Georgia’s CT scans showed extensive brain metastasis and a small lung lesion. A fiberoptic bronchoscopy and biopsy of the lung lesion revealed small cell lung cancer (SCLC). A medical oncologist ordered a bone scan and bilateral bone marrow biopsies, which showed no evidence of disease. Georgia completed both brain radiation and chemotherapy and has been doing well for six months. Georgia credits her success to her family and to the support she had from the nurses involved in her care. Not only did they teach her what to expect and how to manage adverse effects, but she felt they truly cared about her.

Lung cancer is now the leading cause of cancer deaths, and the second most commonly occurring cancer in men and women in the U.S. In 2007, 213,380 new cases of lung cancer will be diagnosed and an estimated 160,390 people are expected to die of this disease; some 89,510 men and some 70,880 women will succumb to this killer. The average age of people diagnosed with lung cancer is 70.¹

More women die each year from lung cancer than breast cancer. The number of women dying of lung cancer reached a plateau for the first time in 2005, after steadily increasing for several decades.¹ There is no debate that lung cancer is a major health problem. Lung cancer accounts for 15% of all cancer diagnoses.¹ Nurses in diverse practice settings need to be knowledgeable about its causes, pathophysiology, treatment modalities, and management of the adverse effects of the disease and treatment.

The smoking gun

Lung cancer occurs most often following repeated exposure to substances that cause tissue irritation. It has been demonstrated that exposure to more than one carcinogen has interactive and synergistic effects in the development of lung cancer. In addition to cigarette smoking, other agents, exposure, and disease that have a causal relationship to lung cancer include air pollution; occupational-related carcinogens, like asbestos, arsenic, and petroleum; radon; low vitamin A levels; fibrosis or lung scars from tuberculosis and other pulmonary inflammatory processes, such as chronic obstructive pulmonary disease (COPD); and progressive systemic sclerosis. The genetic link for lung cancer is unclear at this time. However, emerging evidence indicates that women may be more predisposed to developing lung cancer than men.²

By far, however, cigarette smoking is the leading cause of lung cancer cases. Some 87% of all lung cancer can be prevented. We know that the risk of developing lung cancer rises with the number of cigarettes smoked per day and the number of total years one has smoked. In addition to these factors, there is a greater risk if a person began smoking before 15 years of age. And each year, approximately 3,000 nonsmoking adults die of lung cancer as a result of secondhand smoke.²

In 1997, 48 million — a quarter of all American adults — smoked cigarettes. The good news is that consumption is declining. The bad news is that some 70% of high school students have tried cigarettes, and one-third of high school students are currently smoking.² Unfortunately, advertisements often depict smoking as glamorous, and young women associate smoking with weight loss. Teenage men may submit to the macho images of smoking.

Saying that lung cancer is hard to beat is an understatement. Unfortunately, many patients have metastatic disease on diagnosis. And tragically, just 16% will survive five years.¹ The five-year survival rate is 48% in cases where the disease is localized. However, only 15% of lung cancer is detected early. The one-year survival rates rose from 37% in 1975-1979 to 42% in 2002 largely due to improvements in surgical techniques and combined therapies.¹

The American Cancer Society and American Lung Association are vocal advocates of smoking prevention and cessation and are now targeting teenagers in their campaigns. On August 23, 1996, the Food and Drug Administration (FDA) issued a regulation prohibiting the sale of tobacco products to individuals under age 18 and requiring photo identification be checked for everyone age 26 and younger.³ Despite this resolution, tobacco use among youth increased considerably in the 1990s, except in those states that vigorously enforced their tobacco control programs.² Nurses have a wonderful opportunity to set an example for smoking cessation; 23.6% of nurses smoke cigarettes compared to 21.5% of people in the general population. The Tobacco Free Nurses www.tobacco freenurses.org/about.php is an organization whose mission is to ensure that the nursing profession is prepared to actively promote health by reducing nurses’ barriers to involvement in tobacco control, addressing lack of education, smoking among professionals, and lack of nursing leadership. Nurses must be equipped to assist with smoking cessation, prevent tobacco use, and promote strategies to decrease exposure to secondhand smoke. Nicotine delivery systems, other medications, and counseling can also be used in this endeavor. It is not too late to encourage smoking cessation after the diagnosis of lung cancer. Studies show that people who stop smoking during chemotherapy respond better than people who continue to use tobacco.

But what about people who have never smoked? Actress and singer Dana Reeve died in 2006 of lung cancer at the age of 44. She never smoked. This brought national attention to the issue of nonsmokers getting lung cancer. There are important reasons to note whether a patient is a smoker or a nonsmoker. Cancers in nonsmokers are more likely respond to certain types of chemotherapy and biotherapy agents. Because two-thirds of people who have never smoked who are diagnosed with lung cancer are women, estrogen is thought to play a role in the development of the disease just it does in breast cancer. Those who have never smoked are more likely to have mutations of epidermal growth factor receptor (EGFR). Activation of the EGFR receptor triggers DNA replication and cell division. Tumors with mutations in the gene for EGFR are found most often in women, people who have never smoked, and Asians. These patients will respond well to EGFR inhibitors. Researchers have found a relationship between the human papillomavirus types 16 and 18 in those who have never smoked, mainly in Asians. This virus is also linked to cervical, vulvar, head, and neck cancers. Genetics may play a role in the development of lung cancer in nonsmokers. National Institutes of Health researchers have identified a lung cancer susceptibility region on chromosome six which could lead to the discovery of the gene or genes responsible for the disease. It is also thought that people who have never smoked with lung cancer may be less able than others to break down carcinogens in secondhand smoke, workplace exposure to toxic substances, or air pollution. This may have a genetic link as well between them because the tumor cells of each type grow and spread differently. The treatment is type-specific.

The subgroups

Lung cancers are divided into two major types: SCLC which accounts for 13% and nonsmall cell lung cancer (NSCLC) which account for the other 87%.¹ It is important for nurses to differentiate between them because the tumor cells of each type grow and spread differently. Treatment is type-specific.

Because the cells look like oats under the microscope, SCLC is also called oat cell cancer. This type of cancer is found in heavy smokers and comprises 18% of all lung cancer cases. It grows rapidly and is characterized by early spread to other organs. It is considered a systemic disease on diagnosis.⁶

NSCLC is comprised of three subgroups and is named for the type of cells found in each group.

• Adenocarcinoma is the most common of all lung cancers, comprising 40% of all cases. It grows along the outer edges of the lungs and the tissue lining the bronchi. It often metastasizes to the brain, bone, liver, kidneys, and other lung. Seventy percent of people who have never smoked are diagnosed with adenocarcinoma.
• Epidermoid carcinoma is also called squamous cell carcinoma. It is strongly associated with smoking and accounts for 30% of all lung cancer cases. It begins in the bronchi and may remain in the lungs without spreading for longer periods of time than other types. It is easier to resect and is usually associated with a better prognosis than other types of lung cancer.
• Large cell carcinoma is most commonly found in the smaller bronchi and makes up 15% of all lung cancer cases. It is associated with a poor prognosis. Large cell cancers metastasize in a manner similar to adenocarcinoma but also may metastasize to the GI tract.⁶

Early detection of lung cancer has not proven to increase survival rates. Fiberoptic examination of bronchial passages, chest x-ray, and analysis of sputum have shown limited effectiveness in early detection. However, newer diagnostic tests, such as low-dose helical CT scans and molecular markers in sputum are currently being evaluated. They may offer some hope for the development of effective lung cancer screening programs. The high risks of lung biopsy and surgery must be measured when considering lung cancer screening. The National Lung Screening Trial is a clinical trial to screen individuals at high risk for developing lung cancer with spiral CT or standard chest x-ray. The study began in 2002 and is a collaboration between the National Cancer Institute, the American College of Radiology Imaging Network, and the American Cancer Society. Study results are expected in 2010.¹ Typically, lung cancer is discovered when individuals seek health care for symptoms.

Cardinal signs

Coughing is one of the most common symptoms of lung cancer and occurs when a tumor grows and blocks an air passage. Chest pain is another common symptom, often described as a constant ache that may or may not occur with coughing. Lung cancer, like many other cancers, can cause fatigue, weight loss, and loss of appetite. Other symptoms may include repeated pneumonia or bronchitis, shortness of breath, hemoptysis hoarseness, or swelling of the neck and face (superior vena cava syndrome). Some of the presenting symptoms of lung cancer may appear to be unrelated to the cancer itself. Occurrences of seemingly unrelated symptoms can indicate the spread of lung cancer to other parts of the body.

Symptoms vary depending on which organs or body areas are affected. Patients may experience headache, weakness, pain, bone fractures, bleeding, or blood clots. Hormones that are produced by the lung cancer cells can also cause symptoms. Certain lung cancer cells produce antidiuretic hormone (ADH), which causes the body to hold onto water, causing a drop in serum sodium. Also known as the syndrome of inappropriate antidiuretic hormone (SIADH), this dilutional hyponatremia can cause confusion, lethargy, decreased urine output, and coma.⁶

First the diagnosis, then staging the disease

Once symptoms have been reported and lung cancer is suspected, the first step for all patients is a thorough history and physical examination. This is usually followed by chest x-rays and a CT scan, MRI, or a PET scan to determine the location of the tumor in the chest and determine whether it has spread to other sites. Next, the team needs to collect tissue for microscopic examination by a pathologist, who can determine whether lung cancer is present and what type it is.

Cells can be collected by sputum cytology, fiberoptic bronchoscopy, CT-guided transthoracic needle aspiration, or open biopsy. Sputum collection is more valuable in epidermoid cancer and is diagnostic about 80% of the time.⁷ While bronchoscopy is most frequently used, cells that are hard to reach using this method can be obtained by CT-guided needle aspiration biopsy. This is less invasive than an open biopsy. Mediastinoscopy — a procedure that requires general anesthesia and an incision — is used to assess for spread of the lung cancer to the lymph nodes in the mediastinum. This procedure may be done in conjunction with an open biopsy.

Further metastatic workup includes nuclear medicine studies, such as brain, bone, or liver scans and bone marrow biopsies. Patients and families are extremely anxious during this time. Nurses can help them get through the diagnostic phase by explaining what to expect during tests and procedures and giving an approximate time frame during which results can be expected. Waiting for biopsy results can be a tortuous time for everyone. Discuss how patients would like the results communicated — by telephone or in person, and by whom, the surgeon or primary care provider. These choices should be routinely available to patients.

The American Joint Committee on Cancer has a tumor, metastasis, and node (TMN) cancer staging system that is useful in prognosis and planning treatment for cancers. TIS indicates lung cancer in situ, and T1-T4 defines the increasing tumor size. M0 reflects no metastasis, and M1 indicates metastatic spread to such distant areas as bone, liver, and brain. N signifies lymph node involvement. Subcategory X is used for situations in which the primary tumor cannot be assessed. It also applies to the M and N classifications for clients on whom evaluation of nodal or distant metastatic sites could not be performed. The TMN system is used for SCLC and NSCLC.⁸

The treatment options

Lung cancer is treated with surgery, radiation therapy, and chemotherapy, either singularly or in combination. Recommendations are based on the type and location of the cancer, as well as the individual’s medical history and general health. While the goals of treatment can differ, the focus is on eradication of the tumor, control of the disease for as long as possible, palliative control of symptoms, and overall quality of life.

NSCL treatment can be divided into three categories —

1. Tumors confined to the lung. Surgery is the treatment of choice for these patients, and complete surgical resection of the lung tumor is the only chance to eradicate the disease. Less than 25% of patients with NSCLC have disease on diagnosis that is minimal enough to make this possible. Wedge resection — removing only a small portion of the lung — is the preferred treatment for small tumors. Lobectomy is the removal of an entire lobe of the lung, while pneumonectomy is the removal of an entire lung.

A relatively new procedure — endoscopic thoracotomy — is now another treatment option for patients in whom the lung lesion is in the periphery of the lung or mediastinum. This procedure is less invasive than traditional thoracic surgery and involves much less pain, decreased morbidity, and a faster recovery time. Endoscopic thoracotomy entails one to four small incisions and can be used for excision of lung lesions, biopsy of mediastinal masses, wedge resection of tumors, and a variety of diagnostic and exploratory procedures. The patient with NSCLC who cannot tolerate any of these surgeries is a candidate for radiation therapy.

Preop teaching for the client with lung cancer undergoing surgery includes —

• Explain the pre- and postop course.
• Teach coughing, turning, deep breathing, splinting, and incentive spirometry.
• Encourage the patient to stop smoking prior to surgery.
• Describe the methods of pain relief and encourage the patients to ask for pain medication. Adequate pain relief will promote coughing and deep breathing.
• Explain that narcotic analgesics may be necessary for several months after the procedure.
• Discuss the possibility of a postoperative chest tube.
• Discuss the importance of early ambulation.
• Teach arm and leg exercises. Explain that the shoulder on the affected side will be sore and exercise will prevent a frozen shoulder.
• Provide written educational materials.

2. NSCLC that has spread locally to nearby tissues or lymph nodes. The usual treatment is radiation therapy to the chest, sometimes in combination with surgery.

3. NSCLC that has spread to other parts of the body. Radiation therapy and chemotherapy are used to reduce tumor size and relieve symptoms, but typically do not greatly improve survival time. Prophylactic brain irradiation can be used for patients with NSCLC at high risk for brain metastasis, especially adenocarcinoma. As for chemotherapy, the agents most commonly used are platinum-based agents, such as carboplatin (Paraplatin) or cisplatin (Platinol), usually in combination with other chemotherapy drugs because of their demonstrated efficacy against both SCLC and NSCLC, and their action as a potentiator of radiation therapy.

Regimens used for NSCLC include —

• Cisplatin and etoposide (VP-16)
• Carboplatin and paclitaxel (Taxol)
• Gefitinib (Iressa) is a growth factor inhibition agent approved for patients who have failed platinum-based therapy.
• Additional agents used either alone or in combination are cyclophosphamide (Cytoxan), doxorubicin (Adriamycin), gemcitabine (Gemzar), vinorelbine (Navelbine), docetaxel (Taxotere), topotecan (Hycamtin), and irinotecan (Camptosar).
• Cyclooxygenase-2 inhibitors have demonstrated benefit when combined with radiation.
• Agents, such as angiogenesis inhibitors, monoclonal antibodies such as bevacizumab (Avastin) and erlotinib (Tarceva), receptor protein kinases, growth factors, and other biological agents are under investigation.¹

Some studies have shown that patients with inoperable NSCLC who are treated with a combination of chemotherapy and radiation therapy have a longer median survival than patients treated with radiation alone.⁷ Radiation implants (brachytherapy) may be combined with surgery as a boost to initial external beam radiation or can be used alone at the time of recurrent disease.

Generally considered a metastatic disease at diagnosis, SCLC quickly spreads to distant sites. Surgery is rarely an option for SCLC unless the tumor is resectable, and there is no evidence of disease in any other area. Treatment involves combination chemotherapy with or without radiation therapy. Combination chemotherapy is more effective than single agent therapy, and multiple simultaneously administered chemotherapeutic agents are most frequently used. Tumor drug resistance can occur and chemotherapeutic regimens may need to be altered. High doses produce a better response. Some individuals have obtained a long-term response.

Regimens used for SCLC include:

• Etoposide plus a platinum based agent
• Cyclophosphamide — doxorubicin — vincristine (Oncovin)
• Cyclophosphamide — doxorubicin — etoposide
• Ifosfamide (Ifex) — carboplatin — etoposide

Patients with SCLC who undergo radiation therapy have a reduced frequency of tumor reoccurrence and an increased survival time. Prophylactic brain irradiation is also used on these clients in an attempt to prevent brain metastasis. In the process of treatment, normal cells are affected and adverse effects will occur.⁷

Coping with adverse effects and advancing disease

Nurses play an integral part in helping patients and families cope with the adverse effects of treatment. Before therapy begins, patients and families need to be told what the treatment is, what to expect during the treatment, what adverse effects they can expect, and how to manage them.

One of the most challenging issues is maintaining nutritional status. Elderly patients who lose weight during therapy have poorer outcomes. Dieticians should be involved as early on in the diagnosis as possible, hopefully even before treatment begins. Weight should be monitored with either chemotherapy or radiation visits. Patients and significant others need to learn about maximizing protein and caloric intake.⁶ Symptoms of advanced lung cancer, such as dyspnea, pain, cough, and hemoptysis, are very distressing to patients and families. Compassionate and knowledgeable nurses can help reduce the suffering associated with advanced symptoms of lung cancer. One of the most distressing symptoms is dyspnea, which occurs when airways are obstructed or lung expansion is restricted. Pleural effusions; atelectasis; and preexisting conditions, such as COPD, can contribute to shortness of breath. This symptom can be particularly frightening. Nurses can teach patients and families additional coping mechanisms, such as positioning, changing or decreasing daily activities, proper use of inhalers, and pursed lip breathing. Low-dose morphine (Roxanol, 2.5 mg to 5 mg every four hours as needed) acts centrally to relieve severe dyspnea associated with end-stage respiratory compromise. Measures to reduce anxiety, such as relaxation techniques, or medications, such as lorazepam (Ativan), may be used. It is helpful to teach families when to give pharmacologic agents, such as sedatives, narcotics, or steroids, during episodes of shortness of breath.

Patients in pain need to obtain adequate relief. Nurses must assess the intensity and ensure that the patient receives an adequate analgesic dose. A cough can be managed with cough suppressants, such as guaifenesin with codeine (Robitussin AC) and benzonatate (Tessalon Perles). A frightening symptom, which may occur as the lung cancer progresses, is hemoptysis, which can indicate erosion of a blood vessel. Hospice nurses are invaluable sources of support during this time and are experts at managing the symptoms of advanced cancer. Ideally, hospice services are discussed before advanced symptoms of lung cancer occur.⁶

When the end is near

Sensitive issues, such as advance directives and durable power of attorney for health care, need to be addressed before a crisis occurs. Patient and family roles and dynamics may be altered in a short period of time, causing a great deal of distress. Nurses can assist in preparing patients for the inevitable changes in lifestyle they may expect to experience.

Patients and families are coping with symptoms, a rapidly progressing disease, and/or the adverse effects of treatment. Unfortunately, they are also coping with the tragic fact that the survival time may be limited. All of this can have a drastic impact on lifestyle and quality of life. Nurses can help to manage symptoms, such as pain, dyspnea, fatigue, and weight loss. As for quality of life, patients and families will need realistic information about what to expect, given with honesty and hope.