Treatment

The treatment of lung cancer depends on the size and location of the tumor, whether the cancer has spread, and the person’s overall health. In many cases, a team of doctors will work with the patient to determine the best treatment plan.

This section outlines treatments that are the standard of care (the best treatments available) for this specific type of cancer. Patients are also encouraged to consider clinical trials when making treatment plan decisions. A clinical trial is a research study to test a new treatment to prove it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. For more information, read the clinical trials section.

There are four basic ways to treat lung cancer: surgery, radiation therapy, chemotherapy, and targeted therapy. Each treatment option is described below, followed by an outline of treatment by the type and stage of cancer.

Surgery

A thoracic surgeon is specially trained to perform lung cancer surgery. The goal of surgery is the complete removal of the lung tumor and the nearby lymph nodes in the chest. The tumor must be removed with a surrounding border of normal lung tissue (called the margin). A “negative margin” means that when the pathologist examines the lung, or piece of lung that has been removed by the surgeon, no traces of cancer were found in the healthy tissue surrounding the tumor.

The lungs have five lobes, three in the right lung and two in the left lung. For NSCLC, a lobectomy (removal of an entire lobe of the lung) has been shown to be the most effective type of surgery, even when the lung tumor is very small. If, for whatever reason, the surgeon cannot remove an entire lobe of the lung, the surgeon can remove the tumor in a procedure called a wedge, surrounded by a margin of normal lung. If the tumor is close to the center of the chest, the surgeon may have to perform a pneumonectomy (surgery to remove the entire lung). The time it takes to recover from lung surgery depends on how much of the lung is removed and the health of the patient before surgery.

Adjuvant therapy

Adjuvant therapy is treatment that is given after surgery to lower the risk of the lung cancer returning. Adjuvant therapy includes radiation therapy, chemotherapy, and targeted therapy. It is intended to eliminate any lung cancer cells that may be lingering in the body. Adjuvant therapy may decrease the risk of recurrence, but does not necessarily eliminate it.

Along with staging, other sophisticated tools can help determine prognosis and help you and your doctor make decisions about whether adjuvant therapy would be helpful in your treatment. The website Adjuvant! Online (www.adjuvantonline.com) is one such tool that your doctor can access to interpret a variety of factors that are important for making the treatment decision. This website should only be used with the interpretation of your doctor.

For additional information, read the What to Know: ASCO's Guideline on Adjuvant Treatment for Lung Cancer.

Radiation therapy

Radiation therapy is the use of high energy x-rays or other particles to kill cancer cells. If you need radiation therapy, you will be asked to see a specialist called a radiation oncologist. Like surgery, radiation therapy cannot be used to treat widespread cancer. Radiation only kills cancer cells directly in the path of the radiation beam. It also damages the normal cells caught in its path, and for this reason, it cannot be used to treat large areas of the body. Patients with lung cancer treated with radiation therapy often experience fatigue and loss of appetite. If radiation therapy is given to the neck, or center of the chest, patients may also develop a sore throat and have difficulty swallowing. Skin irritation, like sunburn, may occur at the treatment site. Most side effects go away soon after treatment is finished.

If the radiation therapy irritates or inflames the lung, patients may develop a cough, fever, or shortness of breath months and sometimes years after the radiation therapy ends. This condition occurs in about 15% of patients and is called radiation pneumonitis. If it is mild, radiation pneumonitis does not require treatment and resolves on its own. If it is severe, radiation pneumonitis may require treatment with steroid medications, such as prednisone. Radiation therapy may also cause permanent scarring of the lung tissue near the site of the original tumor. Typically, the scarring does not lead to symptoms. Widespread scarring can lead to permanent cough and shortness of breath. For this reason, radiation oncologists carefully plan the treatments using CT scans of the chest to minimize the amount of normal lung tissue exposed to the radiation beam.

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells. Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body. Chemotherapy is given by a medical oncologist. Most chemotherapy used for lung cancer is injected into a vein (called intravenous, or IV injection).

The side effects of chemotherapy depend on the individual and the dose used, but can include fatigue, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. Nausea and vomiting are often avoidable; for more information, read the What to Know: ASCO's Guideline on Preventing Nausea and Vomiting Caused by Cancer Treatment. These side effects usually go away once treatment is finished.

Chemotherapy may also damage normal cells in the body, including blood cells, skin cells, and nerve cells. This may result in low blood counts, an increased risk of infection, hair loss, mouth sores, and/or numbness or tingling in the hands and feet. Your medical oncologist can often prescribe drugs to help provide relief from many side effects. Hormone injections are also used to prevent white and red blood cell counts from becoming too low.

Newer chemotherapy treatment plans cause fewer side effects and are as effective as older treatments. Chemotherapy has been shown to improve both the length and quality of life in people with lung cancer of all stages.

The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions through Cancer.Net's Drug Information Resources, which provides links to searchable drug databases.

Targeted therapy

Targeted therapy is a treatment that target faulty genes or proteins that contribute to cancer growth and development. These abnormal proteins are present in unusually large amounts in certain lung cancer cells.

A monoclonal antibody is a drug made in the laboratory that blocks a receptor on the cell surface, which is like the doorway of the cell. Bevacizumab (Avastin) is a monoclonal antibody given in combination with chemotherapy for lung cancer. Drugs like bevacizumab block the formation of new blood vessels (also called angiogenesis), which is necessary for a tumor to grow and spread. The risk of serious bleeding for patients taking bevacizumab is about 2%.

Erlotinib (Tarceva) is a drug approved by the U.S. Food and Drug Administration (FDA) for locally advanced and metastatic NSCLC. It blocks the epidermal growth factor receptor (EGFR), a protein that helps lung cancer cells grow and multiply. This medication is a pill that can be taken by mouth. The side effects of erlotinib include rash that looks like acne and diarrhea.

Many doctors recommend treatment with cetuximab (Erbitux), a monoclonal antibody that targets and blocks the EGFR. This is drug is given along with chemotherapy to treat lung cancer, especially when treatment with bevacizumab is unsafe. The side effects of cetuximab include rash and allergic reactions.

Gefitinib (Iressa) is another drug that works like erlotinib. It is available only to people who were already taking it, had taken it in the past and had a good effect, or as part of a clinical trial.

Combining treatments

Most patients with lung cancer are treated by more than one specialist with more than one type of treatment. For example, chemotherapy can be prescribed before or after surgery, or before, during, or after radiation therapy. Patients should have a sense that their doctors have a coordinated plan of care and are communicating effectively with one another. If patients do not feel that the surgeon, radiation oncologist, or medical oncologist is communicating effectively with them or each other about the goals of treatment and the plan of care, patients should discuss this with their doctors or seek additional opinions before treatment.

Treatment of NSCLC

Stage I and II. In general, stage I and II NSCLC are treated with surgery. Surgeons cure many patients with an operation. Before or after surgery, a patient may be referred to a medical oncologist. Some patients with a large tumor or evidence of spread to lymph nodes may benefit from neoadjuvant chemotherapy (chemotherapy before the surgery, also called induction chemotherapy) or adjuvant chemotherapy to reduce the chance the cancer will return. Radiation therapy is recommended to treat and cure a lung tumor in people for whom surgery is not advisable.

Stage III. Stage III NSCLC has spread to the point that surgery or radiation therapy alone is not enough to cure the disease for most people. Patients with stage III disease also have a high risk of the cancer returning, either in the same place or at a distant location, even after successful surgery or radiation therapy. For this reason, doctors generally do not recommend immediate surgery, and sometimes suggest chemotherapy with surgery to follow.

After chemotherapy, patients with stage IIIa NSCLC may still undergo surgery, especially if the chemotherapy is effective in killing or shrinking the cancer. Because chemotherapy travels throughout the body, if it is killing the cancer the doctors can see, it may also be killing the invisible cancer cells that may have spread from the original tumor. After effective chemotherapy, surgeons can be more confident that removing a stage IIIa NSCLC will result in a cure.

Some patients with stage IIIa NSCLC are not treated with surgery. Instead, patients with stage IIIa disease may be treated with a combination of chemotherapy and radiation therapy with the intent to cure. The chemotherapy may be delivered either before or at the same time as the radiation therapy. This method has shown to improve the ability of radiation therapy to shrink the cancer and to decrease the risk of the cancer returning. Chemotherapy delivered at the same time as radiation therapy is more effective than chemotherapy delivered before radiation therapy, but it results in more side effects. Patients who have received both chemotherapy and radiation therapy for stage IIIa disease may still go on to have surgery. However, there is debate among doctors whether surgery is necessary for patients effectively treated with radiation therapy and if radiation therapy is needed in patients whose tumors are completely removed following treatment with chemotherapy.

For most patients with NSCLC, the tumor is unresectable (cannot be removed by surgery). This may be because they have stage IIIb lung cancer, or the surgeon feels that an operation would be too risky, or that the tumor cannot be removed completely. For patients with unresectable NSCLC, with no signs of spread of cancer to distant sites or in the fluid around the lung, a combination of chemotherapy and radiation therapy can still be used to try to cure the patient.

Stage IIIb with pleural effusion and Stage IV NSCLC. Patients with stage IV NSCLC or stage IIIb due to malignant pleural effusion (cancer cells in the fluid around the lung) are typically not treated with surgery or radiation therapy. Rarely, doctors recommend that a brain or adrenal metastasis be removed surgically if that is the only place the cancer has spread. Radiation therapy can also be used to treat a single site of metastasis, such as in the brain. However, patients with stage IV disease, or stage IIIb with a pleural effusion, are at very high risk for the cancer spreading or growing in another location. Most patients with these stages of NSCLC are only treated with drugs.

The goals of chemotherapy are to shrink the cancer, relieve discomfort caused by the cancer, prevent further spread, and lengthen life. Rarely, chemotherapy can make metastatic lung cancer disappear. However, doctors know from experience that the cancer will return. Therefore, patients with stage IV disease, or stage IIIb with a pleural effusion, are never considered “cured” of their cancer no matter how well the chemotherapy works. These patients must be followed closely by their doctors and require lifelong chemotherapy to control their disease. Chemotherapy has been proven to improve both length and quality of life for patients with NSCLC.

For more information about NSCLC treatment that cannot be removed by surgery, read the What to Know: ASCO's Guideline on Advanced Lung Cancer Treatment.

Treatment of small cell lung cancer

As with NSCLC, the treatment of small cell lung cancer depends on the stage. Small cell lung cancer spreads quickly, so systemic chemotherapy is the primary treatment for all patients. The most commonly used chemotherapy regimen is etoposide (VePesid, Lastet, Etopoph plus cisplatin (Platinol) or carboplatin (Paraplatin). Patients with limited stage small cell lung cancer are best treated with simultaneous chemotherapy plus radiation therapy to the chest given twice a day. Radiation therapy is best when given during the first or second month of chemotherapy. Patients with extensive stage cancer are treated with chemotherapy only. Chemotherapy is given for three to six months. Surgery is rarely appropriate for patients with small cell lung cancer and is only considered for patients with very early-stage disease, such as a small lung nodule. In those cases, chemotherapy, with or without radiation therapy, is given afterwards.

In patients whose tumors have diminished after chemotherapy, radiation therapy to the head cuts the risk that the cancer will spread to the brain. This preventative radiation to the head is called prophylactic cranial irradiation (PCI) and has been shown to extend the lives of these patients.

Like patients with advanced NSCLC, patients with small cell lung cancer of any stage face the risk that their cancer can return, even when it is initially controlled. All patients with small cell lung cancer must be followed closely by their doctors with x-rays, scans, and check-ups.

Stopping smoking

Even after lung cancer is diagnosed, it is still not too late to benefit from stopping cigarette smoking. People who stop smoking have an easier time with all treatments, feel better, live longer, and have a lower risk of developing a second lung cancer. Stopping smoking is never easy and even harder when facing the diagnosis of lung cancer and treatment. People who smoke should seek help from family, friends, smoking cessation programs, and health care professionals. None of the smoking cessation aids available interfere with cancer treatment. For more information, read the Tobacco section.

Controlling physical symptoms caused by lung cancer

Chemotherapy is not as effective as radiation therapy or surgery to treat lung cancer that has spread to the brain. For this reason, lung cancer that has spread to the brain is treated instead with radiation therapy, surgery, or both. Most patients with brain metastases from lung cancer are treated with radiation therapy to the entire brain. This can cause side effects such as hair loss, fatigue, and redness of the scalp. With a small tumor, a type of radiation therapy called stereotactic radiosurgery can focus radiation only on the tumor in the brain and minimize side effects.

Radiation therapy or surgery may also be used to treat metastases that are causing pain or other symptoms.

• A tumor in the chest that is bleeding or blocking the lung passages can be shrunk by radiation therapy.
  
  
• During a bronchoscopy (See Diagnosis), lung passages blocked by cancer can be opened to improve breathing.
  
  
• A surgeon can use a laser to burn away a tumor or place a mechanical stent (support) to prop open an airway passage.
  
  
• Bone metastases that weaken important bones can be treated with surgery and reinforced using metal implants. Bone metastases can also be treated with radiation therapy.

Medications can also help treat the symptoms of lung cancer.

• Medications are used to treat cancer pain. Most hospitals and cancer centers have pain control specialists that design pain-relief treatments even for very severe cancer pain. Many drugs used to treat cancer pain, especially morphine, can also relieve shortness of breath caused by cancer.
  
  
• Medications can be used to suppress cough, open closed airways, or reduce bronchial secretions.
  
  
• Prednisone or methylprednisolone (multiple brand names) can reduce inflammation caused by lung cancer or radiation therapy and improve breathing.
  
  
• Extra oxygen from small, portable tanks can help make up for the lung’s reduced ability to extract oxygen from the air.
  
  
• Medications called bisphosphonates strengthen bones, lessen bone pain, and can help prevent future bone metastases.
  
  
• Appetite stimulants and nutritional supplements can improve appetite and lessen weight loss.

To learn about the terms used in this section, read the Cancer.Net Feature: Cancer Terms to Know: During Treatment.