Lung Cancer

Lung cancer is the leading cause of cancer death in the United States. The Centers for Disease Control and Prevention also reported that it is the second-most common cancer diagnosis after breast cancer for women and prostate cancer for men. It accounts for 25% of all cancer deaths and accounts for more deaths than prostate, breast, and colon cancer combined. The American Cancer Society (ACS) estimates that 235,760 new cases of lung cancer will occur in 2021, and 131,880 people will die. About 14% of all new cancers are lung cancer.

There are two major types of lung cancer: small cell lung cancer (SCLC) and non–small cell lung cancer (NSCLC). Sometimes a lung cancer shows characteristics of both types and is labeled small cell/large cell carcinoma. Both types have the capacity to synthesize bioactive products and produce paraneoplastic syndromes such as syndrome of inappropriate secretion of antidiuretic hormone (SIADH), Cushing syndrome, and Eaton-Lambert syndrome of neuromuscular disorder.

SCLC accounts for 15% of all lung cancers and is almost always caused by smoking. SCLC is characterized by small, round to oval cells generally beginning in the neuroendocrine cells of the bronchoepithelium of the lungs. They start multiplying quickly into large tumors and can spread to the lymph nodes and other organs. At the time of diagnosis, approximately 70% have already metastasized, often to the brain. SCLC is sometimes called small cell undifferentiated carcinoma and oat cell carcinoma. The 5-year survival rate of SCLC that is localized is 27%, and if cancer has spread to distant parts of the body, the 5-year survival rate is 3%.

NSCLC accounts for approximately 85% of all lung cancers and includes three subtypes: squamous cell carcinoma, adenocarcinoma, and large cell undifferentiated carcinoma. Squamous cell carcinoma, also associated with smoking, tends to be located centrally, near a bronchus, and accounts for approximately 25% to 30% of all lung cancers. Adenocarcinoma, accounting for 40% of all large cell carcinoma, is usually found in the outer region of the lung. One type of adenocarcinoma, bronchioloalveolar carcinoma, tends to produce a better prognosis than other types of lung cancer and is sometimes associated with areas of scarring. Large cell undifferentiated carcinoma starts in any part of the lung, grows quickly, and results in a poor prognosis owing to early metastasis; approximately 10% to 15% of lung cancers are large cell undifferentiated carcinoma. The 5-year survival rate for localized NSCLC is 63%, and if cancer has spread to distant parts of the body, the 5-year survival rate is 7%.

The hilus of the lung, close to the larger divisions of the bronchi, is the most frequent site of lung cancer. Abnormal cells divide and accumulate over time. As the cells grow into a carcinoma, they make the bronchial lining irregular and uneven. The tumor may penetrate the lung wall and surrounding tissue or grow into the opening (lumen) of the bronchus. In more than 50% of patients, the tumor spreads into the lymph nodes and then into other organs.

Systemic effects of the lung tumor that are unrelated to metastasis may affect the endocrine, hematological, neuromuscular, and dermatological systems. These changes may cause connective tissue and vascular abnormalities, referred to as paraneoplastic syndromes. In lung cancer, the most common endocrine syndromes are SIADH, Cushing syndrome, and gynecomastia. Complications of lung cancer include emphysema, bronchial obstruction, atelectasis, pulmonary abscesses, pleuritis, bronchitis, and compression on the vena cava.

Causes ⬆ ⬇

Approximately 80% of lung cancers are related to cigarette, pipe, and cigar smoking. Lung cancer is 10 times more common in smokers than in nonsmokers. In particular, squamous cell and small cell carcinoma are associated with smoking. Other risk factors include exposure to carcinogenic industrial and air pollutants (e.g., asbestos, coal dust, radon, and arsenic) and family history.

Genetic Considerations ⬆ ⬇

Lung cancer is predominately caused by environmental factors, with approximately 85% of all cases linked to smoking. However, there are some genetic factors that increase susceptibility. Both somatic and germline mutations in several genes, including SLC22A18, TP53, KRAS2, BRAF, ERBB2, MET, STK11, PIK3CA, and EGFR, have been implicated in pathogenesis of lung cancer. Recently, a locus for a lung cancer susceptibility gene has been linked to a site on chromosome 6 (6q23-25).

Sex and Life Span Considerations ⬆ ⬇

The average age of people diagnosed with lung cancer is 70 years, and it is an unusual diagnosis for people younger than 45 years. Of the total number of deaths from lung cancer each year, 57% are men and 43% are women. The chance of men developing lung cancer is 1 in 13 and women 1 in 18. There has been an observable decline in deaths among younger men, and this is probably related to the diminishing number of young men who smoke, while rates in younger women are climbing. This increase may be related to increased rates of smoking among young women; experts also suggest that women may be more susceptible to the toxins in smoke than young men. Squamous cell carcinoma is most common in male smokers. Adenocarcinoma is equally common in men and women.

Health Disparities and Sexual/Gender Minority Health ⬆ ⬇

The ACS reports that Black men are 15% more likely to develop lung cancer than White men. Conversely, White women are 14% more likely to develop lung cancer than Black women. Health disparities exist because the 5-year survival rate for White people is 16% and non-White people is 13%. In areas of the United States experiencing persistent poverty, mortality rates for lung cancer are higher than in areas with low poverty rates. Sexual and gender minority people have higher rates of tobacco consumption than the general population (Centers for Disease Control and Prevention, 2021), which may place them at risk for lung cancer.

Global Health Considerations ⬆ ⬇

Cancer is the second leading cause of death globally, with 14 million new cases each year. The World Health Organization expects the number of new cases to rise by 70% over the next two decades. Tobacco use is the most important causal agent for cancer worldwide and is estimated to cause 22% of all cancer deaths. The global incidence of lung cancer is approximately 13 per 100,000 females per year and 31 per 100,000 males per year. Worldwide, lung cancer causes 1.8 million deaths each year and is the most commonly diagnosed cancer. The incidence is four to five times higher in developed than in developing countries, with the highest incidence in Hungary, Serbia, Poland, and Korea. As smoking rates increase in developing countries such as India and China, experts expect rates of lung cancer to increase.

Assessment ⬆ ⬇

ASSESSMENT

History

While most patients will have a history of tobacco use, many will not report symptoms of lung cancer until they have advanced disease. Establish a history of persistent cough, chest pain, wheezing, dyspnea, weight loss, or hemoptysis. Ask if the patient has experienced a change in normal respiratory patterns or hoarseness. Some patients initially report pneumonia, bronchitis, epigastric pain, symptoms of brain metastasis, arm or shoulder pain, or swelling of the upper body. Ask if the sputum has changed color, especially to a bloody, rusty, or purulent hue. Obtain a smoking history with the type of tobacco use and the quantity and frequency of use. Elicit a history of exposure to risk factors by determining if the patient has been exposed to industrial or air pollutants. Check the patient's family history for incidence of lung cancer.

Physical Examination

Many people are asymptomatic. As the disease progresses, symptoms are cough, dyspnea, wheezing, and hemoptysis. The clinical manifestations of lung cancer depend on the type and location of the tumor. Because the early stages of this disease usually produce no symptoms, it is most often diagnosed when the disease is at an advanced stage. In 10% to 20% of patients, lung cancer is diagnosed without any symptoms, usually from an abnormal finding on a routine chest x-ray. Approximately 25% have regional metastasis, and 40% have distant metastasis with symptoms that reflect the organ affected (brain, spinal cord, bone, liver).

Auscultation may reveal a wheeze if partial bronchial obstruction has occurred. Auscultate for decreased breath sounds, rales, or rhonchi. Note rapid, shallow breathing and signs of an airway obstruction, such as extreme shortness of breath, the use of accessory muscles, abnormal retractions, and stridor. Tumor involvement of the pleura and chest wall may cause pleural effusion. Typically, pleural effusion causes dullness on percussion and breath sounds that are decreased below the effusion and increased above it. Monitor the patient for oxygenation problems, such as increased heart rate, decreased blood pressure, or an increased duskiness of the oral mucous membranes. Metastases to the mediastinal lymph nodes may involve the laryngeal nerve and may lead to hoarseness and vocal cord paralysis. The superior vena cava may become occluded with enlarged lymph nodes and cause superior vena cava syndrome; note edema of the face, neck, upper extremities, and thorax.

Psychosocial

The patient undergoes major lifestyle changes as a result of the physical side effects of cancer and its treatment. Interpersonal, social, and work role relationships change. The patient is faced with a psychological adjustment to the diagnosis of a chronic illness that frequently results in death. Evaluate the patient for evidence of altered moods such as depression or anxiety, and assess the patient's coping mechanisms and support system.

Diagnostic Highlights

Test	Normal Result	Abnormality With Condition	Explanation
Chest x-ray	Clear lung fields; patent bronchi	Presence of tumors; compression of vital structures	Air-filled lungs are radiolucent (x-rays pass through tissue, which appears as a dark area), but tumors or masses may appear denser
Computed tomography scan	Normal organ and tissues	Presence and size of tumor; enlarged lymph nodes; compression of pulmonary structures	Sequential x-rays combined by computer to produce a detailed cross-sectional image of lungs
Cytological sputum analysis	No cancer cells present in sputum	Presence of cancer cells in sputum	Microscopic examination of sputum sample to determine presence of cancer cells; even with large tumors, cells may not be obtained in sputum
Bronchoscopy	No tumors or lung blockages	Visualization of tumors or blockages	Visual examination of the lungs through the use of a flexible fiberoptic lighted tube; microscopic examination of cells taken by biopsy and bronchial brushings

Other Tests: Magnetic resonance imaging, thoracentesis, thoracoscopy, closed-check needle biopsy, fluoroscopy, positron emission tomography, bone scan, mediastinoscopy, bone marrow biopsy, complete blood count, arterial blood gas

Primary Nursing Diagnosis ⬆ ⬇

Diagnosis

DiagnosisIneffective airway clearance related to obstruction caused by secretions or tumor as evidenced by cough, dyspnea, wheezing, and/or hemoptysis

Outcomes

OutcomesRespiratory status: Airway patency; Respiratory status: Gas exchange; Respiratory status: Ventilation; Symptom severity; Comfort status

Interventions

InterventionsAirway management; Oxygen therapy; Airway suctioning; Airway insertion and stabilization; Cough enhancement; Mechanical ventilation management: Invasive and noninvasive; Positioning; Respiratory monitoring; Anxiety reduction

Planning and Implementation ⬆ ⬇

PLANNING AND IMPLEMENTATION

Collaborative

The treatment of lung cancer depends on the type of cancer and the stage of the disease. Surgery, radiation therapy, and chemotherapy are all used. Unless the tumor is small without metastasis or nodes when discovered, it is often not curable. As experts have understood the molecular changes that occur in lung cancer, molecular-targeted therapy has led to testing for mutations to determine if specific targeted agents might be successful.

Surgical treatment ranges from segmentectomy or wedge resection (removal of a part of a lobe) to lobectomy (removal of a section of the lung) to pneumonectomy (removal of an entire lung). These procedures all require general anesthesia and a thoracotomy (surgical incision in the chest). Video-assisted thoracoscopic surgery is a minimally invasive procedure used for both diagnosis and treatment. It involves a shorter hospital stay, less pain, and a lower perioperative mortality. Outcome measures along with recurrence rates are currently being followed and compared with those from more invasive procedures. If patients are unable to undergo a thoracotomy because of other serious medical problems or widespread cancer, laser surgery may be performed to relieve blocked airways and diminish the threat of pneumonia or shortness of breath. Chemotherapy is used for cancer that has metastasized beyond the lungs. It is used both as a primary treatment and an adjuvant treatment to surgery. Combined treatment with radiation therapy and chemotherapy is the standard of care for SCLC. The chemotherapy most often uses a combination of anticancer drugs; different combinations are used to treat NSCLC and SCLC.

Radiation therapy is sometimes the primary treatment for lung cancer, particularly in patients who are unable to undergo surgery. It is also used palliatively to alleviate symptoms of lung cancer. In conjunction with surgery, radiation is sometimes used to kill deposits of cancer that are too small to be seen and thus to be surgically removed. Radiation therapy takes two forms: External beam therapy delivers radiation from outside the body and focuses on the cancer and is most frequently used to treat a primary lung cancer or its metastases to other organs; brachytherapy uses a small pellet of radioactive material that is placed directly into the cancer or into the nearby airway.

Pharmacologic Highlights

Medication or Drug Class	Dosage	Description	Rationale
Chemotherapy	Varies with drug	Cisplatin or carboplatin in combination with gemcitabine, paclitaxel, pemetrexed, docetaxel, etoposide, or vinorelbine	More effective in treating NSCLC
		Etoposide and cisplatin or etoposide and carboplatin, ifosfamide, carboplatin, and etoposide, or cyclophosphamide, doxorubicin, and vincristine, topotecan, irinotecan	More effective in treating SCLC

Independent

Maintain a patent airway. Position the head of the bed at 30 to 45 degrees. Increase the patient's fluid intake, if possible, to assist in liquefying lung secretions. Provide humidified air. Suction the patient's airway if necessary. Assist the patient in controlling pain and managing dyspnea. Assist the patient with positioning and pursed-lip breathing. Allow extra time to accomplish the activities of daily living. Teach the patient to use guided imagery, diversional activities, and relaxation techniques. Provide periods of rest between activities.

Discuss the expected preoperative and postoperative procedures with patients who are undergoing surgical intervention. Emphasize the importance of coughing and deep breathing after surgery. Splinting the patient's incision may decrease the amount of discomfort the patient feels during these activities. Monitor closely the patency of the chest tubes and the amount of chest tube drainage. Notify the physician if the chest tube drainage is greater than 200 mL/hour for more than 2 to 3 hours, which may indicate a postoperative hemorrhage. Early in the postoperative period, begin increasing the patient's activity. Help the patient sit up in the bedside chair and assist the patient to ambulate as soon as possible.

Explain the possible side effects of radiation or chemotherapy. Secretions may become thick and difficult to expectorate when the patient is having radiation therapy. Encourage the patient to drink fluids to stay hydrated. Percussion, postural drainage, and vibration can be used to aid in clearing secretions.

The patient may experience less anxiety if allowed as much control as possible over their daily schedule. Explaining procedures and keeping the patient informed about the treatment plan and condition may also decrease anxiety. If the patient enters the final phases of lung cancer, provide emotional support. Refer the patient and family to the hospice staff or the hospital chaplain. Encourage them to verbalize their feelings surrounding impending death. Allow for the time needed to adjust while helping the patient and family begin the grieving process. Assist in the identification of tasks to be completed before death, such as making a will; seeing specific relatives and friends; or attending an approaching wedding, birthday, or anniversary celebration. Urge the patient to verbalize specific funeral requests to family members.

Evidence-Based Practice and Health Policy

Becker, N., Motsch, E., Trotter, A., Heussel, C., Dienemann, H., Schnabel, P., Kauczor, H., Maldonaldo, S., Miller, A., Kaaks, R., & Delorme, S. (2020). Lung cancer mortality reduction by LDCT screening—Results from the randomized German LUSI trial. International Journal of Cancer, 146, 1503–1513.

In 2011, the U.S. National Lung Cancer Screening Trial reported a 20% reduction of lung cancer mortality after regular screening by low-dose computed tomography (LDCT), as compared to x-ray screening. A lung cancer screening program in Europe, the German Lung Cancer Screening Intervention, is a randomized trial among 4,052 long-term smokers, 50 to 69 years of age, with a screening arm (n = 2,029 participants) and a control arm (n = 2,023).
They followed both groups for an average of 8.8 years. They found that women showed a significant reduction in lung cancer mortality as compared to men when screened by LDCT. Regular screening by LDCT shows promise in decreasing cancer mortality when compared to screening with x-ray screening.

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DRG Information ⬇

Introduction ⬆ ⬇