Lung cancer pathway

Non-small cell lung cancer (NSCLC)

This is the most common lung cancer and there are three main types:

Adenocarcinoma – developing from the mucus-producing cells that line the airways.

Squamous cell carcinoma – developing in the cells that line the airways.

Non-small cell lung cancer not otherwise specified –when the pathologist (a doctor who examines tissue to help with the diagnosis of diseases) cannot say for certain which type of non-small cell lung cancer it is.

Small cell lung cancer (SCLC)

This cancer gets its name from how it looks under the microscope.

Mesothelioma

Cancer of the mesothelium which is a thin lining that covers the outer surface of many different organs in the body.

What to expect

This information describes cancer that starts in the lung which is called primary lung cancer. It describes the care you can expect from an initial concern about lung cancer and for every step afterwards
– your cancer pathway.

Needing immediate support

Macmillan support line 0808 808 0000 (8am-8pm, 7 days a week)

Directory of Services

COVID-19 update

Please note that aspects of the cancer pathway may have changed due to the COVID-19 pandemic and these changes are highlighted throughout the pathway. If you have any concerns or questions, always speak to your GP or cancer care team.

The aim of the COVID-19 guidance is to:

  • minimise your risk by reducing investigation and visits to hospital
  • reassure you if you have low risk symptoms that you will be investigated within a safe time frame in line with national guidance
  • identify if you are at a higher risk and make sure you are investigated quickly and receive urgent surgery if required.

People you could meet on your pathway

Initial investigation and referral

Symptoms of lung cancer include:

  • a cough for three weeks or more
  • a change in a cough you have had for a long time
  • a chest infection that does not get better or repeated chest infections
  • feeling breathless and wheezy for no reason
  • coughing up blood
  • chest or shoulder pain that does not get better
  • a hoarse voice for three weeks or more.

Other possible symptoms may include:

  • unexplained weight loss
  • feeling tired.

If you are experiencing any of the above symptoms, it is important to always get checked by your GP.

COVID-19 update

If you have symptoms that you are worried may be cancer, it is important to still seek advice from your GP surgery. Your symptoms do not mean you have cancer and could be caused by a number of common conditions but it is always best to get checked.

Your GP will ask about your symptoms and examine you. If they think your symptoms could suggest lung cancer, they will organise blood tests and a chest X-ray straight away.

Chest X-ray –  is the most frequently carried out procedure in any X-ray department. A chest X-ray gives a black and white picture of your lungs, ribs, heart and diaphragm.

The chest X-ray will be done at the hospital. The blood tests could be done at your GP surgery or at the hospital. Results can take a few days.

If your chest X-ray is normal, you may receive a telephone call from one of the cancer care team and/or a letter to let you know. Your GP will also get a letter confirming the results.

The hospital may see the results of your X-ray before your GP does and, if they have concerns, one of the cancer care team may contact you directly. They may ask you a few questions about your symptoms and medications and may recommend a CT scan.

Computerised tomography (CT) scan – a CT scan is carried out by the consultant radiologist at the hospital. A CT scan can produce detailed images of the inside of the body to diagnose conditions.

Suspected cancer

If your chest X-ray shows anything abnormal or you have been coughing blood, or if your GP thinks your symptoms could suggest lung cancer, they will make an urgent referral for you to see a consultant at the hospital within two weeks. This is called a fast track referral.

Your GP may make a fast track referral before getting the results of the chest X-ray if they feel the input of a consultant is needed without delay. 

When making the fast track referral, your GP will provide the respiratory consultant with all the necessary information to help them make a diagnosis, for example your medical history, your family history and the results of any tests already carried out.

When you have your appointment with the respiratory consultant, it will be face to face at the hospital or by telephone. The consultant will ask about your general health and ask about or confirm your previous medical history. They will explain further tests you may need.

COVID-19 update

During the COVID-19 pandemic fast track referrals are still essential but they may be managed differently.

For more information about fast track referrals during the COVID-19 pandemic download a fast track referrals leaflet:

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Tests you may have following your fast track referral

CT Scan

A CT scan can produce detailed images of the inside of the body to diagnose conditions. It may be necessary to have further CT scans to help with your diagnosis.

Positron Emission Tomography (PET)-CT scan

A PET scan produces detailed three-dimensional images of the inside of the body. It is particularly helpful for investigating cancer and can also show how well certain functions of the body are working.

Lung Function Test

This is to test how well your lungs are functioning. You may have a lung function test before, during and after treatment.

You will usually require a biopsy to find out whether you have lung cancer or not. There are different ways of taking a biopsy and your consultant or clinical nurse specialist will talk to you about the type of biopsy you may have.

Bronchoscopy and biopsy

A procedure which allows the consultant to look into your lungs and take tissue samples of the glands in the centre of your chest using an ultrasound scan to assist.

Lung needle biopsy

A procedure in which a thin needle passes into the lung to remove a sample of cells.

Bronchoscopy using Ultrasound guidance also called Endobronchial ultrasound (EBUS)

A procedure which allows the consultant to look into your lungs and take tissue samples of the glands in the centre of your chest using an ultrasound scan to assist.

Endoscopic ultrasound (EUS)

An endoscopic ultrasound is like an endoscopy (a test that looks inside the body using an endoscope) but the endoscope has an ultrasound probe on the tip. The probe uses sound waves to make pictures of the organs in the body.

Biopsy of neck lymph nodes

A procedure in which a thin needle passes into the lymph nodes to take a sample of cells.

CT or ultrasound guided biopsy

An image guided biopsy.

Removing fluid from around the lung (pleural aspiration)

A procedure in which a small needle or tube is inserted into the space between the lung and chest wall to remove any fluid that has built up around the lung.

For more information about the above tests
Macmillan Cancer Support

Diagnosis and staging

If you are diagnosed with lung cancer, you may have further testing to find out:

  • further detail about the size and position of the cancer
  • if the cancer has spread outside of the lung.

This additional testing will help find out how far advanced the cancer is or the stage of your cancer. It will help both you and your consultant to decide on the best treatment for you.

Further tests may include

Bronchoscopy using Ultrasound guidance also called Endobronchial ultrasound (EBUS)

Used for both staging and diagnosis in some instances.

Mediastinoscopy

Allows the consultant to look in the area at the middle of your chest and the nearby lymph nodes. This type of test is performed under a general anaesthetic. Samples are taken from the tissue in the area and from the lymph nodes.

Thoracoscopy

Allows the consultant to look at the pleurae (smooth tissue membranes lining the thorax and enveloping the lungs) and the area around the lungs. This test may be performed under a general or local anaesthetic and will depend on a number of factors to do with the patient and the hospital.

Ultrasound scan

This scan gives detailed images of the body.

MRI scan

Enables the consultant to see if the cancer has spread using soundwaves.

Breathing and heart tests

Sometimes called lung-function tests to see how well the lungs are working. These tests help your consultant work out which treatment would be the best and safest for you.

 

For more information about tests
Macmillan Cancer Support

For more information about staging
Macmillan Cancer Support

COVID-19 update

Any further testing you need will be discussed with you. Please talk to your cancer care team if you have any concerns or questions regarding further testing.

You may be given your results over the telephone to minimise hospital visits.
If you go to Southampton for a mediastinoscopy, you will need to shield beforehand and have a COVID swab. More information will be provided by your cancer care team.

Other Conditions

Sometimes lung cancer causes other conditions that cause symptoms. These may be improved with specific treatments. Information on these will be provided by either your consultant or clinical nurse specialist.

Other conditions include:

Plural effusion
The build-up of fluid between the layers that cover the lung.

Superior vena cava obstruction (SVCO)
The superior vena cava is a large vein in the middle of the chest which carries blood from the upper body to the heart. If lung cancer presses on this vein, it may block the flow of blood. This needs to be treated quickly.
For more information about this condition and its symptoms
Macmillan Cancer Support

Hormonal or biochemical changes
Blood tests may show low sodium (salt) levels or high calcium levels.

Treatment

The best course of treatment for you will be discussed within a team of specialists called a multidisciplinary team (MDT).  

Multidisciplinary team

A multidisciplinary team (MDT) is a group of health care professionals who are from one or more clinical disciplines who make decisions together regarding the recommended treatment for individual patients.  

The treatment you may be offered depends on:

  • the stage of your cancer
  • the type of lung cancer
  • your general health.

There are a number of different treatments for lung cancer and your cancer care team will explain any relevant treatments to you. You may have to go to other hospitals to receive certain treatments.

Treatments

Surgery

In early stage non-small cell lung cancers, it can be possible to remove the cancer with surgery. Surgery is rarely used in the treatment of small cell lung cancer.

Surgery is usually carried out at University Hospitals Southampton (UHS).

COVID-19 update

If you are having surgery your cancer care team will talk you through how you need to prepare. You will have either a telephone or virtual appointment both pre-surgery and post-surgery to minimise your hospital exposure.

You should self-isolate for 14 days prior to your surgery and for a month post discharge from surgery. Your cancer care team will discuss this in further detail.

A COVID swab will be undertaken prior to your admission.

Chemotherapy

The use of anti-cancer drugs to destroy cancer cells. This type of treatment can also be used to control symptoms if the lung cancer has spread to other parts of the body.

Radiotherapy

Treats cancer by using high energy X-rays.

Targeted therapy or immunotherapy drugs

These interfere with the way cancer cells signal or interact with each other and stops them from growing and dividing.

Stereotactic ablative radiotherapy (SABR)

This treatment is a way of giving focused radiotherapy which increases the chance of controlling the tumour while sparing the normal tissue. This is currently done at Southampton.

COVID-19 update

Your treatment may be affected by the pandemic and your cancer care team will provide you with information about this. If you have any concerns or questions, please contact your cancer care team.

For more information about treating lung cancer
Macmillan Cancer Support

Community cancer nurses offer support and care to patients receiving treatment for cancer.

Dorset information

Community Oncology Nurse Specialist Team
Acorn Building
St Leonards
Ringwood
BH24 2RR
Tel: 01202 714965

After treatment

You will have regular check-ups and your consultant will arrange further CT scans or chest X-rays to monitor your progress. You will have a care plan detailing your follow-up care based on the type of treatment you have had.

Your consultant or clinical nurse specialist should give you information on maintaining a healthy lifestyle to help recover following your treatment and can help to reduce other illnesses.

They will also  share information about the signs and symptoms to look out for, talk to you about  your needs and refer you to support groups.

COVID-19 update

Due to the pandemic, your follow up appointment may be a telephone or virtual clinic to minimise hospital visits.

If lung cancer returns

Your clinical nurse specialist will let you about the symptoms you need to look out for. It is important you report any symptoms you have to your clinical nurse specialist or to your GP.

Further treatment will depend on your symptoms and where the cancer has returned.
If your cancer returns, your consultant will talk to you about what treatment options are available and help you decide what feels right for you.

For more information on cancer returning
Macmillan Cancer Support

Living with and beyond cancer

Emotional impact

How you cope with your diagnosis and treatment will be specific to you. You may expect to feel relief once your hospital-based treatment ends but this is not always the case and it can be a difficult and emotional time.

Following treatment, you may have time to reflect on the impact of your diagnosis. It is completely normal to have a mixture of emotions if you are living with or affected by cancer. There are a lot of support services available to help you through. It is important to remember you are not alone.

You may benefit from:  

  • talking to friends and family 
  • communicating with others in the same situation
  • talking therapies and counselling – your clinical nurse specialist can refer you
  • moving forward courses
  • local support groups
  • health and wellbeing events.

For more information on dealing with your feelings and emotions
Macmillan Cancer Support
Penny Brohn UK

Local support groups
Directory of Services

Online support – You can get support on the internet via online support groups, social networking sites, forums, chat rooms and blogs for people who are affected by cancer.

For information about counselling services
British Association of Counselling and Psychotherapy

If you are feeling depressed or need to speak to someone immediately, please contact Samaritans 116 123

If you are struggling with how you are feeling emotionally, it is important to speak to your GP or your cancer care team, they will be able to provide you information on the treatments and support available to you.

Side effects and symptoms

You will most likely feel very tired and may also have some side effects or be coping with symptoms. Your body will need time to recover from treatment.

Maintaining a healthy lifestyle

Following your treatment, there are many things you can do that may help to reduce the risk of lung cancer recurrence and prevent other health conditions.

You can take care of yourself by:

  • Stopping smoking
    Your cancer care team and your GP can help as well as the national stopping-smoking service.
    NHS
    Livewell Dorset
  • Managing tiredness
    Your clinical nurse specialist can discuss this with you and perhaps how family and friends could support you with day to day tasks.
  • Getting more active
    SafeFit
  • Eating well and maintaining a healthy weight
    NHS
  • Sticking to sensible drinking guidelines
    Drinkaware
  • Reducing stress

For more information on taking care of yourself
Macmillan after treatment for lung cancer
Macmillan lifestyle and wellbeing after treatment
Macmillan in your area
Macmillan online community

You can get in contact with your GP for further information regarding maintaining a healthy lifestyle and they will be able to offer you advice and support. 

Talking about cancer

It can be difficult to tell people you have cancer, however talking to your closest friends and family can make you feel more supported and reassured that the feelings you may be experiencing are normal. Everyone you tell may have a different reaction and it is important to be prepared for this. Some will be keen to support you but this may not always be the case as some people may find the conversation difficult and uncomfortable. This may be through lack of experience, fearing your reaction or they may go into denial.

View videos of people talking about their own experiences and coping with people’s reactions
healthtalk 

It can also help to talk to people who also have cancer as they may have a better understanding of what you are going through.

For more information on talking about cancer
Macmillan Cancer Support

Complementary therapies

Complementary therapies can be used alongside conventional breast cancer treatments. These are not the same as alternative therapies which are used instead of conventional treatments, such as chemotherapy or radiotherapy.  

Complementary therapies can give you comfort and help you feel more relaxed after treatment and diagnosis. Types of complementary therapies can include:

  • activities that improve mindfulness 
  • acupuncture
  • acupressure and shiatsu
  • aromatherapy 
  • healing and energy therapies 
  • herbal therapies 
  • hypnotherapy 
  • massage 
  • meditation
  • mindfulness 
  • reflexology 
  • special ‘cancer diets’ and dietary supplements  
  • yoga, Tai Chi and Chi Gung.

You can discuss what complementary therapies are available to you with your cancer care team.

For more information about complementary therapies
Macmillan Cancer Support

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