LUNG CANCER INFORMATION
Lung Cancer Consortium Singapore
C/O National Cancer Centre Singapore
11 Hospital Crescent, Singapore 169610
LUNG CANCER INFORMATION
The Lung Cancer Consortium Singapore (LCCS) aims to bring together the clinical and research communities in order to advance the diagnosis and management of thoracic cancers.
We want to use our page as a platform to increase awareness and support for patients in their journey with lung cancer. Stay tuned for updates and information about lung cancer and the various screenings and treatments available.
LUNG CANCER INFORMATION BOOKLET FOR PATIENTS
It can be intimidating to be diagnosed with lung cancer, let us help you navigate this journey one breath at a time. In this LEAP! initiative, we provide an overview of lung cancer with the aim of enhancing patient education, improving patient support as well as facilitating patient advocacy. Patient advocacy involves empowering patients to participate in shared decision making during their lung cancer journey, through educational resources, peer support and community outreach.
Thoracic Medical Oncology Team @ NCCS
Who are we?
A group of medical oncologists who specialize in the treatment of lung cancers and are responsible for prescribing systemic treatment (chemotherapy, targeted therapy, immunotherapy).The Lung Cancer Consortium Singapore (LCCS) was established in 2001, with the aim to bring together the clinical and research community in order to advance the diagnosis and management of thoracic cancers. Both public and private sector clinicians across all hospitals collaborate with research institutions in Singapore in order to better understand the origins of lung cancer, as well as introduce improved interventions and novel therapies for cancer patients.
As an academic centre, we endeavour to deepen our understanding of lung cancer and thereby deliver quality care to our patients. The National Lung Cancer Research (NLCR) study is part of this effort, which includes in-depth study on our patients as well as cutting-edge scientific research. You may be approached by our research coordinators to participate in this – do your part for lung cancer today!
Lung Cancer Education and Advocacy for Patients (LEAP) was established in 2019, with the aim of enhancing patient education, improving patient support as well as facilitating patient advocacy. Patient advocacy involves empowering patients to participate in shared decision making during their lung cancer journey, through educational resources, peer support and community outreach.
If you are keen to join LEAP, find out more and/or make a donation, please kindly email us at email@example.com
What services do we provide?
Lung Cancer Basics
What is lung cancer?
How does lung cancer develop?
Cancer cells acquire genetic changes which cause them to grow abnormally in the lung. These abnormal cancer cells may invade normal parts of the body and spread to other parts of the body through blood/lymphatic vessels (metastasis).
Risk factors for lung cancer
Tobacco smoking is the most common risk factor for developing lung cancer, both SCLC and NSCLC. Your risk increases the longer you smoke and the more you smoke. If you are keen to stop smoking and would like some help, kindly speak to your doctor about our Smoking Cessation clinic.
Exposure to certain chemicals such as asbestos also increases the risk of lung cancer. Asbestos was used in shipbuilding and the construction industry in the 1960s but has since been banned.
Symptoms of lung cancer
The most common symptoms of lung cancer are chronic cough and breathlessness. Coughing up blood, fatigue, pain, loss of appetite and loss of weight are also frequently encountered. However, some patients with an early lung cancer might not have any symptoms.
Diagnosis and Staging
How is lung cancer diagnosed?
Comprises a combination of scans and biopsy of an abnormal growth that was detected on a scan or on clinical examination.
How is lung cancer staged? Why do we do staging?
After confirming the diagnosis of lung cancer, your doctor may order additional tests to determine if the cancer has spread to other parts of the body. This information is used to decide on the stage of the lung cancer. Different stages of lung cancer require different types of treatment.
Stages of lung cancer
Small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC) are staged differently.
• Limited-stage: cancer cells are only on one side of the chest and can be treated with a single radiation field
• Extensive-stage: cancer cells have spread throughout the chest, the other side of the chest and/or other body parts far away.
• Stage 0: cancer cells are in airways but have not grown into lung tissue or spread outside the lung
• Stage 1 – 3: cancer cells have grown into lung tissue, some have spread to nearby lymph nodes but not spread to body parts far away.
• Stage 4 (metastatic): cancer cells have spread to body parts far away from the primary lung tumour. Common sites of spread include brain, adrenal gland and other parts of the lungs
Molecular/Biomarker testing (for NSCLC)
Please note that not every test is appropriate for every patient and doctors may recommend different tests depending on each individual’s cancer condition. Talk with your doctor on which procedures and tests are right for you.
1. Stage 1 and 2
2. Stage 3
3. Stage 4
Please note that this is just a guide and does not apply to all patients as each patient’s condition is unique. Please speak with your doctor if you have further questions
4. Clinical trials
Surgery for lung cancer can be done for diagnostic or therapeutic purposes
How does radiotherapy work?
Radiotherapy uses high energy x-rays to destroy cancer cells. As normal cells can also be damaged by radiotherapy, radiation treatment is carefully delivered in a targeted manner to achieve therapeutic outcomes while minimizing side effects. Following radiotherapy, the side effects will gradually resolve as the normal cells repair themselves.
Radiotherapy may be given:
What is the radiotherapy process like?
For radiation treatment to be delivered in a targeted manner, it needs to be carefully planned by your radiotherapy team.
Planning for radiotherapy usually involves having a CT scan of the area of treatment (known as a CT simulation scan). A mould (known as a vac-lok) will also be carefully fitted to help you lie on your back, with both arms raised above your head (supported by arm rests) during the scan. Information from the simulation scan will then be sent to a treatment planning computer, which will work out the radiation doses to be delivered to the target area.
It is important for you to lie still, so that your position can be recorded. If you feel uncomfortable during the simulation scan, please inform your radiotherapy team so that they can make you more comfortable. You will need to be in the exact same position when you receive your radiotherapy treatment. To aid your radiation therapist in positioning your body for treatment, some treatment setup marks or lines may be applied to your skin. These must be kept throughout the course of your treatment. Do NOT erase them or apply soap when washing over the area being treated.
During the simulation scan and treatment, you are required to breathe in a regular and uniform pattern. To maintain the regularity of your breathing and your arms’ position comfortably during the course of treatment, we recommend deep breathing, arms, shoulders and side bending exercises. Please speak to your radiotherapy team for more information on these exercises.
Figure 1. A patient undergoing a CT simulation scan for chest radiotherapy. The patient lies on his back, with both arms raised above his head, in the treatment position. The vac-lok keeps the patient in a comfortable and consistent position. A respiratory localization box and an infra-red camera, allows tracking of the patient’s breathing. Sometimes patients may be required to hold their breath during treatment, to reduce the field of radiation. This is known as deep inspiration breath-hold (DIBH) treatment. In these instances, patients will have a visual accessory to guide them in holding their breath.
Different types of radiotherapy treatments
Radiotherapy is directly aimed at cancer cells from a radiotherapy machine. Depending on the lung cancer stage and area of treatment, radiotherapy can be delivered in different ways.
Stereotactic body radiotherapy (SBRT)
SBRT delivers extremely precise, very intense, high doses of radiation to small lung cancers while minimizing damage to surrounding healthy tissue. Treatment courses are usually short (approximately 2 weeks). It is only suitable for some patients.
Conventional radiotherapy is delivered in short daily sessions (Monday to Friday) over a period of 4 to 7 weeks. This form of radiotherapy is often used in multimodality treatment with surgery and/or chemotherapy.
Palliative radiotherapy can be delivered to shrink cancers and control symptoms such as pain, coughing up blood or breathlessness. This can either be delivered in one session or over a few days to weeks. The type of palliative radiotherapy used is highly specific to each individual patient. Please speak to your radiation doctor for more information.
What are common side effects during the course of chest radiotherapy?
During the course of radiotherapy, the treatment itself is not painful. However, over time, you may experience some side effects from treatment. Please do not be distressed, as these side effects are usually temporary and specific to the area of radiation. Below is some advice on what you can do to minimize discomfort during your radiation treatment.
1. Difficulty swallowing
If your gullet receives some radiation, you may feel discomfort when eating. This is due to inflammation. To minimize the problem:
You may experience increased coughing and some breathlessness during or sometimes after treatment. Some medication from your doctor can alleviate these problems. If you have fever and/or your phelgm becomes dirty, green or foul smelling, please inform your radiation doctor or therapist.
Your skin, especially at the back region, may become darker (similar to a sun tan effect). This does not require any medication and will disappear gradually after treatment.
If you experience any issues during the course of your radiotherapy, please do not hesitate to inform your radiation doctor or radiation therapists.
What are possible late effects following chest radiotherapy?
Rarely, some patients may develop side effects weeks or months after radiotherapy. These are typically known as late effects. Possible late effects include:
Targeted ways of radiotherapy delivery have reduced the risks of these late effects happening. Therefore, most patients do not experience them. If you are worried about late effects, please talk to your radiation doctor for more advice.
Figure 2. A patient undergoing chest radiotherapy. Radiation is directly aimed at the tumour target from a radiotherapy machine known as a linear accelerator (LINAC).
How does chemotherapy work?
Chemotherapy works by interfering with DNA, which results in cell death. Normal healthy cells are also affected this process, which gives rise to side effects such as hair loss and low blood counts as common examples.
What is the chemotherapy process like?
What are common side effects related to chemotherapy?
Side effects will differ between the various chemotherapy agents. Common general side effects would include hair loss, fatigue, change in taste, nausea/vomiting and low blood counts as some examples. These side effects are usually temporary and steps can be taken to prevent or reduce them. Your doctor will discuss in detail what other specific side effects to look out for.
If you are on Pemetrexed (Alimta) chemotherapy, you will need regular oral Folic acid and Vitamin B12 injections to prevent side effects such as low blood counts.
How does targeted therapy work?
Patients’ whose tumours have specific abnormalities present within the lung cancer cells may be sensitive to certain drugs which target these specific abnormalities. The most common ones would be EGFR and ALK, for which oral tyrosine kinase inhibitors (TKI) tablets have been shown to have benefit over standard chemotherapy.
What are some examples of targeted therapy?
EGFR TKI: Gefitinib, Erlotinib, Afatinib, Osimertinib
ALK TKI: Crizotinib, Ceritinib, Alectinib, Lorlatinib
What are common side effects caused by targeted therapy?
Side effects are dependent on the type of drug and the severity may vary from person to person. Common side effects include rashes, diarrhoea, paronychia (nail bed infection), nausea/vomiting and oral ulcers. These are usually mild and manageable with medications and/or medication dosage adjustments. Rare but potentially dangerous side effects would include pneumonitis (inflammation of the lungs) and transaminitis (liver inflammation). Blood tests will be done at clinic visits to monitor your organ function. If you experience persistent fever, worsening breathlessness and/or cough please inform your doctor immediately.
Figure 4. Paronychia – infection of nail bed
How does immunotherapy work?
Our body’s immune system not only helps us to fight infection, but can also help to prevent or slow cancer growth. However, cancer cells have developed ways to hide from the immune system and continue to survive and grow. Immunotherapy refers to drugs that may help to activate and work with a person’s immune system to recognise and attack cancer cells.
Common types of immunotherapy used in lung cancer are called ‘checkpoint inhibitors’ which are drugs which target a protein called PD-1 or its partner protein PD-L1. These proteins are immune checkpoint proteins which prevent the immune system from killing cancer cells. Checkpoint inhibitors work by interfering with this process, thereby activating the immune system to destroy cancer cells. These drugs are given in a similar way to chemotherapy by a drip in our treatment unit.
Other types of immunotherapy are being tested in lung and other cancer types such as (i) combinations of checkpoint inhibitors or combinations of checkpoint inhibitors with other drugs and (ii) vaccines. Some of these may be given in the context of a clinical trial.
Who is suitable for immunotherapy?
Immunotherapy can be used as adjuvant treatment in Stage 3 NSCLC following chemotherapy and radiotherapy.
It is more commonly used to treat Stage 4 lung cancer especially in patients not suitable for targeted therapy, either in combination with other drugs or as a single agent. PD-L1 is a biomarker which is routinely tested on lung biopsy specimens and the PD-L1 score of the cancer helps doctors decide what would be the best treatment strategy.
What are the common side effects from immunotherapy?
Immunotherapy in general is fairly well tolerated although fatigue may be experienced. The side effects are mainly related to overactivity of the immune system resulting in inflammation of various organs, of which the common ones affected are skin, thyroid, lungs and liver. Rarely, patients may develop life-threatening side effects related to inflammation of vital organs such as the brain and lungs and or heart. Please inform your doctor if you are feeling unwell and seek medical attention early.
What are clinical trials?
Clinical trials are medical research studies involving people. Specifically for cancer research, these studies are performed with the intention of improving the ways we treat and prevent cancer.
Why should I participate?
Clinical trials are needed to establish the efficacy and safety of breakthrough treatments which can become the new standard of care. Participating in a clinical trial may also give you access to cutting-edge treatment options which may have not been readily available otherwise.
Clinical trials not only have potential direct benefit to the participant, but also help others. When you participate in a clinical trial, you are contributing to a body of knowledge which serves to improve our understanding of cancer and also advance treatment and prevention strategies.
What is multidisciplinary care and who may be involved in my care?
Treatment of lung cancer involves multiple specialties, otherwise termed as multidisciplinary care. The specialties involved may include some, if not all, of the following:
National Cancer Centre Singapore provides a myriad of trained Allied Health professionals to help patients through their cancer journey. These include:
Please ask your doctor if you are interested to know more or access any of these services
What is Supportive and Palliative Care?
Supportive and palliative care is an approach to care, that focuses on the management of problems related to your cancer and its treatment. It aims to improve the quality of life of cancer patients and their families and is appropriate at any stage of your illness. It has been strongly recommended by major clinical cancer societies that supportive and palliative care be given alongside usual oncology care for any patient with advanced cancer.
In NCCS, our supportive and palliative care specialists from the Division of Supportive and Palliative Care (DSPC) work very closely with your lung cancer team. Our DSPC team consists of a multidisciplinary team of doctors and nurses. Your doctor may have already referred you to a supportive and palliative care specialist before or during your treatment; or you may be newly introduced to this team. This does not mean your doctor has abandoned or given up on you, but rather, your doctor has done this, to ensure that you will have an additional layer of care, support and attention – to allow you and your caregivers, to cope with the physical, emotional, mental, social, spiritual and practical needs.
As a patient living with lung cancer, here are some of the symptoms that might occur (the list is not exhaustive, but we have listed the more common symptoms).
We hope to provide you with some quick tips regarding how you can cope better with these symptoms.
Symptoms that a lung cancer patient might face:
Shortness of breath, also known as dyspnoea or breathlessness, refers to the feeling of having difficulty in breathing. The severity may vary from person to person, but the feeling of suffocation can cause much anxiety and distress in many people with cancer.
There are many possible causes of breathlessness, which may (or may not) be related to your cancer.
Your doctor will ask you further questions (e.g. when it started, associated symptoms) and conduct a physical examination, to find out the cause of your shortness of breath.
New or sudden onset shortness of breath usually requires urgent attention to investigate and treat the cause, whilst more chronic shortness of breath can be managed with medicines to relieve the symptom.
Your doctor may also order further investigations (e.g. x-rays) if needed. Treatment for dyspnoea depends on its cause.
Some of the methods to manage your breathlessness include:
1. General/ environmental e.g. maintaining a calm atmosphere, encouraging air flow to the face (From the window or a hand-held fan)
2. Energy conservation (The 4 ‘P’s)
When sitting on your chair or sofa, sit upright with your back against the chair with feet apart, and lean forward with your arms on your knees
When standing, lean back against the wall with your feet slightly apart. Keep your shoulders relaxed
3. Learning relaxation techniques
4. Using pursed lips breathing
i. Pursed Lip Breathing Technique:
ii. To get speed and posture of your body into the rhythm of breathing:
iii. Coordinate breathing with body movement:
Application of Energy Conservation in basic self-care
Using a handheld fan:
These can include:
Your doctor will have a discussion with you regarding your medication and the benefits and side effects of the medication. Opioid medications are not addictive and are safe for consumption, if prescribed for the appropriate condition and in the appropriate dose.
Other methods for managing your breathlessness could involve referring you to another group of professionals e.g. physiotherapists or occupational therapists to help you manage your breathlessness.
Some patients develop fluid collections in their chest which can make it difficult for them to breathe especially when doing some physical activity example walking or climbing stairs. It may be necessary to remove this fluid to help the lungs expand again. This is done under sterile conditions by inserting a small needle through the skin into the chest cavity under ultrasound guidance. This is known as “fluid aspiration”.
In many cases, it is necessary to insert a small soft plastic tube to allow the fluid to drain out gradually over a few days. The tube is connected to a specialised plastic box known as an underwater seal. Under sterile conditions, a small needle is inserted through the skin into the chest cavity under ultrasound guidance. Then, a wire inserted through the needle and the needle is removed. Then the soft tube is inserted by sliding it over the wire, and then the wire is removed. The tube is stitched to the skin. This is known as “fluid drainage”.
Both the fluid aspiration and fluid drainage procedures are commonly performed and are considered very safe. Very uncommonly, there may be problems due to bleeding, infection, tube dislodgement, tube blockage or pneumothorax (air in chest cavity).
Pain is an unpleasant sensation and experience caused by damage to any body tissue or nerve. Although it may seem common, not every person with cancer will experience pain. Even if you do, it may help to know that all pains can be treated, and most pains can be controlled.
Causes of pain
These can be related to:
As treatment of pain depends on its cause, your doctor will ask you more questions regarding your pain (e.g. when it first started, how it feels like) and perform a physical examination to find out what is causing the pain. Your doctor may also advise for further investigations (e.g. x-rays) if needed.
Treatment then involves:
Your doctor will have a discussion with you regarding your treatment and the benefits and side effects of the medication. Opioid medications are not addictive and are safe for consumption, if prescribed for the appropriate condition and in the appropriate dose.
A cough is a natural reflex and is your body’s way of clearing the airways of irritants and protecting your lungs from infection.
A cough can be acute (starts suddenly, lasts less than 3 weeks) or persistent (lasts more than 8 weeks).
A cough that brings up mucus or other secretions is called a productive (or wet cough), one that does not is called a dry cough.
These can be related to the
Danger signs (which you should tell your doctor about) include:
Your doctor might order up some tests to diagnose the reason for your cough. Your doctor might also start some medicines. These could include:
Some patients might also undergo specific treatment that target the tumour causing the cough, e.g. chemotherapy, radiation, surgery. Other methods to help manage the cough include:
https://www.cancer.net/coping-with-cancer (doctor approved information from ASCO)
Living with advanced cancer or being told that treatment is no longer working can cause you to experience a wide range of emotions. You may be anxious about the uncertainties ahead, or you may feel defeated that your cancer has progressed despite everyone’s best efforts. You may feel sad or perhaps worry about leaving your loved ones behind. These feelings are normal, and there is no right or wrong to how you should feel. Many people find that talking to their families, close friends or healthcare team about their feelings and concerns help them feel and plan better during this time.
Below are some common topics that you might feel that you want to talk to your loved ones about:
The following are some useful resources and readings:
Should you feel you need more help about these topics, please ask your healthcare team about it. They might consider making a referral to the appropriate healthcare specialist for you to further discuss this.
What about caregivers?
Below are some common questions that caregivers might ask.
Are caregivers expected to put up a strong front all the time?
Caregiver stress is real. Take time to pause and reflect. Do acknowledge your feelings regularly. You are allowed to feel sad or inadequate. You are not expected to know everything. You are definitely allowed to rest.
Should I approach end of life topics with my loved one?
Not all loved ones might be ready to have this conversation with each other. However, along this journey, there are certain trigger points that might be important for one to have a frank and open conversation with each other (such as whilst one is approaching a change in different treatments or whilst one notices that your loved one is getting weaker)
How can I approach end-of-life topics with my loved one?
You do not have to approach these topics if you are not comfortable. But if you would like to, here are somethings you can do while discussing end-of-life topics with your loved one.
Listen actively and observe if there are underlying fears, anxiety and worries. Talking about these emotions and issues earlier will allow for one complete unfinished business, encourage reconciliation or forgiveness in relationships.
Overall, should you feel you need more help about these topics, please ask your healthcare team about it. They might consider making a referral to the appropriate healthcare specialist for you to further discuss this.
Why do I need a repeat biopsy if I already had one at diagnosis?
Cancer cells can acquire mutations over time which change their behavior including response to treatment. A repeat biopsy may be recommended to look for these mutations to see if a change in treatment strategy would be appropriate, and/or assess suitability for clinical trials.
How is a biopsy done?
Tissue biopsies typically involve needle biopsies, where small needles are inserted through the skin to extract cancer cells from a tumour. This is commonly done under imaging-guidance (Ultrasounds/CT scans etc). Select cases may require other biopsy methods, which your doctor will discuss with you.
Surgical biopsy: done under general anaesthesia either through minimally invasive techniques or open surgery Liquid biopsies usually involve blood draws.
How will I afford treatment?
Cost of treatment is an understandingly important concern for patients and we are here to help.
Many anti-cancer drugs offered at our centre are standard cancer treatment options which are covered by Medisave/Medishield. Patient assistance programmes and/or subsidies are also available for selected drugs including targeted therapy and immunotherapy which tend to be costlier.
NCC also has dedicated Medical Social Workers (MSWs) who are able to provide financial assistance for needy patients.
If you have financial concerns, please speak to your doctor.
Glossary/Useful Terms to Know
A subtype of cancer which originates from the lining of organs, for example the airways
A small organ on top of each kidney which produces hormones
ALK (Anaplastic lymphoma kinase)
A type of protein on the edge of a cell that sends signals for cell growth
A procedure that removes fluid or tissue samples for testing
One of the two main airways that extends into the lungs
Cancer arising from cells that line the inner or outer surfaces of the body
Computed Tomography (CT)
A scan that uses x-rays from many angles to make a picture of the insides of the body
A dye put into the body to make clearer pictures during scans
EBUS (Endobronchial ultrasound)
A procedure that involves putting an ultrasound probe down the windpipe to visualize structures inside the lung. Commonly combined with a biopsy.
EGFR (Epidermal growth factor receptor)
A protein on the edge of a cell that sends signals to the cell to grow
FNA (Fine needle aspiration)
A procedure that removes tissue samples with a very thin needle
Coded instructions in cells for making new cells and controlling how cells behave
Growth of cancer cells from their origin into another tissue
Small glands that are widely present throughout the body and form part of the immune system
The spread of cancer from the original tumour site to other areas of the body
MRI (Magnetic Resonance Imaging)
A scan that uses radio waves and magnets to make pictures of the insides of the body
Abnormal changes in coded instructions within cells (genes)
NGS (Next Generation Sequencing)
A modern technology used to sequence DNA and RNA efficiently
NSCLC (Non-small cell lung cancer)
A cancer originating from lung cells
A procedure that removes fluid from around the heart with a needle
PET (Positron Emission Tomography)
A scan which uses a radioactive drug (tracer) to show activity within the body on a cellular level
An excess of fluid between the two layers of tissue lining around the lungs
The likely course and outcome of a disease
PFT (Pulmonary Function Tests)
A set of breathing tests used to test the strength of the lungs
A type of protein on the edge of a cell that sends signals for cell growth
Small cell lung cancer
TTNA (Transthoracic needle aspiration)
A procedure that removes tissue samples with a thin needle guided through the chest wall
LEAP held a webinar on this topic in May 2020, the video is available on the NCCS Youtube channel.
How can I find out more?
We hope you have found this booklet helpful. Please email us at firstname.lastname@example.org if you have further queries.
We would like to thank Dr Apoorva Gogna (Interventional Radiology), Dr Cynthia Chia (Cardiothoracic Surgery), Dr Kevin Chua (Radiation Oncology) and Dr Shirlyn Neo (Palliative Medicine) for their invaluable help in the production of this pamphlet.
EARLY STAGE – NON SMALL CELL LUNG CANCER
Here are some interesting facts about Early Stage – Non Small Cell Lung Cancer, including its treatment overview, as well as treatments available.