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* From the Brigham and Women’s Hospital, Division of Thoracic Surgery, Harvard Medical School, Boston, MA
Correspondence to: Jeanne M. Lukanich, MD, Brigham and Women’s Hospital, Division of Thoracic Surgery, 75 Francis St., Boston, MA 02115; e-mail: jmlukanich{at}bics.bwh.harvard.edu
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Abstract |
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Introduction |
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Information on tobacco and lung cancer is now widely available to patients, the media, citizen groups, and physicians. However, this information is often misleading, conflicting, inaccurate, and incomplete. Clearly, education remains a primary weapon of this war being waged in the public health arena. It behooves us, therefore, as medical caregivers, to make ourselves familiar with the information and the issues. When treating patients with tobacco-related lung diseases, it is important to consider the patients, their families, and the public at large while developing a strategy. In this way, we can have the largest impact on personal and public health.
The following sketches are drawn from actual patients seen in a busy thoracic surgical service. These illustrate different types of patients’ relationships with tobacco, and they segue neatly into the topics to be discussed under the heading "Tobacco and Public Health." While some of the accompanying questions have no absolute answers, they are submitted in an effort to encourage thought and discussion.
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Case Number 1 |
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Question:
Which answer below describes this patient’s
relative risk for developing a primary lung cancer ?
a. The risk is increased over that of someone who never smoked.
b. The risk is the same as that of someone who never smoked.
The answer is a: The risk of developing lung cancer begins to decrease soon after smoking cessation, but remains substantially higher than that of a lifelong nonsmoker regardless of the length of abstinence. For former smokers, the lung cancer risk drops by approximately 30% if they remain tobacco free for 20 years.3
Examination of the patient demonstrated hyponatremia, which prompted further investigation. A 3.5-cm nodule in the anterior segment of the left upper lobe was identified on chest x-ray (CXR).
Question:
Which of the following statements about
paraneoplastic syndromes are true?
a. They are caused by production of biologically active substances by tumor cells.
b. They are caused by production of biologically active substances in response to tumor cells.
c. They are caused by unknown mechanisms.
d. They are caused by poor prognostic indicators.
e. a, b, and c only
The answer is e: Paraneoplastic syndromes have not been shown to be poor prognostic indicators and often resolve after the primary lung cancer has been treated.4
This patient’s past medical history is notable for mild hypertension and occasional chest tightness with exertion. Metastatic workup for the newly diagnosed lung mass was negative. Pulmonary function tests showed an FVC of 2.59 (86%) and a FEV1 of 1.43 (74%). Bronchoscopy demonstrated cells suspicious for malignancy. This man subsequently underwent thallium exercise stress testing, echocardiogram, and coronary angiography. Catheterization demonstrated a 70% proximal left anterior descending stenosis and 100% proximal circumflex and proximal right coronary artery occlusions.
Question:
Which of the following options would you choose for
your surgical plan?
a. Arrange coronary artery revascularization before consideration of this pulmonary malignancy.
b. Obtain a fine needle aspiration of the pulmonary mass.
c. Perform cervical and anterior mediastinoscopies before consideration of his cardiac abnormalities.
d. Perform a combined thoracic and cardiac procedure.
The answer is d: Recent reports have substantiated the safety and feasibility of combined cardiac and thoracic procedures.5
The patient then underwent bronchoscopy, cervical mediastinoscopy, left upper lobe wedge resection, and coronary artery bypass grafting of the left internal mammary artery to the left anterior descending coronary artery and saphenous vein grafts to the posterior descending artery and obtuse marginal. Subsequently, he underwent completion left upper lobectomy. His pathology demonstrated a T2N0 adenocarcinoma. He has been doing well in follow-up.
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Case Number 2 |
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Question:
What is the chance that this lesion is a primary
non-small cell lung cancer?
a. 30%
b. 50%
c. 70%
The answer is c. A general rule of thumb suggests that the chance of malignancy of solitary pulmonary nodule in a smoker is approximately equal to the person’s age.6 7
Pulmonary function tests demonstrated an FVC of 1.96 (63%) and an FEV1 of 1.35 (56%). Of note, this patient had two dogs at her home, both of which were diagnosed with lung cancers. Her family history is significant for emphysema in one sister and lung cancer resulting in the death of another.
Question:
Identify the false statement. A positive family
history with regard to the development of lung cancer is:
a. Independent of a patient’s tobacco history.
b. Additive from a relative risk standpoint with smoking.
c. Significant in both women and men.
The answer is b. The mathematical increase in relative risk of development of lung cancer in a smoker with a positive family history is much greater than the summation of the relative risks of either smoking or positive family history alone.8 9 The diagnosis of emphysema itself in a first-degree relative signifies an increase in relative risk of developing lung cancer on the basis of family history.10
This patient first underwent bronchoscopy and cervical mediastinoscopy, which were negative, followed by right thoracotomy with upper lobectomy for a TIN0 adenocarcinoma. She then quit smoking and remains well in recent follow-up. Follow-up information on her dogs is not available.
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Case Number 3 |
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Question:
What would be your treatment strategy?
a. Arrange photodynamic therapy/laser therapy.
b. Resect the appropriate segment and monitor radiologically postoperatively.
c. Resect the appropriate lobe and follow symptomatically.
d. Resect using parenchymal sparing techniques and monitor bronchoscopically postoperatively.
e. Declare patient to be unresectable due to diffuse metaplasia.
f. Arrange brachytherapy to the lesion.
The preferred answer is d, although this is an evolving topic, and a is showing promise as the preferred treatment.11 12 It is important to note that metaplasia is a field defect and does not influence resectability.
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Case Number 4 |
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Question:
Based on this knowledge, you would...
a. Hope her primary care physician would arrange a CXR.
b. Congratulate her.
c. Obtain a CXR.
d. Do nothing, because she is asymptomatic.
The answer is c: While it is estimated that nearly 90% of lung cancer cases are smoking related, a 1997 study by the American Cancer Society revealed a 20% higher lung cancer death rate among nonsmoking women whose spouses were smokers over the death rate from lung cancer of nonsmoking women whose spouses were nonsmokers.13 In the United States, approximately 1,500 women per year develop lung cancer due to second-hand or sidestream smoke.1
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Case Number 5 |
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Question:
As a primary care physician you would do which of
the following?
a. Get a baseline CXR if the patient insisted.
b. Order a CXR only if she develops respiratory symptoms.
c. Obtain a detailed history and obtain CXR only if other significant information is uncovered.
d. Obtain a baseline CXR and CXRs at intervals.
The answer is d. Her social history suggests an increased risk of developing a lung cancer.14 15
A CXR was obtained when she failed to pass the exercise pulmonary function testing that was administered as part of her yearly examination through the airline. A 2-cm pulmonary nodule was identified in the right upper lobe. After appropriate workup, she underwent right upper lobectomy for a TIN0 squamous cell carcinoma.
Question:
Which of the following professions is not at
high-risk for developing lung cancer?
a. Miner
b. Lifeguard
c. Wait staff
d. State mental health worker
e. Bartender
The answer is b. All other professions listed are associated with significant passive smoking or other environmental exposures such as radon or heavy metal dust.15 16
Six years later, routine follow-up CXR demonstrated a new right middle lobe nodule. The subject had continued to work as a flight attendant since her pulmonary resection, but had not worked on smoking flights thereafter.
Question:
Identify the lifetime chance of developing a second
primary lung malignancy after treatment of a smoking-related lung
cancer:
a. Negligible
b. Approaching 15%
c. Greater than 50%
d. Inevitable
The answer is b. Approximately 15% of lung cancer patients will be diagnosed with a second primary lung malignancy during follow-up.17
Question:
What is the chance of this second nodule being
malignant?
a. Greater than 50%
b. Less than 50%
c. Negligible
The answer is a. Recent data have shown that new lung nodules in a patient with a previously documented malignancy anytime in the past have a high incidence of being identified as primary or secondary malignancy.
A second primary lung cancer was resected by means of lobectomy 6 years after her initial resection.
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Case Number 6 |
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Question:
Which of the following definite environmental
agents is not linked to lung carcinogenesis?
a. Asbestos
b. Coal combustion products
c. Nickel
d. Environmental tobacco smoke
e. Radon
The answer is b. While some association has been suggested between coal combustion products, such as coal and gas, and the development of lung cancer, this has not been scientifically proven.15 16
On routine preoperative CXR, the patient was found to have a 3-cm irregularly shaped right hilar mass. Bronchoscopy revealed an obstructive lesion in the posterobasilar segments of the right lower lobe. Mediastinoscopy was negative. At thoracotomy, a necrotic subcarinal lymph node was biopsy positive for squamous cell carcinoma.
Question:
Your next step would be to:
a. Continue with planned pulmonary resection and lymph node dissection.
b. Perform a right pneumonectomy.
c. Close the thoracotomy and arrange radiation therapy.
d. Close the thoracotomy and arrange neoadjuvant chemotherapy.
e. Close the thoracotomy and arrange hospice care.
The best answer is d. Along with three prospective randomized trials, more and more data are becoming available suggesting that outcomes are improved with neoadjuvant chemotherapy in the treatment of stage IIIA (N2) non-small cell lung cancer if the patient is otherwise a candidate for aggressive therapy.
The patient received neoadjuvant chemotherapy and subsequently underwent right lower lobe lobectomy. He continued to smoke.
Question:
What would be your response to this situation?
a. Insist on smoking cessation.
b. Refer the patient for smoking cessation intervention.
c. Prescribe medications to assist with smoking cessation.
d. Not get involved.
The only unacceptable answer is d. As caregivers, this is an extremely important area on which we can have an impact.
Four years later, the subject was found to have a new right upper lobe mass. After a negative metastatic workup and with adequate pulmonary functions, he underwent right upper lobe anterior segmentectomy for cancer. He quit smoking 2 months after his second pulmonary resection.
Question:
What would be your overall course of action?
a. Maintain your usual follow-up schedule.
b. Step up your usual follow-up schedule.
c. Discontinue routine follow-up.
The answer is a or b. As the patient has now been satisfactorily treated for two primary lung cancers, it should not be assumed that further therapy for either recurrence or yet another primary lung cancer could not be tolerated by the patient.
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Summary |
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Footnotes |
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References |
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