Lung Cancer

Smoking is on the decline. But if you are one of the 28 million Americans still smoking, you probably know how hard it is to quit. 

Close to 70% of smokers report that they want to stop smoking. Of those, 53% said they tried to quit in the previous year. Only around 9% succeeded. 

There are plenty of reasons to try to reduce your nicotine addiction: Tobacco use – and smoking, in particular – accounts for about one-third of all cancers, and up to 90% of lung cancer cases. It also contributes to heart disease, stroke and lung disease. 

So, what's the best way to quit smoking? 

“The best way to quit smoking is with a combination of medication and counseling,” says Maher Karam-Hage, M.D., medical director of the Tobacco Research and Treatment Program at MD Anderson. “They both help. But you double your chances by using both compared with one of them.” 

What products can help you quit smoking?

There are several products that can help reduce your nicotine cravings.

Prescription medication

Smoking cessation options that require a doctor’s prescription include:

Varenicline (formerly sold as Chantix) works in two ways. First, it provides a mild version of nicotine’s effects. This helps reduce withdrawal symptoms and cravings. Second, it stops your brain from feeling the pleasurable effects of nicotine when you smoke. This makes smoking less appealing. Varenicline is the most effective single medication, Karam-Hage says. But it's also the most expensive.

Bupropion (also sold as Zyban or Wellbutrin) blocks the effects of nicotine in your brain. This makes smoking feel less pleasurable, but it does not replace the effect of nicotine.

Nicotine nasal spray is a nicotine replacement therapy that is sprayed into the nostril and absorbed into the nasal lining and bloodstream. This product provides nicotine without the other harmful effects of cigarettes.

Over-the-counter options

Over-the-counter nicotine replacement therapies partially satisfy nicotine cravings by giving the body small amounts of nicotine. This can help with cravings and make it easier to stop smoking. 

The over-the-counter nicotine replacement therapies available in the United States are:

Nicotine patches are 3- or 4-inch-wide patches that release a steady dose of nicotine. They are applied to the upper body and changed daily. They come in 7 mg, 14 mg and 21 mg doses.

Lozenges release nicotine as they dissolve in the mouth. They are available in mini and regular sizes and 2 mg and 4 mg doses.

Nicotine gum users follow the ‘chew and park’ method. The gum is chewed for 5 to 10 seconds then parked between the teeth and cheek for another 5 to 10 seconds. This process is then repeated in different parts of the mouth. It comes in 2mg and 4 mg doses.

Why is counseling important?

Working with a counselor can help you better understand your medication. A counselor can also give you the tools to cope with setbacks, stress and cravings by building skills in several areas. These include:

Problem solving

We all run into problems in life, like personal conflicts, that can make us feel helpless. Working with a counselor to tackle them one at a time can help you build knowledge and skills that can be used in other areas.

Coping strategies

Anything from a traffic jam to a death in the family can set off a strong urge to smoke. Learning strategies like deep breathing exercises, meditation and mindfulness can help a smoker get to the other side of a crisis without smoking.

Behavior change

Smokers who quit may miss the “hand-to-mouth” act of smoking. Counseling can help them find substitutions like using a straw, cinnamon stick or gum.

Identifying triggers

Counseling can help you identify what triggers you to smoke, like that morning cup of coffee or spending time with friends who smoke. Once you identify your triggers, you can learn to deal with them or avoid them.

Once smokers start counseling, they appreciate the tools and support it provides in their effort to quit smoking, Karam-Hage says.

“Finally, somebody understands the struggle they're going through,” he says. “Someone is acknowledging that it's not a simple thing to quit. That is very helpful.”

What option should you try first?

Not sure where to start? For many, over-the-counter nicotine replacement therapies are quicker and easier to get than medication because they don’t require prescriptions and can be purchased at most pharmacies.

However, remember that nicotine replacement therapies must be used consistently to be effective. If you find it hard to regularly use options like the patch, lozenges or gum, or if they don’t help you quit, Karam-Hage says you might consider medication.

Your doctor can prescribe medication to help you quit. They can also advise you on how to combine nicotine replacement therapies. This might look like using the patch along with either nicotine gum, lozenges or nicotine nasal spray. 

Additionally, a professional counselor can help you monitor what is and isn’t working and work with a prescriber on your care team to adjust the medication you take to set you up for success.

Want to quit but don't have access to a comprehensive program that includes both counseling and medication? You have options.

You can get phone and text support through the National Institutes of Health Quitline by calling 1-800-784-8669, texting QUIT to 47848, or visiting SmokeFree.gov. If you live in Texas, you can use the Texas Tobacco Quitline by calling 1-877-YES-QUIT or visiting YESQUIT.org.

Should you quit smoking cold turkey?

Knowing the health risks and addictive properties of nicotine, you might be wondering whether you should simply quit smoking cold turkey.

Karam-Hage says it’s wonderful if a smoker can quit cold turkey, but notes it is not necessarily better than using medication and counseling. This is because while it works for some, it does not work for everyone. 

Most people who attempt to quit smoking on their own fail to do so, he says. Because of this, he notes people may benefit from using both medication and counseling in future attempts to quit smoking. He says the unfortunate reality is that only about 30% of people attempting to quit get either medication or counseling, and only 5% of people get both medication and counseling.

If you’ve tried and failed to quit smoking long-term, Karam-Hage recommends a combination of counseling and medication. Enrolling in a comprehensive tobacco treatment program like MD Anderson’s Tobacco Research and Treatment Program, which is open to MD Anderson patients and caregivers, can be helpful for those seeking additional support. A 2019 study showed that 45% of people enrolled in MD Anderson’s program managed to quit smoking.

What happens to your body when you quit smoking?

Let’s start with the organ that is perhaps most associated with smoking: the lungs. 

Those who quit smoking might note that they can breathe a little easier – and not just metaphorically! Karam-Hage says this is because the toxins from cigarette smoke are gone.

As for whether the lungs can regenerate after you quit smoking, the answer depends on just how damaged the lung tissue is. For lung tissue that is damaged but still alive, Karam-Hage says it is possible for it to recover. However, totally damaged cells can’t be reversed.

“Whatever cells have died are gone and no regeneration is possible,” he says, noting this is why conditions like chronic obstructive pulmonary disease (COPD) are permanent.

While smoking’s effects don’t entirely go away when you quit, Karam-Hage says there are many positive health impacts that happen when you quit smoking.

These benefits include:

• Reduced heart rate and blood pressure
• Reduced level of carbon monoxide in blood
• Improved circulation and lung function
• Improved sense of taste and smell
• Reduced risk of heart disease
• Reduced risk of stroke
• Reduced risk of mouth, throat, larynx, esophageal, bladder, cervical, lung, kidney, liver, colorectal, leukemia and pancreatic cancer

“There are many benefits, and they continue to get better as time passes,” he says.

Request an appointment at MD Anderson online or call 1-877-632-6789.

Lung nodules — or pulmonary nodules — are small growths that can develop in the lungs. By definition, they are no larger than 3 cm, or about 1.25” across. Anything bigger than that is considered a mass.  

Lung nodules are very common. But most lung nodules are not due to cancer.  

So, why do lung nodules even form? Do they ever cause any symptoms? And, what should you do if you find out you have one? 

Read on to learn the answers to these and other questions about lung nodules. 

How serious is a lung nodule?

The answer to that question depends on the answer to several others.  

• Number: Is there only one, or are there many lung nodules?  
• Size: How big is it/are they? 
• Age: How old are you? 
• Family history: Does any type of cancer run in your family? 
• Medical history: Have you ever had a lung infection? 
• Work history: Have you ever been exposed to asbestos or radon? 
• Social history: Have you ever smoked, vaped or used other tobacco products?  

The older you get, the more common benign — on non-cancerous — lung nodules become, particularly if you live in certain parts of North America. But it’s more concerning if you have many nodules and have had cancer before than if you only have one and have never had cancer.

Anything larger than a green pea (about 5 mm) is worth investigating, but even smaller nodules might call for monitoring. And, answering “yes” to any of the history-related questions above significantly raises the risk that a nodule might be cancerous. 

Why do lung nodules even occur?

People may develop lung nodules for many reasons. These include:  

• Old infections, which can cause scarring 
• Chronic infections, such as tuberculosis 
• Sarcoidosis and rheumatoid arthritis, both autoimmune disorders 
• Prior trauma, such as a gunshot wound or auto accident 
• Cysts, or hollow sacs filled with fluid 

Congenital conditions

• Arterial venous malformation, which shows up as dark spots in the middle of lung 
• Pulmonary sequestration, when a segment of lung has its own blood supply 
• Congenital emphysema, which some babies are born with 

Certain fungal infections

• Blastomycosis (Great Lakes area)
• Coccidiodomycosis or Valley Fever (San Joaquin Valley)
• Histoplasmosis (Mississippi Valley)

Lung nodules may also be cancerous. When that happens, they could either be caused by lung cancer or a different type of cancer that has spread to the lung from another place.  

Unfortunately, the lung is a very common location for metastatic disease. That means many other cancers tend to spread there. Sarcomas, for instance, often spread to the lungs. So does colorectal cancer. But technically, any type of cancer can spread to the lungs. 

How are lung nodules usually found?

There are four main ways: 

1. An X-ray taken for an unrelated reason, such as an auto accident 
2. Imaging related to a lung problem, such as a cough that won’t go away or pneumonia symptoms 
3. A lung cancer screening  
4. A health screening performed before an operation    

A rapid CT scan of the heart called a calcium score test is done to assess coronary artery disease. Sometimes, it catches the edges of the lungs in its field of vision, revealing nodules. Abdominal CT scans can also sometimes catch nodules in the lower third of the lungs. 

Do lung nodules ever go away on their own? 

Yes, especially if they’re related to an infection. Not so with any of the other possible causes, though. Cancer, in particular, will not go away on its own. 

Do lung nodules ever cause any symptoms?

Yes. Even if they’re benign, the nodules themselves or their underlying causes can cause some of the same symptoms as lung cancer, including: 

• A nagging cough 
• Shortness of breath 
• Chest pain or pressure 
• Persistent or recurrent upper respiratory infections 

How can you tell if a lung nodule is cancerous?

If a nodule appears completely calcified on imaging, as if the whole thing has turned to stone, it is not cancer. If it has some flecks of calcium in it, it might be cancerous. But if there’s no calcium in a nodule at all, we’re always going to find that suspicious. Still, there are three approaches to learning more.  

1. Watch it: Also known as surveillance, this means we monitor a nodule over time to see if it grows bigger, gets smaller or just stays the same. 
2. Re-image it: We use advanced imaging techniques — such as PET scans and high-resolution CT scans — to take a closer look. 
3. Sample it: We can either stick a needle in the nodule or remove the whole thing surgically. Either way, we’ll get a piece of it so we can biopsy the tissue. 

The only way to know for sure if something is cancer is to look at its cells under a microscope. But we have to balance the risk of biopsy with the risk of it being cancer. That’s why we usually take a wait-and-see approach if your risk is very low or there’s a clear reason for a nodule, such as a recent case of the flu.

On the other hand, if you have multiple nodules, smoke a pack a day and have a family history of lung cancer, we might go straight to biopsy, because all of those factors put you at higher risk of lung cancer. 

The longer a nodule remains unchanged, the lower your risk of cancer is and the more justified continued observation is, rather than exposing you to the risk of a biopsy. If a nodule remains stable and doesn’t grow over two years or more, it is not a cancer.  

How are lung nodules usually treated?

That depends on how many there are, what kind they are, and whether they are causing any problems. Even if a lung nodule is not cancerous, if it’s causing repeated infections or making breathing difficult, we’ll often remove it. 

But lung cancers and those that originate in other locations are treated very differently. So, there’s no one-size-fits-all answer.

A lobectomy is the surgical removal of one of the five lobes — or main sections — of the lungs. It is the most common type of operation used to treat lung cancer, and it may be performed on patients with various stages of the disease.

But is a lobectomy considered major surgery? How long does it take to fully recover? And will you feel short of breath after having one?

Read on for the answers to these questions and more.

What is a lung lobe?

Think of your airway as an upside-down tree. The trachea, or windpipe, is the trunk. The first two branches leading off of it go to the left and right lungs. Branches further down lead to the upper, middle, and lower lobes on the right, and the upper and lower lobes on the left.

We have five lung lobes in all: two on the left side and three on the right. These lobes can be further subdivided into 19 smaller units called “segments.” A segmentectomy is the surgical removal of a segment rather than an entire lobe.  

How long does it take to fully recover from a lobectomy?

That varies widely. It depends on many factors, including:

• Which surgical approach is being used
• Your overall health status
• How well the rest of your lung lobes are functioning

On average, you can expect to spend two to three nights in the hospital afterward and have several chest X-rays taken to monitor your progress.

A chest tube will be inserted at the time of the operation. It will be left in place to allow the lung to re-expand and drain any air or fluid that accumulates. The tube is usually removed within a day or two of surgery when the volume of fluid draining is minimal and there is no longer any air bubbling from it.

In some circumstances, you may be ready to leave the hospital before that happens. In those situations, you’d likely return to the clinic within a few days to have the tube taken out.

What will my life be like after a lobectomy? Will I always feel short of breath? 

No. A lobectomy would not be performed if it would leave you unable to breathe adequately or feeling permanently short of breath.

That being said, you might feel slightly short of breath for the first few weeks after a lobectomy while your body adjusts to its new anatomy. You may also experience some discomfort when taking deep breaths, but that should improve over time.

You will be assessed for your lung function before a decision is made to perform lung surgery. We calculate your eligibility based on pre-operative lung function and what percentage of lung tissue would be removed.

Is a lobectomy considered major surgery?

Yes. Any lung surgery is considered major surgery. 

Is a lobectomy considered a high-risk procedure? 

No. We might describe certain tumors or patients as high-risk based on their anatomy or overall health status. But it’s a very common operation. Even in complex situations, risks can be reduced by going to an experienced center of excellence like MD Anderson, where thoracic surgeons do it every day.  

What are the risks of a lobectomy? 

The greatest risks associated with lung surgery are:

• Prolonged air leaks: when the lung continues to leak air for more than a few days after surgery, requiring ongoing management with a chest tube
• Pneumonia: an infection of the lungs, which can be treated with antibiotics
• Atrial fibrillation (A-fib): an abnormal heart rhythm seen in roughly 8-10% of lobectomy patients, which is treated with medications

Fortunately, most of these conditions are temporary. Air leaks, in particular, are usually self-limiting. Pneumonia can often be prevented, too, with deliberate coughing, deep breathing, and a lot of walking after surgery.

What’s the difference between a pneumonectomy and a lobectomy? 

A pneumonectomy is the removal of an entire lung. A lobectomy is just the removal of part of it (a single lobe).

What’s the most important thing to know about lobectomies?

Lobectomies are the most commonly performed operation on the chest. So, it’s important to have yours done well. That’s why you should go to a place like MD Anderson, where surgeons perform these procedures all the time. 

Mara Antonoff, M.D., is a thoracic surgeon who specializes in the treatment of lung cancer.

Request an appointment at MD Anderson online or call 1-877-632-6789.

A bronchoscopy is a minimally invasive medical procedure in which doctors use a special scope to examine the inside of your lungs and airways. It is used frequently to diagnose and stage lung cancer.  

But can a bronchoscopy tell us anything else? Do you have to be put to sleep to have one? And how long does it take to recover? 

Read on, for answers to these questions and more. 

What are the different types of bronchoscopy?

Diagnostic bronchoscopy

We use robotic bronchoscopy to biopsy lung nodules and a technique called endobronchial ultrasound (EBUS) to sample lymph nodes for cancer staging.  

We also use a technique called bronchoalveolar lavage (BAL), typically in immunocompromised patients, to diagnose opportunistic infections of the lungs. To do a bronchoalveolar lavage, we wedge the bronchoscope in the section of the lung we’re interested in, flush it with a saline solution, extract the fluid, and culture it in a lab to see what grows.  

Therapeutic bronchoscopy

Mostly performed via rigid bronchoscopy, this procedure is used to remove tumors that are blocking the windpipe, to cauterize bleeding tumors, or to place stents that keep the windpipe open. It won’t cure cancer, but it should make breathing easier. 

How long does a bronchoscopy take? 

That depends. The shortest procedure is the bronchoalveolar lavage, which can take just 10 to 20 minutes. The diagnostic bronchoscopy of a lung nodule can take 45 minutes to an hour, and the sampling of lymph nodes for staging can add another 45 minutes.  

But if we’re doing it strictly for therapeutic purposes, it can take from one to two hours, depending on the complexity of the case. 

Keep in mind, though, that these are all estimates. The length of each procedure is determined by the number of lung nodules or lymph nodes being biopsied, and doctors don’t know this until they are looking inside your lungs. 

Are you awake during a bronchoscopy?

Not necessarily. You’ll be given general anesthesia in most cases, but moderate sedation if you only need bronchoalveolar lavage. 

Is a bronchoscopy considered a serious procedure? 

That depends on how you define it. I consider anything requiring general anesthesia to be a serious procedure.  

But doctors will be working inside your lungs, which are the most vital organs aside from the heart. So, it is more serious than a colonoscopy, for example, but less serious than most surgeries.  

Is a bronchoscopy considered a high-risk procedure? 

Bronchoscopy for the diagnosis of lung nodules, sampling of lymph nodes, or bronchoalveolar lavage is commonly considered a moderate-risk procedure. On the other hand, therapeutic bronchoscopy is always considered high-risk because patients are sicker to begin with. They often have collapsed or obstructed airways, low oxygen levels, or they are actively bleeding.  

What are the risks of a bronchoscopy? 

With diagnostic and staging bronchoscopies, the risks are mainly from the anesthesia, rather than the procedure itself. General anesthesia can lower your blood pressure, which can be risky if you have underlying cardiovascular disease. It can also weaken the breathing muscles, so you tend to take shallower breaths when you wake up from anesthesia, and that can make your blood oxygen levels drop.  

Biopsies of the lung nodules or lymph nodes have minimal risk of bleeding and infection, but biopsy of lung nodules can sometimes lead to lung collapse (pneumothorax). That’s why even if everything goes well, we prefer our patients to avoid long-distance traveling or air travel until the next day.  

With therapeutic bronchoscopies, the risks are higher, and they generally involve bleeding, having low oxygen levels, and difficulty breathing. But all of these are dependent on each patient’s particular situation, and your doctor will go over which ones apply to you in detail.  

How long does it take to recover from a bronchoscopy?

Most diagnostic and staging bronchoscopies are outpatient procedures. Patients remain in the recovery area for 45 minutes to an hour afterward, and then they go home. They generally feel tired on the day of their bronchoscopy, but they are back to their baseline the following day.  

The recovery time is similar for therapeutic bronchoscopy patients, even if they are already admitted to the hospital.  

Is a bronchoscopy painful?

No. The lungs have no pain receptors, so they do not hurt, and you are also sedated. You should not experience chest pain after bronchoscopy, either, unless you are coughing really hard. 

Does a bronchoscopy have any side effects?

Some patients report having a sore throat due to the breathing tube. And patients can expect to cough up mucus tinged with blood for the next 2 or 3 days. But those are both normal and will resolve on their own. 

Is a bronchoscopy better than a CT scan? 

These two tests play very different roles. A CT scan is the test that generally finds out there is something wrong in your lungs. But it can only tell you that there’s an abnormality present. It cannot tell you exactly what it is. A CT scan is just the beginning. 

For an accurate diagnosis, we have to examine tissue under a microscope. A bronchoscopy allows us to obtain that sample and make a diagnosis. If it turns out to be lung cancer, the tissue we obtain through a bronchoscopy can also be used for molecular profiling, so we can tailor your treatment to any specific genetic mutations. And bronchoscopy can, in addition, sample the lymph nodes to determine the stage of lung cancer. 

Can a bronchoscopy detect tuberculosis? 

Yes. Bronchoalveolar lavage is considered the gold standard for detecting any type of lung infection. For patients with pneumonia, we can determine exactly which pathogen is causing it.  

What’s the one thing people should know about bronchoscopies?

Go to a place like MD Anderson which does a large number of complex bronchoscopies each year and has a lot of expertise in them. That level of experience will give you a better outcome.  

MD Anderson is also at the forefront of using ablation therapy during bronchoscopy to treat small, peripheral lung cancers through clinical trials. We are the pioneers in this field, and only a handful of cancer centers offer it right now.  

Roberto Casal, M.D., is an interventional pulmonologist specializing in bronchoscopies.

Request an appointment at MD Anderson online or call 1-877-632-6789.