Lung cancer will kill an estimated 160,000 people in the U.S. in 1999. It is the most common cause of cancer death, causing one-third and one-fourth of cancer deaths in men and women, respectively. Incidence rates increase with age, occurring most often between the ages of 50 and 70; only 3% of cases occur in patients under 40. Incidence rates among men are declining but among women are rising. Four major histologic types of lung cancer, listed in declining frequency, include: adenocarcinoma, squamous cell carcinoma, small cell carcinoma, and large cell carcinoma. Clinically, it is important only to distinguish between small cell carcinoma (SCLC) and non-small cell carcinoma (NSCLC).

Lung cancer arises after multiple separate events, resulting in DNA damage (mutations) caused by carcinogens. These mutations accumulate to the point at which control over normal cell growth is lost.

Tobacco smoke is the most clinically significant carcinogen, responsible for 85% of all U.S. lung cancers. Risk increases with exposure (e.g., packs per week, number of years), and there is no zero-risk threshold, with passive smoking (environmental tobacco smoke) believed responsible for 500 to 5,000 lung cancer deaths annually. Other risk factors include:

• Family history (lung cancer in first-degree relative)
• Environmental, occupational exposures (often synergistic with tobacco smoke). Known carcinogens include arsenic, asbestos, bis(chloromethyl) ether, chloromethyl methyl ether, chromium, nickel, and radon. Probable carcinogens include acrylonitrite, beryllium, cadmium, and formaldehyde. Possible carcinogens include acetaldehyde, synthetic fibers, welding fumes, silica.
• Ionizing radiation (e.g., wartime or industrial exposure, extensive radiotherapy to chest)
• Non-neoplastic lung diseases (e.g., tuberculosis, chronic obstructive pulmonary disease [COPD], interstitial lung disease)
• Dietary factors (e.g., decreased risk with diets high in fruits and vegetables; slightly increased risk in high- risk patients who use vitamin A and beta-carotene supplements)

• Early lesions may be asymptomatic and an incidental radiographic finding.
• Hemoptysis
• Wheezing
• Cough—new onset or change in chronic cough
• Fever, chills, sweats, and radiographic pneumonia (from an obstructive lesion)
• Pleural effusion

• Granulomatous infection (e.g., tuberculosis, fungi)
• Noninfectious granulomatous disease (e.g., sarcoidosis, rheumatoid arthritis, silicosis, Wegener's granulomatoses)
• Benign tumors (e.g., hamartoma, chondroma, hyaline granuloma)
• Infection (e.g., pneumonia)
• Asthma
• COPD
• Chronic or acute bronchitis
• Congestive heart failure
• Gastroesophageal reflux disease
• Drug reaction
• Foreign body aspiration

In early stage lung cancer, patients may be asymptomatic with a normal examination, or they may present with a localized wheeze, cough, fever, and dullness or rales over areas of consolidation, and dyspnea with bronchial breath sounds over areas of atelectasis. Advanced intrathoracic disease may present as nonspecific systemic findings (e.g., weakness, weight loss), hoarseness from laryngeal nerve involvement, dysphagia from esophageal involvement, chest pain from pleural or chest wall invasion, and dyspnea from pleural effusion. Advanced extrathoracic disease may present as seizures, headache, and visual disturbances from brain metastases; bone pain, pathologic fractures, unexplained hypercalcemia or elevated alkaline phosphatase, and spinal cord compression from bony metastases; and abdominal pain, elevated liver enzymes, and hepatomegaly from hepatic, adrenal, or lymphatic metastases.

• Sputum cytology—noninvasive but low sensitivity
• Calcium levels—to detect bony metastases or paraneoplastic syndrome
• Liver enzymes—to detect hepatic metastases

Intrathoracic disease:

• Chest radiograph
• Chest computed tomography (CT) scans—to detect tumor, define anatomical relations, assess pleural space, and assess mediastinal lymph nodes
• Magnetic resonance imaging (MRI) scans—to detect suspected extrathoracic extension not on CT
• Positron emission tomography (PET)—to detect mediastinal lymph node metastases

Extrathoracic disease:

• Radionuclide bone scan—to detect bone metastases
• Brain CT or MRI scan—to detect metastases in patients with central nervous system symptoms
• Abdominal CT scan with contrast—to detect hepatic metastases

• Rigid and fiber-optic bronchoscopy—to obtain cytologic and histologic specimens for diagnosis and staging of central lesions and to determine lymph node involvement
• Mediastinoscopy—to determine tumor involvement of mediastinal lymph nodes
• Transthoracic fine needle biopsy (fluoroscopically or CT-guided—to diagnose peripheral lesions
• Thoracentesis, closed plural biopsy—to diagnose malignant pleural effusions
• Thoracoscopy with lung or plural biopsy—to diagnose malignancies that remain obscure
• Thoracotomy—for definitive diagnosis and staging prior to resection

Treatment depends on cell type, stage, resectability (ability of tumor to be completely removed), and operability (ability to survive surgery with acceptable morbidity). Options include surgery, radiation, and chemotherapy, singly or in combination. NSCLC is staged according to the TNM classification (primary tumor characteristics [T], regional lymph node involvement [N], and metastatic involvement [M]). Resection is possible only for stages I through IIIA, while stages IIIB and IV are unresectable. SCLC, characterized by aggressive growth and early extrathoracic metastases, is only rarely amenable to curative resection and is staged by a simple two-stage system that defines limited and extensive disease.

• NSCLC: One or two drugs are combined with cisplatin or carboplatin; for example, the CAP regimen includes cyclophosphamide plus adriamycin plus cisplatin. Other agents include vindesine, vinblastine, docetaxel, etoposide, gemcitabine, mitomycin-C, and ifosfamide
• SCLC: Two common regimens are etoposide with cisplatin; and cyclophosphamide, etoposide, and vincristine.

Surgery is the only treatment that offers a cure of NSCLC. Procedures are chosen to minimize loss of lung function without compromising chances of cure.

• Wedge resection—does not permit assessment of local lymph nodes and yields poor resection margin
• Segmental resection—the best limited procedure
• Lobectomy—standard definitive resection
• Pneumonectomy—carries highest mortality rate

Nutrition and herbs may provide antioxidant protection, minimize side effects of conventional therapy, and improve treatment response and overall health. Mind-body modalities such as relaxation techniques, meditation, yoga, and qi gong may increase the immune response, enhance quality of life, and improve sense of well-being.

• Avoid foods that compromise immune function and constitute nutrient-poor calories. Eliminate refined foods, sugar, alcohol, and saturated fats (animal products, especially dairy).
• Include foods rich in antioxidants such as dark green, yellow, and orange vegetables, and dark berries. Also include foods which enhance detoxification such as green tea, onions, garlic, broccoli, brussels sprouts, kale, and cabbage. Increase whole grains and anti-inflammatory oils (nuts, seeds, and cold-water fish). Green tea polyphenols have anti-tumor activity and protect against lipid peroxidation.
• Vitamin C (1,000 mg qid), vitamin E (400 IU bid), selenium (200 mcg bid), zinc (30 mg/day), and coenzyme Q10 (100 mg tid) for antioxidant protection. Vitamin A (25,000 IU/day) induces differentiation but may be rendered toxic by ingestion of alcohol; avoid vitamin A (and beta carotene) supplements if history is positive for alcohol or nicotine abuse. Coenzyme Q10 and L-carnitine (600 mg tid) protect against cardiac toxicity secondary to doxorubicin.
• Anti-inflammatory omega-3 and omega-6 oils, especially eicosapentaenoic acid (EPA) and evening primrose oil (EPO), 1,500 mg tid.
• Glutathione (500 mg bid) for antioxidant protection, detoxification, and preventing secondary recurrence.
• N-acetylcysteine (200 mg tid) to facilitate DNA repair.
• Melatonin (10 mg/day) improves survival rate in NSC lung cancer patients unresponsive to cisplatin therapy.
• Bromelain (250 to 500 mg between meals) is a proteolytic enzyme that has anticancer activities and may enhance chemotherapy.

Herbs may be used as dried extracts (pills, capsules, or tablets), teas, or tinctures (alcohol extraction, unless otherwise noted). Dose is 1 heaping tsp. herb/cup water steeped for 10 minutes (roots need 20 minutes).

• Turmeric (Curcuma longa): 500 mg qid potentiates the effects of bromelain and has antitumor activities.
• Quercetin (250 to 500 mg tid to qid) has an affinity for type II estrogen binding sites abundant in NSC lung cancer and inhibits proliferation.
• Ginkgo (Ginkgo biloba): 120 mg standardized extract bid may protect against nephrotoxicity secondary to cisplatin.
• To enhance detoxification, tone normal lung tissue, and stimulate the immune system, combine equal parts of red clover (Trifolium pratense), gotu kola (Centella asiatica), mullein (Verbascum densiflorum), elecampane (Inula helenium), indian tobacco (Lobelia inflata), and blood root (Sanguinaria canadensis). Take 30 to 60 drops tincture tid to qid, or drink one cup tea tid.
• Commercial herbal mixes in the form of teas or formulas containing herbs such as sheep sorrel (Rumex acetosella), burdock root (Arctium lappa), slippery elm inner bark (Ulmus fulva), turkey rhubarb (Rheum palmatum), red clover (Trifolium pratense), and watercress (Nasturtium officinale) may be helpful. A usual dose is one cup tea bid, or 2 tbs. formula bid for six months.

May be helpful in addressing symptomatic complaints, alleviating side effects from treatments, and reducing the effects of stress. An experienced homeopath would consider the individual's constitution.

Castor oil pack over lungs may decrease side effects of chemotherapy and aid the lungs in detoxification. Saturate a cloth with castor oil and apply directly to the skin, placing a heat source (e.g., water bottle) on top. Leave in place for 30 minutes or more. For best results, use castor oil packs for three to four consecutive days per week. Packs may be used daily.

May aid in palliation of symptoms as well as strengthening constitution and enhancing the overall sense of well-being.

Periodic monitoring is useful to detect locally recurrent and disseminated lung cancer, secondary primary lung cancers, and other smoking-related malignancies such as head and neck cancers. In most cases, frequent monitoring for loss of lung function from cancer, surgery, or other treatment may be supportive only, as the prognosis is often poor.

Recurrence of lung cancer following treatment is common in any stage and with any cell type. It usually manifests as distant metastases in the bone, brain, liver, lung, and adrenals. In all survivors, the risk of second primary lung cancers is increased, with the highest risk in patients who continue to smoke. Anger, anxiety, depression, and other psychological complications are common.

Prognosis depends on cell type and TNM stage.

NSCLC: Prognosis is generally better for squamous rather than adenocarcinomas, reflecting the greater likelihood that the latter will have silently metastasized at the time of apparently curative surgery. Assuming surgical staging, one- two- and five-year survival rates for the following stages are:

• IA: 94%, 86%, 67%
• IB: 87%, 76%, 57%
• IIA: 89%, 70%, 55%
• IIB: 77%, 56%, 39%
• IIIA: 64%, 39%, 24%
• IIIB: 35%,13%, 5%
• IV: 20%, 5%, 1%
• SCLC: Prognosis is generally poor. With optimal chemotherapy, median survival for patients with limited disease is 15 months, with a 20% to 25% two-year survival rate. Median survival for advanced disease is seven months.

Many treatment procedures are contrainidicated during pregnancy. Therapeutic abortion and watchful waiting are considered.

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