Accuracy is the name of the game when it comes to treating lung cancer. In the past decade, the FDA approved targeted therapies (which precisely target the DNA changes that cause cancer to grow) and immunotherapy drugs (which harness the power of the immune system to fight cancer). Clinicians are now using blood tests to determine how a patient’s cancer might respond to a targeted therapy or immunotherapy. In addition, the development of more precise equipment has improved surgical techniques, allowing for many lung cancer surgeries to now be performed minimally invasively

Before a patient’s lung cancer treatment begins, clinicians need to determine how to categorize the cancer. This may include identifying the type of cancer cell, biomarker status, and cancer stage. Staging explains if and where the cancer has spread to other parts of the body. While it may seem like a simple step in the diagnostic process, staging lung cancer can be complicated. There are many lymph nodes around the lungs and in the chest, which is where it is common for lung cancers to initially spread to. This term is known as regional spread and is used when the cancer hasn’t spread to any other “regions” of the body. Determining the extent of regional spread is necessary to accurately treat the patient. Miscategorizing a lymph node as cancerous or non-cancerous could result in a patient being staged incorrectly and, consequently, not receiving the best treatment for their cancer.   

To confirm which lymph nodes around the lung are cancerous, clinicians need to take tissue samples using a procedure called a biopsy. Commonly, a procedure called EBUS-TBNA (endobronchial ultrasound transbronchial needle aspiration) is used to diagnose and stage the cancer at the same time. This procedure uses a device called a bronchoscope, which is inserted in the airway. In this procedure, the bronchoscope can remove tissue or fluid samples from the lung nodule and lymph nodes under the guidance of an ultrasound machine.

There are other procedures that biopsy regional lymph nodes, like a mediastinoscopy, in which the lymph nodes are accessed by a tube with a cutting tool at the end inserted directly into the chest. The process of determining regional spread is sometimes called invasive nodal staging or invasive mediastinal staging. 

Ideally, patients are staged before treatment begins so clinicians can recommend the most appropriate treatment plan. Expert-developed physician guidelines are in place to ensure patients are accurately staged using the most appropriate procedure for their specific circumstance. 

However, like with many situations in healthcare, there can be gaps in knowledge and barriers to patients receiving the highest quality care possible. A 2022 study (Henderson et al) found more than one-quarter of thoracic surgeons and pulmonologists surveyed were unaware that invasive nodal staging guidelines exist. Nine out of ten physicians surveyed identified at least one barrier to guideline adherence, including patient anxiety associated with treatment delays, difficulty implementing guidelines into routine practice and time delays of additional testing.1

While this was only one study, it does suggest the need for more education about accurate staging for patient and providers. “All patients deserve access to the highest level of care possible,” says American Lung Association Chief Medical Officer Albert Rizzo, MD. “Clinicians should have the full picture of their patient’s health before making treatment recommendations. Accurate staging is a crucial part of gathering that full picture and treating patients appropriately.” 

Both lung cancer patients and caregivers can play a role in improving components of care. Asking questions is a great way to ensure you are getting the care you need and reduce any additional anxiety you may feel. Some sample questions are:

  1. I want to make sure I am accurately staged. Can you tell me about the process to learn exactly where my lung cancer has spread?
  2. Do I need to undergo any additional tests or procedures before I begin treatment? I want to be sure you have the full picture before we make any treatment decisions. 
  3. What do the experts recommend for staging and treating my cancer?

To learn more about staging and lung nodules, visit the following resources.

As lung cancer care becomes more personalized, it's imperative that advancements serve all patients. Communication is key to improving patient outcomes. With a complete and accurate picture of a patient’s cancer, open communication lines and a commitment to high-quality care, patient outcomes will improve. And that is a goal everyone can agree on.

Support for this educational initiative is provided by Olympus.

  1. Henderson et al. CHEST. 2022 Mar; 161(3): 826–832. Published online 2021 Nov 18. doi: 10.1016/j.chest.2021.11.010
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