Lung Cancers – Causes, Signs and symptoms

Lung Cancer

Also called: Bronchogenic Cancer, Lung Carcinoma

Reviewed By:
Mark Oren, M.D., FACP
Fernando de Zarraga, M.D.,

Summary

Lung cancer is the leading cause of cancer deaths in both men and women worldwide. Comparatively rare in the early 20th century, lung cancer cases soared with the introduction of mass-produced cigarettes.

About 87 percent of lung cancers are due to tobacco products, either through direct smoking or passive exposure to smoking, according to the American Cancer Society (ACS). The number of cigarettes smoked per day and the length of time a person smokes directly impacts the risk of developing lung cancer. Men have a slightly greater chance of developing lung cancer – 1 in 12 – as compared to women who have a 1 in 17 chance. Lung cancer will account for 12 percent of all new cases of cancer.

The ACS estimates that about 213,000 new cases of lung cancer will be diagnosed in 2007. In the same year, lung cancer will be responsible for more than 160,000 deaths. The disease causes more deaths than colon, breast and prostate cancers combined. Although the prognosis for lung cancer is often poor, there are currently about 330,000 long-term survivors.

There are two basic types of lung cancer: non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). The type of lung cancer is important because it affects how the disease is treated. Most cases of lung cancer are NSCLC, which generally grows more slowly than SCLC.

Both types of lung cancer can be very difficult to treat. By the time patients report symptoms, the disease has often spread to other parts of the body. Common symptoms of lung cancer include persistent cough (often called “smoker’s cough”), breathing problems, blood in sputum, pneumonia and respiratory infections, chest pain, weight loss and fatigue.

When lung cancer is suspected, diagnostic tests such as a chest x-ray, MRI, CAT scans and PET scans can be used to determine the location of the cancer. These tests, as well as bone scans may be performed to determine if and where the cancer has spread (metastasis). A sample of lung tissue may be obtained through a needle biopsy to analyze the cells for presence and type of cancer.

If the cancer is detected early and it remains in the lung, surgery may be an option. For lung cancer that has spread, chemotherapy and radiation therapy are standard treatment methods. Small cell lung cancer, which metastasizes quickly, can be treated with brain radiation to prevent spreading of the cancer to the brain.

Because smoking is such a strong risk factor for developing lung cancer, quitting smoking can greatly reduce the likelihood of lung cancer. The incidence and death rates for lung cancer have declined in the last several years, in part due to the decreased trend in cigarette smoking.

Survival rates of lung cancer vary with the type and stage of the disease. The one-year survival rate for lung cancer has increased slightly during the past decade, primarily due to improved treatments. However, about 60 percent of the people diagnosed with lung cancer will die within one year of their diagnosis. Within two years, nearly 75 percent will die from the disease. Currently, the ACS estimates there are about 330,000 individuals who have survived lung cancer.

Whether to screen for lung cancer remains an ongoing debate among scientists. Some studies suggest that screening with certain tests, such as CAT scans or e-rays, may help detect early stage lung cancer. However, other studies found no significant reduction in deaths from lung cancer due to screening tests. Additional studies are needed to determine definitively the value of screening for lung cancer.

Patients should discuss the use of screening tests with their physicians. Currently, the best method to combat lung cancer of all types is by refraining from or quitting smoking.

About lung cancers

Lung cancer is the leading cause of cancer deaths worldwide and will account for more than 160,000 deaths in the United States in 2007. It is responsible for more deaths than breast, colon and prostate cancers combined, according to the American Cancer Society (ACS).

Lung cancer is the abnormal growth of malignant cells in the tissues of the lungs and/or airways that grow uncontrollably and destroy healthy cells. This uncontrolled growth may develop over many years and often goes undetected.

The lungs are sponge-like cone-shaped organs located in the chest cavity. The left lung has three lobes and the right has two lobes. The lungs are part of the respiratory system and are responsible for the healthy exchange of gases that nourish and cleanse the body’s cells.

A system of small tubes (bronchioles) and larger tubes (bronchi) carry air to and from the lungs for processing in air sacs called alveoli. The oxygen is carried through the bloodstream and made available to the cells in the body. The bloodstream also picks up the carbon dioxide from the cells, a waste product that is sent to the lungs to exhale.

Cancer cells develop because of damaged DNA, which is the genetic blueprint that governs the behavior of cells. In most cases, when the DNA becomes damaged, the body is able to repair it. In cancer cells, however, the DNA is not repaired, which causes the abnormal cells to reproduce more quickly and live longer than normal cells.

Most lung cancers begin in the lining of the bronchi, which is why lung cancer is also known as bronchogenic cancer. Lung cancer spreads quickly and is often not detected until it has metastasized to other areas of the body.

Lung cancer is often thought of as a single disease, but there are two main types: non-small cell lung cancer (NSCLC), which is the most common, and small cell lung cancer (SCLC). The ACS estimates that about 87 percent of lung cancer cases are NSCLC and the remaining 13 percent are SCLC. NSCLC can be divided into subtypes, such as adenocarcinoma, squamous cell carcinoma, and large-cell undifferentiated carcinoma.

Before the 20th century, when cigarettes were not mass produced or readily available, the disease was rarely seen. As cigarettes became widely available, cases of lung cancer rose dramatically. Today, smoking is responsible for about 87 percent of lung cancer cases, according to the ACS. In areas of the world where more people smoke, there has been a corresponding rise in lung cancer cases.

Lung cancer has declined in the last several years, in conjunction with the decreasing trend in smoking. Although a decine has been found in new cases among men, while the rates for women have remained stable. However, the ACS estimates that there will be about 213,000 new cases of lung cancer in 2007. The disease is typically found in the older population, with nearly 70 percent of the newly diagnosed cases occurring in people over the age of 65.

In general, lung cancer is a particularly deadly form of cancer because most cases are not diagnosed until the disease has metastasized. Death rates following diagnosis have fallen slightly, but they have remained relatively static over the past decade, according to the Centers for Disease Control and Prevention (CDC).

The ACS estimates that almost 60 percent of people diagnosed with lung cancer die within one year of their diagnosis, and nearly 75 percent will die within two years. These rates have not improved over the past 10 years. The overall five-year survival rate for all stages of lung cancer is only 16 percent. Although the chance of survival is typically poor with lung cancer, the ACS estimates that currently there are about 330,000 long-term survivors.

Types and differences of lung cancer

There are two types of lung cancer: non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). They have different cells, spread in different ways and are treated differently.

Non-small cell lung cancer generally grows and spreads less quickly than small cell lung cancer. It accounts for 87 percent of lung cancers, according to the American Cancer Society (ACS). There are several subtypes of NSCLC:

  • Adenocarcinoma. Cancer in the mucus-producing glandular cells in the outer part of the lungs in the bronchi and bronchioles. This is the most common type of lung cancer and is most common in women and non-smokers. This cancer rarely shows symptoms in the early stages and therefore may be metastasized by the time of diagnosis. However, it is also most responsive to treatment. About 40 percent of lung cancers are this type.

  • Squamous (epidermoid) cell carcinoma. Cancer of the cells lining the bronchi or airways in the central part of the lungs. These cells are thin and flat and look like fish scales. They can be easily found in sputum, which assists in early detection and cure. This form of lung cancer is most common in men. This is the slowest growing of the three non-small cell types and 25 to 30 percent of lung cancers are this type.

  • Large cell carcinoma. Cells originating in the peripheral parts or edges of the lungs. These cells are large, grow and spread aggressively to distant organs. This lung cancer is strongly associated with smoking with 10 to 15 percent of lung cancers being large cell carcinoma.

About 20 percent of lung cancers are small cell lung cancers, also called oat cell cancer because of a resemblance to oat grains. This type of cancer generally is more aggressive than the non-small cell cancers. It begins in the cells of the bronchi and can quickly spread before any symptoms appear. This cancer metastasizes early to distant organs and tissues such as the brain, bone and liver and is particularly life-threatening. The cell type does respond to chemotherapy but is often widely metastasized at the time of diagnosis. Approximately 90 percent of people with small cell lung cancer are current or past smokers.

There are more rare forms of lung cancer, which include:

  • Carcinoid tumors. They are slow growing, often benign and usually cured by surgery. Fewer than 5 percent of lung tumors are of this type, according to the ACS.

  • Adenosquamous carcinoma. Cancer with features that are a mix of adenocarcinoma and squamous cell.

  • Bronchioalveolar carcinoma. A subtype of adenocarcinoma that often does not involve bleeding and death of tissue.
  • Sarcoma. Cancer of soft connective tissue, including muscle, nerves and fat. Risk factors include certain hereditary syndromes, damage to the lymphatic system and exposure to toxic chemicals.

  • Lymphoma. Cancer of the lymphatic system. Risk factors include immune disorders, aging and genetic mutations caused by exposure to chemicals, radiation or other sources.

In addition, benign (noncancerous) growths called carcinoid tumors sometimes develop in the lungs. Surgery is usually successful in removing these growths.

Risk factors and causes of lung cancers

Cigarette smoking is responsible for 90 percent of male and 80 percent of female lung cancer deaths, according to the National Center for Biotechnology Information. The length of time a person smokes and the number of cigarettes smoked per day impacts the likelihood of developing cancer. These factors can be calculated in “pack years.”

A pack year is a method to measure the amount a person has smoked over a long period of time. It is calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the person has smoked. For example, one pack year is equal to smoking one pack per day for one year, or two packs per day for half a year, and so on. A person who smokes two packs a day for 15 years is said to have 30 pack years.

However, not everyone who smokes will get lung cancer. Studies by the National Institutes of Health estimate that about 20 percent of people who smoke will develop lung cancer. Scientists are researching whether some people are genetically predisposed to developing lung cancer, but the data is inconclusive thus far.

Other risk factors may or may not be related to smoking. For instance, age by itself is a risk factor of cancer, but it may also relate to the length of time a person smokes. Lung cancer is rarely seen in patients under age 40. Cases begin to increase after age 45 and the number of cases is even greater after age 65.

Race also plays a role. African Americans have a 50 percent greater chance than whites of developing lung cancer. They are also more likely to get it at a younger age and are less likely to survive. However, these risks are more likely due to smoking and reduced access to health care than to genetic factors. African nations have some of the lowest rates of lung cancer.

Men have a slightly greater risk than women of developing lung cancer. Men have a 1 in 12 of developing the disease in their lifetime, while women have a 1 in 17 chance.  The American Cancer Society (ACS) notes that death rates in men have declined from 1991 to 2002 by nearly 2 percent. In women, mortality rates are approaching a plateau after a steady increase for several decades. Overall, death rates in men and women combined have decreased by 0.6 percent since 1991.

Other risk factors for lung cancer include the following:

  • Passive smoking or second-hand smoke (also called environmental tobacco smoke). Those who breathe in smoke daily whether at home or in the workplace may have a greater chance of developing lung cancer. The link between lung cancer and second-hand smoke is likely but still somewhat controversial.
  • Marijuana. The content of tar in marijuana is much higher than in cigarettes.  Other factors adding to the cancer risk include deep inhalation, holding smoke in the lungs for a long time, smoking down to the area of highest tar content and other unknown elements such as possible fungus, pesticides or additives.

  • Occupational or environmental exposure to toxins. These include:

    • Radon. A colorless, odorless gas released from the natural breakdown of uranium. Not normally dangerous outdoors, this gas can collect in homes built over soil with natural uranium deposits.

    • Asbestos. People who have worked with this mineral fiber are seven times more likely to die of lung cancer, according to the ACS.

    • Other carcinogens found in the workplace. Arsenic, coal products, gasoline, diesel exhaust, nickel chromates, vinyl chloride and talc dust are associated risk factors for lung cancer.

    • Air pollution. A contributing factor to lung cancer. This risk is very slight as compared to smoking, however.

  • Previous lung cancer. Patients with a history of lung cancer have a high risk of recurrence, especially if they continue to smoke.

  • Other lung diseases. At higher risk are patients with tuberculosis, emphysema, etc. These diseases cause scarring and/or abnormalities in the lung tissue that predispose it to lung cancer.

  • Family history of lung cancer. A slightly higher risk exists for patients with family members with lung cancer but this genetic link is still unclear.

  • Diet. Some researchers are finding that a diet low in fruits and vegetables may increase the risk of developing certain cancers. The reverse is true – a diet high in these nutrients may offer some protection.

Signs and symptoms of lung cancers

Lung cancer often does not show any symptoms until it has reached an advanced stage, which is a reason why few lung cancers are detected at an early stage. The disease may be found initially when individuals are undergoing tests for other medical conditions.

As the cancer grows, blocking airway passages and eventually metastasizing, the following symptoms may appear:

  • Persistent cough
  • Coughing up blood (hemoptysis)
  • Wheezing
  • Breathing difficulties (shortness of breath, wheezing, pain)
  • Dysphagia (swallowing problems)
  • Chest pain
  • Repeated pneumonia (fever and mucus-producing cough) or bronchitis
  • Enduring hoarseness
  • Collapse of the lung
  • Loss of appetite and weight loss
  • Fatigue
  • Pain at metastatic sites, such as in the bones

Some lung cancers produce a hormone-like substance that enters the bloodstream and affects distant tissues and organs (a condition called paraneoplastic syndromes). Small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC) can cause different symptoms, but they include:

  • Production of substances that cause blood clots to form, usually in the legs but which may occur in vital blood vessels

  • Low salt levels (syndrome of inappropriate antidiuretic hormone), which can cause fatigue, muscle weakness, loss of appetite and other symptoms

  • Unexplained loss of balance

  • High blood calcium levels, causing frequent urination, confusion and other related symptoms

  • Excess breast growth in men

When cancer occurs in the upper section of the lung, it can impact a nerve that runs from the upper chest into the neck. These cancers are sometimes called Pancoast tumors, and the most common symptom is shoulder pain.

Diagnosis methods for lung cancers

There has been limited progress in the area of early detection of lung cancer. Routine chest x-rays, sputum cell analysis and examination of bronchial passages in high-risk individuals have not shown much success in detecting early-stage lung cancer and improving the chances of survival. Surgery and lung biopsy presents high risks and, therefore, lung cancer screening is not usually advised.

Currently, there is a large scale test being conducted regarding lung cancer screening. The National Lung Screening Trial (NLST) utilizes an x-ray test known as a spiral CT scan in smokers and former smokers in an attempt to detect early lung cancers. It is not yet known if this method will be effective in detecting cancer early enough to save lives. Research continues to evaluate other screening tests to determine their effectiveness in detecting early stage lung cancer and improved survival from the disease.

If lung cancer is suspected, there are number of tests that will be conducted to diagnose the disease. A physician will first obtain a medical history, including smoking habits, environmental factors and family history of smoking. A physical examination will be completed with emphasis on breathing function.

Other tests will be conducted to determine the location, type and stage of the lung cancer. Staging is the process of determining if and the extent that the cancer has spread in the body. Common tests for lung cancer include:

  • Blood and urine tests. These tests are taken to determine chemical or hormonal imbalance that may indicate disease in the organs. For instance, abnormal calcium levels or alkaline phosphatase in the blood can be detected, indicating metastasis to the bones.

  • Sputum sample. A sample of phlegm is taken and tested for microscopic examination. This test is used to detect squamous cell carcinoma.

Diagnostic imaging tests include:

  • CAT scan. Images are taken of the body from different angles with specialized x-rays and computer technology. CAT scan can be used to locate tumors in the body, such as growths in the lungs.  In some cases, a contrast medium (dye) can be injected into the patient to help highlight abnormalities.
  • Magnetic resonance imaging (MRI). Magnetic and radio waves are used to create detailed three-dimensional images of internal organs to locate tumors.
  • X-rays. A chest x-ray is taken to show if there are masses in the organs and bones in the chest cavity. However, chest x-rays often miss early-stage lung cancer in comparison to CAT scans.

  • Radionuclide scanning. This scan is used to view the spread of cancer to other organs such as the liver. A radioactive substance is swallowed or injected. The scanner images the radioactivity of the organs to show any tumor growth.

  • Video-assisted thoracoscopic surgery (VATS). A thin, lighted tube is connected to a video camera and monitor. The space between the lungs and the chest wall is viewed for tumors. Biopsies can be taken of the tumor, the lymph nodes or fluid.

  • Positron emission tomography (PET) scan. A radioactive sugar is injected into the bloodstream and is rapidly absorbed by the cancer cells making them detectable to a camera that creates an image of the tumors.This test is often used to determine if and where the cancer has metastasized.  
  • Bone scan. Radioactive material injected into the bloodstream collects in the bones and images are taken by scanner. The images detect cancer cells in the bones.

Other tests include:

  • Bronchoscopy. A bronchoscope is placed through the mouth, down the esophagus and into the breathing passages to look for tumors or blockages. Samples of tissue may be taken in a biopsy for analysis. A biopsy is a definitive test to determine the presence and type of a cancer.

  • Mediastinoscopy. After the patient undergoes general anesthesia, lighted instrument is placed through an incision in the neck and used to view the inside of the chest cavity. The mediastinum (center of the chest between the lungs) and nearby lymph nodes are viewed for tumors. A biopsy may also be taken.

  • Anterior mediastinotomy (Chamberlain procedure). A lighted instrument is placed through a surgical incision in the chest and used to view the inside of the chest cavity. The mediastinum (center of the chest) and nearby lymph nodes are viewed for tumors. A biopsy may be taken during the procedure.

  • Thoracentesis. After the skin is numbed, a needle is inserted between the ribs to remove fluid around the lungs to observe for cancer cells.

Treatment options for lung cancers

Treatment for lung cancer is typically coordinated by a patient’s cancer care team. The team may be headed by a medical oncologist and can include a surgeon and radiation oncologist.  Non-small cell lung cancer (NSCLC) is usually treated with surgery at the early stages. Wherever possible, only the tumors are removed. However, in cases of the cancer spreading in the lung, a lobe or an entire lung may be removed. Treatment of lung cancer can include one or more of the following options:

  • Surgery. For NSCLC, surgery is recommended for stages 0 through IIIA. Beyond that, metastasis precludes using surgery. These operations involve thoracotomy, a surgical incision through the chest, after general anesthesia. The following procedures are options that depend on the extent of spread through the lung:
    • Lobectomy. An entire lobe of one lung is removed. This is the most common lung cancer surgery performed.
    • Wedge resection (also called segmentectomy). Only the tumor and small portion of surrounding normal lung tissue is removed.
    • Pneumonectomy. Surgery to remove an entire lung. This surgical procedure will result in reduced lung capacity and is preformed only when absolutely necessary and if the patient’s remaining lung can sufficiently function alone.
  • Radiation therapy. Use of precise x-ray radiation focused directly on the tumor to kill or shrink tumor cells, while avoiding contamination of the surrounding healthy cells. External radiation is directed from a machine outside of the body to the site of the tumor inside the body. Internal radiation (brachytherapy) involves putting radioactive “seeds” in or near the tumor site. Radiation may be used as a primary treatment of cancer, particularly if the patient is not healthy enough to undergo surgery. It also may be used to kill any cancer cells that remain in the area after surgery.
  • Chemotherapy. Powerful drugs that are take either orally or intravenously to kill cancer cells. Chemotherapy is absorbed into the bloodstream and carried throughout the body and is typically used if cancer has spread from the initial site to other parts of the body.

Radiation and chemotherapy can be used in addition to surgery to prevent a return of cancer cells. Radiation is usually used after surgery. Chemotherapy is not as effective as radiation therapy. Chemotherapy and radiation may be recommended for stages I through IV.

Other possible treatments for NSCLC include:

  • Laser therapy. Laser beams (narrow stream of intense light) are used to kill cancer cells.
  • Cryotherapy (also called cryosurgery). A treatment that freezes and destroys cancer tissue.
  • Photodynamic therapy. A cancer treatment that uses drugs that activate when exposed to light at which point the cells die.
  • Chemoprevention. The use of drugs, vitamins and other substances to reduce the risk of developing or recurring cancer.
  • Clinical trials. A physician may recommend participation in a clinical trial that will test new experimental treatments. Patients in all stages of lung cancer can seek to participate in such trials because of the limitations of standard treatments. Experimental therapies may include biological therapy (also called immunotherapy), gene therapy and angiogenesis inhibitors.

Small cell lung cancer (SCLC) usually has spread beyond the lungs by the time it is diagnosed. For this reason, surgery is seldom recommended. Chemotherapy is often recommended with or without radiation. Other treatment options for small cell lung cancer:

  • Brain prophylactic radiation. Radiation therapy used to reduce the chance of tumors spreading to the brain. Small cell lung cancer often spreads to the brain.
  • Clinical trials
  • Comfort (palliative) care

Prevention methods for lung cancers

Because smoking is tied so strongly to lung cancer, not smoking is naturally the most effective preventive method. People who smoke, however, can reduce their risk by quitting. Research has shown that the beneficial effects of quitting smoking increase the longer a former smoker does not smoke.

For instance, a study had found that after five years of abstinence from cigarettes, former smokers had 16 times the risk of developing cancer. But that risk was reduced to 8 percent after the next five years and gradually declined to 2 percent over the next 30 years.

Avoiding passive smoke is another prevention method. Smoke-free restaurants, hotels and workplaces help in avoiding unwanted smoke. Requesting that smokers do so outdoors when in the home, car or workplace also helps.

People should be aware of potential occupational and environmental toxins. Radon, asbestos, nickel, chromate, diesel smoke and vinyl chloride should be avoided because they increase risk of lung cancer.

Finally, studies are beginning to show how diet relates to cancer risk. Researchers are finding that diets high in antioxidants (contained in fruits and vegetables) appear to offer some protection against cancers.

Ongoing research regarding lung cancers

Research is being conducted to discover new ways of early detection, prevention, causes and treatments of lung cancer. The objective of this research is to prevent cancer and/or increase survival rates. Some of the research studies being conducted for lung cancer involve:

  • Developing screening tests for early detection of lung cancer

  • New effective chemotherapy drugs or drug combinations with fewer side effects

  • Gene therapy to correct genetic defects that cause a predisposition

  • Antiangiogenesis drugs to inhibit cancer cell growth by blocking blood vessel growth in tumors

  • Vaccines to build up the immune system

  • Genetic tests to help identify high-risk individuals and improve detection and plan treatment

  • Biological therapy to boost the body’s natural immune system

  • Improvements to surgical techniques

  • Antigrowth factor drugs to inhibit cell growth

Staging for lung cancers

The stage of cancer represents how far the cancer has spread in a patient’s body. Staging helps doctors plan treatment and determine the patient’s outlook for recovery (prognosis). Staging of non-small cell lung cancer is based on the American Joint Committee on Cancer (AJCC). It uses stages 0 to 4 and a more detailed “TNM” system:

  • “T” describes the extent of tumor growth.
  • “N” describes the extent of lymph node involvement.
  • “M” describes the extent of distant metastasis.

About 14 percent of patients with lung cancer live five years or longer after initial diagnosis. Small cell lung cancer survival rate is 5 to 10 percent after five years.

Prognosis depends on:

  • Stage of the cancer
  • Tumor size
  • Type of cancer cell
  • Presence of symptoms
  • Patient’s overall health

Non-small cell lung cancer (NSCLC) is staged by tumor size, level of spread to the lymph nodes and spread to other organs.The stages of NSCLC are:

  • Stage 0 (carcinoma in situ). Cancer is located in the air passages only. No lung tissue is affected. Cancer treated at this stage can often be cured.
  • Stage I. Cancer has spread to the lung tissue only. Lymph nodes are not affected.
  • Stage II. Cancer is located in the lung and nearby lymph nodes and the chest wall.
  • Stage IIIA. Cancer is located in the lung and distant lymph nodes.
  • Stage IIIB. Cancer is located in the lung and spread locally to the heart, blood vessels, trachea and esophagus within the chest wall.
  • Stage IV. Cancer may be located in both lungs and has spread to distant organs such as the liver, brain or bones.
  • Recurrent. Cancer that recurs after treatment and may return to the lung or other parts of the body.

Stages 0 through IIIA are resectable, meaning they can be surgically removed. Stages IIIB and IV are generally treated with chemotherapy and/or radiation therapy and other treatments because metastasis is extensive.

Because small cell lung cancer (SCLC) spreads aggressively, staging is simple and generalized:

  • Limited. The cancer is located in one lung and the nearby lymph nodes.
  • Extensive. Cancer cells may have spread to the other lungs, distant lymph nodes and/or other organs.

Questions for your doctor about lung cancers

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about lung cancer:

  1. What tests will I receive to diagnose my lung cancer?
  2. What is the type and stage of my lung cancer?
  3. Am I candidate for surgery? If so, what type?
  4. What treatments might I need before or after surgery?
  5. If surgery is not recommended, what are my treatment options?
  6. What are the risks associated with the treatments?
  7. What are the chances that my lung cancer will spread? If so, what are the likely sites?
  8. What are the chances that the lung cancer will return?
  9. Am I at risk for lung cancer based on my medical or family history?
  10. Should I have any regular screening tests?
  11. Are my children at greater risk for developing lung cancer?
  12. Can you refer me to some support groups for lung cancer?
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