Lung cancer: early detection, modern therapy and outpatient care

This article provides an overview of all aspects in layman’s terms: from risk factors and screening to diagnosis and the role of pneumology through to modern therapies – with a focus on thoracic surgery, including minimally invasive and robot-assisted operations. Personalized medicine as well as aftercare, quality of life and the advantages of modern outpatient care (day clinic concept) are also explained.

The aim is to present current scientific findings in an understandable way and to show how modern outpatient care – for example in specialized day clinics – contributes to the optimal care of lung cancer patients.

Early detection and risk factors for lung cancer

The risk factors for lung cancer are well researched. First and foremost is smoking: According to the Robert Koch Institute, around 90 % of all lung cancer cases in men and at least 60 % in women are due to active smoking . Tobacco smoke contains a large number of carcinogenic chemicals that can lead to genetic damage in the cells of the respiratory tract. The risk increases significantly with the number of cigarettes smoked and the duration of smoking.

Passive smoking also increases the risk of lung cancer – regular smoking (e.g. in the home or at work) can increase the risk of the disease by a factor of 1.3 to 3.

Other important risk factors are

• Occupational exposure to harmful substances: Prolonged contact with carcinogenic substances in the workplace can promote lung cancer. Classic examples are asbestos, arsenic, chromium, nickel, polycyclic hydrocarbons or diesel exhaust fumes, such as those found in certain industrial sectors.
  Many of these effects are particularly strong in people who smoke at the same time. For example, it is known that some people develop lung cancer decades after exposure to asbestos. Accordingly, lung cancer is even recognized as an occupational disease in certain cases (e.g. in the asbestos industry).

• Radon and environmental influences: Radon, a naturally occurring radioactive noble gas, can enter buildings via the ground and is considered the second most common cause of lung cancer after smoking – especially in poorly ventilated basements or among miners in uranium mines. Air pollution (particulate matter, pollutants from combustion) is also thought to contribute to a small extent to the risk of lung cancer.
  The overall risk from environmental factors is significantly lower than from smoking, but can have an additional unfavorable effect on people who are already at risk.

• Genetic predisposition and pre-existing conditions: A familial clustering of lung cancer indicates genetic factors, even if specific “lung cancer genes” are not clearly defined. In addition, certain chronic lung diseases can slightly increase the risk – for example, old scars after tuberculosis or advanced COPD.
  Nevertheless: Even people who have never smoked and lead a healthy life can develop lung cancer – but the risk is then much lower.

In view of these risks, early detection is of great importance. Because early stages of the tumor hardly cause any symptoms, lung cancer is often diagnosed late.
Typical symptoms such as a persistent cough, bloody sputum, shortness of breath, weight loss or chest pain usually only occur in advanced stages.

Experts are therefore increasingly focusing on screening programs for risk groups: Long-term heavy smokers in particular should benefit from regular preventive check-ups.

In the USA and other countries, screening using low-dose CT (LDCT) in heavy smokers over the age of 55 has already proved successful in detecting lung cancer at an early stage.

An important step was taken in Germany in July 2024: The authorities have given the green light for structured lung cancer screening with low-dose CT for current or former heavy smokers aged 50 to 75 .

Expert committees are currently preparing the introduction of such an early detection program. Studies have shown that the benefits of such an examination (early detection and increased chance of survival) outweigh the possible risks (e.g. low radiation exposure or false alarms).

Until this program takes effect across the board and is covered by health insurance, every heavy smoker should talk to their doctor about early detection on their own responsibility.

Important: The best prevention is still not to smoke in the first place or to stop smoking.

Those who give up smoking reduce their risk considerably – even if it never quite returns to the level of a lifelong non-smoker.

It is also worth taking protective measures in the workplace (e.g. when handling harmful substances) and having your own home tested for high radon levels if you live in a risk area.

A healthy lifestyle with exercise and a balanced diet generally strengthens the lungs and the immune system, which can also be helpful. However, there is no absolute protection against lung cancer – which is why education and early detection are all the more important.

Diagnostic procedure for suspected lung cancer

X-ray of the chest with a tumor (white shadow in the left lung). Such images provide initial indications, but are not sufficient on their own – further examinations such as CT and biopsy are required to clearly diagnose lung cancer.

The investigation of suspected lung cancer involves several steps. Imaging procedures are usually used at the beginning. A simple X-ray of the thorax can already show larger tumors – round foci from approx. 0.5 cm in diameter are visible on the X-ray.

However, the X-ray easily overlooks small or unfavorably located foci, especially centrally in the lungs or behind the heart and bones.

Therefore, if symptoms or risk factors persist, a computer tomography (CT) scan is ordered at an early stage. CT is much more sensitive: tumors as small as ~3 mm can be visualized.

A spiral CT (often with contrast medium) can produce sectional images of the lung and provides precise information about the location, size and spread of the tumor.

This allows you to see whether neighboring tissue is affected, whether lymph nodes are enlarged or even whether there are metastases in other organs.

CT is therefore indispensable for staging, i.e. determining the stage of the tumor. In addition, positron emission tomography (PET), usually combined with CT (PET-CT), is often used. PET detects metabolic activity – cancer tissue strongly accumulates the radioactive tracer and “glows” on the images. This helps to distinguish whether, for example, a conspicuous lymph node actually contains tumor cells or whether a round focus is a scar rather than an active tumor.

However, a PET finding is not 100% specific (inflammations also show increased metabolism), so any suspicious finding must ultimately be confirmed by a tissue examination.

Tissue sample (biopsy): A definitive diagnosis of “lung cancer” can only be made by examining tumor tissue. For this reason, a biopsy is always required in cases of suspected cancer to find out whether it is actually cancer and what type (histology) it is exactly.

In most cases, this is done by bronchoscopy (lung endoscopy). The specialist (often a pulmonologist) advances a thin, flexible endoscope through the nose or mouth into the windpipe and further into the bronchi.

This procedure is usually carried out under light sedation and with local anesthesia of the airways, so that the patient hardly feels any pain – often only the urge to cough or a feeling of pressure.

Using the bronchoscope, the doctor can view the airways from the inside and, in particular, take tissue samples using small forceps.

If a suspicious tumor or altered tissue is found, targeted biopsies are taken. The material taken is then examined under a microscope by a pathologist to detect cancer cells. Only these histological findings confirm the diagnosis of lung cancer beyond doubt and determine the type of tumor (e.g. non-small cell carcinoma such as adenocarcinoma or squamous cell carcinoma, versus small cell carcinoma). The exact typing is important for therapy planning.

Not every tumor can be reached with the bronchoscope – especially peripheral round foci in the outer lung areas or very small foci sometimes elude bronchoscopy.

In such cases, a CT-guided puncture can be performed from the outside: under local anesthesia, the radiologist, guided by CT images, inserts a fine hollow needle through the chest wall directly into the tumor and aspirates cells or tissue cylinders.

These samples are also sent to the pathologist. Alternatively, a thoracoscopy (pleuroscopy) is occasionally considered for unclear findings, particularly if fluid has accumulated in the lungs (pleural effusion) or foci close to the surface need to be clarified. Video-assisted thoracoscopy (VATS) is minimally invasive and uses small incisions to look directly into the chest cavity and take samples.

It is used, for example, if a bronchoscopy is unsuccessful and the focus is unfavorable for a needle biopsy.

The diagnosis of spread also includes examinations to detect metastases in other organs. An ultrasound of the abdomen is often carried out to examine the liver, adrenal glands, kidneys and lymph nodes.

In certain constellations, an MRI (magnetic resonance imaging) of the skull is performed to rule out possible brain metastases, as around 10% of lung cancer patients already have metastases in the brain at the time of diagnosis (especially in the case of small cell tumors).

In addition, the patient’s lung function (spirometry) and general performance (so-called performance status) are always checked.

This is crucial for weighing up the treatment options – especially with regard to a possible operation, enough lung function must remain so that the patient can still breathe sufficiently after a partial removal of the lung.

A modern procedure that is increasingly replacing traditional surgical lymph node removal is endobronchial ultrasound (EBUS) with fine needle puncture. A special bronchoscopic ultrasound device with a small ultrasound probe at the tip is used during a bronchoscopy.

This allows the lymph nodes in the mediastinum (mediastinal space between the lungs) to be visualized from the inside. Under ultrasound guidance, the doctor punctures suspicious lymph nodes directly through the bronchial wall and obtains cells for examination. The procedure is usually performed under short anesthesia.

The advantage: An EBUS is less invasive than a mediastinoscopy (a surgical procedure on the neck to extract lymph nodes) and can often be sufficient to determine whether there is spread to the lymph node system.

Only if there are doubts or if certain lymph nodes cannot be reached does a classic mediastinoscopy have to be performed.

Overall, EBUS has significantly improved the diagnosis and staging of lung cancer, as it is minimally stressful for the patient and yet very reliable.

Finally, a comprehensive diagnosis also includes the molecular pathology of the tumor. If the diagnosis is confirmed – especially at an advanced stage – the removed tumor cells are now examined for certain genetic changes and biomarkers. The next section on personalized medicine explains why this is so important.

Treatment options for lung cancer (focus on thoracic surgery)

The treatment of lung cancer requires an interdisciplinary team of specialists from various disciplines.

Ideally, a patient is cared for in a certified lung cancer center where pulmonologists (lung doctors), thoracic surgeons, oncologists, radiologists and radiotherapists work closely together.

Together, the experts on the tumor board determine the best possible therapy for the individual case.

The decisive factors here are the tumor type (non-small cell vs. small cell), the stage of the disease (localized or already spread) and the patient’s general state of health.

Often more than one form of treatment is used (combination therapy) in order to maximize the chances of recovery.

Surgery (thoracic surgery): In the early stages of non-small cell lung cancer (NSCLC), surgery is the most important therapy and offers the best chance of cure. If the tumor is confined to the lung and there are no distant metastases (stage I and II, possibly selected IIIA cases), an attempt is made to remove the tumor completely by surgery. In most cases, the affected lobe of the lung is resected (lobectomy).

In some cases, a segment resection (removal of only one segment) is sufficient – especially in the case of very small peripheral tumors or if it is necessary to spare lung tissue due to impaired lung function. In more extensive cases, a pneumectomy (removal of an entire lung) may also be necessary, but this is avoided if possible.

The prerequisite for an operation is always that the patient is physically able to cope with the procedure and still has sufficient lung reserves afterwards. For this reason, lung function tests and, if necessary, heart examinations are carried out beforehand.

During the operation, the surgeon usually also removes the regional lymph nodes in the mediastinum to determine the exact stage of the tumor (lymph node evacuation). After the histological examination of these lymph nodes, it is known whether the tumor has already spread microscopically or not, which in turn influences the further procedure.

Over 80% of anatomical lung resections are now performed minimally invasively at leading centers – a large proportion of these are even robot-assisted. More on this in the next section. The advantages for patients are considerable: less pain, less blood loss, fewer complications and a faster recovery compared to classic open thoracic surgery.

Even in advanced tumor stages, thoracic surgery can often still be used today, sometimes in combination with other therapies, to remove tumor masses and improve quality of life.

However, surgery alone is not always enough. It is often combined with other treatment options to reduce the risk of recurrence or to make the tumor operable in the first place (downstaging):

• Neoadjuvant treatment: In some patients with somewhat advanced non-small cell lung cancer (e.g. stage II or III), chemotherapy or immunotherapy – or a combination of both – is given before surgery.
  This upstream treatment is intended to shrink the tumor and kill any cancer cells that may have spread in order to increase the chances of success of the subsequent operation.
  For example, recent studies have shown that immunotherapy combined with chemotherapy prior to surgery can improve disease-free survival. Such approaches are taken into account in the current guideline.

• Adjuvant treatment: From stage II (and in some high-risk stage I cases), subsequent chemotherapy is often recommended after a successful tumor operation to eliminate any remaining cancer cells in the body.
  In certain situations – depending on the tumor type and biomarkers – chemotherapy can now be followed by targeted therapy or immunotherapy.
  For example, patients with non-small cell lung cancer and EGFR mutation are given a tablet therapy with an EGFR tyrosine kinase inhibitor (targeted drug) for around 3 years after surgery and chemotherapy, as studies have shown a clear benefit here. Immunotherapy as an adjuvant (e.g. with PD-1 antibodies) has also recently been approved in certain cases if the tumor has certain characteristics.
  These advances show how personalized medicine is finding its way into even the early stages (see below).

• Radiotherapy: Radiotherapy of the lungs is used if surgery is not possible or is rejected, or as a supplement in the case of local residual disease.
  Stereotactic radiotherapy is a curative option for small tumors, particularly in patients who cannot undergo surgery for health reasons.
  Here, the tumor is “shot down” with a few high-precision, high-dose radiation treatments.
  For advanced tumors or affected lymph nodes, radiochemotherapy (simultaneous radiation and chemotherapy) is used with curative intent, especially for non-operable stage III tumors.
  Radiotherapy also plays an important role in palliative treatment – for example to control bone metastases or brain metastases and alleviate symptoms.

• Systemic therapy for metastatic stage: If the lung carcinoma is already advanced (stage IV) or inoperable at the time of diagnosis, the focus is on drug therapies.
  Traditionally, chemotherapy (e.g. with platinum derivatives) has been used to inhibit tumor growth. In recent years, however, immunotherapies and targeted therapies (targeted drugs) have revolutionized treatment.
  Immune checkpoint inhibitors – drugs that activate the body’s own immune system against the cancer – can significantly slow tumor growth in many patients and extend their lifespan.
  They are sometimes given alone, sometimes in combination with chemotherapy, depending on the tumor profile (e.g. PD-L1 expression status). Targeted drugs are used if certain gene mutations are present in the tumor (e.g. EGFR, ALK, ROS1, BRAF, etc.). These personalized therapies specifically block the growth signals of the cancer cells that are constantly activated by the mutation.
  Typically, these are tablets that are taken over a longer period of time and often have less severe side effects than classic chemotherapy.
  They can often control tumor growth for months or years, even if a cure is rarely possible in the metastatic stage. More on the importance of personalized medicine follows in the section after next.

• Palliative measures: Regardless of the stage, it is important to treat distressing symptoms and maintain quality of life. In the case of lung cancer, this includes effective pain therapy, treatment of breathlessness (e.g. with oxygen or morphine sprays), cough relief, physiotherapeutic breathing exercises and, if necessary, psychological support.
  Pneumological interventions can also play a role here, for example if the airways need to be reopened through endobronchial therapy (laser therapy, stent insertion for large tumors in the bronchi).
  Such palliative interventions are often carried out by the pulmonologist in collaboration with the thoracic surgeon and can provide patients with noticeable relief.

To summarize: The treatment strategy for lung cancer is individually tailored. In early stages, the aim is to cure the cancer through surgery (plus additional treatments if necessary).

In advanced stages, the aim is to maximize the time and quality of life – through modern medication, radiation and supportive measures. Pulmonologists and thoracic surgeons are always involved as the core of the treatment team, supported by oncologists and other specialists.

Options for minimally invasive and robot-assisted thoracic surgery

Thoracic surgery has experienced a quantum leap in technology over the past two decades.

Where previously an open thoracotomy (large lateral chest incision with the ribs held apart) was the standard procedure, many lung operations can now be performed gently using the keyhole technique.

The two main approaches are video-assisted thoracoscopic surgery (VATS) and robot-assisted thoracic surgery (RATS) using the Da Vinci system.

Both procedures dispense with the large incision and instead use several small incisions (often 3-4 accesses of 0.5-1 cm) through which the camera and instruments are inserted.

Video-assisted thoracoscopic surgery (VATS): During a VATS lobectomy, for example, the lung is inspected with a camera and the affected lobe of the lung is separated using special long instruments and pulled out through one of the openings in a retrieval bag.

The surgeon stands at the operating table and looks at a monitor that shows the magnified camera image of the chest.

Numerous studies have shown that VATS delivers equally good oncological results compared to open surgery, but with significantly less pain, fewer complications and shorter hospital stays.

Patients are often fit again more quickly and can be discharged home earlier. Older patients or those with pre-existing conditions in particular benefit enormously from the reduced strain.

Robot-assisted thoracic surgery (RATS): The latest development is the use of surgical robots (da Vinci system).

The surgeon sits at a console in the operating room and controls four robotic arms attached to the patient from there.

The movements of his hands are transferred to the instruments – with extreme precision and tremor-free fine motor skills.

The system offers a 3D HD view of the surgical field and movable instruments with “wrists” that can rotate in the body, which expands the surgeon’s options.

The term “surgical robot” is used colloquially, even though the device does not do anything independently, of course, but is fully controlled by the surgeon. The robot-assisted method enables even more precise incisions and suturing techniques, even in areas that are difficult to access.

A recent randomized study (RAVAL study) showed that RATS lobectomies have some advantages over VATS lobectomies for patients: the quality of life in the first year after surgery was better, more lymph nodes could be removed for histological examination, and there were fewer complications.

The drainage time and hospital stay also tended to be shorter. However, there were no differences in long-term survival rates – which means that the minimally invasive technique is just as effective oncologically.

However, it is important that such procedures are performed by an experienced surgical team, as both VATS and RATS have a corresponding learning curve. In specialized centers, around 80 % of all anatomical lung operations are now performed using minimally invasive techniques. Patients benefit directly from this high level of expertise.

Comparison of open vs. minimally invasive surgery: The differences between the conventional open surgical procedure (thoracotomy) and minimally invasive thoracic surgery (VATS/RATS) are summarized below:

Open thoracic surgery vs. minimally invasive procedures (VATS / robot-assisted)

1. access to the chest cavity

In open thoracic surgery (thoracotomy), access is gained via a large incision of around 20-30 cm at the side of the chest. The ribs must be widely spread to expose the surgical area.
In contrast, minimally invasive thoracic surgery (e.g. VATS or robot-assisted systems) uses several small incisions of around 0.5-1 cm. It is not necessary to open the ribs.

2. view of the operating field

In open surgery, the view is directly into the surgical field. However, this is restricted by the limited access, so a wide opening may be necessary to gain a sufficient overview.
With VATS and in particular with robot-assisted procedures (RATS), a camera provides high-resolution, magnified images – even in 3D HD quality with RATS. This enables an excellent view, even into deeper structures.

3. surgical technique

Open procedures use conventional surgical instruments, with the surgeon’s hand working directly in the surgical area. Mobility is often restricted due to the limited space.
Minimally invasive procedures use very finely controllable instruments with a high degree of freedom of movement. Robot-assisted procedures are controlled via a console – precisely, jitter-free and with a high degree of control.

4. pain & recovery time

Postoperative pain is usually more severe after a thoracotomy. This is due to the large skin incision and the rib spreading. Pain therapy is correspondingly more complex and the recovery time is usually several weeks.
Minimally invasive procedures lead to significantly less wound pain. Mobilization often begins after just a few days, and the overall recovery time is usually much shorter.

5. duration of hospitalization

After open thoracic surgery, the average length of stay is around 7-10 days – depending on the procedure and course.
In the case of uncomplicated minimally invasive procedures, such as a lobectomy, the stay can be reduced to 3-5 days. The aim is to discharge the patient home as soon as possible.

6. complications

Open procedures involve an increased risk of wound infections, major bleeding and longer chest drainage times. Pneumonia also occurs more frequently due to pain-induced shallow breathing (“easy breathing”).
Minimally invasive procedures have a lower risk of infection, are less likely to lead to major blood loss, require shorter drainage times and cause fewer respiratory-related complications.

7. oncological radicality

Both procedures – open and minimally invasive – enable complete oncological surgery. This also includes all standard procedures such as the systematic removal of lymph nodes. The oncological effectiveness of experienced teams is comparable.

Note: As can be seen from the comparison, minimally invasive thoracic surgery offers considerable advantages for many patients – particularly in terms of pain, recovery time and risk of complications – without compromising oncological efficacy.

Of course, not every case is suitable for this – very large tumors or extensive adhesions may still require open surgery. But the trend is clearly towards less invasive surgery whenever possible.

Example: Mr. M., 66 years old, was diagnosed with a 2 cm tumor in the right upper lobe (early stage I, non-smoker).

He opted for robot-assisted surgery. The procedure was minimally invasive; only four small openings had to be created. On the very first day after the operation, Mr. M. was able to stand up and do breathing exercises under the guidance of physiotherapy. He was discharged home after 5 days – with little pain and no major restrictions.

By comparison: With open surgery, he would probably have had to stay in hospital much longer and endure more pain.

This case illustrates the difference that modern surgical techniques can make.

Role of pulmonology in diagnostics and therapy

Pulmonology (lung medicine) plays a central role in every phase of lung cancer. Pulmonologists are often the first specialists to see patients with suspected lung cancer – for example, when a GP refers them to a pulmonologist because of a persistent cough or abnormal X-ray findings.

They carry out the initial diagnostics (medical history, physical examination, lung function tests) and initiate the imaging examinations.

In particular, bronchoscopy for tissue sampling is usually performed by the pulmonologist, often including modern techniques such as EBUS for mediastinal lymph node biopsy.

A pulmonologist can also assess whether the patient’s lung function is sufficient for surgery and prepare the patient – especially if they are a smoker – for surgery (e.g. through respiratory training or smoking cessation before the procedure to reduce complications).

Pneumologists are permanent members of the tumor conference when planning treatment. Together with thoracic surgeons and oncologists, they consider the best approach for each individual case.

They contribute their specialist knowledge of alternative treatment methods: for example, patients who are unsuitable for surgery can be given stereotactic radiotherapy or systemic therapy by the pulmonologist.

In the case of small cell lung carcinomas that are primarily treated with chemotherapy, pulmonologists with additional oncological training (or oncologists) often take the lead in therapy.

During treatment, pulmonology focuses primarily on the patient’s respiratory organs.

Chemotherapy and radiation can have side effects on the lungs (such as inflammation or reduced lung volume); the pulmonologist can help here with specific medication and respiratory therapy. In the case of immunological side effects (such as immune-mediated pneumonitis during immunotherapy), pulmonologists are also required.

After an operation, pneumologists work together with surgeons to wean patients off mechanical ventilation and, if necessary, treat postoperative respiratory complications such as atelectasis or bronchial obstruction. Pneumological rehabilitation (respiratory gymnastics, training) is often initiated on the ward by physiotherapists and respiratory therapists, but under pneumological supervision.

Finally, in aftercare, many pulmonologists in private practice act as long-term companions for patients. As the Cancer Information Service points out, outpatient care can be provided either in clinics or in specialist practices for oncology or pneumology.

In fact, there are numerous specialist practices in Germany where lung specialists carry out regular lung cancer checks.

They organize the necessary follow-up CT scans or X-ray examinations, check lung function and detect any signs of recurrence at an early stage (see the chapter on follow-up care).

Pneumologists also take care of concomitant diseases (many lung cancer patients have COPD or emphysema, for example) – for example by optimizing inhalation therapies or preventing infections (vaccinations against influenza, pneumococci).

Last but not least, pulmonologists are experts in palliative pulmonary interventions: if a tumor or metastasis is narrowing the airways, they can help with bronchoscopic procedures, e.g. using lasers to remove tissue or inserting stents into the airways to keep them open. The creation of pleural drains or pleurodesis (adhesion of the lung skin in the case of recurring pleural effusion) also falls within their field of activity. In this way, they ensure respiratory function and alleviate shortness of breath, which is essential for the patient’s quality of life.

In summary, pulmonology ensures that lung cancer patients receive expert care from the first suspicion through to long-term follow-up.

In modern care concepts – such as lung cancer centers or specialized day clinics – pulmonologists work hand in hand with surgeons, oncologists and radiotherapists to ensure holistic treatment.

Importance of personalized medicine for lung cancer

In hardly any other tumour area has personalized (individualized) medicine had such an impact in recent years as in lung cancer.

Personalized medicine means that treatment decisions are tailored to the biological characteristics of the tumour and the individual situation of the patient.

Doctors have of course always treated each patient individually – depending on age, general condition, concomitant diseases, etc. . What is new, however, is the possibility of specifically addressing the molecular characteristics of the tumor.

In concrete terms, this means that genetic analyses of the tumor tissue (or of circulating tumor DNA in the blood) provide information about which mutations the tumor carries.

It has been discovered that some non-small cell lung carcinomas are driven by specific genetic changes – for example mutations in the EGFR gene (epidermal growth factor receptor) or rearrangements in the ALK gene.

Targeted drugs have been developed in recent years for a number of these driver mutations. These targeted therapies specifically block the signal in the cancer cell that is misdirected by the mutation and thus effectively slow tumor growth.

A well-known example: In around 10-15% of adenocarcinomas of the lung, an EGFR mutation is present; EGFR tyrosine kinase inhibitors (such as osimertinib) often work excellently here, so that tumors shrink and patients can often live for years with a good quality of life.

Similarly, there are specific inhibitors for ALK translocations, ROS1 fusions, BRAF mutations, MET exon 14 skipping and many more. For this reason, a whole panel of mutations is now tested for every advanced NSCLC (molecular profile). Depending on the test result, the treatment is then tailored – “personalized” in the literal sense, as patient A, for example, receives tablet therapy X, while patient B (without mutation) is better treated with immunochemotherapy.

For the patient, this means a higher chance that the therapy will work and usually fewer unnecessary side effects due to medication that would not be suitable.

Immunotherapy is also part of personalized medicine. Immune checkpoint inhibitors (PD-1/PD-L1 blockers) are directed against a general principle (camouflaging cancer cells from the immune system) and not against a specific mutation.

But the decision as to whether a patient receives immunotherapy and whether alone or with chemotherapy is also made on the basis of tumor biology markers.

The PD-L1 status of the tumor is particularly important here: if it shows high PD-L1 expression (≥ 50 %), the patient often receives immunotherapy alone directly, as it works particularly well in such cases.

If PD-L1 levels are low, immunotherapy is combined with chemotherapy to achieve synergistic effects. This stratified therapy according to biomarkers makes treatment more effective and may protect patients from unnecessary toxicity.

Personalized medicine now also influences earlier stages. In resected tumors, not only the histology but also the mutational profile is determined in order to decide whether, for example, an EGFR inhibitor should be given as an adjuvant (as mentioned above).

Studies on neoadjuvant treatment also use biomarkers, for example to give immunotherapy to patients with high PD-L1 before surgery.

Another exciting area is liquid biopsy. Here, DNA fragments of the tumor are searched for in the blood. This method is not (yet) as sensitive as a tissue biopsy, but already plays a role if the tumor grows again after some time under therapy: it has then often developed new mutations (resistance mutations).

In order to spare the patient another invasive biopsy, an attempt can be made to detect these changes using a blood sample.

One example is the T790M mutation in EGFR-mutated tumors, which indicates resistance to older drugs – this can be detected by liquid biopsy and then qualifies for a new drug.

Overall, the personalized approach has led to a significant improvement in the prognosis, even at an advanced stage.

Although metastatic lung cancer usually remains incurable, many patients now live significantly longer with a good quality of life because the therapies are more targeted and have fewer side effects.

Research is progressing rapidly: new targeted drugs for rare mutations are added every year, and combinations (e.g. immunotherapy plus targeted therapy) are also being tested.

For the patient, personalized medicine sometimes also means that tissue samples are sent in and analyzed in special laboratories.

The waiting time for results (often 1-2 weeks) requires patience, but the information from molecular pathology is now an essential part of the treatment decision. Doctors then explain to the patient exactly what options are available based on their tumor profile.

Patient example: Mrs. K., 59 years old, non-smoker, learns after bronchoscopy that she has adenocarcinoma of the lung. As metastases are already present (stage IV), no surgical approach is taken. Instead, the tumor tissue is tested for mutations. An ALK gene fusion was found, which occurs in around 5% of patients. Mrs. K. then receives a targeted ALK tyrosine kinase inhibitor as a tablet therapy instead of the chemotherapy that was previously used. After just 8 weeks, the control CT scan shows a clear shrinkage of all tumor foci. Mrs. K. has almost no side effects and can lead a largely normal everyday life. This example shows impressively how important molecular diagnostics and personalized therapy are today.

Outpatient care and day clinic models in lung cancer treatment

A paradigm shift is taking place in modern medicine: Wherever possible, treatments are being shifted from the inpatient sector to the outpatient sector.

This aspect is also becoming increasingly important in lung cancer therapy. Outpatient care means that patients do not have to stay in hospital overnight, but can receive examinations and treatment on a day-case basis and then go home again.

This conserves resources, reduces the risk of infection in hospital and often increases the well-being of patients, who can remain in their familiar surroundings.

There are various scenarios in which lung cancer patients can be treated on an outpatient basis:

• Outpatient diagnostics: Many of the examinations mentioned – e.g. CT scans, PET-CT, ultrasound, even bronchoscopies – can be performed on an outpatient basis.
  In specialized facilities or practices, it is common for patients to come in the morning, e.g. to have a bronchoscopy under sedation, and be discharged in the afternoon, provided they have been monitored and are stable. Biopsies (e.g. CT-guided lung biopsy) are also often performed on an outpatient basis or with only a short observation period.

• Day clinic therapies: Most systemic therapies for lung cancer are administered on an outpatient basis. Chemotherapy is usually administered in special oncology outpatient centers or practice clinics, where patients receive their infusion and then return home.
  Immunotherapy infusions (which are often only given every 3-4 weeks) are also given on an outpatient basis. Thanks to good concomitant medication (for nausea etc.), hospitalization is usually not necessary. Even blood transfusions or the administration of supportive agents (such as growth factors) are managed on an outpatient basis.

• Outpatient operations/interventions: Classic lung cancer operations (lobectomies) generally require a short inpatient stay, if only because of the necessary thoracic drainage for 2-4 days.
  Nevertheless, there are also trends towards shorter stays here. Minimally invasive procedures shorten hospital stays considerably – some centers discharge patients after uncomplicated VATS lobectomy on the 3rd postoperative day. Minor thoracic procedures, such as the surgical removal of a single round lung defect (wedge resection) or the insertion of a port, can sometimes be performed on an outpatient basis or in a “24-hour stay”.
  Pleurodesis for malignant effusion is also sometimes performed under local anesthesia on an outpatient basis.
  In addition, interventional pneumological procedures (such as the aforementioned laser bronchoscopy or stent insertion) are available in some clinics as day-case procedures.

In order to offer these outpatient services in a structured manner, more and more specialized facilities are emerging, often as day clinics or medical care centers. These combine the quality of a clinic with the flexibility of a practice.

For example, there are oncology day clinics where patients receive their treatment in the morning and leave in the afternoon, but where the full monitoring and emergency management of a clinic is available.

One example of a modern outpatient concept is the VenaZiel center in Berlin – even though it specializes in venous diseases, it demonstrates principles that are transferable.

As a modern outpatient surgery center, VenaZiel offers highly specialized care according to the latest scientific standards and consistently relies on gentle, minimally invasive methods.

With the addition of new locations, patients are offered an even wider range of state-of-the-art diagnostics and innovative treatment methods – all on an outpatient basis, without the need for a long hospital stay.

Applied to lung cancer care, this means that patients could receive comprehensive care in specialized lung day clinics – from diagnostics (including biopsies) to infusion treatments and aftercare – without having to be admitted to hospital every time.

In fact, the current care structures in Germany already support such an approach: Lung cancer patients can either be cared for as outpatients in clinics or in oncology/pneumology practices with appropriately trained staff.

There is a smooth transition between inpatient and outpatient care: important decisions and major interventions take place in the center/clinic, but many treatment cycles and check-ups are continued on an outpatient basis close to home.

This dovetailing saves the patient stressful hospital stays without compromising on safety.

The advantages of outpatient care are obvious: the patient spends less time in hospital, remains in their social environment and can resume their everyday life more quickly (as far as their health allows).

For older people in particular, their own home is often the preferred place to recover. In addition, outpatient concepts reduce costs and relieve the burden on hospitals.

However, it is important that outpatients have low-threshold access to medical help if something arises – telephone accessibility, emergency outpatient clinics or telemedicine play a role here.

Many modern cancer centers offer patients so-called patient portals or hotline numbers, which they can use to get medical advice quickly if they have questions or problems (e.g. fever during chemotherapy).

Nursing staff and specialized professionals also play an important role in outpatient lung cancer care, for example as case managers or oncology nurses in practices.

They coordinate appointments, monitor the patient’s condition between visits to the doctor and provide training in self-help measures (e.g. handling a stoma or drainage, recognizing warning symptoms).

In summary, the vision is clear: a lung cancer patient should be treated on an outpatient basis as much as possible, provided this is medically justifiable. Only if necessary (surgery, serious complications) should they remain in hospital.

Everything else can be provided by a well-organized outpatient infrastructure, from initial diagnosis to aftercare. Specialized day clinics and care centers such as those in other areas (e.g. the aforementioned vein center) serve as a model here.

The future lies in “cross-sector” care, where the clinic and practice work hand in hand to get the best for the patient.

Aftercare and quality of life

The treatment of lung cancer does not end with the last chemotherapy cycle or discharge after surgery.

Aftercare and rehabilitation are key pillars in ensuring the success of the therapy and guaranteeing the patient’s long-term quality of life. As soon as the acute treatment has been completed and the patient has recovered, a structured aftercare program follows.

Objectives of follow-up care: On the one hand, it should help to detect a relapse (recurrence) or second tumor at an early stage so that countermeasures can be taken in good time if necessary.

Secondly, late effects of the disease and therapy must be monitored and treated – both physical and psychological. Last but not least, aftercare serves to support the patient in reintegrating into everyday life and to deal with any social or psychological problems.

Ideally, each patient receives an individual aftercare plan. In practice, this usually looks like this:

• First examination approx. 4-6 weeks after completion of the initial treatment (surgery, chemotherapy or radiation). Here the doctor checks the patient’s general condition, the surgical site (for patients who have had surgery) and discusses any current complaints.
• In the first 2 years: Quarterly follow-up examinations (every 3 months). These close check-ups are important because the risk of relapse is highest in the first two years.
• In the 3rd to 5th year: six-monthly examinations (every 6 months). If no recurrence has occurred by the 5th year, the disease is considered to be under long-term control.
• From the 5th year: Annual check-ups, especially for those with a history of previous illness and treatment (e.g. reduced lung function) – this is more about general care and cancer prevention (e.g. maintaining smoking cessation permanently).

Of course, this plan is customized. A younger, cured patient could, for example, only come once a year after a few years, while someone at high risk or with permanent problems will continue to be seen more closely. The important thing is If new complaints arise, you should not wait until the next appointment, but contact the doctor immediately. Patients are expressly advised of this.

Contents of the follow-up examinations: The first step is always a consultation and clinical examination. The doctor will specifically ask about symptoms such as a new cough, pain, weight progression, performance, etc.

He listens to the lungs, palpates lymph node sites, checks scars and the general condition. Typically, a pulmonary function test and an X-ray or low-dose CT scan of the chest are also regularly included.

After major surgery, a CT scan is often performed during the course of the procedure in order to have the new anatomical situation as a baseline and to better detect changes later on. If a recurrence is suspected (e.g. a new shadow in the X-ray), further clarification is carried out immediately – for example with a diagnostic CT, PET-CT or bronchoscopy, depending on the case. In certain constellations (e.g. initial involvement of the brain), scheduled MRIs of the skull may also be part of the follow-up care.

In short: The aim of follow-up care is to detect a possible relapse as early as possible in order to be able to offer the patient a chance of treatment.

This is because a localized recurrence can possibly be operated on again or irradiated with curative intent.

Outpatient aftercare: As already mentioned, follow-up care can be provided either at the clinic (e.g. in the thoracic surgery outpatient clinic or oncology outpatient clinic) or by a specialist in private practice (pulmonologist/oncologist) .

Many patients use a combination: they go to the center for the first one to two years, after which the pulmonologist close to home takes over. It is important that the same guidelines are followed everywhere. Clinics often have standardized follow-up questionnaires that are given to the doctor providing further treatment.

Rehabilitation and quality of life: Oncological rehabilitation follows shortly after acute therapy – often even before the actual aftercare phase.

This can take place as an inpatient (in a rehabilitation clinic) or as an outpatient and usually lasts 3 weeks.

The aim is to strengthen patients physically and mentally and to help them return to everyday life and work.

In rehab, lung cancer patients receive a whole package of supportive measures tailored to their needs:

• Breathing training: Particularly important after partial lung resection in order to make optimum use of the remaining lungs and reduce breathlessness. This includes respiratory gymnastics, training the auxiliary respiratory muscles and learning techniques (lip braking etc.).

• Physiotherapy and sport: Build up general fitness and muscle strength, tailored to performance. Targeted exercises increase stamina and reduce fatigue.

• Occupational therapy: Support with everyday activities if there are restrictions due to the illness. Here you learn, for example, how to take it easy in everyday life if you have difficulty breathing and how to use aids.

• Dealing with aids: In rehab, for example, training is given on how to use a portable oxygen supply if the patient needs oxygen permanently .
  The use of inhalation devices or breathing facilitation techniques is also trained.

• Quitting smoking: A very central point – many lung cancer patients manage to stop smoking around the time of diagnosis.
  In rehab, they are motivated to stick with it and offered support (nicotine replacement, behavioral therapy).

• Nutritional advice: After serious illness and therapy, some people find it difficult to regain weight or eat a balanced diet.
  Nutrition experts help to draw up a plan that includes, for example, a high-calorie, healthy diet to make up for weight loss or, if necessary, special diets (for swallowing disorders, etc.).

• Psychosocial support: Psycho-oncologists are available to deal with anxiety, depression or trauma following a cancer diagnosis. Group discussions with other sufferers provide support. Stress management strategies and relaxation techniques are also taught (e.g. progressive muscle relaxation, yoga).

• Social counseling: Many patients have questions about pensions, disability cards and professional reintegration. Social workers help to submit applications and develop prospects.

• Connection to self-help: Rehab clinics often establish contact with self-help groups. For example, there are lung sports groups (outpatient lung sports) in which patients can continue exercising after rehab. Participation in such groups is often prepared during rehabilitation and initiated as an aftercare measure.

Overall, rehabilitation has been proven to improve performance and quality of life after lung cancer. Patients feel less alone and gain confidence in their ability to cope with everyday life again.

Long-term perspective and lifestyle: Once treatment has been completed, it is essential that patients continue to maintain a healthy lifestyle.

Not smoking remains the top priority – even those who have undergone surgery otherwise have a high risk of a second carcinoma in the remaining lung.

A healthy diet, exercise and physical activity (adapted to your fitness level) can help you stay fit in the long term and strengthen your immune system.

Studies suggest that moderate exercise could even slightly reduce the risk of relapse and improve the tolerability of therapies.

Patients should also seek psychosocial support if necessary: professional psycho-oncology or exchanges in self-help groups can help to deal with the fear of a relapse and to cope with “life after cancer”.

Many patients report that they have reorganized their priorities as a result of the illness – aftercare offers the opportunity to talk about this and, if necessary, to set a new course (e.g. professionally) in order to avoid overload.

For patients for whom no permanent cure is possible and who are living with a tumor under control (chronic cancer), aftercare is primarily about maintaining quality of life .

This means: Alleviating symptoms as best as possible, recognizing and treating disease progression in good time, and planning ahead at the same time (advance care planning, including palliative care).

Here, aftercare works closely with outpatient palliative care services or hospices if the disease continues to progress.

Conclusion: Follow-up care for lung cancer is just as important as acute therapy. It requires good interaction between the clinic and outpatient care.

Thanks to clear aftercare guidelines – usually 5 years of close monitoring – recurrences can be detected and treated at an early stage. At the same time, it provides comprehensive care for the patient in order to restore physical fitness, mental stability and social participation in the best possible way.

Patients should not be left alone in their new “life after cancer”, but should know that they have a regular point of contact and will receive help if problems arise.

Aftercare therefore makes a significant contribution to improving quality of life and giving patients a sense of security and perspective – whether they are cured or living with the disease.

Closing words: Lung cancer is still a serious diagnosis, but the progress made in recent years is encouraging. Through consistent early detection, interdisciplinary therapy concepts and the use of personalized treatments, the prognosis is improving step by step.

Modern thoracic surgery – especially minimally invasive and robot-assisted – enables effective procedures with less trauma, which speeds up recovery.

At the same time, the focus is increasingly shifting to outpatient care: patients can now receive the majority of their treatment in day clinics and specialized practices, which makes the treatment process more humane and patient-friendly.

Pneumologists, thoracic surgeons and oncologists work hand in hand to provide each patient with the best possible individual care. And thanks to structured aftercare and rehabilitation measures, there is continuous support even after acute therapy, ensuring that quality of life and enjoyment of life are not neglected.

It is important for those affected to know that they are not alone with lung cancer: Today, there are certified lung cancer centers, comprehensive information (e.g. from the Cancer Information Service) and a network of specialists available from diagnosis to aftercare.

Treatment in such an environment – whether inpatient or outpatient – guarantees that all modern possibilities are utilized.

Thus, even with this serious disease, there are realistic chances of a cure (in early stages) or at least of significantly longer survival with a good quality of life (in advanced stages).