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Lung Cancer
An X-ray scan indicating abnormal masses in the lungs.
SpecialtyOncology
Risk factorsTobacco, asbestos, radon gas
Differential diagnosisSmall cell and Non-small cell carcinoma
TreatmentRadiation therapy, surgery, chemotherapy, and targeted therapy.
Deaths9,168 (2018)

Lung cancer in Australia has killed more than 9,000 people and there are estimated to be over 12,500 new cases as of 2018.[1] Lung cancer is the leading cause of cancer death in Australia and is responsible for one fifth of cancer diagnosis in the nation.[2] It is differentiated into two different types: Non-small cell lung cancer and small cell-lung cancer.[2] There are a range of diagnostic and treatment options available to treat both disease types. Smoking tobacco cigarettes is considered the leading risk factor of lung cancer in Australia, and Government-led public health schemes have aimed to reduce smoking and minimise its lung cancer risk.[3] There has been relative success in these campaigns, and in treatment, as survival rates have improved from 9.2% to 17% as of 2014.[2]Attitudes towards habitual smoking in youth and young adult groups have also subsequently changed in response to this.[4]

Prevalence

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As of 2018, lung cancer remains the leading cause of cancer death in Australia.[1] According to Cancer Australia, it is the fifth most common diagnosed cancer in Australia behind breast, prostate, colorectal and skin cancers.[1] There were 9,168 deaths due to lung cancer in 2018, with 5,229 males and 3,969 females reported by Cancer Australia.[1] Further estimates by Cancer Australia have also predicted that individuals succumbing to lung cancer by the age of 85 will be 1 in 23, being more likely in men than in women.[1] Lung cancer is more commonly diagnosed within smokers over the age of 60.[5]It was the most commonly diagnosed cancer among Indigenous Australians in the 4-year span from 2008 to 2012[6].

Pathophysiology of lung cancer

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Lung cancer § Pathogenesis

The onset of lung cancer is due to the uncontrolled growth of cells in the neoplasm of the trachea, bronchi and lungs that eventually metastasise into other regions of the body such as the brain, adrenal glands and liver.[7] Many of the lung cancer deaths in Australia and worldwide are due to metastasis rather than primary, localised tumours.

The activation of oncogenes and inactivation of tumour suppressor genes facilitates uncontrolled cell growth.[8] Both activation and inactivation of these oncogenes and tumour suppressor genes are due to mutations caused by associated risk factors such as smoking and asbestos.[9] Prevalent oncogenes in the progression of lung cancer include mutations in HER2 and BRAF.[10] Whereas, mutations in the p53 tumour suppressor genes are also said to influence the progression of the disease.[9]

Mutation of the K-ras oncogene and the epidermal growth factor receptor (EGFR) have been identified to contribute to the onset and progression of lung cancer.[11]

Symptoms of lung cancer vary by individual, however it generally includes chest pain, shortness of breath, persistent coughing with excessive blood and phlegm.[2]

Risk factors

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There are a number of associated risk factors in the onset and progression of lung cancer, however the major contributor is tobacco smoking.[12]

Smoking

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Cigarette smoking is considered the leading cause of lung cancer in Australia.

Smoking contributes to 90% of lung cancer diagnosis. This is because cigarette and tobacco smoke contain several known carcinogens that alter and damage DNA sequences affecting its ability to proliferate, undergo apoptosis and DNA repair.[13] Carcinogens include benzene, 2-napthylamine, 4-aminobiphenyl, chromium, cadmium, vinyl chloride, ethylene oxide, arsenic, beryllium, nickel and polnium-210.[14] In addition, nicotine is also an active, toxic component of tobacco smoke that contributes to its addictiveness.[14]

Asbestos

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The carcinogenic effects of asbestos on the lungs.

Asbestos are fibrous material that are found in many industrial buildings in Australia from the 1940's to 1987 . Exposure to asbestos occurs through inhalation of the particulates contained in these fibrous material, and they quickly become trapped and deposited in the airways and passages of the lungs.[15] As such, the exposure to asbestos increases the risk of developing cancers in the lung, ovary and pharynx.[16] The incidence of these cancers are said to occur decades after initial exposure to asbestos.[15] Products containing asbestos were eventually phased out towards the end of the 1980's, and a complete ban on asbestos was initiated in 2003. State and federal law in Australia have guidelines in their duty of care conduct of both employers and employees to reduce the risk of asbestos exposure.[16]

Radon Gas

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Radon is a chemically inert gas that has no colour, smell or taste[17]. It is the byproduct of radium when it undergoes radioactive decay[17]. As such, radon is implicated in lung cancer particularly as it is breathed in and deposited in the lungs[18]. This consequently damages the lining of the lungs and eventually, long-term exposure leads to the development of lung cancer[18].

Diagnosis and treatment of lung cancer

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There are a number of non-invasive diagnostic tools available in Australia to detect lung cancer. These include routine X-ray, CT and PET scans.[2] In large, these tests aim to determine the extent of tumour growth, its localisation or spread and its staging. Whereas invasive diagnostic tools include a lung biopsy, where a sample of the tumour from lung tissue is extracted and sent for pathological testing to confirm the presence of malignant or non-malignant cells.[19] A sputum cytology analysis may also be requested to further evaluate the presence of malignant cells.[2]

Treatment of lung cancer typically depends on the type and stage of the tumours and usually involves surgery, chemotherapy and radiotherapy.[20]According to Cancer Council Australia, the staging and diagnosis of lung cancer in Australia is given through the Tumour-Nodes-Metastasis system (TNM)[21]. The name itself, is an acronym to reflect the progression of the tumour, and to help determine a particular stage for diagnosis[22]. As such, "Tumour" corresponds to size of the tumour, along with its localization and distribution within the lungs[21]. "Nodes" indicates the progression of tumour to the lymph nodes. "Metastasis" reveals the tumour has spread to other organs and tissues in the body[21].

Targeted therapy is a new and emerging treatment option for non-small cell lung cancer. This form of therapy uses a range of cytotoxic drugs that target certain gene mutations which are prevalent in the progression of lung cancer. Drugs that are used in targeted therapy are often kinase, angiogenesis and VEGF inhibitors[23]. According to Cancer Council NSW, currently approved drugs include afatinib, alectinib, ceritinib, crizotinib, erlotinib and gefitinib[24]. Clinical trials are currently being conducted to determine the effectiveness of targeted therapy on small-cell lung cancer[24].  

Government Expenditure on Lung Cancer

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According to the Australian Institute of Health and Welfare, health care expenditure on lung cancer in Australia reached $122.5 million in the period of 2008-2009[25]. This total accounted for 5% of the total cancer expenditure in the 2008-2009 Financial Year[25]. Much of this was largely dedicated towards hospital-admitted patient costs, taking up 91% of the expenditure[25]. This was subsequently followed by out-patient services and prescription medications[25]. A report released by the Lung Foundation Australia detailed the economic burden of lung cancer in Australia in 2018. It reported $283.7 million was spent on direct costs including treatment and of out-hospital costs, and $13.5 million in indirect costs resulting from absent days from work[26]. The Lung Foundation Australia project that these costs will rise over the next 10 years, culminating in $6.2 billion direct costs and $325.9 million in indirect costs[27].   

Public health campaigns in Australia

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Much of the lung cancer deaths in Australia have been attributed to cigarette smoking and many public health schemes have been introduced to increase awareness of the risk of smoking. A number of campaigns have been launched across Australia, most notably QuitNow, which aims to support and encourage Australians to cease smoking.[28] Furthermore, the resources at QuitNow also serve to inform and educate the wider Australian population of the health benefits that cessation has, and guidelines to help families and friends of smokers.[29] In addition, both Federal and State Governments in 2006 initiated schemes that provided graphic health warnings on cigarette packages to reduce youth smoking rates.[30] These would often depict the grotesque effects of smoking on the body as a whole, capturing the detrimental effects on the lungs, heart and brain.[31] The campaign also ventured into television advertisements and large public billboards.[32] Cancer Council Australia have also led nation-wide initiatives in the prevention and minimisation of lung cancer. In tandem with state and territory bodies, Cancer Council Australia conduct clinical research to understand the broad mechanisms of lung cancer.[33]

Effectiveness of anti-smoking campaigns in Australia

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The implementation of plain packaging on cigarette packages has seen changing attitudes towards habitual smoking particularly in adolescent and young adult age groups. A study conducted by the Cancer Institute of NSW highlighted that youth support for plain packing of cigarettes increased, with 60% of 12-17 year olds and 67% of 18-24 in favour.[4] The study also mentioned that 1 in 3 teenage smokers aged 12–17, were less likely to continue smoking because of plain packaging.[4] Dunlop and her colleagues also conclude that 41% of teenage smokers considered quitting as a result of plain packaging on cigarette boxes.[4]

Changing public perception of stigmas associated with Lung Cancer

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In 2018, the Lung Foundation Australia in partnership with PricewaterhouseCoopers (PwC) released a report highlighting the extent of lung cancer burden in Australia in the present and future[34]. One of the findings of the report highlighted that there is a growing stigma towards people living with lung cancer from their communities, health providers, employers and even themselves[34]. According to a study by Jarrett (2015) of Vanderbilt University, approximately 30% of individuals with lung cancer blame themselves for their diagnosis[35]. Furthermore, a national survey conducted by the Lung Foundation Australia also revealed that over a third of Australians believed that individuals living with lung cancer "only have themselves to blame", whilst a tenth believed "they got what they deserved"[26]. It also highlighted that 35% of lung cancer patients chose not to disclose their diagnosis in fear of judgement from others[27]. The social stigmas of living with lung cancer were also identified by Sriram and colleagues in 2017, revealing that a third of Australians have less sympathy for people living with lung cancer than any other form of cancer[36]. These alarming statistics compelled the Lung Foundation Australia to initiate health services that will monitor and support the mental and psychological health of people living with lung cancer.

Lung Cancer Survival Rates in Australia

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The 5-year survival rates of lung cancer in Australia as of 2014 stands at 17%[37]. In previous years, lung cancer survival in Australia was 13% from 2000-2007[38]. Furthermore, during this period the survival rate was significantly higher in females (15%) than males (11%)[39]. In comparison to other cancers in Australia, the prognosis and survival rates of lung cancer were much poorer in both males and females[39]. According to statistics from the Australian Institute of Health and Welfare, the 5-year survival rate of lung cancer in men (11%) was 6-8 times lower than the 5-year survival rates of prostate cancer (89%),lymphoid cancers (64%) and bowel cancer (63%) in men [39]. Correspondingly, these alarming statistics are also seen in comparison with diagnosis of cancers in women. The 5-year survival rates of lung cancer in women (15%) are 4-6 times lower than survival rates for breast cancer (89%), lymphoid (65%) and bowel cancers (64%)[39]. It has been suggested that the relatively low survival rates of lung cancer in both men and women are due to diagnosis made when the cancer has reached an advanced stage, and unable to respond effectively to treatment[39].

See also

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References

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  1. ^ a b c d e Anonymous (2015-12-18). "Lung cancer statistics". lung-cancer.canceraustralia.gov.au. Retrieved 2019-04-29.
  2. ^ a b c d e f Australia, Cancer Council. "The facts on lung cancer: symptoms, causes and more". www.cancer.org.au. Retrieved 2019-04-29.
  3. ^ Statistics, c=AU; o=Commonwealth of Australia; ou=Australian Bureau of (2017-07-26). "Main Features - Lung cancer". www.abs.gov.au. Retrieved 2019-04-29.{{cite web}}: CS1 maint: multiple names: authors list (link)
  4. ^ a b c d Dunlop, Sally; Perez, Donna; Dessaix, Anita; Currow, David (2016-11-15). "Australia's plain tobacco packs: anticipated and actual responses among adolescents and young adults 2010–2013". Tobacco Control. 26 (6): 617–626. doi:10.1136/tobaccocontrol-2016-053166. ISSN 0964-4563. PMID 27852891. S2CID 10391488.
  5. ^ AIHW (2011). Lung Cancer in Australia: an overview. Canberra: Australian Institute of Health and Welfare Canberra. p. 7. ISBN 978-1-74249-222-3.
  6. ^ Australian Institute of Health and Welfare (2017). "Cancer in Australia 2017". Cancer. series no. 101 (Cat. no. CAN 100).
  7. ^ "Lung Cancer". Cancer Council NSW. Retrieved 2019-05-06.
  8. ^ "Oncogenes and tumor suppressor genes | American Cancer Society". www.cancer.org. Retrieved 2019-05-11.
  9. ^ a b Gibbons, Don L.; Byers, Lauren A.; Kurie, Jonathan M. (January 2014). "Smoking, p53 Mutation, and Lung Cancer". Molecular Cancer Research. 12 (1): 3–13. doi:10.1158/1541-7786.MCR-13-0539. ISSN 1541-7786. PMC 3925633. PMID 24442106.
  10. ^ Gkolfinopoulos, Stavros; Mountzios, Giannis (April 2018). "Beyond EGFR and ALK: targeting rare mutations in advanced non-small cell lung cancer". Annals of Translational Medicine. 6 (8): 142. doi:10.21037/atm.2018.04.28. PMC 5952024. PMID 29862231.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  11. ^ Waxman, Elizabeth S.; Fossella, Frank V. (July 2016). "Biomarkers/Molecular Targets, Immunotherapy, and Treatments for Non-Small Cell Lung Cancer". Journal of the Advanced Practitioner in Oncology. 7 (5): 514–524. doi:10.6004/jadpro.2016.7.5.4. ISSN 2150-0878. PMC 5737399. PMID 29282427.
  12. ^ Australia, Cancer (2015-04-21). "Tobacco". canceraustralia.gov.au. Retrieved 2019-04-29.
  13. ^ Research, The Walter and Eliza Hall Institute of Medical (2014-11-12). "Lung cancer". Walter and Eliza Hall Institute of Medical Research. Retrieved 2019-04-29.
  14. ^ a b Health, Australian Government Department of, Cigarettes and poison, Australian Government Department of Health, retrieved 2019-04-29
  15. ^ a b Ageing, Australian Government Department of Health and, Asbestos-related diseases, Australian Government Department of Health and Ageing, retrieved 2019-04-29
  16. ^ a b "Asbestos and Cancer". www.cancer.org.au. Retrieved 2019-04-29.
  17. ^ a b e5605c6d2607f5b521c46cdf7a23082c (2017-04-26). "Radon exposure and health". ARPANSA. Retrieved 2019-05-27.{{cite web}}: CS1 maint: numeric names: authors list (link)
  18. ^ a b "Radon and Cancer". National Cancer Institute. 2011-12-06. Retrieved 2019-05-27.
  19. ^ Anonymous (2015-12-18). "How is lung cancer diagnosed?". lung-cancer.canceraustralia.gov.au. Retrieved 2019-05-06.
  20. ^ Anonymous (2015-12-18). "Treatment options". lung-cancer.canceraustralia.gov.au. Retrieved 2019-05-06.
  21. ^ a b c "Staging & Prognosis for Lung Cancer". Cancer Council NSW. Retrieved 2019-05-30.
  22. ^ "Non-Small Cell Lung Cancer Stages". www.cancer.org. Retrieved 2019-05-30.
  23. ^ Bui, Kim Tam; Cooper, Wendy A.; Kao, Steven; Boyer, Michael (2018-07-31). "Targeted Molecular Treatments in Non-Small Cell Lung Cancer: A Clinical Guide for Oncologists". Journal of Clinical Medicine. 7 (8): 192. doi:10.3390/jcm7080192. ISSN 2077-0383. PMC 6111731. PMID 30065223.
  24. ^ a b "Targeted Therapy for Lung Cancer". Cancer Council NSW. Retrieved 2019-05-28.
  25. ^ a b c d Australian Institute of Health and Welfare (2012). "Health expenditure on cancer and other neoplasms in Australia:2008-09". Cancer. Series no. 81 (Cat. no. 78).
  26. ^ a b Lung Foundation Australia (2018). Making Lung Cancer A Fair Fight: A Blueprint For Reform. PricewaterhouseCoopers (PwC).
  27. ^ a b Lung Foundation Australia (2017). Lung Foundation Australia Annual Report 2017.
  28. ^ Ageing, Australian Government Department of Health and. "Welcome to the Quitnow Website". www.quitnow.gov.au. Retrieved 2019-05-06.
  29. ^ Health, Australian Government Department of. "Quit for your family". www.quitnow.gov.au. Retrieved 2019-05-06.
  30. ^ Health, Australian Government Department of, Health warnings, Australian Government Department of Health, retrieved 2019-05-06
  31. ^ "Gruesome TV ads you can't watch". www.dailytelegraph.com.au. 2019-03-09. Retrieved 2019-05-11.
  32. ^ "Quit Smoking Campaigns". Cancer Institute NSW. 29 June 2018. Retrieved 10 May 2019.
  33. ^ Australia, Cancer Council. "About us - Cancer Council Australia". www.cancer.org.au. Retrieved 2019-05-06.
  34. ^ a b "New report sparks call to make lung cancer a fair fight". Lung Foundation Australia. Retrieved 2019-05-29.
  35. ^ Jarrett, Lee Ann (2015). Health-related stigma in advanced lung cancer. Vanderbilt University. Nashville, Tennessee.{{cite book}}: CS1 maint: location missing publisher (link)
  36. ^ Sriram, N.; Mills, Jennifer; Lang, Edward; Dickson, Holli K.; Hamann, Heidi A.; Nosek, Brian A.; Schiller, Joan H. (2015). "Attitudes and Stereotypes in Lung Cancer versus Breast Cancer". PLOS ONE. 10 (12): e0145715. Bibcode:2015PLoSO..1045715S. doi:10.1371/journal.pone.0145715. ISSN 1932-6203. PMC 4689531. PMID 26698307.
  37. ^ Anonymous (2015-12-18). "Treatment options". lung-cancer.canceraustralia.gov.au. Retrieved 2019-05-06.
  38. ^ AIHW (2011). Lung Cancer in Australia: an overview. Canberra: Australian Institute of Health and Welfare Canberra. p. 7. ISBN 978-1-74249-222-3.
  39. ^ a b c d e Lung cancer in Australia : an overview. Australian Institute of Health and Welfare., Cancer Australia. Canberra: Australian Institute of Health and Welfare. 2011. ISBN 9781742492223. OCLC 767444015.{{cite book}}: CS1 maint: others (link)
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