Flexible bronchoscopy with a videobronchoscope is the most common type used to diagnose lung cancer. It is basically a long (3ft), soft flexible tube, about as big around as a McDonald’s straw with a light and a camera on the end. The doctor looks at video image displayed on a monitor to guide the bronchoscope in the bronchial tubes.

A biopsy is very important. First, it gives us a diagnosis of lung cancer and tells us what kind of lung cancer a patient has. The type of lung cancer may influence the treatment (small cell versus non-small cell versus carcinoid). Biopsies may also be used to confirm the spread of cancer to lymph nodes or other parts of the body. Finally, biopsies also allow us to test for certain cancer gene alterations that may allow us to treat with medications that specifically target those alterations.

First radiologic studies such as a CT scan or a PET scan is done. If lung cancer is highly suspected, and appears early stage, then surgical resection is suggested if the patient is healthy enough and has good pulmonary reserve. If the disease is suspected to be advanced, then tissue diagnosis is needed. This can be obtained either through transthoracic needle biopsy, transbronchial biopsy, or endoscopic bronchial ultrasound. If the case is unusual, difficult, or more advanced disease, the patient should be evaluated at a center which deals with lung cancer routinely.

Once a patient is diagnosed with non-small cell lung cancer, and then completes staging studies that confirm that the cancer has metastasized, the treatment plan is created. I will sit down with the patient, and hopefully his/her loved ones, to explain the diagnosis and discuss the prognosis. This is often a very anxiety-provoking discussion, but important for patients to understand so they can go into treatment with their eyes open. Metastatic lung cancer is treatable, and the treatments are better than they ever have been in the past, but unfortunately nothing can cure metastatic lung cancer. All treatments are given with the goal of prolonging life for as long as possible while trying to maintain a patient’s quality of life as close to normal as possible.

Based on the specific type of lung cancer we will discuss either standard therapy or participation in a clinical trial. Standard therapy for most patients consists of chemotherapy with a combination of 2 or 3 drugs, usually given every 3 weeks for 4-6 treatments with checks along the way to makes sure it is helping. We discuss the potential side effects and what we will do to manage them, and make arrangement to start as soon as feasible. For some patients, special tests can identify molecular targets that direct us to use different drugs, called targeted agents. The 2 target-drug combinations in use in 2013 are epidermal growth factor receptor (EGFR) mutations and the oral drug erlotinib (Tarceva), and anaplastic lymphoma kinase (ALK) gene fusions and the oral drug crizotinib (Xalkori). These genetic changes are present in about 10% and 4% of non-small cell lung cancers respectively, but are tested for in all new patients.

Finally, we usually discuss the options of participation in a clinical trial, which usually involves the best available chemotherapy or targeted drug PLUS a new drug (or sometimes a placebo) which is being tested to see if it is better than the current combination. We do not do true placebo trials when we have proven treatments, so patients will always get at least the best available standard therapy on a trial.

Smoking is the strongest risk factor for lung cancer. All types of lung cancer are associated with smoking and while there are studies that distinguish gradations of risk due to smoking by histologic type, smoking is the strongest risk factor for both small cell and non-small cell lung cancer.

Delay in diagnosis of breast cancer is the most common cause of medical malpractice litigation and settlement. It is a big problem, especially in young women and in women with inflammatory breast cancer. Mistakes related to errors in mammogram interpretation are also a source of delay in diagnosis.

A family history of lung cancer in a first-degree relative is associated with a 1.5 to 2-fold increased risk of developing lung cancer after taking into consideration shared smoking patterns among family members. This association is seen for all histologic types of lung cancer, and among smokers and never smokers. Slightly higher risks associated with a family history have been shown when the relative is diagnosed with lung cancer under age 50, in African Americans, and when multiple relatives are affected. These findings suggest that there is inherited genetic susceptibility to lung cancer. While a “lung cancer gene” has not yet been identified, reported family history is used clinically to help determine risk. The magnitude of risk associated with having a family history of lung cancer is similar to that associated with familial aggregation of other cancers including breast, colon, and prostate cancer.

In general terms, lung cancer has a certain predisposition to go to brain, bone, adrenals, liver, the other lung, lymphnodes in the middle of the chest and under the collarbones and the linings around the lungs and heart.

However, this doesn't have to happen in everyone. In addition, we published earlier this year that now we are breaking lung cancer down into different molecular subgroups they may behave differently in terms of how they spread as well. For example, ALK+ NSCLC has a higher incidence of spread to the linings in the lung and around the heart than other molecular subtypes of lung cancer. Others have also, for example, shown that EGFR mutant lung cancer can be associated with very small deposits in both lungs - so called miliary disease (as each deposit is the size of a 'millet seed'). But you can't use the pattern of spread as a substitute for molecular testing - they're just patterns that are more or less associated with one type or another.

It is hard to determine how aggressive a lung cancer (like any other cancer) is. Staging is the most important factor to determine the best treatment of care. In general one looks at the cell type (if obtainable) and any clinical history. In general, small cell lung cancer and large cell lung cancer are more aggressive. If there is the luxury of having prior CT scans, this can help on grow rate.

Cigarette smoking increases risk of both lung cancer and chronic obstructive lung disease (COPD) which is defined by airflow limitation from both emphysema and chronic bronchitis. In addition, COPD is an independent risk factor for lung cancer. Once COPD is diagnosed, risk of developing lung cancer increases 2 to 3-fold, even among never smokers. Lung cancer occurrence is linked differentially to specific COPD phenotypes, with highest risk associated with a history of emphysema. A family history of COPD also increases risk of lung cancer development approximately 2-fold. The question remains as to whether COPD is in the causal pathway in the development of lung cancer or a variation in manifestation from the same exposures. Studies that incorporate clinical, inflammatory, genetic and imaging parameters are being conducted that will be of particular interest in furthering lung cancer risk assessment in the presence of COPD.