Like CFIT and many other aviation accidents, today’s disease du jour is largely preventable. Lung cancer is the leading cause of cancer-related deaths worldwide, the third most common cancer in America in men and women, and, like all cancers is due to purposeless and uncontrolled division of cells. CFIT of the lungs if you will, as 85% of cases are due to tobacco use or exposure, an avoidable risk.
Lung cancer risk increases with age, most often diagnosed in those over 65 years, but can be seen as young as 20. It is described as Small Cell Lung Cancer (SCLC) in around 10%, an aggressive, rapidly spreading disease; and Non-Small Cell Lung Cancer (NSCLC), which accounts for 85%; and the remainder being several rare types. Although there are genetic factors that can predispose to developing lung cancer, as above, smoking causes nearly 90% of tumors and non-smokers exposed to “second-hand smoke” have their risk increased 20–30%. Additionally, exposure to asbestos, air pollutants, and radon gas are other precipitants and that is why it is necessary to screen homes and remove such irritants from our environments.
Symptoms that might suggest a lung cancer is lurking often occur late and include a persistent cough for several weeks, perhaps producing flecks of blood, chest pain on deep breathing, hoarse voice, difficulty catching one’s breath, and wheezing. Fatigue or weight loss tend to be later indications, as are manifestations that the cancer has metastasized, the $100 word that means it has spread elsewhere. The symptoms from such secondary cancers depend on where they land, so if in a bone, one might develop constant back or leg pain or a sudden fracture, and if to the brain one might develop headaches or seizures. In fact, secondary brain tumors are much more common than true brain cancers, and lung is a frequent culprit.
There are also non-metastatic, and often bizarre, symptoms such as hallucinations due to chemicals made by the cancer. If the cancer is situated at the top of the lung, it can cause Horner’s Syndrome, where one develops a persistently small pupil on one side, delay in the pupil opening in darker surroundings, a drooping eyelid, and an absence of sweating on that side of the face.
If a doctor suspects lung cancer, they will conduct a full examination and may hear diminished air entry over the tumor and altered noises on breathing. Lymph nodes may be swollen in various areas and there are many other signs that indicate a cancer has spread.
Confirmatory investigations include blood work to look for general signs of illness and either chest X-ray or CT scan to characterize the tumor. At this point, a bronchoscopy may be performed, whereby a flexible scope is inserted into the airways and navigated as far into the lung periphery as possible to try and visualize the malignancy and obtain a biopsy. If the tumor is too deep in the lung, a percutaneous biopsy is performed with a needle passed in through the chest wall under guidance of a CT scanner. More recently, robotic guidance has been introduced to increase accuracy of needle placement. Retrieved tissue is then examined under a microscope and by a series of other tests to characterize what type of cancer this is, and how susceptible it may be to various therapies. With a positive tissue diagnosis, a range of tests are done to stage the cancer to see if it has spread to other parts of the body as this will impact the recommended treatment. This might include bone scans, an MRI of the head and neck, and positron emission tomography (PET) scans.
For high-risk, but asymptomatic patients aged over 55 with a long smoking history, screening with low-dose CT scans can detect lung cancer early and is associated with vastly better prognosis—up to 20 times better!
Once the tumor has been classified, a multi-disciplinary care team will discuss options with the patient. Surgery is a mainstay and involves either pneumonectomy, removing the entire lung, or lobectomy, removing just a segment. One also removes the lymph nodes associated with either the whole lung or section.
Additional medical treatment consists of chemotherapy, potent drugs to kill cancer cells, although other rapidly dividing cells in the gut and skin follicles are also affected, hence the vomiting, diarrhea, and hair loss that accompany such therapy. Newer medications target specific genetic abnormalities in cancer cells, meaning that off-target side effects are limited. Another approach is immunotherapy, including checkpoint inhibitors, to help the patient’s immune system battle the cancer. Radiotherapy consists of different types of radiation to obliterate malignant cells in the lungs or wherever it has spread to. Although this has classically involved external beams to blast the cells, newer targeted alpha therapy, or TAT, tags a chemical that can attach to a cancer cell with an isotope called Actinium-225 that zaps the bull’s-eye; think of the isotope as the explosive and the chemical delivery mechanism as a bomber. Recently, the FDA approved a trial named SANTANA-225 (nothing to do with Carlos of guitar fame) for patients with either widespread SCLC or a rare skin tumor called Merkel Cell Carcinoma and due to start this year. Later in 2025 we are hoping to see data on a drug called Actimab-A, which is combined with a checkpoint inhibitor to treat NSCLC and other cancers. Exciting times!
The outcome of all of this depends on many factors, including the patient’s age and general health, tumor size, cell type, location, and whether it has spread. Despite the wretched reputation that lung cancer has, the prognosis has improved dramatically over the past 25 years and patients can often receive several rounds of treatment and obtain extra years of good quality life. However, as with all diseases, prevention beats cure, so avoid tobacco for the plague it is. There have been many social initiatives to limit smoking, including banning it in public places, raising taxes, extensive educational programs, restricting minors’ access, and providing support programs for those wishing to quit.
Although vaping does help the tobacco-addicted to stop smoking, the jury is still out on how safe it is. Given there are hundreds of chemicals in vapes, including certain compounds known to cause cancer, my gut tells me people should steer clear. Whether or not smoking marijuana alone increases the risk of lung cancer is not clearly understood for several reasons, not least because many who use the drug also smoke cigarettes and obtaining hard data is difficult. But cannabis does contain carcinogens, so it is not beyond the bounds of possibility to imagine it being causative.
If diagnosed, pilots should self-ground immediately and inform their AME and the FAA’s Aerospace Medical Certification Division. A detailed report is required to include full medical records, diagnostic test results, pathology report, detailed treatment records, pulmonary function tests that characterize lung capacity, and a physician’s letter outlining everything including prognosis. The FAA may request additional tests based on given circumstances including other test data.
Each case is unique, but generally the FAA may require a three-year waiting period once recovered to ensure the disease has been dealt with. If there was no evidence of metastases at time of diagnosis, recertification may commence six months after completion of treatment. However, if the tumor has spread, or chemotherapy/radiotherapy was delivered, the FAA usually seeks at least one year of full recovery. Regardless, one must be continuously monitored and followed up with regular reports submitted as specified.
CFIT occurs when a pilot gets into a situation that is beyond their experience or expectations, but with proper planning it should never occur. Just as one might predict a non-instrument-rated pilot is at risk of harm flying into IMC, we know the major risk factors for lung cancer. So, if you smoke, stop. If you love someone who smokes, plead with them to stop, and if you did ever smoke, or spent time with smokers, please speak to your doctor about potentially getting screened. Avoid CFIT and fly well!
Please subscribe to my podcast at www.jointhedocs.com on either Spotify or Apple podcasts — it’s free! Enjoy our social media videos on:
YouTube: @JoinTheDocs
Instagram: @JoinTheDocs
TikTok: @JoinTheDocs
Facebook: @JoinTheDocs
Twitter: @JoinTheDocs
You can send your questions and comments to Dr. Sackier via email: [email protected].
