What Happens After a Lung Cancer Diagnosis

A lung cancer diagnosis arrives with a great deal of information attached, and most of it lands in a single appointment. Patients are asked to take in what stage the cancer is, whether a biopsy is needed and which kind, and whether treatment will mean surgery, medication, radiation or some combination of the three.

Some of what shapes that first visit happened long before the first diagnosis. Many patients picture lung cancer surgery the way it looked 15 or 20 years ago, with a long incision, ribs spread apart and months of difficult recovery, while others assume a diagnosis means there is nothing left to try. These ideas can deter people from coming in at all.

Dr. Geoffrey Pelz is a thoracic surgeon at Hackensack University Medical Center's John Theurer Cancer Center. He spoke with CURE about what he wants patients to understand before they leave that first appointment, what to do when they feel they are not being heard, and why follow-up scans continue for years after treatment ends.

CURE: What should patients understand after a first appointment for a lung cancer diagnosis?

Pelz: Lung cancer is one of the most deadly cancers that people can get, but not everybody's cancer is the same, and every cancer has a treatment. We want to make sure the patient knows there will be a treatment for the cancer.

From there, we figure out what the clinical stage looks to be, where the cancer is and where it isn't. If somebody needs biopsies, what method is best. And then ultimately there will be a treatment plan, whether that includes surgery, chemotherapy or other medications that go throughout the body, or radiation. Sometimes it's one of those three. Sometimes it's different combinations in different sequences.

That's individualized for each patient. Some people have very good heart function and lung function and can undergo whatever surgery needs to be performed. Some people are sick and couldn't undergo a big lung operation. But there are less invasive ways we can treat people, sometimes with just a biopsy and then radiation. All of that has to be tailored to that individual patient.

How do doctors walk patients through lung cancer treatment options?

I try to be very comprehensive. We start by looking at the images and showing where things are and where the areas of concern are. Sometimes patients have had a CT scan of the chest. Sometimes they've also had a PET-CT, so we can show where areas are lighting up on the scan, and that's easier to understand.

Some people come in with a biopsy already and are diagnosed with lung cancer. But a lot of the patients we see just have something that's suspicious, so we don't even know for sure if it is cancer. Then I'll go through the three general ways to biopsy a lung mass, and I can give my opinion as to what I think is best for that patient.

Ultimately it's up to the patient and family to decide what they think is best. I give my recommendation as the clinician for what would be the best way to go, but that decision is theirs.

What can patients do if they feel unheard by their lung cancer care team?

It's very overwhelming for patients when they come in. They've probably been told they likely have lung cancer, so they don't know what is going to happen, what the treatment would be, and whether they are going to be okay at the end of all of it. We try to go over all of that. It's a lot of information, and sometimes patients don't comprehend everything.

So it's always nice if there are other family members present at the visit, so other people can hear and digest the information. We encourage any questions that come up after the visit to give us a call. The nurse navigators, the nurse practitioners or myself can answer questions they may not remember to ask, or can't form right at the clinic visit. I also do a brief recap at the end and then ask the patient for any questions.

Every surgeon has a slightly different way of approaching things. Patients have to be comfortable with their surgeon, able to ask questions, and not get steamrolled and just being told what to do. That physician-patient interaction is very important. Sometimes it's helpful to get a second opinion from other surgeons, or medical oncologists, or pulmonologists, because patients do have to be comfortable with what they're going to be undergoing.

How does a lung cancer care team work together?

Our entire division is very collegial. There's three attending surgeons. We help each other out in the operating room, we take care of each other's patients, and everybody knows all the different patients. For any of the major operations, there are two attending surgeons there to take care of any problems.

But it's not just the surgeons. We have nurse practitioners who see the patients in the office, in the hospital during the post-operative course, and then in follow-up long term. We have nurse navigators who are very involved with the care and get to know these patients very well.

A lot of our staff have been here 10 plus years, so there's that continuity of care. There's a very long-term relationship that gets developed with all the different parts of our care team.

Is scan anxiety common after lung cancer treatment?

Everybody's a little bit different, but I would say probably at least half of my patients are very nervous about the scans, even if it's been fine for years. The blood pressures we take when they first come in are very elevated. Then once we go over the scan and everything's okay, they relax, we retake the blood pressure, and it's much better.

So what I do is, the second I go in and see somebody, I'll say, hey, the scan's okay. Then they can relax, and we can look at the scan and discuss things afterwards. As I follow patients over the years, a lot of them just need that initial everything's okay, and then we can continue on with the visit.

Why do patients keep getting scans after lung cancer treatment ends?

If somebody's had one lung cancer, they are at risk for developing a second one over time. It's a small cumulative risk, maybe 1% to 2% per year. So if somebody's living 20, 30 years after lung cancer, there's a much higher chance that at some point they may develop a second one.

If it's caught early, there are other ways to treat it. Sometimes we can do that biopsy from the inside of the airways and treat it with radiation, three to five treatments over the course of a week, and that can cure it. So not everybody needs repeat surgeries.

And most of the time, if there's something that needs to get looked at, it's not something that needs to get treated right away. Maybe we get a scan in three months instead of six months or a year. A lot of times it's just something we've got to keep a close eye on.

Is there still a stigma attached to a lung cancer diagnosis?

Lung cancer has kind of been thought of as a smoker's cancer, something that people did to themselves. That works externally, where people may think, oh well, that person did it to themselves, and have a bias against it. And the patients themselves sometimes think the same thing — that I did it to myself — and fixate on that.

A lot of patients may think that even if they get diagnosed with lung cancer, there's really nothing that can be done, so why even bother to get the scans. They don't want to know about it, and figure they'll live out their life and whatever happens happens.

There's been such dramatic advances both on the surgical side and on the medical side in the last 15 years that things are not like they used to be. It used to be either surgery or chemotherapy, and if it got outside the lung, essentially there was nothing that could be done. That's not the case anymore.

Not everybody who gets lung cancer got it from smoking. There are other risk factors, like radon exposure, diesel fumes and other job exposures. And even if somebody was a smoker, it doesn't matter. Whatever happened, happened. That's fine. There are ways to treat it now.

There's less invasive surgical methods that can get people potentially cured and back to their normal lives, and there's a lot of new advances in medical treatments. It's not just chemotherapy. There are targeted treatments that can have very good responses for people with much more advanced disease. We're seeing a small number of people even with stage 4 disease where it can be treated and converted into almost a chronic disease, kind of like diabetes, where a patient is on a medication that keeps things at bay and continues to live their life.

What should someone living with lung cancer know about treatment today?

Treatments are very different than they used to be. On the surgical side, minimally invasive surgery means a much faster recovery, and patients can get back to the quality of life they had before surgery. On the medical side, there's a lot of new treatments, where we can treat and potentially cure cancers that may not be surgically treated at all.

Patients should keep up with the scans. Catching things as early as possible is what gives them options.

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