Current status of lung cancer in India: Role of VATS in early cancer.

Current Status

Lung cancer has reached an epidemic proportion. There has been 30 – 40% increase in lung cancer over last decade. All cancers including lung cancer is on rise and the reasons are – control of communicable diseases, increased life expectancy, increase in total population, adoption of cancer associated life style (like smoking, physical inactivity, westernized diet), urbanization, industrialization, radiation, air pollution, water pollution and so on.

Among all cancer, lung cancer is most common cause of cancer death with a figure of 20%. Every year 63 000 people die from lung cancer. Estimated incidence of lung cancer in India is 70 000 per year, 5.6 per 100 000 population.

In India lung cancer occurs in young age group with about 40 % occurring in less than 50 years of age.

80% of lung cancer patients come from rural area which may be due to increased rate of bidi smoking and pesticide exposure. Most cancers in rural area are diagnosed in advanced stage.

Lung cancer is rising in females and non smokers also. 9 out of 10 cases are diagnosed in last stage.

Not much we have achieved in controlling lung cancer which is clearly shown by marginal improvement of 5 year survival of lung cancer from 5% in 1950 to 14% IN 1994 in contrast to other cancer where it is 52%.


Almost 90% of patients with lung cancer have history of active smoking or tobacco use in other form. Tobacco smoke contains over 4000 chemical compounds, many of which have been shown to be causing cancer or carcinogenic like Nitrosamine and polycyclic aromatic hydrocarbons. Smoking can narrow the air passage and make breathing difficult and over the course of time destroy lung tissue and trigger changes in cancer.
Every year 60 lac people die directly from use of tobacco out of which 10% i.e. 6 Lacs due to second hand smoking.

There has been alarming rise of lung cancer among females and non smokers. The reasons are-

1. 2nd hand smoking. People who live with smoker have 24% more chance of developing lung cancer.

2. Air Pollution ( 5% of lung cancer occur due to air pollution)
– a) Domestic coal/wood burning for cooking purpose is significant factor for lung cancer in non smoking females. Coal smoke contains Radon and Thoron gas.
– b) Air pollution from vehicle, industry and power plant can raise the likelihood of developing lung cancer.
– c) Exposure of diesel exhaust to truck driver, toll booth worker, rail road worker, garage worker etc.
– d) Exposure to radon gas which is produced by breakdown of uranium in soil and rock

3. Occupational exposure to Asbestos in insulation worker and shipyard worker, Arsenic, Uranium and Nickel also lead to increase chance of lung cancer.

4. Lack of micronutrient in diet

Symptoms of Lung Cancer

1. A new cough that does not go away
2. Coughing of blood
3. Shortness of breath
4. Chest pain
5. Hoarseness of voice
6. Loosing weight
7. Bone pain
8. Headache
9. Repeated chest infection

Lung cancer in 1/4th cases are silent and do not cause any symptom.
Incidentally diagnosed on X-Ray or CXT scan done for other purpose.

Diagnostic test for lung cancer

1. Chest X- Ray is the most common first diagnostic test.
2. CT Scan
3. PET Scan- helps in deciding whether a lesion is cancerous or not.
4. Sputum cytology
5. Bronchoscopy and biopsy : Visualizing the airways through a thin fiberboptic probe through the nose or mouth may reveal areas of tumor that can be sampled (Biopsied)
6. Needle biopsy : Fine needle aspiration through the skin, most commonly done under ultrasound or CT guidance useful in retrieving cells for diagnosis of tumor nodule in lung.
7. Thoracocentesis of fluid in chest for cancer cells

The stage of cancer is a measure of the extent to which cancer has spread in the body. It is important to decide treatment of cancer.
Stage 1 : Confined to lung
Stage 2 & 3 : Outside lung but in the chest
Stage 4 : outside chest spread

Chest X- Ray and sputum test can be done in every hospital and cheap. Other tests only in tertiary care or referral hospital. They are expensive. Governmen t should subsidize there charges and make them available widely to every section of society in private hospitals and free in government hospitals.

Early diagnosis of lung cancer

Low dose CT scan annually in current or former smoker between ages 55 and 80 with at least 30 pack year history of cigarette smoking or who have smoked cigarette within the past 15 years. If we smoke one packet cigarette ever day for one year it is one pack year.
The lung cancer screening techniques increase the likelihood of detection of smaller earlier and curable lung cancer.
Three year of LDCT has decreased lung cancer death by 20%.

Early diagnosis allows curative surgical treatment for the patient with permanently getting rid of the disease. Furthermore we can offer Minimally invasive, keyhole surgery.
Most of the patients in our society in general are afraid of any surgery and they keep on visiting a physicians is search of medical treatment even for clear cut surgical conditions. The reasons for this is fear of big cut on their body, pain, long hospital stay, big scar causing disfigurement, log term disability after surgery, inability to go back to work, can they become normal after surgery?
All these issues are very well addressed by minimally invasive surgery. So if we screen the high risk population and diagnose lung cancer in early stage, these patients can get benefits of keyhole surgery.

Treatment of Lung Cancer

It involves surgical removal of the cancer, chemotherapy or radiation therapy.

Surgery for stage 1 &2. The cancer which has not spread beyond lungs. 10 – 35 % of lung cancers can be removed surgically .
Depending on the size of tumor.
Surgeon may remove a portion of lobe (Wedge resection), Remove one lobe
(lobectomy), or entire lung may be removed (Pneumonectomy)

Chemotherapy is giving drugs that stop the growth of cancer by killing cancer cells.

With advancement, treatment options include surgical procedures like VATS (Video Assisted Thoracic surgery) a form of minimally invasive keyhole surgical technique used to diagnose and treat diseases of chest. It can be used to trest and manage the complications of lung cancer too.


VATS is a keyhole technique to surgically treat lung lesions by making small cut on the chest through which a tiny camera and fine surgical instruments are inserted into the chest wall. The camera transmits image of the inside of the chest into high definition video monitor guiding the surgeon in performing any procedure in the chest and lungs.

Benefits of VATS
It is done with small incision so it causes less pain, early recovery and more cosmetic scar. Surgery is performed more precisely as better well illuminated magnified vision is there in VATS. There is less blood loss, shorter hospital stay, early recovery, early return to work and start earning there livelihood. Very less breathing problem and better quality of life after surgery.

What conditions can utilize VATS
1. Diagnosis and biopsy test for cancer of lung.
2. Treatment of early lung cancer.
3. Fluid in chest
4. Empyema (Pus in chest)
5. Chylothorax
6. Blebs and bulla causing pneumothorax
7. Bronchopleural fistula
8. Tuberculosis
9. Fungal infection like aspergillosis with hemoptysis (blood in cough)
11. Cyst and tumor in chest
12. Myasthenia gravis (disease with muscle weakness)
13. Esophagus disease
14. Eventration of diaphragm (a membrane between chest and abdomen) It becomes paralyzed.
15. Hyperhydrosis (condition with excessive Sweating hampering the normal life style)

We are doing VATS in DMC & H as a very high volume center almost equal to few high centers in India. We have been doing it since 2002 and done more than 5000 cases with very good results and minimal complications. We were first center to start it in whole of North India and pioneered and published several new innovative and affordable techniques in VATS.

Causes of delay in diagnosis

It starts with patient himself at first level
Lag of time from symptom onset to first visit with primary physicians.
The reasons are :
1. Not taking symptoms seriously
2. No body to escort
3. Long distance
4. Financial reason
5. Family commitment/ marriage in family
6. Fear of death, fear of cancer, denial

-Delay at second level: At primary physician level (upto 5 -6 months delay)
The reasons are:
1. Symptomatic treatment
2. Empirical anti tubercular treatment
3. Miss diagnosis by primary physician : TB, Infection or asthma

In India there is general tendency among physicians to empirically diagnose Tuberculosis more commonly then cancer due to high endeminicity and shortage of facility to confirm cancer like CT scan or bronchoscopy.
Unfortunately the Tuberculosis control program advises physicians to commence empirical ATT for patients with lung shadows that does not resolve with antibiotics treatment.

Remedy for improvement in Early detection

1. Health education and counseling of general public
2. Sensitizing primary physician for timely referral to avoid the situation where curable disease becomes incurable.
3. Increase in facility and availability of diagnostic test at small center to diagnose lung cancer early.

How to prevent lung cancer

1. Don’t smoke / stop smoking
2. Avoid second hand smoking
3. Avoid carcinogen at work (mask)
4. Eat diet full of fruits and vegetables
5. Exercise regularly
6. Make your home and car smoke free
7. Avoid exercise outdoor on bad air days
8. Personal hygiene
9. Radiation control
10. Control of air pollution
11. Legislation for tobacco, alcohol and air pollution
12. Nicotine gums and sprays may be helpful to people trying to quit smoking
13. Screening to early diagnose and treat lung cancer

Tips to keep lung healthy
1. Exercise
2. Get regular health check up
3. Breathing exercise
4. Maintain good posture
5. Stay hydrated
6. Laughing is a good exercise
7. Be active
8. Prevent infection (frequent hand wash, Good oral hygiene,)

You can watch a video of Dr Atul Mishra discussing lung cancer in TV interview