If you are coughing up significant amounts of blood, or severely breathless, seek emergency care now. Also seek urgent care for swelling of the face and neck with breathlessness, new leg weakness, or fever during chemotherapy.
The treatment of lung cancer has changed more in the last decade than almost any other cancer, because of one development: testing the tumour for specific genetic changes that can be targeted with tablets.
This makes one thing critical. Starting chemotherapy before molecular testing has been done can mean missing a treatment that would have worked far better, and the opportunity to test is best taken at diagnosis.
Lung cancers divide into two broad groups. Non-small cell lung cancer accounts for the large majority and includes adenocarcinoma and squamous cell carcinoma. Small cell lung cancer is less common, grows and spreads much faster, and is treated with chemotherapy and radiotherapy rather than surgery in almost all cases.
Within non-small cell lung cancer, the important development has been the discovery that a proportion of tumours are driven by a single genetic change — in EGFR, ALK, ROS1 and several others. Where one of these is present, a tablet blocking that pathway is markedly more effective and better tolerated than chemotherapy.
Separately, testing for PD-L1 expression indicates whether immunotherapy is likely to work. Immunotherapy has produced durable responses in a proportion of patients with advanced lung cancer that were not previously achievable.
The practical consequence is that a lung cancer diagnosis without molecular testing is an incomplete diagnosis. Adequate tissue must be obtained at biopsy — which sometimes means a larger sample than a simple needle aspirate — and testing performed before drug treatment begins.
If you have non-small cell lung cancer, particularly adenocarcinoma, the tumour should be tested for EGFR, ALK, ROS1 and PD-L1 as a minimum before systemic treatment begins. Where a driver mutation is present, the appropriate tablet is substantially more effective than chemotherapy and far better tolerated. Starting chemotherapy without testing risks months of harder treatment for a poorer result. If your biopsy sample was too small for testing, a repeat biopsy or a blood-based test may be possible.
Obtaining enough tissue is as important as making the diagnosis.
A very small needle sample may confirm cancer but leave too little tissue for molecular testing, which then requires a second procedure. If a biopsy is being planned, ask that enough tissue is taken for full molecular profiling. If your diagnosis was made on a small sample and no testing was done, tell us — a blood-based test detecting tumour DNA is sometimes an alternative to repeat biopsy.
Stage and molecular profile determine treatment. Both need establishing before anything begins.
Removal of the affected lobe with sampling of the mediastinal lymph nodes, increasingly performed by keyhole or robotic approach with a considerably faster recovery. It offers the best chance of cure for disease confined to the lung and nearby nodes, provided lung function is adequate to tolerate it.
Tablets blocking a specific driver mutation — EGFR, ALK, ROS1 and others. Where the mutation is present these are substantially more effective than chemotherapy, better tolerated, taken at home, and often work for a considerable time. This is the single strongest argument for testing before treating.
Drugs that release the brakes on the immune system, given alone or with chemotherapy depending on PD-L1 expression and other factors. In a proportion of patients they produce responses lasting considerably longer than chemotherapy achieves.
Chemotherapy remains important where no targetable mutation is present, and is the mainstay in small cell lung cancer alongside radiotherapy. Radiotherapy also treats locally advanced disease that cannot be operated on, and stereotactic radiotherapy can treat small early tumours in patients unfit for surgery.
Small cell and non-small cell lung cancer are treated by entirely different pathways. The pathology report establishes which.
Stage determines whether surgery is appropriate. PET-CT changes the stage in a significant proportion of patients, and brain MRI detects spread that is frequently silent.
For non-small cell disease that is not operable, the molecular result determines whether treatment is a tablet, immunotherapy, chemotherapy, or a combination.
If you are about to start chemotherapy for lung adenocarcinoma and no molecular testing has been done, pause and ask about it. It is one of the few situations where a week's delay may substantially improve your treatment.
Swelling of the face and neck with breathlessness suggests obstruction of the large vein in the chest and needs urgent local treatment. New leg weakness may indicate spinal cord compression, which is an emergency measured in hours.
Photographs taken on your phone are fine. Reports in Arabic, Russian or Bengali are fine — we translate them ourselves.
Because it can change your treatment from chemotherapy to a tablet that is more effective, better tolerated and taken at home. Around a third of lung adenocarcinomas in Asian populations carry an EGFR mutation, and the targeted drugs for it work considerably better than chemotherapy in those patients. Treating without testing risks missing that entirely.
Yes, and lung cancer in people who have never smoked is a recognised and important group. It is more likely to be adenocarcinoma and more likely to carry a targetable driver mutation such as EGFR or ALK — which means molecular testing is even more important, and the outlook with the right targeted drug can be considerably better than many people assume.
It depends on the stage and on your lung function. Surgery offers the best chance of cure for disease confined to the lung and nearby nodes. PET-CT and brain imaging are needed to establish the stage properly, and lung function tests determine whether you would tolerate the operation. Send the scans and we will give you a straight answer.
It is treatment that enables your own immune system to recognise and attack the cancer. Whether it is likely to help is indicated by PD-L1 testing on the tumour and by the absence of a targetable driver mutation. In a proportion of patients it produces responses lasting far longer than chemotherapy, but it does not work for everyone and it has its own side effects.
Usually not. Diagnosis, staging, molecular testing and surgery are worth travelling for. Targeted therapy is tablets taken at home. Most chemotherapy can be given locally once the protocol is set. Radiotherapy requires you to stay for the course. We will tell you exactly which parts need to be here.
The mutations that drive lung cancer are usually acquired in the tumour rather than inherited, so testing family members is not generally indicated. What matters far more for your family is not smoking, and avoiding exposure to indoor smoke and industrial dusts.
Send the biopsy report, the PET-CT and any molecular testing results. If molecular testing has not been done, say so — it is usually the first thing we recommend.
Your reports go directly to our medical team. We do not share your records with hospitals until you tell us to.
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