Dr. Gerard Silvestri, Medical University of South Carolina, describes the steps necessary to work up a lung cancer diagnosis, from initial scan to choice of treatment.
What are the basics of working up a lung cancer? When I see a patient in my clinic, usually they haven’t had anything done yet. They’ve been referred to me with a “spot” or lesion, or a mass on their lungs, and again, the first thing I need to do is take a good history and physical. How long have you had your symptoms, have you had weight loss, do you have bone pain, have you had headaches, what are some of the things going on — what diagnostic workup have you had? Sometimes they’ll already have had a biopsy. My job though is to do these three steps, absolutely simultaneously and sometimes in order — what is it, where is it, what I can do about it — diagnosis, stage and treatment.
The first visit is almost always trying to review the imaging and decide whether you need more imaging, do a good physical exam, do a good smoking history, find out what other health issues the person may have like heart disease, that can give us a challenge in terms of how we’re going to treat the cancer. So that’s the first part.
Sometimes I have to say that some patients are — it’s thought they may have a lung cancer, and in fact it’s something else. It could be a fungal infection or something else going on in the lungs. So usually what happens over sort of the course of the next ten working days is, either some more imaging, or a biopsy, and then perhaps a PET scan to help us with the staging portion of this. So sometimes we get a PET scan that will help us both direct the biopsy, but also help us with the stage. Over the next ten days or so we’ll try to get those tests done.
In addition, we always present our new cases at a multidisciplinary tumor board. What’s that? A multidisciplinary tumor board is where all the different specialties get together to look over the imaging, the biopsy results, the pathologic results, and come up with a better treatment plan. So who’s in the room during the tumor board? A pulmonologist usually, a chest surgeon or a thoracic surgeon, a medical oncologist, a radiation therapist, a pathologist, sometimes you’ll have a dedicated chest radiologist who will help review the films, and then also people from other ancillary services that are extremely helpful like clinical trials staff, like palliative care nursing. So we have all those people in the room at the same time, and they’re either reviewing brand new cases, or difficult and challenging cases that are coming back to the tumor board for consideration.
So that kind of happens in that first ten days and for us, we know how anxious patients can get during that time period that they just want to get something started, but I would urge anyone listening to this to consider is, if you don’t get it right, if you don’t give the person the correct stage and the correct treatment options, you won’t get the best care. Yes, speed is important, but you’ve got to get it right — what is it, the diagnosis, where is it, the appropriate stage, and then what are your treatment options, which really differ depending on stage. For stage I it’s usually surgery, for stage II, surgery followed by chemotherapy, for stage III, chemotherapy and radiation, and for stage IV, chemotherapy alone or some of the targeted agents. So if you don’t get that right, you’re going to get the wrong treatment, so be patient with that and if your doctors need to biopsy in a different area, as long as they’re explaining it appropriately to you, you should try to stay with that program.
So that’s the general workup of a patient. I will say, every patient gives a little bit of a nuance and so sometimes a patient seemingly needs something that’s a bit unusual in terms of a biopsy or the location of a biopsy or how to best go about getting that biopsy, and I can also say that sometimes the tumor board is split. Sometimes there’s no right answer about whether we should do it via a needle biopsy through the chest wall, or a bronchoscopy, and sometimes talking that through with a patient, they can help us – you can help us as patients make a decision about which way we would go next. That’s the general workup of a lung cancer.