Cancer - lung - non-small cell; Non-small cell lung cancer; NSCLC; Adenocarcinoma - lung; Squamous cell carcinoma - lung

Non-small cell lung cancer (NSCLC) is the most common type of lung cancer. It usually grows and spreads more slowly than small cell lung cancer.

There are three common forms of NSCLC:

• Adenocarcinomas are often found in an outer area of the lung.
• Squamous cell carcinomas are usually found in the center of the lung next to an air tube (bronchus).
• Large cell carcinomas can occur in any part of the lung. They tend to grow and spread faster than the other two types.

Smoking causes most cases of lung cancer. The risk depends on the number of cigarettes you smoke every day and for how long you have smoked. Being around the smoke from other people (secondhand smoke) also raises your risk for lung cancer. However, some people who do not smoke and have never smoked develop lung cancer.

Research shows that smoking marijuana may help cancer cells grow, but there is no direct link between the drug and developing lung cancer.

High levels of air pollution and drinking water containing high levels of arsenic can increase your risk for lung cancer. A history of radiation therapy to the lungs can also increase the risk.

Working with or near the following cancer-causing chemicals or materials can also increase your risk:

• Asbestos
• Chemicals such as uranium, beryllium, vinyl chloride, nickel chromates, coal products, mustard gas, chloromethyl ethers, gasoline, and diesel exhaust
• Certain alloys, paints, pigments, and preservatives
• Products using chloride and formaldehyde

Early lung cancer may not cause any symptoms. Symptoms you should watch for include:

• Chest pain
• Cough that doesn't go away
• Coughing up blood
• Fatigue
• Loss of appetite
• Losing weight without trying
• Shortness of breath
• Wheezing

Other symptoms that may be due to NSCLC:

• Bone pain or tenderness
• Eyelid drooping
• Hoarseness or changing voice
• Joint pain
• Nail problems
• Swallowing difficulty
• Swelling of the face
• Weakness
• Shoulder pain or weakness

Note: These symptoms can be due to other, less serious conditions. It is important to talk to your health care provider.

The health care provider will perform a physical exam and ask questions about your medical history. You will be asked if you smoke, and if so, for how long you have smoked.

When listening to the chest with a stethoscope, the health care provider can sometimes hear fluid around the lungs, which could (but doesn't always) suggest cancer.

Tests that may be performed to diagnose lung cancer or see if it has spread include:

• Bone scan
• Chest x-ray
• Complete blood count (CBC)
• CT scan of the chest
• MRI of the chest
• Positron emission tomography (PET) scan
• Sputum test to look for cancer cells
• Thoracentesis (sampling of fluid build-up around the lung)

In some cases, the health care provider may need to remove a piece of tissue from your lungs for examination under a microscope. This is called a biopsy. There are several ways to do this:

• Bronchoscopy combined with biopsy
• CT-scan-directed needle biopsy
• Endoscopic esophageal ultrasound (EUS) with biopsy
• Mediastinoscopy with biopsy
• Open lung biopsy
• Pleural biopsy

If the biopsy shows that you do have lung cancer, more imaging tests will be done to determine the stage of the cancer. Stage means how big the tumor is and how far it has spread. Non-small cell lung cancer is divided into five stages:

• Stage 0 - the cancer has not spread beyond the inner lining of the lung
• Stage I - the cancer is small and hasn't spread to the lymph nodes
• Stage II - the cancer has spread to some lymph nodes near the original tumor
• Stage III - the cancer has spread to nearby tissue or to far away lymph nodes
• Stage IV - the cancer has spread to other organs of the body, such as the other lung, brain, or liver

There are many different types of treatment for non-small cell lung cancer. Treatment depends on the stage of the cancer.

Surgery is the often the treatment for patients with non-small cell lung cancer that has not spread beyond nearby lymph nodes. The surgeon may remove:

• One of the lobes of the lung (lobectomy)
• Only a small part of the lung (wedge or segment removal)
• The entire lung (pneumonectomy)

Some patients need chemotherapy. Chemotherapy uses drugs to kill cancer cells and stop new cells from growing.

• Chemotherapy alone is often used when the cancer has spread outside the lung (stage IV).
• It may also be given before surgery or radiation to make those treatments more effective. This is called neoadjuvant therapy.
• It may be given after surgery to kill any remaining cancer. This is called adjuvant therapy.

Controlling symptoms and preventing complications during and after chemotherapy is an important part of care.

Radiation therapy can be used with chemotherapy if surgery is not possible. Radiation therapy uses powerful x-rays or other forms of radiation to kill cancer cells. Radiation may be used to:

• Treat the cancer, along with chemotherapy, if surgery is not possible
• Help relieve symptoms caused by the cancer, such as breathing problems and swelling
• Help relieve cancer pain when the cancer has spread to the bones

Controlling symptoms during and after radiation to the chest is an important part of care.

The following treatments are mostly used to relieve symptoms caused by NSCLC:

• Laser therapy - a small beam of light burns and kills cancer cells
• Photodynamic therapy - uses a light to activate a drug in the body, which kills cancer cells

For additional information and resources, see cancer support group.

The outlook varies widely. Most often, NSCLC grows slowly. The cancer may spread to other parts of the body, including the bone, liver, small intestine, and brain.

However, in some cases, it can be very aggressive and cause rapid death. Chemotherapy has been shown to prolong the life and improve the quality of life in some patients with stage IV NSCLC.

Cure rates are related to the stage of disease and whether you are able to have surgery.

• Stage I and II cancers have the highest survival and cure rates.
• Stage III tumors can be cured in some cases.
• Patients with stage IV disease or cancer that has returned are almost never cured. The goals of therapy are to extend and improve their quality of life.

• Spread of disease beyond the lung
• Side effects of surgery, chemotherapy, or radiation therapy

If you smoke, stop smoking. It's never too late to quit. Your risk of lung cancer drops dramatically the first year after you quit. Stopping even after you've been diagnosed with early-stage lung cancer may improve your outlook.

Also avoid breathing in the smoke from other people's cigarettes, cigars, or pipes.

Routine lung cancer screening using chest x-ray or lung CT scan is not currently recommended for people who don't have symptoms. Many studies have been done to test the benefit of screening. Most experts have concluded that screening will not cure the disease or help people live longer. Screening may lead to many unneeded biopsies or surgeries.

The long-term use of vitamin C, vitamin E, and folate does not seem to reduce the risk of lung cancer.

Parsons A, Daley A, Begh R, Aveyard P. Influence of smoking cessation after diagnosis of early stage lung cancer on prognosis: systematic review of observational studies with meta-analysis. BMJ. 2010;340:b5569.

Croswell JM, Baker SG, Marcus PM, Clapp JD, Kramer Bs. Cumulative incidence of false-positive test results in lung cancer screening: a randomized trial. Ann Intern Med. 2010;152:505-512.

Bach PB, Silvestri GA, Hanger M, Jett JR. Screening for lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132:69S-77S.

Jett JR, Schild SE, Keith RL, Kesler KA. Treatment of non-small cell lung cancer, stage IIIB: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132:266S-276S.

Johnson DH, Blot WJ, Carbone DP, et al. Cancer of the lung: non-small cell lung cancer and small cell lung cancer. In: Abeloff MD, Armitage JO, Niederhuber JE, Kastan MB, McKena WG. Clinical Oncology. 4th ed. Philadelphia, Pa: Churchill Livingstone Elsevier; 2008:chap 76.

Tassinari D, Scarpi E, Sartori S, Tamburini E, Santelmo C, Tombesi P, Lazzari-Agli L. Second-line treatments in non-small cell lung cancer. A systematic review of literature and metaanalysis of randomized clinical trials. Chest. 2009;135:1596-1609.

Silvestri GA, Jett J. Clinical aspects of lung cancer. In: Mason RJ, Broaddus VC, Martin TR, et al, eds. Murray and Nadel's Textbook of Respiratory Medicine. 5th ed. Philadelphia, Pa: Saunders Elsevier; 2010:chap 47.

Slatore CG, Littman AJ, Au DH, Satia JA, White E. Long-term use of supplemental vitamins, vitamin C, vitamin E, and folate does not reduce the risk of lung cancer. Am J Respir Crit Care Med. 2008;177:524-530.