Question: My doctors discovered something abnormal on a scan of my lungs that they suspect may be lung cancer. I’ve been told that I need a bronchoscopy to biopsy the growth to confirm this diagnosis and determine the stage of my cancer. Do I still need to do this if a PET scan showed that my lymph nodes were clear?

(*Answered by Dr. D. Kyle Hogarth from the University of Chicago during his September 2023 Lung Cancer Living Room appearance. It has been edited slightly for this use.)

Answer: Almost everyone with lung cancer’s journey with the disease begins with an abnormal scan. There is a long list of what that abnormal thing in your lung might be, but until we take a biopsy, we’re just guessing. Other testing may say that the probability is high that it is lung cancer, but until a sample is taken, we don’t know.

Historically, when we took a biopsy, all I had to do was prove that you had lung cancer – small cell or non-small cell. It didn’t matter beyond that because you treated them all the same. But the field has evolved dramatically since then. Now I definitively need to know not just that it’s lung cancer, but what subtype, what’s the mutational analysis, and what stage are you.

There are essentially three ways to perform a biopsy.

  • You can have surgery.
    If it looks like you’re early stage from various testing, and the probability is high enough, it is reasonable in certain scenarios to go straight to surgery to have it both diagnosed and removed. But there are a lot of caveats to that option because there are a lot of things that mimic lung cancer, and you don’t want to have unnecessary surgery and have part of your lung removed for no reason.
  • You can have a needle biopsy.
    This is still a predominant method in this country, unfortunately. I say unfortunately because it’s fraught with complications including a very high rate of pneumothorax – or popping the lung – and it doesn’t stage the patient. So, if I biopsy this mass in your lung, and we prove it was the cancer we suspected it was, I still don’t know what stage you are. I didn’t sample a single lymph node, because I can’t sample a lymph node that way.
  • You can have a bronchoscopy.
    This method is arguably superior because it allows us to do both: we will prove what the mass in your lung is, and I am going to sample every one of your lymph nodes and prove that there is or isn’t cancer there.

Some people will say, “well I had a PET scan, and my lymph nodes were negative, so I’m early stage.” I wish that were true. Normal lymph nodes on CT and PET scans still have up to a 10% chance of having cancer. So, there is a one in ten chance when your doctor says, “good news; you’re early stage, the scan says so” that they’re wrong.

And historically the approach was that they would go and remove everything and say, “you’re cured!” and then six months later, your cancer would come back, and they’d say, “lung cancer is so aggressive.” But the reality was, no; you were never stage one. They assumed you were stage one. But I want to prove you’re stage one, and bronchoscopy allows us to do that.

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