Lung cancer

​Lung cancer includes non-small cell, small cell, mesothelioma, thymoma and neuroendocrine tumours. The Royal Marsden offers a full range of lung cancer treatments and care services.

What causes lung cancer?

In the majority of people, lung cancer is caused by smoking tobacco. Research shows that passive smoking may also be dangerous to non-smokers. Sometimes lung cancer develops in people who have never smoked and the cause is unknown.

Lung cancer can also be caused by chemicals such as asbestos, which produces a kind of cancer called mesothelioma. If it is thought that this cancer could be related to a job, past or present, discuss this with a doctor.


What are the symptoms of lung cancer?

The signs and symptoms of lung cancer may include:

  • a persistent cough or a change in a smoker's usual cough
  • a bright red or rust coloured blood in sputum (phlegm)
  • hoarseness of the voice
  • shortness of breath
  • a dull ache in the chest or a sharp pain when breathing in deeply.

Sometimes people feel generally unwell, for example, tired with general aches or pains. There may be loss of appetite and weight loss. Symptoms may be due to the cancer in the lungs, spread of cancer to lymph glands in the chest, or secondary tumours in the bones, liver or brain.


How is lung cancer diagnosed?

Tests will confirm or rule out a diagnosis of lung cancer, and find out whether the cancer has spread to other parts of the body. Initial assessments will include a chest X-ray and blood tests. Further investigations are usually hospital-based and will take place after being referred to a chest physician.

Note that specific diagnostic tests may only be available at one site, for example, CT-guided biopsies only take place at our Chelsea site.

Chest X-ray

This will be performed to examine the lungs and heart. If a tumour is present, the size and position of it may be seen. Not all lung cancers show up on an X-ray and the doctor may ask about having a more complex X-ray or a scan.

Sputum cytology

Patients are sometimes asked to cough up a mixture of saliva and mucus (sputum) from the lungs, into a pot. This will be examined under the microscope for cancer cells.


A bronchoscope is a thin flexible tube, like a very fine telescope, with a light on the end. It is passed through the nose or mouth, down the trachea and into the bronchi. The doctor may be able to see the tumour and take a biopsy (a sample of tissue for examination under the microscope).

The procedure takes about 30 minutes. The patient will usually be admitted to hospital as a day case, and given a drug to make them relaxed and sleepy beforehand. A local anaesthetic will be sprayed onto the back of the throat.

It is normal not to eat or drink for a few hours afterwards until the local anaesthetic wears off. This is to prevent any food or liquid going down the wrong way.


This is carried out under a general anaesthetic by a surgeon. A small cut is made near the collar bone. The doctor can examine lymph glands in the chest through this incision and take samples of tissue (biopsies) at the same time.

This will usually involve an overnight stay in hospital. This test is not carried out at The Royal Marsden and requires referral to a surgeon at another hospital such as St George's Hospital or Royal Brompton Hospital.


This involves making a small cut in the skin for the surgeon to insert a tube, similar to a bronchoscope, into the chest to take tissue samples from it. This procedure is also carried out under a general anaesthetic and will require a short stay in hospital.

This test is not carried out at The Royal Marsden and requires referral to a surgeon at another hospital such as St George's Hospital or Royal Brompton Hospital.

Endobronchial ultrasound

EBUS is a special type of bronchoscopy that allows the doctor to examine and take samples from tissue that lie just outside of the airways. Samples from some lymph glands in the chest can be taken during this procedure.

The procedure is very similar to a bronchoscopy and is usually performed as a day case. On rare occasions the procedure is performed under general anaesthetic and may require an overnight stay in hospital. This test cannot currently be performed at RM and will require a referral to another hospital – usually SGH, RBUH or STH (St. Thomas’).


Other tests can include an abdominal ultrasound, CT scan, MRI scan, PET scan or bone scan. The information from these tests is used to assess the size of the cancer and how far it has spread. This is called ‘staging’.

Doctors need to know the extent of the cancer to help them decide on the most appropriate treatment. Staging of lung cancer is based on a physical examination and the results of tests.


How is lung cancer treated?


Surgery is a very effective way of treating lung cancer as long as the surgeon can remove all the cancer. The operation is carried out through a cut along the side of the chest (a thoracotomy). Glands may also be removed from the centre of the chest. The surgeon then has to check carefully that all of the cancer can be removed with the smallest amount of lung tissue.

If part of the lung is removed (a lobectomy) this will not affect breathing or ability to exercise in the future. If the surgeon needs to remove the whole lung (a pneumonectomy) then breathing will be affected.


Radiotherapy uses high energy X-rays to kill cancer cells and is given using a machine similar to an X-ray machine but slightly larger. The treatment area will include the tumour and the surrounding lymph nodes (glands) if necessary. The treatment will be planned specifically to make sure that the cancer cells are destroyed with the least amount of damage to normal tissues.

Some people become breathless and develop a hoarse cough during radiotherapy. This should ease in the weeks following treatment. The oesophagus (gullet) may be within the treatment field and may become inflamed. This may result in heartburn or pain when swallowing. If this happens, please tell the doctor or radiographer who can prescribe medicines to relieve the problem. Heartburn or pain usually wears off within two weeks of finishing treatment.


The main treatment for small cell cancer is with chemotherapy drugs. Surgery is not usually used because the cancer is likely to have spread to other parts of the body. Sometimes radiotherapy is given to the chest after chemotherapy. It may also be given to the head to reduce cancer cells spreading to the brain. Chemotherapy is often recommended for more advanced disease, and is sometimes followed by either radiotherapy or surgery. Chemotherapy can be administered either orally or by IV.

Targeted therapy

This treatment targets a specific genetic mutation abnormality. Targeted therapy can be administered either orally or by IV.


Lung cancer may spread to the bones and cause pain. Radiotherapy is very good at relieving bone pain, and patients are offered treatment as needed. One single treatment or a course of a few days will be given. It doesn't usually have any side effects.


After treatment

Illness and treatment often unsettle the usual pattern of a person's life. However, there is no reason not to resume or continue with work or social activities if well enough.


During treatment, and for a time afterwards, it is normal to feel more tired than usual. People may choose to work part time or reduce social activities for a while. It is wise to accept offers of help with shopping, housework or jobs around the home. After any operation, patients are usually advised not to drive, or lift any heavy objects for several weeks.

Walking is a good exercise for people with lung problems. It is also exercise which can be increased gradually. If unsure how much exercise should be taken, ask the physiotherapist.


At some stage during illness people may find that they become breathless or occasionally have problems with breathing. Relaxation techniques and breathing exercises may help with this. Ask if classes are available in the hospital, family doctor practice, or local support group. Medication to reduce breathlessness may also be prescribed by the doctor.

There are usually no restrictions on what a patient can eat and drink, including alcohol. For advice about diet, please ask to see the dietitian.

Smoking will affect breathing and, perhaps, recovery. Smokers should try to give up completely or at least cut down. For help and advice about this, talk to a doctor or nurse. There are many methods and ways of providing support.


The doctor will ask the patient to attend hospital at regular intervals during and after treatment. Clinic appointments will probably become less frequent as time passes.

At each examination, blood tests or X-rays may be repeated to check recovery. If worried about anything between appointments, for example any unexplained aches and pains, please contact the hospital doctor.


For further support and information, Macmillan is a good port of call. Their website offers access to support groups and detailed information as to the different types of lung cancer.


Clinical trials

We continue to place a high priority on drug development and new treatment strategies, and are actively involved in national and international multi-centre trials to evaluate therapies. We also have a developing laboratory programme looking at genetic signatures in the lung cancer diagnosis and treatment pathway.

Routine tests must be done in order to confirm if it is safe for patients to partake in clinical drug trials, which include screening for genetic tumour mutations. It is important for patients to be aware that certain trials may require additional tissue to be taken in the form of biopsies, in some cases these may need to be repeated on a regular basis throughout the trial. Ultimately it is the decision of the clinician to decide if a patient is eligible for a clinical drug trial.

Out of area patients are able to be referred for consideration of clinical drug trials at The Royal Marsden. Note that some patients may find it difficult to commit to commuting to the hospital on a long-term basis.