How is lung cancer diagnosed?
If lung cancer is suspected, a number of tests will be done to help make a diagnosis.
Some of these tests can also show if cancer has spread to other parts of the body. Not every person will have all the tests described in this booklet. Your doctors will determine the best tests for you.
Imaging tests
Chest x-ray
An x-ray of the chest can show tumours as small as 1cm wide.
Occasionally a tumour is found on a chest x-ray that has been taken for other reasons. X-rays are painless and effective in identifying tumours, but sometimes small, hidden tumours don't show up on the x-ray.
View an example of an x-ray showing a lung cancer tumour.
CT scan
A computerised tomography (CT) scan is a special type of x-ray that gives a three-dimensional picture of the organs and other structures (including any tumour) in your body. This test is painless.
CT scans are usually done at a hospital or a radiology service. They help:
- identify smaller tumours than those found by x-rays
- assess whether lymph nodes are enlarged
- determine whether the cancer may have spread to other parts of the body.
A CT scan usually takes less than 10 minutes. You will be asked to lie flat on a table while the CT scanner, which is large and round like a doughnut, rotates around you.
Before the scan, a dye may be injected into a vein, probably in your arm. This will make the scanner’s pictures clearer.
You will be asked not to eat or drink for a while before your scan. Most people are able to go home as soon as their scan is done.
PET scan
A positron emission tomography (PET) scan is a specialised imaging test that is available in only some hospitals.
- You will have an injection of a radioactive glucose solution.
- The glucose circulates the body.
- Active cells, like cancer cells, may take up more of this glucose solution.
The PET scan is useful in diagnosing lung tumours where a biopsy is not possible. It is also very helpful in staging lung cancer, and finding cancer that might have spread to other body organs, such as the lymph nodes, bones, brain, liver and adrenal glands.
Bone scan
In a bone scan, a small amount of radioactive substance is injected into a vein. It travels through the body and collects in areas of abnormal bone growth. A scanner measures the radioactivity levels in these areas and records them on x-ray film.
- Test is often used after cancer has been diagnosed -- it can identify spread of cancer to the bones.
- Sometimes done if the patient is complaining of pain and aches in their bones and joints.
- A bone scan might identify a spread of the cancer to the bones.
- Takes several hours.
Brain scan
- The brain scan is most useful once lung cancer has been diagnosed.
- Sometimes used if the patient is complaining of unexplained symptoms such as headaches and dizziness.
- A brain scan might identify a spread of the cancer to the brain.
Tissue sampling test
Sputum cytology
The sputum cytology test is an examination of sputum (liquid phlegm coughed up from lungs) under a microscope to check for abnormal cells.
You can collect sputum samples by coughing deeply to bring up sputum from your lungs. You can do this at home, storing the sample in the fridge before taking it to the doctor or pathology collection centre.
Brushing and washing
If a lung tumour is near your main respiratory tract, the cells that line the respiratory tract can be sampled using a collection technique process called brushing and washing. This is done during a bronchoscopy.
- In "washing", a small amount of fluid is injected into the lungs and then withdrawn.
- The sample is examined under a microscope.
- "Brushing" is when the tool lifts some cells from the lining of the bronchi.
Bronchial biopsy
If a tumour can be seen in your airway during a bronchoscopy, a biopsy might be taken. A sample of tissue from your lungs is examined under the microscope.
Fine-needle aspiration
A fine-needle aspiration biopsy is done when tumours are accessible (in the outer parts of the lung). Not every tumour can be safely sampled this way.
- The procedure is done in a hospital or radiology department.
- A local anaesthetic is injected into the skin and, under the guidance of an x-ray machine, a needle is inserted through the chest wall and into the tumour.
- Cells are withdrawn through the needle.
- You will be observed afterwards because the lung is at risk of being punctured during this procedure.
- A procedure called thoracentesis also uses a fine needle. Instead of going into the tumour, fluid from between the membranes that cover the lungs (the pleural space) is sampled to check for cancer cells.
Tests to look at growth
Bronchoscopy
Bronchoscopy allows the doctor to look directly into your bronchi (airways). The bronchoscope can only look at the larger airways, so if the tumour is in the outer part of the lung, it may not be seen.
- You will be given a light sedative.
- A flexible tube called a bronchoscope is inserted through the nose or windpipe.
- A sample of tissue (biopsy) may be taken during the bronchoscopy.
- Can be uncomfortable, but it shouldn't be painful.
Mediastinoscopy
A mediastinoscopy is a procedure that allows a cardiothoracic surgeon to examine lymph nodes at the centre of your chest (and remove a sample, if necessary).
- You will have a general anaesthetic/
- A rigid tube is inserted through a cut in your neck and down the windpipe (trachea).
- The surgeon inspects the area between the lungs (mediastinum).
- Usually a day procedure in hospital, but you may have to stay overnight.
Video-assisted thoracoscopic surgery
Thoracoscopes are instruments like bronchoscopes and mediastinoscopes. The doctors can see inside your chest using these instruments, and take tissue samples if necessary.
A small video camera guides the surgeon, who watches a video screen. You may have up to three small cuts in your chest, one for the camera and two for the surgical instruments. You will have a general anaesthetic and be in hospital for 2-3 days.
Thoracotomy
- A thoracotomy is a major operation performed under a general anaesthetic.
- The cardiothoracic surgeon opens the chest cavity through a cut on the back and examines, biopsies and/or removes the tumour.
- It is only required when all other tests fail to provide a diagnosis.
Other test
You may also have blood and breathing tests.
If surgery is being planned, it is important to check that you are fit to have an operation, particularly that your breathing capacity is good enough. Some people who smoke develop a condition called emphysema, in which the alveoli of the lungs are enlarged and damaged. They may have reduced breathing capacity.
Staging
Staging describes the size of a tumour and if it has spread from its original location. Staging the cancer helps determine what treatment is required.
Staging small cell lung cancer
Small cell lung cancer has often spread outside the chest when it is diagnosed. It is staged in two ways:
- Limited disease -- when the tumour can be detected in only one lung and nearby lymph glands.
- Extensive disease -- other cases.
Staging non-small cell lung cancer
Staging non-small cell lung cancer is more complex. The following is a simplified guide to staging this condition:
- Stage 1 - Tumours are only in one lobe of the lung.
- Stage 2 - A tumour in the lung with limited spread to nearby lymph nodes, or a tumour that has grown into the chest wall.
- Stage 3A - Tumours have spread to lymph nodes in the centre of the chest (the mediastinum).
- Stage 3B - Tumours have spread more extensively to lymph nodes in the mediastinum, or there is a collection of fluid in the pleural space around the lung, or there are tumours in more than one lobe.
- Stage 4 - The cancer cells have spread to distant parts of the body. Lung cancer sometimes spreads to the bones, the liver and to the adrenal glands (the glands that sit on top of the kidneys and regulate stress response).
Prognosis
Prognosis means the expected outcome of a disease.
You will need to discuss your prognosis with your doctor, but it is not possible for any doctor to give you a 100% accurate prognosis.
It will be important to complete any tests to assess the stage of the tumour and then to observe how quickly it grows and how well you respond to treatment.
As in most types of cancer, the results of treatment are best when the cancer is found and treated early. People operated on in the early stages of lung cancer have the best chance of cure.
Which health professionals will I see?
Your GP will arrange the first tests to check out your symptoms.
If these tests do not rule out cancer, you will generally be referred to a lung specialist. This specialist will arrange further tests and advise you about treatment options.
You should expect to be cared for by a team of health professionals associated with a treatment centre that can diagnose and treat your lung cancer.
Other health professionals you may see include:
- respiratory physician -- usually responsible for investigating symptoms, making a diagnosis, assessing how far the cancer has spread (staging the disease), and helping you optimise your lung function
- cardiothoracic (chest) surgeon -- responsible for some biopsies and removing tumours using surgery
- medical oncologist -- responsible for chemotherapy
- radiation oncologist -- responsible for radiotherapy
- nurses and clinical care coordinators -- support and assist you through all stages of your treatment
- dietician -- recommends the best diet to follow while you are in treatment and recovery
- social worker, physiotherapist and occupational therapist -- advise you on support services and help you get back to normal activities.
Treatment
Types of lung cancer and treatment options
Small cell lung cancer
- Chemotherapy.
- Radiotherapy – usually for people with limited disease. Sometimes radiotherapy is also given to the brain to prevent the cancer spreading.
Non-small cell lung cancer
The main treatments for this type of lung cancer are:
- surgery
- radiotherapy
- chemotherapy.
The choice of treatment will depend on the stage of your cancer, your general health, whether you are fit enough to have an anaesthetic and operation, and whether your lungs are working well enough.
The aim of treatment is to keep you as well and symptom-free as possible, even if your cancer cannot be cured.
Surgery
Surgical removal of the tumour offers the best chance of cure for patients who have early-stage disease.
The surgeon will assess three important factors when deciding if surgery is an option:
1. Whether the cancer has spread beyond the lungs.
2. Your health (apart from the cancer) -- whether or not you will withstand a major operation
3. Your breathing capacity -- if it is sufficient.
Types of surgery:
- Lobectomy -- a lobe of the lung is removed
- Wedge resection -- part of the lung (but not the lobe) is removed.
- Pneumonectomy -- a lung is removed.
In some patients who have breathing difficulties before the operation, less of the lung is removed. Your doctor will advise which type of surgery is best for you.
Chemotherapy
Chemotherapy is treatment with drugs to stop the cancer cells from growing and multiplying. The aim of chemotherapy is to kill cancer cells while doing the least possible damage to your normal cells.
Chemotherapy on its own cannot cure non-small cell lung cancer. It is usually combined with surgery or radiotherapy in patients whose cancers are large or have spread to the lymph nodes in the centre of the chest.
May be combined with surgery or radiotherapy, or used as palliative treatment.
Generally, chemotherapy is given through a drip (intravenously) -- a plastic tube called a catheter is inserted into a vein in your arm or hand. Less commonly, chemotherapy is given in tablet form.
Chemotherapy is given in cycles. Each cycle lasts about three weeks. During this time you might have treatment for 3-5 days, depending on the drugs needed to treat you.
Oral treatments
In recent years new oral treatments have emerged for lung cancer that has recurred or spread beyond the lungs. These drugs continue to be tested.
Oral treatments are sometimes lower in toxicity, so people who take these drugs may have milder side effects. If you want to see if you are suitable for this type of treatment, ask your oncologist.
Radiotherapy
Radiotherapy treats cancer by using x-rays to kill or damage cancer cells.
- Radiotherapy may be used to cure lung cancer that is confined to the chest. It is used instead of surgery if the tumour is too large for an operation or if your general health or lung function make surgery an unsafe option for you. This generally involves 5-7 weeks of daily treatment.
- After surgery. radiotherapy may be used for people who have cancer in their lymph nodes.
- Treatment can also be used to treat symptoms such as coughing up blood, chest pain and shortness of breath. It is also used to treat symptoms from secondary cancers in the brain (headaches, nausea, vomiting) and bone (pain).
Radiotherapy planning involves taking an x-ray or CT scan of your chest (or the area to be treated) in a radiotherapy department. To ensure that the same area is treated each time, the radiation therapist will make a number of marks on your skin. These are usually 3-4 small dots that are permanent tattoos.
In most cases you will be lying on your back in a comfortable position for treatment and breathing normally. Treatment takes 10-15 minutes to deliver. You won’t feel anything during the actual treatment – it’s just like having an x-ray.
Other interventions
Thoracentesis (pleural tap)
When fluid builds up in the pleural space (the area between the lung and the chest wall), symptoms like breathlessness, tiredness, lethargy and pain sometimes occur.
To relieve the symptoms, fluid can be removed by inserting a hollow needle between the ribs into the fluid, and draining some or all of the fluid. This procedure is performed under a local anaesthetic.
Pleurodesis
If fluid in your chest is drained (in a thoracentesis/pleural tap) and it comes back, it may be necessary to have another thoracenteis.If the fluid recurs again, a thoracic surgeon may perform a procedure called a pleurodesis under a general anaesthetic. Pleurodesis is an injection between the layers of hte lung tissue (pleura). This inflames and closes the space between the pleura, preventing fluid from re-accumulating.
Palliative treatment
Palliative treatment is treatemnt to relieve symptoms of illness, particularly pain, without trying to cure the disease. It is available for all people who have cancer symptoms, whatever their stage of treatment.
Treatment can include radiotherapy, chemotherapy and pain-relieving medications.
Palliative treatment is particularly helpful and important for people with advanced cancer.