Receiving a diagnosis of lung cancer can be an overwhelming experience. It’s normal to feel confused, lost, or frightened. Understanding the various steps and procedures involved in the diagnosis and staging process can help you feel more in control.
Being diagnosed with lung cancer is a process that generally starts with a visit to your family doctor. Your doctor will discuss your symptoms with you and perform a physical exam. They may then order tests such as blood work or refer you to a specialist.
The Process of Diagnosing Lung Cancer
The process of diagnosing lung cancer involves testing to rule out other causes of symptoms and identify if lung cancer is present. If you are experiencing the early symptoms of lung cancer or if screening has revealed the potential for lung cancer, your doctor will want to investigate further.
Your doctor will take a detailed medical history. They will ask about:
- Any medical problems you have experienced
- Where you live and work
- Your smoking history
- Whether you have a family history of lung cancer or other cancers
- If you have noticed any symptoms
The next step is a physical exam. The doctor may listen to your heart and lungs using a stethoscope, feel your lymph nodes, feel your abdomen to see if your liver is enlarged, check your pulse and blood pressure, and check your weight.
Testing is recommended when a person is experiencing symptoms that could indicate lung cancer. If you are experiencing some of the symptoms listed above, your doctor may want you to have certain tests done. These may include:
- Diagnostic Imaging
- Biopsies
Diagnostic Imaging
Imaging tests are used to help doctors see inside the lungs.
- A chest x-ray is a single image of the chest area.
- A CT scan is a series of detailed x-rays that are blended together in a computer. An X-ray may be used as a preliminary test, but a CT scan is generally preferred during the diagnostic process as it gives more detailed information. During a CT scan, you lie on a table and stay very still while the scans are being done. Before the first scan you receive an injection of dye to help the CT scan take a better picture. The scan is painless, but you may find lying still is uncomfortable.
- MRI (magnetic resonance imaging) produces high-resolution images of the inside of the lungs and body
- A PET (Positron Emission Tomography) scan is a scan that uses radioactive materials to show patterns in metabolic activity. PET scans may be used to see how far lung cancer has spread.
- An endobronchial ultrasound (EBUS) uses high-frequency sound waves to capture live images from the inside of the airways. First, you’ll receive a local anesthetic that will numb any pain. A thin, flexible tube (bronchoscope) will be fitted with an ultrasound device and inserted into your airways. Images are then sent to a monitor. Biopsies can be taken if lesions are identified.
Biopsy
A biopsy is an analysis of body tissues to determine whether cancer cells are present. There are several kinds of biopsies doctors commonly use when diagnosing lung cancer:
- Fine needle aspiration
- Thoracentesis
- Surgical biopsy or thoracotomy
- Bronchoscopy
- Mediastinoscopy or thoracoscopy
- Liquid Biopsy
Fine needle aspiration
First, you’ll receive a local anesthetic that will numb any pain. Next, a thin needle is inserted into your chest. The needle collects a small piece of the tumor for examination under a microscope.
Thoracentesis
First, you’ll receive a local anesthetic that will numb any pain. Next, fluid from around your lungs will be drawn out with a needle and looked at under the microscope. This test can also be used to treat a condition called pleural effusion, where too much fluid collects between the lining of the lungs (pleura) and the wall of the chest cavity.
Bronchoscopy
You will be sedated for this procedure. A thin, flexible tube (bronchoscope) with a tiny light and camera will be inserted through your mouth or nose and into your lungs. This helps to find tumors and can break a piece of tumor off for examination under a microscope.
Mediastinoscopy or thoracoscopy
This test helps to find out if tumor cells have spread to the lymph nodes. It is done under general anesthesia. During the procedure, the doctor makes a small cut at the base of your neck and inserts a thin tube. The tube collects fluid samples and small pieces of tissue from the lymph nodes near your throat and lungs behind your breastbone. These samples are tested for cancerous cells.
Thoracotomy (surgical biopsy)
A thoracotomy is a form of surgical biopsy. This procedure is usually done if previous testing hasn’t confirmed a diagnosis. It is done under general anesthetic. A surgeon will open your chest and take samples of your lung tissue and lymph nodes.
Liquid Biopsy
A liquid biopsy is the process by which blood or bodily secretions are tested for cancer cells. The tests can detect cancer cells or genetic material that primary tumours release into body fluids.
Stigma Spotlight
Around 30% of people with lung cancer blame themselves for their diagnosis. This self-blame can leave them hesitant to disclose their diagnosis to friends and family and can lead to social isolation at the exact time when a person needs their community to rally behind them!
Lung Cancer Staging
An important part of a lung cancer diagnosis is determining the stage (extent) of the cancer. This will help guide decisions about the most appropriate treatment approach.
The stages of non-small cell lung cancer:
- Stage 0: Abnormal cells are found, but they are precancerous (not considered cancer yet).
- Stage I: The cancer is found only in the lung and has not spread to any lymph nodes. The tumor is quite small – generally smaller than 2 inches (5 centimetres) across.
- Stage II: The tumor is larger than 2 inches (5 centimetres) across, or it may be a smaller tumor that involves nearby structures such as the chest wall, the diaphragm, or the lining around the lungs (pleura). Stage II cancer may also have spread to nearby lymph nodes.
- Stage III: The tumor has grown very large and has invaded other organs near the lungs, or a smaller tumor is accompanied by cancer cells in lymph nodes farther away from the lungs.
- Stage IV: Cancer has spread beyond the affected lung to the other lung, or to distant areas of the body. Almost half of all lung cancers are diagnosed at this stage.
Small cell lung cancer is staged a little differently:
- Limited stage: The cancer is only on one side of the chest. It is found in one lung and maybe in nearby lymph nodes on the same side of the chest.
- Extensive stage: The cancer is in both lungs or in distant lymph nodes and organs of the body.
Biomarker Testing
“This field of personalized medicine offers not just a glimmer or a peek, but a huge bay window of hope and opportunity for prolonging and improving the lives of patients living with cancer.”
Biomarker testing, also called molecular testing or genomic testing, is the first step in connecting patients with a group of therapies called targeted therapies.
A biomarker is a molecule or molecular change that can be detected in bodily fluids or tissues. In the context of lung cancer, a biomarker may provide information about how a cancer will respond to a particular treatment.
Biomarker testing is done in a lab, where a pathologist examines tumour tissue samples for biological changes in genes or proteins. Based on the results, a person may qualify for common targeted therapies, like epidermal growth factor receptor (EGFR) inhibitors, anaplastic lymphoma kinase (ALK) inhibitors, or immune checkpoint inhibitors.
If you have been diagnosed with lung cancer, it’s a good idea to ask your doctor about biomarker testing.
Current Biomarkers
There are several biomarkers for targeted therapies for both non-small cell lung cancer and small cell lung cancer.
For non-small cell lung cancer:
Mutation
- Epidermal growth factor receptor (EGFR) mutations
- Anaplastic lymphoma kinase (ALK) mutations
- ROS1 mutations
- KRAS G12C mutation
- BRAF mutations
- Neurotrophic tyrosine receptor kinase (NTRK) mutations
- MET exon 14 skipping mutations
- RET gene fusions
For small cell lung cancer:
Mutation
- PD-1 and PD-L1 immune checkpoints
- CD56 surface marker
- BCL-2 overexpression
Sharing Your Diagnosis
When you make your diagnosis known to others , how you announce it, and to whom you announce it is your choice. These tips can help you prepare for these conversations.
Talking about your diagnosis may help you adjust to the situation and start to think about the way forward. It can be helpful to talk with a social worker at your cancer centre, too.
Friends and family
Telling your family and friends about a lung cancer diagnosis can be challenging. You may still be reeling from the news yourself. You might be worried about being able to talk about it without losing control, or you may be uncertain about what to say because you do not fully understand the disease or what treatment options will be available for you yet.
Here are some ideas about what to do when you are ready to talk:
- Start the conversation somewhere you won’t be interrupted. Turn off the TV and put your phone away
- If it makes you feel more comfortable, have someone who already knows about your diagnosis with you
- Provide information a few sentences at a time to give the person a chance to absorb the details.
- As you speak, periodically ask if they have any questions.
- Don’t be alarmed by silence. The person may just need some time to take everything in. If you do want to break the silence, you can ask “What are you thinking?”
Children and teens
When speaking with children or teenagers, it’s usually best to explain your diagnosis in an open and honest way. Try to tailor the amount of details to age and developmental stage of the child, knowledge, capacity for understanding, relationship to the person with the diagnosis, and prognosis of the disease.
Just like many adults, children and teenagers may not be prepared to discuss everything all at once. Look for cues as to how much they are ready to take in and follow their lead. Tell them they can ask you questions at any time.
Coworkers
You do not have to tell your coworkers if you don’t want to. However, applications for leave or disability may need your employer’s support. It may also be beneficial to share a plan with your immediate supervisor about how your workload will be managed.
If you do share your diagnosis with your coworkers, be prepared for different reactions. Some may be preoccupied with how your illness will affect them or increase their workload. Some may be very supportive and seem to know just what to say and do, while others may struggle to find the words. They may feel sad and uncomfortable and be afraid of upsetting you. Some people might act overly cheerful and attentive.
Ask for support if you need it. You may be able to receive counselling through an employee assistance program, if your company has one. Your human resources department may be able to tell you about other programs or employee benefits that may help you.
What to do when someone asks, “Do you smoke?”
It’ll probably happen at least once. You’ll start a conversation about your lung cancer diagnosis, only to be met with blame and judgement – usually in the form of a question like “Well, did you smoke?”
This is the wrong question. In fact, we feel so strongly that this is the wrong way to react to a lung cancer diagnosis that we teamed up with Lung Cancer Canada to create an entire campaign dedicated to asking the right questions about lung cancer.
This kind of blame game just doesn’t happen with other cancers and illnesses. Details about your smoking history belong in a respectful, confidential medical history with your healthcare provider, not in a conversation with family, friends, or co-workers – whether you’re an ever-smoker or a never-smoker. Nobody deserves lung cancer.
If you choose to respond to this type of question, here are a few responses that can be helpful:
- Lung cancer has a number of causes, of which smoking is only one.
- If you have lungs, you can get lung cancer.
- My smoking history doesn’t matter anymore – I need support now.
Lung Cancer Screening
“Screening” means checking for cancer before symptoms develop, even if you feel healthy. Screening can help detect cancer in its earliest stages.
Diagnosis and Staging
Being diagnosed with lung cancer is often life-changing, and emotional distress is common. Understanding the steps and procedures can help you feel more in control, prepare you to advocate for yourself during your treatment.
The cancer care system can seem overwhelming at first, but we’re here to help you navigate it in a way that makes you feel empowered and supported.
The questions we list here are the top coping questions reported by people with lung cancer. Our answers provide some basic information, but we encourage you to discuss any concerns or questions with your oncologist and other members of your cancer care team.