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Lung cancer is not just one disease

Key learning points:

- Risk factors and symptoms associated with lung cancer

- How treatment decisions are made

- Management of potential side-effects of treatment

Lung cancer is a malignancy of the respiratory system and can develop in either the lung tissue or in the airways.

It is divided into two main histological types, small cell lung cancer (SCLC), which accounts for 20% of cases, and non-small cell lung cancer (NSCLC), which accounts for the remainder. NSCLC can be further sub-divided into squamous cell, adenocarcinoma and large cell. It is important to differentiate between the histological types as this will help determine the type of treatment recommended for the individual. The stage of the cancer at diagnosis ranging from one to four will also influence the treatment choice.

Lung cancer is the second most common cancer for both men and women in England and is the biggest cause of cancer deaths (1). The Office for National Statistics (ONS) released figures in 2013, which showed there were 34,900 new cases of lung cancer diagnosed in 2011 in England and 28,200 deaths from this disease.

Five-year survival in the UK is less then 10% (2,3). The incidence for the whole of the UK is around 42,000 new diagnoses each year (2). Lung cancer still remains more common in men than women although in recent years the gap has been closing, which reflects the increased number of women taking up smoking after the second world war (1).

Despite these figures, unlike many other cancers there still remains no screening programme to detect lung cancer at an early stage and it is widely felt that late diagnosis is the main reason for the poor prognosis of many lung cancer patients with almost 80% of those diagnosed dying within the first year following diagnosis (3,4).

There has been a large study performed in the United States, which compared CT thorax screening with chest x-ray in high-risk patients and this showed a decrease in mortality of 20% in the CT screened group (5). A further study in Europe The Dutch-Belgium Randomised Lung Cancer Screening Trial (NELSON) was almost completed. Early results are favourable however until the final results have been published there are no plans to introduce a lung-screening programme in the UK (6).

Risk Factors

One reason suggested for late diagnosis was that there was a lack of public and professional awareness of the risks and symptoms of lung cancer (7). Several public awareness campaigns have been launched to raise knowledge regarding the signs and symptoms of lung cancer and urging early presentation to the GP.

The main focus of risk is smoking, which remains the major contributory factor in 85%-90% of lung cancers. However, other risk factors include age (more than 75% of lung cancers are diagnosed in people over the age of 651) (8) socioeconomic deprivation (9), asbestos or radiation exposure, family history and other chronic lung diseases, predominantly COPD (3).

Those living alone have been identified as either presenting late at the GP or being diagnosed following an emergency admission. It should be remembered that ex-smokers, particularly those with a long smoking history or who started smoking at an early age, are also at risk.

What should raise suspicion?

There are a range of symptoms that may suggest that a person has lung cancer. These include a cough that has lasted for three weeks or more or a change in the nature of a longstanding cough, increased or new dyspnoea, haemoptysis, chest pain, weight loss, anorexia and fatigue (see Box 1). It has been found that a cough is present more frequently in earlier rather than later stage disease and that haemoptysis and dyspnoea can be present up to six months prior to diagnosis (7).

Unfortunately, many of the symptoms for lung cancer can appear non-specific and are often indicative of some other benign disease, which again makes early diagnosis problematic as when multiple symptoms are present the disease is often at quite an advanced stage.

Not one size fits all with treatment

Surgery remains the treatment most likely to cure early stage NSCLC in patients who are assessed as fit enough to undergo an operation (3). This can be either removal of a whole lung (pneumonectomy) or part of a lung (lobectomy or segmentectomy). The surgeon will perform the operation that spares most of the healthy lung whilst removing all the cancer.

Radical radiotherapy is an option for people who either don't want to have surgery, are not quite fit enough for surgery or whose tumour is in such a position it would be difficult to remove it all without doing undue harm to the patient.

While the intention of this treatment is again curative, the success rate is not as good as it is for surgery. Radiotherapy uses high dose X-ray beams to kill the cancer cells most commonly using specialised machines known as linear accelerators (LINAC).

This can be given as standard radiotherapy treating patients daily, Monday to Friday, over a four-week period. Alternatively accelerated hypofractionated radiation therapy (CHART) can be given in some centres. This is given three times a day over a period of 12 days continuously and has been shown to have slightly better survival outcomes however it may cause increased short term side-effects (10).

Chemotherapy, usually by intravenous infusion is offered to patients with SCLC who are fit enough to tolerate the treatment and likewise to patients who have metastatic NSCLC or where the tumour is confined to the thorax but is involving the mediastinal lymph nodes. This can sometimes be followed by either radical radiotherapy or surgery in NSCLC patients if there has been a good response to chemotherapy or by consolidation radiotherapy to the chest and prophylactic cranial irradiation, which is preventative brain radiotherapy, in the case of SCLC patients.

Recently there have been developments in newer therapies, which include stereotactic body radiotherapy (SBRT), radiotherapy given at a very high dose to a small targeted area. The patients who are offered this are those whose fitness and lung capacity excludes them from surgery or radical radiotherapy. This is usually due to multiple co-morbidities such as chronic obstructive pulmonary disease and cardiovascular disease. The most appropriate patients are those whose tumour measures less the five centimetres (3,11).

Targeted treatment is also a relatively new concept with treatment being customised to patients based on histological and molecular typing (12). The two most common molecular mutations that have been identified are the epidermal growth factor receptor (EGFR) protein and anaplastic lymphoma kinase (ALK) rearrangement. This has allowed researches to develop treatment that target these specific mutations.

Erlotinib is given to patients with the EGFR mutation and is an oral medication that can be taken at home on a daily basis. The two main side-effects of this are diarrhoea and an acne-like skin rash. Crizotinib is used for ALK rearrangement and again is an oral medication with a similar side-effect profile.

Clinical practice

Nurses in the community setting are in an ideal position to not only help reduce the incidence of lung cancer but also encourage earlier diagnosis and help optimise quality of life.

Many patients will have multiple co-morbidities and are likely to attend surgery for either a medical or nursing review on a regular basis. Health promotion to encourage stopping smoking and taking regular exercise is important. It is also important for lung cancer patients to be given the flu vaccination as they are more prone to developing chest infections and are very vulnerable should they develop flu.

If armed with the information a practice nurse can spot signs that may suggest a person has lung cancer and encourage early presentation at the GP, reducing the number of emergency presentations of lung cancer therefore giving patients an increased survival advantage. Evidence has shown that patients diagnosed following an emergency presentation are associated with having the poorest survival rates (13,14).

Many patients have side effects from their treatment, which can include nausea, vomiting, and constipation from chemotherapy or increased dyspnoea, dysphagia and skin discolouration following radiotherapy.

The oral growth inhibitors are likely to cause diarrhoea, skin rash and a reduced appetite. Management of these include general anti-emetics for nausea in most cases and loperamide for the diarrhoea. This symptom can be alarming and patients may pass loose stools up to six times a day. If it is any more frequently or associated with poor oral intake then the oncologist should be made aware.

For the radiotherapy associated skin discoloration and the growth inhibitor skin rash, an un-perfumed moisturiser is recommended. If the skin rash is severe then doxycycline antibiotic and hydrocortisone cream may be prescribed.

All of these side-effects can not only have a physical impact on patients but also may affect them socially and emotionally (15) Although these patients are reviewed regularly in secondary care by the oncologist and CNS they still spend much of their time at home and can feel very vulnerable and uncertain.

Community nurses have a significant role to play in supporting patients at home and good communication between secondary and primary care is key.


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