#30724: Lung Cancer: Diagnosis and Management

Several risk factors for lung cancer have been associated with lifestyle choices, meaning that the risks can be either managed or avoided in many cases. The most common lifestyle risk factor in the development of lung cancer is smoking. A 1954 study was one of the first to substantiate the connection between smoking and lung cancer. This study demonstrated that a person who had smoked for 20 years, the equivalent of two packs per day for 10 years or one pack per day for 20 years, was, on average, 20 times more likely to have died from lung cancer than a nonsmoker [6]. Approximately 80% of lung cancer deaths and 30% of all cancer deaths in the United States each year are related to smoking [2,7].

There are several other risks that contribute to the development of lung cancer besides smoking, including involuntary or secondhand smoking, industrial and environmental hazards, and geography. Smoke that is breathed in from the environment is not as concentrated as if it was inhaled directly, but it contains the same harmful materials. Secondhand smoke, also known as environmental tobacco smoke, is a complex mixture of gases and particles that includes smoke from the burning cigarette, cigar, or pipe tip (sidestream smoke) and exhaled mainstream smoke. Secondhand smoke contains at least 7,000 chemicals, 250 or more that are known to be toxic, including more than 70 that cause cancer. Secondhand smoke exposure causes lung cancer in nonsmoking adults. Nonsmokers who are exposed to secondhand smoke at home or work increase their lung cancer risk by 20% to 30% [8,9,10]. Secondhand smoke exposure also causes respiratory symptoms in children, including asthma and 150,000 to 300,000 lower respiratory infections each year, and slows their lung growth. There is no risk-free level of secondhand smoke exposure. Even brief exposure can be dangerous [8].

The role of particulate air pollution in the incidence of lung cancer was the source of serious debate and contention for many years. Between 1982 and 2006, the American Cancer Society conducted a study (the Cancer Prevention Study II [CPS-II]) to examine the impact of environmental and lifestyle factors on cancer etiology in men and women in the United States. Researchers determined that fine particulate and sulfur oxide-related pollution, from vehicle and industrial sources, was associated with an increased incidence of cancer, heart disease, and all-cause mortality. Long-term exposure to these pollutants was determined to be a significant environmental factor in lung cancer incidence and mortality [11]. Another study published in 2017, the Adventist Health and Smog Study-2 (AHSMOG-2), followed more than 80,000 participants for an average of 7.5 years and determined that there was a positive incremental association between ambient fine particulate air pollution and the incidence of lung cancer and associated mortality [12].

Those who work around certain industrial substances, such as asbestos, have been found to have an increased risk for developing lung cancer, as well as mesothelioma and nonmalignant lung and pleural disorders [13]. In the late 1970s, the U.S. Consumer Product Safety Commission imposed a limited ban on the use of asbestos. This was followed by a 1989 ban on all new uses of asbestos by the U.S. Environmental Protection Agency [14]. Studies have shown that cigarette smoking combined with asbestos exposure is particularly hazardous. Smokers who are exposed to asbestos have a risk of developing lung cancer that is greater than the individual risks from asbestos exposure and smoking added together [13,14].

In addition to asbestos, many other materials have been linked to the development of lung cancer, including [9,12,15]:

These substances are handled in many occupations, including by workers in chemical factories, automobile maintenance, uranium mining/processing, copper smelts, foundries, shipyards, mines, construction, and glass, pottery, and linoleum factories [16]. Individuals in any of these occupations who also smoke cigarettes have an increased risk of developing lung cancer [9].

Geography has also been shown to be a significant risk factor for lung cancer. A report compiled by the American Cancer Society, the Centers for Disease Control and Prevention (CDC), the National Cancer Institute, and the North American Association of Central Cancer Registries found large geographic variations in smoking that are delaying a decrease in lung cancer death rates in women and slowing the decrease in men. For example, the average percentage decrease in the lung cancer death rate among men in California was more than twice that of many Midwest and Southern states during the period 2014 through 2018 [17]. In women, the lung cancer death rate remained stable in four states (Rhode Island, South Dakota, Nebraska, and Utah) and decreased in all remaining states for the same time period [17]. Another report from the American Cancer Society shows that, between 2011 and 2015, death rates attributable to lung cancer were highest for men (in order of highest to lowest) in Mississippi, Arkansas, West Virginia, Tennessee, and Alabama, and highest for women in Kentucky, West Virginia, Arkansas, Tennessee, and Maine [2]. State variations have been attributed to several factors, including the level of public awareness about the harmful effects of smoking, social norms (e.g., acceptability of smoking), state educational levels, racial/ethnic variations among states, tobacco control activities, industry promotional activities, and economic dependency on tobacco farming and production [2,5].

The risk factors mentioned so far have all been manageable or preventable (i.e., the decision to smoke or where to work is generally a personal choice). Race, gender, socioeconomic status, and family history are not factors that can be changed, but they nevertheless influence an individual's likelihood of developing lung cancer.

Significant racial and ethnic differences in the smoking-related incidence and progression of lung cancer have been reported [16]. Tobacco use varies within and among racial/ethnic minority groups and sex. In 2020, American Indian/Alaska Native adults had the highest prevalence of tobacco use (27.1%), followed by Black Americans (14.4%), White Americans (13.3%), Hispanic Americans (8.0%), and Asian Americans (8.0%) [18]. The overall rate of cigarette smoking is higher among men (13.1%) than women (10.1%). Traditional uses of tobacco in ceremonial, religious, and medicinal roles in native cultures may affect behaviors and attitudes toward commercial tobacco use, leading to the high prevalence in this group [19].

Differences in the magnitude of disease risk are directly related to differences in patterns of smoking. No single factor determines patterns of tobacco use among racial/ethnic minority groups; these patterns are the result of complex interactions of multiple factors, such as socioeconomic status, cultural characteristics, acculturation, stress, biologic elements, targeted advertising, price of tobacco products, and varying capacities of communities to mount effective tobacco control initiatives [19].

There seems to be an identifiable trend of lung cancer in persons who have a family history of lung cancer, particularly in those cases where the patient was young. Studies have shown that there may be a specific gene that predisposes a person to lung cancer. Researchers studying the genetics of familial lung cancer have found strong evidence linking a major lung cancer susceptibility region of chromosome 6, specifically 6q23-25, to lung and other tobacco-related cancers [20,21].

There are two main categories of lung cancer: small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC), each with their own pathology. NSCLC accounts for approximately 85% of all lung cancers and is further divided into two types: non-squamous carcinoma (this includes adenocarcinoma, large cell carcinoma, and other cell types) and squamous cell (epidermoid) carcinoma, each with distinct histologic and clinical characteristics [24,32,33,34].

Chest x-rays help find masses or lesions on the lungs. When anteroposterior and lateral films are taken, a peripheral tumor at least 1 cm in diameter can be visualized. Additionally, there will be evidence of a widened mediastinum or hilar adenopathy visible with this view [36. These findings are suggestive but not diagnostic of lung cancer and require follow-up with CT or combined Positron emission tomography (PET)-CT scans to assist in diagnosis and staging [36].

CT scans film cross-sectional soft tissue images of the body to analyze tissue for density and reveal tumors or displaced organs. A CT scan of the chest with contrast is recommended for patients with known or suspected lung cancer who are eligible for treatment [47]. A chest x-ray and chest CT scan with contrast material is recommended for staging locoregional disease [48].

The patient may be asked to take nothing by mouth (NPO) prior to the procedure and may be asked to drink, or receive intravenously, a contrast solution to help outline structures in the body. The images can provide precise information about the size, shape, and position of tumors and can help find enlarged, potentially cancerous lymph nodes. The test can also be used to detect masses in the adrenal glands, brain, and other internal organs [32,47]. While CT of the chest is the reference standard for detecting focal lung disease, missing lung lesions during CT is a well-recognized phenomenon [33,47]. Although the computer-aided detection system has been shown to increase the overall accuracy of lesion detection when used as a second reader on chest CT studies, further research is needed to determine its value for experienced radiologists [49,50,51,52,53].

Spiral CT (also called helical CT) uses a faster, continuously rotating machine. The spiral CT allows for a more rapid collection of images than the standard CT. It also reduces blurred images, lowers the dose of radiation received, and produces thinner images that yield a more detailed picture for analysis [54].

With CT-guided needle biopsy, a CT scan is used to guide a biopsy needle into the suspected area. The scans are repeated until the physician is certain that the needle is within the mass. A biopsy sample is then removed and reviewed under a microscope [32].

Magnetic resonance imaging (MRI) is a noninvasive radiologic procedure used in some cases to aid in diagnosing lung carcinomas. It is more commonly used to stage lung cancers and identify possible metastases, particularly of the brain and spinal cord [32,33]. However, it may also be employed to visualize areas of the lungs not well demonstrated on axial images. Head CT or MRI brain imaging has been recommended for use in patients with signs or symptoms of central nervous system disease as well as for patients with stage III disease who are being considered for aggressive local therapy [33,47,48].

PET scans may also be useful in the diagnosis of lung cancer. An 18F-deoxyglucose PET scan should be performed to investigate solitary pulmonary nodules or masses, particularly in cases where a biopsy is not possible or has failed, depending on nodule size, position, and CT characterization [33,47,48,55,56]. This study may also be useful in detecting metastatic spread of the disease but is not intended to replace conventional imaging techniques. The American College of Chest Physicians (ACCP) does not recommend PET scanning in the routine staging of SCLC, although the National Comprehensive Cancer Network (NCCN) guideline recommends combined PET-CT if limited-stage disease or metastasis is suspected [24,55]. PET has been recognized as a valuable tool in developing a treatment plan in the management of lung cancer [55,57]. While PET scanning is more accurate than CT scanning, tissue biopsy is still required to confirm PET scan findings [47].

Endobronchial ultrasound (EBUS) uses sound waves to produce images [58]. EBUS has been found to be a useful adjunct in the diagnosis of lung cancer, particularly when the lesions occur in the periphery of the respiratory tract [59]. Additionally, EBUS has been shown to have a high sensitivity and specificity for node staging compared to CT or PET scans and may be considered in staging lesions [60]. Endoscopic esophageal ultrasound is similar to EBUS, except it involves passing an endoscope down the throat into the esophagus. Ultrasound images taken inside the esophagus may help find cancerous lymph nodes inside the chest [61].

Newer imaging techniques, such as four-dimensional computed tomography (4DCT), are being explored to help in diagnosis and improved treatment. 4DCT continuously scans the chest for about 30 seconds, as the patient breathes, and shows where the tumor is in relation to other structures. This can help practitioners to deliver radiation more precisely and can also show if a tumor is interfering with any other structures in the chest [62].

Blood work is done to assess the respiratory status and to look for metastasis to other organs. These tests may include arterial blood gases, complete blood count, serum calcium, alkaline phosphatase, and liver function studies [33].

Sputum specimens for cytology are completed in order to microscopically identify any malignant cells that may have been sloughed off and expectorated. This requires collecting three early morning specimens in an attempt to obtain deep sputum production, not just saliva from the mouth. Samples are placed in a fixative and processed before viewing. Sputum cytology is not routinely recommended and should be reserved to investigate patients with centrally placed nodules or masses and who are unable to tolerate or unwilling to undergo bronchoscopy or other invasive tests [33,55].

A bronchoscopy is performed routinely on patients suspected of having lung cancer. This procedure allows an opportunity to visualize the lung structure for possible narrowing, inflammation, bleeding, or tumors (Table 2). The ability to actually see some tumors permits a more representative tissue sample to be obtained. A sample of the tissue may be obtained through needle aspiration (transbronchial), brush or forceps biopsy, bronchoalveolar lavage, or bronchial washings [24,33]. There is some controversy regarding the use of bronchoscopy and fine-needle aspiration. While some have challenged the practice as unsafe and useless, based on instances of complications and false-negative results, use of these procedures remains a recommended approach to diagnosis [55,63,64,65]. The additional use of ultrasound imaging when using fine-needle aspiration is often utilized.

The patient is kept NPO prior to the procedure and given mild sedation. There are different types of bronchoscopes available; the fiber optic bronchoscope is generally less uncomfortable than the rigid type. The tube is inserted through the nares in most patients, or through the mouth in those whose nasal passages are obstructed. Once inserted, the bronchoscope allows visualization of the tracheobronchial tree down to the finer branches. It is customary in this procedure to obtain washings, brushings, and possibly even a biopsy.

While the bronchoscopy can easily find tumors that lie in or on the main airways, those that are more peripheral are not easily accessed. In these cases, a percutaneous fine-needle aspiration biopsy may be done with the assistance of the CT scan, ultrasound, or fluoroscopy to direct the needle [32,55]. Ninety-five percent of the time this procedure is sufficient to diagnose the lesion, but there are some disadvantages as well. A pneumothorax or hemorrhage may occur. Also, if the tumor is cancerous, those malignant cells may be drawn along the path of the biopsy needle [66]. One study found that the resection rate of nonmalignant nodules was significantly lower for patients with preoperative CT-guided fine-needle aspiration biopsy than in those without [67]. Bronchoscopy should be performed on patients with central lesions who are able and willing to undergo the procedure. Chest CT should be performed before an intended fiber optic bronchoscopy [55].

Mediastinoscopy and mediastinotomy may be done in instances when mediastinal lymph nodes must be assessed for possible metastasis. These are invasive procedures, involving incisions made over the sternal notch to allow access into the mediastinum with a mediastinoscope. The primary difference between the two procedures is in the size and location of the incision [32]. Biopsies may be taken from the nodes or other suspicious structures. Mediastinoscopy is considered to be the long-standing "criterion standard" for evaluating mediastinal lymph nodes; however, it is a high-risk procedure, typically used prior to surgery to confirm or exclude the presence of tumor in enlarged nodes [24,68,69,70]. Studies have shown that mediastinoscopy may be replaced by newer, more well-tolerated technologies, such as EBUS, which are safer and generally preferred by patients. Training to either maintain mediastinoscopy procedures skills or to elevate levels of accuracy for technologies such as EBUS is necessary to ensure a consistent level of accuracy between mediastinoscopy and other evaluation options [71].

Thoracenteses are done to obtain pleural fluid for analysis. They are most often performed when the patient has a pleural effusion [24]. In this procedure, fluid is removed, thereby improving the patient's comfort while also allowing that fluid to be sent to the laboratory for examination [32]. Local anesthetic is given to allow insertion of a trocar into the chest. In some cases, fluoroscopy is used to direct the needle insertion. Table 3 provides more detail regarding thoracentesis.

In 2004, the FDA approved a CT system called the superDimension/Bronchus system (SDBS), a minimally invasive device used to diagnose lung cancer. It has undergone several series of hardware and software upgrades since its approval and is currently the most widely used navigational bronchoscopy system [72]. The SDBS uses overlaid CT images to navigate to lesions in the lungs in real time and has a greater capability to reach peripheral masses, lymph nodes, and areas outside the range of a traditional bronchoscopy [73,74]. The procedure is proven to be safe, effective, and useful in establishing a diagnosis of lung cancer, especially when combined with other biopsy modalities [73,74,75]. Other navigational systems include the SPiN Thoracic Navigation System and Archimedes. The SPiN system features electromagnetic sensors that allowing tracking of the instrument position and target lesion. Archimedes is a virtual planning and navigational platform that displays an endoscopic map adjacent to the live endoscopic image [72].

Staging of any tumor is done to determine the extent of the disease and the prognosis, to select patients for surgical or other intervention modalities, and to decide on a plan of treatment. The extent of the disease is the most important prognostic indicator. To determine this, a staging system has been developed by the American Joint Committee on Cancer (AJCC). This widely used TNM tumor classification system examines and classifies three different aspects of the cancer's development and growth: tumor, regional lymph node involvement, and metastasis (Table 4). "T" indicates the features of the primary tumor; "N" indicates metastasis to regional lymph nodes; and "M" indicates the presence or absence of distant metastases. Based on the presence and extent of these three aspects, the cancer may be staged (Table 5). It is this set of criteria that tumor registrars use to classify cancers and compile statistics for study and research [37,77,78].

The Veterans Administration Lung Study Group has been the basis for treatment recommendations for SCLC for decades. This system classifies patients as having either limited-stage disease (i.e., tumor confined to one hemithorax and to the regional lymph nodes) or extensive-stage disease (i.e., tumor beyond this area in contralateral lung or extrathoracic sites). In 2009, the International Association for the Study of Lung Cancer (IASLC) launched a lung cancer staging project (using the sixth edition of the AJCC TNM staging system) designed to analyze clinical TNM staging for SCLC. The IASLC found a better correlation of patient survival when the TNM staging system was used and recommended that the AJCC TNM staging system be adopted more uniformly. These recommendations were incorporated into the seventh edition of the AJCC staging manual, and all cancer cases diagnosed between 2010 and 2017 use the seventh edition criteria. In 2017, updates based on new evidence in clinical cancer care were incorporated into the eighth edition of the AJCC TNM staging system, and all cases of cancer diagnosed after January 1, 2018 use the updated staging criteria [37,38,77].

There are two subtypes of SCLC: small cell carcinoma and combined small cell carcinoma (i.e., SCLC combined with neoplastic squamous and/or glandular components). The classification of "SCLC combined" is used when at least 10% of the tumor bulk is composed of an associated non-small cell component. "SCLC" is reserved for tumors with pure SCLC histology [79].

As previously noted, SCLC accounts for approximately 10% to 15% of all bronchogenic carcinomas in the United States [34,35,79]. Without treatment, it is a highly aggressive malignancy with a median survival rate of only two to four months from the time of diagnosis. The overall survival at five years is 5% to 10% [79]. Approximately two-thirds of patients with SCLC have bilateral lung involvement at the time they are diagnosed [79]. Because distant metastasis is often present, SCLC is almost always considered metastatic. When found early, it is particularly sensitive to chemotherapy and radiation therapy; however, a cure is difficult to achieve. As discussed, SCLC is the cancer most commonly associated with paraneoplastic syndromes [79].

There are several types of NSCLC, each with a different kind of cancer cell that grows and spreads in different ways [39]. Squamous cell carcinoma, also called epidermoid carcinoma, arises from the flat, scaly, stratified columnar epithelial cells that line the airways. It is almost always related to smoking and accounts for about 25% to 30% of all diagnosed cases [33,38,80]. Squamous cell carcinoma tends to be located centrally, causing atelectasis and pneumonia before it metastasizes. Squamous cell cancers grow slowly and are easier to surgically resect than some of the other types. Because of this, the prognosis is better for these patients [39]. One lesion most often caused by squamous cell carcinoma is Pancoast tumor. This cancer is located high in the lung apex, causing pain in the shoulder and radiating down the ulnar nerve distribution path [33].

Adenocarcinoma is the most common lung cancer. It represents approximately 40% of all cases and is increasing in frequency [33,39,80]. It is easy to diagnose, as it is most often located peripherally and can be readily visualized on chest x-rays. Adenocarcinoma metastasizes rapidly, and patients are often found to have distant lesions at the time of diagnosis [39]. Common sites for metastasis include the brain, bone, liver, kidneys, and the other lung [15]. A subtype of adenocarcinoma, adenocarcinoma in situ, is characterized by pneumonia-type infiltrates present on chest x-ray films. Patients with this subtype often have a better prognosis than those with other types of lung cancer [33].

Large cell carcinoma is the least common of the three major types of lung cancer, accounting for about 10% to 15% of cases [33,39,80]. It has characteristics similar to adenocarcinoma, but microscopically, the cells appear different. Metastasis occurs frequently, with the gastrointestinal tract being the most common site of metastatic symptoms. With improved histopathologic procedures and the use of electron microscopy, most NSCLCs that would previously have been classified as large cell carcinomas are instead identified as undifferentiated adenocarcinomas or SCLCs. Large cell undifferentiated carcinomas have the same prognosis as adenocarcinomas [33].

Other less common types of NSCLC include [38]:

Malignant mesothelioma is a type of lung cancer that tends to be grouped into the "other" category, mainly because there are fewer patients with the disease. Asbestos has been identified as the main carcinogen involved in the development of mesothelioma. Even when exposure is brief and occurs many years prior to the tumor development, a link may often be found. In most cases, the exposure was heavy and patients often have a history of asbestosis prior to the appearance of the mesothelioma [81]. Approximately 80% of patients diagnosed with mesothelioma also report a history of asbestos exposure [81,82].

Prognosis in mesothelioma is difficult to assess because of the variability in the time before diagnosis and the rate of disease progression. The latency period between a patient's first exposure to asbestos and the manifestation of disease is generally between 20 to 40 years [82,83,84]. On a cellular level, mesothelioma is similar to several different cancer types, including adenocarcinoma and metastases [83]. Immunohistochemistry and electron microscopy are the most common tools used to identify malignant mesothelioma and to distinguish between it and lung adenocarcinoma [24,81]. It may be difficult to differentiate mesothelioma from adenocarcinoma on small tissue specimens; therefore, obtaining a tissue sample, usually through thoracoscopy, is generally necessary for diagnosis [81]. Because it is usually advanced by the time it is diagnosed, prognosis in mesothelioma is poor. For patients with malignant pleural disease, the median survival time with trimodal treatment is 16 to 19 months; for those with extensive disease, the median survival time is four to eight months [81].

The American College of Chest Physicians recommends that patients with lung cancer be assessed for curative surgical resection by a multidisciplinary team, which includes a thoracic surgeon specializing in lung cancer, a medical oncologist, a radiation oncologist, and a pulmonologist.

(https://journal.chestnet.org/issue/S0012-3692(13)X6006-4 Last Accessed: August 27, 2024)

Strength of Recommendation: 1C (Strong recommendation based on low-quality evidence that the benefits outweigh the risks/burdens)

Surgery is a frequent and logical choice for removing a cancer. Many patients respond to the announcement of their diagnosis with comments indicating that they want the cancer removed from their body immediately. While this is not always an option, it is the best choice for many patients (e.g., those with stage I or stage II disease) [24,85]. In general, the type of surgery performed depends upon the extent of the disease [24].

The surgical procedures used to remove lung cancers include wedge resection, lobectomy, pneumonectomy, and sleeve resection. Wedge resection removes the tumor and a small amount of the normal surrounding tissue (called "segmental resection" or "segmentectomy" when more tissue is taken). Lobectomy removes the affected lobe of the lung, whereas pneumonectomy removes an entire lung. The sleeve resection removes only part of the bronchus [24,38]. According to the American College of Surgeons Oncology Group, a complete mediastinal lymphadenectomy should obtain one or more lymph nodes from each mediastinal station [86]. For cancers on the right side, lymph nodes should be removed from stations 2R, 4R, 7, 8, and 9; in cases of left-sided cancers, stations 4L, 5, 6, 7, 8 and 9 should be sampled.

Surgery may be performed for the treatment of [24,38]:

Approximately 20% of NSCLC patients are at stage I or stage II at the time of diagnosis [87]. These patients have traditionally been treated with surgical resection alone; however, adjuvant treatment in these early-stage patients has shown promise [87]. Many stage IIIA patients may be helped by surgical resection, but those at stage IIIB or beyond are not considered surgical candidates [38]. NSCLC is considered inoperable when there is distant metastasis, esophageal obstruction, or involvement into the chest wall or mediastinum. Sleeve lobectomy is generally preferred over pneumonectomy when anatomically appropriate. In patients with severely reduced pulmonary function who are otherwise not candidates for surgery, the use of lung-sparing surgeries (i.e., wedge resection) is controversial [24]. Surgical resection of a solitary metastasis (particularly a brain metastasis) may improve survival in select patients with stage IV disease. Resection of metastasis in other sites remains controversial [24].

Patients who are diagnosed with SCLC are generally considered to be metastatic at diagnosis and therefore are not usually advised to consider surgery. Fewer than 1 out of 20 patients with SCLC will have cancer in only one localized tumor nodule, with no spreading. Among patients with limited-stage disease, surgery after chemotherapy or chemoradiation is an option; however, there is little to no evidence to support the utility of surgery in this cohort [79]. Overall survival is not increased with the addition of surgery.

Preoperatively, patients should be advised of what to expect with the surgical experience. Patients tend to do better postoperatively if, prior to surgery, they are told or shown [88]:

If there are critical pathways in place in the hospital where the patient will be admitted, these should be reviewed to allow the patient to anticipate the flow of postoperative events. For nurse case managers working inside the hospital, the primary postoperative focus will be on maintaining the patient's immediate bodily functions: airway, secretions management, intravenous (IV) fluids and medications, wound care, and chest tube maintenance. As the patient progresses, an increase in activity and dietary intake should be encouraged, with the anticipated outcome of discharging to home.

Case managers working outside the hospital setting may or may not have direct contact with patients before surgery or communication with the hospital case manager during the patient's hospitalization. If contact is established, these case managers will help to coordinate the postdischarge plans and will follow the patient to home, hospice, or other facility as necessary.

Radiation therapy is defined as the use of ionizing radiation to kill cancer cells. It is usually considered local therapy because it treats only the cells at which the radiation is directed; however, systemic radiation therapy, or introduction of radioactive material (i.e., radiopharmaceuticals) into the circulatory system, is also available. When healthy cells surrounding the cancerous lesion are exposed to radiation, they may also be destroyed; however, they are better able to repair DNA damage than are cancer cells. Radiation treatments may be administered IV or orally, whichever is determined most effective to treat the specific tumor type and magnitude [123,124].

External beam therapy, or teletherapy, can be delivered by several different types of machines, depending on the type and extent of the tumor [123]. The linear accelerator is the most commonly used machine. With the linear accelerator, electrons bombard a target and produce high-energy photons. Because the electrons have both mass and charge, they lose energy more quickly than, for example, x-rays. This limits their ability to penetrate and minimizes damage to surrounding tissue. An extension of external beam therapy is conformal radiation therapy, which uses a three-dimensional CT scan of the affected area in order to better target the tumor. An extension of conformal therapy and a more advanced method is intensity-modulated radiation therapy (IMRT). The IMRT facilitates shaping of the intensity of the radiation beam, which allows for a more precise distribution of the desired dose around the target site [123,124].

Prior to beginning any type of external radiation therapy, CT scans, MRIs, and/or other imaging results are studied to determine the exact area for the best effect of the radiation. The patient is tattooed or marked to ensure that the technician will correctly position the beam each time the treatment is given. Patients may also be fitted with a support to help them hold the correct position during the radiation therapy treatments [123,124]. Patients should be told to allow one to two hours for the initial planning session prior to beginning treatment. Daily treatments usually take less than five minutes, but positioning may take a few minutes longer [124].

Both NSCLC and SCLC patients are likely to have courses of radiation therapy. NSCLC is treated most commonly with five treatments, also called "fractions," of external beam radiation per week for five to eight weeks. The amount of radiation and the duration of treatment with this therapy is dependent on the stage of the cancer and its responsiveness to treatment [124]. Research has supported the use of hyperfractionated accelerated radiotherapy, in which smaller radiation doses are administered several times a day five times a week, or continuous hyperfractionated accelerated radiotherapy, in which radiation is given several times a day every day, especially in later stages of lung cancer [125].

Intraoperative external beam radiation therapy may be an option for some patients, depending on the inaccessibility of their tumors or metastasis. During surgery, organs may be moved out of the line of radiation and treatment is given directly to the affected site [123,124].

Internal radiation, known as brachytherapy, is the temporary or permanent implantation of radioactive isotopes. It provides an opportunity to deliver a large amount of radiation to a small site in a relatively short period of time. The usual procedure involves surgery to insert the wires, tubes, or needles into the tumor. After the tubes are sutured into place, the patient is returned to the hospital room and the radioactive isotopes are loaded into the receptacles [123,126].

Patients undergoing brachytherapy should be informed prior to the procedure that the staff caring for them will be maintaining precautions to prevent overexposure to the radioactive source. Nurses and other healthcare professionals should keep the time spent in close contact to a minimum and should encourage the patient to do as much self-care as possible. Shielding is placed in the room to protect workers from being exposed when doing tasks not directly involving the patient. When the radioactive substances have been removed from the patient, these precautions are no longer necessary.

Radiation therapy may cause a variety of side effects, including [123,124]:

For patients with superficial limited mucosal lung cancer in the central airway who are not candidates for surgical resection, the American College of Chest Physicians recommends endobronchial treatment with photodynamic therapy, brachytherapy, cryotherapy, or electrocautery.

(https://journal.chestnet.org/issue/S0012-3692(13)X6006-4 Last Accessed: August 27, 2024)

Strength of Recommendation: 1C (Strong recommendation based on low-quality evidence that the benefits outweigh the risks/burdens)

Photodynamic therapy (PDT) (also called photoradiation therapy, phototherapy, or photochemotherapy) combines a photosensitizing agent with a specific type of light. The FDA has approved porfimer sodium for use in PDT to treat symptoms of certain cancers, including endobronchial NSCLC. Porfimer is administered intravenously and retained in cancer cells at a greater concentration than healthy cells. A light source (e.g., laser, light-emitting diodes) is used to illuminate, via bronchoscopy, the photosensitized cells, which results in increased laser light uptake, photochemical reaction, and the subsequent death of cancer cells. Both primary and metastatic tumors present in the tracheal or bronchial passages respond to PDT. However, this treatment is not appropriate and not effective for all tumors (e.g., large tumors, those located in areas difficult to expose to light). The advantages of this therapy are that no resistance has been found and there are no significantly adverse side effects. Due to increased skin photosensitivity, patients who have undergone PDT should avoid sunlight for at least six weeks following treatment [128,129].

Alternative therapy encompasses any method used to treat cancer that is out of the mainstream of medical protocol. Patients who have a poor prognosis or who have not responded to conventional treatments may look to these methods as a source of hope. Some alternative therapies offer psychologic comfort, others are being investigated as possible advances in the treatment of lung cancer, and many are seriously questionable. Patients may feel they have nothing to lose by trying these methods, but alternative treatments may prove to be harmful if they result in [130]:

False therapies that should be avoided include devices that supposedly rid the body of tumors, hyperoxygenation products, diets that espouse only one or two foods and thereby deprive the body of needed nutrients, and psychic surgery.

Dietary approaches to cancer treatment have not been proven to diminish or eliminate cancer in the body. However, good nutrition strengthens the immune system, which in turn may help patients withstand the rigors of legitimate therapy.

It is helpful to be able to discuss these methods while encouraging adherence with the established protocol. Any question regarding the safety of herbs, foods, or other ingested substances should be referred to the physician and/or pharmacist immediately.

Metastasis presents a very real concern and complication for the patient with lung cancer. Distant metastasis is the most common reason for failure to cure. A vital portion of the role of the healthcare professional is to maintain close contact with the patient to be alert for early signs of metastasis.

Progressive lung cancer ultimately involves respiratory distress of some degree. Obstruction of airways and/or restriction of lung expansion results in dyspnea. Also, postobstructive pneumonitis, atelectasis, or pleural effusions may occur.

Pleural fluid accumulates when the lymphatic drainage system is obstructed. This results in poor lung expansion and decreased gas exchange. Treatment consists of thoracentesis or a chest tube. Some patients may require the insertion of a sclerosing agent through the chest tube into the pleural space (i.e., pleurodesis). The pleura's reaction to the sclerosing agent causes scarring, which will help to keep the lung inflated [139].

Dyspnea may be alleviated by several nursing measures. Patients and healthcare staff should be encouraged to schedule activities that require exertion so that they do not follow one another and are spaced with rest periods. Relaxation techniques may help and can be demonstrated to most patients. Pursed lip breathing is advantageous to some patients. Still others find that opioid inhalers provide relief; early use of opioids for dyspneic cancer patients has been associated with a reduction in stress and improved quality of life. Whenever possible, assessing and treating the underlying cause of the condition is recommended [140].

When oxygen is required, several factors should be considered before choosing the best system for the patient. Most patients use a concentrator at home. This small device converts normal room air into a higher concentration of oxygen. The system is electrical and generates a sound that may be annoying to some patients. Its main advantage is that the oxygen is supplied continuously with no need to change tanks or have deliveries. It works well for patients who require a high flow rate.

Oxygen cylinders are used for backup for concentrators in the case of power failure. They are also useful for patients who need only occasional oxygen. They are large, heavy, and require replacement as the oxygen is consumed. However, they are quiet and require no electricity to run.

Liquid oxygen systems are also available in some areas. A larger tank is filled by a delivery truck; small portable units can be replenished by the patient as needed. This type of system requires some physical strength but is preferred by many patients.

It is important to note that most insurance providers do not reimburse for the amount of oxygen used, but rather pay a monthly fee. Insurance carriers also require documentation of the need for oxygen, most often in the form of arterial blood gas reports or oximetry records. It is necessary to report the blood gas that shows the oxygen pressure (pO2) when the patient has desaturated the most; usually, this is after ambulation or other activity.

When a patient on oxygen reports increased shortness of breath, it is advisable to have the oxygen delivery system examined to make sure that everything is functioning properly before deciding that the patient is deteriorating. Holes may appear in tubings, gauges can operate incorrectly, or any number of mechanical problems can be the cause of decreased effectiveness.

In adult patients with lung cancer experiencing cough despite anticancer treatment, the American College of Chest Physicians suggests cough suppression exercises as alternative or additional to pharmacologic therapy where such services are available.

(https://journal.chestnet.org/article/S0012-3692(13)X6006-4 Last Accessed: August 27, 2024)

Strength of Recommendation: 2C (A weak and conditional recommendation based on low-quality evidence that the benefits outweigh the risks/burdens)

Some patients feel dyspneic, but their blood gases are normal. The potentially correctable underlying causes of dyspnea include hypoxia, anemia, bronchospasm, respiratory muscle dysfunction, poor oxygenation, muscle fatigue, abnormal cortisol and catecholamine levels, circulating cytokines, tumor obstruction, superior venal cava obstruction, pleural effusions, pericardial effusions, cardiac failure, and pulmonary embolism. Lack of understanding about the pathophysiologic mechanisms underlying dyspnea may hamper a clinician's ability to effectively manage it [140].

Coughing may be caused by an infection or inflammation in the lung or by the tumor pressing against the bronchial tree. Severe cough may result in major suffering for the patient in the form of lost sleep, fractured ribs, worsened fatigue, and hemoptysis. The optimal therapy is treatment of the underlying disorder. Hydration and humidification of the air may provide symptom relief. However, if the cough persists, an order may be obtained for a cough suppressant [140].

Debilitating fatigue may be a problem for the patient with lung cancer and has been associated with a diminished quality of life [141]. It is different from the fatigue experienced by healthy individuals and may be so severe that it is difficult to deal with treatment or to carry out simple activities of daily living [142]. The fatigue may be directly related to chemotherapy treatments, or it may be solely a result of the cancer. Fatigue related to cancer treatment is categorized as chronic fatigue that is not relieved by sleep and rest, and it has been reported in 39% to more than 90% of patients undergoing cancer treatment and in 19% to 82% of patients post-treatment [142]. Cancer-related fatigue is prevalent in 75% of patients with metastatic disease and affects cancer survivors for months to years after cessation of treatment [142].

The best method to combat severe fatigue is to increase both rest and exercise. Even mild exercise can improve endurance and decrease stress from normal activities. The exercise may be an activity that encourages the patient to socialize, such as golfing or walking with others. Companionship may improve mental outlook and relieve some depression, which may also be part of the cause of the fatigue [142].

Patients may benefit from scheduling their activities to maximize their strength. For example, if a patient is exhausted simply by showering, shaving, and getting dressed each morning, it may be helpful to suggest that the patient shave and shower upon rising, then read the newspaper over coffee and breakfast while still wearing a bathrobe. The rest will ease the strain of dressing, which can be done later. This type of division of activities can ease shortness of breath and decrease fatigue [142].

This triad of complications is often linked to treatment with either radiation or chemotherapy but may occur solely from the cancer. The most common causes are chemotherapy drugs and radiation therapy directed at the gastrointestinal (GI) tract, liver, or brain. Nausea and vomiting that result from cancer therapy occur in up to 80% of patients and have been classified as [143]:

Previous severe episodes, female sex, age (50 years and younger), fluid and/or electrolyte imbalance, tumor location (e.g., GI tract, liver, brain), constipation, certain drugs (e.g., opioids), infection, blood poisoning, kidney disease, and anxiety all indicate the likely occurrence of nausea and vomiting [143].

Anorexia-cachexia syndrome occurs in patients with advanced cancer. As a response to the stress of the disease and/or treatment, the body's immune system triggers the development of increased metabolism, decreased intake, and wasting. Anxiety and depression may also worsen the problem in some patients. Treatment depends upon the type of nausea and vomiting (e.g., acute, delayed, anticipatory, chronic) and is more likely to be effective when the symptoms are recognized and treated early [144].

Patients may have gluconeogenesis to meet the demands for nutrients by the cancer cells. There may also be vitamin deficiencies and fluid and electrolyte imbalances caused by decreased intake. A nutritional assessment from a dietitian is recommended for most patients. The measurements and calculations made by a dietitian may be used to develop a plan of care to improve the patient's nutritional status. Being well-nourished has been linked to a better prognosis [144].

Simple counseling may be very helpful. Dietitians can often suggest ways to increase the caloric content of simple foods without requiring the patient to eat a great deal more food. Adding dry milk powder to milk, ice cream, or puddings, for example, can substantially increase calorie intake.

For patients experiencing nausea, soda crackers and ginger ale may help settle their stomachs. For some patients, simply eliminating spicy foods or foods with strong odors may make a tremendous difference. Encouraging the family to eat with the patient and making it a social event can be helpful. Most antiemetics have not shown benefit for the treatment of acute nausea and vomiting once it has developed, but their use during chemotherapy may have a dramatic effect in decreasing subsequent episodes of nausea and vomiting [143].

Antiemetics commonly given alone or in combination include prochlorperazine, droperidol/haloperidol, aprepitant, netupitant, rolapitant, and lorazepam. Other agents include metoclopramide (an antiemetic and motility agent); ondansetron, granisetron, dolasetron, and palonosetron (antiemetics and serotonin receptor antagonists); dexamethasone and methylprednisolone (synthetic steroids); dronabinol and nabilone (synthetic forms of tetrahydrocannabinol [THC]); midazolam, lorazepam, and alprazolam (benzodiazepines used to treat anxiety); and olanzapine (an antipsychotic) [143].

For those who do not have relief, enteral nutrition may be required. Whether using a nasogastric tube for feeding or total parenteral nutrition via an intravenous line, the patient may be given the nutrients required to decrease wasting and maintain a strong immune system [144]. A brief overview of the care of patients receiving nutrition by nasogastric or gastrostomy tube is provided in Table 7.

One of the primary concerns voiced by patients who are given a diagnosis of cancer is that they will be in severe pain. Some patients are so certain their diagnosis equates to suffering that they are willing to forego treatment that would prolong their life. It is vital that patients and their families be assured that pain will be relieved effectively.

It has been estimated that pain occurs in 20% to 50% of patients with cancer; 70% to 90% of these patients can experience pain relief when properly treated. Nonetheless, studies also indicate that approximately 30% to 60% of cancer patients fail to receive adequate pain relief, with more than one-third experiencing moderate-to-severe pain [145,146]. Pain usually occurs due to the location and stage of the tumor. For example, a tumor that is compressing a nerve or other organ will cause a great deal of pain. A late stage tumor produces more pain than one in the early stages. There are several different types of cancer pain. Table 8 is provided to assist in the identification of a patient's type of pain.

How a patient responds to pain is highly individualized and should be managed accordingly by considering the patient's diagnosis, stage of disease, responses to pain and treatments, and personal likes and dislikes [146]. Anxiety will affect the patient's ability to cope with pain, and measures taken to reduce anxiety are often helpful in also reducing pain. Culture and background may play a role, as some cultures view the expression of pain as a weakness, while others more openly express it. The patient's level of pain should be measured at regular intervals, such as after the start of treatment and at each new report of pain. Patient self-reporting of pain should also be considered [146].

The WHO has developed a three-step approach for the management of cancer-related pain based upon the severity of the patient's pain. Patients who experience mild-to-moderate pain (a rating of 1–3 on a scale of 1 to 10) should receive a Step 1 pain medication, such as aspirin, acetaminophen, or a nonsteroidal anti-inflammatory drug (NSAID). Patients who experience moderate pain (4–6 on scale of 1 to 10) while already taking a Step 1 medication should receive a Step 2 medication, such as tramadol or acetaminophen products containing hydrocodone, oxycodone, and codeine. Step 3 indicates severe pain (7–10 on a scale of 1 to 10) and treatment includes strong pain medication, such as opioids (e.g., morphine, hydromorphone, oxycodone, methadone, fentanyl, oxymorphone, levorphanol). This will apply to most patients with cancer-related pain. Patients should be monitored for any side effects of opioids, such as nausea, sleepiness, constipation, vomiting, and breathing problems [146].

Analgesics may be administered in many ways. Oral administration is preferred because it is noninvasive and convenient. If the patient is unable to swallow, the medications may also be given in the form of rectal suppositories or infusions, transdermal patches, subcutaneous injections, intravenous drips, patient-controlled analgesia (PCA), or intramuscular injections [146]. Due to the pain and unreliable absorption associated with intramuscular administration, it is not usually used. If one route does not prove effective, another may be tried.

It is recommended that patients take pain medication regularly, as prescribed, to maintain a constant level of the drug in the body and to prevent pain from becoming so severe that it cannot be controlled [146]. Prevention of pain is more effective than trying to eradicate it once it has a grip on the patient.

Nonpharmacologic techniques for relief of pain include cutaneous stimulation, applications of heat and cold, transcutaneous electrical nerve stimulation (TENS), relaxation techniques, distraction, humor, music, prayer, biofeedback, and hypnosis. Other, more invasive techniques, in the form of nerve blocks, alcohol injections, or acupuncture, may also be employed to control pain [146].

Even when the prognosis is not good, pain should not be overwhelming. It should be controlled or alleviated for nearly every patient, allowing them to spend quality time with loved ones.

As lung cancer progresses, there may be obstruction of the venous drainage, which in turn produces dilation of the veins of the upper chest and neck. Symptoms of superior vena cava syndrome (SVCS) are edema of the face, neck, and chest, dyspnea, headache, visual disturbances, and a depressed level of consciousness [147].

Prompt evaluation is necessary to determine if the cause of SVCS can be corrected. Chest x-rays will usually show a mediastinal mass. A CT scan is useful to obtain more exact information on the tumor's location and anatomy. MRI, contrast or nuclear venography, and ultrasound may be useful, depending on expertise of the healthcare provider. A sputum specimen should be obtained when bronchogenic carcinoma is suspected. A bronchoscopy with biopsy may allow diagnostic tissue to be removed in an attempt to establish a treatment plan [147].

Treatment of SVCS depends upon the etiology of the obstruction, the severity of the symptoms, the prognosis of the patient, and patient preferences. Radiation therapy is often used to treat SVCS because it is easily given and has minimal side effects. However, it should be withheld until the etiology of the obstruction is clear. Relief of symptoms following administration of radiation therapy is reported to be 62% to 80% in patients with SCLC and 46% in patients with NSCLC [147]. The treatment course involves a low dose of radiation, given daily for five to seven weeks [64]. Chemotherapy is effective for some patients (e.g., those with lymphoma or SCLC). Thrombolytic agents may also be used. A few patients (generally those with a benign obstruction) may require surgical resection of the tumor and bypass grafting of the vessels involved. Some patients will require no treatment [147]. The prognosis is not good for patients whose lung cancer causes SVCS; the 24-month survival rate is 9% in patients without SVCS and 3% in those with the syndrome [147].

A pneumothorax occurs when the pleura is ruptured and the lung and chest wall separate as air enters. Lung volume is reduced as the air in the pleural space compresses the lung. A primary spontaneous pneumothorax is one with no obvious underlying lung disease; a secondary spontaneous pneumothorax is one with underlying lung disease. Iatrogenic pneumothorax is traumatic but typically smaller and more easily managed. Up to 10% of patients may be asymptomatic; some may have symptoms that are mild. Symptoms of acute, sudden onset of sharp chest pain and dyspnea occur in approximately 64% to 85% of patients. An estimated 80% to 90% of primary spontaneous pneumothoraces occur in smokers [148].

When a pneumothorax is greater than 20% of the lung, insertion of a chest tube is the usual treatment [148]. The chest tube is left in place until the lung has fully re-expanded and there is no evidence of an air leak. When a patient has a chest tube connected to a water-seal chamber, fluctuations that occur in the fluid level with each respiration should be checked. The tube should be clamped off if it becomes disconnected, as the pressure differences would be disturbed in such a case [149].

Respiratory distress resulting from pneumothorax may cause increased fatigue in the patient. If all of a patient's strength is required to breathe, there will be little energy left for activity. When respiratory distress becomes significant, decisions should be made as to whether the patient desires to have intubation with ventilator support.

It is not uncommon for the patient with lung cancer to experience some degree of hemoptysis, ranging from mildly blood-tinged sputum to major hemorrhage. The cause of the bleeding can be capillary trauma, tumor sloughing, or even a pulmonary infection. Bronchitis, bronchiectasis, tuberculosis, and necrotizing pneumonia or lung abscess account for 70% to 90% of cases [36].

One objective of treatment is to protect the uninvolved lung, which may be achieved with positioning maneuvers and selective intubation and obstruction of the bronchus going to the bleeding lung. Massive hemoptysis (i.e., production of ≥600 mL of blood) is an indication for rigid bronchoscopy, which allows for better suctioning and therapeutic interventions, such as laser therapy. Embolization of a pulmonary segment is the preferred method to stop massive hemoptysis. Success rates with this method have been reported at 90% [36,150]. Bronchial adenoma or carcinoma may indicate the need for early resection. Treatment with antibiotics is important, as bronchiectatic bleeding is usually the result of infection [36]. Most patients suffering even mild hemoptysis worry that they will have a major hemorrhage, so it is important that an emergency plan is developed. This plan will help both the patient and the patient's loved ones feel more comfortable and less anxious.

Whether caring for patients in a hospital or outpatient setting, the nurse is likely to encounter questions about the use of VADs.

The inability to withdraw blood or infuse fluids may be the result of migration of the catheter, causing the tip to rest in a smaller vessel or against a vessel wall. Having the patient change position, breathe deeply, cough, or walk around to move the catheter is often effective. In some cases, the catheter is damaged between the clavicle and the first rib or within the subcutaneous tunnel. A gentle flush of 10–20 cc of normal saline solution may solve the problem [152]. Other problems may be a kink or knot in the catheter or clot formation within the tubing. In these cases, a physician should be notified to consider x-ray and/or removal of the VAD [151].

Arm or neck edema may indicate extensive thrombosis or SVCS. These conditions require the prompt attention of a physician [151].

Local infection may occur when poor technique is used for site care or when the needle is not well secured. This is evidenced by a reddened, edematous, and/or painful insertion site. If drainage is present, a culture should be taken. Do not use occlusive dressings until the infection resolves. If necessary, remove sutures. If not resolved, the VAD may require removal [151,152]. A physician should be alerted of any infections.

Systemic infection is usually caused by a local infection that was not treated, by contaminated solutions or hubs, or by a cause unrelated to the VAD. Symptoms include fever, chills, diaphoresis, malaise, hypotension, oliguria, and change in mental status. A physician should be notified immediately of signs or symptoms of systemic infection [152].

Learning about and recognizing the stages of grief may be helpful in developing a deeper understanding of death and dying. Dr. Elizabeth Kübler-Ross has identified the five stages of grief as [155]:

These emotions do not necessarily occur in any particular order, and a patient may move back and forth between stages within a relatively short period of time [156].

Denial is, however, often the first response. It may be the initial reason there was a delay in seeking medical treatment or assessment. Patients may have known that their cough was very different from anything they had ever before experienced; they also know their smoking history and may be acquainted with others who have been diagnosed with cancer. Delays in treatment regardless of this knowledge may, in many cases, be attributed to denial. Patients who are deeply in denial may have a difficult time making wise decisions about health care. Ideally, patients will work through this stage quickly, so that there is time to accomplish goals before dying.

Anger is another step in the grief process. In this stage, patients still have plans for the future, family to care for, and work to accomplish. They may be angry that their lives are being disrupted and that the cancer is demanding so much time.

Bargaining is a toned-down response to anger. It is generally characterized by the patient promising to make a change in exchange for some improvement in their condition. Patients may want the disease to go away completely, or they may just want more time; in any case, it is all considered bargaining. Often, bargaining is linked to religion or to a relationship with religious figures.

Depression is an understandable and normal response. It should not be treated as something for which the patient should be ashamed, nor should the patient be told to cheer up. Feeling depressed is appropriate for the patient who has suffered losses and is coping with a terminal diagnosis. Patients in this state are sad that this is their fate and wish it could be different.

Acceptance comes when the previous four stages have been worked through and the patient accepts and calmly acknowledges the reality of the situation. Patients in this stage do not seem fearful of death but may instead see it as a welcome rest from a long and tiring struggle [156].

Achieving acceptance does not necessarily mean that the patient will cease to feel anger or depression. Also, more than one stage can be felt at any one time. The patient's loved ones, particularly caregivers, will also experience disbelief, anger, bargaining, and depression. Acceptance is generally not as easily achieved by those who will be left as it is for those who are dying.

As a result of medical technologic advancements, patients are living longer and in different circumstances than ever before. The introduction of life-sustaining treatments, such as parenteral feeding and hydration and mechanical ventilation, has also produced vigorous debate regarding care decisions. Several landmark court cases regarding these issues have prompted the creation of laws to protect the right of patients (or the designated proxy) to make their own medical decisions.

In 1990, the U.S. Congress passed the Patient Self-Determination Act (PSDA), which requires hospitals and other healthcare facilities to recognize the living will and durable power of attorney for health care to provide patients with written information about their rights [157,158]. Facilities cannot require a patient to sign an advance directive, but they must make the information available. Because physicians will direct the care the patient receives, they should participate in the discussion, answer questions the patient may have, and when the forms are signed, be given a copy of the advance directive. An advance directive may help to eliminate family dissension about what steps should be taken during the course of a patient's care. This can be a great relief to many patients.

Advance directives vary based on state law and individual preferences within the states' legal requirements. Advance directives include the durable power of attorney for health care (also called the health care power of attorney or health care proxy), physician directives (living wills), and do not resuscitate (DNR) or "no code" orders [157]. All healthcare professionals should understand these documents in order to successfully discuss the options they offer patients.

The durable power of attorney for health care allows the patient to authorize another individual, called a proxy or agent, to make healthcare decisions if the patient becomes incapacitated. Some states restrict the ability of the agent to carry out some requests (e.g., to stop feeding). The durable power of attorney must specifically list the designated person(s) by name. It must also be in writing, signed by the patient choosing the proxy, and witnessed. A backup proxy is often named in case the first choice becomes unable or unwilling to act on the patient's behalf [157,158].

Physician directives (also referred to as living wills) are designed to control future healthcare decisions at a time when the patient is unable to make them. They are guides for physicians that are meant to ensure that the care the patient desires is provided. Physician directives may specify that all measures be taken to save the patient's life, or they may allow the physician to stop trying to prolong life in a terminally ill patient. If a patient has hope of recovery, the living will generally does not apply. There are endless variations on this, but the more specific a directive is, the easier it is to follow. Most states require that the document be witnessed and notarized by someone other than heirs, the attending physician, or employees of the healthcare facility. Where no written advance directive exists, some states recognize oral advance directives; others require a written and notarized form [157].

Physician/provider orders for life-sustaining treatment (POLST) is a set of portable medical orders that communicate patient wishes in emergency situations to healthcare facilities and providers, including emergency medical services [159,160]. Although the POLST form helps describe a patient's wishes for health care, it is not an advanced directive. Emergency medical service personnel cannot use an advance directive, but they can use a POLST form. The POLST must be signed by a qualified member of the patient's healthcare team. The first POLST form was developed by a task force in Oregon in 1995. Since then, 40 states and the District of Columbia have codified their POLST programs into law or an official form [159].

DNR orders are written by physicians only, in accordance with the wishes of the patient and the family, and added to the patient's medical record [157]. As required by the Joint Commission, all healthcare facilities must have a DNR policy [161]. Laws vary from state to state as to when physicians may write these orders, but they are not advance directives in the strict definition. They are merely outward signs that the advance directive is being followed. Because a DNR order is valid only while the patient is hospitalized, some states have advance directives called "do not attempt resuscitation (DNAR)" orders that may be used outside the hospital, such as when emergency medical teams respond to 911 calls. This order allows the patient to refuse resuscitation in advance, even when emergency personnel have been summoned. This order must be signed by the patient and the patient's physician [157].

It is important for the patient to understand that these directives do not eliminate the provision of normal care. For example, a request for no cardiopulmonary resuscitation (CPR) means only that no chest compressions or mechanical breathing would take place should the patient have a cardiac arrest. It does not mean that the patient will be denied antibiotics for potential infections or refused hospitalization when necessary [157].

The American College of Chest Physicians recommends that all physicians caring for patients with advanced lung cancer should initiate conversations about the goals of care, the pros and cons of life-sustaining treatment, and end-of-life care options.

(https://journal.chestnet.org/article/S0012-3692(13)X6006-4 Last Accessed: August 27, 2024)

Strength of Recommendation: 1B (Strong recommendation based on moderate-quality evidence that the benefits outweigh the risks/burdens)

Many patients with lung cancer are cared for at home with the assistance of a home health agency. There may be nurses coming in on an intermittent basis to check the patient's condition, monitor total parenteral nutrition (TPN), change dressings, or any number of other interventions. There will come a time, however, when hospice should be considered.

The term hospice is used in this country to refer to a program, not necessarily an institution. Hospice is a type of care provided not only to the terminally ill patient, but to the patient's family as well. Hospice strives to meet physical, psychologic, and spiritual needs through an interdisciplinary team of physicians, nurses, social workers, therapists, and volunteers. The goal of hospice is to allow the patient to die comfortably, surrounded by family, with the support that is needed to provide the best possible quality of life and death. Hospice nurses are adept in aggressive pain management and also in communicating effectively with family [154,162].

It is not uncommon for a family caregiver to be afraid of not knowing what to do when death finally does occur. Hospice is able to educate the caregiver to relieve that anxiety, but will also have someone there to physically help with care when the time comes. The hospice team is attuned to the needs of the family and the patient and may provide support to all involved parties. This can be very comforting to patients who may be concerned about the effect their death will have on loved ones [162].

Hospice has certain rules for participation, but they are not rigid rules and may be adapted to a patient's special needs. The entrance requirements state that the patient's physician must certify that the disease is terminal and that the patient is in the last six months of life [154,162]. The six-month time frame is simply an attempt to define the type of patient participating in the program; if a patient lives seven months, the hospice service is not cut off.

Another guideline is that there is a caregiver. This also is not an ironclad rule, but it certainly facilitates the program [162]. Under normal circumstances, a spouse, adult child, close friend, or significant other will step in to provide care for the last days.

Medicare hospice programs require the patient to switch their standard Medicare benefits for the Medicare hospice package. This provides broader coverage for the patient, including health problems unrelated to the terminal illness. It also requires that hospice care be given by a Medicare-certified hospice program [162]. Medicare coverage primarily provides for care at home but will allow hospitalization for illnesses other than the terminal illness. It also allows respite care, which is temporary relief to the caregiver.

Whether they are called clinical pathways, critical pathways, case management plans, treatment plans, or care maps, they are all similar methods for managing patient care. As a vital part of the managed care environment, clinical pathways have often been the catalyst for hospitals to move to a case management type of nursing. It is important to note that the clinical pathway may or may not be part of the medical record.

Clinical pathways are multidisciplinary, sequential guides to patient care that are created through a collaboration of healthcare professionals. Anticipated events are included in a day-by-day grid, allowing the nurse, patient, and family members to know what can be expected on any given day [163]. This serves many purposes:

Factors to consider when creating clinical pathways include [15]:

Although each of these factors may vary to meet the specific needs of the individual hospital, they all have certain common traits.

The pathway is usually posted within patients' rooms, so they and their families can follow along to see if their progress is as expected. It is motivating to a patient to see, for example, that he or she is expected to walk from the bed to the bathroom the afternoon of surgery or to successfully self-administer an insulin injection by the third day of instruction. Whatever the task, most patients make an effort to do what is expected of them.

The pathway may also be useful to the nurse case manager. For example, a patient's culture and sensitivity report comes back from the laboratory indicating that the patient is receiving the incorrect antibiotic. The report is ordinarily left on the patient's chart for the physician to review during the next rounds, but this might not occur for several hours or into the next day. However, if the nurse sees on the pathway that the patient is expected to be afebrile by the next day and homeward bound the day after, the nurse might be motivated to contact the physician for orders for a new antibiotic.

Clinical pathways are also particularly helpful to the relief nurse. It is always difficult to be the nurse called in to substitute for a nurse who has the day off, is ill, or is on vacation. The patients are new to the relief nurse, and it takes time to learn about the idiosyncrasies and needs of each one. The clinical pathway provides a way for the relief nurse to quickly determine each patient's point on the route to recovery.

Not every patient will have a clinical pathway. They are normally assigned by common diagnosis or diagnosis-related group (DRG) or by clinical unit. Most often, those patients who have been chosen for inclusion are those with high-risk and/or high-cost illness that can effectively use clinical resources for cost savings. The more generic the pathway, the more patients that may be included [163].

The pathway may be a tool for the nursing staff; however, just as important is its ability to increase security and confidence for patients who are part of a case management program [163].

Evaluating the efficacy of WTW or BTW case management programs depends on how well the chosen outcomes have been met. If outcomes were thoughtfully considered, they should be indicative of the success of case management. For example, if one of the chosen standards of care is that the patient admitted for chemotherapy is educated about exposure to hazardous waste, and procedures are used to reduce that possibility, then a desired daily outcome may be, "No spills of chemotherapeutic agents." Whether this goal was met will be recorded in the medical record and/or in the clinical pathway. If the desired outcome is not met, it is identified as a variance [163].

Patients are not removed from the case management program or even from the use of clinical pathways if there is a variance. Ideally, the pathway will tend to be more generic than specific and will be applied to a homogeneous group of patients. Within that group of patients, however, there may be a wide range of differences. For example, chemotherapy patients may be considered a homogeneous group, but within that group are men, women, young adults, the elderly, those on their first course of chemotherapy, and those on their sixth course. These patients may live in their own home with several loving relatives, or they may live in a nursing home and have no one. It is natural and expected that there will be variances among them.

Variances should be analyzed to determine why the outcomes were not met [163]. Was it a patient problem (e.g., refusal to cooperate)? Was it a clinical problem (e.g., the patient's condition changed)? Was it a staff problem (e.g., failure to give the chemotherapeutic agent as scheduled)? Or was it a facility problem (e.g., the equipment failed)? If, when checking variances, something stands out as preventable, then that is an opportunity to change either the practice or the pathway.

After all the data has been collected, it can be reviewed while considering the various components of the quality improvement program [163]. For example, if it is found that 61% of all patients developed a nosocomial infection, then practice patterns should be reviewed and evaluated.

Good quality health care is less costly in the long run. It only makes sense to deliver the best care possible while also taking into consideration the cost benefits. Reviews and evaluations of variances are easy ways to assess costs associated with errors, misuse of staff, delays, or dissatisfaction [163].

Preoperative teaching can be done prior to admission. In the past, patients were admitted the evening before surgery, partially in order to carry out teaching before the patient went to surgery. Now, with patients being admitted the morning of surgery, very little time is available for teaching, let alone for allowing patients to absorb and understand what to expect. A better time for patient teaching is at the preoperative visit, when the electrocardiogram (EKG), lab work, and other testing are done. Nurses can use this visit as an opportunity to meet with the patient, begin preoperative teaching, and obtain useful history, which can assist in an early start to discharge planning. It has been found that preoperative patient teaching is very useful and comforting for the patient. This establishes a connection that will continue through future admissions as well.

There is a great deal of fear experienced by the patient and the patient's family when lung cancer is diagnosed. On the first admission, when pathology and staging have not been completed, there is anxiety associated with not knowing what the prognosis may be. There is also an understanding that this may be the beginning of the end. The rapport that is built between the nurse and the patient/family can greatly reduce anxiety and facilitate teaching goals.

Prior to surgery, patients should be able to explain the reasons for their surgery and the benefits of the particular type chosen. They should also be able to articulate what is involved in the type of surgery, whether it is a lobectomy, pneumonectomy, or wedge resection. This method of testing gives nurses confidence in patient knowledge. When patients explain what they believe is happening, misconceptions become evident and may be corrected.

Surgery that involves the lung can easily result in postoperative respiratory distress. It will be painful to breathe, cough, and move; yet, all of these activities will be vital to the patient's well-being. A thorough discussion and practice sessions prior to surgery will help the postoperative transition go more smoothly.

Ideally, patients will have stopped smoking preoperatively. This will enable them to have maximum ventilatory capability at the time of surgery. Patients should know that they will be expected not to smoke after the procedure is completed. Additionally, they should be trained in how to turn, cough, and breathe deeply, so these maneuvers will seem more natural after the procedure.

Positioning for lung surgery involves moving the arm on the affected side out of the surgical field. This usually results in a very painful shoulder and/or arm. It is helpful to warn the patient about this and stress the importance of exercising the affected arm. A review of exercise techniques may be done preoperatively and should include information about the leg exercises that will be required to prevent thrombophlebitis.

Patients will most likely have thromboembolic deterrent or pneumatic inflating stockings on their legs after surgery to discourage clot formation. These stockings may be fitted prior to surgery, which will then present an opportunity to teach the patient about their purpose and let the patient know that they will be changed during each shift.

Patients are often concerned about the amount of pain that they will encounter postoperatively. Some are fearful of it, while others present a stoic demeanor. It is beneficial for patients to know that there will be pain, but that measures will be taken to alleviate it as much as possible. Patients should be told what type of analgesia will be ordered and that it should be taken or requested before their pain becomes so severe that it depresses their ability to fully expand their lungs during respiration. If a patient will be receiving PCA, the patient should be taught how to use it and reassured that it will eliminate any delay in relief.

A chest tube is not pleasant but is more tolerable if the patient is prepared to have one. Teaching should include a simple explanation of its necessity and how it will be handled when moving about in bed and ambulating in the room. Some patients are fearful that the tube may fall out or be pulled into their chest, causing damage. Nurses should provide reassurance that neither will happen, and exercise should not be restricted because of the tube. Patients should also be encouraged to seek assistance to correctly position or move the tube.

Specific routine postoperative procedures should also be discussed with the patient. Patients will feel better if they know where their family will be during and immediately after surgery. It is also helpful for patients to know that they will go to the recovery room and, in most cases, continue on to the intensive care unit (ICU). If a patient is unaware that he or she is expected to be in ICU, the placement may cause apprehension regarding the severity of the condition. Understanding vital sign monitoring, dietary restrictions, and other routine care will also make for a more confident and relaxed patient. These procedures should be outlined on the clinical pathway, if possible.

There should be a reinforcement of the applicable teaching goals in the first few hours after surgery. Patients should be reminded about the necessity of coughing, breathing deeply, exercising in bed, ambulating, and being properly medicated for pain. The transitional time will go more quickly and smoothly if the patient is well prepared for this period.

When a patient is thoroughly awake and has the ability to communicate and concentrate, more extensive training can take place. This usually begins the first postoperative day and may be expanded and reinforced as the patient progresses. Teaching should be repeated often in order for the patient to absorb all of the information completely during such a stressful time.

Dressings and wound care are of primary importance to most patients. They may be concerned about the amount of drainage on the dressing, especially if blood is present, or about the risk of infection. Reassurance during wound care is helpful to the patient's overall well-being. If, however, there is a wound infection or complication, there should be reassurances given that home health care can address these issues at the time of discharge, if necessary.

Some patients suffer emotionally from the sight of the wound and the fear that the scar, as well as the diagnosis, will have an adverse effect on relationships and sexuality. Patients can be reassured, allowed to explore feelings, and, if necessary, referred to a social worker or staff psychologist for counseling.

Prior to discharge, it is important to reinforce several teaching points. Primarily, patients should know which medications have been prescribed for them at the time of discharge, their purpose, the correct dosage, administration schedule, and side effects. Signs of possible complications, emergency telephone numbers, and other safety information should also be provided.

Chemotherapy creates additional patient education needs. The chemotherapeutic agents that will be used should be discussed, including details regarding their mechanisms of action and instructions on how to use verbal information and written instructions. Booklets or pamphlets that might be available should be reviewed and distributed.

Patients and families should be taught about the side effects that can be anticipated with chemotherapy. They should understand that there are immediate side effects as well as delayed symptoms, which may arise one to two weeks after treatment. They should also be taught which effects can be expected as normal and which should be reported to the physician.

Emotional support is also extremely important during this time. Patients and families will have questions, fears, and misunderstandings that should be discussed. They should be encouraged to express those feelings and articulate the worries, anger, or frustrations they feel.

All of this information will obviously not be given to the patient in the first chemotherapy session. The education process takes time. Some patients are eager to learn all they can about their disease and treatment, while others must be encouraged. If a patient is not receptive to learning, it makes the process more difficult; however, teaching can still progress if clues are taken and acted upon. For example, when the patient complains of nausea, this is the cue to discuss prevention and treatment of nausea.

Patients involved in clinical trials will also require teaching to assist them through the process. They should know about the drug, its action, method and time of administration, side effects, and other information that would be available with the use of any drug. Due to the nature of clinical trials, there will likely be a diary to be kept or other special instructions from the group that is conducting the trial.

Radiation therapy treatments provide similar opportunities for teaching. Again, the first concept that patients will learn is when and where their appointments are scheduled. There may already have been a preliminary session in which the positioning and markings are accomplished. Patients should be alerted that subsequent sessions will be shorter. This will help with planning and transportation arrangements.

Patients who have been taught well will understand the process of radiation therapy, be aware of potential side effects, and know how to combat the symptoms of those side effects. These patients will know to notify a healthcare professional when there are symptoms that should be addressed in order to prevent those symptoms from escalating into a more serious problem. Furthermore, they will recognize that the amount and duration of radiation will affect their response. For example, skin changes are expected, as are fatigue and myelosuppression. Radiation to the chest can lead to local problems such as esophagitis, dysphagia, or radiation pneumonitis [117]. The combination of both radiation and chemotherapy treatments will undoubtedly lead to symptoms that must be controlled.

As soon as the BTW case manager has been notified of the diagnosis, he or she will contact the patient and the WTW case manager to begin the teaching program. This contact should include an explanation of the program to the patient and/or family, stressing that the goals are to improve the quality of care, reduce hospitalizations, and smooth the logistics of care. Some individuals will be anxious to participate; others will not want the intervention of a stranger into their lives. Depending on the specifics of the insurance carrier, those patients who choose not to participate may still be case managed, but indirectly and less extensively. The case manager will still work to approve care providers, but will not be conducting the interviews and teaching required with a fully participating case management patient.

BTW case managers often have an initial admission questionnaire to assist in providing a baseline as to the disease stage and progression, patient understanding, and potential knowledge deficit and opportunities for teaching. The case manager will alert the patient that there will be future contact and provide a telephone number for any questions.