Warning Symptoms, Physical Signs, and Complications

By Lynne Eldridge, MD 

 Medically reviewed by Doru Paul, MD

The early symptoms of non-small cell lung cancer may include shortness of breath, a cough, shoulder or back pain, and more, but can depend on the subtype of the tumor. There can also be physical signs of the disease, such as a lump above the collar bone or clubbing.

In some cases, the first symptoms of non-small cell lung cancer arise due to complications of the disease, such as blood clots or spinal cord compression. While some of the signs and symptoms are well-known, there are others that may be surprising.

Symptoms and Subtypes

Before discussing the most common symptoms of non-small cell lung cancer, it's important to note that these signs can differ based on the different subtypes of the disease. Non-small cell lung cancer is broken down into three primary types:

• Lung adenocarcinoma (40 percent to 50 percent of cases)

• Squamous cell carcinoma of the lungs (around 30 percent)

• Large cell lung cancer (around 15 percent)

• Carcinoid tumors (roughly 1 percent to 2 percent)

• Other tumors

Squamous cell lung cancers tend to grow near the large airways of the lungs. Symptoms often occur early due to obstruction in the airways that can lead to a cough, or coughing up blood.1

Lung adenocarcinomas and large cell lung cancers, in contrast, tend to grow in the outer regions (periphery of the lungs) and can sometimes grow quite larger before any symptoms occur. The first symptoms with these tumors may only include unintentional weight loss or a vague sensation of shortness of breath.2

Frequent Symptoms

While the most common first symptoms may differ somewhat between subtypes of non-small cell lung cancer, there are a number of symptoms that occur frequently in all.

Persistent Cough

A persistent cough, or a cough that lasts more than eight weeks, is the most common symptom of non-small cell lung cancer, especially squamous cell tumors.3 While often annoying, the cough is often first attributed to something other than lung cancer, such as allergies, dry air, or the tail end of a cold.

Unfortunately, a cough due to lung cancer can appear similar to a cough due to other conditions. Some conditions associated with a cough are COPD, asthma, or tuberculosis and these increase the risk of lung cancer.

Shortness of Breath

Shortness of breath is a common first symptom of non-small cell lung cancer, particularly lung adenocarcinoma.4 This symptom can be challenging to recognize, however, as it's often very subtle at first. Early on, difficulty breathing may only occur with activity and is often dismissed as being due to a lack of exercise, weight gain, or simply age.

Coughing up Blood

Coughing up blood (hemoptysis) is the symptom that was found to be the strongest predictor of lung cancer and is the first symptom of non-small cell lung cancer for 7 percent of people. That said, hemoptysis is present in only a minority of people with the disease, and there are many other potential causes ranging from bronchitis to blood clots.

Back Pain

Back pain occurs in many people with non-small cell lung cancer.5 There are a number of underlying causes including pressure on nerves, direct pressure from a tumor near the spine, or the spread of the cancer to bones. Back pain due to lung cancer can appear similar to other causes of back pain, but there are some characteristics that raise concern.

Warning signs that back pain may be lung cancer-related include pain that is present at rest, pain that worsens when lying down (and increases the longer a person is in bed), and pain that worsens with a deep breath.

Shoulder Pain

While shoulder pain is most often due to another condition, shoulder pain can be a symptom of lung cancer and is sometimes the first symptom.5 Like back pain, lung cancer can lead to shoulder pain in a number of ways. Irritation of the diaphragm or the phrenic nerve at any point as it passes through the chest can lead to shoulder pain. This "referred pain" occurs when the brain interprets the pain as beginning in the shoulder.

Pancoast tumors are a type of lung cancer that arises in tissues at the top of the lungs. Due to their location, they often invade nerves such as the brachial plexus which can lead to shoulder pain. These tumors are often first misdiagnosed for a few reasons. They do not often cause "typical" lung cancer symptoms such as a cough or shortness of breath, and due to their location, they are easily missed on a chest X-ray.

In addition to shoulder pain, symptoms of a Pancoast tumor may include tingling and weakness of the fingers or hands, swelling of the upper arm, and Horner's syndrome; this collection of symptoms may include a droopy eyelid, increased sweating on one side of the face, and a constricted pupil in one eye.6 Shoulder pain may also occur if lung cancer has spread to the bones around the shoulder.

Chest Pain

Chest pain is a fairly common early symptom of non-small cell lung cancer, and even though the lungs themselves do not have pain receptors, people may describe this as lung pain. When lung cancers occur in the outer regions of the lungs near the lung lining (such as with lung adenocarcinomas), pain with deep breathing, or pleuritic chest pain may occur.

Repeated Respiratory Infections

Recurrent respiratory infections such as bronchitis or pneumonia are fairly common before a diagnosis of lung cancer is made.7 Tumors that grow near the large airways can cause an obstruction that raises the risk of infections.

Fatigue

Since tumors such as lung adenocarcinomas can grow quite large before being diagnosed, and fatigue is a common "early" symptom.8 Unlike ordinary tiredness, people often describe cancer fatigue as being "profound fatigue" or exhaustion. It's not the type of tiredness that improves with a cup of coffee or a good night's sleep.

Depression

The link between lung cancer and depression or any cancer depression is fairly clear, but it appears that depression may be an early warning sign of lung cancer as well. A 2018 clinical update noted that for roughly 20 percent of people with non-small cell lung cancer, the onset of depression precedes the diagnosis. It's thought that some lung cancers release inflammatory chemicals such as cytokines that lead to depression.

Blood Clots

Blood clots in the legs (deep vein thromboses) that sometimes break off and travel to the lungs (pulmonary emboli) are unfortunately common with non-small cell lung cancer, and can sometimes be the first sign of the disease. A 2014 study looking at people newly diagnosed with lung cancer found that 13 percent had blood clots, with almost 5 percent having pulmonary emboli.

Symptoms of deep vein thrombosis can include swelling, pain, warmth, and redness of one leg (often the calf) that often increases with bending the foot. When pulmonary emboli occur, a person may develop the sudden onset of shortness of breath, chest pain, palpitations, sweating, coughing up blood, and when severe, loss of consciousness.

Unexplained Weight Loss

Unintentional weight loss, defined as the loss of 5 percent or more of body weight over a 6 month period without trying, can be a sign of lung cancer.9 Though some people may welcome the loss of those pounds, it isn't something to ignore. For three out of four people, the weight loss is due to an underlying medical condition, and when combined with any other symptoms, is thought to be highly predictive of cancer.

Rare Symptoms

There are a number of symptoms that occur less often, but should definitely be evaluated if they occur.

Clubbing

Clubbing is a condition in which the ends of the fingers take on the appearance of upside-down spoons. People may also notice that their fingers feel spongy, or that they are constantly red. While measurements can be done to confirm the presence of clubbing, it's important to talk to your healthcare provider if your fingers and/or nails change in any way. Clubbing is sometimes a normal finding that runs in families, but roughly 90 percent of the time it is a warning sign of underlying lung cancer.10

Hoarseness

Hoarseness is a fairly common symptom of advanced lung cancer but may occur as an early symptom as well. Many people associate hoarseness with a soft or raspy voice, but any change in the volume or pitch of the voice may occur. More common with tumors of the left lung than the right, a hoarse voice occurs when a cancer presses on a nerve that supplies the vocal cords (the recurrent laryngeal nerve).

Wheezing

Wheezing can occur with squamous cell cancers, and is often caused by a tumor invading and obstructing the large airways of the lungs.11

New onset of wheezing, especially in someone who does not have a history of asthma, should always be evaluated.

Swollen Lymph Nodes in the Neck and Upper Chest

For some people, the first sign of non-small cell lung cancer may be due to the spread of the tumor to lymph nodes.3 These may be felt in the neck (cervical lymph nodes), or just above the collarbone (supraclavicular lymph nodes). Nodes that are enlarged due to cancer are often painless and firm, but this can vary.

Face and Neck Swelling

Not immediately obvious as a potential symptom of lung cancer, swelling in the face, neck, and chest may occur due to a complication of non-small cell lung cancer known as superior vena cava syndrome (SVC syndrome), and is sometimes the first sign of the disease.12 SVC syndrome occurs when a tumor (usually cancers near the top of the lungs) pushes on the superior vena cava, the large blood vessel that returns blood from the head, neck, and chest to the heart.

In addition to swelling, people may notice dilated veins in their neck and chest. If the symptoms come on rapidly, it can be a medical emergency.

Paraneoplastic Symptoms

Paraneoplastic syndromes are a collection of symptoms that occur due to hormone or hormone-like substances secreted by a tumor, or by the body in response to a tumor. Symptoms vary widely and may affect the brain and spinal cord, blood cells, electrolytes, and more.

The most common syndromes with non-small cell lung cancer (in contrast to small cell lung cancer) include hypercalcemia with squamous cell carcinoma and carcinoid syndrome (facial flushing, diarrhea, hives, and more) with carcinoid tumors.

Symptoms Due to Metastases

Roughly 40 percent of non-small cell lung cancers are stage IV or metastatic at the time of diagnosis, and for some people, the first symptoms may be related to this spread to distant sites.13 The most common sites of metastases and some symptoms that may occur include:

• Brain metastases: Visual changes, speech changes, weakness, lack of coordination, headaches, seizures, personality changes, nausea and vomiting, and more

• Liver metastases: Abdominal pain, jaundice (a yellowish discoloration of the skin), and itching

• Bone metastases: Bone pain, fractures with only mild trauma (pathological fractures)

• Adrenal gland metastases: Back pain in the mid-back, and abdominal pain

Signs That Others May Notice

Sometimes a family member or friend is the first to notice potential signs of non-small cell lung cancer. These include changes that can be seen visually or heard, such as:

• Coughing

• Coughing up blood

• Wheezing

• Hoarseness

• Weight loss

• Clubbing

• Reduced energy

• Jaundice

• Change in balance or strength

When symptoms develop slowly and gradually, people may be unaware that their symptom is worsening. A friend or family member who does not see the person every day, in contrast, may pick up on these changes over time. For example, when fatigue worsens slowly, people may adapt to the change and not notice the extent.

On the other hand, a loved one who visits infrequently may see someone who has a greatly reduced energy level relative to their last visit.

If you are concerned about possible signs of lung cancer in a loved one, make sure to speak up.

Complications

There are a number of complications that may occur with non-small cell lung cancer. Many of these occur with advanced disease, but since non-small cell lung cancer is often diagnosed in the advanced stages, these complications are sometimes the first symptoms of the disease as well.

Malignant Pleural Effusion

Roughly 40 percent of people with non-small cell lung cancer will develop a malignant pleural effusion at some point in their journey.14 In this condition, fluid builds up in the space between the two membranes surrounding the lungs (the pleural cavity) causing shortness of breath and sometimes a cough or chest pain that varies with position.

Spinal Cord Compression

When lung cancer spreads to bones (bone metastases), it commonly affects the bones in the chest region and the spine. Metastases to the spine can result in pressure on the spinal cord (metastatic spinal cord compression) with symptoms that can include worsening back pain, weakness of the legs, and sometimes loss of bladder or bowel control.15 Spinal cord compression is a medical emergency, and immediate treatment is needed to prevent permanent paralysis.

Blood Clots

As noted earlier, non-small cell lung cancer increases the risk for blood clots, and sometimes they occur even before the diagnosis is made. Treatments for lung cancer such as surgery and chemotherapy further increase the risk.

Hemorrhage from the Lungs (Massive Hemoptysis)

Bleeding into the lungs with consequent coughing up blood—even just a teaspoon or two—can be life-threatening. Coughing up one-third of a cup of blood is referred to as massive hemoptysis and has a high mortality rate.16

Superior Vena Cava Syndrome

SVC syndrome may be the first symptom of lung cancer as noted above but can occur at any time with the disease. The rapid onset of swelling in the face, neck, or chest along with dilated neck veins requires immediate medical care.

Hypercalcemia

An elevated calcium level in the blood (hypercalcemia) may occur for a number of reasons, including metastases to bones, paraneoplastic syndromes, dehydration, kidney dysfunction, and more. Symptoms may include muscle pain, nausea and vomiting, increased thirst, an irregular heart rate, and confusion. If not recognized and promptly treated, it can lead to coma and death.

Febrile Neutropenia

A low white blood cell count due to chemotherapy (chemotherapy-induced neutropenia) can increase the risk of serious or life-threatening infections. Developing a fever while on chemotherapy is usually treated aggressively with broad-spectrum antibiotics.

Suicide

Depression can be an early symptom of lung cancer (inflammatory depression) but can occur at any point during the course of the disease. It's recently been noted that the suicide risk in cancer patients, especially people with lung cancer, is very high.17

While it would seem that advanced tumors and the spread of cancer would be a risk factor, this isn't always true. The highest risk of suicide is soon after diagnosis, even when symptoms are mild or if a tumor is highly curable. It's important for everyone to be familiar with the warning signs of suicide, especially those who have been diagnosed with cancer.

When to See a Healthcare Provider

Lung cancer is more treatable in the early stages of the disease, and unfortunately, the diagnosis is often delayed or misdiagnosed for a lengthy period of time.

It's important to see your healthcare provider if you have any of the signs or symptoms noted above.

When to Seek Urgent Medical Care

With some symptoms, you shouldn't wait to talk to your healthcare provider and should seek immediate assistance or call 911. These include:

• difficulty breathing that is worsening, accompanied by bluish skin or lips (cyanosis), or a respiratory rate higher than 24 breaths per minute at rest

• coughing up even small amounts of blood

• chest pain

• confusion

• a change in your level of consciousness

• severe lightheadedness or fainting

• swelling of your face, neck, or tongue

• new onset leg weakness

• loss of bladder or bowel control

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Kathiresan G, Clement RF, Sankaranarayanan MT. Dyspnea in lung cancer patients: a systematic review. Lung Cancer (Auckl). 2010;1:141-150. doi:10.2147/LCTT.S14426

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Hamilton JG, Long JM, Brandt AC, et al. Patients' Medical and Psychosocial Experiences After Detection of a Variant With Multigene Panel Testing. JCO Precis Oncol. 2019;3 doi:10.1200/JCO.2018.36.15_suppl.e13586

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Patel PH, Sharma S. Wheezing. Treasure Island, Fl: StatPearls Publishing.

Talapatra K, Panda S, Goyle S, Bhadra K, Mistry R. Superior vena cava syndrome: A radiation oncologist's perspective. J Cancer Res Ther. 2016;12(2):515-9. doi:10.4103/0973-1482.177503

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Lei M, Liu Y, Liu S, Wang L, Zhou S, Zhou J. Individual strategy for lung cancer patients with metastatic spinal cord compression. Eur J Surg Oncol. 2016;42(5):728-34. doi:10.1016/j.ejso.2016.01.018

Radchenko C, Alraiyes AH, Shojaee S. A systematic approach to the management of massive hemoptysis. Journal of Thoracic Disease. 2017;9(S10). doi:10.21037/jtd.2017.06.41

Henson KE, Brock R, Charnock J, Wickramasinghe B, Will O, Pitman A. Risk of Suicide After Cancer Diagnosis in England. JAMA Psychiatry. 2019;76(1):51-60. doi:10.1001/jamapsychiatry.2018.3181

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Additional Reading

Pitman, A., Suleman, S., Hyde, N., and A. Hodgkiss. Depression and Anxiety in Patients With Cancer. BMJ. 2-18. 361:k1415. DOI:10.1136/bmj.k1415

Walter, F., Rubin, G., Bankhead, C. et al. Symptoms and Other Factors Associated With Time to Diagnosis and Stage of Lung Cancer: A Prospective Cohort Study. British Journal of Cancer. 2015. 112 Suppl 1:S6-13. DOI:10.1038/bjc.2015.30

Zhang, Y. et al. Prevalence and Association of VTE in Patients with Newly Diagnosed Lung Cancer. Chest. 2014. 146(3):650-8. DOI: 10.1378/chest.13-2379

Zhu, X., Xing, Y., Wang, L. et al. Clinical Symptoms and Physical Signs for Non-Small Cell Lung Cancer Patients in China: A Nation-Wide Multicenter 10-Year Retrospective Study. Journal of Clinical Oncology. 2018. 36(15_suppl):e13586. DOI:10.1200/jco.2018.36.15_suppl.e13586

By Lynne Eldridge, MD
 Lynne Eldrige, MD, is a lung cancer physician, patient advocate, and award-winning author of "Avoiding Cancer One Day at a Time."