Symptoms of lung cancer

There are no symptoms absolutely specific to lung cancer. In fact, some 25% of patients with lung cancer get the diagnosis because they are having a chest x-ray or CT scan for some other reason, and a mass is observed that indicates cancer.

Symptoms of lung cancer fall into three basic groups

• those involving the lung
• general symptoms of a significant illness like cancer
• those coming from outside the lung if the cancer has spread.

Symptoms from the cancer’s growth in the lungs include a cough that gets worse, cough bringing up blood (hemoptysis), shortness of breath, wheezing, and chest pain. A person with lung cancer might also have repeated bouts of bronchitis or pneumonia. A smoker may already have a cough, and may have chronic obstructive pulmonary disease (COPD), but the cough will get worse, and may be associated with different type of phlegm. If the cancer has spread locally it can cause hoarseness or trouble swallowing, and other problems in the neck area.

Lung cancer patients often feel weak and tired, have loss of appetite and lose weight, and even feel depressed. They may have a fever.

If the cancer has spread to bone, there will be severe bone pain. If the cancer has metastasized to the brain, a person can have headaches, or symptoms that look like a stroke or other loss of function like confusion or trouble walking. Spread to the lymph glands may cause swollen lymph nodes.

Some lung cancers make hormone-like substances which have effects on the patient’s body. These are called paraneoplastic syndromes. This may or may not cause symptoms, but will probably lead to abnormalities visible with testing.

It is important to note that most people who have a cough do not have lung cancer, and that not everyone who has lung cancer has a cough. Remember, 25% of people with lung cancer have no serious symptoms before diagnosis.

Still, the most significant symptoms in a patient 45 years of age or older is a severe, worsening cough, with or without blood, with or without chest pain or shortness of breath.

Acute coughs are usually from viral illnesses, allergies or asthma, among other things.

Wheezing is another symptom that is not usually from lung cancer. Most people who wheeze have asthma or COPD or an acute viral illness. But new or increasing wheezing, or noisy breathing called stridor, especially in older people, may signal lung cancer.

Anyone who smokes with a cough that won’t go away or is associated with other symptoms should see a doctor. Older people who have been smoking for many years need to be especially careful.

Anyone with a long smoking history who feels generally weak and tired, or who has unexplained bone pain, weight loss or other evidence of a significant illness needs to be evaluated by a physician. Many other things including other cancers can cause similar symptoms.

People who smoke need to be aware of these symptoms, as do other people at risk for lung cancer for other reasons. Physicians need to have a high index of suspicion for lung cancer when seeing patients with these symptoms.

Diagnosis

A diagnosis of lung cancer has to include proof of the malignancy as well as tissue typing of the cancer. This is important because different types of lung cancer behave differently and need different treatments.

Lung cancer diagnosis usually begins with a chest x-ray, which could be as simple as a standard two-view chest x-ray. Perhaps surprisingly, 25% of lung cancer diagnoses start when a tumor shows up either on a chest x-ray or other test being done for some other reason. The patient is at the doctor for another reason and lung cancer turns up. This is another reason to always tell your doctor about your past exposure to asbestos, even it was decades ago

A person who goes to the doctor with respiratory symptoms including chest pain, cough, and shortness of breath will get a chest x-ray, and suspicious masses may be seen on those x-rays. Even someone with systemic complains of weakness and weight loss should get a chest x-ray because of the chance of either a primary lung cancer, or cancer from another site that has spread to the lungs. Patients who are symptomatic with lung cancer usually have easily visible tumors.

Usually a mass or more on chest x-ray is where the diagnosis starts. From there, it is mandatory to get tissue for a diagnosis. This is usually done whatever way is the easiest on the patient. It all depends on how big the mass is, and where it is. It is important to know that if a test detects cancer cells, it is usually correct. If a test does not find cancer cells, it can be wrong, which is called a false negative. The doctors then need to move on to doing the next test.

The easiest thing is to look at sputum (phlegm) for cancer cells. The patient will be given stimulus to cough and the fluid collected. This is usually done three times. If cancer cells are present, the diagnosis can be made.

If the cancer is inside the bigger tubes in the lung, called bronchi, it may be visible on bronchoscopy. For this procedure, a small fiberoptic tube with a light at the end is passed inside the trachea and into the bronchial tubes. The physician can see what is at the end of the tube. Brushings as well as needle biopsies can be taken of any visible or suspicious masses. This is easiest when the cancer is on the interior surfaces of the lung.

Often patients with lung cancer will have it extend to the outer surface of the lung, which has a lining called the pleura. Fluid may then collect in the space between the lung and chest wall, the pleural space, and this is visible on x-ray. The fluid can be removed by a needle, and analyzed for cancer cells. Sometimes a small piece of the lining can also be removed and sent to be analyzed.

If these methods have not worked, a needle biopsy can be obtained directed by x-ray, if the mass can be reached from outside the chest. There is also a test called mediastinoscopy where a small incision is made and a fiberoptic tube is placed to look inside the chest outside the lungs, for possible lymph node spread or an outer lesion.

As some of these tests are being performed, patients will also be checked for possible metastatic disease. This can be done with scans of various organs and systems. Lung cancer can spread to many places, including bone, lymph glands, liver, and the brain. CT scans, PET scans, and MRI tests can all be done.

If the doctors cannot get cells from the tumor in the lungs, they can try and biopsy a metastatic lesion. For example, they could remove an enlarged lymph node, or perform a needle biopsy of a mass inside the liver.

It is very unusual for surgery to be necessary to make the diagnosis of lung cancer, because tissue/cells can almost always be obtained in one of the above ways. In a person with a single lung lesion out in the periphery of the lungs, and with no symptoms, there is a chance the cancer has not spread. If there is no evidence of metastasis, that is the only time when a surgical excisional biopsy would be made, and if positive, part of the lung removed. That patient might have treatable, early cancer.

Based on the histology of the cancer, meaning the type of lung cancer, and the amount of spread inside the chest and to other parts of the body, lung cancer is staged. Treatment is based on type and spread. However, almost all lung cancer has a grim prognosis.

There have been many attempts to screen people at risk for lung cancer with chest x-rays, and or sputum cytology. Nothing has improved the outcome. Neither the National Cancer Institute nor other groups recommend screening at the current time.

The key to lowering lung cancer mortality remains prevention.

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