How Lung Cancer Is Diagnosed

Lung cancer is often suspected after an abnormal spot is found on a chest X-ray done to evaluate a cough or chest pain. But since this test can miss early cancers, additional testing is needed to confirm (or rule out) a lung cancer diagnosis. This can include a chest computed tomography (CT) scan and, if a nodule or mass is found, a biopsy.

It's helpful to know more about some of the procedures that may be recommended to find out if an abnormality is benign (noncancerous) or malignant (cancerous).

If the latter, further studies are done to see if the cancer has spread to other areas in the body and to figure out the stage of the disease.

lung cancer diagnosis
Verywell / Hugo Lin

Screening

It's important to catch lung cancer as early as possible. Some cases may first be detected during lung cancer screening, which is advised for people who do not have symptoms but who:

  • Are between 50 and 80
  • Have a 20 pack-year history of smoking
  • Continue to smoke or quit within the past 15 years
  • Are healthy enough to undergo treatment if lung cancer is found

Knowing the risk factors for lung cancer and getting screened when appropriate can lead to earlier detection, diagnosis, and treatment. Talk to your healthcare provider about whether lung cancer screening would be beneficial and appropriate for you.

If you have any symptoms of lung cancer, such as a persistent cough, shortness of breath, or unexplained weight loss, further tests will be needed.

Physical Examination

When lung cancer is suspected, a healthcare provider will perform a thorough history and physical exam. This is done to evaluate symptoms and risk factors for lung cancer, and to look for any physical signs suggestive of the disease.

These can include:

  • Abnormal lung sounds
  • Enlarged lymph nodes
  • Unintentional weight loss
  • Clubbing of the fingernails (chubby fingernails)

Imaging

A number of different imaging studies may be needed, depending on specific symptoms and findings during an exam. These may include chest X-ray, CT scan, and other imaging.

Chest X-Ray

A chest X-ray is usually the first test performed to evaluate any concerns based on a careful history and physical. This may show a mass in the lungs or enlarged lymph nodes.

Sometimes the chest X-ray is normal and further tests are needed to look for a suspected lung cancer. Even if a mass is found, it may not be cancerous, and further studies are required to confirm its status.

Chest X-ray alone is not sufficient to rule out lung cancer, as it can easily miss early cancers. In fact, about 90% of missed lung cancer diagnoses are due to a reliance on chest X-ray.

What Does a Shadow on an X-Ray Mean?

A spot on the lung (lung lesion) could be benign or malignant. A shadow on an X-ray could be a sign of either or simply represent the overlapping of normal structures in the chest.

CT Scan

A CT scan is frequently done to follow up on an abnormal chest X-ray finding or to evaluate troublesome symptoms in those with a normal chest X-ray.

CT scanning involves a series of X-rays that create a three-dimensional view of the lungs.

If the CT is abnormal, the diagnosis of lung cancer still needs confirmation through examination of a sample of lung tissue.

MRI

For some people, magnetic resonance imaging (MRI) will be used to evaluate the possibility of lung cancer. This procedure uses magnetism without radiation.

Certain individuals, such as those with metal implants (e.g., pacemakers) should not have MRI scans. The technician will ask questions to make sure these are not present.

PET Scan

A positron emission tomography (PET scan) uses radioactive material to create colorful, three-dimensional images of a region of the body. This type of scan differs from the others in that it defines tumors that are actively growing.

A small amount of radioactive sugar is injected into the bloodstream and given time to be taken up by cells. Cells that are actively growing take up more sugar and light up on films.

The test is usually combined with a CT scan (PET/CT).

Some researchers suggest that PET scanning may detect tumors even before they are visible through other studies.

PET scans are also useful for distinguishing between tumors and scar tissue in people who have scarring in their lungs for any reason.

Lung Nodule vs. Mass

lung nodule is considered a spot on the lung that is 3 centimeters (1.5 inches) or less in diameter.
lung mass refers to an abnormality that is larger than 3 centimeters in diameter.

Lung Biopsy

If lung cancer is suspected on imaging studies, the next step is to have a lung biopsy done to determine whether or not the abnormality is truly cancer and, if so, to determine the type of lung cancer.

The biopsy material can be obtained via bronchoscopy, endobronchial ultrasound, fine needle aspiration, thoracentesis, or mediastinoscopy.

When lung cancer spreads, it's important to re-biopsy tissue, as cancers can change in time. These changes can, in turn, help you and your healthcare provider choose the best treatment options.

Bronchoscopy 

In a bronchoscopy, a lung specialist inserts a tube with a scope into the airways to visualize a tumor. A biopsy of any tumor or other abnormalities that are seen may be taken during this procedure.

Bronchoscopy is only used when the tumor is found in the large airways and can be reached using these instruments. Patients are given anesthesia to minimize discomfort.

Endobronchial Ultrasound

Endobronchial ultrasound is a relatively new technique for diagnosing lung cancer.

During a bronchoscopy, healthcare providers use an ultrasound probe within the airway to examine the lungs and area between the lungs (mediastinum).

A biopsy with this imaging may be done when a tumor is relatively close to the airways.

Fine Needle Biopsy

In a fine needle aspiration (FNA) biopsy, a healthcare provider inserts a hollow needle through the chest wall to take a sample of the tumor. A CT is usually done along with this to help the practitioner visualize the process.

This can be performed for tumors that can't be reached by bronchoscopy, especially those that are near the periphery of the lungs.

Thoracentesis

When lung cancer affects the periphery of the lungs, it can cause fluid to build up between the lungs and the lung lining (pleura).

Thoracentesis involves the use of local anesthesia and a large needle to either remove a small amount of fluid from the pleural cavity to test for cancer cells (malignant pleural effusion) or a large amount to improve pain and/or shortness of breath.

Mediastinoscopy

A mediastinoscopy is done in the operating room under general anesthesia. A scope is inserted just above the breast bone (sternum) into the region between the lungs (mediastinum) to take tissue samples from lymph nodes.

These samples can help determine how far a cancer has spread and may provide insight when deciding the best possible treatment options.

A positron emission tomography (PET) scan is a non-invasive way to examine the mediastinum and can now often provide similar results to those obtained from a mediastinoscopy. However, it may not be as effective in detecting cancer in normal-sized lymph nodes, nor does it provide tissue samples.

Labs and Tests

Non-diagnostic tests are frequently performed during the diagnosis of lung cancer as well. These can include:

  • Pulmonary function tests (PFTs): These test lung capacity and can determine how much a tumor is interfering with breathing and, sometimes, whether it's safe to perform surgery.
  • Blood tests: Certain blood tests can detect biochemical abnormalities caused by lung cancers and can also suggest spread of the tumor.

Sputum Cytology

Sputum cytology—the examination of mucus from the lungs under a microscope—is the easiest way to confirm a lung cancer diagnosis and type. However, its use is limited to those tumors that extend into the airways.

Sputum cytology isn't always accurate and can miss some cancer cells. The test is of most benefit when the result is positive, but says little if it's negative.

Molecular Profiling/Gene Testing

It's now recommended that everyone with non-small cell lung cancer—and especially lung adenocarcinoma—have molecular profiling done on their tumor.

This does not diagnose the cancer, but instead confirms characteristics that can help tailor treatment—namely, mutations in cancer cells for which targeted medications are available.

These aren't mutations that you're born with or can pass on. They occur in the process of a cell becoming cancerous and "drive" the growth of cancer.

Targeted treatments are currently approved for people with EGFR mutations, ALK rearrangementsROS1 rearrangements, and a few other mutations. In addition, other treatments are currently being studied in clinical trials.

What Is a Liquid Biopsy?

A liquid biopsy is a test done on a sample of blood to look for cancer cells or pieces of tumor DNA. Most biopsies involve tissue samples, but liquid biopsies allow healthcare providers to monitor some people with lung cancer without invasive procedures.

Currently, they're approved only for detecting EGFR mutations, but they're a good example of how the diagnosis and treatment of lung cancer is improving every year.

PD-L1 Testing

PD-L1 is a protein that's expressed in greater amounts on some lung cancer cells. This protein serves to enhance the "brakes" of the immune system, reducing its ability to fight off cancer cells.

Some cancer cells have found ways to overexpress this protein as a method of hiding from the immune system. Medications known as checkpoint inhibitors work by blocking this action and essentially freeing the immune system to do what it is meant to.

Since the first immunotherapy drug was approved for the treatment of lung cancer in 2015, three additional medications have become available. A PD-L1 test may be done to determine the percent of expression of PD-L1 on your cancer cells which, here too, can help further define the characteristics of your tumor and help guide treatment.

Still, the test's utility is not fully understood. Both lung cancers that overexpress PD-L1 and those that don't may respond to these drugs.

Currently, it's thought that such testing may be cost-effective, but limiting the use of these drugs only to people who have tumors that overexpress PD-L1 could reduce the number of people who would benefit from these treatments.

Identifying Type and Stage

Cytology testing performed on biopsy samples can determine whether lung cancer is present and, if so, the type.

After that, careful staging—figuring out the extent of a lung cancer—is important in designing a treatment regimen. Stages differ by lung cancer type.

Non-Small Cell Lung Cancer

Non-small cell lung cancer (NSCLC) is the most common type, accounting for 80% to 85% of lung cancer diagnoses.

Non-small cell lung cancer is further broken down into three types:

  • Lung adenocarcinoma is the most common type of lung cancer in the U.S. today, responsible for 40% of all lung cancers. It's the most common type of lung cancer found in women, young adults, and in people who don't smoke.
  • Squamous cell carcinoma of the lungs used to be the most common type of lung cancer, but its incidence has dropped. These cancers tend to occur in or near the large airways—the first place exposed to smoke from a cigarette. Lung adenocarcinomas, in contrast, are usually found deeper in the lungs, where smoke from a filtered cigarette would settle.
  • Large cell lung cancer tends to grow in the outer regions of the lungs. These cancers are usually rapidly growing tumors that spread quickly.

There are five stages of non-small cell lung cancer: stage 0 to stage 4.

Small Cell Lung Cancer

Small cell lung cancer (SCLC) accounts for 15% of cases.

It tends to be aggressive and may not be found until it has already spread, especially to the brain. While it usually responds fairly well to chemotherapy, it has a poor prognosis.

Small cell lung cancer is broken down into only two stages: limited stage and extensive stage.

Less Common Types

Other, rarer types of lung cancer include:

Determining Spread

Lung cancer most commonly metastasizes, or spreads, to the liver, the adrenal glands, the brain, and the bones.

Common tests to determine if this has occurred include:

Differential Diagnoses

You may be feeling overwhelmed by what your symptoms could mean and any abnormality your healthcare provider has seen (or may see) on an X-ray or CT scan.

While lung cancer is a possibility, your healthcare provider will consider a variety of conditions when working to make a diagnosis.

Physical symptoms that occur in cases of lung cancer could also occur with:

Likewise, the finding of a mass or nodule on imaging could instead be due to:

Findings of indeterminate pulmonary nodules on CT scan are very common, but the majority of them prove not to be lung cancer.

A Word From Verywell

Knowing what's behind a screening or diagnostic test that turns up a spot, shadow, or nodule on the lung can be daunting—for some, to the point that they don't seek further testing.

While it's true that it could be lung cancer, it's also possible that it may not be. Whatever the cause, early diagnosis is always best. If it does end up being lung cancer, know that the sooner it is caught and treated, the better your chance for survival.

Frequently Asked Questions

  • What are usually the first signs or symptoms of lung cancer?

    The symptoms that are first noticed when someone has lung cancer include persistent cough, coughing up blood, chest pain that worsens with cough or laughing, loss of appetite and unexplained weight loss, fatigue, weakness, shortness of breath, and new onset of wheezing.

  • What does lung cancer look like on diagnostic imaging?

    Lung cancer will show up as a shadow or white spot on the lungs depending on the type of imaging used during diagnosis.

  • What are the survival rates for lung cancer?

    For non-small cell lung cancer, the five-year relative survival rates are 63% for localized cancer, 35% for regional metastasis, and 7% for distant metastasis. For small cell lung cancer, the five-year relative survival rates are 27% for localized, 16% for regional metastasis, and 3% for distant metastasis.

Was this page helpful?
16 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. U.S. Preventive Services Task Force. Screening for Lung Cancer: US Preventive Services Task Force Recommendation StatementJAMA. 2021;325(10):962–970. doi:10.1001/jama.2021.1117

  2. Sarkar M, Mahesh DM, Madabhavi I. Digital clubbing. Lung India. 2012;29(4):354-62. doi:10.4103/0970-2113.102824

  3. Johns Hopkins Medicine. Positron emission tomography (PET).

  4. Schmidt-Hansen M, Baldwin DR, Hasler E, Zamora J, Abraira V, Roqué i Figuls M. PET-CT for assessing mediastinal lymph node involvement in patients with suspected resectable non-small cell lung cancer. Cochrane Database Sys Rev. 2014;2014(11):CD009519. doi:10.1002/14651858.CD009519.pub2

  5. Ojha P, Madan R, Bharadwaj R. Correlation between sputum and bronchoscopy-guided cytology (bronchoalveolar lavage fluid, transbronchial needle aspiration, and bronchial brush) with bronchial biopsy in the diagnosis of pulmonary pathologyArchives of Medicine and Health Sciences. 2019;7(1):25. doi:10.4103/amhs.amhs_135_18

  6. National Cancer Institute. Liquid biopsy.

  7. Aguiar PN, Perry LA, Penny-dimri J, et al. The effect of PD-L1 testing on the cost-effectiveness and economic impact of immune checkpoint inhibitors for the second-line treatment of NSCLC. Ann Oncol. 2017;28(9):2256-2263. doi:10.1093/annonc/mdx305

  8. Bareschino MA, Schettino C, Rossi A, et al. Treatment of advanced non small cell lung cancerJ Thorac Dis. 2011;3(2):122–133. doi:10.3978/j.issn.2072-1439.2010.12.08

  9. Myers DJ, Wallen JM. Cancer, lung adenocarcinoma. StatPearls Publishing. 2019.

  10. Kalemkerian GP, Akerley W, Bogner P, et al. Small cell lung cancerJ Natl Compr Canc Netw. 2013;11(1):78–98. doi:10.6004/jnccn.2013.0011

  11. Milovanovic IS, Stjepanovic M, Mitrovic D. Distribution patterns of the metastases of the lung carcinoma in relation to histological type of the primary tumor: an autopsy study. Ann Thorac Med. 2017;12(3):191-198. doi:10.4103/atm.ATM_276_16

  12. Chest imaging. In: Primer of Diagnostic Imaging. Elsevier; 2011:1-71. doi:10.1016/B978-0-323-06538-2.00001-9

  13. Massion PP, Walker RC. Indeterminate pulmonary nodules: risk for having or for developing lung cancer?Cancer Prev Res (Phila). 2014;7(12):1173–1178. doi:10.1158/1940-6207.CAPR-14-0364

  14. American Cancer Society. Lung cancer signs & symptoms. Updated October 1, 2019.

  15. Purandare N, Rangarajan V. Imaging of lung cancer: Implications on staging and managementIndian J Radiol Imaging. 2015;25(2):109.

  16. American Cancer Society. Lung cancer survival rates. Updated January 29, 2021.

Additional Reading