Lung cancer scan

Lung Cancer Experts Answer Your Top Questions

City of Hope thoracic specialists, including oncologists, surgeons and radiologists, address common concerns and debunk some misconceptions

Nearly 240,000 Americans are diagnosed with lung cancer each year. Lung cancer remains the most common cancer and the No. 1 cancer killer in the U.S., claiming some 125,000 lives annually — three times more than colorectal cancer, the second leading cause of cancer death. Each year, more people die of lung cancer than of colon, breast and prostate cancers combined, according to the American Cancer Society. But if it’s caught early, survival rates can top 90%.

A few stubborn myths about the disease persist, especially the notion that lung cancer is primarily a smoker’s disease and that late-stage lung cancer always carries a grim prognosis. We spoke with City of Hope® lung cancer experts who shared some helpful things to know.

What are the symptoms of lung cancer?   

At first, there may be none. “Lung cancer is one of the silent diseases,” explained Ravi Salgia, M.D., Ph.D., a lung cancer specialist and the Arthur & Rosalie Kaplan Chair in Medical Oncology at City of Hope. “The majority of cases go undetected until the later stages.” When symptoms do appear, they can include coughing up blood — a major warning sign — and also shortness of breath; weight loss; chest, shoulder or rib pain; and loss of energy.

How can you tell the difference between lung cancer and other conditions like asthma or pneumonia? 

Generally, if symptoms don’t get better over time, or if they get worse, that’s a red flag. At that point, it’s important to see a physician for a definitive diagnosis.

How is lung cancer diagnosed? 

Imaging plays a key role. A chest X-ray may detect some abnormalities, but more detail can be picked up with a computed tomography (CT) scan, positron emission tomography scan or magnetic resonance imaging. If a mass is detected and it’s larger than 1 centimeter in diameter, a biopsy — taking a tissue sample — would be the next step.

Is there more than one kind of lung cancer?  

The two main forms of lung cancer are named for the way they appear under the microscope: nonsmall cell lung cancer (NSCLC) is the most common variety, making up 80% of cases. NSCLC can be further divided into three groups: adenocarcinoma, squamous cell carcinoma and large cell carcinoma. The less common small cell lung cancer tends to be more aggressive and more closely associated with smoking.

I’ve never smoked. Am I safe? 

“I hope,” said thoracic surgeon Loretta Erhunmwunsee, M.D., associate professor in the Division of Thoracic Surgery, Department of Surgery, “that in my lifetime we move away from calling lung cancer just a smoker’s disease. It’s a people-with-lungs disease.”

Doctor Loretta Erhunmwunsee
Loretta Erhunmwunsee, M.D.

While it is true that about four out of five cases of lung cancer are caused by smoking, 80% of regular smokers don’t get lung cancer, and many people who’ve never picked up a cigarette do develop the disease. Environmental factors, such as air pollution and exposure to radon, asbestos or secondhand smoke, and other factors like genetics, can play a role.

A thoracic surgeon, Dr. Erhunmwunsee conducts research on the impact of environmental, socioeconomic and racial factors on lung cancer risk. Her research has shown that low socioeconomic status is an independent prognostic factor for poor survival in patients with nonsmall cell lung and esophageal cancer. She also seeks to understand why ethnic minorities and poor/underserved populations have worse outcomes and worse quality of life in early-stage lung cancer.

Does lung cancer spread? 

“Lung cancer can go to just about every organ,” said Dr. Salgia. Cancer cells may travel through the bloodstream or lymphatic system and invade the brain, bones, liver, mediastinum (a membrane between the lungs), lymph nodes and adrenal glands.

Is there a good screening test for lung cancer?

The gold standard for screening is the low-dose CT scan (LDCT). It uses only about a fifth of the radiation in a regular CT scan and it can pick up signs of cancer in its early stages. 

Unfortunately, getting an LDCT scan can be complicated. It is not recommended — nor will insurance cover it — for the general population, the way mammograms are for women or colonoscopies for people over 45. For now, LDCT scans are reserved for people at high risk — smokers or former smokers over 50. Sadly, even among that population, screening rates are quite low, hovering at only about 6% nationally. Fewer than 2% of those eligible in California ever get scanned.

Doctor Dan Raz
Dan Raz, M.D., M.A.S.

“For people who’ve smoked, this screening can save lives,” said thoracic surgeon Dan J. Raz, M.D ., M.A.S., associate professor in the Division of Thoracic Surgery, Department of Surgery, and co-director of City of Hope’s Lung Cancer and Thoracic Oncology Program.

“It is so important to know about lung cancer screening,” agreed Dr. Erhunmwunsee. “It saves more lives than mammography or colonoscopy.”

Dr. Raz and DELFI Diagnostics Inc. are trying out a new kind of screening for lung cancer that uses a simple blood test, which is much more convenient and less costly than an LDCT. The test looks for cancer biomarkers. If found, the patient is referred for a CT scan. The study is focusing on high-risk populations, including longtime smokers and low-income socio-economic populations with barriers to health care. Such screening has the potential to save upward of 10,000 lives each year.

Can lung cancer be cured? 

Here’s the good news. Over the last couple of decades, researchers have made enormous strides in treating — and curing — lung cancer, even in its late stages. Across every form of treatment — surgery, radiation, chemotherapy and now targeted therapies and immunotherapy — the options keep getting better and the cure rate keeps going up.

Kristin Higgins
Kristin Higgins, M.D.

“We cure lung cancer all the time, much more than we used to,” said City of Hope Atlanta chief clinical officer and radiation oncologist Kristin Higgins, M.D., who focuses on treating lung cancer. She says her tools — like the newest stereotactic body radiotherapy — have improved considerably, becoming more precise and doing less damage to healthy tissue. “This is not your grandfather’s radiation.”

Surgery — still the most effective choice for early-stage cancer — has made equally impressive leaps forward. Where once it was common to perform a lobectomy — removing an entire lobe of the lung — when cancer is found, now surgeons can opt for a segmentectomy, a much smaller procedure, and achieve equal or better success.

Helping to make surgery more effective is the dramatic progress in drug therapy that can shrink or even eliminate many tumors, enabling once “inoperable” cancers to be removed.

Ravi Salgia lab coat
Ravi Salgia, M.D., Ph.D.

But the newest drug treatments are also keeping patients alive longer when cancer has spread to multiple organs and surgery can no longer cure it.

This is especially true with so-called targeted therapies that act on specific genetic mutations found in lung cancer. At City of Hope, every tumor is analyzed for genetic anomalies, with a special emphasis on mutations in the EGFR, ALK and KRAS genes. A new generation of immunotherapy drugs targets those mutations, eliminating cancer without harming surrounding tissue and with far fewer side effects than standard chemotherapy.

Several such drugs, including pembrolizumab (Keytruda), nivolumab (Opdivo), durvalumab (Imfinzi) and atezolizumab (Tecentriq), have been approved by the Food and Drug Administration in recent years.

Researchers are also combining targeted or immunotherapy with conventional chemotherapy. One such example is the antibody-drug conjugate, which combines a targeted therapy with chemotherapy. The antibody finds and attaches itself to the cancer cell so that chemotherapy can home in and kill it, destroying cancer from the inside out.

Bottom line, lung cancer, even at Stage 4, is no longer a death sentence, and cures are more achievable than ever before.

“I love talking about cures,” said Dr. Salgia. “Even in the late stages, we’re seeing cures or long-term control for years and years and years.

“Yes, it’s a challenging illness, but at City of Hope we keep saying, ‘Let’s find a way to make treatments even better.’

“That’s why I’m here.”