Lung Cancer And Pathway To Diagnosis And Care Biology Essay

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Lung cancer is known to be one of the major causes of death in both UK and United States of America. Smoking is generally the major cause of lung cancer with patients diagnosed with it, having a survival rate of 15% in five year. Lung cancers are categorized under non-small cell carcinoma and small cell carcinoma (NICE, 2011). To give example, we have large cell carcinoma, squamous cell carcinoma and adenocarcinoma. These cancer categories are used for its management and pathway diagnosis and the symptoms and the signs may vary on the basis of the extent of metastases and the type (Barron, 2009).

The diagnostic evaluation of patients suspected of having lung cancer is done by functional patient evaluation and also the evaluation of the metastases. In lung cancer histology, diagnosis is obtained by thoracotomy or the video assisted thoracoscopy, thoracentesis, bronchoscopy, accessible lymph node and biopsy (Carafaro, 2005). A good percentage of the initial evaluation of the lung cancer rely on the physical examination, chest computed tomography, tissue confirmation of the mediastinal involvement, laboratory tests and the patients history. Further evaluation significantly depends on the clinical reports while the prognosis and the treatment are based on the stage and type of the tumor that has been identified. For stage 1, a surgical resection is done through IIIA non-small cell carcinoma while for the advanced stages of the non-small cell carcinoma; the treatment is done through a multimodality approach that may include chemotherapy, palliative care and the radiography (Ferreiro and Alcamo, 2007).

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The following table shows the various recommendations for practice on the management and pathway diagnosis of the lung cancer.

Table 1: Recommendation for practice on the management and the pathway diagnosis of the lung cancer

Clinical recommendation

Evidence rating

references

For the prevention of lung cancer, people who are smoking are given a substitute of nicotine which are bupropion (Wellbutrin), nortriptyline (Pamelor), and intensive counseling for smoking cessation.

A

50-53

There is no enough proof to show that there is suggestion in support or against the routine screening for lung cancer.

C

40-42

Patients with central lung tumors need to seek flexible bronchoscopy.

C

34,35

Patients in the process of receiving mediastinal staging for lung disease are advised to have computed tomography and the positron emission tomography.

C

Patients with peripheral lung tumors and who are not surgical candidates need to undergo transthoracic needle aspiration.

C

27,28

There is various risk factors that are associated with lung cancer, but smoking remain the predominant risk. It observed that the cause of 90 percent of women patients and 79 percent of men with lung cancer is linked to smoking. In addition the second hand smoke exposure is also a possible risk factor in that approximately 3,000 adults die each year as a result of being exposed to the second hand smoke on the basis of dose response relationship in regard to the duration and the intensity of the exposure (Fossella et al, 2003).

But the most common occupational risk factor for this disease is the effects that results from the exposure to asbestos. Other causes associated with it are exposure to the following things which include chromium, vinyl chloride, nickel, ionizing radiation, radon as well as arsenic among others (Henschke et al, 2003).

To manage lung cancer, there is the use of the pathology in order to facilitate treatment and prognostic decisions in which the lung cancer is either categorized as non-small cell carcinoma and the small cell carcinoma (NICE, 2011). In this case, there is the use of light microscopy to facilitate further differentiation of the lung cancer into four main and manifold minor histological classes. The table below shows the histological classification of the lung cancer.

Table 2: Lung cancer histological classification

class

Prevalence %

subtypes

Bronchial gland carcinoma

< 5

-

Adenosquamous carcinoma

< 5

-

Carcinoid

< 5

-

Large cell carcinoma

10

Large cell with rhabdoid phenotype ,large cell neuroendocrine, , lymphoepithelial-like, basaloid,

Small cell carcinoma

20

Pure small cell carcinoma, combined small cell carcinoma

Squamous cell carcinoma

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25

-

Adenocarcinoma

40

Acinar, papillary, solid carcinoma with mucus formation, mixed, bronchioalveolar

The adenocarcinoma type of the lung cancer is a histological heterogeneous mass that are metalized early and most occur in patients with lung diseases. While the cell carcinoma are end bronchial masses that are centrally located and may present themselves with post obstructive pneumonia, lobar collapse or hemoptysis in contrast to the adenocarcinoma and the squamous cell carcinomas that may metastasize late in the lung cancer course (Johnston, 2001)

According to Miller and Driscol (2002) in most cases, small cell carcinomas acre clinically aggressive and are central located characterized by mediastinal involvement. In addition to being associated with early occurrence of the extrathoracic metastases such as the paraneoplastic syndrome. Despite being responsive to the chemotherapy, the small cell carcinomas are usually advanced during the time of the diagnosis, thus making the patients to have a poor prognosis. On the other hand, the large cell carcinoma is in most cases poorly differentiated and they have large peripheral masses that are characterized with early metastases (Stewart, 2009).

Clinically presented, being that close to 10 percent of lung cancers patients who exhibit symptoms are detected through the use of chest radiographs, a good number of patients show the symptoms when they are being diagnosed and these symptoms may include weight loss, fatigue, anorexia or the direct signs caused by the intrathoracic or the extrathoracic spread (Sujal, 2007).  

In diagnosis of the lung cancer, there are various techniques that physicians can put in place to obtain an accurate diagnosis of the tissue. In order to achieve this multidisciplinary teams which comprises the thoracic surgeon, intervention radiologist and the pulmonologist are needed. For patients with an early non-small carcinomas are likely to go for the operation and the most recommended test for both tissue diagnosis and staging is the thoracotomy. However for the patients with the small cell carcinoma, bronchoscopy, transthoracic, excisional biopsy of an accessible node and the thoracentesis of the pleural effusion are the most convenient and the least invasive methods of diagnosis (Williams, 1992). The table below shows various methods of tissue diagnosis of the lung cancer

Table 3: Various methodologies of diagnosing tissue for lung cancer

Diagnostic method

sensitivity

indication

comments

Video assisted

Small peripheral tumors (< 2 cm in diameter), pleural tumors, or pleural effusions

Might avoid the necessity for thoracotomy

Sputum cytology (at least three specimens)

Central tumors: 99, 71Peripheral tumors: < 50

Central tumor and hemoptysis

Noninvasive; additional testing is necessitated after getting negative result

Thoracotomy

Only clearly resectable tumors

Suggestion for analysis and cure of early non-small cell carcinoma

Flexible bronchoscopy with or without transbronchial needle aspiration

Central tumors: 90 88Peripheral tumors: 60 to 70

Central or peripheral tumor and mediastinal lymphadenopathy

Fluoroscopic or CT guidance; transbronchial needle aspiration has greater chances of improving sensitivity in peripheral tumors

Transthoracic needle aspiration

Peripheral 97 tumors: 90

Peripheral tumor in nonsurgical candidates or when transbronchial needle aspiration is inconclusive

Fluoroscopic or CT guidance; the assistance of a cytopathologist results to improvement in diagnostic yield

Thoracentesis Excisional biopsy of an accessible node

80 > 90

Pleural effusion ,Palpable lymphadenopathy

-

It is evident that, there are various options that can be adopted in cases when the types of the lung cancer are less clear. These options include flexible bronchospy, the sputum cytology and the transthoracic needle aspiration. The sputum cytology is a test that is non invasive and it can be used in identification of centrally located tumors. The test is capable of detecting 71 percent of the centrally located tumors and less than 50 percent of the peripheral tumors. This indicates that further tests on the using the same must follow a result that is negative. On the other hand, the flexible bronchoscopy is best suitable for patients with central tumors and a combined sensitivity of 88 percent (Williams, 1992).

In the initial evaluation of the lung cancer, a primary care physician can perform the metastasis and it should include aspects such as the physical examination of the patient, a detailed history of the patient, complete blood count and the various levels of the alkaline phosphatase, hepatic transaminases and the levels of the electrolyte. It has also been approved that 80 percent of patient s who has abnormal evaluation do have the metastatic diseases and patients who exhibit anorexia, fatigue and weight loss in most cases have a poor prognosis (NICE, 2011). On the other hand, the non invasive radiographic imaging that involves the chest CT and the position tomography scans is usually performed in patients who are suspected to be having the metastatic lung cancer. This is because the chest and the upper abdomen scans can reveal mediastinal adenopathy, liver or adrenal involvement (Henschke et al, 2003).

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