"Using the most advanced technologies, we can now deliver powerful doses of radiation directly to your tumour with exquisite precision."

Diagnosis

 

After conducting a physical exam and reviewing your health and family history, your oncologist will order various tests to diagnose and analyze your condition. An accurate diagnosis helps your medical team determine the best course of treatment. The most common tests for lung cancer include:

Imaging
  • Chest X-rays look for a mass or spot on the lungs.
  • Imaging tests, such as CT scan, PET scan, bone scan, MRI and ultrasound that show detailed images of the lungs and other parts of the body.
  • Bronchoscopy guided interventions also help in diagnosing these cancers.
Pathology
  • Sputum cytology, to study mucus or phlegm cells.
  • Fine-needle aspiration, using a small needle to remove a small amount of tissue for biopsy.
  • CT guided or bronchoscopy guided biopsy.
Other Tests
  • Thoracentesis, to remove fluid from the chest wall and check for cancer cells
  • Bronchoscopy, which examines the bronchi using a thin flexible tube with a tiny camera. A bronchoscope also can take a small tissue sample for biopsy. Bronchoscopy and Endoscopic Bronchoscopic ultrasound (EBUS) guided interventions help in assessing mediastinum for lung cancer staging.
  • Occasionally VATS staging of the mediastinum is also performed.
Staging of Lung Cancer

The staging system most often used for NSCLC is the American Joint Committee on Cancer (AJCC) TNM system, which is based on 3 key pieces of information:


  • The size and extent of the main tumor (T): How large is the tumor? Has it grown into nearby structures or organs?
  • The spread to nearby lymph nodes (N): Has cancer spread to nearby lymph nodes? (See image.)
  • The spread (metastasis) to distant sites (M): Has cancer spread to distant organs such as the brain, bones, adrenal glands, liver, or the other lung?

Treatment

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At APCC, we offer the most advanced therapies for lung cancer performed by lung cancer specialists who have extraordinary expertise. Your care team collaborates to determine the best plan to fight your cancer based on the stage, location, genetic profile and overall health.

Surgery

Surgery is an important aspect of multi-modal treatment for Lung Cancer. It is effective when the cancer is confined to the lungs. Surgery is also used to take out residual cancerous tissue after chemotherapy or radiation treatment. The most common surgical procedures are :


  • Wedge resection to remove a small section of lung that contains the tumour along with a margin of healthy tissue.
  • Segmental resections to remove a larger portion of the lung, but not an entire lobe.
  • Lobectomy to remove the entire lobe of one lung.
  • Pneumonectomy to remove an entire lung.
Advances surgical techniques available at APCC

Video-assisted thoracoscopic surgery (VATS) and Robotic-assisted thoracoscopic surgeries (RATS)


Thoracic surgery is considered the standard of care for people with early-stage lung cancer who are deemed fit enough. Modern surgical techniques have been developed, including less invasive video-assisted thoracoscopic surgery (VATS) for lung resections. that are changing the boundaries of surgical fitness. Perioperative mortality and long-term survival following VATS lobectomy has been shown to be better than open surgery in some studies. A large European retrospective cohort study found in-hospital mortality following VATS lobectomy to be 1% vs 1.9% for open lobectomy. Similarly, a systematic review and meta-analysis found 5-year survival following VATS lobectomy for early-stage lung cancer to be 80.1% vs 65.6% for open lobectomy. Video-assisted thoracoscopic surgery lobectomy also has a lower risk of total complications (29.1% VATS vs 31.7% open) and a shorter hospital stay (8.3 days VATS vs 13.3 days open).

Radiation Therapy

The treatment can be given to cure patients whose lung cancers are confined to the chest but cannot be removed surgically. Using the most advanced technologies, we can now deliver powerful doses of radiation directly to your tumour with exquisite precision. Highly trained medical physicists work in subspecialized teams with radiation oncologists to create an individualized radiation treatment plan for every patient. Radiation therapists are present during each radiation procedure to ensure that the correct dose of radiation is being delivered precisely where it’s needed.

Intensity-modulated radiation therapy (IMRT)

IMRT uses sophisticated computer programs to calculate and deliver variable doses of radiation directly to the tumour from different angles. This technology targets the tumour while sparing the healthy tissue that surrounds it, enhancing your radiation oncologist’s ability to administer a lethal dose of radiation to a lung tumour and increasing your chance for cure.


Some people with lung cancer may be treated with a specialized form of IMRT called image-guided radiation therapy (IGRT). IGRT involves the use of sophisticated imaging tests to verify the position of the patient and the location of the tumour prior to and during the delivery of the treatment. Imaging tests play a crucial role in helping doctors to accurately plan and effectively deliver radiation therapy

Stereotactic Body Radiation Therapy

Stereotactic body radiation therapy (SBRT) is a treatment for non-small cell lung tumours that are small in size and confined to the lung. It can also be used to treat lung metastases when cancerous cells from another area of the body have spread to the lungs.

Proton Therapy

Proton therapy for lung cancer is one of the many exciting developments in the field. Despite best advances with photon therapy such as IMRT, IGRT, Cyberknife, Helical tomotherapy, the doses received by heart and lungs sometimes remain prohibitive. Even if the dose is within the thresholds, there is significant cardiopulmonary toxicity leading to significant morbidity (upto 80%) and even mortality (up to 5%). Proton therapy because of its unique physical and biological properties can deliver significantly lower doses to critical structures such as healthy lung as well as heart thereby limiting the collateral damage.

Benefits of Proton Therapy in Lung Cancer

This ability to limit the dose to the critical structures ensures a significant reduction in acute and long-term side effects associated with treatment. The reduction in the acute side-effects during the treatment also results in reduced hospitalizations, reduced requirement of additional supportive treatments and reduced treatment interruptions. Reduction in late effects may lead to lesser dependence on respiratory support, reduced morbidity and mortality. It is also expected to improve the quality of life in this subgroup of patients. Reducing bone marrow exposure may reduce treatment-related fatigue and, when necessary, allow for the delivery of more intensive chemotherapy during or after proton therapy.


An illustrative example for benefit of proton therapy


63 years old gentleman, hypertensive diagnosed with squamous cell carcinoma of left lung T3N3M0 and was deemed inoperable. He was planned for chemoradiation which is the standard of care in this setting and stage.




However, the IMRT plan led to prohibitive doses to the heart and normal healthy lungs. The patient was referred to us for consideration of proton therapy. The intensity-modulated proton therapy plan showed significantly reduced doses to the heart and normal healthy lungs.




Chemotherapy

In treating Lung Cancer, Chemotherapy is often used after surgery to kill any cancer cells that may remain. It can be used alone or combined with radiation therapy. Chemotherapy may also be used before surgery to shrink cancers and make them easier to remove; it can also be used to relieve pain and other symptoms. Palliative chemotherapy is used in advanced stages to prolong survival and relieve symptoms associated with advanced cancer.

Targeted Therapy

In recent years, there has been a major paradigm shift in the management of non-small cell lung cancer (NSCLC). NSCLC should now be further sub-classified by histology and driver mutations such as EGFR, ALK, KRAS, MET, ROS1, etc. Translational research advances now allow such mutations to be inhibited by either receptor monoclonal antibodies (mAb) or small molecule tyrosine kinase inhibitors (TKI). Other rare targets are being identified on a routine basis based on the next generation sequencing (NGS).

Immunotherapy for Lung Cancer

Immunotherapy for cancer, sometimes called immune-oncology, is a class of drugs that treats cancer using the body's own immune system. The immune system protects us from harmful foreign agents such as bacteria and viruses. Normal immunity attacks everything that is foreign to the body. The immune system also ensures that the body’s immune cells do not attack the body’s own cells or organs. However, cancer is a complex issue as when cells change to cancer, they acquire some new features that ideally should be recognized as foreign and labeled for immune destruction. Immunotherapy drugs for lung cancer help the body recognize cancer as foreign and harmful so that it can fight it.

Types of immunotherapy
  • Immune checkpoint inhibitors- Several immunotherapy agents have been approved for non-small cell as well as small cell lung cancer both for metastatic and locally advanced stages.
  • Cancer Vaccines - Not yet approved by FDA
  • Adoptive T-cell therapy - Not yet approved by FDA
Palliative Care

People with lung cancer often experience and often suffer both the symptoms of cancer, as well as side effects of treatment. Supportive care is essential in the treatment process. Our multi-faceted team is focused on ensuring patient comfort and a better quality of life.

Genomics and Molecular testing in Lung cancer

In recent years, personalized medicine has begun to bring new hope to people with lung cancer. Personalized medicine involves looking at the cells obtained from a biopsy to see if there are any genetic mutations, changes in your genes, that could be linked to the type of cancer you have. Genetic testing is now a routine part of metastatic disease. The molecular testing for EGFR, ALK and KRAS are commonly done in nonsquamous lung cancers. Other molecular testing is also done, with few to a name like MET, BRAF and PDL1. EGFR (the gene that produces a protein called epidermal growth factor receptor) is abnormal, or mutated, in about 10 percent of patients with non-small cell lung cancer and in nearly 50 percent of lung cancers arising in those who have never smoked. Another mutation we regularly test for is in a gene called KRAS. KRAS is mutated in about 25 percent of patients with non-small cell lung cancer. Patients whose tumors do not have mutations in either EGFR or KRAS may have another abnormality involving the ALK gene. Nearly 5 percent of patients with non-small cell lung tumors and about 10 to 15 percent of people with non-small cell lung cancer who have never smoked have this abnormality. If no known identifiable mutation is detected you may be advised next-generation sequencing (NGS), multi-biomarker assay.

Screening and Prevention of Lung Cancer

The global epidemic of lung cancer is linked most strongly to cigarette smoking. While other modifiable risk factors (e.g., exposure to occupational or domestic carcinogens) are clearly identifiable, it is tobacco smoking that has driven the steep rises in lung cancer incidence and mortality witnessed over the last century in developed and developing nations. Primary prevention has the greatest overall potential to minimize lung cancer risk, and smoking cessation is still the most powerful intervention to diminish lung cancer risk in persons who smoke. Smoking cessation even into the seventh decade of life results in a decrease in lung cancer incidence, and so it is never too late to quit.


There is no national screening programme for lung cancer. This is because of three reasons i.e. it isn't clear that screening everyone saves lives from lung cancer, the tests have risks, they can be expensive. Low-dose CT scans are used as a screening test for lung cancer. There is evidence that screening people based on their risk of lung cancer saves lives. But tests like CT scans still have risks. The lungs are very sensitive to radiation and frequent scans might cause lung damage. Tests can also find lung changes that look like cancer. This leads to further tests such as a biopsy. Lung screening might also cause overdiagnosis.


The complexities of the identification of the “right” population or individuals to screen, combined with the potential harms associated with CT screening, argue strongly that screening for lung cancer is a multifaceted process, involving much more than the simple ordering of a scan. The process for most individuals should include an individualized risk assessment for lung cancer. US Preventative Services Task Force now recommends “annual screening for lung cancer with low-dose computed tomography in adults ages 55 to 80 years who have a smoking history of smoking one pack per day for the past 30 years and currently smoke or have quit within the past 15 years. Smoking cessation intervention should be an integral part of this process for individuals still smoking or at risk for relapse.

Life beyond lung Cancer

We know that even after you’ve finished your cancer treatments, you may still need our help. We’re committed to supporting you in every way we can - physically, emotionally, spiritually, and otherwise for as long as you need us. Cancer treatment can sap your strength, flexibility, mobility, and endurance. The experts at our center can teach you therapeutic exercises and training programs that can help you heal. The state-of-the-art facility is specially tailored to the needs of people who’ve undergone treatment for cancer. Many people with cancer have questions about diet and nutrition. Our food and nutrition team is trained in helping you understand and cope with a variety of conditions relating to cancer treatment. Our expert dietitians provide medical nutrition therapy that can help you manage digestion problems, changes in taste, weight, and other issues. They’ll work closely with your treatment team to customize a dietary plan that fits your own specific needs Our specialists can help you cope with the side effects of therapy. These include pain, nausea, and fatigue. If you are in pain during your treatments or even after they’re over, we have pain specialists who can help. We will build a plan that makes sense for you and your needs. Our experts can give you solutions for both acute physical pain, which comes on suddenly, as well as chronic pain, which can linger. Our goal is to keep you as comfortable as possible.

Winning Over Cancer

Mr Mohammed Jamal Uddin from Bangladesh shares his experience about undergoing Proton treatment for his lung tumour at Apollo Proton Cancer Centre.

Watch him speak about his journey.

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Mr. Praboth Palit from Mumbai shares an emotional journey of his treatment at Apollo Proton Cancer Centre. Despite facing a lot of challenges in the beginning, Praboth never lost his hope which is highly commendable.

He thanked Mr. John Chandy , Dr. Srinivas Chilukuri, and the entire team for their support and guidance.

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