Lung Cancer

- Is a disease of uncontrolled cell growth in tissues of the lung. This growth may lead to
metastasis, which is the invasion of adjacent tissue and infiltration beyond the lungs. The
vast majority of primary lung cancers are carcinomas of the lung, derived from epithelial
cells. Lung cancer, the most common cause of cancer-related death in men and women, is
responsible for 1.3 million deaths worldwide annually, as of 2004. The most common
symptoms are shortness of breath, coughing (including coughing up blood), and weight
loss.

Cross section of a human lung. The white area in the upper lobe is cancer; the black areas are
discoloration due to smoking.

Classifications

1.) Non-small Cell Lung Carcinoma (NSCLC)

Micrograph of squamous carcinoma

 The non-small cell lung carcinomas are grouped together because their prognosis and
management are similar. There are three main sub-types: squamous cell lung carcinoma,
adenocarcinoma, and large cell lung carcinoma.

Accounting for 25% of lung cancers, squamous cell lung carcinoma usually starts near a
central bronchus. A hollow cavity and associated necrosis are commonly found at the
center of the tumor. Well-differentiated squamous cell lung cancers often grow more
slowly than other cancer types.
Adenocarcinoma accounts for 40% of lung cancers. It usually originates in peripheral
lung tissue. Most cases of adenocarcinoma are associated with smoking; however, among
people who have never smoked ("never-smokers"), adenocarcinoma is the most common
form of lung cancer. A subtype of adenocarcinoma, the bronchioloalveolar carcinoma, is
more common in female never-smokers, and may have different responses to treatment.

2.) Small Cell Lung Carcinoma (SCLC)

Small cell lung carcinoma (microscopic view of a core needle biopsy)

Small cell lung carcinoma is less common. Also called oat cell cancer, it tends to arise in
the larger airways (primary and secondary bronchi) and grows rapidly, becoming quite
large. The small cells contains dense neurosecretory granules (vesicles containing
neuroendocrine hormones), which give this an endocrine/paraneoplastic syndrome
association. While initially more sensitive to chemotherapy, it ultimately carries a worse
prognosis and is often metastatic at presentation. Small cell lung cancers are divided into
limited stage and extensive stage disease. This type of lung cancer is strongly associated
with smoking.

Secondary Cancers

The lung is a common place for metastasis from tumors in other parts of the body. These
secondary cancers are identified by the site of origin; thus, a breast cancer metastasis to the lung
is still known as breast cancer. They often have a characteristic round appearance on chest
radiograph. In children, the majority of lung cancers are secondary.

Primary lung cancers themselves most commonly metastasize to the adrenal glands, liver, brain,
and bone.
Signs and Symptoms

Symptoms that suggest lung cancer include:

• dyspnea (shortness of breath)

• hemoptysis (coughing up blood)
• chronic coughing or change in regular coughing pattern
• wheezing
• chest pain or pain in the abdomen
• cachexia (weight loss), fatigue, and loss of appetite
• dysphonia (hoarse voice)
• clubbing of the fingernails (uncommon)
• dysphagia (difficulty swallowing).

If the cancer grows in the airway, it may obstruct airflow, causing breathing difficulties. This can
lead to accumulation of secretions behind the blockage, predisposing the patient to pneumonia.
Many lung cancers have a rich blood supply. The surface of the cancer may be fragile, leading to
bleeding from the cancer into the airway. This blood may subsequently be coughed up.

Depending on the type of tumor, so-called paraneoplastic phenomena may initially attract
attention to the disease. In lung cancer, these phenomena may include Lambert-Eaton
myasthenic syndrome (muscle weakness due to auto-antibodies), hypercalcemia, or syndrome of
inappropriate antidiuretic hormone (SIADH). Tumors in the top (apex) of the lung, known as
Pancoast tumors, may invade the local part of the sympathetic nervous system, leading to
changed sweating patterns and eye muscle problems (a combination known as Horner's
syndrome) as well as muscle weakness in the hands due to invasion of the brachial plexus.

Many of the symptoms of lung cancer (bone pain, fever, and weight loss) are nonspecific; in the
elderly, these may be attributed to comorbid illness. In many patients, the cancer has already
spread beyond the original site by the time they have symptoms and seek medical attention.
Common sites of metastasis include the brain, bone, adrenal glands, contralateral (opposite) lung,
liver, pericardium, and kidneys. About 10% of people with lung cancer do not have symptoms at
diagnosis; these cancers are incidentally found on routine chest radiograph.

Causes

The main causes of any cancer include carcinogens (such as those in tobacco smoke), ionizing
radiation, and viral infection. This exposure causes cumulative changes to the DNA in the tissue
lining the bronchi of the lungs (the bronchial epithelium). As more tissue becomes damaged,
eventually a cancer develops.
 Smoking
Smoking, particularly of cigarettes, is by far the main contributor to lung cancer. Across the
developed world, almost 90% of lung cancer deaths are caused by smoking. In the United
States, smoking is estimated to account for 87% of lung cancer cases (90% in men and 85%
 in women). Among male smokers, the lifetime risk of developing lung cancer is 17.2%;
among female smokers, the risk is 11.6%. This risk is significantly lower in nonsmokers:
1.3% in men and 1.4% in women. Cigarette smoke contains over 60 known carcinogens,
including radioisotopes from the radon decay sequence, nitrosamine, and benzopyrene.
Additionally, nicotine appears to depress the immune response to malignant growths in
exposed tissue.

The time a person smokes (as well as rate of smoking) increases the person's chance of
developing lung cancer. If a person stops smoking, this chance steadily decreases as damage
to the lungs is repaired and contaminant particles are gradually removed. In addition, there is
evidence that lung cancer in never-smokers has a better prognosis than in smokers, and that
patients who smoke at the time of diagnosis have shorter survival times than those who have
quit.

Passive smoking—the inhalation of smoke from another's smoking—is a cause of lung

cancer in nonsmokers. A passive smoker can be classified as someone living or working with
a smoker as well. Studies from the U.S., Europe, the UK, and Australia have consistently
shown a significant increase in relative risk among those exposed to passive smoke. Recent
investigation of sidestream smoke suggests that it is more dangerous than direct smoke
inhalation.

Roughly ten-fifteen percent of lung cancer patients have never smoked. That means between
20,000 to 30,000 never-smokers are diagnosed with lung cancer in the United States each
year. Because of the five-year survival rate, each year in the U.S. more never-smokers die of
lung cancer than do patients of leukemia, ovarian cancer, or AIDS.

 Radon Gas
Radon is a colorless and odorless gas generated by the breakdown of radioactive radium,
which in turn is the decay product of uranium, found in the Earth's crust. The radiation decay
products ionize genetic material, causing mutations that sometimes turn cancerous. Radon
exposure is the second major cause of lung cancer, after smoking. Radon gas levels vary by
locality and the composition of the underlying soil and rocks. For example, in areas such as
Cornwall in the UK (which has granite as substrata), radon gas is a major problem, and
buildings have to be force-ventilated with fans to lower radon gas concentrations.

 Asbestos
Asbestos can cause a variety of lung diseases, including lung cancer. There is a synergistic
effect between tobacco smoking and asbestos in the formation of lung cancer.

 Viruses
Viruses are known to cause lung cancer in animals, and recent evidence suggests similar
potential in humans. Implicated viruses include human papillomavirus, JC virus, simian virus
40 (SV40), BK virus, and cytomegalovirus. These viruses may affect the cell cycle and
inhibit apoptosis, allowing uncontrolled cell division.

 Particulate Matter
 Studies of the American Cancer Society cohort directly link the exposure to particulate
matter with lung cancer. For example, if the concentration of particles in the air increases by
only 1%, the risk of developing a lung cancer increases by 14%. Further, it has been
established that particle size matters, as ultrafine particles penetrate further into the lungs.

Risk Factors

A number of factors may increase your risk of lung cancer. Some risk factors can be controlled,
for instance, by quitting smoking. And other factors can't be controlled, such as your sex. Risk
factors for lung cancer include:

• Smoking. Smoking remains the greatest risk factor for lung cancer. Your risk of lung cancer
increases with the number of cigarettes you smoke each day and the number of years you
have smoked. Quitting at any age can significantly lower your risk of developing lung
cancer.
• Exposure to secondhand smoke. Even if you don't smoke, your risk of lung cancer
increases if you're exposed to secondhand smoke.
• Exposure to radon gas. Radon is produced by the natural breakdown of uranium in soil,
rock and water that eventually becomes part of the air you breathe. Unsafe levels of radon
can accumulate in any building, including homes. Radon testing can determine whether
levels are safe.
• Exposure to asbestos and other chemicals. Workplace exposure to asbestos and other
substances known to cause cancer — such as arsenic, chromium, nickel and tar — also can
increase your risk of developing lung cancer, especially if you're a smoker.
• Family history of lung cancer. People with a parent, sibling or other first-degree relative
with lung cancer have an increased risk of the disease.
• Excessive alcohol use. Drinking more than a moderate amount of alcohol — no more than
one drink a day for women or two drinks a day for men — may increase your risk of lung
cancer.
• Certain lung diseases. People with certain lung diseases, such as chronic obstructive
pulmonary disease, may have an increased risk of lung cancer.

Complications

Lung cancer can cause complications, such as:

• Shortness of breath. People with lung cancer can experience shortness of breath if
cancer grows to block the major airways. Lung cancer can also cause fluid to accumulate
around the lungs, making it harder for the lungs to expand fully when you inhale.
• Coughing up blood. Lung cancer can cause bleeding in the airway, which can cause you
to cough up blood (hemoptysis). Sometimes bleeding can become severe. Treatments are
available to control bleeding.
• Pain. Advanced lung cancer that spreads to the lining of the lung or to another area of the
body can cause pain. Tell your doctor if you experience pain. Pain may initially be mild
 and intermittent, but can become constant. Medications, radiation therapy and other
treatments may help make you more comfortable.
• Fluid in the chest (pleural effusion). Lung cancer can cause fluid to accumulate in the
space that surrounds the lungs in the chest cavity (pleural space). Pleural effusion can
result from cancer spreading outside the lungs or in reaction to lung cancer inside the
lungs. Fluid accumulating in the chest can cause shortness of breath. Treatments are
available to drain the fluid from your chest and reduce the risk that pleural effusion will
occur again.
• Cancer that spreads to other parts of the body (metastasis). Lung cancer often
spreads (metastasizes) to other parts of the body — most commonly the opposite lung,
brain, bones, liver and adrenal glands. Cancer that spreads can cause pain, nausea,
headaches or other signs and symptoms depending on what organ is affected. In some
cases, treatments are available for isolated metastasis, but in most cases, the goal of
treatment for metastasis is only to relieve signs and symptoms.
• Death. Unfortunately, survival rates for people diagnosed with lung cancer are very low.
In most cases, the disease is fatal. People diagnosed at the earliest stages have the greatest
chances for a cure. Your doctor can discuss your chances for survival with you.

Screening
Screening refers to the use of medical tests to detect disease in asymptomatic people. Possible
screening tests for lung cancer include chest radiograph or computed tomography (CT). As of
December 2009, screening programs for lung cancer have not demonstrated any benefit.

Tests and Diagnosis

• Imaging tests. An X-ray image of your lungs may reveal an abnormal mass or nodule. A
CT scan can reveal small lesions in your lungs that might not be detected on an X-ray.
• Sputum cytology. If you have a cough and are producing sputum, looking at the sputum
under the microscope can sometimes reveal the presence of lung cancer cells.
• Tissue samples (biopsy). A sample of abnormal cells may be removed in a procedure
called a biopsy in order to diagnose lung cancer. Your doctor can perform a biopsy in a
number of ways, including bronchoscopy, in which your doctor examines abnormal areas
of your lungs using a lighted tube that's passed down your throat and into your lungs;
mediastinoscopy, in which an incision is made at the base of your neck and surgical tools
are inserted behind your breastbone to take tissue samples from lymph nodes; and needle
biopsy, in which your doctor uses X-ray or CT images to guide a needle through your
chest and into a suspicious lump or nodule to collect cells. A biopsy sample may also be
taken from lymph nodes or other areas where cancer has spread, such as your liver.
 Chest radiograph showing a cancerous tumor in the left lung

CT scan showing a cancerous tumor in the left lung

Lung cancer staging

Once lung cancer has been diagnosed, the doctor will work to determine the extent, or stage, of
the cancer. The cancer's stage helps the patient and doctor to decide on what treatment is most
appropriate.

Staging tests may include imaging procedures that allows the doctor to look for evidence that
cancer has spread beyond the lungs. These tests include CT scans, magnetic resonance imaging
(MRI), positron emission tomography (PET) and bone scans.

Stages of non-small cell lung cancer

• Stage I. Cancer at this stage has invaded the underlying lung tissue but hasn't spread to
the lymph nodes.
• Stage II. This stage cancer has spread to neighboring lymph nodes or invaded the chest
wall or other nearby structures.
• Stage IIIA. At this stage, cancer has spread from the lung to lymph nodes in the center of
the chest.
 • Stage IIIB. The cancer has spread locally to areas such as the heart, blood vessels,
trachea and esophagus — all within the chest — or to lymph nodes in the area of the
collarbone or to the tissue that surrounds the lungs within the rib cage (pleura).
• Stage IV. The cancer has spread to other parts of the body, such as the liver, bones or
brain.

Stages of small cell lung cancer

• Limited. Cancer is confined to one lung and to its neighboring lymph nodes.
• Extensive. Cancer has spread beyond one lung and nearby lymph nodes, and may have
invaded both lungs, more-remote lymph nodes, or other organs, such as the liver or brain.

Treatment and Drugs

The patient and the doctor choose a cancer treatment regimen based on a number of factors, such
as patient’s overall health, the type and stage of cancer, and preferences. Options typically
include one or more treatments, including surgery, chemotherapy, radiation therapy or targeted
drug therapy.

In some cases one may choose not to undergo treatment. For instance, one may feel that the side
effects of treatment will outweigh the potential benefits. When that's the case, the doctor may
suggest comfort care to treat only the symptoms the cancer is causing, such as pain.

Treatment options for non-small cell lung cancers

Stage Common options
I Surgery, sometimes chemotherapy
II Surgery, chemotherapy, radiation
Combined chemotherapy and radiation, sometimes surgery based on results of
IIIA
treatment
IIIB Chemotherapy, sometimes radiation
IV Chemotherapy, targeted drug therapy, clinical trials, supportive care
Treatment options for small cell lung cancers
Stage Common options
Limited Combined chemotherapy and radiation, sometimes surgery
Extensive Chemotherapy, clinical trials, supportive care

Surgery
During surgery the surgeon works to remove the lung cancer and a margin of healthy tissue.
Procedures to remove lung cancer include:
 • Wedge resection to remove a small section of lung that contains the tumor along with a
margin of healthy tissue
• Segmental resection to remove a larger portion of lung, but not an entire lobe
• Lobectomy to remove the entire lobe of one lung
• Pneumonectomy to remove an entire lung

If one undergoes surgery, the surgeon may also remove lymph nodes from the chest in order to
check them for signs of cancer.

Lung cancer surgery carries risks, including bleeding and infection. Expect to feel short of breath
after lung surgery. Lung tissue will expand over time and make it easier to breathe. The doctor
may recommend a respiratory therapist who can guide one through breathing exercises to aid in
recovery.

Chemotherapy
Chemotherapy uses drugs to kill cancer cells. One or more chemotherapy drugs may be
administered through a vein in the arm (intravenously) or taken orally. A combination of drugs
usually is given in a series of treatments over a period of weeks or months, with breaks in
between so that the body can recover.

Chemotherapy can be used as a first line treatment for lung cancer or as additional treatment
after surgery. In some cases, chemotherapy can be used to lessen side effects of cancer.

Radiation therapy

Radiation therapy uses high-powered energy beams, such as X-rays, to kill cancer cells.
Radiation therapy can be directed at the lung cancer from outside the body (external beam
radiation) or it can be put inside needles, seeds or catheters and placed inside the body near the
cancer (brachytherapy).

Radiation therapy can be used alone or with other lung cancer treatments. Sometimes it's
administered at the same time as chemotherapy.

Targeted drug therapy

Targeted therapies are newer cancer treatments that work by targeting specific abnormalities in
cancer cells. Targeted therapy options for treating lung cancer include:

• Bevacizumab (Avastin). Bevacizumab stops a tumor from creating a new blood supply.
Blood vessels that connect to tumors can supply oxygen and nutrients to the tumor,
allowing it to grow. Bevacizumab is usually used in combination with chemotherapy and
is approved for advanced and recurrent non-small cell lung cancer. Bevacizumab carries
a risk of bleeding, blood clots and high blood pressure.
• Erlotinib (Tarceva). Erlotinib blocks chemicals that signal the cancer cells to grow and
divide. Erlotinib is approved for people with advanced and recurrent non-small cell lung
 cancer that haven't been helped by chemotherapy. Erlotinib side effects include a skin
rash and diarrhea.

Prevention

There's no sure way to prevent lung cancer, but you can reduce your risk if you:

• Don't smoke. If you've never smoked, don't start. Talk to your children about not
smoking so that they can understand how to avoid this major risk factor for lung cancer.
Many current smokers began smoking in their teens. Begin conversations about the
dangers of smoking with your children early so that they know how to react to peer
pressure.
• Stop smoking. Stop smoking now. Quitting reduces your risk of lung cancer, even if
you've smoked for years. Talk to your doctor about strategies and stop-smoking aids that
can help you quit. Options include nicotine replacement products, medications and
support groups.
• Avoid secondhand smoke. If you live or work with a smoker, urge him or her to quit. At
the very least, ask him or her to smoke outside. Avoid areas where people smoke, such as
bars and restaurants, and seek out smoke-free options.
• Test your home for radon. Have the radon levels in your home checked, especially if
you live in an area where radon is known to be a problem. High radon levels can be
remedied to make your home safer. For information on radon testing, contact your local
department of public health or a local chapter of the American Lung Association.
• Avoid carcinogens at work. Take precautions to protect yourself from exposure to toxic
chemicals at work. In the United States, your employer must tell you if you're exposed to
dangerous chemicals in your workplace. Follow your employer's precautions. For
instance, if you're given a face mask for protection, always wear it. Ask your doctor what
more you can do to protect yourself at work. Your risk of lung damage from these
carcinogens increases if you smoke.
• Eat a diet full of fruits and vegetables. Choose a healthy diet with a variety of fruits and
vegetables. Food sources of vitamins and nutrients are best. Avoid taking large doses of
vitamins in pill form, as they may be harmful. For instance, researchers hoping to reduce
the risk of lung cancer in heavy smokers gave them beta carotene supplements. Results
showed the supplements actually increased the risk of cancer in smokers.
• Drink alcohol in moderation, if at all. Limit yourself to one drink a day if you're a
woman or two drinks a day if you're a man. Anyone age 65 and older should drink no
more than one drink a day.
• Exercise. Aim to achieve at least 30 minutes of exercise on most days of the week.
Check with your doctor first if you aren't already exercising regularly. Start out slowly
and continue adding more activity. Biking, swimming and walking are good choices. Add
exercise throughout your day — park farther away from work and walk the rest of the
way or take the stairs rather than the elevator.
Assessment

• New or changing cough, dyspnea, wheezing, excessive sputum production, hemoptysis,

chest pain (aching, poorly localized), malaise, fever, weight loss, fatigue, or anorexia.
• Decreased breath sounds, wheezing, and possible pleural friction rub (with pleural
effusion) on examination.

Nursing Interventions

1. Elevate the head of the bed to ease the work of breathing and to prevent fluid collection
in upper body (from superior vena cava syndrome).
2. Teach breathing retraining exercises to increase diaphragmatic excursion and reduce
work of breathing.
3. Augment the patient’s ability to cough effectively by splinting the patient’s chest
manually.
4. Instruct the patient to inspire fully and cough two to three times in one breath.
5. Provide humidifier or vaporizer to provide moisture to loosen secretions.
6. Teach relaxation techniques to reduce anxiety associated with dyspnea. Allow the
severely dyspneic patient to sleep in reclining chair.
7. Encourage the patient to conserve energy by decreasing activities.
8. Ensure adequate protein intake such as milk, eggs, oral nutritional supplements; and
chicken, fowl, and fish if other treatments are not tolerated – to promote healing and
prevent edema.
9. Advise the patient to eat small amounts of high-calorie and high-protein foods frequently,
rather than three daily meals.
10. Suggest eating the major meal in the morning if rapid satiety is the problem.
11. Change the diet consistency to soft or liquid if patient has esophagitis from radiation
therapy.
12. Consider alternative pain control methods, such as biofeedback and relaxation methods,
to increase the patient’s sense of control.
13. Teach the patient to use prescribed medications as needed for pain without being overly
concerned about addiction.
Far Eastern University – Institute of Nursing

Lung Cancer

Submitted to:
Prof. Nerissa Marcelino

Submitted by:
Aceveda, Armie Mae F.
Dumdum, Aracelie T.
Macaraig, Anna Shiela B.
Obdin, Jelanie Mae L.
Padaoan, Richard A.
Parallag, Michael Jerome V.
Peralta, Marry Dale B.
Rapanut, Robin John P.
Rivera, Anthony N.
Salido, April Marie D.
Santos, Neciel Ann M.
Soriano, Ria Rocelle C.

BSN 129 – Group 113