• Academic and consultant chest/respiratory physician Dr. Yamuna Rajapakse says this is due to secondary smoking, biomass fuel smoke 
• Calls for halt to vaping as it can lead to nicotine addiction while benzene/formaldehyde can cause genetic mutations 

Lung cancer remains one of the deadliest cancers worldwide, not necessarily because it is untreatable, but because it often goes undetected until it is too late. 

One of the biggest challenges is the lack of clear early warning signs and the public’s lack of attention to the same. In many cases, people are only diagnosed after a routine scan or check-up reveals something suspicious, and by then, opportunities for cure may be limited. 

These concerns were expressed by the Colombo University Faculty of Medicine, Department of Anatomy Senior Lecturer and consultant chest/respiratory physician Dr. Yamuna Rajapakse, who stressed that patients coming in at later stages when symptoms have persisted or worsened is a major challenge. She made these remarks during an interview with The Daily Morning in the backdrop of the World Lung Cancer Day, which fell on 1 August. 

Following are excerpts from the interview:

What is lung cancer?

When you take lung cancer in its broadest term, lung cancer is any cancer which occurs in the lungs. But now, this can be divided into two types, those primarily occurring in the lung, or primary lung cancer, and cancers which have metastasised or spread from another organ in the body.

In primary lung cancer, we have mainly two varieties called non-small cell cancer and small cell cancer. The commoner variety is the non-small cell cancer, which is again divided as adenocarcinoma and squamous cell carcinoma. Smokers generally used to get squamous cell carcinoma, while the adenocarcinoma variety is actually the most common variety. When it comes to small cell cancer, it is rarer, and it is the type which spreads from other places, like from organs like the breasts, the colon, the kidneys or the prostate. 

The other key type, which sometimes is known as lung cancer, is the case of pleural cancer. The pleura is the covering of the lung, or the pleural membrane, in which also cancer can occur. 

What are the early warning signs of lung cancer that the public should be aware of? What steps should one take if they notice these signs?

The problem with lung cancer is that you don’t get very clear early warning signs. Most of the people who we have actually managed to cure of lung cancer are the people who found a small patch in their lungs in situations such as tests or health check-ups. Only if we find something like that and investigate at that stage can we determine if it is curable. However, in most cases, the sad situation in our country and most parts of the world is that lung cancer is found rather late. But, if you are vigilant about certain symptoms, such as a cough that lasts for more than like two to three weeks in the Sri Lankan context, one of the reasons could be tuberculosis (TB) and the another reason could be lung cancer. You have to keep that in mind when it comes to patients who don’t have a history of health issues such as asthma or if you have not had a respiratory infection like a week before. However, if there is no apparent reason and a lasting cough appears suddenly with a feeling of irritation, it is better to speak to a doctor and get it checked.

If you are a smoker having a never-ending cough, be sure to get yourself checked. If the cough produces blood, that is a sign of danger. If you are losing weight without intending to lose weight, or if you suddenly completely lose your appetite along with weight loss, that combination of symptoms is something you need to get checked.

What other organs can be directly affected due to lung cancer?

Lung cancer can directly grow in the local region, or your chest cavity. Cancer can either invade tissues or they can spread via the bloodstream or lymphatics to far away regions. So, when lung cancer starts growing, because of the local invasion, firstly, they can affect the large blood vessels inside the thoracic cavity and even the lining of the heart, the pericardium, the aorta, and pulmonary vessels. All those large vessels inside the chest can get affected. 

Then, the cancer can spread to the chest wall. So, it can secondarily affect the pleural cavity and the pleural membranes, leading to fluid collection in the pleural cavity, or it can further spread into the chest wall and even appear outside the chest wall like a lump. If the cancer is closer to the neck or the apical part of the lung, it can affect the nerves in the root of the neck and even show certain signs on the face. 

Regarding the indirect spread, lung cancer can affect organs such as the liver as it can travel to the liver, brain, bones other than the ribs, and adrenal glands (through the bloodstream or lymphatic system). Those places are where we check if we find lung cancer in somebody. We do either a full body computed tomography (CT) scan or a positron emission tomography (PET) scan to find out if the lung cancer has travelled outside the lung or the chest wall.

Apart from smoking, how might lifestyle or environmental factors influence the risk of developing lung cancer?

Smoking accounts for more than 75% of lung cancer cases that we encounter. But, it is changing because of high environmental pollution, especially the fact that there are micro particles in the atmosphere, which come with the smog. Those can also lead to cancer. There are also a lot of chemicals (in the air) such as vehicle fumes. If you are living in a place that exposes you to these, it is best to be careful and protect yourself. 

If you are working in a factory that produces certain fumes or carbon particles, even if you are not smoking, please use protection like a proper mask. In the construction industry, exposure to materials such as cement dust, tile dust, and asbestos can increase the risk of developing lung cancer. 

In addition, smoking among the younger generation of females is on the rise, which is a tragic trend. However, we have seen a lot of lung cancer cases in women aged 40 and above. They develop cancer due to other reasons such as secondary smoking, and biomass fuel smoke such as in the cases of burning firewood, cow dung and coconut husks. If you are cooking in a place where there is not a lot of ventilation, like in a closed room, and if you are breathing the fume, that inhalation is very harmful. Moreover, things used in our houses such as incense sticks and mosquito coils are also harmful. Although we cannot directly link those to lung cancer, they all have a cumulative effect. 

There is another factor generally seen in the Asian region, mostly in China, which has been studied. A certain genetic mutation can occur – we are not born with it, but one involving genes that have the potential to be switched on due to certain factors such as certain chemicals in our surroundings. It has been observed that younger females who have never smoked are developing lung cancer associated with this gene being expressed. This happens because the genes are activated by random chemicals that they are exposed to.

Sri Lanka has introduced various smoking-related regulations. In your opinion, what gaps or challenges still remain in relation to preventing lung cancer?

Our regulations are very good. If you look at the regulations, a lot of areas in Sri Lanka are smoke free, especially indoors, public places, schools, and workplaces. However, the situation in certain places such as entertainment-related events, restaurants, and hotels is different. 

Their regulations say that smoking is restricted and some have designated smoking areas. It is good in a way. However, what we have noticed is that people don’t really restrict themselves to those smoking areas, and at times, the smoke spreads to places with non-smoking people as well. People smoke in places such as bus stations and train stations, although smoking inside buses and trains is prohibited. If it is possible to make all these places smoking free, it would be an ideal situation.

What steps can individuals take to reduce the possibility of developing lung cancer?

One of the key steps is to refrain from smoking. If you notice someone smoking near you, you can certainly walk away. But, it is also your right to tell them, ‘please don’t smoke near me’ and that ‘I don’t like it’. If somebody wants to smoke, they can go to a designated area and smoke and come back. If somebody in your family is smoking in the house and especially if you have young children, guide them to go out of the house to smoke.

At the same time, if you are working in an industry in which you get exposed to fumes and chemicals, wear proper protective equipment. For example, wearing proper masks is important because particulate matter 2.5 particles can only be effectively filtered by specific types of masks, such as N95 or higher-grade respirators. In companies, the management should make sure that their workers get that type of mask when they work. Enforcement is also important to ensure that workers wear them. 

In addition, open your windows as much as you can if you are not living near a road. However, if you are living near a road, I think that it is better to keep them closed. Ensure proper ventilation. If you open just one window, you can avoid a lot of polluted air and get harmful fumes out of your house. Such steps are beneficial not only when it comes to lung cancer, but also concerning general lung health. There are a number of such steps, one of the main ones being making people aware that it is not only smoking that causes lung cancer.

We must pay attention to things like vaping as well, as it is not a good substitute for smoking. Children are starting to vape, thinking that it is the next best thing and that it would help them feel included. However, it has been proven by studies that children who start to vape now later take up smoking, because all vaping does to you is getting you addicted to nicotine. Then, they go on to find the next nicotine fix. Vapes also have their own bad content such as benzene and formaldehyde in them. They can enter your lungs and cause your cells to change. In such a context, the aforementioned genetic mutation could occur in genes. If benzene is the one factor that switches on your lung cancer gene, that person starts to develop lung cancer. Not only smoking, vaping must also be stopped.

Which specialist institutions in Sri Lanka offer services for lung cancer diagnosis and treatment?

Sri Lanka has a very good network of chest clinics called district chest clinics, and we have at least 25 of them. We also have clinics attached to main hospitals up to the base hospital level. We usually have chest physicians manning these clinics. We have such a good network in place because we had TB, and these clinics were started in order to stop TB. However now, they not only cater to TB cases, they also cater to other chest-related diseases such as asthma, chronic obstructive pulmonary disease, and interstitial lung disease. Since there is such a good network, any person in any district can go to their closest chest clinic. They all have X-ray facilities. At the very least, get an X-Ray done if you feel as if you have a cough and you are concerned about it. We have about 50 chest physicians manning these facilities all over the country. 

There are bigger centres as well. The main one is the National Hospital for Respiratory Diseases (NHRD) in Welisara, which was historically known as the TB Hospital. The bulk of lung cancer management is done there, because that is where most of the surgeons are. Around 90% of thoracic surgeons are based in the NHRD. We now have thoracic surgeons in the Galle National Hospital as well. In addition, the National Hospitals in Colombo and Kandy also have larger units with several chest physicians which offer more sophisticated investigations.

How have testing and treatment methods for lung cancer improved with technological advancements? Are there challenges or gaps in this regard?

An X-ray is the test which used to be the only test that we have and which we have everywhere. But, we have CT scan machines, which are a much better investigation to detect lung cancer and are available in every district in most hospitals from the base hospital level. A few hospitals have PET scanners too. But, in the general investigative process, what happens is, if a patient comes to you, we get a chest X-ray done, and then we do a CT scan. If we find a mass or a nodule, we then have to do a test called a bronchoscopy. Bronchoscopy is like an endoscopy where we put a camera into the respiratory tract. 

So, at this point, based on the CT scan, we have a fairly good idea about where it is, and we look for it. If we see it inside the airways, we can get a sample then and there, and we send it for testing. Since 10 years ago, we have had another technology called endobronchial ultrasound (EBUS). That is where we put the bronchoscope, but that particular scope has an ultrasound probe. Imagine an ultrasound hitching a ride on the bronchoscope, and it goes into your main airways and it can see outside the airways. A usual scope will only see inside the tubes, but this can see outside the tubes as well, and it is really effective for locating and getting a biopsy from the masses or cancers outside the major tubes. Regarding pleural malignancy and pleural fluid collections, we used to have something called pleural biopsy needles. But, since about 15 years ago, we have been using a procedure called thoracoscopy or pleuroscopy. There is another procedure called video assistant thoracoscopic surgery, which is performed by surgeons. Both are minimally invasive procedures. 

The technology for a bronchoscopy is available in all major hospitals, and every chest physician is trained to perform bronchoscopy as well as the EBUS. The problem with the EBUS is that those scopes are a bit pricier, and therefore, they are only available in the National Hospitals in Colombo and Kandy, the NHRD in Welisara, and in Jaffna. There is one centre also in the private sector. Thoracoscopy is available in more centres than that, and about 10 big hospitals have thoracoscopy facilities and all chest physicians are trained to perform all these procedures.

The Health Ministry recently stated that statistics from key hospitals show a clear increase in lung cancer cases. What factors may have contributed to this rise?

That is correct. However, in any case, when you start looking for something only you start finding it. So, one of the biggest reasons for this observation would be that we are actively looking to detect them more, and therefore, we are trying to find lung cancer earlier. That will also happen if we conduct  proper screening processes. 

Therefore, we are finding more cases. It does not mean that there was a sudden, huge rise in lung cancer. Lung cancer was always there, but either the patients died before getting any treatment, or we only find them in stage three. In cancer, we have stages 1, 2, 3 and 4, and stage three is pretty late. 

Another reason is that we are experiencing all these female lung cancers and younger lung cancers, and that may have accounted for a bit of a rise as well. They are certainly not talking about a huge rise. At the same time, environmental pollution could have contributed too.