Lung Cancer

Lung cancer is the leading cause of cancer death in Australia. The cardiorespiratory physiotherapist plays a defined role across the patient journey — from prehabilitation before surgical resection, to post-operative pulmonary care, to exercise prescription during and after systemic therapy, to symptom management in advanced disease.

Definition

Lung cancer refers to malignant tumours arising from the cells of the airways or lung parenchyma. The two principal histological groupings are non-small cell lung cancer (NSCLC), which accounts for approximately 85% of cases and includes adenocarcinoma, squamous cell carcinoma and large cell carcinoma, and small cell lung cancer (SCLC), which accounts for the remaining 10–15% and is characterised by rapid growth and early metastasis.

Pathophysiology

Lung cancer develops through the accumulation of genetic and epigenetic alterations in airway epithelial or alveolar cells, most often driven by long-term exposure to inhaled carcinogens. In NSCLC adenocarcinoma, identifiable driver mutations (EGFR, ALK, ROS1, BRAF, KRAS G12C, MET, RET, HER2, NTRK) underpin much of the modern treatment landscape and are routinely tested at diagnosis.

Tumours produce local effects (airway obstruction, post-obstructive pneumonia, pleural effusion, haemoptysis), regional effects (mediastinal invasion, superior vena cava obstruction, recurrent laryngeal nerve palsy, Pancoast syndrome), and distant effects through metastasis (brain, bone, liver, adrenal) and paraneoplastic phenomena.

Co-morbidities

Most patients with lung cancer carry significant cardiorespiratory co-morbidity related to shared risk factors — COPD, ischaemic heart disease, peripheral vascular disease, and chronic kidney disease. Co-existing COPD is present in 40–70% of patients and has direct implications for surgical candidacy, radiotherapy planning, and rehabilitation prescription.

Sarcopenia, cachexia, depression, anxiety, and cognitive impairment are common and are independently associated with poorer treatment tolerance and survival.

Prevalence

Lung cancer is the fifth most commonly diagnosed cancer in Australia but the leading cause of cancer death, accounting for approximately one in five cancer deaths. Five-year survival has improved over the last decade with the advent of targeted and immunotherapies but remains around 24% overall, with stage at diagnosis the strongest determinant of outcome.

Causes and risk factors

Tobacco smoking is responsible for the majority of lung cancer in Australia, with risk proportional to pack-years and time since cessation.

Other established risk factors include second-hand smoke, occupational exposures (asbestos, silica, diesel exhaust, radon, arsenic, nickel, chromium), prior chest radiotherapy, pulmonary fibrosis, COPD, family history of lung cancer, HIV infection, and air pollution.

A meaningful proportion of lung cancer in Australia (particularly adenocarcinoma in women) occurs in never-smokers, in whom driver mutations such as EGFR are over-represented.

Symptoms

New or changed cough, haemoptysis, persistent dyspnoea, chest or shoulder pain, recurrent or non-resolving chest infection, wheeze or stridor, hoarseness, dysphagia, unexplained weight loss, fatigue, and finger clubbing.

Early-stage disease is frequently asymptomatic, which is the rationale for the National Lung Cancer Screening Program.^1,2 Symptoms that should prompt urgent investigation in a person with a smoking history include haemoptysis at any age and any of the above persisting for more than three weeks.

Screening — the National Lung Cancer Screening Program

The National Lung Cancer Screening Program commenced in Australia on 1 July 2025 and offers a free low-dose CT scan every two years to eligible people aged 50–70 who show no signs or symptoms of lung cancer, currently smoke or have quit within the past ten years, and have a tobacco smoking history of at least 30 pack-years.

Eligibility is assessed by a healthcare provider on age, smoking history and the absence of symptoms — there is no risk-score calculation — and entry to the program requires a referral. Once a person is enrolled, they remain eligible to continue screening even if they later pass ten years since quitting.³ The program is delivered through primary care, including Aboriginal and Torres Strait Islander Health Workers and Health Practitioners, with mobile screening services in some rural and remote areas to improve access for communities carrying a disproportionate lung cancer burden.

Patients identified through screening, or with incidental pulmonary nodules on imaging performed for other reasons, are managed according to the Australian and New Zealand pulmonary nodule guidelines (a Fleischner-aligned algorithm with Australian adaptation).

Diagnosis

Why diagnosis matters

Stage at diagnosis is the strongest determinant of survival in lung cancer. Five-year survival exceeds 60% for stage I disease and falls below 5% for stage IV. Earlier diagnosis enables curative-intent treatment (surgery, stereotactic radiotherapy, or chemoradiotherapy) and access to a broader range of clinical trial options.

Australian patients should be managed through a multidisciplinary team in accordance with the Optimal Care Pathway for people with lung cancer.

How the diagnosis is made

Diagnosis combines clinical assessment, imaging, and tissue or cytological confirmation. The typical pathway is chest X-ray or CT identifying a suspicious lesion, followed by contrast-enhanced CT chest/upper abdomen, then tissue sampling guided by lesion location and accessibility.

Sampling modalities include bronchoscopy with endobronchial ultrasound (EBUS-TBNA) for central lesions and mediastinal nodes, CT-guided percutaneous biopsy for peripheral lesions, pleural fluid cytology with pleural biopsy if effusion is present, and surgical biopsy where less invasive methods are non-diagnostic.

Radiology

CT chest with contrast remains the cornerstone of diagnosis and staging. PET-CT is used to refine staging in patients being considered for curative-intent treatment, MRI brain to exclude cerebral metastases in higher-stage disease or symptomatic patients, and bone scan or PET to identify skeletal metastases.

Staging follows the TNM classification (IASLC 9th edition, in use from 2024) which has refined the N and M descriptors and improved prognostic stratification.

Lung function

Pulmonary function testing including spirometry, lung volumes, and DLCO is required for any patient being considered for surgical resection or radical radiotherapy. Predicted post-operative FEV₁ and DLCO are calculated, and patients with values below threshold proceed to cardiopulmonary exercise testing (CPET) for further risk stratification.

Exercise-based assessments (CPET, 6-minute walk test, incremental shuttle walk test) inform both surgical candidacy and prehabilitation prescription.

Pathology and molecular testing

Histological subtyping distinguishes NSCLC from SCLC and identifies the NSCLC subtype (adenocarcinoma, squamous, large cell). For non-squamous NSCLC, reflex molecular testing is performed for EGFR mutations, ALK and ROS1 rearrangements, BRAF V600E, KRAS G12C, MET exon 14, RET, NTRK, and HER2 alterations, along with PD-L1 immunohistochemistry.

These results determine eligibility for PBS-listed targeted therapies and immunotherapy and should be available before treatment decisions are finalised.

Investigations for staging and fitness

Baseline bloods (FBC, U&E, LFT, calcium, LDH), assessment of cardiac function where indicated (ECG, echocardiogram), nutritional assessment, frailty screening, and review of co-morbidities including COPD, IHD, and renal function.

A formal multidisciplinary discussion with thoracic surgery, medical oncology, radiation oncology, respiratory medicine, palliative care, pathology, and allied health is the Australian standard of care.

Management

Treatment goals

Treatment goals are stratified by stage, histology, molecular profile, and patient fitness. Early-stage NSCLC is managed with curative intent (surgery, stereotactic body radiotherapy, or concurrent chemoradiotherapy). Locally advanced disease combines chemoradiotherapy with consolidation immunotherapy.⁴ Metastatic disease is managed with systemic therapy guided by driver mutation and PD-L1 status. SCLC is managed with chemotherapy and immunotherapy in extensive stage, and chemoradiotherapy in limited stage.

For all patients, parallel goals are symptom control, preservation of function, psychological support, and timely integration of palliative care.

Surgery

Anatomical lung resection (lobectomy, segmentectomy, or pneumonectomy) with systematic lymph node dissection is the standard for stage I–II NSCLC and selected stage IIIA disease. Video-assisted thoracoscopic surgery (VATS) and robotic-assisted resection are now standard at most Australian thoracic centres.

Prehabilitation (typically 2–4 weeks of exercise training, smoking cessation, nutritional optimisation, and respiratory physiotherapy) is increasingly delivered as part of the surgical pathway and is associated with reduced post-operative pulmonary complications and shorter length of stay.^5,6

Radiotherapy

Stereotactic body radiotherapy (SBRT) delivers high-dose ablative radiotherapy in a small number of fractions and is the standard of care for medically inoperable early-stage NSCLC. Conventional radical radiotherapy or concurrent chemoradiotherapy is used in locally advanced disease. Palliative radiotherapy is highly effective for symptomatic bone metastases, haemoptysis, SVC obstruction, and brain metastases.

Systemic therapy

Systemic therapy options are determined by histology, driver mutation, PD-L1 status, performance status, and patient preference. Platinum-based chemotherapy remains the backbone for many treatment lines. Targeted therapies (e.g. EGFR, ALK, ROS1, BRAF, KRAS G12C inhibitors) and immune checkpoint inhibitors (anti-PD-1, anti-PD-L1, anti-CTLA-4) have transformed outcomes for selected patients.

Treatment is delivered through medical oncology, with close monitoring for immune-related adverse events, infusion reactions, and treatment-specific toxicities.

Identifying complications and recurrence

Post-treatment surveillance follows the Optimal Care Pathway, with structured clinical review and imaging at defined intervals. New or worsening symptoms — pain, breathlessness, neurological symptoms, weight loss, haemoptysis — should prompt urgent re-imaging.

Patients on systemic therapy require vigilance for immune-related adverse events (pneumonitis, colitis, hepatitis, endocrinopathies, dermatitis), which can occur at any time during or after treatment.

Survivorship plan

Every patient should leave active treatment with a written survivorship care plan covering surveillance schedule, late-effects monitoring (cardiac, pulmonary, endocrine, neurological), exercise prescription, psychological support, smoking cessation support, and clear pathways for re-referral if symptoms recur.

Medications

Chemotherapy

Platinum doublets (cisplatin or carboplatin combined with pemetrexed, paclitaxel, gemcitabine, or etoposide) remain widely used. Common toxicities include myelosuppression, nausea, neuropathy (platinum, taxanes), nephrotoxicity (cisplatin), and fatigue.

Targeted therapy

Oral tyrosine kinase inhibitors targeting EGFR (osimertinib, erlotinib, gefitinib), ALK (alectinib, brigatinib, lorlatinib), ROS1 (entrectinib, crizotinib), BRAF (dabrafenib + trametinib), KRAS G12C (sotorasib, adagrasib), and other actionable mutations. Side-effect profiles are class-specific and include skin rash, diarrhoea, transaminitis, pneumonitis, QTc prolongation, and cardiac effects with selected agents.

Immunotherapy

Immune checkpoint inhibitors (pembrolizumab, nivolumab, atezolizumab, durvalumab, ipilimumab) are used as monotherapy or in combination, in both metastatic and locally advanced settings. Immune-related adverse events require prompt recognition and corticosteroid management. Pneumonitis is the most relevant complication for the physiotherapist to be aware of, as it can mimic infection or disease progression and is a contraindication to ongoing exercise progression until resolved.

Supportive and symptom medications

Anti-emetics, analgesics (including opioids titrated for cancer pain and dyspnoea), bronchodilators for co-existing COPD, low-molecular-weight heparin for cancer-associated thromboembolism, bone-modifying agents for skeletal metastases, and corticosteroids for symptomatic brain metastases or immune-related adverse events.

Multi-system manifestations

Paraneoplastic syndromes

A range of paraneoplastic syndromes is associated with lung cancer, particularly SCLC. These include SIADH, ectopic ACTH (Cushing’s syndrome), hypercalcaemia of malignancy, Lambert-Eaton myasthenic syndrome, hypertrophic pulmonary osteoarthropathy, and limbic encephalitis. Symptoms can pre-date the cancer diagnosis and should be considered in unexplained neurological or endocrine presentations.

Cancer-related fatigue, cachexia and sarcopenia

Cancer-related fatigue affects the majority of patients and is multifactorial — disease, treatment, anaemia, deconditioning, sleep disturbance, depression, and medication effects. Cachexia (involuntary loss of skeletal muscle with or without fat loss) is independently associated with poorer treatment tolerance and survival.

Structured exercise (aerobic and resistance), nutritional support including dietitian referral, and treatment of contributing factors form the cornerstone of management.

Venous thromboembolism

Lung cancer carries a particularly high risk of venous thromboembolism, which is itself a marker of poorer prognosis. Any new unilateral leg swelling, pleuritic chest pain, or unexplained worsening of dyspnoea should prompt assessment for DVT or PE.

Musculoskeletal and chest wall pain

Pain from rib metastases, post-thoracotomy syndrome, brachial plexopathy (Pancoast), and chest wall radiotherapy effects are common physiotherapy referrals. Management combines pharmacological analgesia, manual therapy, breathing retraining, and graded activity.

Treatment-related cardiotoxicity

Mediastinal radiotherapy and certain systemic therapies are associated with cardiotoxicity (cardiomyopathy, pericarditis, conduction disease, accelerated coronary disease). Long-term survivors warrant cardiovascular risk-factor surveillance and intervention.

Living with lung cancer

Smoking cessation

Smoking cessation at any point in the lung cancer journey improves outcomes — surgical recovery, treatment tolerance, second primary cancer risk, and survival.⁷ Quitline (13 78 48), pharmacotherapy (NRT, varenicline, bupropion), and behavioural support are all PBS or state-funded and should be offered systematically.

Exercise and rehabilitation

Exercise is safe and beneficial across all stages of lung cancer, including during active treatment.^8,9 Australian and international guidelines recommend a combination of aerobic and resistance training, individualised to fitness, treatment phase, and symptom burden.

Prehabilitation before surgery, post-operative pulmonary physiotherapy, and structured exercise during and after systemic therapy are all delivered at Inspire Clinic. For patients in regional and remote Central Queensland, home-based programmes with telehealth supervision are an effective alternative to in-clinic attendance.

Nutrition

Early dietitian involvement is recommended, with attention to maintaining lean body mass through adequate protein intake (typically 1.2–1.5 g/kg/day), management of treatment-related taste change, mucositis and nausea, and consideration of oral nutritional supplements where intake is inadequate.

Sleep, mood, and psychological care

Insomnia, anxiety, depression, fear of recurrence, and adjustment difficulties are common and under-treated. Routine screening and referral to psycho-oncology, social work, or GP-led mental health care should be normalised. Cancer Council Australia (13 11 20) provides free information and counselling.

Travel

Patients on active systemic therapy, those with significant pulmonary impairment, or with central airway involvement should obtain pre-travel medical review. Air travel may require supplemental oxygen assessment (high-altitude simulation testing) for patients with marginal resting saturations or impaired DLCO.

Prognosis and goals-of-care conversations

Prognostic estimates vary widely by stage, histology, molecular profile, performance status, and response to treatment. Early integration of palliative care, alongside active anti-cancer treatment, is supported by Australian and international evidence and is associated with improved quality of life and, in some studies, survival.¹⁰

Advance care planning conversations — values, preferences, substitute decision-maker, written advance care directive — are best initiated early and revisited as the disease course evolves.

Exercise & physiotherapy precautions during cancer treatment

Exercise is safe and beneficial for most people during and after treatment for lung cancer, and physiotherapy supports breathing, fitness and recovery throughout. A few sensible, treatment-specific precautions keep that activity safe — these apply across cancer care and are summarised below for patients and clinicians.

General Principles

Patients receiving active cancer treatment or systemic immunosuppression require an individualised approach that adapts to their current treatment phase, recent blood counts, symptom trajectory, and known treatment-specific complications. Communication with the oncology, haematology, or rheumatology team is essential before commencing or modifying a programme.

Many treatment complications first present as new or worsening dyspnoea, fatigue, or chest pain during exercise — the physiotherapy session is often a more detailed functional and symptom assessment than the routine medical review and may be the point at which deterioration is first identified. A low threshold for pausing a session and communicating concerns to the treating team is appropriate.

Neutropenia and Infection Risk

Neutropenia is graded by absolute neutrophil count (ANC): moderate 0.5–1.0 × 10⁹/L, severe <0.5, profound <0.1. Most chemotherapy regimens produce a nadir around days 7–14 of the cycle.

Practical implications: confirm recent FBC before high-intensity sessions, strict hand hygiene, surgical mask use during sessions for both physiotherapist and patient, avoidance of contact with other unwell patients and clinicians, and decontamination of all shared equipment. The physiotherapist must defer patient contact if they have any acute respiratory or gastrointestinal symptoms.

Thrombocytopenia and Bleeding Risk

Platelet count >50 × 10⁹/L: most physiotherapy interventions safe. Platelets 20–50: caution with vigorous percussion, vibration, deep-tissue work, and high-resistance IMT; avoid manual therapy with risk of bruising. Platelets <20: avoid percussion and vibration; gentle mobilisation only. Platelets <10: bed rest is often advised; assisted range of motion and gentle in-bed activity only.

Where airway clearance is essential despite low platelet counts, prefer device-based techniques (PEP, oscillating PEP, autogenic drainage) over manual techniques.

Anaemia and Cancer-Related Fatigue

With haemoglobin <80 g/L, reduce exercise intensity and monitor for tachycardia, dyspnoea, and pre-syncope; with Hb <70 g/L, defer formal exercise testing and discuss with oncology. Cancer-related fatigue is multifactorial and structured exercise (not rest) remains a core intervention — but intensity, modality, and pacing must be individualised.

Cardiotoxicity and Pulmonary Toxicity from Cancer Therapy

Anthracyclines (doxorubicin, epirubicin) carry cumulative dose-related risk of cardiomyopathy. Trastuzumab and other HER2-targeted agents cause largely reversible LV dysfunction during therapy. Several tyrosine kinase inhibitors produce QTc prolongation, hypertension, or heart failure. Immune checkpoint inhibitor myocarditis is rare but carries high mortality — new chest pain, palpitations, or dyspnoea in a patient on immunotherapy is a red flag.

Pulmonary toxicity: bleomycin causes cumulative dose-related fibrosis with risk of oxygen-mediated injury persisting for life. Radiation pneumonitis typically occurs one to six months after thoracic radiotherapy. ICI pneumonitis can occur at any point during or after treatment. Any unexplained drop in exercise tolerance, new desaturation, or worsening dyspnoea in a patient on these therapies should pause progression and prompt urgent communication.

Bone Metastases and Skeletal Fragility

Review the most recent imaging and any orthopaedic or radiation oncology input. Avoid high-velocity manipulation, deep manual therapy, and aggressive joint mobilisation through affected regions. New or worsening localised pain at a known metastasis site warrants urgent imaging review before exercise progression.

Peripheral Neuropathy and Falls

Platinum agents, taxanes, vinca alkaloids, and bortezomib all cause peripheral neuropathy. Routine falls risk assessment, balance and sensory-motor training, footwear review, and removal of environmental hazards are core. Caution with barefoot exercise.

Lymphoedema Precautions

Resistance exercise of the affected limb is safe and beneficial — the earlier blanket restrictions on lifting are no longer supported by evidence (PAL trial and subsequent literature). Compression garment fit and review remain part of routine care.

Immune Checkpoint Inhibitor Adverse Events

Physiotherapy-relevant immune-related adverse events: pneumonitis (dyspnoea, cough, hypoxia), myocarditis (chest pain, dyspnoea, arrhythmia), and endocrinopathies including adrenal insufficiency and hypothyroidism. Patients carry immunotherapy alert cards; any new symptom should be considered in the context of recent or remote checkpoint inhibitor therapy.

Methotrexate and Other Immunosuppressants

Low-dose methotrexate (typically 10–25 mg weekly with folic acid co-prescription) is widely used. Common effects relevant to physiotherapy: infection susceptibility, fatigue, mucositis, cytopenias, and hepatotoxicity.

Other commonly encountered immunosuppressants: long-term corticosteroids, azathioprine, mycophenolate, cyclophosphamide, calcineurin inhibitors, JAK inhibitors, and biological agents. All increase infection risk; live vaccines are generally contraindicated.

Methotrexate Pneumonitis — Recognition

Methotrexate pneumonitis is an idiosyncratic, hypersensitivity-type interstitial pneumonitis. Onset can be acute, subacute, or chronic. Cardinal features: progressive dyspnoea, dry cough, low-grade fever, fatigue, and hypoxia, often with bilateral interstitial infiltrates. Mortality is reported up to 13% in older series — early recognition matters. From the physiotherapy perspective, any unexpected new or worsening dyspnoea in a patient on methotrexate should pause progression and trigger urgent communication with the prescriber.

Communication and Shared Care

Physiotherapy for patients on cancer therapy and systemic immunosuppression is delivered as part of a multidisciplinary team. Practical expectations: a referral note specifying current treatment, recent investigations, and known complications; documented communication of any concerning symptoms; and shared documentation accessible to the treating team.

Role of the physiotherapist

The physiotherapist supports people through treatment and recovery: prehabilitation before surgery, post-operative airway clearance and mobilisation, and exercise rehabilitation to counter deconditioning, alongside breathlessness management and a palliative approach where appropriate.

Warning signs

Part 1 · References

1. National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011;365(5):395–409.
2. de Koning HJ, van der Aalst CM, de Jong PA, et al. Reduced lung-cancer mortality with volume CT screening in a randomized trial (NELSON). N Engl J Med 2020;382(6):503–513.
3. Australian Government Department of Health and Aged Care. National Lung Cancer Screening Program: program overview. Canberra: Commonwealth of Australia; 2025.
4. Antonia SJ, Villegas A, Daniel D, et al. Durvalumab after chemoradiotherapy in stage III non-small-cell lung cancer (PACIFIC). N Engl J Med 2017;377(20):1919–1929.
5. Cavalheri V, Granger C. Preoperative exercise training for patients with non-small cell lung cancer. Cochrane Database Syst Rev 2017;(6):CD012020.
6. Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, et al. Guidelines for enhanced recovery after lung surgery: recommendations of the ERAS Society and the European Society of Thoracic Surgeons. Eur J Cardiothorac Surg 2019;55(1):91–115.
7. Parsons A, Daley A, Begh R, Aveyard P. Influence of smoking cessation after diagnosis of early stage lung cancer on prognosis: systematic review of observational studies with meta-analysis. BMJ 2010;340:b5569.
8. Cavalheri V, Burtin C, Formico VR, et al. Exercise training undertaken by people within 12 months of lung resection for non-small cell lung cancer. Cochrane Database Syst Rev 2019;(6):CD009955.
9. Peddle-McIntyre CJ, Singh F, Thomas R, Newton RU, Galvão DA, Cavalheri V. Exercise training for advanced lung cancer. Cochrane Database Syst Rev 2019;(2):CD012685.
10. Higginson IJ, Bausewein C, Reilly CC, et al. An integrated palliative and respiratory care service for patients with advanced disease and refractory breathlessness: a randomised controlled trial. Lancet Respir Med 2014;2(12):979–987.

References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.