context: If a routine physical exam reveals swollen lymph nodes above the collarbone, a mass in the abdomen, weak breathing, abnormal sounds in the lungs, dullness when the chest is tapped, abnormalities of the pupils, weakness or swollen veins in one of the arms, or even changes in the fingernails, a doctor may suspect a lung tumor. Some lung cancers produce abnormally high blood levels of certain hormones or substances that can lead to an abnormally high calcium level in the bloodstream. If a person shows such evidence and no other cause is apparent, a doctor should consider lung cancer. Once a malignant tumor begins to cause symptoms, it is usually visible on an X-ray. Occasionally a tumor that has not yet begun to cause symptoms is seen on a chest X-ray taken for another purpose. A CT scan of the chest may be ordered for a more detailed look. Though tests of mucus or lung fluid may reveal fully developed cancer cells, diagnosis is usually confirmed through a biopsy. Using bronchoscopy, the patient lightly anesthetized, the doctor guides a thin, lighted tube through the nose or mouth and down the air passages to the site of the tumor, where a tiny tissue sample can be removed. Another procedure uses a CT scan to guide a needle into an abnormality in order to take a biopsy. If the biopsy confirms cancer, other tests will determine the type of cancer and how far it has spread. Nearby lymph nodes can be tested for cancer cells, using a procedure called a mediastinoscopy, which requires general anesthesia, and involves having a small cut made in the front of the neck to pass a hollow, lighted tube into the chest to take biopsies. Endobronchial ultrasound and endoscopic esophageal ultrasound are two other ways to biopsy lymph nodes to test for cancer cells. Both require light anesthesia. Imaging techniques such as CT, MRI, PET, and bone scans can detect cancer that may have spread. Because sputum tests and chest X-rays have not proved particularly effective in detecting small tumors characteristic of early lung cancer, annual chest X-rays for lung cancer screening are not recommended. However, groups such as the American Cancer Society and the National Cancer Institute say CT screening should be offered to those at high risk of lung cancer. That includes smokers and former smokers ages 55 to 74 who have smoked for 30 pack-years or more and either continue to smoke or have quit within the past 15 years. A pack-year is the number of cigarette packs smoked each day multiplied by the number of years a person has smoked. Their guidelines are based on research that showed CT screening decreases the chance of death overall but increases the chance of having a false alarm that requires more testing. If the cancer can be successfully removed surgically, the patient has an excellent chance of surviving at least one year and usually a better than 50% chance of living at five years or more. The challenge comes in detecting lung cancer early enough to make surgery possible. The decision to perform surgery is based not only on the type of lung cancer and how far it has spread but also on the patient's overall health, especially the function of their lungs. Many patients with lung cancer -- especially smokers -- have existing lung or heart problems that make surgery difficult. Cancer that has spread to lymph nodes between the lungs was once considered inoperable, but combining surgery with chemotherapy afterwards has improved survival rates. When feasible, the preferred treatment for non-small-cell lung cancer is surgery. During the operation, the surgeon removes the tumor along with surrounding lung tissue and lymph nodes. Sometimes, the entire lung must be taken out. After surgery, patients stay in the hospital for several days. Radiation therapy may be necessary to kill remaining cancer cells, but it is usually delayed for at least a month while the surgical wound heals. Non-small-cell lung cancers that cannot be treated surgically are usually treated with radiation therapy, usually in combination with chemotherapy. Because of its tendency to spread extensively, small-cell lung cancer is typically treated with combination chemotherapy -- the use of more than one drug -- often in conjunction with radiation therapy. Surgery is occasionally used, but only if the cancer is thought to be at a very early stage. This is uncommon. Patients whose cancers have metastasized, or spread to distant parts of the body, are usually treated with either chemotherapy or radiation therapy. Since metastatic lung cancer is very difficult to cure, the main goals of treatment are to provide comfort and prolong life. Current treatments can shrink tumors, which may lessen pain and other symptoms. It is now recommended that all patients with advanced lung cancer receive palliative care (care designed to only ease pain and other symptoms) while also having the cancer actively treated. This has been shown not only to provide comfort, but to improve outcome if chemotherapy is given at the same time. Recent data also suggests that chemotherapy helps prevent recurrence of lung cancer in patients with early stages of the disease. Researchers are constantly looking for better ways to treat lung cancer, to relieve symptoms, and to improve patients' quality of life. New combinations of chemotherapy, new forms of radiation, and the use of drugs that make cancer cells more sensitive to radiation are always being studied. Stereotactic radiosurgery and radiofrequency ablation have been used to treat early lung cancers in persons who are not candidates for surgery. This type of therapy may be used to treat localized recurrent tumors as well. Drugs that target a growth factor receptor ( EGFR) such as afatinib ( Gilotrif), dacomitinib ( Vizimpro), erlotinib ( Tarceva), necitumumab ( Portrazza) and osimertinib ( Tagrisso) and the tumor blood supply bevacizumab ( Avastin) and ramucirumab ( Cyramza) have shown significant activity in helping to control advanced lung cancer. Gefitinib ( Iressa) has been most recently approved as a first-line treatment of patients with metastatic NSCLC and offers another targeted therapy for tumors with specific EGFR mutations. Atezolizumab ( Tecentriq), durvalumab ( Imfinzi), nivolumab ( Opdivo) and pembrolizumab ( Keytruda) are immunotherapy drugs which block a protein that keeps the body from fighting cancer. These drugs are given by IV infusion every 2 â 3 weeks. The drugs alectinib ( Alecensa), brigatinib ( Alunbrig), certinib ( Zykadia), crizotinib ( Xalkori), and lorlatinib ( Lorbrena) have been found to attack a certain molecule,an ALK gene rearrangement, seen in some lung cancers. Dabrafenib ( Tafinlar) and Trametinib ( Mekinist) target certain proteins in tumors that have changes in the BRAF gene. Entrectinib ( Rozlytrek) and larotrectinab ( Vitrakvi) work to target a gene called neurotrophic tyrosine kinase ( NTRK) found in some tumors. It is now common for patients to be tested to determine if these drugs can effectively fight their type of lung cancer. If you've had lung surgery, a nurse or doctor can show you special exercises to improve breathing and strengthen chest muscles. You can relieve skin irritation associated with radiation therapy by wearing loose clothes and keeping your chest protected from the sun. Avoid using skin lotions unless approved by your doctor.