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Lung Cancer

Online Health Chat with Dr. Peter Mazzone, Dr. Gregory Videtic and Dr. Sudish Murthy

November 15, 2011

Introduction

Cleveland_Clinic_Host: Lung cancer is the most common malignancy worldwide, with more than 1 million cases diagnosed yearly. In the United States, an estimated 200,000 new cases were diagnosed in 2009, and more than 150,000 deaths were due to lung cancer – making it the leading cause of cancer death in both men and women. At Cleveland Clinic, lung cancer is diagnosed and managed by collaboration among pulmonologists (lung specialists), pathologists (doctors who study tissue under the microscope), medical and radiation oncologists (cancer treatment specialists), and thoracic (chest) surgeons.

Lung cancer is a very challenging cancer to treat. The most critical factor in determining the survival rate is the stage at the time of diagnosis. Using a multidisciplinary approach to lung cancer care is vital to managing the disease. The Cleveland Clinic Chest Cancer Center, which includes specialists from the Respiratory Institute, Taussig Cancer Institute and Heart and Vascular Institute, uses a multidisciplinary approach to cancer care, focusing the entire team’s expertise and energy on providing the best outcomes for each patient. Take this opportunity to learn more about lung cancer, including diagnoses and treatment options, and have your questions answered by Dr. Sudish Murthy from the Cleveland Clinic.

Sudish Murthy, MD, is the Surgical Director of the Center of Major Airway Disease and a staff thoracic surgeon in the Department of Thoracic and Cardiovascular Surgery, Sydell and Arnold Miller Family Heart & Vascular Institute. He holds joint appointments with the Transplant Center and the Taussig Cancer Institute. Currently, Dr. Murthy is the NetWork Chair of the Interventional Chest/Diagnostic Procedure NetWork. He is board-certified in general surgery and thoracic surgery. His specialty interests include esophageal surgery; minimally invasive surgery including robotics, bronchoscopic, laparoscopic, and thorascopic procedures; general thoracic surgery; and lung transplantation.

Cleveland_Clinic_Host: To make an appointment with Dr. Sudish Murthy or any of the lung cancer specialists, please call the Cancer Answer Line at 216.444.HOPE (4673) or 866.223.8100. Same-day appointments are available.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Sudish Murthy. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.


Symptoms

Clara: What are some of the symptoms of lung cancer? Is shortness of breath one of them?

Dr__Sudish_Murthy: It is uncommon for lung cancer to present with shortness of breath. The more likely explanation is that there is some element of underlying lung disease, such as emphysema, that is present in addition to the lung cancer.

Odysseus: Are there early warning signs of lung cancer to look for?

Dr__Sudish_Murthy: Lung cancer symptoms unfortunately present quite late in the disease course, so by the time someone actually has symptoms, their cancer is more likely advanced. Some early symptoms include cough and the coughing up of blood. Chest pain is an intermediate symptom. Weight loss and lack of energy are late symptoms.


Tests and Screenings

Tommy: I have been hearing a lot about lung cancer screening. Is there a benefit to having one done, and is there a certain facility I should look for?

Dr__Sudish_Murthy: The usual screening chest CT scan is a spiral CT with cuts spaced out to 2 to 3 millimeters. This should be a relatively standard machine at most institutes. It’s the use and the interpretation of the information that is critical, and that's where a larger, more experienced center might be of some use.

Macanne: Is a PET scan a definitive test for a cancer nodule in the lung?

Dr__Sudish_Murthy: No. It merely gives you and your physicians a better idea of the chance that a certain nodule is cancer. Without a PET scan, a former or current heavy smoker, age >55, with a 2 cm spiculated, non-calcified lesion noted on a chest CT scan and some emphysema will have about an 80 percent to 90 percent chance of that nodule being cancer (especially if it's growing on serials scans). A positive PET scan in the same patient might more accurately predict cancer, and if positive, the percent chance of lung cancer.

Macanne: How do you rule out other lesions, such as Wegener’s granulomatosis?

Dr__Sudish_Murthy: It can be difficult. Wegener's is more than just lung nodules, but determining whether a nodule is a GRANULOMA is much more difficult (given that Wegener's is just one of several causes of lung granulomata). This situation requires knowledge of history, appearance on CT scan, PET scan results, and perhaps a needle biopsy.


Treatment Options

A923: My mother was diagnosed with lung cancer. Would a transplant be an option for her? Can I donate one of my lungs to her?

Dr__Sudish_Murthy: Unfortunately, lung transplant is not an option in the setting of cancer. The majority of lung cancer, especially when advanced, is a systemic disease and not simply confined to the lung, so transplanting the affected side does nothing. The immunosuppression required for transplant makes any existing cancer massively accelerate, and, consequently, one of the more common problems when transplanting patients (without suspected cancer) is actually discovering a rapidly progressing cancer.

FishEyes: My brother, 62, was diagnosed with lung cancer last week. He is going to be talking with his doctor about his options. How would you determine whether he needs radiation, chemo, or surgery?

Dr__Sudish_Murthy: The stage of the cancer is critical when determining treatment options. Also important is how fit someone is. These two issues will collaborate to determine the most appropriate therapy. For early stage cancers in fit patients, removal (surgery) would likely be the best option and offer the greatest chance of cure. For sicker patients with advanced cancer, chemotherapy to control (though not usually cure) would likely be recommended.

Butternut: My brother was diagnosed with lung cancer and was treated with chemotherapy. His CT scans have since come out clean -- no sign of any tumors. His white blood cell count is low. His doctors recommend chemo as maintenance every three to four weeks at this time. Is this normal, with no tumors present?

Dr__Sudish_Murthy: That your brother was only offered chemotherapy suggests that he has advanced cancer (primary therapy). If his chemo was given in addition to an operation, then this would be termed adjuvant therapy. Chemotherapy, when given as primary therapy, has a set course determined by your oncologist. Often, a chemo treatment may be one to three weeks per cycle repeated multiple times. Chemotherapy given after an operation is usually limited to about four cycles.

Macanne: I have been diagnosed with a 1.9 cent. nodule in my right lower lobe. What is the normal treatment? I would like to come to CCF for surgery. Will I have a long wait time?

Dr__Sudish_Murthy: I think that the risk of the nodule being cancer would have to be assessed first before you necessarily need to have it taken out. If you are a smoker, your risk for a possible operation would also have to be determined. I think that some detective work regarding the nodule and your state of health would be in order. It is possible, depending upon circumstances, that no operation would be necessary. I think that if you contact the Cancer Answer line at 866-233-8100, we should be able to sort this out and get you an appointment.

Leila24: My grandfather was recently diagnosed with lung cancer at 76. Are there any clinical trials that would be available to him?

Dr__Sudish_Murthy: Cancer trials are predicated upon stage of presentation of the patient and other coexisting conditions. Hopefully, your local care team has assessed these issues appropriately. Once these facts are determined, enrollment into potential trials is considered. There are a few unique cancer markers within a specific tumor that often can be assessed to determine if a specific therapy might actually work. These include examining a cancer for a specific mutation (EGFR).


Surgery

Bitsey: I'm having surgery on my left lung lower lobe for cancer. The cancer is small and is in only one place. How much of my lower left lung will they remove, and what is the recovery time?

Dr__Sudish_Murthy: I will assume that you must be in good enough shape for the operation itself. No matter how a lung operation for cancer is performed, it is NOT a small deal. Depending upon the size and location of the cancer, most patients will usually undergo a LOBECTOMY (removal of 1/2 of the left lung), although for small cancers, a slightly lesser but more sophisticated operation can be used. A wedge resection, the smallest operation employed, has a 3 percent to 5 percent higher chance of having a cancer recurrence than lobectomy.

Macanne: What is a wedge resection surgery?

Dr__Sudish_Murthy: A wedge resection is removal of a small amount of lung. It is most commonly employed when the nature of the nodule is not clear (can't tell whether it's cancer or not), OR if the person does not have enough lung reserve to tolerate a larger operation (lobectomy) if cancer is present. There is an increased risk of cancer returning with wedge resection versus a bigger operation (lobectomy), but in some cases, especially in older patients, the lesser operation with the higher chance of recurrence might be favored.

Macanne: How long after lung surgery is a patient able to fly home?

Dr__Sudish_Murthy: Very good question. There are very few guidelines to direct physicians, surgeons, and – importantly -- patients as to when someone can fly after a lung operation. It is feared that the pressurization and depressurization of an airplane cabin might compromise the healing of the recently operated lung and lead to leak of air into the chest cavity (pneumothorax).


Risks

Doug: I smoked for 10 years before quitting five years ago. What are my chances of getting lung cancer? I'm 35 now.

Dr__Sudish_Murthy: The standard accepted risk for cancer is usually a one-pack/day history for 20 years and age >55. In that group, there is about a 1 percent to 2 percent chance that a lung cancer will be picked up by accident on a screening CT scan. In your case, your risks are lower, but clearly NOT ZERO. Smoking cessation is indicated as a first intervention.

Pat: I have been a casual smoker for the last 30 years, smoking a few cigarettes on the weekends. Do I have an increased chance of getting lung cancer?

Dr__Sudish_Murthy: ANY amount of tobacco smoke is injurious, though our threshold for identifying the highest risk people for lung cancer is above what you have related. I will caution you that though you may have a limited habit, your exposure to secondhand smoke is far greater than you might think. If non-smokers have a risk value of, say, 1, 20-year smokers with a 1 pack/day habit get a risk of 25. People with more limited exposure are nestled in between.


General Questions

Mary_Ann: What can I expect as a caregiver to my 82-year-old mother with squamous cell carcinoma in her left lung who will have lung surgery to remove her lower left lobe? I want to be prepared.

Dr__Sudish_Murthy: It gets to how vigorous your mother is and what is the planned operation. There is little doubt that her age makes this a formidable hurdle, but we do operate in the age group quite frequently. For someone to offer her an operation there must have been some pretty comprehensive heart and lung tests that she would have to have passed. You should use my equation I alluded to before regarding hospital stay and out of hospital recovery, but in this age group, I think it’s 10 to 14 days per hospital day (for every hospital day it is usually 10-14 days estimated for recovery.)


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Sudish Murthy is now over. Thank you again, Dr. Murthy, for taking the time to answer questions about lung cancer.

Dr__Sudish_Murthy: Thank you very much.


More Information

To make an appointment with one of the lung cancer specialists, please call the Cancer Answer Line at 216.444.HOPE (4673) or 866.223.8100. Same-day appointments are available.

You may request a remote second opinion from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit eclevelandclinic.org/myConsult.

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