LUNG CANCER SCREENING FOR WOMEN IN PRIMARY CARE LAU BYE, RN, BS. Nursing 702

Transcription

1 Lung Cancer LUNG CANCER SCREENNG FOR WOMEN N PRMARY CARE LAU BYE, RN, BS By Nursng 702 A manuscrpt sujmtted n partal fulfllment of the requrlments for the degree of MAS ER OF NURSNG WASHNGT N STATE UNVERSTY COllege ofnursng rtober2009 NngtDA...at..,...cer-... fuverpon~""".0..1_...--,.. l.te.twa._.1

2 Lung Cancer To the Faculty of Washngton State Unve sty: The members of the Commttee ap onted to examne the manuscrpt of LAURA BYE fnd t satsf:actory and recommend that t be accepted. Melody Rasmor, MS, ARNP

3 Lung Cancer! LUNG CANCER SCREENNG FOR WOMEN N PRMARY CARE Abstract By L'lura Bye, RN, BSN Char: Louse Kaplan Washnlgton State Unversty October 2009 Lung cancer klls more people thah any other cancer. Women are more lkely to contract lung cancer than men whle women are also ncreasngly lkely to survve lung cancer. Lung cancer klls more people than colon, brea,t and prostate cancer combned. The ncdence of lung cancer has decreased n men by 15% whlf t has ncreased n women by 150%. The prevalence of lung cancer n women, the number of deaths from the dsease, the stage at whch lung cancer s dagnosed, and the mortalty rate makej ths subject one of the most mportant topcs n health care today. Nurse practtoners need to be knowledgeable and famlar wth the latest evdence based research regardng lung cancer as ""ell as known rsk factors and recommendatons for screenng. Ths artcle provdes an overv~ew of the epdemology, hstology, rsk factors, and symptoms of lung cancer. t specfcally tddresses lung cancer n women, recommendatons for lung cancer screenng n women and potehtal for reduced morbdty and mortalty f screenng s done by a dlgent and knowledgeable njlse practtoner. Early detecton and treatment, lves can be saved as well as costly medcal dollars. These facts should encourage prmary provders to screen hgh rsk women patents.

4 Lung Cancer v TABLE OF CONTENTS Page ABSTRACT 1 LST OF FGURES v LST OF TABLES v NTRODUCTON 1 RSK FACTORS 4 SMOKNG ' 4 NCREASED RSKS AMONG WOME 6 RSK FACTORS OTHER THAN SMOK NG 5 LUNG CANCER DAGNOSS r SCREENNG GUDELNES 8 CLNCAL TRALS POTENTAL TOOLS FOR LUNG CANfER SCREENNG STRATAGES FOR NURSE PRACTTfNS 8 10 ll 13 CONCLUSON 14 EDUCATON AND HARM REDUCTO~ 13 TABLES 16 FGURES

5 Lung Cancer v REFERENCES 22

6 Lung Cancer v U$T OF TABLES, 2007 estmated cancer deaths Types of lung cancer. j 16 17

7 Lung Cancer v Lung cancer rsk factors Lung cancer symptoms LST OF FGURES Lung cancer screenng recommendatons.l Lung cancer health assessment questonnare 20 21

8 Lung Cancer 1 Lung Cancer Screenng for Women n Prmary Care Lung cancer klls more people tham any other cancer. Smokng s the number one reason for contractng lung cancer yet an ncreasng number of non-smokers are beng dagnosed. Lung cancer wll account for almost 15% of all hew cancer cases (Amercan Cancer Socety (ACS), 2008 and Amercan Lung Assocaton (A~A), 2008). n 2008, the ACS estmated that approxmately 215,000 people would be d~agnosed wth lung cancer of whch almost 162,000 would de, an ncrease of two percent ove1 the number ofdeaths n The expected fve-year survval rate for all patents dagnosed wt~ nng cancer s 15% compared to 63% for colon, 89% for breast and 99% for prostate cancer (A~S, 2008; ALA, 2008; Centers for Dsease Control and Preventon (CDC), 2008). Over the last three decades, the n~dence of lung cancer has decreased n men by 15% and ncreased n women by 150% (lamel, Murray, Ward, Samuels, Twar, Ghafoor, et a, 2005). Women are more lkely to contract lung ctncer than men due to ncreased estrogen levels, changes n smokng habts, and ther susc1ptblty to adenocarcnoma. Women are also ncreasngly lkely to survve lung cancer than n pror years. The prevalence of lung cancer n women, the number ofdeaths from the dtase, the stage at whch lung cancer s dagnosed, and the mortalty rate makes ths subject one 4fthe most mportant topcs n health care today. Despte the fact that women have hgher rftes of lung cancer than breast cancer, there s no standard for screenng (Hopkn, 2008; HUrg, McKay, Gaboreau, Boffetta, Hashbe, Zardze" et al. 2008; nternatonal Early Lung CancerlActon Program nvestgators (lelcap), 2006a; Natonal Cancer nsttute (NC), 2009a). Nurse practtoners need to be kn0ledgeable and famlar wth the latest evdence based research regardng lung cancer as well as ~nown rsk factors and recommendatons for screenng.

9 Lung Cancer 2 Ths wll ensure tmely and approprate counselng wth patents who are at rsk for lung cancer, weghng the pros and cons of screenng (Smon, 2007). Ths artcle provdes an overvew ofthe epdemology, hstology, rsk factors, and symptoms of lung cancer. t specfcally addresses lung cancer n women, recommendatons for lung cancer screenng n women and potental for reduced morbdty and mortalty f screenrg s done by a dlgent and knowledgeable nurse practtoner. Epdemology The epdemologcal pcture of ludg cancer n women has changed n the last several decades. Between 1990 and 2003, the nu~ber ofwomen dagnosed wth lung cancer ncreased by 60% (Fu, Kau, Severson, et al. 2005). rn the last 30 years there has been a 150% ncrease n women, whch makes the 60% ncrease ar extremely steep one n such a short perod of tme. The most recent statstcs from the centerl for Dsease Control and Preventon (CDC) (2009) are for n that year 107,416 men and 8r,271 women were dagnosed wth lung cancer, and 90,139 men and 69,078 women ded from the dsease. Patel, Bach and Krs (2004) refer to ths monumental ncrease as a "contemporary Fpdemc".! The World Health Organzaton (tho) (2009) reports that there s strong evdence lnkng gender factors wth lung cancer. Women are twce as lkely to develop lung cancer from cgarette carcnogens, however once da40sed they have better survval rates than men. Women are dagnosed at an earler age than men, lut women are overrepresented n the less than 50 year old group whch suggests a hgher gender specfc susceptblty to tobacco carcnogens (Fu, Kau, Severson, et al. 2005). The mortalty rate for women wth lung cancer s 60% hgher than breast cancer. Lung cancer now accounts Lr more deaths n women than any other cancer, ncludng breast and colon cancer combntd (Table 1).

10 Lung Cancer 3 t s estmated that 25% of alllung'cancer occurs n people who never smoked makng t an mportant publc health ssue and one that also has lnks to gender. The rate of new cases n ths never-smokers group s slowly rsng'lat a 10% hgher rate n women than n men, and s predomnately found n younger women'1wakelee, Chang, Gomez, Keegan, Feskanch, Clarke, Holmberg, et a, (2007). Hstology The hstology of lung cancer s dvded nto two major classes: non-small cell lung cancer and small cell lung cancer. Small cell reptesents approxmately 81 % of all lung cancer whle non-small cell, also called "oat cell carcntma", only accounts for 13%; the remanng sx percent s caused by other types of lung c~ncer. The prognoss s poor for all lung cancer found at late stages n that there s no effectve ttalment (ELCAP, 2007; Mnna & Schller, common, faster growng, more lethal and spreads rapdly to other organs and the lymph system. 2008).Non-small cell and small cell lung rncers dffer n many ways. Small cell tends to be less Small cell ncludes oat cell, mxed small ahd large cell, and combned small cell. Non-small cell ncludes adenocarnoma, squamous, and l~rge cell lung cancer. Of all lung cancer types, adenocarcnoma s the most common (Tatle 2). t s slow growng and commonly assocated wth smokng (Mnna & Schller, 2008; ~HO, 2004; ELCAPl, 2007a). Sxty percent to 80% of non-smokers who contract lung cancer arel dagnosed wth adenocarcnoma (Swerzewsk, 2007). Lung cancer s one of the most letjal forms of cancer (WHO, 2004). Ths s due n part to the fact that t s usually not symptomatc untl the late stages when there s lttle chance of treatment workng. f detected early, the lurvval rates greatly mprove (ELCAP, 2006a, 2006b; WHO, 2004). Stagng s used to determne the extent of the dsease, prognoss and

11 Lung Cancer 4 canddacy for surgcal nterventon (Rozenshten, 2005). The current stagng system used nvolves three factors: tumor extent, lymph node nvolvement, and metastass. Overall stage s done once each factor s establshed. The combnaton of each factor determnes the overall stage. Ths system s lmted by the fact th~t other possble prognostc factors are not used (Chen, Xng, Henson, Sheng, Schwartz and Cheng, 2009). Rsk Factors The rsk factors for lung cancer are numerous and span soco-economc and gender lnes. Cgarette smokng accounts for 87% of lung cancer (Smth R, von Eschenbach A,Wender R, et a, 2001). The earler age, at whch a persbn begns smokng, the greater number of cgarettes smoked and deeper nhalaton, the hgher the lfetme lung cancer rsk. (Tyczynsk J, Bray F, and Parkn D, 2003; Sasco AJ, Secretan MB, ~nd StrafK, 2004). Smokng Those that smoke have a tmes greater chance of developng lung cancer over nonsmokers (ACS, 2004). However, non-smjkers exposed to secondhand smoke are also at rsk. There are two types of secondhand smokef smoke exhaled by a person smokng and smoke from a burnng cgarette. Both types have carcnogens and ncotne but hgher concentratons are emtted from burnng cgarettes (Sasco, S~cretan, and Straf, 2004). Studes have found that exposure to secondhand smoke n the hoole ncreases the rsk of lung cancer by 20-30% whle second hand smoke n the work place ncr~ases the rsk by 16-19% (Sasco, Secretan, and Straf,, 2004). Chldhood exposure to secondhanq smoke approxmately doubles the lfetme rsk of lung cancer. Chldren have a greater resp~atory rate than adults and so ncreases the amount of second hand smoke they nhale (Boffetta, T'redanel, and Greco, 2000). Addtonal rsk factors

12 Lung Cancer 5 for lung cancer are exposure to wood smoke, asbestos, coal, radon, lung dsease and multple of occupatonal rsks. Rsk/actors other than smokng Approxmately 10-15% of lung ca~cer cases are dagnosed n people that have never smoked; most of these patents are women (Swerzewsk, 2007). Several rsk factors besdes smokng have been dentfed and are mpbrtant to consder as possble causes of lung cancer n the non-smoker (Amercan Cancer Socety, 2006). Fgure #1 The second major rsk factor for l~ng cancer s radon (Pawel and Puskn, 2006; Cersosmo,2004). Radon, a gaseous ele~ent, s found n the sol beneath homes and buldngs and dffuses nto the ar va foundaton cnwks, nsulaton gaps, drans, ppes, or walls (Amercan Lung Assocaton, 2008). Radon exposur causes damage to lung tssue va the emsson of radoactve alpha partcles (Gnsberg, 2005). These partcles cause cellular damage that s known to lead to lung cancer (Cersosmo R., 2004). Smoke from wood stoves, freplac~s and camp fres contan smlar carcnogens as found, n tobacco smoke (Delgado, Martnez, Sa~chez, et al. 2005). One study revealed a postve! correlaton to lung cancer n 38.7% ofn09-smokers who were exposed to wood smoke for a perod ofat least 10 contnuous years (De,gado, Martnez, Sanchez, et al. 2005). The nternatonal Agency for Research on Cancer based n Lyon, France conducted the largest study of possble genetc causes of lung cancer nvolvng over 10,000 people from 18 countres. The study dentfed a major g~netc factor that contrbutes to lung cancer rsk. The varant s a ncotnc acetylcholne recept~r subunt gene on 15q25. People who carry these DNA! varants are 30% more lkely to develop 'fg cancer compared to those who do not have the

13 Lung Cancer 6 varants. An ndvdual who carres two copes of the varants s at an 80% ncreased rsk of developng lung cancer (Hung et al. 2008). For adults and chldren wth lung qsease that cause scarrng, such as tuberculoss, chronc bronchts, asthma and pneumona, there s an ncreased rsk for adenocarcnoma (Amercan Cancer Socety, 2006). Atomc bomb survvors and those undergong thoracc radaton therapy, such as for the treatment of Hodgkns dsease and breast cancer are at ncreased rsk for developng lung cancer (Shuryak, Hahnfeldt, Hlatky, Sachs & Brenner, 2009; Travs, Gospodarowcz, Curts, Clarke, Andersson, Glmelus, et al. 2002; Preston, Ron, Tokuoka, Funamoto, Nsh, Soda, et al. 2007). Occupatonal rsk factors for lung cancer nclude workng n underground mnes, asbestos, textle factores, hot smeltng pl~nts, vneyards, fur companes, and cadmum battery factores (Boffetta, 2004). Workers expos~d to polycyclc aromatc hydrocarbons found n roofng, chmney sweepng, road pavng, ~esel engne fumes, alumnum manufacturng, and coke producton, are also consdered at ncreased rsk for lung cancer (Boffetta, 2004). Bartenders and restaurant servers are another group at rsk due to extensve passve smoke exposure (Chan-Yeung & Dmch-Ward, t003; Mulcahy, Evans, Hammond, Repace, & Bryne, 2005). ncreased rsk among women Cohen (2007) reports evdence that women are more susceptble to the carcnogenc effect of tobacco smokng due to estrogenlevels and the up-regulaton of cytochrome P450 enzymes n lungs and lver. Cgarette sm9ke and estrogen n the lung both up-regulate the number of cytochrome P450 (CYP) enzy~es n the lver, whch n tum ncreases the metabolsm

14 Lung Cancer 7 of ncotne. Adenocarcnomas, more common n women, naturally exhbt more estrogen receptors than other types oftumors (Avel-Ronen, Blackhall,Shepard & Tsao, 2006). Estrogen receptors are found n both healthy and dseased lung tssue. t s hypotheszed that estrogen functons as a carcnogen by formng DNA adducts, a pece of DNA covalently bonded to a chemcal. DNA adducts have been shown to ntate carcnogeness. DNA adducts result n ncreased p53 mutatons whch actvate the growth factors that cause cell dvson and the prolferaton of cancer cells (Thomas, Doyle, and Edelman, 2005). Because of ther hgher levels of DNA adducts, women are more lkely to have p53 mutatons than men (Thomas, Doyle, and Edelma, 2005). There s conflctng nformaton aqout lung cancer and women who use estrogen replacement therapy (ERT). One study fojnd that estrogen replacement therapy had a rato of 1.7! postve correlaton wth adenocarcnoma. Of the group that had smoked and receved ERT therapy, the study revealed 32.4% more cases developed lung cancer over the non-smoker subjects (Segfred, 2001). n contrast, KrFuzer et al. (2003) concluded that women who were! prescrbed ERT were at a lower rsk for developng lung cancer, though ths study only dentfed the subjects as "ever-smokers" and "neve-smokers", and omtted ther amount of exposure to smoke. (Segfred, 2001). A more recent study evaluated the relatonshp between the extent of estrogen treatment to the duraton of the l~ness n lung cancer survvors (Natonal Cancer nsttute, 2009a). One group of patents were gven a specfc treatment and the control group was gven another treatment or a placebo. Ths was a retrospectve study on women wth lung cancer. Eghty sx percent of the women f the study were smokers. Women who never receved ERT treatment and never smoked had the hghest survval rate, whle women who smoked and receved ERT treatment had the lowest surval rate. (Gant, Sahmoun, Panwalkar, Rendulkar

15 Lung Cancer 8 and Pott, 2006). Each study lnked estrogen and not progesterone to the ncreased rsk of lung cancer development. Lung cancer dagnoss Patents whose lung cancer s detected early are the ones who wll most beneft from treatment. However, most people are not pagnosed untl the dsease has progressed to a more serous level (stage or V) when symptoms cause a patent to seek care. As much as 85% of patents dagnosed wth lung cancer are ~ the late stage of the dsease when the cancer has metastaszed and has a very poor prognoss. Even when lung cancer has metastaszed, symptoms may not appear to be cancer related makng dagnoss more challengng. The most common symptoms are shortness of breath, coughrg, hemoptyss, and weght loss (Fgure 2). Whether or not lung cancer screenng could detect lurlg cancer at an earler stage of the dsease was the central purpose of ths revew. Specal att nton was pad to screenng of women who are now at, greater rsk than men (Hamlton, Peters, ~ound, & Sharp, 2005; Palear, Granon, Grozo, Cesaro, & Russo, 2007); Screenng Gudelnes A revew of the lterature was con~ucted to locate current screenng gudelnes for lung cancer wth specal attenton to recommerdatons for women. The keywords use to search were: lung; cancer; women; gudelnes; and screenng. A database search of the Natonal Gudelnes Clearnghouse, PubMed, Cnhal and the Cochrane lbrary resulted n research artcles about screenng for lung cancer. Eghty t~o artcles were revewed wth ncluson crtera were: Englsh, human, women, screenng gudelnes, evdence based, peer revewed.

16 Lung Cancer 9 A revew of professonal assocatons and government agences was also conducted to determne f any had current lung cancer screenng gudelnes. An nternet search for "gudelnes for lung cancer screenng" determned whch assocatons and agences to revew. None of the researchers, professonal assocatons, or government agences recommends routne screenng for lung cancer. Evaluaton of evdence basedl data was used to determne whether to make recommendatons and gudelnes for prevtfntatve servces. No studes ndcated morbdty reducton wth early screenng (Fgure 3). Pror to 1980, the Amercan Canc+ Socety (ACS) (2006) recommended mass screenng for lung cancer wth yearly chest flms. ACS reports that there s currently no evdence to support routne screenng. The new recommendaton was for health care professonals and patents to decde f there was suffcent e~dence to warrant screenng on an ndvdual bass. The ACS currently recommends that nd\lduals at rsk for lung cancer, ncludng current and past smokers, those wth sgnfcant exposrre to second hand smoke or those wth occupatonal rsk factors should seek screenng wth ch~st x-rays, CT scans, or bronchoscopy for early detecton. The Amercan College of Radologsts (ACR) (2008) n part bases ts decson not to recommend routne screenng on the evdence that CT screenng s not cost-effectve and dd not decrease mortalty. The ACR also states that there s no evdence to support any other type of routne screenng. n addton, the ACR h~s concerns of false postves leadng to unnecessary follow ups and treatment, ultmately wastng resources and money and encourages 'watchful watng'. Watchful watng refers to mon~orng hgh rsk patents for sgns and symptoms of lung cancer, before testng.

17 Lung Cancer 10 Accordng to the U.S. Preventve Servces Task Force (USPSTF) (2004) there s nsuffcent evdence to recommend screenng for lung cancer n asymptomatc patents. The Amercan Academy of Famly Physcans 1(2007) recommends aganst any screenng and only evaluatng symptomatc people. The Nat~nal Cancer nsttute (2009b) revewed numerous studes conducted on early screenng for h;mg cancer and none of those studes have found evdence that lung cancer screenng decreases mortalty. Stll most organzatons are recom~endng no screenng or watchful watng untl more conclusve data can be found, clamng bds n the ELCAP studes. Currently clncal trals are beng conducted worldwde wth a study ~eng conducted by NC, whch s the largest to date. Clncal Trals Screenng gudelnes may change lbased on these mportant clncal trals worldwde to assess dfferent methods for screenng an~ the outcomes when they are used. The most promsng ones nvolve CT screenng alth~)ugh the current data ndcate that CT screenng produces too many false postves. Accordng to ClncalTrals.gov (2009) there are three US studes that are currently recrutng whch nclude: The Dana-Farber Cancer nsttute's Low-dose chest computed tomography screenng for lung cancer n survvors of Hodgkn's dsease - nterventon of chest computed tomography scan; New York School of Medcne's Bomarkers n screenng partcpants for lung cancer - nterventon of bronchoscopy and bopsy; Semens Molecular magng's A mult - center study of PET magng wth [F-18] FLT & [F-18] FDG n cancer patents for treatment evaluaton - nterverton of drug [F-18]FLT. The only tral that focus on womed. s the ECAP study. The nternatonal Early Lung Cancer Acton Program (-ELCAP) (2007~ has three studes on gong, but s not currently

18 Lung Cancer recrutng. ELCAP's 13 year landmark study found CT screenng was able to detect lung cancer at ts earlest stage. The FAMR-ELCAP project s explorng detecton of lung cancer and ts relatonshp to secondhand cgarette smo~e. The Legacy Project looks at current smokers who desre to qut and the relatonshp to smokng-related dseases ncludng chronc obstructve pulmonary dsease (COPD), cardac dsease, and lung cancer. The NC (2009b) s conductng the Natonal Lung Screenng Tral whch s comprsed of current and former smokers to compare standard chest X-rays and CT scannng for screenng for lung cancer. t nvolves 50,000 smokers ~nd prevous smoker to determne the effectveness of annual chest x-rays and CT scans. Ths t~al s beng conducted at 30 dfferent locatons and s expected to be completed ths year (HOPkrns, 2008). A prelmnary analyss ofthe results has shown no reducton n mortalty wth eth~r chest X-rays or spral CT scans. Once the results are deaths. publshed, t wll determne whether use d,r ether test for screenng for lung cancer wll reduce The NC study wll also attempt to answer other mportant questons (NC, 2009b) such as: Wll CT scans or standard chest X-rays reduce deaths related to lung cancer? What are all of the causes of death n groups who are screened for lung cancer? At what stage s lung cancer dagnosed when screened? How well doe$ the screenng test detect early lung cancer and all lung, cancers? What follow-up medcal tests ar~ used when CT screenng tests or chest x-ray screenng tests are postve n hgh-rsk people? Hot cost effectve s lung cancer screenng? How does lung cancer screenng affect qualty of lf~ for those who test postve? How does lung cancer screenng nfluence smokng behavor anej belefs? Potental tools for lung cancer screenng

19 Lung Cancer 12 Currently varous types of tests are beng evaluated as possble lung cancer screenng tools based on what s beng used for dagnosng lung cancer n symptomatc ndvduals ncludng chest X-ray, sputum cytology, bronchoscopy and low-dose computerzed tomography [CT]. Chest X-rays specfcty s 89% wth a senstvty of 50% and s only able to detect masses greater than 1 cm. Sputum cytology s useful for the detecton of abnormal cells. Bronchoscopy s manly used for the cytologc or hstolokc dagnoss of lung cancer, but t fals to dagnoss as many as 20-30% of the cases (Sngh, et al( 2007). Mahadeva et a, (2003) found C~ scans were not cost-effectve n that they resulted n over-dagnosng lung cancer by the hgh r~te of false postves and the frequency of bengn lung nodules found. Another negatve aspect df CT scans s that the amount of radaton produced s 15 tmes greater than that from a regular chest x-ray, addng the potental for an unnecessary rsk of radaton exposure to patents (MacRecrond, Logan, and Lee, et al. 2004). A study conducted at Mount SnalSchool of Medcne looked at the cost effectveness of low dose radaton CT scannng as a screerng tool for lung cancer. The study concluded that low dose CT scans were potentally hghly cost-effectve and was as cost-effectve when compared wth other screenng programs. However, due to the absence of evdence regardng mortalty and concerns about over dagnoss, the recommendaton s aganst screenng wth low! dose CT scans for ndvduals wthout sy~ptoms or a hstory of cancer (Wsnvesky, Mushln, Scherman, and Henschke, 2003). ECAP has been studyng low dose CT scans worldwde for over 10 years. The nvestgators have publshed 45 peer revewed artcles on lung cancer screenng on ther 13 year study. Accordng ELCAP research (2006), more that 80% of patents who have a lung cancer detected by CT screenng can be cured. vyfhen found early and treatment s actvated early the

20 Lung Cancer 13 cure rate ncreases to 92%. ELCAP also states that 95% of lung cancer patents wll de from the dsease wthout early screenng. Strateges for Nurse Practtoners Nurse practtoners have the ablty to ncorporate screenng for hgh rsk patents nto practce. Although there are no screenng gudelnes for lung cancer, t s mportant for nurse practtoners (NPs) to dentfy rsk factorslfor lung cancer. NPs can assess people at hgher rsk for lung cancer n a more crtcal manner (jlnd be alert to sgns and symptoms that may be the harbngers of the early stages of lung canoer. The NP determnes the rsk of a patent by usng the health hstory assessng for cgarette smokng, exposure to cgarette and wood smoke, radon, radaton, and occupatonal hazards. The revew of systems can provde red flags as to early symptoms such as coughng, wheezng, f,tgue, weght loss, and chest pan. The Lung Health Assessment Queptonnare (Smon, 2007) s a comprehensve tool that can be used wth patents who need counselng on screenng rsks and benefts (Fgure 4). The questonnare s self admnstered by the ~atent and revewed by the NP to help determne hgh rsk patents (Smon, 2007). NPs can educate hgh rsk patent~ on strateges to reduce or elmnate rsk factors. For example, a person wth occupatonal rsk should be advsed on the mportance of usng personal protectve devces. Smokng cessaton or reducton and household radon detecton are other examples of recommendatons the NP ca~ make n the approprate stuatons. Patent educaton and harm reducton

21 Lung Cancer 14 The mportance of the NP beng able to educate patents cannot be overlooked. By drawng from ther educaton and expertse, NP's play an essental role n the educaton of patents about the factors that help prevent lung cancer; dscussng such topcs as envronmental and occupatonal rsk awareness, and nformng about the benefts of harm reducton and smokng cessaton. Occupatonal rsks vary from one locaton to another and the NP should make themselves aware of the local rsks.for example, n West Vrgna coal mnng would put both the mner and ther famles at rsk frpm the coal dust n the mnes and on clothng. n the Washngton's Puget Sound, San Francscr Bay Area, Boston, South Carolna as well as many other parts of the world naval and shp yards are a huge source of asbestos. Georga and Mnnesota have a large textle ndustry whch produces dusts that are known to lead to lung cancer. The NP must know the local area rsks as well as across the country there are roofers, chmney sweepng, road pavng and desel engne fumes all at rsk for lung cancer. Smokng cessaton s stll the num~er choce for reducng the rsk of lung cancer (Rchens, 2009). However, harm reductop s valuable for those n hgh rsk occupatons and addtonally so for smokers. Smokng remans the number one rsk factor and cessaton s the best way to prevent and reduce the chanc~ of lung cancer. However, many smokers are unable to qut by conventonal or tradtonal methods. Ths artcle reports that the "qut or de" approach does not always work. An alternatve ap~roach to smokng cessaton s harm reducton. Harm reducton ncludes the substtuton of safer sources of ncotne, ncludng tobacco products, such as powdered dry snuff and loose cut tobaqco (Rodu & Godshall, 2006). Concluson

22 Lung Cancer 15 Lung cancer klls more people than any other cancer. Over two hundred thousand people wll de from lung cancer ths year. Women are twce as lkely to be dagnosed wth lung cancer however they have better survval rates. The mortalty rate for women wth lung cancer s 60% hgher than breast cancer. The most comlllon lung cancer s adenocarcnoma, whch women are more lkely to contract. The rsk factors are numerous and span soco-economc and gender lnes. Smokng and secondhand smoke account for the major~y of lung cancer. Genetc factors, radon, wood smoke, occupatonal hazards and lung dsease arelall rsk factors for lung cancer. Women are at an ncreased rsk due to estrogen levels and smokng. The earler lung cancer s found the more lkely t can be cured. However, most lun~ cancer s not found untl stage or V. Ths s n part due to the lack of screenng. Once a patent presents wth symptoms, lung cancer s already n the advanced stages and n most cases trere s less than a 5 year survval rate., Screenng for asymptomatc pate~ts s not recommended at ths tme. There are a few clncal trals beng conducted, that look at CT scannng, yearly chest radographs, and bronchoscopes. Nurse Practtoners are n a poston to determne who s at rsk for lung cancer, gudelnes ths does not mean that nurse practtoners cannot educate ther patent and refer those at hgh rsk to specalst for more thorough workups, untl we have screenng tools such as those for breast, colon and prostate cancer. educate on smokng cessaton and harm r~ducton. Although there s currently no screenng

23 Lung Cancer 16

24 Lung Cancer 17 Type of Lung Cancers 0/0 Totals Adenocarcnoma 38 Squamous cell carcnoma Large cell carcnoma 20 5 Other non-small cell carcnom*s, 18 NSCLC Small cell carcnoma SCLC Other Table #2 Total cases oflung Cancer 100%....

25 Lung Cancer 18 Fgures Lung Cancer Rsk Factors x Radon exposure to whch can occjr n the home (Pawel & Puskn, 2006; Cersosmo, 2004); x Wood smoke from wood stoves, freplaces and camp fres (Delgado J, Martnez L, Sanchez T, et a., 2005); x Famly hstory of lung cancer (Ntfdor, noue, wasak, Otan, Sasazuk, Naga, & Tsugane, 2006); x Hstory of lung dsease that causes; scarrng, such as tuberculoss, chronc bronchts, asthma and pneumona (ACS, 2006); x Radaton exposure therapy that s jexperenced by atomc bomb survvors and people treated wth radaton for health problems such as Hodgkn's lymphoma and breast cancer (Znzan, Martell, Polett, Vtolo, pobb, Chses, et a., 2008; Preston, Ron, Tokuoka, Funamoto, Nsh, Soda, et a. 200~ & Shuryak, Hahnfeldt, Hlatky, Sachs, Brenner, 2009); x Occupatonal rsk factors n many work places (Boffetta P., 2004). x Endocrne factors ncludng exogepous estrogen (Chen, Hsao, Chang, Tsa, Su, Pemg, Huang, Hsung, Chen, and Yang, ~007 & Schwartz, Wenzlaff, Prysak, et a., 2009) x Nutrton ncludng det and vtam~ns. Researchers found those takng combned betacarotene and vtamn E supplemen~s and those takng antoxdant supplements had a greater ncdence of lung cancer ard death from lung cancer (Tanvetyanon & Bepler, 2008). Fgure #1

26 Lung Cancer 19 Lung cancer symptoms Common symptoms nclude: New onset of coughng, or wheezng Reoccurrng pneumona or bronchts Unusual tredness or fatgue Hoarseness Unexplaned pan n the chest, upper back, shoulder or arm Unexplaned weght loss or loss of appette Less expected symptoms due to metastas~ nclude: Swellng n the area of the neck or even the face Headaches Bone fractures and pan Unexplaned bleedng or clottng (Hamlton, W; Peters TJ, Round A, Sharp! D., 2005). Fgure #2

27 Lung cancer screenng recommendatons Organzatons that recommend no screenng u.s. Preventve Servces Task Force (2004) Amercan Academy of Famly Physcans (009) Natonal Gudelnes Clearng House (2009) Amercan College of Chest Physcans (20P7) World Health Organzaton (2002, 2009) Amercan College of Radologst (2008) Amercan Cancer Socety (2001) Natonal Cancer nsttute (2009) Fgure #3 Lung Cancer 20 Organzatons that make no recommendatons Amercan Lung Assocaton (2009) Socety of Thoracc Surgery (2006)

28 Lung Health Assessment Questonnare Lung Cancer 21 The followng assessment fonn has been gven to you to determne f you have any known rsk factors for, and/or symptoms suggestve of, the development of lung ~ancer. Please take a few moments to complete ths questonnare. Smoke Exposure Occupat0l1al Exposure Chronc bronchts? Do you currently smoke cgarettes? Do you work, or have you worked [1Ye~ No DYes DNo n the past,ln any of the followng Chronc obstructve pulmonary f yes, how many packs per job settngs: dsease? day? Underground mnes [Ye~ No Do you nhale when you smoke? 'Ye~ No Asthma? DYe~ No Asbestos textle factores DYe~ No At what age dd you begn Ye~ No Have you ever been dagnosed smokng? Hot smelt~g plants wth cancer? Do you smoke nonfltered or '-'Ye~ No nye~ No handrolled cgarettes? Vneyards: f so, what type of cancer? DYe~ No Ye~ No f you no longer smoke, at what Fur companes Have you had radaton therapy to age dd you qut? [Ye~ No your chest or back? Do you currently smoke cgars? Cadmum battery factores L1Ye~ No DYe~ No 'Ye~ No Lung Symptoms Do you currently smoke a ppe? Roofng Please check any of the followng DYe~ No Ye~ No symptoms that you have Do you have a hstory ofexposure Chmney sweepng experenced to wood smoke? ' Ye~ No n the last 12 months: DYe~ No Road pavng Hoarseness Passve Smoke Exposure c,ye~no Naggng cough Do you lve wth someone who Exposure to desel engne fumes Changes n your pattern of cough smokes? f'yes No Cough that produces blood-tnged DYe~ No Alum num! manufacturng or rust-colored sputum f yes, for how many total ~Ye~ No Repeated epsodes of pneumona years? Coke prod~cton or bronchts Were you exposed to cgarette '!Ye~ No ' Pan n your chest, shoulder, or smoke as a chld? Bartender e;>r restaurant server arm DYe~ No ~'Ye~ No Shortness of breath or dffculty f yes, for how many total years? Famly Hstory breathng Do you have a frst-degree relatve Wheezng Are you exposed to cgarette wth cancer? Swellng of your face or anns smoke at work? '~Ye~ No Fatgue DYe~ No f yes, wh~t type of cancer? Weakness f yes, for how many total years?! Change n taste Past medcal Hstory Loss ofappette Envronmental Exposure Do you hare a hstory ofany of the Dffculty eatng or swallowng Do you have any known exposure followng: : Loss of weght (wthout tryng to to radon? Chldhood 'pneumona? lose weght) DYe~ No L:1Ye~ No f yes to the above, how much Do you have any known exposure Tuberculo~s? weght have you lost? to asbestos? JYe~ No, Nght sweats DYe~ No Pan n your bones Fgure #4 (Smon, 2007)

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37 Lung Cancer 30 the talan Socety of Hematology, the talan Socety of Expermental Hematology and the talan Group for Bone Marrow Transplantaton. Haematologca, 93(9),