Lung Cancer

Overview

What Is It?

Lung cancer occurs most often in people over 50 who have a long history of cigarette smoking.

For many years, lung cancer was considered a man's disease. The reality, however, is that lung cancer is the most common cancer-related cause of death among men and women. In 1987, lung cancer surpassed breast cancer to become the leading cause of cancer death among U.S. women.

In 2016, there will be an estimated 224,390 new cases of lung cancer accounting for about 14 percent of all cancers: an estimated 117,920 cases will be diagnosed in men and 106,470 in women. There will be approximately 158,080 lung cancer deaths (72,160 in women), accounting for one-quarter of all cancer deaths, according to the American Cancer Society.

Overall, a woman has a one in 17 chance of developing lung cancer during her lifetime; if she smokes, her chances are much higher. The incidence of lung cancer in women has climbed at an alarming rate. And since 1950, the lung cancer mortality rate for American women has increased significantly. These increases are clearly attributable to the increases in the number of women who have smoked.

Lung cancer occurs most often in people over 50 who have a long history of cigarette smoking. Normal lung tissue is made up of cells programmed by genes to create tissue in a certain shape and to perform certain functions. Lung cancer develops when the genetic material responsible for the production of these cells is damaged, or mutates. Repeated exposure to carcinogens, such as tobacco smoke, causes the mutations. This damage is known as genetic mutation.

Mutations in the genetic material of the lung cells cause the instructions for those cells to go awry. Consequently, those cells and their offspring reproduce at a dramatic pace without regard for the normal shape and function of the lung. That wild reproduction causes the formation of tumors that may block air passages in the lung and prevent it from functioning as it should. Mutations may also prevent normal programmed cell death, in which normal cells commit a kind of "suicide." Because cancer cells are abnormal, this lack of cell death adds to the accumulation of cells and tumor formation.

Some genes are known as tumor suppressors. Their job is to keep abnormal cells from growing and forming tumors. Some women inherit genes from their parents that are more resistant to damage and cancer than others. Those whose genes do not provide as much protection against cancer are said to be genetically susceptible to the disease. Scientists have shown that some cancers (e.g., breast cancer) involve genes that are passed down from parents to their children, and the link between such genetic mutations and lung cancer is also becoming more probable. But the link to heredity has not been absolutely confirmed in lung cancer.

While genetic mutations may play a role, we know that smoking is the number one cause of lung cancer—about 80 percent of lung cancers are thought to be the result of smoking, according to the American Lung Association. Cigarette smoke contains more than 4,000 different chemicals, 60 of which are proven carcinogens, and hundreds of others increase the cancer-causing power of carcinogens.

The more you smoke and the longer you smoke, the greater your risk of lung cancer. But if you stop smoking, the risk decreases steadily each year as abnormal cells are replaced by normal ones. However, the risk never completely returns to the same risk as that of people who never smoked. Since smoking cessation efforts in the United States in the past few decades have been quite successful, lung cancer is now very often a disease of former smokers.

The second most common risk factor for lung cancer in the United States is exposure to radon, particularly when combined with cigarette smoking. Radon is a radioactive gas found in the earth's rocks and soil. It is formed by the natural breakdown of radium, which is a radioactive product of decaying uranium. Radon problems have been identified in almost every state. This invisible, odorless gas can enter homes from the soil under foundations. Lung cancer risk increases when radon levels are present at high levels in the home and exposure occurs over a long time, according to the American Cancer Society.

You can measure the radon level in your home with a test kit available in hardware stores. You can also hire a company to come to your home to check radon levels. The testing should be conducted more than once, with the results averaged together.

Another leading cause of lung cancer is on-the-job exposure to carcinogens. Asbestos is perhaps the best-known industrial substance associated with lung cancer, but there are many cancer-causing substances that people may deal with at work. Others include uranium, arsenic and certain petroleum products.

Lung cancer takes years to develop. After exposure to carcinogens, a few unusual cells begin to develop. With continued exposure, more abnormal cells appear. These cells may be on their way to becoming cancerous and forming a tumor.

Lung tumors almost always start in the spongy, pinkish-gray walls of the bronchi—the tubular, branching airways of the lungs. Although there are numerous types of malignant tumors that originate in the lung itself (primary lung cancer), the two major types are small-cell lung cancer and non-small-cell lung cancer.

Non-small-cell lung cancer has three subvarieties:

• Adenocarcinoma accounts for about 40 percent of lung cancers. Adenocarcinoma tends to originate along the outer edges of the lungs in the small bronchi or smaller bronchioles. People with a type of adenocarcinoma called adenocarcinoma in situ (previously called bronchioloalveolar carcinoma) generally have a better outlook than those who have other types of lung cancer. Patients with adenocarcinoma have usually been smokers, but when lung cancer develops in nonsmokers, it is almost always adenocarcinoma type.
• Squamous cell carcinoma accounts for about 25 percent to 30 percent of lung cancers. These tumors are usually found in the middle of the lungs, near a bronchus, and are almost always linked to smoking. Squamous cell carcinoma most often starts in cells of the central bronchi, the largest branches of the bronchial tree.
• Large-cell (undifferentiated) carcinomas are a group of cancers with large, abnormal-looking cells that may appear in any part of the lung.

Small-cell lung cancer comprises about 10 percent to 15 percent of lung cancers and is the most aggressive form of the disease. Like squamous cell carcinoma, this cancer usually originates in the central bronchi. It spreads quickly, often before symptoms appear, making it particularly threatening. It frequently spreads (metastasizes) to the liver, bone and brain. Although usually very responsive to chemotherapy, small-cell lung cancer is less curable than other types because it usually isn't discovered until it has spread.

The symptoms of lung cancer vary, depending on several factors, including where in the lung the tumor is located. If the cancer is in one of the bronchi, it can irritate the lining of the bronchus (one of the main airways that branches off of the trachea or windpipe) and cause a chronic cough. The cancerous area may bleed when a person coughs.

If the tumor grows larger, it may gradually fill the bronchus so air can't pass in or out. A blocked bronchus may cause repeated lung infections or pneumonia.

A tumor in the outer part of the lung may not produce any symptoms until it is fairly large. Sometimes the first sign may be chest pain from the tumor growing into the lining of the lung or the ribs and muscle of the chest wall. If the pleura, or lining of the lung, is involved, it often produces fluid, called a pleural effusion. This leads to shortness of breath because the fluid prevents the lung from expanding during breathing. Tumors that develop at the very top of the lung may irritate the nerves that supply the arm and cause severe pain or numbness in the arm. This is known as a superior sulcus, or Pancoast, tumor.

A person's lungs have extensive networks of blood and lymph vessels. Cancer cells may grow into these vessels and be carried by the blood or lymph to circulate through the body. The cancer cells may then be deposited in other organs of the body. A new colony of cancer cells, which starts in another organ, is known as a metastasis.

The first site of tumor metastasis is usually the lymph nodes at the root of the lungs (hilar nodes) and the mediastinum (the space between the two lungs in the middle of the chest). Lymph nodes are small, bean-shaped structures found throughout the body. They produce and store infection-fighting cells.

It is possible for cancer cells that begin in other organs to spread to the lungs. These cases are very different medical problems, however. Depending on the organ of origin, such cases might be termed "primary breast cancer, metastatic to the lungs," or "primary kidney cancer, metastatic to the lungs."

Diagnosis

Lung cancer can cause many symptoms, including:

• Nagging cough
• Chest, shoulder or back pain, which feels like a constant ache that may or may not be related to coughing
• Shortness of breath
• Fatigue and weakness
• Weight loss
• Repeated episodes of pneumonia or bronchitis
• Coughing up blood
• Hoarseness from left-sided tumors if the nerve that controls the left vocal cord becomes injured by the tumor
• Swelling of the neck, face and arms due to a right-sided tumor compressing the superior vena cava, the main vein that drains the upper body
• Symptoms related to a metastasis, such as headache or weakness from the spread of the tumor to the brain, or back pain related to its spread to the spine.
• Symptoms from paraneoplastic syndromes, disorders caused by a hormonal or an immune response of the body to the presence of the cancer. Examples include certain hormone imbalances, neurologic complications and kidney problems. The symptoms of a paraneoplastic syndrome occur regardless of the location of the tumor or its spread. Sometimes a paraneoplastic syndrome precedes the diagnosis of the cancer and leads to a search for cancer.

A lung cancer may sometimes grow undetected for more than a year without producing symptoms. In fact, lung cancer usually spreads outside the lungs without initially causing any symptoms.

It is difficult to diagnose lung cancer at an early stage. Frequently, people don't have symptoms, or symptoms are vague or attributed to other ailments, such as stress, bronchitis, pulled muscles or pneumonia.

When lung cancer is suspected, a series of tests are conducted to confirm the disease and to determine how widely the cancer has spread (staging). The major tests include:

• X-rays: A chest X-ray is frequently ordered as a first step in diagnosis. An X-ray is a two-dimensional picture that can help locate a tumor. If nothing shows up on the X-ray, you probably don't have lung cancer. If your health care professional sees something suspicious, he or she may order additional tests.
• Computed tomography imaging (CT scan) or magnetic resonance imaging (MRI): These tests may help your health care professional confirm a diagnosis suspected from a chest X-ray. CT scans and MRIs use computerized pictures to show very detailed three-dimensional and cross-sectional images of the body. They can depict the size, shape and location of a tumor. These tools are also used to find out if the tumor has spread from the lung to lymph nodes or other organs in the chest or to other parts of the body.
  
  In recent years a type of CT scan called spiral CT has become increasingly more available in medical centers across the country. Spiral CT uses a faster machine that rotates continuously around the body, allowing it to more quickly detect images and identify abnormalities. It can also detect small nodules (early-stage disease) that are not very visible on chest X-rays. Another advantage of spiral CT is that it delivers a lower dose of radiation than traditional CT scans. The disadvantages of spiral CT scans are that they are expensive, and they often find tiny nodules that are not cancerous; in that case, additional testing or even major surgery are required to prove they are benign. Spiral CTs also can be used to look for masses in the adrenal glands, brain and other internal organs that may be affected if lung cancer has spread.
• Low-dose computed tomography (LDCT): As of December 2013, the U.S. Preventive Services Task Force recommends adults ages 55 to 80 who have a 30 pack-year smoking history and currently smoke or have quit smoking within the past 15 years get an annual screening for lung cancer with a low-dose computed tomography. (A pack year is a way to measure the amount a person has smoked over an extended period of time. It is calculated by multiplying the number of packs of cigarettes a person has smoked per day by the number of years a person has smoked. For example, 1 pack year is equal to smoking 1 pack per day for 1 year, 2 packs a day for ½ a year, etc.) Screening can be discontinued after a person has not smoked for 15 years or develops a health problem that limits their ability or willingness to have curative lung surgery or limits their life expectancy.
• Positron emission tomography (PET): In this procedure, the patient is injected intravenously with a small amount of radioactive sugar that cancer cells absorb, enabling the cells to be seen by a special camera. It is based on the premise that cancerous tissue utilizes more sugar than normal tissue, leading cancers to "light up" on the PET scan. The technique is very sensitive and even very small malignant tumors can show up easily. The test is used to determine if the cancer has spread to lymph nodes or other distant places. It is also used to tell if a shadow on your chest X-ray is cancer. Most insurance companies cover expenses for PET imaging, including Medicare. Both false-positive and false-negative PET findings may occur, however (in which the scan shows what looks like cancer, but really isn't, or doesn't show the cancer when it really exists), so it's important that the scans be interpreted very carefully.
• Bone scan: A bone scan can help determine whether lung cancer has spread to the bones. During this test, a small amount of radioactive dye is injected into a vein. It accumulates in areas of bone that may be cancerous. Then a gamma camera scans your body to detect where bone repair is occurring faster than the surrounding bone. This is a sign that the cancer has infiltrated and is destroying the bone.
• Needle biopsy is just like it sounds: a needle is inserted through the chest wall to take a sample of tissue from a known tumor after it's been located by chest X-ray, CT scan or fluoroscopy (fluoroscopy is like an X-ray, but the image is viewed on a screen in real time rather than on film). The sample is then examined under a microscope to see if cancer cells are present. A biopsy is necessary for your health care professional to confirm a cancer diagnosis and to identify the specific type of cancer and its stage. Sometimes a needle biopsy will be done of an area that is suspicious for a metastasis, such as the liver or adrenal gland, to prove that a metastasis is present.
• Surgical biopsy is a test in which the chest wall is opened to remove part or all of the tumor. A pathologist examines tissue samples and provides information about the type of cancer present and the stage of the cancer.
• Bronchoscopy is a procedure in which a flexible lighted tube (bronchoscope) is inserted through the nose or mouth and into the airways to collect bronchial and/or lung secretions or to biopsy for tissue specimens. To make the procedure more comfortable, your mouth and throat may be sprayed first with a numbing medicine, or you may be given medication to make you feel more relaxed. Bronchoscopy is often combined with endobronchial ultrasound, also called EBUS. When the two are combined, an ultrasound probe on the bronchoscope can evaluate the lymph nodes that lie along the trachea and mainstem bronchi. If the nodes are enlarged, the probe can obtain needle aspiration biopsies of them. This technique is often used for staging the mediastinum in people who are newly diagnosed. It may reduce the need for surgical mediastinoscopy (see below).
• Mediastinoscopy is a procedure in which a surgeon makes a small cut in your neck and inserts a hollow lighted tube behind the sternum (breast bone), while you're under general anesthesia. The surgeon then uses the tube to guide instruments into the chest to sample tissue from the mediastinal lymph nodes along the windpipe and major bronchial tube areas. The samples are evaluated under a microscope.
• Thoracoscopy is a procedure in which the surgeon uses a thin, lighted tube connected to a video camera and monitor to view the space between the lungs and chest wall and remove small pieces of tissue for examination under a microscope. It is commonly called VATS (video-assisted thoracic surgery). Like thoracentesis (below), this examination checks whether a pleural effusion is the result of cancer metastasis to the pleural membranes or related to some other condition such as heart failure or an infection. It may also be used to sample lymph nodes that are not accessible to mediastinoscopy in a procedure called mediastinotomy. This surgical procedure opens the chest cavity to remove samples of mediastinal lymph nodes while you're under general anesthesia. More lymph nodes can be sampled in this way than with mediastinoscopy, particularly those on the left side.
• Thoracentesis is a procedure in which the doctor places a needle between your ribs to drain accumulated fluid around the lungs (called pleural effusion) and examines it microscopically for the presence of cancer cells. Malignant pleural fluid can indicate that cancer has spread to the delicate membranes that cover the lungs (called pleural membranes). Fluid accumulation can also prevent the lungs from filling with air, so thoracentesis can improve your breathing.
• Blood counts and blood chemistry tests are not used alone to diagnose lung cancer, but they can spot abnormalities in some of your organs that may signal cancer and may be used to determine whether you are healthy enough to undergo surgery. If cancer has spread to the liver and bones, for instance, it may cause certain chemical abnormalities in the blood. If one of these abnormalities in particular, called the LDH, is significantly elevated, it usually means that the outlook for cure or long-term survival isn't good. A complete blood count (CBC) may also be performed and repeated regularly if you are being treated with chemotherapy to make sure you're not becoming anemic as a result of the treatment and that your white blood cells and platelets are sufficiently high to permit continued therapy.
• Sputum cytology takes a sample of mucus coughed up from the lungs and looks at it under a microscope to check for cancer cells. Typically, you collect early morning sputum samples for three days in a row. Sputum cytology is more likely to find cancers that start in the major airways of the lung, such as squamous cell lung cancers.
• Pulmonary function studies are breathing tests that measure how much air you can breathe into your lungs, how fast you can empty your lungs and how well gas exchange occurs in the lung membranes. These are routinely done before considering surgery that would remove a portion of the lung to ensure you will be able to breathe comfortably after surgery. These tests also help predict the likelihood of postoperative lung complications. Many people who have smoked for many years have also developed chronic obstructive pulmonary disease, which may affect their lung function and make them riskier candidates for surgery.
• Molecular tests are tests that look for specific gene changes in cancer cells to best treat the cancer. They are routinely performed on adenocarcinoma tumor samples, where they are most likely to be positive. Drugs called targeted medications specifically target certain proteins and gene changes. For example, some oral targeted drugs specifically fight a protein called epidermal growth factor receptor (EGFR) that helps cancer cells grow. Lung cancers with certain changes in the EGFR gene are more common in certain groups, including women, nonsmokers and Asians. Other oral targeted drugs target genetic changes such as ALK, ROS-1 or RET, again more commonly positive in people who've never smoked or only smoked minimally.

The stages of non-small-cell cancer are:

• Stage 0: Cancer is only found in a local area and only in a few layers of cells. It has not grown through the top lining of the lung or spread to lymph nodes or distant sites. Another term for this type of lung cancer is carcinoma in situ.
• Stage I: The cancer is confined to the lung, without extension to the lining of the lung or chest wall and not involving lymph nodes. This stage of lung cancer most often does not cause symptoms, so it is often found either on screening examinations or as an incidental finding when an x-ray or scan is done for some other purpose.
• Stage II: The cancer has spread to the lymph nodes at the root of the lung (called hilar or peribronchial nodes). It may also mean the cancer has spread to the chest wall but not to the lymph nodes.
• Stage IIIa: The cancer has spread to the mediastinal nodes (nodes in the space between the lungs) on the same side of the chest as the primary tumor or to the nodes at the point where the windpipe splits into the right and left bronchi (called the carina).
• Stage IIIb: The cancer has spread to the mediastinal nodes on the opposite side of the chest from the primary tumor or to the nodes near the collarbone on either side.
• Stage IV: Cancer has spread to other parts of the body, including if there is a malignant pleural effusion.
• Recurrent: Cancer has come back (recurred) after previous treatment.

There are many ways health care professionals stage small-cell lung cancer, with the simplest method being the following:

• Limited stage: Cancer is found only in one lung and in nearby lymph nodes. This stage is found in about one-third of patients with small cell lung cancer.
• Extensive stage: Cancer has spread outside of the lung to other tissues in the chest or other parts of the body. This stage is found in the other two-thirds of patients.

Recurrent disease means that the cancer has come back (recurred) after it has been treated. It may come back in the lungs or in another part of the body.

Treatment

The three primary forms of treatment for lung cancer are surgery, radiation therapy and chemotherapy. One or more of these therapies may be used to treat lung cancer, depending on the type and stage of the disease as well as your age and overall health. When you're considering treatment options, it's a good idea to seek a second opinion to get more information and help you feel more confident about your chosen treatment plan.

Surgery

Surgery is primarily used to remove the cancerous tumor from the lung. This therapy, called surgical resection, is typically used when the cancer has not spread to other tissues in the chest or elsewhere in the body. It may be the first type of treatment you receive or it may follow chemotherapy and/or radiation, which are sometimes used first to shrink the tumor(s).

During the procedure, a surgeon usually removes nearby lymph nodes to check them for cancer. A widespread misconception is that lung surgery exposes tumors to the air, which makes them spread. This is absolutely false. If the cancer does spread, the growth occurred microscopically before the cancer was diagnosed and before surgery was ever performed.

Three types of surgery are used in the treatment of lung cancer:

• Wedge or segmental resection: If the tumor is small enough, a surgeon may be able to treat it by removing only the immediate part of the lung that is affected. This type of surgery may also be used in patients whose lung function does not allow for more lung tissue to be removed.
• Lobectomy: An entire section (lobe) of the lung is removed. This is the most common operation performed for lung cancer. The right lung has three lobes, and the left lung has two.
• Pneumonectomy: Removal of the entire lung.

There are cases where initial surgery is not recommended. (Other types of surgery still may be used to relieve symptoms, however.) For example, when:

• Cancer has spread to the other lung;
• Cancer has grown from the lung into mediastinal lymph nodes or other organs in the chest;
• Cancer has spread to the lymph nodes in the neck or to other organs, such as the liver, bones or brain;
• There are other health-related problems that make major surgery unsafe.

More recently, a less invasive surgical procedure for treating early stage lung cancer—called video-assisted thoracoscopic surgery (VATS)—has been developed. This procedure involves the insertion of a small hollow tube with a video camera attached to the end into the chest to help the surgeon see the tumor. Only small incisions are needed to make room for the tube, so there is less pain and a shorter recovery period than with standard surgery. However, most experts recommend the procedure only be used for tumors smaller than three to four centimeters (about an inch and a half). Also, because this surgery requires more technical skill than the standard procedure, it is important that it be done by a specially trained and experienced thoracic surgeon.

After surgery, you may experience significant pain, and you should receive pain medication to control it. Some pain, however, is tenacious. Many people who have lung surgery complain of lasting pain at the incision sites. This is especially difficult for women because the incision line is often right at the bra line. Many women find alternatives to tight clothing to avoid this irritating and lasting pain. In some instances, nerve blocks performed by an anesthesiologist may help this problem.

Radiation therapy

Many women with lung cancer will need radiation therapy at some time during their illness, either as a primary treatment or as a means of symptom management called palliation. Radiation therapy consists of directing a beam of high-energy rays at a tumor. By injuring cancer cells so they can't continue to multiply, the radiation slows or stops tumor growth. The amount of radiation used is based on the size and location of the tumor. Another form of radiation, called brachytherapy, involves placing a small pellet of radioactive material through a bronchoscope right into the tumor or the airway closest to the cancer. Side effects associated with radiation include fatigue, dry or sore throat, skin irritation and loss of hair in the treated area. In patients with stage III non-small-cell lung cancer, radiation is a key part of the therapy, usually combined with chemotherapy. Remissions are common, and long-term remissions may occur in some patients.

Chemotherapy

Anticancer drugs are taken intravenously or, sometimes, orally. They circulate throughout the bloodstream killing fast-growing cells like cancer cells. Chemotherapy can be used to destroy the cancer, slow its growth, keep it from spreading or relieve symptoms. Even if chemotherapy doesn't get rid of all the cancer, studies find it can help lung cancer patients live longer and more comfortable lives.

Chemotherapy is usually administered in an outpatient setting and in regular intervals (cycles) at regular doses for several months. In most cases, cycles last three to four weeks, and initial treatment usually consists of four to six cycles. A wide variety of chemotherapy drugs are used for the treatment of lung cancer, and sometimes, two different chemotherapy drugs are given at the same time. For non-small-cell lung cancer, the most common combinations include the use of carboplatin (Paraplatin) or cisplatin (Platinol), in combination with a second drug.

Other commonly used drugs are docetaxel (Taxotere), paclitaxel (Taxol), vinorelbine (Navelbine), gemcitabine (Gemzar), irinotecan (Camptosar), etoposide (VePesid, Toposar, Etopophos, VP-16), vinblastine, and pemetrexed (Alimta).

Combining cisplatin or carboplatin with other drugs such as gemcitabine and paclitaxel appears to be more effective than using one drug alone to treat non-small-cell lung cancer. However, single-drug chemotherapy may be used for people with non-small-cell lung cancer who might not tolerate combination chemotherapy well, such as those in poor general health.

Studies have shown that combinations of two chemotherapy drugs are as effective as combinations of three, and that two-drug combinations produce fewer side effects.

If non-small-cell lung cancer relapses, the drugs typically used for therapy are docetaxel (Taxotere), pemetrexed (Alimta) or one of the new immunotherapy drugs (see below).

Patients with small-cell lung cancer usually initially receive a combination of two to three chemotherapy drugs. The most common combinations are:

• cisplatin (Platinol) and etoposide (VePesid)
• carboplatin (Paraplatin) and etoposide (VePesid)
• cisplatin (Platinol) and irinotecan (Camptosar)
• carboplatin (Paraplatin) and irinotecan (Camptosar)

If the cancer progresses during treatment or returns after treatment, your health care professional may try different chemotherapy drugs depending in part on how soon the cancer begins to grow again.

For people with advanced lung cancers that meet certain criteria, treatment may include a targeted therapy such as bevacizumab (Avastin), ramucirumab (Cyramza) or necitumumab (Portrazza).

If the cancer relapses six months or more after treatment, your health care professional may try the original chemotherapy regimen again.

Because they reach all the parts of your body, chemotherapy drugs also affect normal cells. Side effects vary greatly. The most common include nausea and vomiting, hair loss, fatigue, constipation and susceptibility to infection due to a temporary fall in the white blood cell count. Your health care professional can help you manage these side effects, but you must be sure to communicate how you feel.

Targeted therapy

Newer biologic drugs designed to specifically target and interfere with some aspect of tumor cell function are also used to treat lung cancer. Three—erlotinib (Tarceva), afatinib (Gilotrif) and gefitinib (Iressa)—prevent the production of epidermal growth factor receptor (EGFR), a protein that helps tumor cells grow. In some patients with EGFR mutations, osimertinib (Tagrisso) is used as a second-line drug if one of the three noted above stops working.

A second type of targeted therapy drug, bevacizumab (Avastin), targets a protein that helps new blood vessels form called vascular endothelial growth factor (VEGF). A drug called ramucirumab (Cyramza) works similarly.

Because of the increasing development and availability of targeted drugs, it is becoming more common to test tumor tissue for the presence of the markers that would predict responsiveness to those targeted drugs, for example, EGFR mutations predicting response to erlotinib. Sometimes that requires obtaining additional tumor tissue biopsies to have sufficient material to test.

Immunotherapy

Immunotherapy is the use of medications that stimulate a person's immune system to identify and attack cancer cells. Specific immunotherapy drugs for lung cancer include immune checkpoint inhibitors, as well as medications that target PD-1, a protein on immune system cells called T cells. These drugs block PD-1 or PDL-1, which boost the body's immune system response to cancer cells, slowing the growth of cancer or, in some cases, actually shrinking tumors.

Specific drugs in this category include nivolumab (Opdivo), pembrolizumab (Keytruda) and atezolizumab (Tecentriq). Immunotherapy drugs have side effects, including some that can be serious, such as potentially life-threatening problems with the liver, kidneys, lungs, intestines and other organs. It's important to discuss the risks and benefits of any treatment regimen with your doctor.

Prevention

Unlike many other cancers, there are some steps you can take to prevent lung cancer. If you are a smoker, stop. Numerous smoking cessation courses and aids are available today. Talk to your doctor about options you can explore. If you are a nonsmoker, try to avoid second-hand smoke. Other preventive steps include:

• Test your home for radon, especially if you live in an area known to have high levels. State radon offices can offer more information on correcting this problem. The U.S. Environmental Protection Agency website, located at www.epa.gov/iaq/contacts.html also provides information on how to lower radon levels in homes.
• Be aware of and limit exposure to industrial agents at work such as nickel, chromate, asbestos and vinyl chloride.

Facts to Know

1. Cigarette smoking is responsible for about 80 percent of lung cancers among women. Women who smoke are also at increased risk for cancers of the oral cavity, pharynx, larynx, esophagus, pancreas, kidney, bladder and cervix.
2. In 2016, there will be an estimated 224,390 new cases of lung cancer, accounting for about 14 percent of all cancers: 117,920 will be diagnosed in men and 106,470 in women, according to the American Cancer Society.
3. About 158,080 people will die from lung cancer in 2016, including 72,160 women.
4. Since 1950, lung cancer mortality rates for U.S. women have increased significantly. Women still have lower rates of lung cancer than men, but the gap is closing. In 1987, lung cancer surpassed breast cancer to become the leading cause of cancer death among U.S. women.
5. There are two major types of lung cancer—small-cell and non-small-cell. Small-cell lung cancer is the more aggressive but less common form, though overall survival rates for the same stages are similar for both types.
6. Persistent cough, sputum streaked with blood, chest pain and recurring pneumonia or bronchitis may sometimes be signs of lung cancer.
7. Other risk factors for developing lung cancer include exposure to certain industrial substances, such as arsenic, some organic chemicals, radon and asbestos (particularly for people who smoke); radiation exposure from occupational, medical and environmental sources; air pollution; and second-hand tobacco smoke.
8. If a woman stops smoking before cancer develops, damaged lung tissue gradually starts to return to normal.
9. Surgery, radiation therapy and chemotherapy are the primary forms of treatment for lung cancer. One or more of these therapies may be used, depending on the type and stage of the disease as well as your age and overall health.
10. The five-year relative survival rate for lung cancer depends on the stage the cancer is at when it is found. The survival rate is 60 percent to 70 percent for cases detected when the disease is still localized (stage I), but only a small percentage of lung cancers are discovered that early.

Questions to Ask

Review the following Questions to Ask about lung cancer so you're prepared to discuss this important health issue with your health care professional.

1. What is my risk for lung cancer and how can I limit my risks?
2. How will I be informed of the results of my testing?
3. If I have lung cancer, what treatment options are available?
4. I've been exposed to second-hand smoke. Does that put me at risk for getting lung cancer?
5. What is the stage (extent) of my disease?
6. What are the chances that the treatment you recommend will be successful?
7. Would participating in a clinical trial be appropriate for me?
8. What is the treatment you recommend likely to cost?
9. Assuming the treatment is successful, how often will I need to have checkups?

Key Q&A

Organizations and Support

For information and support on coping with Lung Cancer, please see the recommended organizations, books and Spanish-language resources listed below.

American Cancer Society (ACS)
Website: https://www.cancer.org
Address: 250 Williams Street
Atlanta, GA 30303
Hotline: 1-800-ACS-2345 (1-800-227-2345)
Phone: 404-315-1123

American College of Surgeons Commission on Cancer
Website: https://www.facs.org/cancer
Address: 633 N. Saint Clair Street
Chicago, IL 60611
Phone: 312-202-5085
Email: coc@facs.org

American Institute for Cancer Research
Website: https://www.aicr.org
Address: 1759 R Street, NW
Washington, DC 20009
Hotline: 1-800-843-8114
Phone: 202-328-7744
Email: aicrweb@aicr.org

American Lung Association (ALA)
Website: https://www.lung.org/
Address: 61 Broadway, 6th Floor
New York, NY 10006
Hotline: 1-800-LUNG-USA (1-800-586-4872)
Phone: 212-315-8700

Association of Cancer Online Resources, Inc.
Website: https://www.acor.org
Address: 173 Duane Street, Suite 3A
New York, NY 10013
Phone: 212-226-5525

Cancer Care, Inc.
Website: https://www.cancercare.org
Address: 275 Seventh Ave., Floor 22
New York, NY 10001
Hotline: 1-800-813-HOPE (1-800-813-4673)
Phone: 212-712-8400
Email: info@cancercare.org

Cancer Hope Network
Website: https://www.cancerhopenetwork.org
Address: Two North Road, Suite A
Chester, NJ 07930
Hotline: 1-877-467-3638
Phone: 908-879-4039
Email: info@cancerhopenetwork.org

Cancer Information and Counseling Line (CICL)
Address: AMC Cancer Research Center
1600 Pierce Street
Denver, CO 80214
Hotline: 1-800-525-3777
Email: contactus@amc.org

Cancer Survival Toolbox
Website: https://www.cancersurvivaltoolbox.org
Address: National Coalition for Cancer Survivorship
1010 Wayne Avenue, Suite 770
Silver Spring, MD 20910
Hotline: 1-888-650-9127
Phone: 301-650-9127
Email: info@canceradvisory.org

Cancervive
Website: https://www.facebook.com/cancervive/
Address: Los Angeles, CA
Email: cancervivr@aol.com

Corporate Angel Network
Website: https://www.corpangelnetwork.org
Address: Westchester County Airport
One Loop Road
White Plains, NY 10604
Hotline: 1-866-328-1313
Phone: 914-328-1313
Email: info@corpangelnetwork.org

Lung Cancer Alliance
Website: https://lungcanceralliance.org/
Address: 888 16th St, NW Ste 150
Washington, DC 20006
Hotline: 1-800-298-2436
Phone: 202-463-2080
Email: info@lungcanceralliance.org

Mesothelioma Applied Research Foundation
Website: https://www.curemeso.org
Address: 1317 King Street
Alexandria, VA 22314
Phone: 1-877-363-6376
Email: info@curemeso.org

National Cancer Institute (NCI)
Website: https://www.nci.nih.gov
Address: NCI Public Inquiries Office
6116 Executive Boulevard, Room 3036A
Bethesda, MD 20892
Hotline: 1-800-4-CANCER (1-800-422-6237)
Phone: TTY: 1-800-332-8615

National Coalition for Cancer Survivorship (NCCS)
Website: https://www.canceradvocacy.org
Address: 1010 Wayne Ave., Suite 770
Silver Spring, MD 20910
Hotline: 1-877-NCCS-YES (1-877-622-7937)
Phone: 301-650-9127
Email: info@canceradvocacy.org

National Comprehensive Cancer Network
Website: https://www.nccn.org
Address: 275 Commerce Dr, Suite 300
Fort Washington, PA 19034
Phone: 215-690-0300

National Heart, Lung, and Blood Institute (NHLBI) - NHLBI Health Information Center
Website: https://www.nhlbi.nih.gov
Address: Attention: Website
P.O. Box 30105
Bethesda, MD 20824
Phone: 301-592-8573
Email: nhlbiinfo@nhlbi.nih.gov

Native American Cancer Research
Website: https://www.natamcancer.org
Address: 3022 South Nova Rd.
Pine, CO 80470
Phone: 303-838-9359
Email: info@natamcancer.net

Prevent Cancer Foundation
Website: https://www.preventcancer.org
Address: 1600 Duke Street, Suite 500
Alexandria, VA 22314
Hotline: 1-800-227-2732
Phone: 703-836-4412

Women's Cancer Resource Center
Website: https://www.wcrc.org
Address: 5741 Telegraph Avenue
Oakland, CA 94609
Hotline: 1-888-421-7900
Phone: 510-420-7900
Email: info@wcrc.org

Books

Breathe Right Now
by Laurence A. Smolley

Coming Out of Cancer: Writings from the Lesbian Cancer Epidemic
by Victoria A. Brownworth

Intimacy After Cancer: A Woman's Guide
by Dr. Sally Kydd and Dana Rowett

Living with Lung Cancer: A Guide to Patients and Their Families
by Barbara G. Cox , David T. MD Carr, Eloise Harman, and Robert E. Lee

Smokers & Quitters - What Smoking Means to People & How They Manage to Quit
by Erli Gronberg and Katherine Srb

Spanish-language resources

Medline Plus: Lung Cancer

Website: https://www.nlm.nih.gov/medlineplus/spanish/lungcancer.html
Address: Customer Service
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov