Diagnosing lung cancer

Tuesday 1 November, 2016

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On this page: General tests | Tests to find cancer in the lungs | Further tests | Staging lung cancer | Prognosis | Which health professionals will I see? | Lillian's story | Key points


Your doctors will perform a number of tests to obtain a diagnosis, and work out whether the cancer has spread beyond the lung. This information will help your health care team develop a treatment plan.

General tests

To investigate abnormal symptoms, your doctor may arrange several imaging tests.

Chest x-ray

A chest x-ray is painless and can show tumours 1 cm wide or larger. Small tumours may not show up on an x-ray or may be hidden by other organs within the chest cavity. After a chest x-ray, you may need more detailed tests.

CT scan

A CT (computerised tomography) scan uses x-ray beams to take many pictures of the inside of your body and uses a computer to compile them into one detailed, cross-sectional picture. It can detect smaller tumours than those found by chest x-rays, and provides detailed information about the tumour, the lymph nodes in the chest and other organs.

CT scans are usually done at a hospital or a radiology clinic. You may be asked to fast (not eat or drink) for several hours before the scan to make the scan pictures clearer and easier to read. Before the scan, you will be given an injection of dye into a vein in your arm. This dye is known as the contrast and it makes the pictures clearer. The dye may make you feel hot all over, and leave a bitter taste in your mouth, and you may feel a sudden urge to pass urine.

The CT scanner is a large, doughnut-shaped machine. You will lie flat on a table that moves in and out of the scanner. The scan itself takes 10–20 minutes, but you will also need to prepare and then wait for the scan. While a CT scan can be noisy, it is painless.

The dye used in a CT scan usually contains iodine. If you have had an allergic reaction to iodine or dyes during a previous scan, let the person performing the scan know in advance. You should also let them know if you are diabetic, have kidney disease or are pregnant.

PET scan

A PET (positron emission tomography) scan is a specialised imaging test, which is available at most major hospitals. It is used to stage lung cancer, usually after the diagnosis is confirmed.

Before the scan, a small amount of radioactive glucose solution will be injected into a vein, usually in your arm. This makes cancer cells show up brighter on the scan because they take up more of the glucose solution than normal cells do. You will be asked to sit quietly for 30–90 minutes while the glucose solution moves around your body, then you will lie on a table that moves through the scanning machine. The scan will show ‘hot spots’ that have taken up the high levels of radioactive glucose.

Lung function test (spirometry)

This test checks how well the lungs are working. It measures how much air the lungs can hold and how quickly the lungs can be filled with air and then emptied. You will be asked to take a full breath in and blow out into a machine called a spirometer.

Tests to find cancer in the lungs

Sputum cytology

A sputum cytology test examines a sample of mucus (sputum) from your lungs. Sputum is different to saliva as it contains cells that line the respiratory passages. To collect a sample, you will be asked to cough deeply and forcefully into a container. This can be done in the morning at home. The sample can be refrigerated until you take it to your doctor, who will send it to a laboratory to check under a microscope for abnormal cells.

Biopsy

If a tumour is suspected after an x-ray or CT scan, a sample of tissue will be taken to confirm whether you have lung cancer. The sample can be collected in different ways.

CT-guided core biopsy

This is used to obtain cells when the tumour is in the outer parts of the lungs. A CT scan will be used to guide the needle through your chest wall and into position. A small piece of tumour can usually be removed with the needle. A core biopsy is done in a hospital or radiology clinic. You will be observed for a few hours afterwards, as there is a small risk this procedure can damage the lung.

Bronchoscopy

A bronchoscopy allows the doctor to look inside the large airways (bronchi). A bronchoscope is passed down your nose or mouth, down your windpipe (trachea) and into the bronchi. The bronchoscope is a flexible tube with a light and lens for viewing. It may feel uncomfortable, but it shouldn’t be painful. You will be given sedation to help you relax or a general anaesthetic, and the back of your throat will be sprayed with a local anaesthetic to numb it.

If the tumour is near your main respiratory tract, the cells can be collected using the washing or brushing technique. During ‘washing’, a small amount of fluid is injected into the lung and withdrawn for further examination. ‘Brushing’ involves the use of a brush-like instrument to remove some cells from the bronchi.

Endobronchial ultrasound

An endobronchial ultrasound (EBUS) is a type of bronchoscopy that allows the doctor to see cancers deeper in the lung. Samples may also be taken from a tumour or a lymph node in the middle of the chest or next to the airways. In other cases, samples can be taken from the outer parts of the lung.

The doctor will use a bronchoscope with a small ultrasound probe on the end. The ultrasound probe uses soundwaves to create pictures that show the size and position of the tumour and allow the doctor to measure it. After an EBUS, you may have a sore throat or cough up a small amount of blood. These side effects usually pass quickly, but tell your medical team how you are feeling so they can monitor you.

Mediastinoscopy

This is not used as often as other biopsy methods, but is sometimes used if a sample is needed from the area between the lungs (mediastinum). A small cut is made in the front of the neck and a rigid tube is passed down the outside of the trachea. Some tissue is removed from the mediastinal lymph nodes. A mediastinoscopy is usually a day procedure but you may need to stay overnight in hospital for observation.

Thoracoscopy

A thoracoscopy is an operation used to take a tissue sample (biopsy). It is usually done if other tests are unable to provide a diagnosis. For a thoracoscopy you will have a general anaesthetic. The surgeon will make one or two small cuts in your chest and insert a surgical instrument called a thoracoscope, which has a camera attached. You will wake up with a drain coming from your side and stay in hospital for a few days.

Gene mutation testing

Genes are found in every cell of the body and inherited from both parents. A change in genes is called a mutation, and this can cause cancer to grow. A mutation can occur after you are born.

Some genetic mutations have been identified in lung cancers. Tumour tissue from a biopsy can be tested to find a mutation. The results help guide treatment decisions. Some medicines target particular mutations, so one option may be targeted therapy. However, not all gene mutations associated with lung cancer have a targeted therapy available.

Further tests

If the tests described above show that you have lung cancer, further tests are done to see whether the cancer has spread to other parts of your body. These tests may include an abdominal CT scan (to look for liver metastases); bone scan (to look for bone metastases); and brain CT or MRI scan (to look for brain metastases). Small cell lung cancer can also spread to the bone marrow, so you may have a bone marrow biopsy to look for this.

For information about these tests, talk to your doctor or call Cancer Council 13 11 20.

Staging lung cancer

Working out how far the cancer has spread is called staging, and it helps your health care team recommend the best treatment for you.

Both NSCLC and SCLC are staged in similar ways. The most common staging system for lung cancer is the TNM system (see below). TNM stands for tumour-nodes-metastasis. Each letter is assigned a number (and sometimes a or b) to show how advanced the cancer is. This information may be combined to give the lung cancer an overall stage of I, II, III or IV.

Stages I and II generally include T1–2 N0–1 M0 tumours and are usually referred to as early lung cancer. Stage III covers any T N2–3 M0 tumours and is called locally advanced lung cancer. Stage IV refers to any T and N M1 tumours that are metastatic (advanced cancer) and have spread beyond the lung and regional lymph nodes.

TNM system

The TNM system is complex. If you have any questions, ask your doctor to explain.

T (Tumour)

Indicates the size of the tumour and the depth of any tumour invasion into the lung.

  • T1a – tumour is less than 2 cm
  • T1b – tumour is between 2cm and 3cm
  • T2a – tumour is between 3cm and 5cm
  • T2b – tumour is between 5cm and 7cm
  • T3 – tumour is more than 7cm or has grown into the chest wall, mediastinal pleura, diaphragm or pericardium, or it has made the lung collapse
  • T4 – tumour has grown into nearby structures, such as the mediastinum, heart, trachea, area where the main airway divides to go into each lung, oesophagus or the backbone, or two or more separate tumours are present in the same lobe of a lung
N (Nodes)

Shows if the tumour has spread to nearby lymph nodes, includes N0–3

M (Metastasis)

Shows if the tumour has spread to other parts of the body.

  • M0 – cancer has not spread to distant parts of the body
  • M1a – separate tumour in a contralateral lobe, tumour with pleural nodules or malignant pleural effusion
  • M1b – cancer has spread to distant parts of the body, such as the liver or bones

Prognosis

Prognosis means the expected outcome of a disease. You may wish to discuss your prognosis and treatment options with your doctor, but it is not possible for any doctor to predict the exact course of the disease. Instead, your doctor can give you an idea about the general prognosis for people with the same type and stage of cancer.

As in most types of cancer, the results of lung cancer treatment tend to be better when the cancer is found and treated early. See more information about staging lung cancer.

To work out your prognosis, your doctor will consider your test results; the type of lung cancer; the rate and extent of tumour growth; how well you respond to treatment; and other factors such as your age, fitness and overall health, and whether you’re currently a smoker.

Which health professionals will I see?

Your general practitioner (GP) will usually arrange the first tests to assess your symptoms. If these tests don’t rule out cancer, you’ll usually be referred to a respiratory physician, who will arrange further tests and advise you about treatment options.

A range of health professionals will work as a multidisciplinary team (MDT) to treat you. The table below lists the health professionals who may be in your MDT. The health professionals you see will depend on whether you have early stage lung cancer or more advanced lung cancer.

Health professional

Role

respiratory physician* (thoracic physician)

diagnoses and stages the cancer and determines initial treatment options

thoracic (chest) surgeon*

conducts some diagnostic tests and performs surgery for lung cancer

radiation oncologist*

prescribes and coordinates the course of radiotherapy

radiation therapist

plans and delivers radiotherapy and provides care throughout treatment

medical oncologist*

prescribes and coordinates the course of chemotherapy and targeted therapy

oncology nurses

administer drugs, including chemotherapy, and provide care throughout treatment

cancer nurse coordinator

coordinates your care, liaises with other members of the MDT and supports you and your family throughout treatment

dietitian

recommends an eating plan to follow during treatment and recovery

speech pathologist

helps with communication and swallowing

social worker

links you to support services and helps with emotional or practical problems

physiotherapist, occupational therapist

assist with physical and practical issues

counsellor, psychologist

provide emotional support and help manage anxiety and depression

palliative care team

specialise in pain and symptom control to maximise wellbeing and improve quality of life

* Specialist doctor

Lillian’s story

"Two days after my 34th birthday I woke up with a sore shoulder and arm. I didn’t think too much of it because the pain went away quickly. After I felt a lump on my left collarbone, I mentioned it to my dad and brother because they’re doctors. They said it was probably because I’d had a cough in the past weeks but to get an ultrasound.

"After some further scans and tests, it was confirmed to be stage IV non-small cell lung cancer. I was devastated.

"When I first tell someone that I have lung cancer, the first thing most people say is ‘did you smoke?’ While I think that people have the best intentions and it’s human nature to want to find the cause of a problem, does it really matter whether I had smoked or not? I’m a never- smoker, but if I did smoke, even if it was just one cigarette, should I feel that somehow it’s my fault?

"I want to reduce the stigma suffered by lung cancer patients and their families who are already going through so much. I use statistics to educate people and raise awareness. I explain that many other lifestyle choices are linked to cancer and that smoking causes other health conditions, such as cardiovascular diseases and other cancers. I let them know that one in three women diagnosed with lung cancer is a never-smoker such as myself.

"A lot of the people I’ve met with lung cancer, say they’re guarded about their diagnosis. One carer said she didn’t tell anyone for three years that her spouse had lung cancer for fear of being stigmatised. There needs to be a lot more compassion. I think that taking away the stigma will lead to greater funding for research. I am feeling hopeful about my future. It’s important to me to stay in the moment and appreciate what I have."

Tell your cancer story.

Key points

  • Several tests may be performed to diagnose lung cancer. These include general tests and tests to determine whether the cancer has spread.
  • Chest x-rays and CT scans are painless scans that will take pictures of the inside of your body.
  • If you are coughing up phlegm, your doctor might ask you for a sample to send to a lab for testing. This is called sputum cytology.
  • A biopsy is when a sample of tissue is removed from your chest. The sample can be collected in different ways, including CT-guided core biopsy, bronchoscopy, endobronchial ultrasound (EBUS), mediastinoscopy and thoracoscopy.
  • Some genetic mutations have been identified in lung cancers. Tumour tissue can be tested to find a mutation. The results can help guide treatment options.
  • Scans and biopsy results can show whether the cancer has spread. They can also help your medical team decide on the best treatment plan.
  • The lung cancer is assigned a stage to describe how much cancer there is and whether it has spread.
  • Prognosis is the expected outcome of the disease. No-one can predict the exact course of the illness.
  • A range of health professionals who specialise in different areas will work together to care for you. This multidisciplinary team (MDT) may include a respiratory physician, thoracic surgeon, radiation oncologist and a medical oncologist.

Reviewed: Dr Dishan Herath, Medical Oncologist, Royal Melbourne Hospital, VIC; Sue Lilley, 13 11 20 Consultant, Cancer Council SA; Nev Middleton, Consumer; A/Prof Matthew Peters, Professor of Respiratory Medicine, Faculty of Medicine and Health Sciences, Macquarie University, and Senior Staff Specialist, Department of Respiratory Medicine, Concord Hospital, NSW; Dr Shawgi Sukumaran, Medical Oncologist, Flinders Medical Centre, SA; and A/Prof Shalini Vinod, Radiation Oncologist, Liverpool Hospital, NSW.

Updated: 01 Nov, 2016