other medical condition, so other tests will be required to confirm.
• Bronchoscopy. Bronchoscopy is a test that involves passing a thin, flexible lightened tube into the mouth or nose down through the main windpipe into the breathing passages of the lungs. The test helps the doctor see inside the lungs. In addition to that, the tube can take a small sample of tissue for examination in the laboratory. This test is normally done by a surgeon or a doctor specialized in diagnosis and treatment of lung diseases (pulmonologist)
• Sputum cytology.It is a test that involves examining a phlegm under microscope. It is normally done by a specialized doctor called pathologist. The doctor may ask you to cough up some phlegm so it can be looked at under a microscope. Phlegm from morning cough is the best one to be used for diagnosis purpose.
• Biopsy. This is a test that is most of the time used as conclusive test. Biopsy requires removal of small sample of the affected tissue and view it under microscope. This procedure is done by specialized doctor (pathologist). Basing on appearance of cells, the doctor will be able to tell if it is small cell lung cancer (SCLC) or non-small cell lung cancer (NSCLC).

Staging of lung cancer
Staging is a standard way used by cancer care team to explain how far the cancer has grown or spread. Staging also enables the oncology team to decide the suitable treatment option. In this process of staging, doctors normally use systems in order to describe the stage of cancer.Both NSCLC and SCLC are staged in similar ways. The most common staging system for lung cancer is the TNM system whichis the combination of tumor, node and metastasis meaning it include assessment of tumor size, nodes involved and its metastasis as described below.
• Tumor. Describes size and extent of cancer spread.
• Node. This explain lymph nodes involvement
• Metastasis. Metastasis explains how far has disease spread?
Tumor
Description of tumor is as follows;
• T1a – tumor is less than 2 cm
• T1b – tumor is between 2 cm and 3 cm
• T2a – tumor is between 3 cm and 5 cm
• T2b – tumor is between 5 cm and 7 cm
• T3 – tumor is more than 7 cm or hasgrown into the chest wall, mediastinalpleura, diaphragm or pericardium, orit has made the lung collapse
• T4 – tumor has grown into nearbystructures, such as the mediastinum,heart, trachea, area where the mainairway divides to go into each lung,esophagus or the backbone, or twoor more separate tumors are presentin the same lobe of a lung.
Node
• NX– Nearby lymph nodes cannot be assessed.
• N0– There is no spread to nearby lymph nodes.
• N1– The cancer has spread to lymph nodes within the lung and/or around the areawhere the bronchus enters the lung (hilar lymph nodes). Lymph nodes involved are onthe same side as the primary tumor.
• N2– The cancer has spread to lymph nodes around the carina (the point where thewindpipe splits into the left and right bronchi) or in the space between the lungs (mediastinum). Involved lymph nodes are on the same side as the primary tumor.
• N3–The cancer has spread to lymph nodes near the collarbone on either side, and/orspread to hilar or mediastinal lymph nodes on the side opposite the primary tumor.
Metastasis
• M0 – cancer has not spread to distantparts of the body.
• M1a– separate tumor in acontralateral lobe, tumor with pleuralnodules or malignant pleural effusion.
• M1b – cancer has spread to distant partsof the body, such as the liver or bones.

Description of staging of lung cancer according to TNM system is as follows;
• Stage IA (T1a/T1b, N0, M0). Tumor is no longer than 3cm. It has not spread to near organs or lymph nodes and has not grown to reach membranes surrounding the lung (visceral pleura)
• Stage IB (T2a, No, Mo). Tumor is larger than 3cm but not more than 5cm. It may have grown into surrounding membrane (visceral pleura) but there is no lymph nodeinvolvement or distant metastasis.
• Stage IIA
• (T1a/T1b, N1,Mo). Tumor is less than 3cm and it hasn`t grown to reach membranes surrounding lung (visceral pleura) but it has spread to nearby lymph nodes within the lung or where bronchus enters the lung. There is no distant metastasis.
• (T2a,N1,Mo). Tumor is larger than 3cm but not longer than 5cm and has grown to reach visceral pleura. It has also spread to lymph nodes within the lung or to the lymph nodes where bronchus enters the lung but there is no distant metastasis.
• (T2b,No,Mo). Tumor is larger than 5cm but not longer than 7cm. There is no lymph node involvement or distant metastasis.
• Stage IIB
• (T2b, N1, Mo). Tumor is larger than 5cm but not longer than 7cm. Tumor has grown to reach visceral pleura. Tumor has also spread to the lymph nodes within the lung or where bronchus enters the lung but there is no distant metastasis.
• (T3a, N0, M0). Tumor is larger than 7cm. There is no lymph node or distant sites involvement. It has grown into the chest wall, diaphragm and the membranes surrounding the space between the lungs (mediastinal pleura).
• Stage IIIA
• (T3a, N1, M0). Tumor is larger than 7cm. It has grown into the chest wall, diaphragm and the membranes surrounding the space between the lungs (mediastinal pleura). Tumor has invaded lymph nodes within the lung or at the area where bronchus enters the lung but there is no distant metastasis.
• (T1 to T3, N2, M0). Tumor is of any size, but has not invaded nearby organs such as trachea, heart, aorta and mediastinum. Tumor has reached carina (the site where windpipes splits into left and right bronchi).
• (T4, N0 or N1, M0). Tumor is of any size. Tumor has grown into mediastinum, large blood vessels, trachea, heart, esophagus, backbone or carina. Tumor has either invaded or not invaded lymph nodes within the lung or around the areas where bronchi enters the lungs.
• Stage IIIB
• (T4, N2, M0). Tumor is of any size and may have grown into mediastinum, heart, large blood vessels, windpipe, esophagus, backbone and carina.
• (Any T, N3, M0). Tumor has spread to the lymph nodes at the junction where windpipe split into left and right bronchi or around mediastinum.
• Stage IV
• (Any T, any N, M1a). Tumor can be of any size and may or may not involve nearby structures and lymph nodes. It has spread to the other lung.
• (Any T, any N, M1b). Cancer can be of any size, may or may not involve nearby lymph nodes. Cancer has invaded distant lymph nodes and organs such liver, brain and bones.

Treatment
Following cancer diagnosis, the doctor will break the news and it is normally not very easy to accept that it is cancer. The doctor will be there to help the patient process the news and to help the patient in taking the next steps.
After the patient receives and processes the news that he/she has cancer, one of the most important steps that will follow is decision making. The doctor will present to the patient (relatives/parents/guardians) with all the possible treatment options and explain what they mean. Then with the help of the doctor, the patient (relatives/parents/guardian) will have to choose which treatment option is good depending on benefits of such option.
Despite all the information given by the doctor, sometimes the patient may still be unsatisfied with what he/she has been told. In such situation, the patient is free and advised to seek a second opinion. Second opinion is the opinion that the patient may seek from another specialist (doctor) regarding his/her health problem and in this case it is cancer. Second opinion may include confirmation of the diagnosis, more clarification on your primary doctor recommendations or even reassurances that all the options have been explored.
In addition to standard care treatment options, sometimes there are those new treatments or drugs or combination of treatments that have not been approved yet to be used as standard care treatments for a particular cancer (disease) but have shown some promising results that they may help. These type of treatments are called clinical trials.
If there are some clinical trials for your case, the doctor may present to the patient or the patient may ask if there are any clinical trials for the particular cancer case. Over the years, have improved treatments and led to better outcomes to people diagnosed with various diseases including cancer. If you have decided to take part in clinical trial, you can also withdraw at any time.

Treatment options
In cancer care, different types of doctors and other health care professionals often work together to create a patient’s overall treatment plan that normally combines different types of treatments. This group of cancer care is called a multidisciplinary team. When it comes to lung cancer, multidisciplinary team for small cell lung cancer (SCLC) may differ from that of non-small cell lung cancer (NSCLC).
Difference in multidisciplinary team when dealing with SCLC and NSCLC is due to the difference in how these two types of lung cancer are treated. One of the difference between SCLC and NSCLC is the way these two differ in their treatment options. The difference is mostly contributed by the difference in their growth rate as SCLC grows faster than NSCLC and in most cases, it is detected when it is already at late stage with the possibility of wide spread compared to NSCLC.

Treatment options of lung cancer by type and stage

- -
# Type Stage and option - -
1  Non-small cell lung cancer (NSCLC)  Early stage (I-II) Treated with surgery, including removal of nearby lymph nodes. If surgery is not an option, radiotherapy is offered. Sometimes, chemotherapy may be given after surgery or with radiotherapy (chemoradiation)
2  Local advanced (stage III)  This can be treated with combination of surgery and chemotherapy or radiation therapy and chemotherapy - -
3    Advanced stage (stage IV)            In this stage, surgery is not an option. So palliative chemotherapy in combination with radiation therapy is the option so as to relieve symptoms. - -
4    Small cell lung cancer              (SCLC)            Stage I-III  In this chemotherapy and radiotherapy are mostly used. Surgery is not mostly used because cancer is usually already spread by the time is found.
5    Stage IV            Palliative chemotherapy is preferred although palliative radiation therapy may be given to the areas where cancer has spread including brain, bones and spine.

Surgery
This is mostly used to those with early stage NSCLC and those with stage three of NSCLC but in combination with chemotherapy or radiation therapy. Chemotherapy may be given before surgery (Neo adjuvant therapy) or after surgery (adjuvant therapy).
In very rare cases, surgery may be used for treatment of small cell lung cancer (SCLC). This may be done to those SCLC cases that are detected while at very early stage that disease hasn`t spread to other organs.
Surgery for lung cancer can be done in three ways depending on the extent of the disease. These include the following.
• Lobectomy. This involve removing the entire lobe with tumor.
• Pneumonectomy.This involve removing the entire lung.
• Wedge resection. Involves removing only small affected part of the lobe.

Side effects of surgery
After completion of surgery, there are the effects of surgery that a patient may experience. Cancer care team will be around to help relieve any side effects that you may experience. Common side effects include,
• Pain
• Breathlessness
• Breeding
• Blood clot in your lungs and legsbr.
• Risk of infection
• Reaction from anesthesia.

Chemotherapy
Chemotherapy is the treatment option that involves using drugs to destroy or stop growth of cancer cells. Ant-cancer drugs aim on killing cancer cells with minimal effects to normal cells. Chemotherapy can be injected into veins (intravenous) or taken by mouth (orally).
Chemotherapy can be administered before surgery (neo adjuvant therapy) so as to shrink tumor before surgery or can be given after surgery (adjuvant therapy) in order to remove any remaining cancer cells.
Also sometimes chemotherapy can be administered in combination with radiation therapy (chemoradiotherapy).

Side effects of chemotherapy
Side effects of chemotherapy depend on the dose given, type of drug used and periodic time by which it has been used. Some of the possible side effects include the following.
• Hair loss
• Risk of infection. This is due to decreased white blood cell count from chemotherapy.
• Easily bruising and excessive bleeding. This is due to decreased platelets.
• Low blood cell count due to drugs may cause breathlessness feeling tired.
• Nausea and vomiting
• Mouth sores

Radiation therapy
Radiation therapy is the treatment of cancer by using high energy x-rays or other radiation particles to kill cancer cells. For lung cancer, radiation therapy is used alone or in combination with chemotherapy or surgery. Radiation therapy is used in treating both types of lung cancers either at early or late stage.
Radiotherapy may be delivered in different ways depending on the type of lung cancer. It is usually given as daily treatment over a number of weeks. For treatment of lung cancer external beam radiation therapy (EBRT) is the type of radiation therapy mostly used. EBRT involve treatment of cancer by directing beam of radiation to the treatment site while the machine is outside the body.

Side effects of radiation therapy
The side effects of radiotherapy vary depending on the dose of radiation given. Some of the possible side effects include the following;
• Difficult in swallowing and heart burn. This is mainly caused by sore throat.
• Loss of appetite
• Fatigue
• Nausea and vomiting
• Skin changes
• Shortness of breath and coughing

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