Lung cancer is one of the most common cancers worldwide and is often associated with significant physical, emotional, and social challenges. Before treatment even begins, many patients already experience a reduced quality of life due to the disease itself and related risk factors. Understanding these causes and risks is important for doctors to plan holistic treatment strategies and for patients to prepare for the journey ahead.

Biological and Clinical Factors

1. Stage of disease at diagnosis: Advanced lung cancer patients often present with severe symptoms like breathlessness, cough, hemoptysis, and pain that immediately lower QoL.

2. Comorbidities: Conditions such as chronic obstructive pulmonary disease (COPD), ischemic heart disease, hypertension, and diabetes compound the burden.

3. Nutritional status: Malnutrition and cancer-related cachexia contribute to fatigue, weakness, and poor immunity.

4. Age and frailty: Older adults generally have reduced physiological reserve, affecting treatment tolerance and recovery.

Lifestyle and Environmental Factors

1. Tobacco smoking: Not only the primary cause of lung cancer but also contributes to chronic respiratory dysfunction.

2. Alcohol consumption: Heavy drinking worsens immunity and nutrition.

3. Pollution and occupational hazards: Prolonged exposure to asbestos, silica, or fine particulate matter increases lung damage before therapy begins.

4. Physical inactivity: A sedentary lifestyle reduces lung capacity and resilience.

Psychosocial and Emotional Factors

1. Emotional distress: Nearly half of newly diagnosed patients report depression, anxiety, or denial, all of which affect QoL.

2. Financial toxicity: The high cost of cancer care-especially in countries without universal health coverage-can devastate families.

3. Social support: Patients lacking caregivers or community backing often feel isolated.

4. Stigma: Particularly among smokers, feelings of guilt and blame further damage emotional well-being.

Health System-Related Risks

1. Delayed diagnosis: Inadequate screening and late referrals mean patients often arrive at treatment with advanced symptoms.

2. Limited access to palliative care: In many regions, supportive care is not integrated early enough.

3. Cultural barriers: In some cultures, patients are shielded from full disclosure of their diagnosis, which can prevent early psychological adjustment.

Before starting cancer treatment, many lung cancer patients already suffer from a diminished quality of life (QoL). This decline results from both the cancer itself and related physical, psychological, and social burdens. Recognizing these symptoms and signs early is crucial for doctors, patients, and caregivers to implement timely interventions that improve the patient's overall well-being before treatment begins.

Physical Signs

1. Dyspnea (shortness of breath): One of the most distressing symptoms, limiting physical activity and independence.

2. Chronic cough and chest pain: Affect sleep and daily comfort.

3. Severe fatigue: A hallmark symptom of cancer and predictor of poor survival.

4. Weight loss and cachexia: Reflect metabolic imbalance and nutritional depletion.

5. Frequent infections: Indicate compromised immunity.

Psychological and Emotional Signs

1. Depression and hopelessness: Common at diagnosis, often reducing treatment adherence.

2. Anxiety and fear: About treatment side effects, prognosis, and family responsibilities.

3. Cognitive impairment or “chemo brain” anticipation: Some patients already fear memory and focus issues before therapy.

Functional and Social Signs

1. Reduced ability to perform daily tasks: Walking, cooking, self-care may already be compromised.

2. Dependence on caregivers: Loss of autonomy worsens distress.

3. Social withdrawal: Patients may avoid gatherings due to cough or appearance concerns.

4. Financial stress: Visible in discussions about work, insurance, or treatment affordability.

These symptoms not only affect quality of life but also serve as red flags for poorer prognosis if left unaddressed.

Diagnosing pretreatment quality of life (QoL) in lung cancer is a crucial step in understanding how the disease and its anticipated treatments will affect the overall well-being of the patient. The process combines clinical, psychological, and functional assessments to identify baseline health status and anticipate risks during treatment.

Clinical Evaluation

1. General physical exam: Weight, BMI, nutritional state.

2. Pulmonary function tests: Spirometry, oxygen saturation, exercise tolerance.

3. Performance scales:

   1. ECOG (Eastern Cooperative Oncology Group): Ranges from 0 (fully active) to 5 (dead).

   2. Karnofsky Performance Status (KPS): Scores from 0-100 assessing ability to carry out daily activities.

Patient-Reported Outcome Measures (PROMs)

1. EORTC QLQ-C30 and LC13: Internationally validated lung cancer-specific tools.

2. FACT-L (Functional Assessment of Cancer Therapy - Lung): Measures symptoms, function, and emotional well-being.

3. EQ-5D-5L: Covers mobility, self-care, usual activities, pain/discomfort, and anxiety/depression.

Psychological and Social Assessment

1. Hospital Anxiety and Depression Scale (HADS).

2. Distress Thermometer: A quick screening tool used in oncology clinics.

3. Social support mapping: Identifying caregivers, family support, and community resources.

Integrative Assessment

1. Combining PROMs with lab values, imaging results, and psychosocial assessment provides the most accurate baseline.

2. Increasingly, digital health platforms allow real-time QoL tracking through apps and wearables, enabling early intervention.

Lung cancer treatment is no longer about attacking the tumor alone-it is about managing the whole patient. Pretreatment quality of life (QoL) plays a central role in determining which treatment options are suitable, safe, and effective for each individual. A patient's physical condition, psychological resilience, social support, and functional independence must all be assessed before starting therapy. This ensures that the chosen treatment not only extends life but also maintains dignity, comfort, and well-being.

Surgical Management

1. Candidates with good QoL and lung reserve may undergo lobectomy or pneumonectomy.

2. Prehabilitation (exercise, nutrition) is recommended to improve candidacy.

3. Poor baseline QoL predicts higher surgical complications and longer hospital stays.

Chemotherapy

1. Still standard for advanced cases.

2. Patients with poor baseline QoL are more prone to dose-limiting toxicities.

3. Supportive interventions (nutrition, psychological care) can improve tolerance.

Radiotherapy

1. Often used in non-surgical candidates.

2. Fatigue and esophagitis worsen if baseline QoL is already low.

3. Combining radiotherapy with QoL monitoring allows timely supportive care.

Targeted Therapy and Immunotherapy

1. Molecularly guided therapies often have better side-effect profiles.

2. Patients with higher pretreatment QoL show better adherence and improved long-term outcomes.

Palliative and Supportive Care

1. For patients with very low QoL or advanced disease.

2. Focuses on symptom relief, dignity, and family support rather than cure.

3. Early palliative care integration has been proven to extend survival in lung cancer while improving QoL.

The period before starting lung cancer treatment is often filled with uncertainty, anxiety, and physical challenges. This “pretreatment” stage can have a significant impact on a patient's overall quality of life (QoL), which in turn influences treatment tolerance, outcomes, and long-term survival. Effective prevention and management strategies during this critical time can reduce stress, improve resilience, and prepare patients both physically and emotionally for the journey ahead.

Preventive Strategies to Protect Pretreatment Quality of Life

1. Early Screening and Timely Diagnosis