Lung Cancer: Diagnosis, Treatment Principles, and Screening

 

Am Fam Physician. 2022 May ;105(5):487-494.

  Patient information: See related handout on lung cancer, written by the authors of this article.

Published online April 1, 2022.

Author disclosure: No relevant financial relationships.

Lung cancer is the second most common cancer in men and women in the United States; however, it remains the leading cause of cancer-related death in the United States and worldwide. The most common but nonspecific symptom of lung cancer is cough. Associated symptoms, including hemoptysis or shortness of breath, or systemic symptoms, including anorexia or weight loss, greatly increase the likelihood of having lung cancer. Referral to a multidisciplinary lung cancer team, imaging, and confirmation through sputum cytology, thoracentesis, fine-needle aspiration, or mediastinoscopy are recommended. If lung cancer is confirmed, treatment options vary based on staging, histology, immunotherapy biomarker testing, and patient health status. Treatments include surgical resection, immunotherapy, chemotherapy, and/or radiotherapy. Family physicians should focus on primary prevention of lung cancer by encouraging tobacco cessation and early recognition by screening at-risk individuals and following guidelines for pulmonary nodules. As of 2021, the U.S. Preventive Services Task Force recommends annual lung cancer screening using low-dose computed tomography starting at 50 years of age in patients with a 20 pack-year history.

Lung cancer remains the leading cause of cancer-related death in the United States and worldwide; in the United States, it is the second most common cancer among men and women.1,2 The majority of lung cancers are divided into two histologic types: non–small cell lung cancer (NSCLC; 84%) and small cell lung cancer (SCLC; 13%), which helps guide treatment.3 Smoking is closely linked to 80% to 90% of lung cancer deaths, whereas radon exposure is a leading cause of nonsmoking-related lung cancer.4 Several guidelines address the management of lung cancer, with the goal of improving patient outcomes.5 In the United Kingdom, the National Institute for Health and Care Excellence has developed clinical pathways that were last updated in 2019, whereas in the United States, the most recent comprehensive lung cancer guideline from the American College of Chest Physicians was last updated in 2013, with more recent treatment recommendations from the National Comprehensive Cancer Network.2,68

 Enlarge     Print

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

The initial evaluation for lung cancer begins with laboratory testing, including a complete blood count, serum chemistries, calcium levels, liver function tests, and chest radiography; CT of the chest with intravenous contrast media should be performed when there is a high level of suspicion, even if radiographic results are normal.2,9,10,1315

C

Practice guidelines, expert opinion, disease-oriented studies

Adults 50 to 80 years of age who have a 20 pack-year smoking history and currently smoke or have quit smoking within the past 15 years should undergo annual low-dose CT screening.36,40,44

B

USPSTF and AAFP guidelines and limited evidence from one large, randomized controlled trial showing moderate benefit

Patients with lung cancer should be offered smoking cessation interventions.45

B

Cochrane review that shows reduction in morbidity and mortality; no randomized controlled trials to identify specific smoking cessation interventions are recommended

Patients with lung cancer can improve symptoms with exercise training and nurse counseling.46,47

B

Cochrane reviews, with studies limited by heterogeneity, small sample sizes, and high risk of bias


AAFP = American Academy of Family Physicians; CT = computed tomography; USPSTF = U.S. Preventive Services Task Force.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

The initial evaluation for lung cancer begins with laboratory testing, including a complete blood count, serum chemistries, calcium levels, liver function tests, and chest radiography; CT of the chest with intravenous contrast media should be performed when there is a high level of suspicion, even if radiographic results are normal.2,9,10,1315

C

Practice guidelines, expert opinion, disease-oriented studies

Adults 50 to 80 years of age who have a 20 pack-year smoking history and currently smoke or have quit smoking within the past 15 years should undergo annual low-dose CT screening.36,40,44

B

USPSTF and AAFP guidelines and limited evidence from one large, randomized controlled trial showing moderate benefit

Patients with lung cancer should be offered smoking cessation interventions.45

B

Cochrane review that shows reduction in morbidity and mortality; no randomized controlled trials to identify specific smoking cessation

The Authors

show all author info

JEFFREY KIM, MD, FAAFP, is director of Family Medicine Inpatient Service, the thread director of telehealth, and an assistant professor in the Department of Family Medicine at Loma Linda (Calif.) University School of Medicine....

HOBART LEE, MD, is director of the Family Medicine Residency Program and an associate professor in the Department of Family Medicine at Loma Linda University School of Medicine.

BRIAN W. HUANG, MD, is co-chief resident in the Department of Family Medicine at Loma Linda University Health Education Consortium.

Address correspondence to Jeffrey Kim, MD, FAAFP, Loma Linda University, 1200 California St., Ste. 240, Redlands, CA 92374 (email: jlkim@llu.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

References

show all references

1. Centers for Disease Control and Prevention. United States cancer statistics: data visualizations; June 2021. Accessed January 28, 2022. www.cdc.gov/cancer/dataviz...

2. Maconachie R, Mercer T, Navani N, et al.; Guideline Committee. Lung cancer: diagnosis and management: summary of updated NICE guidance [published correction appears in BMJ. 2019;365:I1514]. BMJ. 2019;364:l1049.

3. American Cancer Society. Cancer facts & figures; 2021. Accessed October 13, 2021. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2021/cancer-facts-and-figures-2021.pdf

4. Centers for Disease Control and Prevention. What are the risk factors for lung cancer? Accessed October 2021. https://www.cdc.gov/cancer/lung/basic_info/risk_factors.htm

5. Wilshire CL, Rayburn JR, Chang SC, et al. Not following the rules in guideline care for lung cancer diagnosis and staging has negative impact. Ann Thorac Surg. 2020;110(5):1730–1738.

6. Detterbeck FC, Lewis SZ, Diekemper R, et al. Executive summary: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 suppl):7S–37S.

7. National Comprehensive Cancer Network. Non-small cell lung cancer (version 04.2021). Accessed May 7, 2021. https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf

8. National Comprehensive Cancer Network. Small cell lung cancer (version 03.2021). Accessed May 5, 2021. https://www.nccn.org/professionals/physician_gls/pdf/sclc.pdf

9. Ost DE, Yeung S-CJ, Tanoue LT, et al. Clinical and organizational factors in the initial evaluation of patients with lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 suppl):e121S–e141S.

10. Alberg AJ, Brock MV, Ford JG, et al. Epidemiology of lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 suppl):e1S–e29S.

11. Hamilton W, Peters TJ, Round A, et al. What are the clinical features of lung cancer before the diagnosis is made? A population based case-control study. Thorax. 2005;60(12):1059–1065.

12. Latimer KM, Mott TF. Lung cancer: diagnosis, treatment principles, and screening. Am Fam Physician. 2015;91(4):250–256. Accessed December 17, 2021. https://www.aafp.org/afp/2015/0215/p250.html

13. Foley RW, Nassour V, Oliver HC, et al. Chest x-ray in suspected lung cancer is harmful. Eur Radiol. 2021;31(8):6269–6274.

14. Dwyer-Hemmings L, Fairhead C. The diagnostic performance of chest radiographs for lung malignancy in symptomatic primary-care populations: a systematic review and meta-analysis. BJR Open. 2021;3(1):20210005.

15. National Institute for Health and Care Excellence. Lung cancer: diagnosis and management. NICE guideline [NG122]; March 28, 2019. Accessed December 22, 2021. https://www.nice.org.uk/guidance/ng122/chapter/Recommendations

16. MacMahon H, Naidich DP, Goo JM, et al. Guidelines for management of incidental pulmonary nodules detected on CT images: from the Fleischner Society 2017. Radiology. 2017;284(1):228–243.

17. Gould MK, Donington J, Lynch WR, et al. Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 suppl):e93S–e120S.

18. Lee HJ, Mazzone P, Feller-Kopman D, et al.; Percepta Registry Investigators. Impact of the Percepta genomic classifier on clinical management decisions in a multicenter prospective study. Chest. 2021;159(1):401–412.

19. Massion PP, Antic S, Ather S, et al. Assessing the accuracy of a deep learning method to risk stratify indeterminate pulmonary nodules. Am J Respir Crit Care Med. 2020;202(2):241–249.

20. American College of Radiology. Lung-RADS version 1.1; 2019. Accessed May 18, 2021. https://www.acr.org/-/media/ACR/Files/RADS/Lung-RADS/LungRADSAssessmentCategoriesv1-1.pdf

21. Rivera MP, Mehta AC, Wahidi MM. Establishing the diagnosis of lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 suppl):e142S–e165S.

22. Detterbeck FC, Boffa DJ, Kim AW, et al. The eighth edition lung cancer stage classification. Chest. 2017;151(1):193–203.

23. Goldstraw P, Chansky K, Crowley J, et al.; International Association for the Study of Lung Cancer Staging and Prognostic Factors Committee, Advisory Boards, and Participating Institutions. The IASLC Lung Cancer Staging Project: proposals for revision of the TNM stage groupings in the forthcoming (eighth) edition of the TNM classification for lung cancer. J Thorac Oncol. 2016;11(1):39–51.

24. Silvestri GA, Gonzalez AV, Jantz MA, et al. Methods for staging non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 suppl):e211S–e250S.

25. Howington JA, Blum MG, Chang AC, et al. Treatment of stage I and II non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 suppl):e278S–e313S.

26. Antonia SJ, Villegas A, Daniel D, et al.; PACIFIC Investigators. Overall survival with durvalumab after chemoradiotherapy in stage III NSCLC. N Engl J Med. 2018;379(24):2342–2350.

27. Nakamura H. Systematic review of published studies on safety and efficacy of thoracoscopic and robot-assisted lobectomy for lung cancer. Ann Thorac Cardiovasc Surg. 2014;20(2):93–98.

28. Tsao MN, Xu W, Wong RKS, et al. Whole brain radiotherapy for the treatment of newly diagnosed multiple brain metastases. Cochrane Database Syst Rev. 2018;(1):CD003869.

29. Planchard D, Popat S, Kerr K, et al.; ESMO Guidelines Committee. Metastatic non-small cell lung cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up [published correction appears in Ann Oncol. 2019; 30(5): 863–870]. Ann Oncol. 2018;29(suppl 4):iv192–iv237.

30. Gandhi L, Rodríguez-Abreu D, Gadgeel S, et al.; KEYNOTE-189 Investigators. Pembrolizumab plus chemotherapy in metastatic non-small-cell lung cancer. N Engl J Med. 2018;378(22):2078–2092.

31. Howlader N, Noone AM, Krapcho M, et al.; National Cancer Institute. SEER cancer statistics review (CSR), 1975–2017; April 15, 2020. Accessed January 28, 2022. https://seer.cancer.gov/csr/1975_2017

32. Rossi A, Di Maio M, Chiodini P, et al. Carboplatin- or cisplatin-based chemotherapy in first-line treatment of small-cell lung cancer: the COCIS meta-analysis of individual patient data. J Clin Oncol. 2012;30(14):1692–1698.

33. Aupérin A, Arriagada R, Pignon JP, et al.; Prophylactic Cranial Irradiation Overview Collaborative Group. Prophylactic cranial irradiation for patients with small-cell lung cancer in complete remission. N Engl J Med. 1999;341(7):476–484.

34. Eckardt JR, von Pawel J, Pujol J-L, et al. Phase III study of oral compared with intravenous topotecan as second-line therapy in small-cell lung cancer [published correction appears in J Clin Oncol. 2007;25(22):3387]. J Clin Oncol. 2007;25(15):2086–2092.

35. Jett JR, Schild SE, Kesler KA, et al. Treatment of small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 suppl):e400S–e419S.

36. Krist AH, Davidson KW, Mangione CM, et al. Screening for lung cancer: US Preventive Services Task Force recommendation statement. JAMA. 2021;325(10):962–970.

37. Moyer VA. Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(5):330–338.

38. Aberle DR, Adams AM, Berg CD, et al.; National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395–409.

39. de Koning HJ, van der Aalst CM, de Jong PA, et al. Reduced lung-cancer mortality with volume CT screening in a randomized trial. N Engl J Med. 2020;382(6):503–513.

40. Jonas DE, Reuland DS, Reddy SM, et al. Screening for lung cancer with low-dose computed tomography: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2021;325(10):971–987.

41. Aldrich MC, Mercaldo SF, Sandler KL, et al. Evaluation of USPSTF lung cancer screening guidelines among African American adult smokers [published correction appears in JAMA Oncol. 2019;5(9):1372]. JAMA Oncol. 2019;5(9):1318–1324.

42. Pinsky PF, Kramer BS. Lung cancer risk and demographic characteristics of current 20–29 pack-year smokers: implications for screening. J Natl Cancer Inst. 2015;107(11):djv226.

43. Meza R, Jeon J, Toumazis I, et al. Evaluation of the benefits and harms of lung cancer screening with low-dose computed tomography: a collaborative modeling study for the U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality; 2021. AHRQ publication 20-05266-EF-2.

44. American Academy of Family Physicians. Clinical preventive service recommendation. Lung cancer screening, adult. Accessed April 25, 2021. https://www.aafp.org/family-physician/patient-care/clinical-recommendations/all-clinical-recommendations/lung-cancer.html

45. Zeng L, Yu X, Yu T, et al. Interventions for smoking cessation in people diagnosed with lung cancer. Cochrane Database Syst Rev. 2019;(6):CD011751.

46. Peddle-McIntyre CJ, Singh F, Thomas R, et al. Exercise training for advanced lung cancer. Cochrane Database Syst Rev. 2019;(2):CD012685.

47. Rueda J-R, Solà I, Pascual A, et al. Non-invasive interventions for improving well-being and quality of life in patients with lung cancer. Cochrane Database Syst Rev. 2011;(9):CD004282.

48. Pistelli F, Aquilini F, Falaschi F, et al.; ITALUNG Working Group. Smoking cessation in the ITALUNG lung cancer screening: what does “teachable moment” mean? Nicotine Tob Res. 2020;22(9):1484–1491.

49. Tanner NT, Kanodra NM, Gebregziabher M, et al. The association between smoking abstinence and mortality in the National Lung Screening Trial. Am J Respir Crit Care Med. 2016;193(5):534–541.

50. Goffin JR, Flanagan WM, Miller AB, et al. Biennial lung cancer screening in Canada with smoking cessation-outcomes and cost-effectiveness. Lung Cancer. 2016;101:98–103.

51. Tindle HA, Stevenson Duncan M, Greevy RA, et al. Lifetime smoking history and risk of lung cancer: results from the Framingham Heart Study [published correction appears in J Natl Cancer Inst. 2018;110(10):1153]. J Natl Cancer Inst. 2018;110(11):1201–1207.

52. Leone FT, Evers-Casey S, Toll BA, et al. Treatment of tobacco use in lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 suppl):e61S–e77S.

53. Collins LG, Haines C, Perkel R, et al. Lung cancer: diagnosis and management. Am Fam Physician. 2007;75(1):56–63. Accessed December 22, 2021. https://www.aafp.org/afp/2007/0101/p56.html

 

 

Copyright © 2022 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP


Editor's Collections


Related Content


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article