How Lung Cancer Is Diagnosed

Lung cancer is often missed on an initial chest X-ray and other tests are needed to make a diagnosis when lung cancer is suspected. A tissue sample, or lung biopsy, and images such as a chest computed tomography (CT) scan, are among the tests used to confirm a cancer and any needed next steps for treatment.

This article discusses the types of lung cancer and tests commonly used to make a diagnosis. It explains who should be screened for lung cancer and what the results of any tests typically mean.

Lung Cancer Diagnosis - Illustration by Hugo Lin

Verywell / Hugo Lin

Who Should Be Checked for Lung Cancer?

Anyone with symptoms of lung cancer should be tested. It's also important for people who have risk factors for the disease to be screened. Lung cancer screening 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 have quit within the past 15 years
  • Are healthy enough to undergo treatment if lung cancer is found


Physical Examination

When lung cancer is suspected, a healthcare provider will perform a thorough history and physical exam. This is done to evaluate risk factors, such as radon exposure or a smoking history.

It also is used to investigate symptoms of lung cancer, such as a cough or unexplained weight loss.

Other findings from the exam may include:

Imaging

Your healthcare provider may want imaging studies done. This will depend on the specific symptoms and findings of your exam. These tests may include chest X-ray, CT scan, and other imaging.

Chest X-Ray

When lung cancer is suspected, the first test done is usually a chest X-ray. This may show a mass of abnormal cells in the lungs, or a smaller spot called a lung nodule. Lymph nodes, which are a key part of your immune system, may appear enlarged on an X-ray.

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

Sometimes the chest X-ray is normal and further tests are needed to look for lung cancer. Or, a shadow on a lung X-ray could mean there is a spot on the lung. It also could be a normal part of a person's chest.

Even if a mass does appear on X-ray, it may be benign and not related to lung cancer. Your healthcare provider will want additional tests to confirm any diagnosis.

A chest X-ray alone is not enough to rule out lung cancer. In fact, about 90% of missed lung cancer diagnoses are due to a reliance on chest X-rays.

Recap

When you have symptoms that may be lung cancer, your healthcare provider will do a thorough exam to evaluate your concerns. It's likely that a chest X-ray will be needed to get a first look at your lungs, though this imaging isn't enough for diagnosis.

CT Scan

A CT scan is frequently done to follow up on an abnormal chest X-ray finding. Even when chest X-ray findings are normal, it can be used to further evaluate symptoms that may be associated with lung cancer.

CT scans are done by using a series of X-rays to create a three-dimensional view of the lungs. This approach allows your healthcare team to look at the lungs from more than one angle.

If the CT is abnormal, the diagnosis of lung cancer will still need to be confirmed. This is done through a biopsy, which is used to examine a sample of lung tissue.

MRI

For some people, magnetic resonance imaging (MRI) will be used to evaluate the possibility of lung cancer. The MRI can deliver high-quality images of what's going on inside the body.

It's based on a process that uses radio waves and a magnetic field to create the images. For this reason, some people may need to avoid having an MRI.

They include people with older metal implants, such as heart pacemakers, although newer devices are designed to be safe for MRIs.

PET Scan

A positron emission tomography (PET scan) uses radioactive material approved for medical use. A PET scan will create a colorful, three-dimensional image of the lungs.

What's different is that a PET scan is used to evaluate a tumor, or tumors, that are actively growing. PET scans also can help to show the difference between tumors and scar tissue in people who have scarring in their lungs.

This test is usually combined with a CT scan (PET/CT). Some studies suggest that PET scanning may detect tumors even before they are visible through other studies.

Recap

Imaging tests often used to help diagnose lung cancer include the CT scan and MRI. The PET scan is used to assess an existing tumor, often along with a CT scan. It may be able to identify tumors earlier than other imaging techniques do.

Lung Biopsy

If lung cancer is suspected on imaging studies, the next step is to have a lung biopsy done.

A biopsy relies on a tissue sample that's removed from where the lung cancer is suspected. These cells are then evaluated in a laboratory by a pathologist, who uses a microscope to see if they are cancerous or not. The biopsy also can reveal what type of cancer cells they are.

If lung cancer is diagnosed and spreads, other biopsies may be needed. This is done to evaluate how a cancer is changing over time and to make the most of treatment options as it does.

Removing the tissue for a biopsy can be done through several procedures discussed below.

Bronchoscopy 

In a bronchoscopy, a lung specialist inserts a tube with a lighted scope into the airways to see a tumor. If they see abnormal tissues, the biopsy may be taken during this procedure.

Bronchoscopy is only used in the large upper airways that lead to the lungs, when a tumor there can be reached by using these devices. Patients are given anesthesia to minimize discomfort.

Endobronchial Ultrasound

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

During a bronchoscopy, healthcare providers use an ultrasound probe within the airway to examine the lungs. They also look at the mediastinum, an area of the body that's between the lungs.

If a tumor is relatively close to the airways, a biopsy can be done by using this technique.

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 provider find the precise site while doing the biopsy.

This type of biopsy can be done when tumors can't be reached by other techniques. It's especially useful for tumors found near the periphery, or along the outer edges, 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. This lining is called the pleura, and the space is called the pleural cavity.

Thoracentesis is done by using a large needle to remove a small amount of fluid from this space. This fluid is then tested for cancer cells.

The procedure also can be done to remove a large amount of fluid in people experiencing pain or shortness of breath. In either case, anesthesia is used at the site to keep the person comfortable.

Mediastinoscopy

A mediastinoscopy is done in the operating room under general anesthesia, meaning that a person is fully sedated. A scope is inserted just above the sternum, or breast bone, into the mediastinum in order to take tissue samples from lymph nodes.

These samples can help to determine how far a cancer has spread. This may help your healthcare team to better understand the best possible treatment options.

A PET scan also can be used to look at the mediastinum. It will often provide similar results while avoiding the need for an invasive surgical procedure.

However, the PET scan may not be as effective in detecting cancer in normal-sized lymph nodes. It also cannot be used to provide biopsy tissue samples.

Recap

A biopsy, or tissue sample, is done to verify a lung cancer diagnosis. There are several methods, such as bronchoscopy or fine needle aspiration, used to complete this test. The sample cells are viewed under a microscope to confirm lung cancer and its type.

Labs and Tests

During the diagnosis of lung cancer, other tests may be done as well. These are for related reasons but not a part of a diagnosis itself. The tests can include:

  • Pulmonary function tests (PFTs): These are used to test lung capacity. They can help to determine how much a tumor interferes with your breathing. They also may be used to see if a specific type of surgery will be safe to do.
  • Blood tests: Certain blood tests can detect abnormal changes in chemicals that are made in the body. These changes are caused by lung cancers and can also suggest spread of the tumor.

Sputum Cytology

Sputum cytology involves looking at mucus from the lungs under a microscope. It is the easiest way to confirm a lung cancer diagnosis and type. However, its use is limited to lung cancer cases where the tumors extend into the airways.

Sputum cytology isn't always accurate and it can miss some cancer cells. The test is of most benefit when the result is positive. It is less reliable when the test is negative.

Gene Testing

Gene testing, sometimes called molecular profiling, is often used to understand the changes that occur with specific cancers. These changes, or mutations, won't actually diagnose the cancer.

Rather, they are used to identify specific genes that may be involved. These aren't mutations that you're born with or can pass on. They change as cancer develops and continue to drive its growth.

For example, it's now recommended that people diagnosed with non-small cell lung cancer, and especially the lung adenocarcinoma type, have genetic testing.

This is because treatments that target specific genetic changes may be of benefit.

These targeted therapies are currently approved for people with EGFR mutations, ALK rearrangementsROS1 rearrangements, and a few other mutations. Other treatments are currently being studied in clinical trials.

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.

They can't be used in all cases but are a good example of how the diagnosis and treatment of lung cancer is evolving.

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 manipulate this protein to evade the immune system. Drugs known as checkpoint inhibitors work by blocking this action. They free the immune system to do what it is meant to do.

A PD-L1 test may be done to measure the PD-L1 levels related to your cancer cells. The results may be used to determine if you may benefit from treatment with any of these immunotherapy drugs. However, the understanding of how they work and who might be treated is still limited.

Recap

As part of a lung cancer diagnosis, you also may need other tests related to your condition. Genetic testing, for example, can help to determine if certain targeted therapies may be a part of your treatment plan. Blood tests may help to confirm how much the cancer has spread.

Identifying Type and Stage

Once the tests to confirm a cancer diagnosis are complete, it's important to identify the type and stage of the cancer. This tells you much about how aggressive a cancer might be or how far it has spread. This is essential for your healthcare team to develop the best possible treatment plans.

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 type of lung cancer often found in women, young adults, and in people who don't smoke.
  • Squamous cell carcinoma of the lungs tends 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 used to see if your cancer has spread may include:

  • CT scan of the abdomen to check for spread to the liver or adrenal glands
  • MRI of the brain to look for spread to the brain
  • Bone scan to test for spread to bones, especially the back, hips, and ribs
  • PET scan to look for the spread of cancer elsewhere in the body. A PET scan may replace some or all of the other tests listed above.

Recap

Once you have a confirmed lung cancer diagnosis, other tests will be used to see how far the cancer has spread and assign its stage. These stages are assigned depending on the type of lung cancer.

Differential Diagnoses

Your healthcare provider will consider other possibilities when working to make a diagnosis. Some of the physical symptoms common to lung cancer also might occur with conditions such as:

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

  • Pneumonia
  • Fungal or parasitic infections
  • Empyema or abscess, a pus-filled infection in the lung
  • Benign lung tumor (pulmonary hamartoma) that isn't cancer
  • Granuloma, a small area of inflammation, and related infections
  • Round atelectasis (partial lung collapse)
  • Cysts in the bronchi
  • Lymphoma, a cancer that affects the lymphatic system
  • Cancer spread from another part of the body

It's common for CT scan results to show lung nodules of an unknown cause. The majority of them prove not to be lung cancer.

Summary

A lung cancer diagnosis is typically made through a series of tests. These tests often begin with a chest X-ray and a physical exam to discuss your symptoms with your healthcare provider.

What's key to know is that the chest X-ray itself cannot diagnose a lung cancer. In fact, many lung cancers are missed on a chest X-ray. So other tests, including the CT, MRI, and PET are used to better evaluate a lung spot or other abnormality.

If needed, a biopsy is then done to confirm a lung cancer diagnosis and what type it is. Other tests are used to stage the cancer and evaluate its spread, and to help develop a treatment plan. As you progress through treatment, some tests may be used to reassess the cancer.

A Word From Verywell

When your tests show a lung spot, shadow, or nodule, it may seem alarming. It's important to follow through to a diagnosis. Even if it is cancer, your chances of survival are better the sooner that you know.

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?
22 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. Molassiotis A, Smith JA, Mazzone P, et al. Symptomatic treatment of cough among adult patients with lung cancer: CHEST guideline and expert panel reportChest. 2017;151(4):861-874. doi:10.1016/j.chest.2016.12.028

  3. Ciello A del, Franchi P, Contegiacomo A, Cicchetti G, Bonomo L, Larici AR. Missed lung cancer: when, where, and why? Diagn Interv Radiol. 2017;23(2):118-126. doi: 10.5152/dir.2016.16187

  4. National Cancer Institute. Computed tomography (CT) scans and cancer.

  5. Gupta S, Ya’qoub L, Wimmer A, Fisher S, Saeed I. Safety and clinical impact of MRI in patients with non–MRI-conditional cardiac devicesRadiol Cardiothorac Imaging. 2020;2(5):e200086. doi:10.1148/ryct.2020200086

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

  7. Mclean AEB, Barnes DJ, Troy LK. Diagnosing lung cancer: The complexities of obtaining a tissue diagnosis in the era of minimally invasive and personalised medicineJ Clin Med. 2018;7(7):163. doi:10.3390/jcm7070163

  8. Jalil BA, Yasufuku K, Khan AM. Uses, limitations, and complications of endobronchial ultrasoundProc (Bayl Univ Med Cent). 2015;28(3):325-30. doi:10.1080/08998280.2015.11929263

  9. 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

  10. 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

  11. National Cancer Institute. Targeted Therapy to Treat Cancer.

  12. National Cancer Institute. Liquid biopsy.

  13. 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

  14. American Cancer Society. What is lung cancer? 

  15. National Cancer Institute. Non-Small Cell Lung Cancer Treatment (PDQ®)-Health Professional Version.

  16. Smolle E, Pichler M. Non-smoking-associated lung cancer: A distinct entity in terms of tumor biology, patient characteristics and impact of hereditary cancer predispositionCancers (Basel). 2019;11(2):204. doi:10.3390/cancers11020204

  17. 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

  18. 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

  19. 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

  20. American Cancer Society. Lung cancer signs & symptoms.

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

  22. American Cancer Society. Lung cancer survival rates.

Additional Reading