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Lung cancer is the leading cause of cancer-related deaths in women and men, which is taking away 1.3 million lives worldwide annually, as of 2004 [i] . It is a disease of uncontrolled growth of abnormal cells in the lung tissues, usually in the cells lining air passages. This disease is usually caused by the use of tobacco, sometimes is due to radon, asbestos or air pollution. It can give rise from local tumour growth to the growth in distant metastatic sites, which is the invasion of adjacent tissues and infiltration beyond the lungs. It has some common signs and symptoms include chronic coughing (sometimes with blood), shortness of breath and weight loss. According to World Health Organization (WHO), the five years survival rate for lung cancer is only 15 %. [ii] However, the survival rate can be increased if treatments are given earlier. So what are the current available treatments to treat lung cancer in order to decrease the number of death?
Surgery is a method to remove cancer tissues from the lung by operating. There is an operative death rate of 4.4% on this treatment, depending on the function of the patient's lung and other risk factors. [iii] It is always used to treat non-small cell lung cancer limited to one lung, up to stage IIIA.
This treatment is not reliable for widespread cancer as the cancer cells are not confined to a specific site, but have travelled to other parts of the body widely. Thus, it is important to determine whether the cancer cells are localized or they have been spread to the point that cannot be cured surgically. This often can be done by CT scan and positron emission tomography (PET). Besides, blood tests and spirometry (lung function testing) are important assessments for patient's condition to be operated on as surgery must be contraindicated to the people with poor respiratory reserve.
The procedures of the lung cancer surgery include wedge resection- removal of part of lobe, segmentectomy- removal of an anatomic division of a particular lobe, lobectomy- removal of one lobe, bilobectomy- removal of two lobes and also pneumonectomy- removal of the whole lung. All these procedures taken are varying among each patient. Lobectomy minimizes the chance of local recurrence, but it is only prefer to the patients with adequate respiratory reserve. Wedge resection could be the second choice for the patients who do not have enough functioning lung for lobectomy. Radioactive iodine brachytherapy at the margins of wedge excision may reduce recurrence to that of lobectomy. [iv] There is another two types of surgery that give a quicker recovery in treating minimally invasive approaches to the lung cancer surgery, which are video-assisted thoracoscopic surgery and VATS lobectomy.
During surgery progression, the patient is often anaesthetized, usually in the range of 4 to 8 hours in order to minimize the pain. As the operation may cause the entire tumour and the neighbouring normal tissues to be exposed, the incision must be shaved and cleansed to reduce the risk of infection. Besides that, surgery always involves the cutting of some blood vessels, thus five to six pints of blood must be prepared for blood transfusion in case if the patient's blood level drop to a dangerous level.
Unlike surgery and radiotherapy, chemotherapy has an advantage that is it can work on cancer cells in anywhere of the body. Thus, it is largely reserved for small cell lung cancer. In fact, it works for both small cell and non small cell lung cancer but it is more effective to small cell lung cancer. This is proved as only half of people who have small cell lung cancer survive for four months without chemotherapy. With chemotherapy, their survival time is increased up to four- to fivefold. [v]
This treatment cures cancer using cytotoxic medications, either by stopping the division of the rapid dividing cancer cells, killing them or making them less active. Normally, combination of two or more types of medications is used at a time to kill as many cancer cells as possible because different medications work on different stages of cell division. The drugs in common use are carboplatin, ifosfamide, cyclophophamide, vincristine, adriamycin and etoposide. While a number of chemotherapeutic drugs have been developed, the class of drugs known as the platinum-based drugs have been the most effective in treatment of lung cancers. [vi]
Chemotherapy is always used as adjuvant chemotherapy (in addition to surgery) for non small cell lung cancer to kill any spread cancer cells that are undetectable by scanning. In some cases, it is given to shrink a tumour before surgery and improve the chances of effectiveness of the surgery. In addition, chemotherapy can help to prolong life of patient with advanced cancer and also relieve the symptoms of cancer.
There are several ways of giving chemotherapy, where it can be given as oral pills, through injection into veins or through drip. However, injection is more common. Chemotherapy is normally given at least four to six times, taking three to four weeks interval over a period of several months. It may be given alone, in combination with radiotherapy or as adjuvant chemotherapy after surgery.
Radiotherapy is an alternative treatment for non-small cell lung cancer except than surgery. It is also a treatment for small cell lung cancer. It can be used as curative therapy, palliative therapy or the most effective - adjuvant therapy in combination with chemotherapy or surgery.
In radiotherapy, lung cancer is treated by destroying the cancer cells with high energy ionizing radiation such as X-rays or gamma rays. The radiation is delivered externally by machines directed toward cancer. This external delivery method can be done by an outpatient basis and it requires simulation process which maps out the exact location where the radiation will be delivered by using CT scans, computers and precise measurements. Besides, radiation can also be delivered internally by placing radioactive substances in sealed containers within the localized area of tumour, which need hospitalization.
Radiation prevents cell division and the formation of DNA (deoxyribonucleic acid). Thus, cancer cells which divide more rapid than normal cells are particularly vulnerable to radiotherapy. Most of the irradiated cells die only when they attempt to divide, while some die instantly. Radiation can also destroy the cancer cells that comprise a tumour in the lung or damage the blood vessels that nourish the tumour. Besides, lung cancer tissues are considerably more sensitive than normal tissues to the destructive effect of X-ray, thus irradiation of large parts of the body do not cause excessive damage to the normal tissues. Due to this reason, it is the best choice of treatment.
However, this treatment is only used when the area to be treated is small, aiming to reduce as much of the destructive effect to the normal tissues as possible and also allow the body to tolerate with the destruction. If the cancer is already widespread, just like surgery, radiotherapy cannot cure it but it can help to alleviate the symptoms of the cancer and prolong the life of the patient by controlling the growth of the cancer tissues.
Hospitalization and treatments of lung cancer include diagnostic test, physician visit, drugs and rehabilitation require a huge amount of money. These may directly bring along economic implication to patients' family in order to pay for the both. In addition, it may even increase the economy burden of a family if the patient is the backbone of the family as they lost their ability to work. Normally, patients cannot hold a job particularly at the late stage of the disease, which means there is no income for the family.
Total cost of diseases
The annual economic burden of respiratory diseases in Europe is estimated to be approximately â‚¬102 billion or â‚¬118 per capita.
The factors costing the most are lost work days, accounting for â‚¬48.3 billion or 47.4%, and inpatient care â‚¬17.8 billion or 17.5%. Outpatient care contributes a further â‚¬9.1 billion (8.9%) and prescription drugs add â‚¬6.7 billion (6.6%) including VAT.
Premature mortality and rehabilitation are estimated to contribute another â‚¬20.0 billion (19.6%). [vii]
Many patients who are suffering from lung cancer tend to be suicidal especially at the terminal stage of the disease due to pain. This situation is commonly seen on dying patients where their cancers had come to critical stage where cancer cells are widely spread and cannot be cured. Most of them refuse to accept any treatment as they think that treatments are useless to them and the pain they are experiencing make them tend to give up their lives. Moreover, the side effects of medication such as hairless and tired look are difficult to tolerate or may even embarrass them. Besides, they will also feel that they are useless and bring troubles to the people around them, thus the stronger the desire to commit a suicide. These actually cause a great burden to their loves one. They not only have to take care of the patients and spending time by their sides, but also have to find the possible ways to help them in their recoveries. Besides, they too, need to worry about the psychological problems of the patients, console them, and give them support along the period. This is a very serious social impact.
Benefits and Risks
Surgical removal of the tumour is generally a better treatment for non small cell lung cancer compared to small cell lung cancer as cancer cells in the latter are localized. However, it is performed for limited-stage (stage I or sometimes stage II), before metastasis occurs. One of its benefits is that it is a step treatment, which does not take a long period of time. It is essential in removing the entire tumour from body, yet does not always result in cure as the tumour may have become metastasis and reappear in other body parts. Among people who have an isolated, slow-growing lung cancer removed, 25%-40% are still alive five years after diagnosis. [viii] Although it is the simplest way of treatment, there is a limitation, that is, surgery is contraindicated if the cancer is too close to the trachea or if the person has other serious conditions. Besides, patients may experience difficulty breathing, shortness of breath, pain, and weakness after the surgery. The risks of surgery include complications due to bleeding, infection, and complications of general anesthesia. [ix]
It is an effective treatment for lung cancer particularly small cell lung cancer since the cancer cells do not spread. Moreover, it is another choice for non small cell lung cancer patient that refuses surgery or having not suitable conditions for surgery. It is less painful compared to surgery as well. Another benefit is that it can kill all the cancer cells all around the body. However, there are also some risks or side effects of taking chemotherapy as the drugs used may kill normal body cells as well. If blood cells are killed, it may give rise to susceptibility to infections and problems with blood clotting. Besides, it may also carry some side effects such as fatigue, weight loss,Â hair loss,Â nausea,Â vomiting, diarrhea, andÂ mouth sores. However, all the side effects can be controlled by the dosage and combination of drug used.
Radiotherapy not only can treat lung cancer, but it can also treat the lung cancer that spread to the brain. Besides, it may reduce the chance of cancer developing in the brain. Radiation following surgery for stages II or III non-small cellÂ lung cancerÂ may reduce the risk of cancer recurrence in the chest, but long-term survival rates are not significantly improved because cancer may have already spread to other areas of the body. [x] Although radiotherapy does not carry the risks of surgery, it still has some side effects, including fatigue and lack of energy. It may cause the patient to be vulnerable to infection and difficulty in blood clotting due to reduced number of white blood cells and platelets. Patients may experience nausea, vomiting or diarrhea if digestive organs are affected.
Targeted therapy is an alternative to chemotherapy that stop the cancer cells from growing and spreading by interfering with molecules involved in tumour growth and progression. It can be drugs or other substances. Compared to chemotherapy and radiotherapy, targeted therapy may be more effective and less harmful to normal cells. Most of them target on proteins involving in cell signalling pathways. One of the drugs used is erlotinib, which can be applied to patient with small cell lung cancer that does not respond to chemotherapy. This drug targets cancer cells more specifically, so reducing the damage to normal cells. It targets a protein that is important in promoting the division of cells, found abundantly on surfaces of cancer cells, called epidermal growth factor receptor (EGFR). Other than erlotinib, there is also other attempts at this therapy such as drugs known as antiangiogenesis