Back pain that won’t go away? Oncologist Dr George Karimundackal reveals when it could be a sign of lung cancer

Back pain is often blamed on poor posture or long hours at a desk. But when it persists or feels unusual, it could signal lung cancer, says a thoracic surgeon.

Back pain is so common that it is often blamed on a bad mattress, long commute or hours spent at a desk. While most back pain is mechanical and harmless, certain patterns, particularly persistent pain in the upper back or shoulder, may warrant further investigation.

In an interview with HT Lifestyle, Dr George Karimundackal, Director, Thoracic Surgery, Nanavati Max Super Speciality Hospital, Mumbai, explained how back pain can sometimes be an overlooked symptom of lung cancer and when it should not be ignored.

When back pain deserves a second look

“Back pain is so ordinary that we have stopped taking it seriously. A bad mattress, a long commute, ten hours at a desk, there is always an explanation available, and usually it is the correct one. The overwhelming majority of back pain is mechanical and harmless,” said Dr Karimundackal.

He added that pain that is constant and unrelated to posture, becomes worse at night or wakes a person from sleep, progressively intensifies over several weeks, or occurs in the upper or mid-back between the shoulder blades deserves closer attention. Unexplained weight loss, persistent fatigue, loss of appetite or low-grade fever can make these symptoms more concerning.

How lung cancer can cause back or shoulder pain

“Back pain in lung cancer can occur through several mechanisms,” explained Dr Karimundackal. A tumour at the outer edge of the lung can invade the pleura, chest wall or ribs, causing deep and persistent pain. Tumours at the top of the lung, known as Pancoast tumours, can affect the nerves supplying the shoulder and arm.

“Tumours at the very top of the lung, Pancoast tumours, press on the nerves supplying the shoulder and arm, which is why some patients spend months being treated for ‘frozen shoulder’ or ‘cervical spondylosis’ before a chest scan is done,” he said. “Tingling, numbness or weakness in the hand alongside shoulder pain is a particularly important combination.”

Lung cancer can also spread to the spine, where deposits in the vertebrae may cause severe, progressive pain. “Any back pain accompanied by numbness, limb weakness, difficulty walking, or a change in bladder or bowel control is a medical emergency and needs same-day assessment,” he added.

Prolonged sitting is often blamed for back pain, but symptoms like persistent pain or unexplained weight loss may indicate lung cancer. (Pexel)

When should persistent back pain be checked

The widespread assumption that prolonged sitting is responsible for every backache can sometimes delay medical evaluation. “Sedentary work has given us a ready-made diagnosis for every ache, and this has certainly made it easier to normalise symptoms that deserve investigation,” said Dr Karimundackal, adding that self-medication can further mask persistent symptoms.

“My rule of thumb is simple. Back pain that has not improved after four to six weeks of rest, exercise correction and simple analgesia should be evaluated by a doctor. If any red flag is present, night pain, weight loss, neurological symptoms, escalating pain, do not wait six weeks. Go now,” he said.

No cough does not rule out lung cancer

A persistent cough is commonly associated with lung cancer, but its absence does not necessarily mean the disease can be ruled out. “Cough occurs when a tumour involves the larger central airways. A cancer growing in the outer parts of the lung can reach a considerable size without ever irritating an airway, so a patient can have entirely normal breathing and no cough at all,” Dr Karimundackal explained.

Other symptoms can include shoulder or upper back pain, hoarseness, pneumonia that repeatedly affects the same part of the lung, unexplained weight loss, severe fatigue, clubbing of the fingertips, blood clots in the legs, or swelling of the face or neck.

Lung cancer can affect non-smokers too

“Smoking remains the single biggest risk factor, but a substantial and growing proportion of the lung cancer patients I operate on in Mumbai have never smoked, and they are often younger, and more often women,” said Dr. Karimundackal.

He noted that some never-smokers may have mutations such as EGFR or ALK, which can make them candidates for targeted therapies. Other potential risk factors include air pollution, indoor smoke from biomass fuels, second-hand smoke, radon and occupational exposure to asbestos, silica, diesel exhaust and welding fumes. Previous tuberculosis and chronic lung scarring may also contribute to risk.

“‘I never smoked’ is not a reason to skip a chest scan,” he said.

Who should be more vigilant

People over 50, current or former smokers, those with a family history of lung cancer, individuals working in high-exposure occupations and people with pre-existing lung disease should be particularly attentive to unexplained symptoms.

“In this group, unexplained back pain lasting more than a few weeks warrants a chest X-ray at minimum, remembering that a normal X-ray does not exclude cancer,” Dr Karimundackal said. “A CT scan is definitive, and low-dose CT screening for high-risk individuals is the one tool proven to catch lung cancer early enough to cure it.”

Most back pain is not a sign of lung cancer. However, pain that is persistent, progressive, occurs at night or comes with unexplained weight loss or neurological symptoms should not automatically be attributed to poor posture or a sedentary lifestyle.

“If your back pain is not behaving like back pain, ask for a picture of your chest. Most of the time, the scan will be normal, and you will have lost nothing but an hour. Occasionally, it will find a small, operable cancer at a stage when we can still cure it, and that hour will have bought you decades,” Dr Karimundackal concluded.

Dr George Karimundackal is a Surgical Oncologist specialising in Thoracic Surgery, with over 16 years of experience. He completed his MCh in Surgical Oncology from Tata Memorial Hospital and his MS in General Surgery from Seth G.S. Medical College & KEM Hospital.

Note to readers: This article is for informational purposes only and not a substitute for professional medical advice. Always seek the advice of your doctor with any questions about a medical condition.