Lung Cancer


A mostly preventable disease

Lung cancer is the leading cause of cancer deaths in the U.S. in both men and women. It mostly occurs in people ages 45 to 70. Often, the disease can be prevented by avoiding sources of carcinogens (cancer-causing chemicals), chiefly smoking, which is responsible for 90% of lung cancers (smokers are exposed to 2,000 known carcinogens from tobacco smoke). Even with early detection, the cure rate for lung cancer is quite discouraging -- only about 13% are cured completely.

In the early stages of lung cancer, no symptoms may show. As the disease progresses, warning signs may include persistent coughing with bloody sputum or phlegm, shortness of breath, wheezing, fever, loss of appetite, and weight loss. Surgical removal of the tumor, radiation therapy, and chemotherapy are the general treatments for lung cancer. The type of treatment prescribed depends on the size, type and location of the tumor, as well as your age and overall health.

Synonyms

    • Primary lung malignancy
    • Bronchogenic carcinoma
    • Carcinoma of lung

Detailed Description

Lung cancer is broadly defined into two types: small cell or non-small cell cancers.

Small cell cancer makes up about 25% of all lung cancer cases. This type of cancer is also called oat cell cancer because under the microscope, the cells look like oats. The cells are small, but they can multiply fast and create large tumors, as well as spread to the lymph nodes and other organs in the body. In fact, small cell cancer is the most aggressive form of lung cancer. By the time symptoms appear, the cancer has most likely spread throughout the body via the bloodstream. Although it almost always responds to chemotherapy and radiation, it also almost always recurs. This form of cancer often appears in smokers or former smokers.

Non-small cell cancer is more common, making up about 75% of lung cancer cases. It often affects former smokers, or those exposed to passive smoke or radon. Non-small cell cancer can be divided into four types, some which grow faster than others:

    • Adenocarcinoma: One of the most common forms of lung cancer in the United States, adenocarcinoma is linked to scarring in the lung caused by infections such as tuberculosis. Because this cancer usually develops in the outer edges of the lung, it is more likely to invade the lung lining and produce fluid in the chest cavity. Often, no symptoms appear until the later stages. Adenocarcinoma commonly metastasizes (spreads) to the other lung, or to the brain, spinal cord, bone, adrenal glands, and liver.
    • Squamous cell carcinoma: This is the second most common type of lung cancer. It is most often found in the bronchi, the large central air passages of the lung. Because this type of cancer is located in the airways, it produces earlier symptoms, such as coughing with bloody sputum, wheezing, and shortness of breath. It is one of the easier cancers to detect, through a sputum (phlegm) test. It grows slowly but easily metastasizes.
    • Large cell carcinoma: This cancer occurs in 10% of the non-small cell cases. It lacks definitive structural characteristics, and may be hard to distinguish from secondary lung cancer. It frequently grows near the pleura (lung lining), and, like adenocarcinoma, it tends to spread beyond the lung.
    • Bronchioalveolar cell carcinoma: This type of cancer begins in the alveoli, or air sacs, in your lung, and represents 5% of lung cancer cases. It seldom spreads beyond the lungs. If discovered early (when the tumor is still a single mass), this type of lung cancer has a good outlook for recovery. After the tumor is removed surgically, the five-year survival rate is between 75% and 90%. However, prognosis is poor if the cancer has spread beyond a single mass.

Besides the small cell and non-small cell categories, lung cancer also can be described as primary lung cancer or in terms of lung metastasis connected to another primary cancer (such as breast cancer). With primary lung cancer, the disease originates in the lungs. In secondary cancers, the disease starts in another part of the body, most commonly the breast, colon, kidney, prostate, or thyroid, then spreads to the lungs.

Surgical removal of the tumor, radiotherapy, and chemotherapy are common treatments for lung cancer. However, even with early detection, the prognosis for lung cancer is usually not very good. At the time of diagnosis, only 15% of all lung cancer patients will have a localized disease (meaning the cancer remains confined to the lung), while 25% will have disease that has spread to regional lymph nodes, and more than 55% will have a distant spread. Even in patients with the localized disease, the five-year survival rate is only 47%. For patients with the regional disease (which means lymph nodes are involved), the five-year survival rate is 2% to 30%, depending on the stage to which the cancer has progressed.

Fortunately, you can cut your risk of lung cancer considerably by avoiding exposure to carcinogens. Tobacco smoke has 2,000 known carcinogens, which places smokers at a very high risk. Exposure to secondhand smoke also increases your risk. Other known carcinogens of the lungs are asbestos, radon, chloromethyl ether, heavy metals (nickel, chromate), coal tar, copper radioactive materials, and arsenic. Some possible causes and risk factors for lung cancer that have not been fully established include living in urban areas, genetic predisposition, lung scars, and chronic obstructive pulmonary disease.

Characteristics of Lung Cancer

    • Leading cause of cancer death in the United States for both sexes
    • Often no symptoms in the early stages
    • Later stage symptoms include coughing, wheezing, and weight loss
    • Primary cause is tobacco smoking
    • May also be caused by other lung carcinogens
    • The cancer often metastasizes to other parts of the body
    • Prognosis outlook not good even with early detection
    • Usually treated with surgery, radiotherapy, and chemotherapy
    • Can be prevented effectively by avoiding exposure to lung carcinogens

How Common Is Lung Cancer?

Lung cancer is the leading cause of cancer death in the United States. It is also the most common form of noncutaneous (non-skin) cancer. It is responsible for 32% of cancer deaths in men, and 25% in women. About 180,000 new cases arise each year. The predominant age group is 45 to 70 years. Lung cancer is more common among men, but women's rates are catching up. The ratio of men to women is 10 to 7.

What You Can Expect

Lung cancer generally develops gradually. The early stages usually display no symptoms. Early detection can improve survival rates for some forms of lung cancer, but not for others. Many factors determine the type of treatment and long-term survival rate. They include the size, location, type, involvement of lymph nodes, and whether the cancer has metastasized. Generally, cancer is staged according to the following criteria:

    • Stage I: The tumor is small and confined to the lung. There is no sign of lymph node involvement, and no sign of cancer having spread to other parts of the body.
    • Stage II: The tumor is larger, and there is some local spread. Lymph nodes in the immediate vicinity are involved, but no sign of spread to distant parts of the body.
    • Stage III: The size of the tumor may vary, but it has spread all around the local regions (i.e., lining of the lung or heart). Distant lymph nodes within the chest are involved as well, but still no sign of spreading to distant parts of the body.
    • Stage IV: The size of the tumor may vary, but it has invaded other organs close by. Lymph nodes are involved and the cancer has spread to distant parts of the body as well.

Surgical removal of the tumor is the only treatment that may offer a complete cure. For non-small cell cancer, if it has not spread and does not involve lymph nodes, the five-year survival rate after surgery is 47%. If cancer has spread, the survival rate decreases. If your cancer (usually small cell lung cancer) is not suitable for surgery (unresectable), the prognosis is poor -- survival rate is less than 2%. Unfortunately, secondary lung cancer is almost always incurable.

Established Causes

The established cause for primary lung cancer is exposure to lung carcinogens. With certain less common lung cancers, no risk factors may be involved and the cause is unknown. If cancers develop in other parts of the body besides the lung, the lung is a common site for the cancer to spread. This is called a secondary lung cancer.

Lung carcinogens include:

    • Tobacco/marijuana smoking
    • Secondhand smoke
    • Heavy metals
    • Asbestos
    • Industrial carcinogens (chloromethyl ether)
    • Air pollutants
    • Radon

Theoretical Causes

Unsupported theoretical causes include genetic links.

Risk Factors

Many of the risk factors involve carcinogens that are preventable or avoidable:

    • Tobacco/marijuana smoking
    • Secondhand smoke
    • Heavy metals
    • Asbestos
    • Industrial carcinogens (chloromethyl ether)
    • Air pollutants
    • Radon
    • Family history of lung cancer
    • Lung scarring
    • Chronic obstructive pulmonary disease

Risk factors are traits or behaviors that may make you statistically more likely than others in the general population to have a certain condition. They are not necessarily "causes" of the condition.

Symptoms

Lung cancer often shows no symptoms in the early stages. As the disease advances, the following symptoms may appear. If you have any of these warning signs, see your doctor right away.

    • A cough that lasts and worsens with time
    • Persistent chest pain
    • Blood-streaked sputum (phlegm), or coughing up blood
    • Wheezing, shortness of breath
    • Hoarseness
    • Frequent bouts of pneumonia or bronchitis
    • Swelling of face and neck
    • Loss of appetite
    • Weight loss
    • Weakness and fatigue
    • Unexplained fever

If lung cancer spreads to the brain, bones, liver, heart or other organs, several other symptoms may appear, including trouble with swallowing, pain and weakness in the arm, bone pain, seizures, confusion, headaches, and dizziness.

Conditions That May Be Mistaken for Lung Cancer

The following conditions may be confused with lung cancer because of similar symptoms:

    • Asthma
    • Congestive heart failure
    • Tuberculosis
    • Fungal infections
    • Bronchitis (chronic)
    • Lung abscess
    • Benign tumors of the lung (such as hamartomas)
    • Emphysema

How Lung Cancer Is Diagnosed

Early detection may improve your chances of surviving lung cancer. In a small number of cases, a chest X-ray taken for other health reasons happens to reveal the presence of lung cancer.

Unfortunately, because of the lack of early warning signs, lung cancer is more commonly diagnosed at a later stage, when the cancer is harder to treat. About 75% to 90% of patients are diagnosed in the later stages.

To diagnose lung cancer, your doctor may do the following:

    • Medical history and physical exam: Your doctor will ask about your family and medical history, and whether you've ever smoked or been exposed to substances that can cause lung cancer. He or she will also perform a physical exam.
    • Chest X-ray: A chest X-ray can detect most lung tumors, although it may miss small ones. The tumor may show up as a shadow on the X-ray film, but only a biopsy can yield a firm diagnosis of lung cancer.
    • Sputum cytology: A sample of mucus coughed up from your lungs will be checked under a microscope for cancer cells.
    • Biopsy: A biopsy, in which lung cells, tissues, or fluid are removed and checked under a microscope for cancer, is the only way to make a sure diagnosis of lung cancer. There are several ways to obtain a biopsy sample from the lung:

      • Bronchoscopy: A long, flexible, lighted tube called a bronchoscope is inserted through the mouth or nose and into the windpipe. The doctor can see the inside of the bronchial tubes, and he or she can gather tissue samples through the tube. You'll be given a local anesthetic in the back of the throat before the procedure begins, although in some cases, general anesthesia may be used. If you're awake, you may feel some pressure during the procedure, but probably not pain.
      • Needle aspiration: Under the guidance of computed tomography (CT), the doctor inserts a thin needle through the chest to draw a tissue sample from the lung tumor. Often, needle aspiration is done when the doctor needs tissue from a part of the lung that can't be reached with a bronchoscope. You'll be given a local anesthetic.
      • Thoracentesis: A needle is inserted to remove a sample of pleural fluid from the lining that surrounds the lungs.
      • Thoracotomy: In some cases, surgery to open the chest may be needed to diagnose lung cancer. This is a major operation that requires hospitalization.

Staging Lung Cancer

If your doctor diagnoses lung cancer, you'll need more tests to check whether the cancer has spread (metastasized) to nearby lymph nodes or to other sites in the body. These "staging" tests are crucial to helping your doctor assess your chances of recovery and to plan the best treatment for you.

Several imaging techniques are used to stage lung cancer:

    • Mediastinoscopy/mediastinotomy: These procedures allow a doctor to take tissue samples from lymph nodes along the windpipe to check for the spread of cancer. Both methods involve inserting a lighted viewing scope into the chest while you're under general anesthesia. In mediastinoscopy, the scope is placed into a small neck incision; in mediastinotomy, the incision is made in the chest. The tissue samples are removed through the viewing scope.
    • Before mediastinoscopy, your doctor may use other imaging tests, such as CT (computed tomography) and MRI (magnetic resonance imaging) scans, and radionuclide scanning to check for the spread of lung cancer to the brain, bones, adrenal glands, liver, or other parts of the body. Small-cell cancer often spreads to the bone marrow, so if you have this form, you may also need a bone marrow biopsy.


Goals of Treatment

If lung cancer is found before it spreads beyond the lung (Stage I), surgery can remove the tumor and provide a cure in some cases. When surgery is done at this early stage, the one-year survival rate is 80%, the five-year survival rate, 47%. Unfortunately, few cases are detected in the early stages because the disease often shows no symptoms until later. When all cases of lung cancer are taken into account, only 13% of people are still alive five years later.

While early detection and surgery may provide a cure, overall, lung cancer is a difficult cancer to treat. The main therapies for lung cancer are surgery, radiation therapy, and chemotherapy. How well these treatments work depends on the type and extent of the cancer, as well as its responsiveness to radiation and chemotherapy. The more aggressive and widespread the cancer, the harder it is to treat. Small-cell cancers are tougher to treat than non-small cell cancers because, although they respond to treatment, they tend to spread quickly.

During treatment, your doctor and other healthcare providers will attempt to destroy the tumor and to rid your body of any remaining cancer cells. You may also need treatment to prevent the cancer from spreading or recurring. In cases in which a cure isn't possible, your doctors will strive to relieve your symptoms and to slow the progression of the disease.

Follow-up appointments with your doctor after cancer treatment is important to make sure the cancer doesn't recur. If it does come back, the outlook is usually poor. The cancer may not be curable, but radiation or chemotherapy may prolong life and ease pain and other symptoms.

Treatment Overview

The type of treatment you receive depends on many factors, including your age, general health, and the type and stage of cancer you have. Non-small cell lung cancer and small cell lung cancer are treated in different ways.

Non-small cell lung cancer

If caught in the early stages, non-small cell cancer can be treated with chemotherapy, radiation therapy, or surgery. If non-small cell cancer has spread, chemotherapy may also be used.

Small cell lung cancer

This fast-growing type of lung cancer is most often treated with chemotherapy because it has usually spread to other parts of the body by the time it's detected. Chemotherapy is a systemic treatment, meaning that the drugs circulate throughout the body. (Surgery usually isn't effective, although it may be used in the unlikely event that the small cell cancer is detected while it still remains confined to one lung and nearby lymph nodes.)

Radiation may also be used to destroy cancer cells in the lungs or other parts of the body. Some people with small cell cancer also choose to have preventive radiation therapy to the chest and brain, even if no evidence of cancer has been found there. Radiation therapy to the brain is called prophylactic cranial irradiation (PCI). Because PCI can affect brain function, you'll want to weigh the pros and cons of this treatment with your doctor first.

Small cell cancer is difficult to cure, but treatment can prolong life. If left untreated, people with small cell lung cancer have a median survival time of only six to 17 weeks; with treatment, the median survival time lengthens to 40 to 70 weeks.

Treatment Methods

Surgery

Surgery to remove lung cancer can be done in several ways, depending on the size and location of the cancer. Removal of only a small portion of the lung is called a wedge resection. In a lobectomy, the surgeon removes an entire lobe of the lung. (The left lung has two lobes; the right lung has three.) In a pneumonectomy, the entire lung is taken out.

Unfortunately, only 25% to 50% of lung cancer patients are candidates for surgery. Others can't have surgery because their tumors have spread, or they have other health problems that make surgery too risky, or the other lung isn't strong enough to take over breathing functions. About 5% to 10% of patients who have lung surgery may not survive the operation. In some cases, even when a cure isn't possible, surgery may work to temporarily control the cancer and ease symptoms. After surgery, you may still need radiation or chemotherapy to kill any cancer cells that may remain.

    • Cryosurgery: This type of treatment, in which the cancer cells are frozen to death, may be used to control symptoms in the later stages of non-small cell cancer.
    • Laser surgery: If conventional surgery can't be used to remove a tumor, laser surgery can be used to restore breathing if the tumor is obstructing the airways.

Chemotherapy

Chemotherapy is more effective for treating small cell lung cancers, sometimes in combination with radiation. Chemotherapy can be given in the form of pills or shots, or through intravenous chemotherapy, in which the drugs enter the bloodstream through a catheter (thin tube) inserted into a vein. Chemotherapy may not provide a cure, but it can control cancer growth and relieve symptoms.

Chemotherapy is given by a medical oncologist. A variety of effective combination chemotherapy regimens has been reported for small cell lung cancer. The most widely used combination at present is etoposide and cisplatin. In about one-quarter of people with small cell cancer, chemotherapy prolongs survival substantially.

To a lesser degree, chemotherapy is used for non-small cell cancer. New drugs for non-small cell lung cancer include paclitaxil, vinorelbine, and gemcitabine. Using chemotherapy drugs for non-small cell lung cancer requires careful judgment to balance potential benefits and toxicity. For those with metastatic disease whose tumors respond to chemotherapy, median survival time is 30 to 40 weeks, compared to 10 to 20 weeks for those who do not respond to therapy.

Radiation therapy

Radiation in the form of high-energy X-rays is used to treat lung cancer in several ways. It may be used before surgery to shrink a tumor or after surgery to destroy any remaining cancer cells at the site. If surgery can't be performed, radiation may be combined with chemotherapy to cure tumor growth. Radiation is also used to to relieve cancer symptoms, such as pain, bleeding, or trouble swallowing.

Radiation can be delivered from outside the body through a machine, or it can be given internally by implanting a container of radiation material into or near the tumor.

Photodynamic therapy

In this newer therapy, you may be given chemicals that make cancer cells more sensitive to light. Then a laser beam is focused on the tumor and the cancer cells absorb the light, causing them to die. Photodynamic therapy is used to destroy lung cancers that have not spread beyond the lung. It is still considered experimental.

Appropriate Healthcare Setting

Lung cancer surgery requires hospitalization, while other types of treatment can be done on an outpatient basis. Certain diagnostic tests, such as bronchoscopy, are also usually done in a hospital.

Healthcare Professionals Who May Be Involved

    • Family physicians
    • General internists
    • Radiologists
    • Pulmonologists
    • Thoracic surgeons
    • Pathologists
    • Medical oncologists (chemotherapists)
    • Surgical oncologists
    • Radiation oncologists (radiotherapists)
    • Nurse oncologists
    • Psychologists

Activity & Diet Recommendations

There are no special diets or activity restrictions. Try to maintain your normal daily routine as much as you can. After treatment, rest and exercise are also very important for you to recover. Speak with your physician about starting an exercise program that suits you.

Monitoring Lung Cancer

Lung cancer can recur. Talk to your doctor about a regular schedule of follow-up appointments to keep an eye on your general health and to make sure that cancer doesn't come back. You may need to visit your doctor every six months for the first two years, when the chance of recurrence is highest, and annually after that. During these checkups, blood chemistry lab tests, physical exams of the chest, lymph nodes, and abdomen, and chest X-rays are performed. Of course, if you have any new symptoms, be sure to see your doctor rather than waiting for your next appointment.

Possible Complications

All cancer treatments have benefits and drawbacks, including complications and side effects.

Surgery:

    • Air and fluid collected in chest
    • Pain or weakness of the chest or arm
    • Shortness of breath
    • Lack of strength and energy for several weeks to several months

Radiation:

    • Sore throat
    • Trouble swallowing
    • Fatigue
    • Skin changes (the skin may look burned, then tanned, at the site of treatment)
    • Loss of appetite

Radiation to the brain:

    • Headache
    • Skin changes
    • Fatigue
    • Nausea and vomiting
    • Hair loss
    • Problems with memory and thinking

Chemotherapy:

Quality of Life

Having a serious illness such as lung cancer is hard physically and emotionally. It's natural for people who have been diagnosed with lung cancer to feel deep anxiety and depression. It may be helpful to talk about your fears and concerns with a close friend or counselor, or to join a support group with other people who have cancer. Gathering emotional support from others may enable you to better cope with the distress and isolation of having a serious illness. If you're interested, ask your doctor or hospital for suggestions on where to find a support group.

If you're troubled by the adverse effects of treatment, talk to your doctor about ways to relieve them. For instance, antinausea drugs can be given with chemotherapy. Also, lung cancer often causes breathing difficulties, even after treatment. If you have this problem, oxygen therapy and drugs to open the airways may help. If lung cancer is advanced, breathing problems can be severe, and pain may be substantial. In these late stages, adequate doses of pain-killing narcotics may provide relief.

Considerations for Women

Pregnancy

Lung cancer rarely occurs during pregnancy. If it does, you'll need to weigh the possible adverse effects of chemotherapy and/or radiation therapy to the fetus against the harm you may incur if treatment is delayed. In some cases, therapeutic abortion may be advised.

Four drugs used for chemotherapy can cause serious damage to the fetus during the first trimester: 5-fluorouracil (5-FU), methotrexate, vinblastine, and vincristine. During the second and third trimesters, the risk greatly decreases, but the risks of miscarriage, premature birth, and low birth weight still exist.

Diagnostic tests (X-ray and CT, or "CAT," scans) do not put the fetus at significant risk. Surgery can be performed during the second and third trimesters.

Considerations for Older People

Older people may not be able to have lung cancer surgery if they have other health problems, such as severe heart disease or other lung illnesses. Before surgery on a cancerous lung, pulmonary function tests are done to find out whether the opposite lung is capable of providing enough breathing function. If the test results are discouraging, an older person may need other treatment besides surgery.


Because lung cancer needs medical and surgical treatments, alternative therapy shouldn't be considered as a substitute for conventional medical and surgical treatments. However, several alternative approaches can be helpful, especially for relieving the symptoms and prevention.

Meditation, self-hypnosis, and visualization

These are relaxation techniques that you can do alone or with your support group. These techniques may improve survival rate because they stimulate the immune system to fight the cancer.

Nutrition Therapy

Nutrition Therapy plays mainly a preventative role. Dietary factors have been shown to influence the risk of lung cancer. Studies have shown that certain antioxidant vitamins, particularly derivatives of vitamin A and vitamin E, may help prevent lung cancer. There is substantial evidence for a reduction in lung cancer risk by eating fruits and vegetables regularly. These antioxidants work better if they came from a food source rather than from a pill form. Foods rich in these antioxidants include yellow and orange fruits, and orange and dark-green vegetable. Broccoli, brussels sprouts, cabbage, and cauliflower are especially great source of antioxidants. Some studies have suggested a low-fat diet may reduce the risk of lung cancer.


Preventing Lung Cancer

The importance of prevention cannot be overemphasized; lung cancer is easily prevented but in many cases difficult to treat. Using the following guidelines, you can help prevent lung cancer.

    • Don't smoke. Smokers comprise 90% of all lung cancer cases. If you don't smoke, don't start. If you smoke, quit. Smokers who quit for 10 years reduce their risk down to just a little higher than a person who does not smoke. Try to stay away from sources of secondhand smoke, such as the smoking sections of restaurants and bars.
    • Avoid cancer-causing substances. Check your environment for carcinogens. Radon gas is colorless and odorless. You can test your home for it with a radon testing kit available at most hardware stores. Asbestos is commonly used as insulation, particularly for soundproofing. Educate yourself about the many carcinogens potentially in your environment.
    • Get your antioxidants. Your diet mainly plays a preventative role. Some nutritionists suggested that daily supplements of antioxidants, which include vitamin C, and vitamin E, may help prevent cancer. These antioxidants work better if they came from a food source rather than from a pill. Foods rich in these antioxidants include yellow and orange fruits and orange and dark-green vegetables. Broccoli, brussels sprouts, cabbage, and cauliflower are especially good sources.
    • Eat a low-fat diet. Some studies have suggested that a low-fat diet may reduce the risk of lung cancer.

Early detection

Early detection may give you an edge on treatment, preventing cancer from becoming more serious before treatment begins. Try to include a chest X-ray in your routine checkup, especially if you are at risk. However, early screening of asymptomatic persons at high risk (men over 45 years of age who smoke 40 or more cigarettes per day) for lung cancer by means of sputum cytology and chest X-rays has not been proven effective in improving survival rates. Newer screening methods involving fluorescent bronchoscopy and molecular analysis are being studied in clinical trials in the hope of improving detection of lung cancer before a metastasis develops. Increasingly, experts are using spinal CT scans for more precise detection.

Websites & Organizations

American Cancer Society
1599 Clifton Road NE
Atlanta, GA 30329
Phone: 800-ACS-2345 (800-227-2345)

American Lung Association
1740 Broadway
New York, NY 10019
Phone: 212-315-8700 or 800-LUNG-USA (800-586-4872)

Cancer AnswerLine
800-865-1125

Cancer Care Inc.

Comprehensive Cancer Center University of Michigan
1500 E. Medical Center Dr.
Ann Arbor, MI 48109
Cancer Information Line: 800-865-1125
Email: wwwcancer@umich.edu

Medicine Online

National Cancer Institute
National Institutes of Health
Bethesda, MD 20892
Phone: 301-496-4000 or 800-4-CANCER (800-422-6237)

National Coalition for Cancer Survivorship
1010 Wayne Avenue, 5th Floor
Silver Springs, MD 20910
Phone: 888-837-6227 or 301-650-8868

Occupational Safety and Health Administration
US Department of Labor
200 Constitution Ave.
Washington, DC 20210
Phone: 202-523-6138

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