Lung cancer

In Spain alone, 20.000 new cases of lung cancer are diagnosed each year, making it the third most frequent tumor in our country, after colon and prostate cancer. Its figures, mainly due to the increase in tobacco consumption that is taking place in recent times, is continuously increasing. It is estimated that in 2035 there will be 40.000 people affected in Spain, when the data for 2015 put the affected individuals at about 28.000 (23.119 men and 5.205 women).

Lung cancer is the most frequent cause of death from cancer because it is usually diagnosed late, only 15% of cases are detected in its early stages. For all these reasons, it is essential to work on its early diagnosis and, above all, to stop smoking, since it is the origin of 90% of cases.

– Stretching procedures: They allow a direct view of the lung and adnexal areas and obtain tissue samples.

1. bronchoscopy with biopsy: A thin tube (bronchoscope) is inserted through the patient's nose or mouth into the lungs. During the journey, images and tissue samples are obtained.
2. mediastinoscopy: It is used to obtain lymph nodes through small cuts above the breastbone.
3. transthoracic puncture: Guided by the CT scan, it allows obtaining samples of peripheral lung lesions where the bronchoscope cannot reach.
4. Thoracoscopy: To obtain samples under general anesthesia.
5. Thoracentesis: Under general anesthesia, pleural fluid is extracted to assess the involvement of the pleura.

– Analysis of tissue samples: It is used to determine if the tissue samples obtained contain the presence of cancer cells and their type. In non-small cell cancers, it will also be assessed whether there are any of the identified genetic alterations that indicate the mode of tumor development.

The lungs are two large organs located on either side of the heart and are protected by the ribs. Breathing occurs in them, an action that we perform about 20 times per minute and that we cannot spend more than 2 minutes without performing.

When we breathe, we take in oxygen-rich air from outside and introduce it into our body through the nostrils. From here it passes through the pharynx, larynx and trachea until it divides into two bronchi and enters the lungs. Once inside, it branches into increasingly fine tubes (bronchioles) until it ends in the alveoli, a kind of sac surrounded by blood vessels. In these alveolar sacs, oxygen passes into the blood, which will distribute it throughout the body, and carbon dioxide is collected to be expelled in reverse.

The lungs are divided into lobes, two on the left and three on the right, and covered by the pleura, a fine two-layered membrane that prevents the lungs from rubbing against the rib cage and helps in the expansion and contraction of the lungs during breathing. .

There are different types of lung cancer:

-Small cell
-Non-small cell (the most frequent), which is divided into three subtypes:

1. Squamous or epidermoid carcinoma
2. adenocarcinoma
3. large cell carcinoma

The symptoms usually appear when the disease is very advanced because, as the lung is a large organ, the symptoms take time to become visible.

The most frequent symptoms depending on the location and extension are:

None of the symptoms is a definitive sign of lung cancer since they can appear in other benign processes such as flu, asthma... In the event that they appear, you should see your doctor.

The prognosis of lung cancer and the choice of the most appropriate treatment will depend on:

– Early diagnosis: The less advanced it is, the more likely it is to be cured.
– Type of tumor
– General condition of the patient: A poor condition can contraindicate or compromise the effectiveness of the treatment.
– Size and location of the lesion: A small tumor that does not affect vital structures will have a better prognosis.
– Presence or not of affected lymph nodes
– Existence of metastases: If it occurs, the prognosis is bad.

Early diagnosis is one of the best weapons in the fight against lung cancer. To do this, the doctor may use:

– Interview or anamnesis or with a Physical exam.
- Lab tests: analytical
– Imaging tests: To determine the size, shape, location of the tumor and the presence or absence of metastases

1. Chest X-ray: Used when cancer is suspected and shows suspicious areas in the lung and/or chest
2. Computerized axial tomography (CT/Scanner): To identify damaged bone areas.
3. Positron emission tomography (PET): With it, the spread of cancer can be identified, which makes it possible to distinguish between benign, non-cancerous and malignant lesions.
4. Magnetic resonance: When there is suspicion of metastasis in the spinal cord or brain, or to see, at the thoracic level, the involvement of the blood vessels.
5. Bone scintigraphy: To determine bone involvement.

Determining the stage and stage of the cancer is very important both from a prognostic standpoint and when determining the best treatment.

The current classification is based on the TNM system, where T is the size of the tumor, N is lymph node involvement, and M is the presence or absence of metastasis. To this is added the general stage, which goes from 0 (least advanced) to IV (most advanced). Some stages are subdivided into a and b.

Source: University of Navarra Clinic. Infographic Phases of Lung Cancer.

Treatments

The treatment of lung cancer depends on the stage of the disease, the type of tumor and the characteristics of each patient..

Surgery

It is the most curative option. It is used in patients with a local tumor with exclusive involvement of the lung, without involvement of the great vessels or any other organ that could prevent complete removal of the cancer.

The removal can be of a small part (segmentectomy), of a lobe (lobectomy) or of the entire affected lung (pneumectomy). If the lymph nodes located between the two lungs have to be removed, a mediastinal lymphadectomy will be performed.

After the intervention, the recovery process is annoying and long. Respiratory capacity may be lost. Respiratory rehabilitation is usually necessary after its completion. Patients recover after several weeks or months.

Radiotherapy

It is the use of high-energy X-rays capable of killing cancer cells or preventing them from dividing.

It is applied alone or as a complement to surgery.

It can be administered as a quick treatment of the symptoms produced by the tumor.

La external radiation therapy it is applied from the outside, does not require hospital admission and is not painful. Each session usually lasts about 10-15 minutes, in which you have to maintain the position, and is applied between 1 and 6 weeks, for 5 days in a row and resting for two.

The side effects of radiation therapy are:

– Feeling more tired than usual: It disappears when the treatment is finished.
– Skin reactions: Irritation in the treatment area slightly annoying. It is advisable:

1. Do not apply cream without consulting it first
2. Do not cover the area with tape...
3. Wash the treatment area with water or a mild, non-irritating soap
4. Dry the area with small touches
5. Avoid injuring the treated skin
6. Wear loose clothing made of natural fibers
7. Do not sunbathe without protecting the area

– Difficulty swallowing or dysphagia: The lining of the esophagus becomes inflamed which can make it difficult to swallow solid food especially. For this reason it is advisable to eat in small bites, not eat foods that are difficult to swallow and take everything in the form of a puree. It improves rapidly at the end of the treatment.
– Breathing difficulty: Increases or appears dry cough and slight difficulty breathing.

In general it is recommended that:

– Discuss with your treating radiation oncologist any new symptoms that appear.
– Avoid tobacco and alcohol consumption.

Chemotherapy

It is the use of very powerful drugs intravenously or orally for the treatment of cancer. Its objective is to stop the growth of tumor cells, either by destroying them or by preventing their division and growth.

It is used for purposes:

• healing: When the intention of its application is to cure the disease. It is used alone or associated with another treatment.
• Palliative: When it is intended to control the symptoms produced by the tumor, improving the quality of life of the patient and their survival.

Before applying a chemotherapy treatment, it is necessary to assess that the levels of red blood cells and leukocytes are normal and that the kidneys function properly.

It is administered in cycles alternating with rest periods. Usually requires admission. Between the cycles, urine and blood tests will be carried out to determine the above.

In order not to prick each cycle, a catheter is usually placed in a large-caliber vein that remains, without being removed, until the end of the treatment.

The most common side effects are:

– Digestive alterations

1. Nausea and vomiting. To cope with them it is recommended:
2. Eat slowly, chewing well and in small amounts (5-6 times a day).
3. Avoid unpleasant odors and foods rich in fat.
4. Drink cold liquids in small sips.
5. Rest for at least an hour after meals.
6. Avoid that the clothes tighten at the height of the stomach.
7. Do not forget to take the medication that the doctor sends you.
8. Diarrhea: We must be careful with dehydration being recommended:
9. Carry out an absolute diet in the first hours of diarrhea.
10. After two or three hours, start drinking liquids in small sips every 5 or 10 minutes throughout the day.
11. Avoid the intake of dairy products and derivatives.
12. Eat cooked or grilled foods.
13. Avoid irritating drinks.
14. Alterations in the perception of the taste of food: The taste buds of the tongue and palate are damaged so that a decrease in the taste of food or a metallic or bitter taste is perceived.
15. To improve these problems it is recommended:
16. Prepare foods that look good and smell pleasant using spices or mild seasonings in their preparation.
17. Rinse before eating.
18. Use plastic cutlery if metallic taste appears.
19. Alterations in the mucosa of the mouth: The mucosa of the mouth becomes inflamed accompanied by sores or painful ulcers that can sometimes bleed. In these cases it is advisable to maintain good oral and dental hygiene.
20. Using a soft toothbrush and toothpaste.
21. Brush your teeth after all meals.
22. Do not use mouthwashes that contain alcohol.
23. Clean the space between the teeth with dental floss.
24. Do not smoke or drink irritating drinks.
25. Wear the dentures for a short time.
26. The doctor can order local anesthetics and specific treatment to prevent fungal infection.

-Bone marrow changes: The bone marrow is responsible for producing blood cells such as red blood cells, white blood cells and platelets.

1. Decrease in red blood cells: These cells are responsible for transporting oxygen from the lungs to the rest of the body. We will talk about anemia when its amount is low. This situation gives rise to fatigue, shortness of breath with small efforts, palpitations, dizziness and paleness of the skin and mucous membranes. To help feel better it is recommended:
2. rest as much as possible
3. not make efforts
4. limit your activities
5. Decrease in white blood cells or leukocytes: These are the cells that are responsible for defending ourselves against infections, if their number is low, the risk of infections increases. If the decrease is significant, chemotherapy cycles can be delayed. To reduce the risk of infection it is recommended that:
6. Consult your oncologist and go to the hospital as soon as possible if you are over 38^oC of fever or spontaneous bruising.
7. Avoid contact with people with some type of infection (flu, pneumonia...)
8. Before getting any vaccine consult your oncologist, some are not recommended.
9. Avoid the vaccine with newly vaccinated people.
10. Avoid skin lesions:

• Do not cut cuticles.
• Wear gloves when preparing food to protect you from burns and cuts.
• If you have any wounds, wash them with soap and water.
• Frequently wash your hands and teeth.

1. Platelet drop:These are the cells responsible for plugging and preventing bleeding when a wound occurs. If their number decreases, it can increase the risk of bleeding in the event of minimal trauma. To avoid it, it is recommended:

• Avoid blows, trauma or cuts.
• Be extremely careful when handling scissors, knives or any other sharp utensil.
• Avoid contact or risk sports.
• See your doctor if red spots appear on the skin, bruises without previous trauma, blood in the urine, bleeding gums...

-Hair loss: The most frequent thing is that it is not complete or that the hair becomes thinner. When the treatment is finished, the hair will grow back.
-Neurotoxicity: The most frequent symptoms that the patient may notice are a tingling sensation in the hands and feet, blurred vision and decreased hearing. These are also temporary effects that disappear when the treatment ends.

Targeted therapy

Drugs designed to block or kill cancer cells are used. Its effectiveness will depend on:

– Identify the therapeutic target, that is, those tumor targets that play an important role in the development of mutations that lead a healthy cell to become cancerous.

• The development of agents that are capable of attacking those specific targets.

This is an investigational treatment that is leading to encouraging results.

small cell lung cancer

It is a very aggressive tumor that is usually accompanied by metastasis. It is usually treated with chemotherapy alone or with chemo.

Stage I-II Non-Small Cell Lung Cancer

The treatment of choice is surgery, in patients considered inoperable with good lung reserve, radiotherapy is used to avoid damaging important organs such as the heart...

Stage IIIA Non-Small Cell Lung Cancer

They are considered technically operable patients but their performance depends on the involvement of the ganglia located between the lungs, the general condition of the patient and the existence or not of other serious diseases.

When the operation is not possible, the combined treatment of chemotherapy with radiotherapy is chosen.

Stage IIIB Non-Small Cell Lung Cancer

They are not candidates for surgery initially. The treatment of choice may be initial chemotherapy, chemotherapy with radiation therapy, or radiation therapy alone.

Non-small cell lung cancer is stage IV

The treatment in this stage is palliative as long as the secondary effects of the treatments are less toxic than the symptoms caused by the evolution of the disease.

The treatment of choice is chemotherapy or radiotherapy for specific cases.

To these treatments explained above, we must add other complementary ones that will help improve the quality of life of patients. These treatments are included in the rpulmonary rehabilitation, that is, in a comprehensive intervention based on a patient assessment and followed by tailor-made therapies that include, among others, muscle training, education, respiratory physiotherapy, occupational therapy, psychosocial support and nutritional intervention.