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3. Lung Cancer Treatment in India - Are you aware that it
is the leading cause of cancer death in the world?
The high incidence of lung cancer and the poor survival rate
make lung cancer a very important public health problem, and
the leading cause of cancer death in the world. Most patients
have locally advanced lung cancer at the time of diagnosis. As
per the Madras Metropolitan Tumor Registry (MMTR) Chennai,
in 2006-2008, cancer of the lung was the most common among
males, and was ranked among the top ten in females.
It constituted 10.9 percent and 3.3 per cent of all cancers among
males and females respectively. The peak incidence occurred in
the age group of 65-69 years among both sexes.

4. Risk factors
•Cigarette smoking is the single highest cause of the lung cancer
epidemic
•Other contributing factors are asbestos, arsenic, chromium,
nickel, and radon in the work environment
•Other environmental factors such as passive smoking and air
pollution
•Molecular changes that commonly occur in lung cancer are
mutations of tumour suppressor genes p16, p53, and H, K, N-ras
family of oncogenes
•Studies have shown that individuals with a higher dietary intake
of fruits or vegetables have a lower risk of lung cancer.

5. Lung cancers are classified into:
Non-Small Cell Carcinoma (NSCLC) that includes
squamous cell carcinoma, adenocarcinoma, large cell
carcinoma and their subtypes (80 per cent) Small Cell
Carcinoma (SCLC) (20 percent) There are other rare types
of lung cancers that can occur apart from these
Types

6. Prognostics
1. Well differentiated squamous cell carcinomas and non mucinous bronchiloalveolar
carcinomas have favourable prognosis.
2. Poor prognostic factors include: higher tumour size and extent, regional nodal
involvement, absence or presence of distant metastasis, weight loss of more than 10 per
cent, age less than 40 years, tumour size more than 3 cm, Iymphovascular invasion, and
mutation of the tumour suppressor gene p53.

7. Spread
Spread can occur along bronchus into lung parenchyma, to mediastinum or pleura
causing pleural effusion. Diaphragm and chest wall involvement are not
uncommon. 50 per cent have nodal metastasis at resection. Distant spread
commonly involves adrenals to 50 per cent, liver to 30 percent, apart from brain,
bone opposite lung, pericardium and kidneys.
Common Symptoms
Cough, weight loss, chest pain, shortness of breath, blood in the sputum, superior
vena cava syndrome, ulnar nerve and Horner's syndrome (Pancoast tumour) are
common symptoms of lung cancer.

8. Screening for lung cancer
At present, screening for early detection of lung cancer is not recommended, probably
because of the failure of early studies to demonstrate any mortality reduction from lung
cancer evaluation based on sputum cytology and/or chest radiography. With the
introduction of helical computerised tomography, a new imaging modality that can
detect nodules as small as a few millimetres, the potential benefits of lung cancer
screening is being re-examined.

9. Imaging in lung cancer
•Chest radiography remains the basic modality for the detection of lung cancer.
•Computerised tomography (CT) provides information about the primary lesion,
thoracic lymph nodes, pleura, chestwall and upper abdomen. It is the standard
imaging modality for staging lung cancer.
• Magnetic resonance imaging (MRI) appears to be superior to CT in detecting
mediastinal, chest wall tumour invasion into the pericardium, heart and great vessels,
brachial plexus, vertebral body and spinal canal.
• Positron emission tomography (PET) is a molecular imaging modality that detects
metabolic changes in tumour cells. PET improves the rate of detection of the extent of
primary tumour, draining nodes and distant metastases thereby improving the staging
accuracy in patients with NSCLC that can have a significant impact on clinical
management.

10. Other diagnostic modalities
•Clinical and radiological findings should guide the diagnostic approach, depending
on the size and location of the tumour, the presence of metastatic disease, and the
clinical status of the patient. Diagnostic and staging work is taken up concomitantly.
•Sputum cytology, flexible bronchoscopy for biopsies, brushings and washings, CT
guided transthoracic needle aspiration, oesophageal endoscopic ultrasound guided
fine needle aspiration/trucut biopsy of the mediastinal nodes, anterior
mediastinoscopy to assess lymph nodes, are the aids used to establish the
histopathological diagnosis. Distant metastatic sites need to be documented with
microscopic diagnosis.

11. Management
•Surgery is the preferred modality of primary management for resectable NSCLC.
•Based on initial stage and postoperative histopathological report, patients will be
planned for adjuvant radiation therapy with or without chemotherapy, or
chemotherapy with or without radiation therapy.
•For medically inoperable and unresectable tumours chemoradiation therapy is the
preferred line of management.
•With the rapid technological explosion in diagnostic imaging and radiation delivery
techniques, radiation oncologists are now able to deliver external beam radiation
therapy with high precision using Image Guided Intensity Modulated Radiation
Therapy (IG IMRT), Stereotactic Body , Radio surge with real time positional
management respiratory gating system delivering significantly higher doses to the
tumour and minimum dose to the surrounding normal lung and other critical
structures like the opposite lung, heart, spinal cord, oesophagus, and breast,
resulting in increased cure rates and lesser side effects respectively.

12. Management
•Radiation along with chemotherapy has a role in palliation of symptoms due to
recurrent, advancing and metastatic cancer.
•Newer targeted therapy compounds have resulted in progression-free and overall
survival advantage in NSCLC.
•For SCLC, chemoradiation therapy is the preferred choice of treatment, except in T1-
2 NO MO where surgery followed by chemotherapy is the standard of care.
•The by and large outcome for patients with lung cancer may not be gratifying at
present. But with improved surgical techniques, newer anti-cancer drugs, and modern
radiation therapy delivery techniques, we are able to confer superior progression-free
and overall survival period ensuring a good quality of life for our patients. Lung
cancer surgery hospitals in India attracts many international patients because of
availability of very good treatment facilities, good success rate and very low cost of
treatment.

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