Lung cancer: Smoking the biggest threat
View(s):Consultant Thoracic Surgeon Dr. Waruna Karunaratne explains the importance of seeking treatment early
Lung cancer, which is known to be the No.1 killer in the world, is less well known and less well understood in Sri Lanka. There are many misconceptions about lung cancer among patients as well as many medical professionals.
The lack of knowledge and understanding of the advances made in the treatment of lung cancer deals an early death sentence to the patient, which can on most occasions be delayed significantly.
Delays in diagnosis, the wrong diagnosis being made on investigations carried out and treating blindly without a definitive diagnosis significantly delays proper management in these patients. On many occasions this reduces life expectancy significantly. Sometimes the treatment maybe curative if diagnosed early. Currently by the time the lung cancers are diagnosed there are only palliative procedures available and the patient is given a death sentence.
Unfortunately in Sri Lanka on many occasions the patients diagnosed are also given the wrong information regarding the prognosis of lung cancer and an extremely bleak picture is painted causing the patient only to be considered for palliative treatment.
The scope of surgical procedures in diagnosis, curative resection and palliative surgery is poorly understood even among medical professionals and education of patients and health professions is the mainstay of saving lives.
So it must be remembered that early diagnosis and the appropriate management of lung cancer can prolong a very good quality of life significantly!
There is a need for every suspected lesion to be seen by a specialist who is trained in lung cancer surgery as the gold standard of treatment for early lung cancer is early surgical removal.
So what do we need to know?
Lung cancer is the highest cause for cancer related deaths in men and women worldwide.In Sri Lanka it is the third highest, the highest being oral cancer. Men are far more likely to be affected compared to women. According to statistics from the Ministry of Health published in 2007 the incidence in Sri Lanka is about 7.17 per 100,000 (this is confirmed by WHO statistics). This amounts to approximately 1960 cases per year. This is a high incidence and taking into account that this maybe under reported.
- Smoking increases the risk significantly
- Early diagnosis and removal of a suspicious growth can be curative
- All suspicious looking abnormalities noted in the lungs should be further investigated
- A scan cannot give a diagnosis; a scan only gives an indication as to what the abnormality could be. For a definitive diagnosis a biopsy/removal is required.
Proper follow-up is integral to the management of a suspicious
diagnosed abnormality
A multidisciplinary approach is required where the chest physician, thoracic surgeon, oncologist discusses the best treatment option for the patient. The treatment maybe palliative or curative.
Risk factors for lung cancer
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Though until 2005, proper surgical resections for lung tumours were not readily available in Sri Lanka, it has now been established. Awareness is important because surgical resection is the gold standard for lung tumours.
Causes for lung cancer
Incidence of lung cancer starts to increase once you are over 40 years of age. That does not mean that you will not have cancer if you are below 40. There are several atypical cancers, which occur, in younger age groups, such as carcinoid tumours, which can be cured after surgical removal.
Symptoms that
should prompt a visit to your doctor
- A persistent cough lasting more than two weeks
- Blood with cough (haemoptysis)
- Difficulty in breathing
- Chest pain (pleuritic)
- Hoarseness of voice
- Tiredness
- Recurrent pneumonia
- Weight loss
Investigations
- Chest X ray
- Bronchoscopy is passing a tube containing a camera to inspect your air passage. It only sees the things inside the air passage. It cannot detect lesions in the lung tissues. Usually it is done as an out-patient procedure without general anaesthesia. Bronchoscopy will take 15 -30 minutes and the patient can go home within 1 hour.
- CT scan of Chest and EBUs are other special investigations, which will be decided by the lung specialist.
These investigations should be seen and done by a chest physician or a thoracic surgeon.
All solid lung lesions or consolidations occurring without fever need to be seen by a thoracic surgeon.
How is a diagnosis made
If you are found to have a lung lesion (tumour, consolidation without fever or suspicious area) on chest X’ray or CT Scan, it needs to be biopsied to come in to a diagnosis.
How is the biopsy done?
This minimally invasive procedure is done either by the guidance of a CT scan or Ultrasound. You may have to stay 6 to 24 hours in the hospital. It is usually done by a radiologist (who is a Consultant) at the X’ ray department of the hospital. A thin needle is passed through the skin under local anaesthesia into the lungs to get a sample of cells or tissue.
Bronchoscopic biopsy (and EBUS)is passing an endoscope (thin flexible tube) through your air passage with local anaesthesia. This is an out patient procedure and you may be able to go home 1-2 hours after the procedure
If the above methods fail or the lesion is inaccessible you may have to undergo a Video Thoracoscopy or mediastinoscopy (minimally Invasive procedures), which are done under general anaesthesia by a Thoracic surgeon. Thoracoscopy-is when a camera is put into your chest cavity with one centimetre skin incision. It is done under general anaesthesia or under sedation by a thoracic surgeon. The camera will project an image to a video screen and the surgeon can get biopsies from the lung, lymph nodes and pleura (lining of chest cavity). You may have to stay in the hospital for 1-2 days.
Mediastinoscopy- is to introduce a small rigid tube through a 2 cmsmall incision in the neck to get a sample from inside the chest (tumour, lymph nodes). As it is done under general anaesthesia you may have to spend one day in the hospital.
From the information received from the biopsies and CT scans we can ascertain the type of tumour and the extent of its spread. This will allow the specialists to treat the cancer optimally and will determine further management. On occasions if the tumour is resectable and accessible the thoracic surgeon may remove the tumour at the same time to avoid two procedures.
Treatment
Depends on the stage of the cancer and the stage as described depends on the spread. Currently the gold standard is surgical resection. If localised the cancer should be removed. The management will be individualised and discussed amongst the three specialists, the thoracic surgeon, the chest physician and the oncologist and the appropriate management implemented. Unlike years gone by surgical resection is also done by a minimally invasive procedure. This has benefits of less pain, early mobilisation and discharge (generally patients are home after 4 days). The oncologists decide the role of chemotherapy and radiotherapy after surgery with the results.
So what should we remember? Stop smoking! Prevention is better than cure. If you have persisting symptoms seek help early, and if an abnormality is seen make sure this is further investigated. It’s always better to rule out a sinister cause than repeating investigations periodically. Ask to be referred to the relevant specialities for further management.
All procedure and treatment and expertise is readily available in the government sector in Sri Lanka as well as the private sector.