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
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,
- 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
|Signs and Symptoms|
- Early lesions may be asymptomatic and an incidental radiographic
- Cough—new onset or change in chronic
- Fever, chills, sweats, and radiographic pneumonia (from an obstructive
- 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
- Infection (e.g., pneumonia)
- 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
- Calcium levels—to detect bony metastases or
- Liver enzymes—to detect hepatic
- 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
- Radionuclide bone scan—to detect bone
- Brain CT or MRI scan—to detect metastases in
patients with central nervous system symptoms
- Abdominal CT scan with contrast—to detect
- 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
- 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
Surgery is the only treatment that offers a cure of NSCLC. Procedures are
chosen to minimize loss of lung function without compromising chances of
- Wedge resection—does not permit assessment of
local lymph nodes and yields poor resection margin
- Segmental resection—the best limited
- Lobectomy—standard definitive
- Pneumonectomy—carries highest mortality
|Complementary and Alternative
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
- Anti-inflammatory omega-3 and omega-6 oils, especially
eicosapentaenoic acid (EPA) and evening primrose oil (EPO), 1,500 mg
- 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
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
- 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
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
- 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
Many treatment procedures are contrainidicated during pregnancy. Therapeutic
abortion and watchful waiting are considered.
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Copyright © 2000 Integrative Medicine
CommunicationsThis publication contains
information relating to general principles
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