Working with a Client with Lung Cancer

Lung cancer is the most commonly occurring cancer in men and the third most commonly occurring cancer in women. There were 1.2 million new cases and 1.8 million deaths worldwide in 2020. Tobacco use is to blame for 85% of all lung cancers. The other 15% arise mainly from occupational and environmental exposures to radon, asbestos, and second-hand cigarette smoke. Lung cancer has replaced breast cancer as the prime cause of cancer death for women. The incidence of lung cancer decreases when smoking is stopped; after about fifteen years, the risk is the same as that of non-smokers.

While cigarette smoking is by far the most critical risk factor for lung cancer, risk increases with both the number of cigarettes smoked and the duration of smoking. Cigar and pipe smoking also play a role in lung cancer. Exposure to radon gas released from soil and building materials is estimated to be the second leading cause of lung cancer in Europe and North America, according to the World Health Organization. Other risk factors include exposure to secondhand smoke, asbestos, metals that contain chromium, cadmium, and arsenic, radiation, air pollution, diesel exhaust, and even some organic chemicals. Risk is also increased among people who have a history of tuberculosis.

Nearly half of all lung cancer clients will be diagnosed with metastatic disease. Lung cancer cells that break off from the original tumor often form a secondary tumor in the brain. An isolated secondary tumor is potentially curable if treated properly with chemotherapy and surgery. Only 15% of lung cancers are diagnosed at a localized stage, for which the five-year survival rate is 54%. The five-year survival rate for small cell lung cancer is 6% compared to 18% for non-small cell.

The following is a list of potential surgical procedures for the treatment of lung cancer:

Mediastinoscopy – is a relatively non-invasive procedure done under general anesthesia; a small incision is made at the top of the breastbone, and a mediastinoscope is inserted into the chest to take biopsies from the enlarged nodes on the right side of the chest.
Thoracoscopy – is a surgical procedure to look at the organs inside the chest to check for cancer. An incision is made between two ribs, and a thoracoscope is inserted into the chest. Tissue or lymph node samples may be removed and checked under a microscope for signs of cancer. In some cases, this procedure is used to remove part of the esophagus or lung. If certain tissues, organs, or lymph nodes can’t be reached, a thoracotomy may be done. In this procedure, a larger incision is made between the ribs, and the chest is opened.

Thoracotomy – is the first step in many thoracic surgeries; and as such requires general anesthesia with endotracheal tube insertion and mechanical ventilation . Thoracotomies are thought to be one of the most difficult surgical incisions to deal with post-operatively, because they are extremely painful and the pain can prevent the patient from breathing effectively, leading to atelectasis or pneumonia .

Thoracentesis– removal of fluid from the space between the lining of the chest and the lung using a needle. A pathologist views the fluid under a microscope to look for cancer cells.
Video-assisted thoracoscopic surgery (VATS) – a procedure that may be done before or instead of a thoracotomy. The procedure involves inserting a videoscope with a camera attached (as well as small surgical instruments) into the chest, through small incisions made between the ribs. One of the incisions is enlarged if a lobectomy or pneumonectomy is done to allow the specimen to be removed. Because only small incisions are needed, there is usually less pain after the surgery and a shorter hospital stay – typically 4 to 5 days. The VATS method may be used to confirm the diagnosis of lung cancer, biopsy lymph nodes, perform a wedge resection to remove the cancer and the lung tissue surrounding the cancer, and to remove the segment (lobe) of the lung that contains the cancer.

Lymph node biopsy – the removal of all or part of a lymph node to look for signs of cancer.
Segmentectomy – this surgery is designed to remove cancerous tissue from a lung segment when a lobectomy cannot be performed. The lungs have various numbers of segments: three in the right upper lobe, two in the right middle lobe, five in the right lower lobe, four in the left lower lobe and four in the left upper lobe.
Lobectomy – the standard minimal surgery for lung tumors, in which a section (lobe) is taken out. A bilobectomy removes two lobes in the same lung.
Pneumonectomy – surgical removal of the entire lung on either the left or right side. It is performed when the cancer is located in the center of the lung and cannot be removed using a more localized operation. A pneumonectomy is only performed in clients who have good lung function and could recover and live without the need for supplemental oxygen.
Sleeve resection – may be used to treat some cancers in large airways in the lungs. According to the American Cancer Society, if you think of the large airway with a tumor as similar to the sleeve of a shirt with a stain a couple of inches above the wrist, the sleeve resection would be like cutting across the sleeve above and below the stain and then sewing the cuff back onto the shortened sleeve. A surgeon may be able to do this operation instead of a pneumonectomy to preserve more lung function.
Endobronchial Stenting – inserts a plastic tube into the airway as a palliative treatment for breathlessness.

Patients typically will need to spend 5 to 7 days in the hospital after any major lung surgery. Full recovery from lung cancer surgery typically takes several weeks to several months. If the surgery is done through a thoracotomy, the surgeon must spread ribs to get to the lung, so there may be pain in the incision site for quite some time after surgery. Activity should be limited for at least a month or two. People who have VATS instead of thoracotomy tend to have less pain after surgery and to recover more quickly.

Many lung cancer patients experience shortness of breath and have difficulty breathing. Restoring breathing will help with endurance and quality of life and will enable lung cancer patients to accomplish their activities of daily living with greater ease.

Teach diaphragmatic breathing through pursed lips as it will strengthen the diaphragm and the abdominal muscles. This will allow more air to move in and out of the lungs with less tiring of the chest muscles. When the diaphragm becomes weak, the patient compensates by using the shoulders and other muscles to help them breathe. Patients with shortness of breath and limited breathing capacity due to their cancer should perform upper body stretching exercises daily to increase lung capacity.

A stretching program will restore mobility in the chest and back that allows for easier movement of the lungs and diaphragm. Make sure not to apply pressure against the chest either in prone position, or against equipment if there is pain or discomfort.

Potential side effects of lung cancer surgery:

Infection/bleeding associated with incision
Pneumonia
Blood clots in legs or lungs
Allergic reaction to anesthesia
Lung collapse caused by tension pneumothorax (air between the lungs and chest wall)
Hemorrhage
Air/fluid leaking into the surgical area (bronchopleural fistula)
Accumulation of fluid in the chest
Chronic pain
Abnormal heart rhythms
Difficulty breathing and need for prolonged stay on the breathing machine

*** If you have undergone irradiation or removal of the lymph nodes, you will be at risk for lymphedema. You should learn about how you can prevent and identify lymphedema, as well as how to incorporate upper extremity lymph drainage exercises into your daily routine. You can find comprehensive information on lymphedema prevention, identification and management in the Cancer Exercise Specialist Advanced Qualification. You can also watch this short video on lymphedema prevention during exercise.