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Lung cancer

A guide for journalists on Non-Small Cell


Lung Cancer (NSCLC) and its treatment
Contents Overview Section 1 Lung Cancer Section 2 Epidemiology Section 3 Treatment References

Contents
Contents 2
Overview 3
Section 1: Lung Cancer 4
i. Types of lung cancer 4
ii. Causes and risk factors 5
iii. Symptoms and diagnosis 6
iv. Staging 7
v. Prognosis 8
Section 2: Epidemiology 9
i. Incidence & mortality 10
Section 2: Treatment 11
i. Surgery 11
ii. Radiotherapy 11
iii. Chemotherapy 11
iv. Biological (targeted) therapy 11
References 12

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Contents Overview Section 1 Lung Cancer Section 2 Epidemiology Section 3 Treatment References

Overview
Lung cancer is the leading cause of cancer death Five year survival rates for lung cancer
are poor when compared to other high
diagnosed at an advanced stage, making
successful treatment more difficult and
globally. It kills more people than breast, colorectal and incidence cancers. For example, the five survival outcomes poor.5
year survival rate for patients with breast
prostate cancers combined.1 Each year 1.38 million cancer is up to 89%;3 for lung cancer Traditionally, treatment options have
people die as a result of the disease, equating to more patients, that figure is only around 15%.4 included surgery (for patients with earlier
stage disease), radiation therapy and
than 3,000 deaths a day worldwide, or two deaths There are two main types of lung cancer; chemotherapy, alone or in combination.
non-small cell lung cancer (NSCLC) and More recently, new treatment options,
every minute.1,2 small cell lung cancer (SCLC). NSCLC is including biological therapies, have become
the most commonly diagnosed type of lung available and are helping to improve
cancer, accounting for approximately 85% outcomes and survival for patients.
of all cases.5
This guide provides an overview of lung
The early signs and symptoms of lung cancer, including its incidence, risk factors,
cancer are non-specific and as a symptoms, diagnosis and treatment options.
consequence the majority of cases are

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Contents Overview Section 1 Lung Cancer Section 2 Epidemiology Section 3 Treatment References

Section 1
Lung cancer
i. Types of lung cancer? Figure 1 Typical location of the most common types of non small cell lung cancer
Lung cancer arises from the uncontrolled
Squamous Cell Carcinoma
growth (proliferation) of abnormal cells
inside the lung. There are two main forms Develops from cells that line the airways
Often found near the centre of the lung in one
of the disease, non-small cell lung cancer of the main airways (the left or right bronchus)
(NSCLC) and small cell lung cancer (SCLC). TRACHEA Associated with smoking

NSCLC is the most common form of lung


LYMPH Adenocarcinoma
cancer, accounting for approximately NODES
85% of all cases.5 It grows and spreads The most common type of NSCLC
Develops from a particular type of cell which
more slowly than small cell lung cancer. produces mucous (phlegm), which lines the airways.
Early stage disease is associated with few BRONCHI Often found in the periphery (outer areas) of the lungs

specific symptoms; therefore approximately


70% of cases are not diagnosed until the Large Cell Carcinoma
disease is at an advanced stage when the Cells appear large and round when viewed under a microscope.
chances for cure or significant patient LUNG LOBE Grows quickly and can develop in any part of the lung
benefit are limited.6

NSCLC comprises a number of different SCLC is highly aggressive and is


types of lung cancer, which are grouped predominantly caused by smoking. It
as squamous or non-squamous. Non- metastasises (spreads around the body)
squamous NSCLC includes further sub- early in the disease process and accounts
types such as adenocarcinoma and large for approximately 15% of all lung cancers.5
cell carcinoma.7

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Contents Overview Section 1 Lung Cancer Section 2 Epidemiology Section 3 Treatment References

ii. Causes and risk factors Ionising radiation Exposure to ionising Environment Extensive evidence suggests Diseases as risk factors for lung cancer
radiation increases the risk of lung cancer. 10
that lung cancer rates are higher in cities Patients with pulmonary tuberculosis are at
Smoking The most common cause of
Atomic bomb survivors and patients treated than in rural settings. This is likely to be increased risk of lung cancer, as are those
lung cancer is cigarette smoking which
with radiotherapy for some rheumatic caused by urban air pollution, although with chronic bronchitis and emphysema.11
is associated with at least 80% of all
diagnoses.8 The risk of lung cancer diseases or Hodgkins lymphoma are at it may also involve other factors, such
amongst smokers is at least ten times moderately increased risk of developing as tobacco smoking and occupational
higher than that of non-smokers. This lung cancer.8 exposures.8
risk is reduced among ex-smokers, but Occupational risks There is an increased Indoor air pollution Indoor air pollution
a small excess risk may remain for ex- risk of lung cancer amongst workers may be responsible for the increased risk
smokers throughout their lives.8 There is of lung cancer that exists for non-smoking
employed in certain industries and
also a causal link between lung cancer and women in certain regions of China and
occupations which involve high-risk agents.
use of cigars, tobacco pipes, water pipes other Asian countries. This risk is highest
The most significant of these are asbestos
and smoking of other tobacco products.9 for women living in poorly ventilated
and combustion fumes. In industrialised
Evidence also exists of a link between lung homes where coal, wood or other solid
countries, occupational risks account for
cancer risk and passive smoking (estimated fuels are regularly burnt. Fumes from
approximately 5-10% of lung cancers.9
to be 20%).9 high-temperature cooking using unrefined
Underground miners exposed to radioactive
vegetable oils such as rapeseed oil have
radon and its decay products have also
Whilst smoking is the single biggest cause also been associated with an increased risk
of lung cancer, people who have never been found to be at an increased risk of
of developing lung cancer.8 There is also a
smoked also develop the disease. Risk developing lung cancer.12
link between high concentrations of radon
factors include: gas decay particles and lung cancer in
some countries.8 This gas is emitted from
natural sources and can accumulate in
buildings, especially in confined areas such
as attics and basements.10

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Contents Overview Section 1 Lung Cancer Section 2 Epidemiology Section 3 Treatment References

iii. Symptoms and diagnosis Persistent cough Diagnosis allows confirmation of the Cytology: A sample of sputum is taken
disease. Analysis of cancerous cell tissue to confirm the diagnosis and type of
Common symptoms of NSCLC are A change in a persistent cough
(histology) is particularly important in lung cancer.
mostly non-specific and may initially Shortness of breath
obtaining an accurate diagnosis. There are
be disregarded by the patient. As a Coughing up phlegm (sputum) with Bronchoscopy: A visual examination
a variety of tests available to diagnose lung
consequence many patients go to their signs of blood of the trachea and internal parts of
cancer.5
doctor when the disease is at an advanced Aches or pains when breathing or the lungs. Specimens of tissue may be
stage when symptoms become more coughing taken from inside the lungs to gather
troublesome and persist. Symptoms to Loss of appetite cells for analysis.
watch out for include: Fatigue Needle biopsy: Alongside a CT scan
this procedure is used to obtain cells
Loss of weight
for analysis.

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Contents Overview Section 1 Lung Cancer Section 2 Epidemiology Section 3 Treatment References

iv. Staging Magnetic resonance imaging (MRI)


Table 1 Staging of NSCLC
scan: uses a magnetic field to create
Staging reflects how advanced the cancer
an image of the chest to determine the Stage Classification
is and whether it has spread to other parts
location and extent of cancer spread. Early stage Stage I The cancer is present only in one part of the lung.
of the body. It helps to identify the most
Bone scan: allows detection of spread to disease
appropriate treatment options for the Stage II Cancer has spread to the nearby lymph nodes or nearby
the bone. tissues, such as the chest wall.
patient.
Other tests
Later stage Stage III The cancer has spread more extensively within the chest
Staging determines how extensive Abnormal blood chemistry tests: may and, generally to the major lymph nodes.
(advanced) the cancer is.8 There are a suggest the presence of metastases in Stage IV Cancer has spread to other parts of the body, such as the
variety of tests available to stage lung bone or the liver. liver or bones.
cancer.5
With early stage disease there is the chance
Radiological/nuclear medicine of a cure if the tumour can be successfully
X-rays: detect a localised mass in the lungs surgically removed. Late stage disease has a
or enlarged lymph nodes in the chest. worse prognosis than earlier stage disease.

Computed tomography (CT) scan:


a computer assisted technique which
produces cross-sectional images of the
body to confirm the size and location of a
mass as well as possible spread to other
organs.

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Contents Overview Section 1 Lung Cancer Section 2 Epidemiology Section 3 Treatment References

Prognosis Figure 2 Lung cancer average 5 year survival rates depending on stage at diagnosis
Cancer statistics often use an overall
5-year survival rate to give a better idea of
the longer term outlook for people with a
particular cancer. Five year survival rates
for lung cancer are poor when compared to
other high incidence cancers. For example,
the five year survival rate for patients with
breast cancer is up to 89%.3 For lung cancer
patients that figure is only around 15%.4

Average 5 year survival rates at Stage I NSCLC: 58% Average 5 year survival rates at Stage IV NSCLC: 7.5%

Cancer Research UK: http://www.cancerhelp.org.uk/type/lung-cancer/treatment/statistics-and-outlook-for-lung-cancer#nonsmall

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Contents Overview Section 1 Lung Cancer Section 2 Epidemiology Section 3 Treatment References

Section 2
Epidemiology
i. Incidence & mortality Figure 3 Lung cancer incidence by region
2000 where it accounts for an average of
20.3% of all cancer deaths.8
Lung cancer is the most common type of North America Central & South America Europe Asia Africa Australia & New Zealand

cancer worldwide (accounting for 16.5%

1.38 1.6 85%


million deaths
The average estimated age-standardised
of all cancers), and is responsible for from lung cancer
million new
cases of lung
of cases are
non-small cell incidence per 100,000 population was 71.8
every year cancer every year lung cancer
the greatest number of cancer deaths
for men and 21.7 for women, across the
worldwide. Accounts for 28.4% of all
cancer deaths in North America European Union (25-member states), in
Accounts for an average of 20.3%
of all cancer deaths in Europe 2006.8
Worldwide
 1.6 million new cases of lung cancer are 28.4% 20.3% North America and Canada Lung cancer
diagnosed every year.1
Accounts for an average is the most common cause of cancer death
 It is the most common cancer in men,
16.3% of 16.3% of all cancer
deaths in Eastern, South in North America, accounting for 28.4%
and the third most common cancer Eastern, South Central
and Western Asia
of all cancer deaths, and is the third most
in women in both developed and
developing countries.8 9% common type of new cancer cases (14.5%)
11.6%
Accounts for an
average of 9% in this region. North America has one of
 Lung cancer is the leading cause of Accounts for an average of
of cancer deaths
in Southern and
11.6% of all cancer deaths
Northern Africa the highest lung cancer incidence rates for
cancer mortality and is responsible for
22.4%
in South and Central America
men and women with approximately 1.75
1.38 million deaths each year.1 Accounts for an average of 22.4%
of all cancer deaths in Australia,
million new cancer cases and deaths in
 Each day, more than 3,000 people die New Zealand and Micronesia

2007.8
from lung cancer worldwide, equal to two Parkin MD et al. Global Cancer Statistics, 2002. CA Cancer J Clin 2005; 55:74-108
Allen J et al. Neoadjuvant Chemotherapy in Stage III NSCLC J Natl Compr Canc Netw. 2008 6 (3):285-93
Garcia M, et al. Global Cancer Facts & Figures 2007. Atlanta, GA: American Cancer Society, 2007

deaths every minute.2


 Almost half of the diagnosed cases *Developed countries defined as Europe, Japan, South and Central America Lung cancer
Europe Lung cancer is the leading cause of
of lung cancer occur in developing Australia, New Zealand and North America. is the most common cause of cancer death
cancer related death in Europe, accounting
countries (49.9%), with the incidence Developing countries defined as Africa, Latin in South and Central America (accounting
for 18.9% of all cancer deaths in Western
generally being lower in women (globally, America and the Caribbean, Asia, Micronesia, for 12% and 11.6% of all cancer deaths,
Europe and 21.1% of all cancer deaths in
12.1 per 100,000 women compared to Polynesia and Melanesia respectively).8
Northern Europe.8 Approximately 375,000
35.5 per 100,000 in men). cases were attributed to lung cancer in

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Contents Overview Section 1 Lung Cancer Section 2 Epidemiology Section 3 Treatment References

Asia Lung cancer is the most common


Figure 4 Incidence and mortality of some of the most common cancers worldwide
cancer diagnosed in South Eastern Asia
(accounting for 13.3% of all cancer deaths) 1,092 515
Lung
and the second most common cancer 948 427

diagnosed in Eastern and Western Asia 1,384


(diagnosed in 17.1% and 12.8% of all Breast
458
cancer cases, respectively).8 It is also the
663 571
leading cause of cancer death in Eastern, Colorectum
320 288
Western and South Eastern Asia accounting
640 348
for 20.9%, 18.1% and 17.8% of all cancer Stomach
463 273
deaths, respectively), and the second
most common cause of cancer death Liver
523 226

478 217
among South Central Asian populations
(accounting for 8.2% of all cancer deaths).8 899
Prostate
China and Japan in particular have a high 258

incidence and death rate by comparison to 1000,000 500,000 500,000 1000,000

the rest of the world.


Male Female

Incidence and mortality of some of Incidence Incidence


Africa Lung cancer is the third most the most common cancers worldwide
Adapted from GLOBOCAN 2008 Mortality Mortality
common type of cancer (6.9%), as well as
the third most common cause of cancer
death (at 8.5%) in Northern Africa. It is the Australia Lung cancer is the most common
second most common cause of cancer cause of cancer deaths in Australia and
death in Southern Africa, at 9.5%.8 New Zealand (19.6%), and in Micronesia
(25.2%).8

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Contents Overview Section 1 Lung Cancer Section 2 Epidemiology Section 3 Treatment References

Section 3
Treatment
Treatment options vary depending on the In general the treatment options for these cases chemotherapy is often used iv. Biological (targeted)
type and stage of the cancer in addition to NSCLC are: to treat patients. The most common therapy
its size, position in the lung, whether it has chemotherapies used in NSCLC are based
This is a relatively a new approach to
spread to other parts of the body and the i. Surgery on a platinum-containing regimen in
cancer treatment that target specific
overall physical health of the patient. combination with a second therapeutic
Patients with early stage, localised NSCLC biological processes often essential to
agent. Patients usually receive treatment
may be successfully treated using surgery. tumour growth. Biological therapy can
in a number of defined cycles as the
Up to 70% of patients survive for at least include monoclonal antibodies, vaccines
incremental benefit of giving continuous
five years after diagnosis if treated at this and gene therapies. As biological therapies
chemotherapy does not outweigh the
stage, with a proportion of these patients precisely target cancer-specific processes,
cumulative toxicities experienced.
being cured. they may potentially be more effective
than other types of treatment (such as
First-line treatment refers to the initial
ii. Radiotherapy therapy a patient receives for advanced
chemotherapy and radiotherapy) and less
toxic to non-cancerous, healthy cells.12
For patients whose cancer cannot be disease.
Several types of biological therapy exist
operated on, radiotherapy may be offered
Treatment until progression/ for the treatment of advanced non-small
alone or in combination with chemotherapy.
maintenance therapy describes treatment cell lung cancer. These are either given as
In addition, radiotherapy also has a well
given immediately following first-line monotherapy or in conjunction with other
established role in providing control and therapies at various stages of advanced
treatment, when the tumour has not
relief of the symptoms of lung cancer. disease (in accordance with their approved
progressed.
label).
Second line treatment that patients
iii. Chemotherapy
receive after a first-line treatment, following
The majority of cases of NSCLC cases disease progression.
diagnosed at an advanced stage1 when
the cancer has already spread to another
part of the body and can no longer be
successfully removed by surgery. In

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Contents Overview Section 1 Lung Cancer Section 2 Epidemiology Section 3 Treatment References

References
1 GLOBOCAN 2008 facts about lung cancer mortality rate at http://globocan.iarc.fr/factsheet.asp. 9 I ARC (2004). Tobacco smoke. In: IARC Monographs on the Evaluation of Carcinogenic Risks to
Accessed 15.05.12 13. Humans, Volume 83, Tobacco smoke and involuntary smoking Lyon, France: International
Agency for Research on Cancer. 51-1187
2 1.38 million deaths per year / 365 days 3,771 deaths per day / 24 hours = 157 deaths per hour / 60
minutes = 2.61 deaths per minute 10 US Environmental Protection Agency. A Citizens Guide to Radon. http://www.epa.gov/radon/pdfs/
citizensguide.pdf Accessed 22.02.10
3 American Cancer Society. Breast Cancer Facts and Figures 2009-2010. Atlanta. American Cancer
Society Inc. 11 Boffetta P and Trichopoulos D (2008). Biomarkers in cancer epidemiology. In: Adami HO, Hunter
DJ, 17. Trichopoulos D, eds., Textbook of cancer epidemiology. Oxford: Oxford University Press
4 Lung cancer 5 year survival rates at http://lung-cancer.emedtv.com/lung-cancer/lung-cancer-surviv
109 126
al-rate-p2.html. Accessed 11.05.11
12 National Cancer Institute. Targeted cancer therapies. Last accessed April 2011 at http://www.
5 Barzi A and Pennell NA. Targeting angiogenesis in non-small cell lung cancer: agents in practice
cancer.gov/cancertopics/factsheet/Therapy/targeted
and clinical development. EJCMO (2010). 2(1):31-42

6 Schiller JH, et al. Comparison of four chemotherapy regimens for advanced non-small-cell lung
cancer. NEJM (2002). 346(2):92-98

7 Cancer Research UK: About Lung Cancer at http://www.cancerhelp.org.uk/type/lung-cancer/about/.


Accessed 11.05.11

8 WHO World Cancer Report 2008. Edited by Peter Boyle and Bernard Levin. Lung cancer, 12.
Chapter 5.10

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