What are the signs and symptoms of lung cancer, particularly in older adults with a history of smoking?

Signs and Symptoms of Lung Cancer

Lung cancer most commonly presents with cough (65% of patients), hemoptysis (25-33%), dyspnea (17%), and chest pain (17.9%), though approximately 25% of patients remain asymptomatic at diagnosis—particularly those with earlier-stage disease detected through screening. 1, 2

Primary Pulmonary Manifestations

The cardinal respiratory symptoms arise from endobronchial irritation, parenchymal infiltration, or postobstructive changes:

• Chronic cough is the most frequent presenting symptom, occurring in 65% of patients at diagnosis, resulting from endobronchial tumor irritation or postobstructive pneumonia 1, 2
• Hemoptysis warrants immediate concern for endobronchial tumor, particularly in older smokers with COPD—even scant blood-streaking should raise suspicion, as it may occur despite normal chest radiography 1, 3
• Dyspnea affects approximately 17% at presentation and may accompany postobstructive pneumonia, pleural involvement, or large mass effect 1, 2
• Chest pain (17.9% of patients) is often nonspecific initially, but pleuritic pain suggests pleural invasion or chest wall involvement 1, 2
• Localized or unilateral wheezing reflects endobronchial obstruction and should prompt immediate evaluation for neoplasm 1, 4
• Recurrent pneumonia in the same anatomic distribution or relapsing COPD exacerbations should raise concern for underlying malignancy causing postobstructive changes 4

Symptoms of Intrathoracic Spread

As the tumor extends beyond the primary site, specific anatomic complications develop:

• 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, 4
• Phrenic nerve dysfunction manifesting as elevated hemidiaphragm on imaging 1
• Pleural effusion causing dyspnea or chest pain, from direct tumor extension, metastatic implantation, or mediastinal lymphatic obstruction 1

Constitutional and Systemic Symptoms

These symptoms reflect advanced disease burden and paraneoplastic phenomena:

• 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, 2
• Fatigue affects 4.8% at presentation, with an odds ratio of 1.6 for diagnosis 6 months prior 1, 3, 2
• Anorexia represents a classic systemic manifestation of malignancy 5
• Fever occurs in 4.3% of patients and may indicate postobstructive pneumonia or paraneoplastic syndrome 2

Signs of Metastatic Disease

Physical examination and symptom patterns suggesting distant spread:

• Bone pain (5.9% initially, odds ratio 2.7 at 6 months pre-diagnosis) suggesting skeletal metastases, particularly in patients with stage IV disease 1, 2
• Headaches potentially indicating brain metastases 1
• Neck and supraclavicular lymphadenopathy (9.8% of patients), more common in nonsquamous carcinoma 2
• Confusion, nausea, constipation, and weakness from various paraneoplastic syndromes including hypercalcemia, SIADH, or Lambert-Eaton syndrome 1

Physical Examination Findings

Critical signs that substantially increase diagnostic probability:

• Digital clubbing in a smoker with evidence of pleural effusion or lobar collapse is almost pathognomonic for bronchogenic carcinoma 3
• Localized decreased breath sounds suggest lobar collapse or large mass effect 1
• Painful soft tissue masses or rib destruction from chest wall invasion indicate advanced disease 1

Clinical Presentation Patterns by Stage and Histology

Understanding these patterns helps risk-stratify patients:

• Approximately 25% of patients are asymptomatic at diagnosis (typically with earlier-stage disease detected through screening), while the majority present symptomatically with more advanced disease (stage IIIB or IV) 1
• Patients with squamous carcinoma and stage III disease are more likely to present with chronic cough and hemoptysis than patients with other pathological types (odds ratio 2.885 for symptoms) 2
• Metastatic pain and lymphadenopathy are more likely to occur in patients with nonsquamous carcinoma 2
• Patients with stage IV disease have higher percentages of chest pain, shortness of breath, dyspnea, weight loss, and fatigue than patients with earlier stages 2
• Symptomatic patients are more likely to have concurrent COPD 1

Critical Pitfalls to Avoid

• Normal chest radiographs do not exclude significant disease—hemoptysis may be the presenting symptom even with normal or non-localizing chest radiography 3, 4
• Do not dismiss subtle symptoms in high-risk patients—even scant hemoptysis in a smoker warrants thorough evaluation 1, 3
• Recognize that constitutional symptoms may not be addressed unless the treating physician actively screens for them as part of the disease morbidity 6
• The most difficult aspect of managing lung cancer is often recognizing the less apparent symptoms beyond the obvious respiratory complaints 6