DO NOT PUBLISH - Lung Cancer Test 2

Small-cell lung cancer (or SCLC) is a very fast-growing type of lung cancer and is typically caused by smoking. Around 1 out of every 10 lung cancers diagnosed are SCLC.[2]

What are some of the symptoms of SCLC?

The most common symptoms of SCLC may include:

• A cough that does not go away or gets worse
• Coughing up blood or rust-colored spit
• Chest pain that may get worse when taking deep breaths, coughing, or laughing
• Hoarseness
• Weight loss and loss of appetite
• Shortness of breath
• Feeling tired or weak
• Infections such as bronchitis and pneumonia that don’t go away or keep coming back
• New onset of wheezing[16,17]

When small cell lung cancer spreads to distant organs (extensive-stage SCLC), it can cause other symptoms which may include:

• Bone pain (like pain in the back or hips)
• Nervous system changes (such as headache, weakness or numbness of an arm or leg, dizziness, balance problems, or seizures), from cancer spread to the brain
• Yellowing of the skin and eyes (jaundice), from cancer spread to the liver
• Lumps near the surface of the body, due to cancer spreading to the skin or to lymph nodes (collection of immune system cells), such as those in the neck or above the collarbone[18]

Non-small cell lung cancer (or NSCLC) is the most common type of lung cancer. Around 9 out of every 10 lung cancers are diagnosed as NSCLC.[2] There are three main types of NSCLC, with differences seen by looking at a sample of cells under a microscope:[2]

- Adenocarcinoma starts in the gland cells that line the airways and produce mucus.

- Squamous-cell carcinoma develops in the flat cells that cover the airway surface.

- Large-cell carcinoma cells are large and round with big nuclei (the part of the cell that contains all of its genetic information) and it is not clear what kind of cells these start in.

The Stages of NSCLC?

NSCLC can start in any area of the lungs when healthy cells mutate and grow uncontrollably or unusually, forming a tumour. This initial tumour is referred to as the primary tumour. 

As the tumour grows, cancer cells can break away and spread to other organs through the blood or lymphatic system—a collection of tissues or organs (including lymph nodes) that help fight infection and disease. Spreading of cancer cells from a primary tumour to nearby tissue and lymph node(s) is known as locally advanced cancer. Spreading of cancer cells from a primary tumour to other parts of the body is known as metastatic cancer. The tumour size and the extent to which the cancer has spread can help define the stage of NSCLC[15].

What are some of the symptoms of NSCLC?

The most common symptoms of lung cancer may include:

• A cough that does not go away or gets worse
• Coughing up blood or rust-colored spit
• Chest pain that may get worse when taking deep breaths, coughing or laughing
• Hoarseness 
• Weight loss and loss of appetite 
• Shortness of breath 
• Feeling tired or weak
• Infections such as bronchitis and pneumonia that don’t go away or keep coming back
• New onset of wheezing[16,17]

When lung cancer spreads to distant organs (metastatic lung cancer), it can cause other symptoms which may include:

• Bone pain (like pain in the back or hips).
• Difficulty swallowing.
• Swelling of the face.
• Bulging veins on the neck and head
• Lumps in the neck or above the collarbone.
• Yellowing of the skin and eyes.
• Headache. 
• Weakness or numbness of an arm or a leg.
• Dizziness
• Balance problems
• Seizures[18]

Lung cancer is caused by an abnormal and uncontrolled growth of cells in the lungs. Factors that are known to increase the chance of a person developing a disease are called ‘risk factors’. Having a risk factor does not mean that you will definitely get the disease, but the more risk factors you have can make it more likely. Some risk factors for lung cancer are:[3]

• Cigarette smoking 
• Breathing second-hand smoke
• Being exposed to substances such as asbestos or radon
• Infections such as tuberculosis or HIV
• Having a family history of lung cancer
• Previous radiation therapy to the lungs
• Air pollution.

If your doctor thinks you might have lung cancer, they will ask questions about symptoms, examine a certain part of the lungs, refer you to a pulmonologist, and run certain tests. These can include imaging tests such as X-rays, CT scans, biopsies or PET scans.

• X-ray: It is a quick and painless medical imaging tool that produces images of the structures inside your body using radiation technology.
• CT scan: A computerised tomography (CT) is an imaging test that uses X-rays and a computer to create detailed images of the inside of the body.
• PET scan: A positron emission tomography (PET) scan is a functional imaging method that uses safe chemical traces to help visualise and measure changes in the body.
• Lung biopsy: A lung biopsy is a medical procedure that involves removing a small sample of lung tissue for laboratory testing.[4]

The stages of lung cancer describe where the cancer is and if it has spread into nearby tissues and/or around the body. This can help doctors decide how best to treat the disease and the likelihood of reaching a disease-free period (‘remission’). The staging system that is commonly used for lung cancer is:

• Stage 1: the cancer is small and contained in the lungs and has not spread
• Stage 2: the cancer is in the lungs, and the tumour is larger than in stage 1 and/or has spread into lymph nodes close to the tumour
• Stage 3: the cancer is larger; it may have spread into surrounding tissues such as the liver, brain, bones or adrenal glands and/or spread into the lymph nodes.
• Stage 4: the cancer has spread from where it started to brain, bones, liver, or widely around your body.[5]

Your doctor may test a sample of cancer cells taken from the tumour (a biopsy). Different types of lung cancer can be treated using different types of drugs and approaches, so the more your healthcare team knows about your type of lung cancer, the easier it is for them to select the right treatment for you.

If you have been diagnosed with lung cancer, several treatments can help treat the condition and support recovery.

Treatment of lung cancer depends on the type and stage of the disease. Other things to consider when deciding on treatment are the age, overall health, medical history of the patient, type, stage and whether the cancer cells produce high amounts of certain proteins.[6]

The main treatments for lung cancer are listed below, the choice of which depends on how advanced your lung cancer is.[6]

• Surgery: removal of cancer tissue; this may be followed by chemotherapy to destroy any remaining cancer cells.
• Adjuvant/neoadjuvant therapy: neoadjuvant therapy is given before surgery to shrink a tumour. Adjuvant treatment is often given after surgery to kill any remaining cancer cells and lower the risk that the cancer will come back. Adjuvant/neoadjuvant treatment may include chemotherapy, radiotherapy or biological therapy.
• Chemotherapy: chemotherapy uses drugs that stop cancer growing, either by killing the cancer cells or by stopping them from dividing. In some cases, chemotherapy is combined with radiotherapy (known as chemoradiotherapy).
• Radiotherapy: the body is exposed to radiation to damage cancer cells and ultimately kill them. This may be used as the only treatment for your tumour, or before/after surgery or chemotherapy to remove any remaining cancer cells.
• Anti-angiogenesis therapy: angiogenesis means the growth of blood vessels. Tumour angiogenesis is the growth of new blood vessels that a cancer needs in order to survive. Some cancer cells make a protein called vascular endothelial growth factor (or VEGF). The VEGF protein attaches to cells in blood vessels in the tumour. This triggers the blood vessels to grow so that the cancer can grow. Anti-angiogenesis therapy aims to stop tumours from growing new blood vessels. This might slow the growth of a cancer or sometimes shrink the tumour.
• Targeted therapy: targeted therapy is a type of treatment that uses drugs or other substances to identify and attack specific types of cancer cells with less harm to normal cells. Examples of types of lung cancer that can be treated with a targeted therapy are:
  • EGFR-positive NSCLC – during diagnosis, your doctor may order a test to find out whether your lung cancer is positive for an EGFR gene mutation (change); this is also known as EGFR+ NSCLC. Around 1 out of every 7 patients with NSCLC will have EGFR-positive NSCLC. [7] EGFR (or epidermal growth factor receptor) is a protein that is found on the surface of cells, including in the lungs. EGFR helps the cells grow and divide normally.  When the EGFR gene is mutated it is constantly activated and sends increased survival signals meaning that cells can grow too quickly. [8]
  • ALK-positive NSCLC – your doctor may also order a test to find out whether your lung cancer is ALK-positive or ALK+. [9] Around 1 out of every 20 patients with NSCLC will have ALK-positive NSCLC. [9,10] ALK (or anaplastic lymphoma kinase) is a protein that is not normally present in healthy lung cells. In ALK+ NSCLC, the ALK gene is mutated (changed) and these changes result in the production of the ALK protein, which increases the growth of cancer cells. Knowing that a tumour is ALK-positive helps doctors plan cancer treatment by using medicines that specifically target ALK. [9,10]  
  • It is rare for tumours to be both EGFR and ALK positive. [11]
• Cancer immunotherapy: this helps the body’s own immune system to fight cancer and can be used as an alternative to chemotherapy. It is also used in combination with, or after, chemotherapy. While immune cells are able to find and kill abnormal cells, cancer cells are able to protect themselves from immune attacks. Cancer immunotherapy aims to beat this protection so that immune cells can find and destroy cancer cells.[12] Some types of cancer immunotherapy used in NSCLC work by targeting proteins called PD-L1 and PD-1.[13, 14] ] PD-L1 (programmed death ligand 1) is a protein that interferes with the body’s immune responses and can stop the immune system from fighting cancer. Cancer immunotherapies can be used to block PD-L1 activity, allowing the body’s immune system to destroy the cancer cells. [12, 14]

Your doctor will be able to advise what treatment options are available to you, based on your individual type of lung cancer. It is important to remember that some of these lung cancer drugs only work on tumours that have a particular genetic mutation (EGFR+ or ALK+ NSCLC), so some of the therapies that you hear about might not be suitable for you.

The outlook for a person with lung cancer depends on various factors, including the type and stage of cancer, the overall health of the patient and the treatment options available. Unfortunately, lung cancer is often not diagnosed until it has reached an advanced stage, which can make treatment difficult.

Clinical research is looking into new treatments for people living with lung cancer who do not respond or who stop responding to chemotherapy or radiotherapy or biological therapy.

Clinical trials (which can also be called ‘research studies’) are designed to look at how safe these experimental drugs or procedures (such as a new type of surgery) are and how well they work and may compare them with treatments that are already available. If you would like to know more about Roche-sponsored clinical trials or are interested in taking part in a clinical trial, speak to your doctor or visit the Roche ForPatients clinical trials page link.