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If I Had - A Nodule Noted in a Chest X-Ray - Dr. Charles Powell, MD, Columbia University Medical Center
If I Had - A Nodule Noted in a Chest X-Ray - Dr. Charles Powell, MD, Columbia University Medical Center

(September 4, 2008 - Insidermedicine) Welcome to Insidermedicine's If I Had, where we get a chance to ask an expert what they would do if they had a medical condition.
At the recent American Thoracic Society conference in Toronto, we caught up with Dr. Charles Powell, MD, an Assistant Professor of Clinical Medicine at the Columbia University Medical Center, and the Medical Director of their Lung Assessment Program, which specializes in the evaluation and management of patients with suspected lung cancer.

If I had a nodule noted in my chest x-ray…
If I had an abnormality I’d wish to see somebody as soon as possible. I would be uncomfortable with the information that there was something that may not belong in my chest. I want to know whether or not something that is malignant. But I know as a physician, most of the nodules that we see are not cancerous. But as a patient I would like to have that reassurance from a physician as soon as I could.

How will a physician diagnose the problem?
I would expect at the time I see a physician to determine whether or not my nodule is a tumor or not, to have an evaluation that will take into account several different aspects. I know as a physician that the probability of that lesion being malignant or benign depends upon characteristics of the nodule, and characteristics of the patient. For example my age is going to be important. Whether of not I smoke is going to be important. Whether or not I have any symptoms related to potential cancer is going to be important. I expect all that information to be examined during my visit to the doctor. Any other risk factors for cancer I know will be evaluated during that visit. I expect that my nodule be evaluate using the most sophisticated radiology approaches that are available. The shape of the nodule is important. The size of the nodule is important. Any other lesions on the CAT scan of the chest are also important. My doctor may choose to do additional tests such as a PET scan. That may be useful, it may not, either way it may be appropriate. Those are what I would expect at the time of my evaluation.

What types of lung cancer are there?
If there is a cancer diagnosed, there are two main types of lung cancer. They are called non-small cell lung cancer and small cell lung cancer. Small cell lung cancer is about twenty-five percent of cancers. The reason it is important is because the prognosis is much different and the treatment is much different. Within non-small lung cancer there are several different types also. There is adenocarcinoma, squamous cell carcinoma, and large cell carcinoma. So lung cancer is much different than all the other kinds of common cancers. Unlike breast, prostrate, and colon, which are all adenocarcinomas, lung cancer is a heterogeneous disease.

What are the risk factors for developing lung cancer?
The primary risk factor for lung cancer is smoking. However only ten percent of smokers get lung cancer and we know that amongst lung cancer patients ten percent never smoked. So that means that there are other risk factors. And those other risk factors can include a family history of lung cancer, especially with a first generation relative with lung cancer. Other exposures can be associated with lung cancer. Those other exposures can include asbestos exposure, potentially air pollution, potentially other exposures that haven’t been well classified yet. One other factor that may be associated with increased risk is the presence of other lung diseases. Such as COPD, emphysema, and interstitial pulmonary fibrosis, these can also be risk factors for having lung cancer.

What are the treatment options for lung cancer?
If we focus on treatment options for small cell lung cancer the treatment is relatively straight forward. It involves chemotherapy with or without radiation therapy depending upon the extent of the disease. For non-small lung cancer the therapy is dependent upon how much the disease has spread. If there is a rigorous somewhat complicated staging system for non-small cell lung cancer. The treatment is dictated by the stage of the non-small cell lung cancer. In general the early stage lung cancers are treated with the intent of surgical resection, removing the tumor. For patients that have more extensive disease the primary treatment options usually entail chemotherapy often with radiation therapy.

In Summary
If I had an abnormality on a chest CT scan I would seek opinion from an expert in dealing with pulmonary nodules as soon as possible. I would expect that expert to do a detailed comprehensive evaluation of my nodule. I would expect that expert to have access to other experts outside of his or her field to give the best information possible, the best expertise possible, to let me know what I’m dealing with inside of my chest. I understand that there is going to be some uncertainty. I understand that there are going to be some procedures that we are going to have to think about doing. I also understand as a patient that I need the best opinion and the best advice that I can get. That’s what I would expect to get. Then I would expect to have my diagnosis made, at which point it is important to get treatment. A similar approach would be necessary for that. I would go to a center that has available to it the best expertise and experience in taking care of patient with lung cancer. That involves a multi-disciplinary approach. It involves having pulmonologists, thoracic surgeons, oncologists, radiologists, and pathologists all working together. Either in the same place or easily accessible by telephone or the Internet. Such that we can have that kind of expertise to bring to my case. That is what I want to know is going on when I am seeing a physician about treatment of my lung cancer.