Lung Cancer: A Case Study
Submitted by Anna Stewart RN, BSN, MSN-C
Lung cancer is the number one cause of cancer-related death in men and the second most common in women. Lung cancer is responsible for 1.3 million deaths worldwide annually. The main types of lung cancers consist primarily of small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC). In 2008, the National Cancer Institute (NCI) estimated in the United States that there were 215,020 new cases and 161, 840 cancer related deaths of SCLC and NSCLC combined. The most common cause of lung cancer is smoking. Other risk factors include genetics, radon gas, asbestos and air pollution which includes secondhand smoke.
Diagnostics is an important part of cancer treatment. Distinction between lung cancers is important because of the difference in treatments. Chest radiograph and computed tomography (CT scan) are used to visualize the lung cancer. A biopsy is done to confirm the diagnosis and usually achieved via bronchoscopy or CT guided biopsy. Categorization is done by viewing the cells under a microscope. NSCLC arises from epithelial cells and SCLC begins in the nerve cells or hormone-producing cells of the lung. The term “small cell” refers to the size and shape of the cancer cells as seen under a microscope. The histological classification of lung cancers is significant because it determines the type of treatment and prognosis, the stage (degree of metastasis), and patients performance status.
The frequency of NSCLC is 80.4% compared to 16.8% of cases of SCLC. Other types of lung cancers (carcinoid, sarcoma and unspecified lung cancers) are less than 3%. Surgery, chemotherapy, and radiotherapy are possible treatments. The NCI states that the five year survival rate is 15% with treatment.
SCLC has the poorest prognosis of lung cancer because it is the fastest growing and has usually metastasized by the time a diagnosis is made. Although lung cancer can metastasize anywhere in the body, the most common sites are the lymph nodes, lungs, bones, brain, liver, and the adrenal glands. Metastases from lung cancer can cause additional difficulties such as breathing problems, bone pain, abdominal or back pain, headache, weakness, seizures, and/or speech difficulties. Lung tumors can release hormones that result in chemical imbalances, such as low blood sodium levels or high blood calcium levels, but this is uncommon (NCI, 2008).
Staging of small cell lung cancer
Because almost all small cell lung cancer has spread outside the lung when discovered, very few patients with small cell lung cancer are treated with surgery, and all receive chemotherapy. Some patients with small cell lung cancer can benefit from radiation therapy. The staging for small cell lung cancer helps identify which patients can be treated with radiation therapy in addition to chemotherapy. Small cell lung cancer is classified as either limited stage or extensive stage:
- Limited stage means the cancer is located on one side of the chest and involves a single region of the lung and adjacent lymph nodes. This region can be treated in its entirety with radiation therapy. About 30% of patients have limited stage.
- Extensive stage means the cancer has spread to other regions of the chest, or outside of the chest, and cannot be treated completely with radiation therapy. Most patients (70%) have extensive stage disease and are treated with chemotherapy only (McCance, 2006).
Treatment of small cell lung cancer
The treatment of small cell lung cancer depends on the stage. Small cell lung cancer spreads quickly, so systemic chemotherapy is the primary treatment for all patients. The most commonly used chemotherapy regimen is etoposide (VePesid, Lastet, Etopoph plus cisplatin (Platinol) or carboplatin (Paraplatin). Patients with limited stage small cell lung cancer are best treated with simultaneous chemotherapy plus radiation therapy to the chest given twice a day. Radiation therapy is best when given during the first or second month of chemotherapy. Patients with extensive stage cancer are treated with chemotherapy only. Chemotherapy is given for three to six months. Surgery is rarely appropriate for patients with small cell lung cancer and is only considered for patients with very early-stage disease, such as a small lung nodule. In those cases, chemotherapy, with or without radiation therapy is given afterwards.
In patients whose tumors have diminished after chemotherapy, radiation therapy to the head cuts the risk that the cancer will spread to the brain. This preventative radiation to the head is called prophylactic cranial irradiation (PCI) and has been shown to extend the lives of these patients.
Like patients with advanced NSCLC, patients with small cell lung cancer of any stage face the risk that the cancer can return, even when it is initially controlled. All patients with small cell lung cancer must be followed closely by their doctors with x-rays, scans, and check-ups.
Most patients with lung cancer are treated by more than one specialist with more than one type of treatment. For example, chemotherapy can be prescribed before or after surgery, or before, during, or after radiation therapy. Patients should have a sense that their doctors have a coordinated plan of care and are communicating effectively with one another. If patients do not feel that the surgeon, radiation oncologist, or medical oncologist is communicating effectively with them or each other about the goals of treatment and the plan of care, patients should discuss their concerns with their doctors or seek additional opinions before treatment (Roman & Brigham, 2007).
Radiation therapy is the use of high energy x-rays or other particles to kill cancer cells. Radiation therapy is performed by a specialist called a radiation oncologist. Like surgery, radiation therapy cannot be used to treat widespread cancer. Radiation only kills cancer cells directly in the path of the radiation beam. It also damages the normal cells caught in its path, and for this reason, it cannot be used to treat large areas of the body. Patients with lung cancer treated with radiation therapy often experience fatigue and loss of appetite. If radiation therapy is given to the neck, or center of the chest, patients may also develop a sore throat and have difficulty swallowing. Skin irritation, like sunburn, may occur at the treatment site. Most side effects go away soon after treatment is finished.
If the radiation therapy irritates or inflames the lung, patients may develop a cough, fever, or shortness of breath which may begin months or years after the radiation therapy. This condition occurs in about 15% of patients and is called radiation pneumonitis. If it is mild, radiation pneumonitis does not require treatment and resolves on its own. If it is severe, radiation pneumonitis may require treatment with steroid medications, such as prednisone. Radiation therapy may also cause permanent scarring of the lung tissue near the site of the original tumor. Typically, the scarring does not lead to symptoms. Widespread scarring can lead to permanent cough and shortness of breath. For this reason, radiation oncologists carefully plan the treatments using CT scans of the chest to minimize the amount of normal lung tissue exposed to the radiation beam (Wikipedia, 2009).
Chemotherapy is the use of drugs to kill cancer cells. Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body. Chemotherapy is given by a medical oncologist. Most chemotherapy used for lung cancer is given intravenously. The side effects of chemotherapy depend on the individual and the dose used, but can include fatigue, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. Nausea and vomiting are often avoidable; for more information, read the What to Know: ASCO's Guideline on Preventing Nausea and Vomiting Caused by Cancer Treatment. These side effects usually go away once treatment is finished.
Chemotherapy may also damage normal cells in the body, including blood cells, skin cells, and nerve cells. This may result in low blood counts, an increased risk of infection, hair loss, mouth sores, and/or numbness or tingling in the hands and feet. Your medical oncologist can often prescribe drugs to help provide relief from many side effects. Hormone injections are also used to prevent white and red blood cell counts from becoming too low.
Newer chemotherapies cause fewer side effects and are as effective as older treatments. Chemotherapy has been shown to improve both the length and quality of life in people with lung cancer of all stages.
The medications used to treat cancer are continually being evaluated. Talking with your doctor is the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions through Cancer.Net's Drug Information Resources, which provides links to searchable drug databases (Swierzewski, 2007).
DH is a 70 year old female with a diagnosis of small cell carcinoma of the lung limited stage disease. The patient was diagnosed August, 2007 and treated from 10/2007 through 11/2007 with Carboplatin and VP16. The patient had no response to the initial treatment. She was subsequently treated Carboplatin and Taxol from 12/2007 through 3/2008.
After completion of chemotherapy plans were made for her to receive radiation therapy. The plans for radiation were delayed due to the discovery of a parotid tumor. This tumor was identified as a Warthin’s tumor (benign neoplasm of the salivary glands). The patient did receive radiation therapy from 7/2008 to 10/2008. Dosing of 5,580 cGy (cGy= centigray, the gray measures the deposited energy of radiation) and 31 fractions (the smaller, divided doses of radiation that are given each day) was administered over 70 days.
DH has been off chemotherapy since 3/2008 and radiation therapy since 10/2008 with no further treatment. DH returns today in follow up. She has had a relatively stable weight and good appetite. The patient had a mammogram, CT/Abd-Pelvis and chest x-ray on February 3, 2009. All were normal with the exception of a slight prominence of the left hilum thought to be related to original tumor. Patient also had colonoscopy and endoscopy done on 3/30/2009. The endoscopy was negative but the colonoscopy was positive for diverticuli. PET CT done on 3/25/2009 at local hospital showed areas of enlarged nodes located around the bronchial tree, abdomen and left axillary. DH is to return to her primary care physician (PCP) to have an area in the abdomen removed and biopsied. She has an appointment with the PCP on Friday, April 10, 2009. She does complain of non-exertional chest pain and has a history of hypertension. DH does have some general medical arthritis as well as paresthesias and numbness from Taxol therapy.
Patient’s labs values are stable with Hgb of 12.6, and Hct 39.1. Platelets have improved from previous visit from 312 to 371. White blood cell count continues to improve as well up from 7.52 to 8.0. Lymphocytes and monocytes are stable at 14 and 9 prospectively.
Explanations are given to DH and her husband regarding the possibility of further chemo and radiation therapies pending biopsy results. Patient and husband verbalize understanding and agree to plan of care. Biopsy is scheduled with PCP in two days. Patient scheduled for follow up visit with oncologist in two weeks.
- Brashers, V. (2006). Alterations of Pulmonary Function (pp.1237-1243). In McCance, Pathophysiology The Biologic Basis for Disease in Adults and Children (5th ed.)St. Louis, Mosby Elsevier.
- National Cancer Institute (2009). Small Cell Lung Cancer Treatment (PDQ),
- Retrieved April 13, 2009 from: meb.uni-bonn.de/cancer.gov.
- Roman, J., & Brigham, K., (2007) Neoplastic Disorders of the Lung (pp259-263),
- Andreoli and Carpenter’s: Cecil Essentials of Medicine (7th ed.), Philadelphia, W.B. Sanders Company.
- Swierzewski, S. (2007). Chemotherapy. Retrieved April 13, 2009 from: oncologychannel.com.
- Wikipedia (2009). Lung Cancer, Retrieved April 22, 2009 from: wikipedia.org.