The most common symptoms of lung cancer are cough and shortness of breath. Given how common these symptoms are in society, lung cancer needs to be thought about, especially in patients considered ‘high risk’, like smokers. Others symptoms are chest pain, hoarse voice, facial flushing, weight loss, bone pain, headache and nausea, depending on where the cancer has spread. Quite often, there are no symptoms, even in advanced disease, and a lung cancer is picked on a Chest X-Ray or CT scan of the chest done for some other reason.

After a consultation including physical examination, a chest X-ray is usually the next step if lung cancer is suspected. It usually shows a spot, collapsed lung etc. A CT scan of the chest gives far more detail and is often the next test. Sputum analysis can occasionally show cancer cells. A biopsy is usually required to confirm the diagnosis and identify the type of lung cancer, and whether it has started in the lungs or spread from elsewhere. A biopsy of the lung can be done either via a bronchoscopy or it can be CT scan guided.

Although there are various types of primary lung cancer, they are broadly classified into 2 groups. Small cell lung cancer (SCLC) is found in about 10-15% of patients. It is rarely seen in never smokers. Non-small cell lung cancer (NSCLC) makes up the remaining 85-90% of patients. There are subcategories of NSCLC, the most common of which are adenocarcinoma, squamous cell carcinoma, and large cell carcinoma. Less common types are sarcomatoid carcinomas and non-small cell neuro-endocrine tumours. In certain cancers, tissue is sent for genetic mutation testing, since there are now drugs available to treat patients with certain genetic mutations, which lead to a better outcome than the standard drugs.

Small cell cancers behave differently from non-small cancers, and are treated differently. They tend to be more aggressive, spread early, and often lead to a worse outcome.

Once a diagnosis of lung cancer is made, further testing is often done to ‘stage’ it. The stage is dependent on tumour size and location, which lymph nodes are affected (if any), and whether it has spread within the chest or to other organs. Some of the tests that are done to help stage the cancer are CT chest, CT Positron Emission Tomography (or PET - a form of CT scan using a special glucose based contrast) and biopsy of the lymph nodes (using bronchoscopy with ultrasound guided biopsy, or occasionally a surgical biopsy). Not every patient needs all of these tests.

The recommended treatment depends largely on the stage and type of lung cancer. However, age, other health problems and lung capacity also help determine the approach.

Treatment comprises of one or a combination of the following:

• Surgery - offers the best chance of cure. This can be removing a portion of the lung only (wedge resection), a lobe of the lung (lobectomy) or a whole lung (pneumonectomy).
• Radiation therapy — uses radiation to kill cancer cells.
• Chemotherapy – this uses certain medicines to kill the cancer cells. Some medicines work only in patients whose cancer has certain genetic features (this is called targeted therapy) and this is tested via a gene test.
• Palliative care – this is for patients in whom any treatment is unlikely to improve the outcome, and the intention is mainly supportive with emphasis on symptom control and support.

Maybe. The best way to avoid getting lung cancer is to not smoke. If you smoke, you can reduce your chance of getting lung cancer by quitting smoking (the risk goes down several years after quitting, but always remains higher than a never smoker). A smoker's risk of developing lung cancer is 10 to 30 times greater than that of a non-smoker, however, about 10-20% of lung cancer in the Western world is in those who have never smoked. Environmental factors, age and genes also play a role, but are more difficult to modify.

Cigarette smoking (including passive exposure) is the most common cause. About 80% of COPD is due to smoking. Exposure to particulate matter, dusts, gases, fumes, etc may also be a risk factor. There is also evidence for genetic predisposition, allergy, and certain infections.

Symptoms are different in those with Emphysema and Chronic Bronchitis. The most common symptoms are cough with phlegm and shortness of breath. Symptoms are minimal in early disease and gets worse as disease progresses. Others symptoms are wheezing, fatigue and morning headaches.

Symptoms are not entirely dependent on the severity of COPD – patients with severe COPD can have a good functional state, and vice-versa. Other factors that influence the level of functioning are heart function and level of strength and conditioning. Treatment can help with most symptoms. In most patients, the oxygen levels are normal, and the shortness of breath is due to damage to the lungs causing ‘air-trapping’ and ‘hyper-inflation’ of the lungs rather than low oxygen levels. Inhalers help ‘deflate ‘ the lungs, amongst other benefits.

The ‘gold standard’ for diagnosis of COPD is measuring respiratory function. This is done by measuring spirometry, lung volumes and diffusion capacity.

Spirometry involves taking a deep breath, followed by breathing out forcefully and fully. It measures how much air and how fast one can blow out. Lung volumes can be measured in various ways. One of the commonest ways is using a ‘body box’, which looks similar to a phone booth. These tests are also used to assess response to treatment and progression of disease.

Chest X-Ray is often normal, even in severe disease, and is not useful in making a diagnosis.

CT scan of the chest gives far more detail than a Chest X-Ray, however, is not routinely required in every patient.

By far, the most important aspect of managing COPD is stopping smoking. Stopping smoking, no matter how late, slows progression of COPD. The role of inhalers is discussed below. Other aspects of treatment are:

• Keeping active, and having a regular exercise plan. Participating in a Pulmonary Rehabilitation program can be very useful.
• Ensuring vaccinations are kept up to date.
• Treating infections early and aggressively.
• Home oxygen may benefit patients with persistently low oxygen levels.
• Treating other health conditions such as heart disease, obesity etc. which contribute to breathlessness.

There are various categories of medications that are useful in COPD. These include:

• Anticholinergics – (eg. Ipratropium, Tiotropium and Glycopyronium)
• Inhaled steroids (eg. Budesonide, Fluticasone and Ciclesonide)
• Bronchodilators – include short acting (eg Salbutamol) and long acting (Salmeterol, Eformeterol and Indacaterol)

The choice of medications depend on various factors. Some patients may benefit from an inhaler from each of the above categories, but patients with milder forms of COPD may not need any regular inhalers.