A 69-Year-Old Former Smoker With Cough

A 69-year-old man presents with a cough of 3 months' duration. He has taken a variety of over-the-counter suppressants and received a course of antibiotics, without resolution. The cough is not position-related; it produces a small amount of sputum and recently flecks of blood as well.

HISTORY

The patient started smoking when he served in the army in Vietnam, and he has roughly 40 or more pack-years of exposure. He had a moderate morning cough, which resolved after he stopped smoking about 5 years ago.

He denies significant dyspnea but does not perform many vigorous activities. There have been no fevers, exertional or nonexertional chest pains, or ankle swelling. His only other medical problems are degenerative joint disease in his hips and knees, for which he takes NSAIDs as needed, and mild hypertension of 5 years' duration, which is well controlled with an angiotensin-converting enzyme inhibitor.

PHYSICAL EXAMINATION

Vital signs are normal. Head, eyes, ears, nose, and throat are also normal. No enlarged lymph nodes are noted in his neck, axillae, and supraclavicular areas. Heart rhythm is regular, without murmurs or gallops. Chest auscultation reveals a few expiratory wheezes and rhonchi bilaterally. The remainder of the physical findings are normal.

LABORATORY AND IMAGING STUDIES

Chemistry and biochemistry profiles are normal. White blood cell count is normal; hemoglobin level is 16 g/dL. A chest radiograph reveals a 2-cm irregular density in the right lower lobe, medially without other infiltrates, consolidation, or effusions. A chest CT scan confirms an irregular 2- to 3-cm mass with spiculations. The patient undergoes a transbronchial biopsy, which reveals non–small-cell carcinoma (adenocarcinoma).

Answer on Next Page

CORRECT ANSWER: B. Routine screenings would have significantly reduced his mortality risk from lung cancer.

Non–small-cell lung cancer remains the leading cause of cancer death in the United States and throughout the world. Lung cancer is clearly related to cigarette smoking. Fortunately, smoking is in decline in the United States, with a concordant diminution in the incidence of lung cancer. As in this patient, most cases occur in former rather than current smokers.

Screening. Many attempts to screen smokers and detect lung cancer in earlier, perhaps more curable stages have been made over the years. The most recent trials had conflicting results,^1,2 and there was some controversy about the accuracy and disclosure of the positive study.² At this time, neither the US Preventive Services Task Force nor the American Cancer Society believes there are adequate data to recommend or advocate routine screening of at-risk patients for lung cancer. All agree that smoking cessation, rather than screening, results in fewer cases of lung cancer and reduced all-cause mortality.³ Studies are ongoing, but for now choice B is false and thus is the correct answer.

Evaluation and therapy. All of the other choices have demonstrated efficacy in the evaluation and management of non–small-cell lung cancer. Choices D and A relate to initial staging and subsequent early therapy.

THE TAKE-HOME MESSAGE:

Routine screening of patients at risk for lung cancer is not recommended. Smoking cessation, rather than screening, reduces lung cancer incidence and all-cause mortality. PET scanning has become a key study in the initial evaluation of lung cancer patients and their potential candidacy for surgical resection.

As part of the initial evaluation of non–small-cell cancer of the lung, the most accurate imaging study has been PET scanning (choice D), which is far more sensitive than even CT scanning for evaluation of local, regional, and even distant tumor involvement. Thus, PET scanning is now essentially routine in the initial lung cancer evaluation to ascertain initial staging and treatment planning.^3,4

When the tumor has limited, local involvement (stages I and II), non–small-cell cancer is curable by surgical resection (choice A). This requires local criteria for resectability, lack of distant metastases, and patient candidacy for major thoracic surgery (ie, sufficient cardiac and pulmonary function). Local criteria for surgery and staging schemes are available in more detailed references.⁴ Appropriately chosen candidates-who unfortunately represent a distinct minority of lung cancer patients, most of whom present with advanced-stage disease-have a 5-year survival approaching 85% with operative mortality rates in the 1% to 3% range.

Prognosis. Once the initial diagnosis is made and appropriate staging and initial therapy are accomplished, what are some of the determinants of survival for patients with non–small-cell lung cancer? Factors shown to be prognostic indicators include the following:

Specifically, there was a linear relationship in prognosis and risk of death with deterioration as tumor differentiation regressed from well differentiated through moderately to poorly differentiated histologies.^1,3,5

Outcome of this case. A battery of tests, including PET scanning and mediastinoscopy, revealed stage II carcinoma. The patient underwent lobectomy of the involved lung. He then received a course of adjuvant platinum-containing chemotherapy. At 10 months' follow-up, he is clinically well without evidence of recurrence or metastatic disease.

References:

REFERENCES:1. Bach PB, Jett JR, Pastorino U, et al. Computed tomography screening and lung cancer outcomes [published correction appears in JAMA. 2007;298:518]. JAMA. 2007;297:953-961.
2. International Early Lung Cancer Action Program Investigators, Henschke CI, Yankelevitz DF, Libby DM, et al. Survival of patients with stage I lung cancer detected on CT screening [published corrections appear in N Engl J Med. 2008;358:1875, 1862; N Engl J Med. 2009;359:877]. N Engl J Med. 2006;355: 1763-1771.
3. Molina JR, Yang P, Cassivi SD, et al. Non-small cell lung cancer: epidemiology, risk factors, treatment, and survivorship. Mayo Clin Proc. 2008;83:584-594.
4. Pieterman RM, van Putten JW, Meuzllaar JJ, et al. Preoperative staging of non-small-cell cancer with positron-emission tomography. N Engl J Med. 2000; 343:254-261.
5. Neal JW. Histology matters: individualizing treatment in non-small cell lung cancer. Oncologist. 2010;15:3-5.

FOR MORE INFORMATION:
■ Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2008. CA Cancer J Clin. 2008;58:71-96.