Epidemiology

• Lung cancer is the most common cause of death due to cancer in both men and women throughout the world.
• Lung cancer is predominantly a disease of the elderly, almost 70 % of people diagnosed with lung cancer are over 65 years of age, while less than 3 % of lung cancers occur in people under 45 years of age.

 Etiology

• Smoking: Smoking remains the greatest risk factor for lung cancer. Risk of lung cancer increases with the number of cigarettes a person smoke each day and the number of years he/she has smoked. Quitting at any age can significantly lower the risk of developing lung cancer.
• Exposure to secondhand smoke: Even if you don’t smoke, the risk of lung cancer increases if you’re exposed to secondhand smoke.
• Exposure to radon gas: Radon is produced by the natural breakdown of uranium in soil, rock and water that eventually becomes part of the air you breathe. Unsafe levels of radon can accumulate in any building, including homes. Radon testing can determine whether levels are safe
• Exposure to asbestos and other chemicals: Workplace exposure to asbestos and other substances known to cause cancer -such as arsenic, chromium, nickel and tar – also can increase risk of developing lung cancer, especially if you’re a smoker.
• Family history of lung cancer: Family history of lung cancer. People with a parent, sibling or other first-degree relative with lung cancer have an increased risk of the disease.
• Excessive alcohol use: Drinking more than a moderate amount of alcohol- no more than one drink a day for women or two drinks a day for men-may increase your risk of lung cancer.
• Certain lung diseases: People with certain lung diseases, such as chronic obstructive pulmonary disease, may have an increased risk of lung cancer.
• Air pollution: Air pollution from vehiclesi ndustry, and power plants can raise the likelihood of developing lung cancer in exposed individuals. Up to 1 % of lung cancer deaths are attributable to breathing polluted air and is similar to that of passive smoking.

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Classification of lung cancer

• Primary: Cancer that started in the lungs (primary lung cancer): There are several different types of primary lung cancer. These are divided into two main types;
• Small cell lung cancers ( SCLC ) : 20 %
• Non – small cell lung cancers (NSCLC) : 80 %
• Secondary: Cancer that spread into the lungs Secondary cancer is cancer that has spread from somewhere else in the body
• Mesothelioma: Mesothelioma is another rare type of cancer which affects the covering of the lung (the pleura).
• It is often caused by exposure to asbestos

1. Primary Lungs cancer

1. Small cell lung cancers (SCLC)

• Small cell lung cancer is called this because the cancer cells are small cells also known as ‘oat cell’ cancer.
• SCLC comprises about 20 % of lung cancers.
• The most aggressive because they (SCLC) grow rapidly, metastasize widely.
• Eighty percent of SCLC are Metastatic on presentation
• SCLC is strongly related to cigarette smoking , with only 1 % of these tumors occurring in nonsmokers.

1. Non small cell lung cancer: There are three types of non small cell lung cancer. They are
2. Squamous cell carcinoma
3. Adenocarcinoma

• Large cell carcinoma

• Types of Non cell lung cancer
• Squamous cell cancer
• Account for about 30% of NSCLC.
• Squamous cell cancer is the most common type of lung cancer.
• It develops from the cells that line the airways and it is often found near the centre of the lung in one of the main airways (the left or right bronchus)
• This type of cancer is often due to smoking
• Adenocarcinoma
• Adenocarcinoma is the most commonly seen type of NSCLC and comprise up to 50 % of NSCLC
• Adenocarcinoma also develops from the cells that line the airways. But it develops from a particular type of cell that produces mucus (phlegm)
• Brohioalveolar carcinoma is a subtype of adenocarcinoma.
• Large cell carcinoma
• Large cell lung cancer is called this because the cells look large and rounded under a microscope
• This type of lung cancer tends to grow quite quickly

Signs and symptoms of lung cancer

• No symptoms: In up to 25 % of people, who get lung cancer, the cancer is first discovered on a routine chest X-ray or CT scan as a solitary small mass sometimes called a coin lesion.
• These patients with small, single masses often report no symptoms at the time the cancer is discovered.
• Symptoms related to the cancer: The growth of the cancer and invasion of lung tissues and surrounding tissue may interfere with breathing, leading to symptoms such as
• Cough
• Shortness of breath
• Wheezing
• Chest pain
• If the cancer has invaded nerves, for example, it may cause
• Shoulder pain that travels down the outside of the arm (called Pancoast’s syndrome) or
• Paralysis of the vocal cords leading to hoarseness
• Invasion of the esophagus may lead to difficulty swallowing (dysphasia)
• If a large airway is obstructed, collapse of a portion of the lung may occur and cause infections (abscesses, pneumonia) in the obstructed area.
• Symptoms related to metastasis:
• Lung cancer that has spread to the bones may produce excruciating pain at the sites of bone involvement.
• Cancer that has spread to the brain may cause a number of neurological symptoms that may include blurred vision headaches, seizures, or symptoms of stroke such as weakness or loss of sensation in parts of the body.
• Horner syndrome: Cancers of the top part of the lungs (sometimes called Pancoast tumors) may damage a nerve that passes from the upper chest into the neck. This can cause severe shoulder pain. Sometimes these tumors also cause a group of symptoms called Horner syndrome:
• Drooping or weakness of one eyelid
• Having a smaller pupil (dark part in the center of the eye) in the same eye
• Reduced or absent sweating on the same side of the face

Paraneoplastic symptoms:

• Lung cancers frequently are accompanied by symptoms that result from production of hormone-like substances by the tumor cells.
• These Paraneoplastic syndromes occur most commonly with SCLC but may be seen with any tumor type.
• A common Paraneoplastic syndrome associated with SCLC is the production of a hormone called adrenocorticotropic hormone (ACTH) by the cancer cells, leading to over secretion of the hormone cortisol by the adrenal glands (Cushing’s syndrome)
• The most frequent paraneoplastic syndrome seen with NSCLC is the production of a substance similar to parathyroid hormone, resulting in elevated levels of calcium in the bloodstream. High blood calcium levels hypercalcemia). which can cause frequent urination, constipation, nausea, vomiting weakness, dizziness, confusion, and other nervous system problems
• Nonspecific symptoms
• Weight loss
• Weakness and fatigue.
• Psychological symptoms such as depression and mood changes are also common.

Diagnosis of lung cancer

• The history and physical examination may reveal the presence of symptoms or signs, and risk factors for cancer development such as smoking
• Imaging tests (X- Ray and CT): An X-ray image of lungs may reveal an abnormal mass or nodule. A CT scan can reveal small lesions in lungs that might not be detected on an X- ray
• Bone scans are used to determine whether a lung cancer has metastasized to the bones.
• Magnetic resonance imaging (MRI) scans may be appropriate when precise detail about a tumor’s location is required
• Sputum cytology: Examining the sputum under the microscope can sometimes reveal the presence of lung cancer cells.
• Tissue samples (biopsy): Doctor can perform a biopsy in a number of ways including Bronchoscopy.
• Bronchoscopy: The procedure can be uncomfortable, and it requires sedation or anesthesia. It must be carried out by a lung specialist (pulmonologist or surgeon) experienced in the procedure. When a tumor is visualized and adequately sampled, an accurate cancer diagnosis usually is possible
• Positron emission tomography (PET) While CT scans and MRI scans look at anatomical structures, PET scans measure metabolic activity and the function of tissues. PET scans can determine whether a tumor tissue is actively growing and can aid in determining the type of cells within a particular tumor.
• In PET scanning, the patient receives a short half-lived radioactive drug, receiving approximately the amount of radiation exposure as two chest X-rays
• The drug accumulates in tissues, and the drug discharges particles known as positrons from whatever tissues take them up.
• As the positrons encounter electrons within the body, a reaction producing gamma rays occurs.
• A scanner records these gamma rays and maps the area where the radioactive drug has accumulated. For example, combining glucose (a common energy source in the body) with a radioactive substance will show where glucose is rapidly being used, for example, in a growing tumor
• Thoracentesis: Sometimes lung cancers involve pleura and lead to an accumulation of fluid in the space between the lungs and chest wall (called a pleural effusion). Thoracentesis may reveal the cancer cells and establish the diagnosis.
• Blood tests: Elevated levels of calcium or of the enzyme alkaline phosphatase may accompany cancer that is metastatic to the bones. Likewise, elevated levels of certain enzymes normally present within liver cells, including aspartate aminotransferase (AST or SGOT) and Alanine aminotransferase (ALT or SGPT), signal liver damage, possibly through the presence of tumor metastatic to the liver.
• Staging of Lungs Cancer TNM Classification
• Tumor size:
• T1<or= to 3cm
• T2> 3cm
• T3 = local extension (parietal pleura chest wall or within 2cm of carina)
• T4= spread to great vessels, trachea, mediastinum, esophagus or malignant effusion (nonresectable)
• Lymph Node
• NO = no involvement
• N1= hilar nodes
• N2 = mediastinal nodes
• -N3 – contralateral nodes or ipsilateral supraclavicular (nonresectable)
• Metastases
• MO none
• M1-presence (nonresectable)
• Staging of Lungs Cancer
• Stage IA – T1 NO MO
• Stage IB – T2 NO MO (T> 3cm)
• Stage IIA-T1 N1 MO
• Stage IIB- T2 N1 MO

T3 NO MO

• Stage IA-T3 N1 MO

T1-3 N2 MO

• Stage IIIB – Any T N3 MO

T4 Any N MO

• Stage IV – Any T Any N M1

Treatment

• Radiation therapy
• Stereotactic body radiotherapy (SBRT) is a technique that precisely focuses many beams of radiation on a tumor. It is very successful at destroying small tumors while minimizing injury to surrounding healthy tissue. The primary use of this therapy is for patients who have small tumors and who are not good candidates for surgery because of other health problems. SBRT is currently being researched as an alternative to surgery.
• Chemotherapy: Chemotherapy may increase the effectiveness of radiation treatment when both are administered together.
• Photodynamic therapy: Photodynamic therapy is effective in treating lung cancer involving the bronchial tubes. In more advanced cases, photodynamic therapy is used to reduce symptoms from blockage of the bronchial tubes.
• Radiofrequency ablation (RFA): a needle is inserted through the skin into the cancer, usually under guidance by CT scanning. Radiofrequency (electrical) energy is then transmitted to the tip of the needle where it produces heat in the tissues, killing the cancerous tissue and closing small blood vessels that supply the cancer.
• Surgery: Non-small cell lung cancer that has not spread outside of the chest can usually be treated successfully with surgery by removing the tumor and a margin of surrounding healthy tissue. Surgery for non-small cell lung cancer can be performed via several procedures:
• Wedge resection -removing a small section of one lung.
• Segmentectomy– removing a segment (part of a lobe) of one lung.
• Lobectomy-removing an entire lobe of one lung. Lobectomy is the most common type of lung cancer surgery
• Sleeve resection-removing a part of the airway with or without the adjoining lung and reattaching the remaining ends to preserve lung tissue and avoid a larger resection
• Pneumonectomy -removing a lung. Thoracoscopy a minimally invasive procedure used to diagnose and treat lung cancer by accessing the chest through small incisions. It is also called video- assisted thoracic surgery (VATS)

Postoperative Nursing care after Lungs surgery

1. Care of incisions
   • Patient will have more than one incision after his/her surgery, and exactly where they are will depend on the surgery he/she had. There will be incision(s) from the surgical site and incision(s) from the chest tube(s).
   • Surgical incision. By the time patients are ready to leave the hospital incision will be almost healed.
   • Closely observe the incision site and note the drainage, its amount & color
   • Chest tube incision Patient will have small dressing(s) covering any incisions from the chest tube. Some drainage from these areas is normal. The dressing needs to stay on for 48 hours after the chest tube is removed, unless it gets wet. If it gets wet you should change it as soon as you can.
   • Change the dressings at least once a day and more often if it becomes wet with drainage. When these incisions have no drainage they can be left uncovered.
   • Continue to shower daily. Do not take baths until you discuss it with your doctor at your post operative appointment. Use soap when you shower and gently wash all of your incisions. Pat the areas dry with a towel after showering and leave the incisions uncovered. If you go home with adhesive strips on your incision, they may loosen and fall off by themselves. If they have not fallen off, take them off 7 to 10 days after you leave the hospital.
2. Control of incisional pain

• The length of time each person has pain or discomfort varies. Some people may have incisional soreness, tightness, or muscular aches for up to 6 months or longer. It does not mean that something is wrong.
• Do not drive or drink alcohol while you are taking prescription pain medication.
• As your incision heals, you will have less pain. As time goes on, the amount of pain medicine that you need will decrease. A mild pain reliever such as acetaminophen or ibuprofen will relieve aches and discomfort.
• Pain medicine should help you as you resume your normal activities. Take enough medicine to do your exercises in comfort. Pain medicine is most effective 30 to 45 minutes after taking it.
• Keep track of when you take pain medicine. It will not be as effective if the pain has been allowed to increase. Taking it when pain first begins is more effective than waiting for the pain to get worse.
• Do not take any medicine that has aspirin without asking your doctor. Aspirin can cause bleeding. It lists common medicines that have aspirin.
• Pain medicines can cause constipation. To prevent this side effect:

Increase the fiber content of your diet. That will soften your stool naturally. Foods high in fiber include

• Bran and whole grain cereals and breads
• Unpeeled fresh fruits
• Vegetables
• Salad
• Stewed or dried fruits such as prunes, apricots, figs and raisins
• Take a stool softener 3 times a day and take a mild laxative at night. If you have not had a bowel movement in two days, take Milk of Magnesia at bedtime and call your doctor

– Maintain your activity level. Walking helps to prevent constipation. It is also a good form exercise.

• Taking a warm shower is relaxing and helps decrease muscle aches.
• Women may feel more comfortable wearing a soft bra with soft padding. Try using a handkerchief under the part that touches the incision. Some women find they are comfortable not wearing a bra at all as the incision heals.

3. Guide for better breathing

• There are things you can do to improve your breathing and help your lungs heal after surgery. You should do the following for about 4 weeks, or as long as your doctor tells you to:
• Do your coughing and deep breathing exercises and use the incentive spirometer 3 to 4 times a day. These exercises will help keep your lungs expanded and clear of secretions.
• Drink fluids. Liquids help keep sputum thin and easy to cough up. Ask your doctor how much fluid you should drink each day.
• If your fluid intake is not limited, drink at least 6 large glasses of water or other liquids .(preferably juices)each day
• Use a humidifier in your bedroom during the winter months
• Follow the directions for cleaning the machine. Change the water often.
• Avoid sources of infection, such as contact with people with colds sore throats or the flu.
• DO NOT SMOKE! Smoking cigarettes is harmful to your health at any time. It is even more so at this time. Smoking causes the blood vessels in your lungs to become narrow. This causes a decrease in oxygen in the lungs.it can caused problems with breathing an activities.
• If you are a smoker, your doctor, nurse or social worker will suggest ways to stop.
• It is also important to avoid places that are smoky. Your nurse can also give you information to help you deal with others smokers or situations where smoke is present.

4. Deep Breathing

• Relax your shoulders. Place one hand over your abdomen to feel the motion.
• Breathe in deeply through your nose.
• Let your abdominal muscles relax and feel your lower abdomen expand into your hand
• Blow out slowly through your mouth with your lips pursed. As you blow out,
• Tighten your abdominal muscles and feel your abdomen flatten under your hand.
• Keep your shoulders and upper chest relaxed during the exercise. .
• Breathe slowly and deeply.

5. Maintaining Your Nutrition

• Eating a balanced diet high in calories and protein is important for healing after surgery. Your diet should include a good protein source at each meal, as well as fruits, vegetables and whole grains. Good protein sources:
• Meat (beef, pork, lamb) Eggs)
• Poultry (chicken, turkey) Legumes (kidney beans, black beans, lentils)
• Fish Soy (tofu, edamame, soy nuts)
• Dairy (milk, cheese, yogurt) Nuts
• Quinoa (a high protein grain) –
• Have a variety of fruits and vegetables and whole grains. Aim for at least two servings of fruit and three servings of vegetables each day. A serving size is a medium sized fresh fruit, 1/2 cup diced fruit, 1 cup raw leafy greens, 1/2 cup chopped fresh or cooked vegetables or 3/4 cup of fruit or vegetable juice. You should also include whole grain breads, cereals, rice and pasta.
• If you are eating less than usual after surgery, concentrate on the protein foods listed above paired with complex carbohydrates such as : bread, pasta, potatoes or rice. Also try small, frequent meals, as large meals may be overwhelming. Include some of the high calorie, high protein supplements and snacks listed below:
• Double milk : mix 1 quart whole milk with one envelope non-fat dry milk powder. Blend well and refrigerate. Use as a beverage, in cereal, in pudding, pancake and hot chocolate mixes in place of water or regular milk.
• Fruit yogurt or Greek yogurt.
• Puddings and custards
• ½ sandwich with a high protein filling like peanut butter, cheese, tuna, egg salad or turkey
• Cheese or peanut butter with crackers or fruit.
• Hummus with pita
• Roasted nuts, trail mix, sunflower or sesame seeds .
• For more tips on increasing your calorie and protein intake, ask for the booklet Eating Well During and After Your

6. Resuming activity

• It is normal to have less energy than usual. The amount of time that it takes to return to former activities varies with each person. Try to increase your activities each day as much as you can. Always balance activity periods with rest periods. Rest is a vital part of your recovery.
• Spread your activities over the course of the day. Walking and stair climbing are excellent forms of exercise.
• Gradually increase the distance you walk. Avoid walking outdoors if it is very cold, very hot, or very windy. Climb stairs slowly, resting or stopping as needed.
• You can do light household tasks. Try dusting washing dishes, preparing light meals, and other activities as you are able. You may return to your normal sexual activity as soon as your incision is well healed and you can do so without pain or fatigue.
• Your body is an excellent guide in telling you when you have done too much. When you increase your activity, monitor your body’s reaction. You may find that you have more energy in the morning or the afternoon. Plan your activities for times of the day when you have more energy.

7. Regaining arm and shoulder function

• Use the affected arm and shoulder in all of your activities. Use them when bathe, brush your hair, and reach up to a cabinet shelf. Slowly resume your normal activities. That will help restore full use of your shoulder. The exercises shown in the pictures on the following pages will help you to regain full arm and shoulder movement.

8. Axillary  Stretch

• Sit in a straight-backed chair with your feet flat on the floor.
• Clasp your hands together.
• Lift your arms up and overhead.
• Slide your hands back to the back of your neck
• Slowly twist the upper part of your body to the right side
• Hold this position for 5 seconds while bringing your elbows as far back as possible. Return to the starting position
• Slowly twist the upper part of your body to the left side.
• Hold this position for 5 seconds while bringing your elbows as far back as possible.
• Return to the starting position.
• Repeat
• Stretch Stand comfortably with your feet about 6 inches apart.
• Put your arms in front of your body and hold. One end of a hand towel in each hand
• Bring your arms over your head, elbows straight, and stretch towards the upper back. Do not arch your back and do not force the movement if it is difficult.
• Try to hold the position for five seconds.
• Relax and return to the starting position.
• Stand as in # 1 . Start with your hands grasping the towel behind your back and lift upward as far as possible. Be sure to stand straight. Try to hold the position for 5 seconds. Return to the starting position. Repeat

9. Emotional aspects

• After surgery for a serious illness, you may have new and upsetting feelings. Many patients say they felt weepy, sad, worried, nervous, irritable, and angry at one time or another. You may find that you cannot control some of these feelings. If this happens, it’s a good idea to seek emotional support.
• The first step in coning is to talk about how you feel. Family and friends can help. Your nurse, doctor, and social worker can reassure, support and guide you. It always a good idea to let these professionals know how you, your family, and your friends are feeling emotionally. Many resources are available to patients and their families
• Whether you are in the hospital or at home, the nurses, doctors, and social workers are here to help you and your family and friends handle the emotional aspects of your illness.

How can lung cancer be prevented?

• Cessation of smoking is the most important measure that can prevent lung cancer.
• Many products, such as nicotine gum nicotine sprays, or nicotine inhalers, may be helpful to people trying to quit smoking
• Minimizing exposure to passive smoking also is an effective preventive measure
• Using a home radon test kit can identify and allow correction of increased radon levels in the home.
• Methods that allow early detection of cancers such as the helical low-dose CT scan, also may be of value in the identification of small cancers that can be cured by surgical resection and prevented from becoming widespread, incurable, metastatic cancer