What are the symptoms of lung cancer?

Symptoms of Lung Cancer

Primary Pulmonary Symptoms

Cough is the cardinal presenting symptom of lung cancer, occurring in 65% of patients at diagnosis, typically manifesting as a dry, tickling, nonproductive cough with mechanical and environmental triggers. 1, 2

• Chronic cough is the most common initial symptom, present in 65% of patients, resulting from endobronchial irritation, parenchymal infiltration, or postobstructive pneumonia 1, 3
• The cough is characteristically dry and nonproductive in most cases, though approximately 25% present with productive cough indicating postobstructive pneumonia, infection, or coexisting COPD 2
• Hemoptysis occurs in 25-33% of patients and warrants immediate bronchoscopic evaluation, particularly in smokers with COPD—even scant blood-streaking demands investigation as central airway tumors may not be visible on plain chest radiography 1, 2
• Dyspnea affects approximately 17% at presentation and may accompany postobstructive pneumonia or pleural involvement 1, 3
• Chest pain occurs in 17.9% of patients; while often nonspecific initially, pleuritic pain suggests pleural invasion 1, 3
• Localized or unilateral wheezing reflects endobronchial obstruction and should prompt immediate evaluation for neoplasm 1

Symptoms of Intrathoracic Spread

Superior vena cava syndrome, Pancoast syndrome, and hoarseness represent critical manifestations of local tumor extension that require urgent recognition.

• Hoarseness from recurrent laryngeal nerve palsy (more common with left-sided tumors due to the nerve's circuitous route under the aortic arch), causing vocal cord paresis and predisposing to aspiration 1
• Pancoast syndrome from superior sulcus tumors includes shoulder/arm pain from brachial plexus invasion, Horner syndrome (ptosis, miosis, anhidrosis from sympathetic chain infiltration), and C8-T1-T2 distribution weakness and paresthesias 1
• Superior vena cava syndrome (lung cancer is the most common cause) presents with facial and neck swelling, dilated neck veins, prominent chest wall venous pattern, and occasionally dysphagia, cough, headache, or blurred vision 1
• Dysphagia from subcarinal adenopathy compressing the mid-esophagus 1
• Phrenic nerve dysfunction manifesting as elevated hemidiaphragm 1
• Pleural effusion causing dyspnea or chest pain, from direct tumor extension, metastatic implantation, or mediastinal lymphatic obstruction 1

Systemic and Metastatic Manifestations

Constitutional symptoms including weight loss, fatigue, and bone pain indicate advanced disease and carry significant diagnostic weight.

• Weight loss occurs in 8.3-33% of patients with an odds ratio of 2.1 for lung cancer diagnosis within 6 months prior to presentation 1, 3
• Fatigue presents in 4.8% at initial diagnosis with an odds ratio of 1.6 for diagnosis 6 months prior 1, 3
• Bone pain occurs in 5.9% initially with an odds ratio of 2.7 at 6 months pre-diagnosis, suggesting skeletal metastases 1, 3
• Headaches potentially indicate brain metastases 1
• Anemia from chronic disease or bone marrow involvement 1
• Neck and supraclavicular lymphadenopathy occurs in 9.8% of patients, more commonly in nonsquamous carcinoma 3
• Fever presents in 4.3% of patients 3

Clinical Presentation Patterns and Stage Correlation

Approximately 25% of patients are asymptomatic at diagnosis (typically with earlier-stage disease), while the majority present symptomatically with more advanced disease (stage IIIB or IV). 1

• Patients with squamous carcinoma are more likely to present with chronic cough and hemoptysis compared to other pathological types 3
• Patients with stage III disease more commonly present with chronic cough and sputum with blood 3
• Patients with stage IV disease have higher percentages of chest pain, shortness of breath, dyspnea, weight loss, and fatigue than patients with earlier stages 3
• Metastatic pain and neck/supraclavicular lymphadenopathy are more likely in patients with nonsquamous carcinoma 3
• Symptomatic patients are more likely to have concurrent COPD 1

Critical Red Flags Requiring Urgent Investigation

Recurrent pneumonia in the same anatomic distribution, persistent hemoptysis, or unilateral wheezing in a smoker with COPD should trigger immediate bronchoscopic evaluation regardless of chest radiography findings. 2, 4

• Even small amounts of hemoptysis in smokers warrant bronchoscopy, as chest X-rays have only 27-35% specificity and central airway tumors may not be visible on plain films 2, 4
• Recurrent pneumonia in the same anatomic distribution strongly suggests endobronchial tumor 2
• The presence of localized severe chest pain suggests pleural or chest wall invasion 1
• Painful soft tissue masses or rib destruction indicate chest wall invasion and advanced disease 1