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Do I Have Lung Cancer?

By: Qanta Ahmed, MD

“Do I have lung cancer?” I hear this dreaded question many times in my office. My patients have found their way to me for an answer, often hoping against hope. It is a question that fills me with concern, as too often the answer may be yes.

In this article, I will help you understand the rational steps that go into making a diagnosis of lung cancer. Hopefully, understanding the process will help decrease your anxiety and fear when you face this situation. A little knowledge can prevent you from feeling overwhelmed, help you cope with each step and formulate a plan with your doctor.

In all illnesses the first part of diagnosis is always the “history,” which means the story of your illness. We will first look at the common questions you may need to answer to help your doctor arrive at a diagnosis.

The Symptoms of Lung Cancer

Most patients that come to see me in the office do so because they are experiencing a symptom, or a change from their usual state of health. Never hesitate to visit your doctor if you think something is wrong.

Cough
You may be surprised to learn that cough is the most common symptom of lung cancer. But don't be alarmed: most people with a cough do not have lung cancer. However, when lung cancer is present, it is almost invariably accompanied by a cough. Up to 75% of patients with lung cancer have a cough when they visit the office of a pulmonologist (a doctor who deals with the lung and respiratory system). Please remember that a cough is a very nonspecific symptom and will often be seen in association with other lung diseases, ranging from a simple viral illness to more serious, chronic lung diseases. However, some chronic lung diseases that can cause a cough, like emphysema or “COPD,” increase the risk of lung cancer. It is important to tell your doctor about the nature of your cough.

Your doctor will ask you if anything comes up with the cough, such as phlegm (also known as sputum). Some of my patients with chronic bronchitis, cystic fibrosis or COPD produce sputum every day. A change in sputum, however, is of concern for these patients. This may involve a change in the color or quantity of sputum or, most frightening of all for the patient, the presence of blood. One rare type of lung cancer known as bronchoalveolar lung cancer is associated with “bronchorrhea” – the production of voluminous quantities of frothy sputum.

Breathing
“How’s your breathing?” is usually my next question. Shortness of breath or a feeling of breathlessness is seen in one-third to one-half of patients with lung cancer. Lung cancer can cause breathlessness in a number of ways. The cancer may cause an obstruction or a blocking off of a large airway in your lungs, which may cause breathlessness directly or from a resulting pneumonia. Sometimes fluid accumulates around the lung, compressing or squashing the lung and impairing your breathing. Lastly, the tumor may spread into the lung tissue itself; this is known as “lymphangitic spread.”

Chest pain
Chest pain is also an important symptom to tell your doctor, as almost half of patients with lung cancer experience chest pain. There are many causes of chest pain and it is important to tell your doctor if you have pain in your chest. We take this symptom extremely seriously.

More worrying symptoms include weight loss or loss of appetite, a general feeling of not feeling well, and strangely, a hoarse voice. On occasion, this has been the first thing I notice when I walk in to meet my patients.

The Diagnosis

The physical examination, while often the most unpleasant part of visiting the doctor, is a very important first step. There are a number of important signs that can help your doctor suspect your disease. A thorough examination of the chest and the sound of your breath, as well as an assessment of your general health are essential in making a diagnosis.

If lung cancer is suspected, we can use a number of tests to look for the cancer. Remember, however, that a definitive diagnosis cannot be made by the following two tests.

The Chest X -Ray (CXR)
Often you will have had a chest x-ray for routine purposes, such as an employee physical. If you’ve had a CXR before, it is very important to let your doctor know. When we see a suspicious shadow, which is how tumors appear on an x-ray, we always look to see if it is old. If it has been there 2 years or more without changing in size, it is quite unlikely that the shadow represents a lung cancer. This is why an old CXR can be helpful.

The CAT (computer-assisted tomography) Scan
The CAT scan is a sophisticated, high-resolution, x-ray study that allows us to look at the body in cross-section. This test is extremely useful and frequently ordered when an abnormality is noticed on a chest x-ray. Imagine it as a more detailed view of the suspicious area. Special patterns of calcium in a tumor can give us clues to the diagnosis. Even more importantly, the CAT scan lets us see the surrounding glandular structures in the chest, which can be involved if the tumor has spread from its point of origin. In the chest, glands exist in many groups and are called the “mediastinal nodes.” These nodes are located behind the breastbone. I always remind my patients that this test does not hurt and gives us a better view of any disease present.

While the x-ray and CAT scan can be suggestive of a tumor, cancers are always diagnosed by what is called a “tissue diagnosis.” This means literally taking a piece of the cancer (or biopsy) and looking at it under a microscope. A specific diagnosis of cancer cannot be made without getting a biopsy of the suspicious area. The biopsy can be done one of three ways.

CAT scan-guided needle biopsy
On occasion, the CAT scan shows a shadow or nodule that is close to the chest wall. If this occurs, a radiologist may be able to biopsy the area through the chest wall using a special needle. In these instances, local anesthesia is used to numb the area and the CAT scanner provides guidance for the needle placement. Sometimes this is all that is required to make a diagnosis.

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Bronchoscopy
The CAT scan may show a shadow that is not accessible from the chest wall. In these instances, bronchoscopy can often be used. Bronchoscopy is a procedure done with an instrument called a bronchoscope. The bronchoscope is a thin, flexible telescope (about the width of your little finger) with a fiberoptic light and camera attached to it. The camera connects to a video screen so the doctor can see the inside of your lung. During the procedure, the bronchoscope is inserted into the either the mouth or one of the nostrils. It is then guided into the wind-pipe, or "trachea," and from there down into the smaller breathing passages. You might think that this would make breathing difficult, but it does not. There is always enough room around the bronchoscope to breathe.

With a bronchoscope, we can see “hard to reach” tumors. We can estimate how big they may be and even take a biopsy, which is sent to the lab for diagnosis. In addition to a direct biopsy, another maneuver we commonly perform with the bronchoscope is called a bronchoalveolar lavage. This involves rinsing out an area of the lung with salt water and then collecting the salt water with the bronchoscope. The water is sent to the laboratory so that any loose cells present can be analyzed for cancer.

Most patients have no trouble at all with bronchoscopy and adequate sedation is given before the procedure. We don’t use general anesthesia, as many times we need to enlist your cooperation during the test. We do make you very sleepy, however, and you will need someone to drive you home after the test. You won’t need to stay overnight. The oldest patient I ever bronchoscoped was 96 years old. He did fine. When appropriate, even children can be bronchoscoped.

The worst part of bronchoscopy, my patients tell me, is waiting for the results. Several days wait is quite normal, because the tissue needs to be prepared before tests are run to establish the exact nature of the tumor. It is important to surround yourself with friends and loved ones while you wait for the results. When the day arrives and you have your answer, you should be told what the results mean and what the next needed step is.

Surgery

There are times when the above tests are not enough to provide a diagnosis. These are the most challenging of cases, for both the patient and physician. In these cases, a surgical procedure may be required in order to get a biopsy and arrive at a diagnosis. Depending on the appearance of the shadow, a visit to the thoracic or cardiothoracic surgeon may be scheduled. He may recommend a surgery where the chest is opened, known as an “open thoracotomy,” in order to get a piece of tissue for diagnosis.

During the surgery, which requires general anesthesia, a biopsy is done and sent immediately to the lab. While the patient is still asleep on the operating table, the surgeon waits for the biopsy result. If it turns out to be cancer and can be operated on, the surgeon will attempt to remove all of the cancer immediately. If the lesion turns out to not be cancer, the surgery is finished simply by closing the initial wound.

If this option is presented to you, it may very well be the only way to proceed. If there is still any doubt in my patient’s mind, I recommend a second opinion -- there is no room for doubt in these maneuvers. Also, patients must understand beforehand that the surgery may reveal no evidence of cancer. I have had a few patients complain that unnecessary surgery was done when no cancer was found. My feeling is that patients should be happy to know that the lesion was not cancerous.

Looking for Cancer Spread

This is the single greatest concern for the patient and his doctor once the diagnosis of cancer is made. Preliminary blood tests may show anemia (a low blood count) or an abnormality in the function of the liver and raise the suspicion of spread. Below are a few tests which look specifically for cancer spread.

The Bone Scan
The bone scan is a special radiologic test that looks for any bone destruction. Occasionally bone destruction is caused by cancer that has spread. It is important to know that the recommended treatment will change if the cancer has spread to the bones. The bone scan is done in the radiology department and takes about one hour. It is a painless test.

The PET (positron emission tomography) scan/
PET scanning is the newest tool used to examine lung cancer. This is a highly specialized test involving a “label” which can be seen wherever cancer cells are active. While we are still learning how to interpret the outcome of a PET scan, and very few centers can perform them, I suspect we will be using this method more often in the future.

Summary

Finding your way to a diagnosis of lung cancer is very scary, but if you learn a little about each test you will be able to help yourself and your doctor a great deal. Remember, our goal is to help you, and this means finding an answer as soon as possible. Even if your worst fear becomes true and you are diagnosed with lung cancer, we can show you the next step. You are not alone.