In general, concurrent chemotherapy and radiation therapy are considered standard treatment for unresectable clinically staged IIIA disease, but the survival remains poor (median survival, 10 to 14 mo). Patients with stage IIIB disease with contralateral mediastinal nodal disease or supraclavicular nodal disease are offered either radiation therapy or chemotherapy or both. Corticosteroids are commonly used but are of unproven benefit Treatment of Horner's syndrome caused by apical tumors is with surgery with or without preoperative radiation or with radiation therapy with or without adjuvant chemotherapy

Despite advances in treatment, the prognosis remains poor, with only 15% of patients surviving > 5 yr from time of diagnosis.

About 15% of people who develop lung cancer have never smoked. In these people, the exact reason lung cancer develops is unknown. Recent studies have reported that some never-smoking people with lung cancer have genetic mutations in the epidermal growth factor gene (EGFR). Although an environmental association has not clearly been established, it is theorized that exposure to radon gas, a breakdown product of naturally occurring radium and uranium, may be an environmental risk factor.

Other possible risk factors include exposure to secondhand smoke and exposure to carcinogens, such as asbestos, radiation, arsenic, chromates, nickel, chloromethyl ethers, mustard gas, or coke-oven emissions, encountered or breathed in at work The risk of lung cancer increases with combined exposure to occupational carcinogens, toxins, and cigarette smoking. It is suspected that COPD and pulmonary fibrosis (? 1-antitrypsin deficiency) may increase susceptibility to lung cancer.

Small cell lung cancer (SCLC)

However, given the disappointing results in patients with metastatic disease, efforts at reducing mortality have increasingly focused on early detection and active interventions to prevent disease. Treatment. Surgery (depending on cell type and stage) Chemotherapy

SCLC: SCLC of any stage is typically initially responsive to treatment, but responses are usually short-lived.

Lesser resections, including segmentectomy and wedge resection, are considered for patients with poor pulmonary reserve. Surgery is curative in about 55 to 75% of patients with stage I and in 35 to 55% of patients with stage II disease Surgery is done only on NSCLC patients who will have adequate pulmonary reserve once a lobe or lung is resected. Patients with preoperative forced expiratory volume in 1 sec (FEV1) > 2 L generally tolerate pneumonectomy.

Those with FEV1 < 2 L should undergo a quantitative xenon radionuclide perfusion scan to determine the proportion of function the patient can expect to lose from resection. Postoperative FEV1 can be predicted by multiplying percent perfusion of the nonresected lung by the preoperative FEV1. A predicted FEV1 > 800 mL or > 40% of the predicted normal FEV1 suggests adequate postoperative lung function, although studies of lung volume reduction surgery in COPD patients suggest that patients with FEV1 < 800 mL can tolerate resection if the cancer is located in poorly functional, bullous (generally apical) lung regions.

Patients undergoing resection at hospitals that perform more resections have fewer complications and are more likely to survive than those who undergo surgery at hospitals that do fewer lung cancer procedures . Adjuvant chemotherapy after surgery is now standard practice for patients with stage II or stage III disease, possibly also for patients with stage IB disease with tumors > 4 cm. Clinical trials have shown an increase in 5-yr survival rates with the use of adjuvant chemotherapy.

However, the decision for adjuvant chemotherapy should depend on the patient's comorbidities and risk assessment. The role of neoadjuvant chemotherapy in early-stage NSCLC is under investigation Stage III disease is treated with either chemotherapy, radiation therapy, surgery, or a combination of therapies; the sequence and choice of treatment are dependent on the location of the patient's disease and comorbidities.

In general, concurrent chemotherapy and radiation therapy are considered standard treatment for unresectable clinically staged IIIA disease, but the survival remains poor (median survival, 10 to 14 mo). Patients with stage IIIB disease with contralateral mediastinal nodal disease or supraclavicular nodal disease are offered either radiation therapy or chemotherapy or both. Patients with locally advanced tumors invading the heart, great vessels, mediastinum, or spine usually receive radiation therapy.

In some patients (T4 N0 M0 tumors), surgical resection with either neoadjuvant or adjuvant combined chemotherapy and radiation therapy may be feasible. The 5-yr survival rate for patients with treated stage IIIB disease is 5% In stage IV disease, palliation of symptoms is the goal.

Initial treatment of a symptomatic effusion is with thoracentesis; symptomatic effusions that recur despite multiple thoracenteses are drained through a chest tube. Infusion of talc (or occasionally, tetracycline Some Trade Names . ACHROMYCIN V. TETRACYN. TETREX. Click for Drug Monograph . or bleomycin Some Trade Names . BLENOXANE. Click for Drug Monograph . ) into the pleural space (a procedure called pleurodesis) scars the pleura, eliminates the pleural space, and is effective in > 90% of cases (see Mediastinal and Pleural Disorders: Pleural Effusion )

Treatment of SVC syndrome is the same as treatment of lung cancer, with chemotherapy (SCLC), radiation therapy (NSCLC), or both (NSCLC). Corticosteroids are commonly used but are of unproven benefit Treatment of Horner's syndrome caused by apical tumors is with surgery with or without preoperative radiation or with radiation therapy with or without adjuvant chemotherapy Treatment of paraneoplastic syndromes varies by syndrome (see Overview of Cancer: Paraneoplastic Syndromes )

Symptoms of breathlessness can be treated with supplemental oxygen and bronchodilators.