Family doctors urged to pay attention to patient symptoms

Date Published | Jun. 1, 2008

Thoracic surgeons and medical oncologists focused on lung cancer can be excused for their decidedly gloomy disposition.

While progress is being made in the battle against prostate, breast and colon cancer, and screening is available for all three, a diagnosis of lung cancer is all too often a death sentence.

“Only 20 per cent of the people I see in my office have a chance for a cure,” said Dr. Fabio Luison, a thoracic surgeon based in Sudbury. “Most of the people I see present with an advanced stage of the disease. Their cancer has spread to their lymph nodes or to other organs. It’s unfortunate because there are a lot of people I have to turn away.”

In the absence of any officially sanctioned screening, primary care providers have to be “very attuned to their patients’ symptoms, especially smokers,” advised Luison. A localized wheeze, unexplained weight loss, chest pain that’s persistent and unremitting, and phlegm production that doesn’t abate after a course of antibiotics are all warning signs of potential lung cancer, he warned.

Unfortunately, an individual with a small lung nodule can carry it around for several months or up to a year before it causes any problems.

The real warning signals manifest themselves when the tumour gets into the airway and the patient begins to cough up blood, or it starts to penetrate the lung surface and irritates the chest wall. Weight loss, seizures, vision problems, and gait disturbances are generally indications that the cancer has spread to the brain or other organs.

Resectional surgery

For the 20 per cent of patients with early stage tumours that have not spread beyond the lung, resectional surgery offers hope for a cure. Patients with early stage lung cancer who undego surgery have a five-year survival rate of 70 per cent – possibly even 80 per cent, depending on the size of the tumour, said Luison.

“If you go through all the work of an operation, you’d like to have the satisfaction of knowing that your patient has the best chance for a long term cure. Unfortunately, there are sometimes tumour cells floating around in the bloodstream and we have no imaging or blood tests available to detect that.”

Chemotherapy and radiation can prolong survival, but “we measure effectiveness in terms of weeks or months, not years,” said Dr. Andrew Robinson, a medical oncologist at Sudbury Regional Hospital.

In the last few years, it has become more common to administer chemotherapy following surgery to kill cancer cells that have spread beyond the lung, but the treatment increases the chance of a cure by only five to 10 per cent, noted Robinson.
“Most lung cancers are related to smoking, and the damage that’s done to the cells makes them less likely to respond to chemotherapy treatment.”

Black

Luison can vouch for that.

“When I enter a chest cavity during surgery, I can clearly tell who has had a significant smoking history. Someone who has never smoked has nice, pink, healthy-looking lungs. For a long-time smoker, you go in the chest cavity and you see black.

“As one smokes and inhales all that debris, the carbon deposition from all this material gets stuck in the lymphatic channels and it permanently sits there. You see black spots all over the place, or if it’s worse, it’s like a black sheet. If the patient has emphysema, it looks like bubble wrap. It’s no longer a nice smooth lung. There are more than enough reasons why someone should not smoke. The devastation caused by smoking is very real.”

Robinson underlines the importance of early detection.

A family physician in a busy practice may have a two-inch stack of reports to go through, he said. “They get very little remuneration for that and, occasionally, there’s an X-ray report that somehow gets missed.”

There’s no time to lose if a spot is detected on an X-ray because lung cancer, especially small cell tumours, can double in size within a few months, he noted.

“There are small gains being made all the time, but no one has hit a home run yet,” said Robinson, who was born and raised in Matheson. “The amount of money put into breast cancer research dwarfs the amount of money put into lung cancer, even though lung cancer kills more people.”

One cause for optimism is the possibility that screening tests, using low dose CT scans or sputum analysis may be available in the next five to 10 years, he said.
In the meantime, timely access to health-care resources is critical.

“Primary care is important because if you have a cough, you want to have an X-ray ordered and you want to be sure it’s going to get looked at and not going to get lost in the shuffle,” said Robinson.

It’s also important to be able to access surgeons and CT scans.

“We’re in a very fragile state in northeastern Ontario. If one surgeon left for whatever reason, we’d be in trouble. As for chemotherapy and radiation, patients may be slightly underserviced, but our treatments aren’t very effective anyway.”

Thoracic surgery is in the process of being regionalized in Ontario in an effort to improve outcomes.

“Thunder Bay has been established as a regional Level II centre and we have established a formal relationship with University Health Network (in Toronto),” said Dr. Kenneth Gehman, medical mirector of surgical oncology at Thunder Bay Regional Health Sciences Centre. “All thoracic surgery in the Northwest LHIN has been regionalized to Thunder Bay. In fact our success rate for resections is as high as many academic centres.”

Regionalization of resections in the northeast, presumably in Sudbury, is still being addressed.

Any discussion of lung cancer inevitably returns full circle to smoking, the cause of 85 per cent of lung tumours.

It’s never too late to quit, said Robinson, who admits that everyone in his family smoked.

“It used to be part of the culture. If you worked in a mine and you took a break for 10 minutes, you had a cigarette.”

Quitting reduces the risk, but it never goes down to zero, he said.