Cancer of the lungs

Christopher Ekpo
CSON, COHS, Utech
 Definition
 Otherwise known as bronchogenic
cancer
 Malignant tumor of the lungs
 Arises within the wall or epithelial lining
of the bronchus
 The two main types are small cell lung
cancer and non-small cell lung cancer.
 Definition
 NSCLC is divided further into
adenocarcinoma, squamous cell
carcinoma (SCC), and large cell
carcinoma histologies.
 Non-small cell lung cancer (NSCLC)
accounts for approximately 85% of all
lung cancers
(Winston, 2013; National Cancer
Institute, 2013)
 Incidence/epidemiology
• The most commonly diagnosed cancer
worldwide
• In 2007, an estimated 1.5 million new
cases of lung cancer were diagnosed
globally, accounting for approximately
12% of the global cancer burden.
• An estimated 1.35 million lung cancer
deaths occurred in 2007.
 Incidence/epidemiology
• Among all cancers, lung cancer now has the
highest mortality rate in most countries,
with industrialized regions such as North
America and Europe having the highest
rates.
• The highest incidence occurs in the United
Kingdom and Poland (>100 cases per
100,000 population per year). The lowest
incidence rate occurs in Senegal and
Nigeria (< 1 case per 100,000 population
per year)
 Incidence/epidemiology
• Occurs predominately in persons aged 50-
70 years.
• The probability of developing lung cancer
remains very low until age 39 years in both
sexes.
• It then slowly starts to rise and peaks among
those older than 70 years.
• The risk of developing lung cancer remains
higher among men in all age groups after
age 40 years.
 Etiology
 Cigarette smoking-78% in men, 90% in
women
 Exposure to other agents such as
asbestos, inorganic arsenic, nickel,
chromium, coal tar products, halogen
ether, radon, and other environmental
carcinogens
 Etiology
 The development of lung cancer is
directly related to number of cigarettes
smoked, length of smoking history, and
the tar and nicotine content of the
cigarettes
 Risk is highest among current smokers
and lowest among non-smokers.
 Etiology
 A large trial showed that persistent
smokers had a 16-fold elevated lung
cancer risk, which was further doubled in
those who started smoking when
younger than 16 years

(Ginsberg, Vokes & Raben,2007).

 Etiology
 The age-adjusted incidence rates range
from 4.8-20.8 per 100,000 among non-
smokers to 140-362 among active
smokers.
 The risk of lung cancer declines slowly
after smoking cessation
 Etiology
 Long-term follow-up studies show that
the relative risk remains high in the first
10 years after cessation and gradually
declines to 2-fold approximately 30 years
after cessation.
 Etiology
 Cigarette smoke containing the
carcinogenic N-nitrosamines and
aromatic polycyclic hydrocarbons can
be inhaled passively by non-smokers
(second-hand smoke)
 Urinary levels of these carcinogens are 1-
5% of those found in active smokers.
 Etiology

 Asmany as 25% of the lung cancers in

persons who do not smoke are believed
to be caused by second-hand smoke

(Zhong, Goldberg, Parent & Hanley,

2000).
www.doctor care4u.com
 Risk factors
 Tobacco smoke,
 Second-hand (passive) smoke,
 Environmental and occupational
exposures,
 Gender,
 Genetics predisposition
 Dietary deficits.
 Underlying respiratory diseases, such as
COPD and TB
 Pathophysiology
 Both exposure (environmental or
occupational) to particular agents and an
individual’s susceptibility to these agents
are thought to contribute to one’s risk of
developing lung cancer.
 Active smoking is responsible for 90% of
lung cancer cases.
 Occupational exposures to carcinogens
account for approximately 9-15% of lung
cancer cases.
 Pathophysiology
 Tobacco smoke contains more than 300
harmful substances with at least 40
known potent carcinogens
 Lung cancers arise from a single
transformed epithelial cell in the
tracheobronchial airways in which the
carcinogen binds to and damages the
cell’s DNA ( Winston, 2013).
 Pathophysiology
 The damage results in cellular changes,
abnormal cell growth and eventually a
malignant cell.
 As the damaged DNA is passed onto
daughter cells, the DNA undergoes
further changes and becomes unstable
(Smelter, Bare, Hinkle & Cheever,
2010).
 Pathophysiology

 Withthe accumulation of genetic

changes, the pulmonary epithelium
undergoes malignant transformation
from normal epithelium eventually to
invasive carcinoma
Courtesy, www.specialtyclinic.com
 Clinical manifestations
 Lung cancer is often insidious, and it may
produce no symptoms until the disease is
well advanced.
 Approximately 7-10% of patients with
lung cancer are asymptomatic, and their
cancers are diagnosed incidentally after
a chest radiograph performed for other
reasons.
 Clinical manifestations
 At initial diagnosis, 20% of patients have
localized disease,
 25% of patients have regional metastasis,
and
 55% of patients have distant spread of
disease
 Symptoms depend on the location of
cancer
(Spiro, Gould & Colice, 2007).
 Clinical manifestations
Endobronchial symptoms include the
following:
 Cough (45-75%)
 Hemoptysis (57%)
 Bronchial obstruction
 Post obstructive complications (eg,
pneumonitis, pneumonia, effusion)
 Clinical manifestations
Mediastinal symptoms include the
following:
 Dyspnea
 Postprandial coughing (esophageal)
 Wheezing
 Stridor (upper airway obstruction, 2-
18%)
 Clinical manifestations

 Hoarseness (left vocal cord paralysis due

to recurrent laryngeal nerve
impingement, 2-18%)
 Palpitations (pericardial)
 Dysphagia (due to compressing the
middle third of the esophagus)
 Clinical manifestations

Pleural symptoms include the following:

 Chest pain (27-49%)
 Dyspnea (37-58%)
 Cough (45-75%
(Winston, 2013).
 Clinical manifestations

Neurologic symptoms include the

following:
 Arm weakness and paresthesias
(brachial plexus impingement)
 Dyspnea (secondary to phrenic nerve
paralysis)
 Clinical manifestations

Metastatic (8-68%) symptoms include the

following:
 Weight loss
 Cachexia
 Clinical manifestation
Central nervous system (CNS) symptoms
include the following:
 Headache
 Altered mental status
 Seizure
 Meningismus( nuchal rigidity,
photophobia)
 Ataxia
 Nausea and/or vomiting
 Clinical manifestations

Vascular symptoms include the following:

 Phlebitis
 Thromboembolism (Trousseau
syndrome)
 Clinical manifestations
Musculoskeletal symptoms include the
following:
 Bone pain (6-25%)
 Spinal cord impingement
 Systemic findings may include
unexplained weight loss and low-grade
fever.
 Prognosis

 Lungcancer is highly lethal. Data

compiled by the American Cancer
Society show lung cancer to be, by far,
the most common fatal cancer in men
(31%) and in women (26%).
 Diagnostic assessment

 Positronemission tomography (PET)

scans may be useful in the detection of
involved nodes, the presence of which
may influence decisions about
operability.
 Diagnostic assessment

 Chest radiograph: Usually the first test

ordered in patients in whom a lung
malignancy is suggested. If the tumor is
clearly visible and measurable, chest
radiography can sometimes be used to
monitor response to therapy.
 Diagnostic assessment

 Sputum cytologic studies: Centrally

located endobronchial tumors may
exfoliate malignant cells into sputum.
(This location and tendency to exfoliate
are most common in squamous cell
carcinomas (SCCs).
 Diagnostic assessment

 Transthoracic needle biopsy, guided by

CT or fluoroscopy, is preferred for tumors
located in the periphery of the lungs
because peripheral tumors may not be
accessible through a bronchoscope
 Diagnostic assessment
 Bronchoscopy: Provides a means for
direct visualization of the tumor, allows
determination of the extent of airway
obstruction, and allows collection of
diagnostic material under direct
visualization with direct biopsy of the
visualized tumor, bronchial brushings
and washing, and transbronchial
biopsies.
 Diagnostic assessment

 Thorascoscopy: Reserved for tumors that

remain undiagnosed after bronchoscopy
or CT-guided biopsy.
 Thoracoscopy is also an important tool in
the management of malignant pleural
effusions.
 Diagnostic assessment

 Chest CT scan: Is the standard for

staging.
 The findings of CT scans of the chest and
clinical presentation usually allow a
presumptive differentiation between
NSCLC and SCLC.
 Diagnostic assessment

 MRI: Most useful when evaluating a

patient in whom spinal cord compression
is suggested. In addition, brain MRI has a
greater sensitivity than CT scan for
detection of central nervous system
metastasis.
 Diagnostic assessment
 Bone scintigraphy: The skeletal system is
another common site of metastases for
lung cancers.
 If patients report bone pain or if their
serum calcium and/or alkaline
phosphatase levels are elevated, a bone
scan should be obtained to search for
bone metastases
 Diagnostic assessment

 ECG: Helpful in establishing baseline

findings and differentiating clinical
symptoms (eg, chest pain, dyspnea).
 Changing lung hemodynamics often
alters ECG wave patterns.
 Diagnostic assessment
 Staging: The most important prognostic
indicator in lung cancer is the extent of
disease and lymph node involvement. The
TNM (tumor-node-metastasis) staging
system takes into account the degree of
spread of primary tumor, the extent of
regional lymph node involvement, and the
presence or absence of distant
metastases. The TNM system is used for all
lung carcinomas except SCLCs.
 Diagnostic assessment

 Lab studies:
 CBC- should be obtained in every
patient for staging purposes especially
before instituting chemotherapy
 Arterial blood gas (ABG) levels are
useful in the detection of respiratory
failure
 Management
This generally depends on the stage of the
disease, the cell type and the physiologic
status
of the patient:
 Surgical resection
 Radiation therapy
 Chemotherapy
 Immunotherapy
 Management
 Surgical resection remains the mainstay
of treatment for all patients with stage I
and II NSCLC—that is, those patients with
no evidence of mediastinal disease or
invasion of local organs
 Management

 Inthe treatment of stage I and stage II

NSCLC, radiation therapy alone is
considered only when surgical resection
is not possible because of limited
pulmonary reserve or the presence of
comorbidities.
 Management
 Only 30-35% of patients with NSCLC
present with sufficiently localized disease at
diagnosis to attempt curative surgical
resection.
 Approximately 50% of patients who
undergo surgical resection experience local
or systemic relapse; thus, approximately
80% of all patients with lung cancer are
considered for chemotherapy at some point
during the course of their illness.
 Complications
 Patients usually report back pain and
neurological symptoms in the form of
decreased sensation in the lower half of
the body, decreased strength, loss of
bowel control, and loss of bladder
control.
 A careful neurologic examination usually
localizes the level of compression
 Complications
 The most common metabolic
complication associated with NSCLC is
hypercalcemia, (usually associated with
squamous cell carcinoma).
 Other findings can include
hyponatremia, and syndrome of
inappropriate secretion of antidiuretic
hormone (SIADH).
 Nursing management
 History and physical assessment
taking into consideration the onset,
duration of coughing, sputum production
and the degree of dyspnea. A cough that
changes in character should arouse
suspicion of lung cancer
 Identify the needs and manage
according to the nursing diagnoses
Discharge plan
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http://ww2.cancer.org/downloads/STT/5
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National Cancer Institute(2013). Lung
Cancer.
Retrieved from:
http://www.cancer.gov/cancertopics/type
s/lung
Smelter, S. C.; Bare, B. G.; Hinkle, J. L. &
Cheever, K. H. (2010). Brunner &
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nursing (12th ed.). Philadelphia: Wolters
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Retrieved from:
http://emedicine.medscape.com/article/2
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