Lung Cancer Treatment

After the cancer is found and staged, your cancer care team will discuss treatment options (choices) with you. It is important to take time and think about all of the choices. In choosing a treatment plan, factors to consider include your overall physical health, the type and stage of the cancer, likely side effects of the treatment, and the probability of curing the disease, extending life, or relieving symptoms.

How is Lung Cancer Treated?

The treatment options for lung cancer are surgery, radiation therapy, and chemotherapy either alone or in combination, depending on the stage of the tumor.

It is often a good idea to seek a second opinion. A second opinion can provide more information and help you feel more confident about the treatment plan that is chosen. Some insurance companies require a second opinion before they will agree to pay for certain treatments.

Types of Treatment

Surgery

Depending on the type and stage of a lung cancer, surgery may be used to remove the cancer and some of the surrounding lung tissue. If a lobe (section) of the lung is removed, it is called a lobectomy. If the entire lung is removed, the surgery is called a pneumonectomy. Removing part of a lobe is known as a segmentectomy or wedge resection. These operations involve general anesthesia (the patient is "asleep") and a thoracotomy, making a surgical incision in the chest. The patient usually returns home after five to seven days in the hospital. There will be some limitations to strenuous activity for at least a month. Possible complications include excessive bleeding, wound infections, and pneumonia. People whose lungs are in good condition (other than the presence of the cancer) can usually return to normal activities after removal of a lobe or even an entire lung. However, removal of a lobe or more extensive surgery may lead to long-term shortness of breath if the lungs are also affected by noncancerous diseases such as emphysema or chronic bronchitis (which are common among heavy smokers). Pulmonary function tests are done before surgery to determine whether the patient will have enough healthy lung tissue remaining after surgery.

If patients are unable to undergo a thoracotomy because of lung disease or other serious medical problems, or if the cancer is widespread, other types of surgery can be used to relieve some symptoms. For example, laser surgery can be used to relieve blockage of airways that may cause pneumonia or shortness of breath.

Some patients with lung cancers that have spread to certain sites but appear completely resectable (can be completely removed by surgery without damage to critical areas of the brain) may benefit from removal of resectable brain metastases if only a few are present. This involves a craniotomy (surgery through a hole in the skull).

Chemotherapy

Chemotherapy uses anticancer drugs that are given into a vein or by mouth. These drugs enter the bloodstream and reach all areas of the body, making this treatment useful for cancer that has spread or metastasized to organs beyond the lung. Depending on the type and stage of lung cancer, chemotherapy may be given as the main (primary) treatment or as an addition (adjuvant) to surgery. Chemotherapy for lung cancer generally uses a combination of anticancer drugs.

Cisplatin is the chemotherapy drug most often used in treating NSCLC. It is often combined with other drugs such as doxorubicin and cyclophosphamide. Recent studies found new drugs such as gemcitabine, paclitaxel, docetaxel, carboplatin, topotecan, irinotecan and vinorelbine appear to be more effective in treating NSCLC, and may have less severe side effects. The best ways to combine these drugs together is still being tested in clinical trials.

Some of the usual chemotherapy combinations used for patients with SCLC include EP (etoposide and cisplatin), ET (etoposide and carboplatin), ICE (ifosfamide, carboplatin, and etoposide) and CAV (cyclophosphamide, doxorubicin, and vincristine). New drugs such as gemcitabine, paclitaxel, vinorelbine, topotecan and teniposide have shown promising results in some SCLC studies.

Chemotherapy drugs kill cancer cells but also damage some normal cells. Therefore, careful attention must be given to avoiding or minimizing side effects, which depend on the type of drugs, the amount taken, and the length of treatment. Temporary side effects might include nausea and vomiting, loss of appetite, loss of hair and mouth sores. Because chemotherapy can damage the blood-producing cells of the bone marrow, patients may have low blood cell counts. This can result in an increased risk of infection (due to a shortage of white blood cells), bleeding or bruising after minor cuts or injuries (due to a shortage of blood platelets) and fatigue or shortness of breath (due to low red blood cell counts).

Most side effects disappear within a few days after treatment. There are remedies for many of the temporary side effects of chemotherapy. For example, antiemetic drugs can be given to prevent or reduce nausea and vomiting.

Radiation Therapy

Radiation therapy uses high-energy radiation to kill cancer cells. External beam radiation therapy uses radiation delivered from outside the body that is focused on the cancer. This is the type of radiation therapy most often used to treat a primary lung cancer or its metastases to other organs.

Brachytherapy uses a small pellet of radioactive material placed directly into the cancer or into the airway next to the cancer. Radiation therapy is sometimes used as the main (primary) treatment of lung cancer in some patients, especially those whose general health is too poor to undergo surgery. Brachytherapy can be used to help relieve blockage of large airways by cancer.

After surgery, radiation therapy can be used to kill very small deposits of cancer that cannot be seen and removed during surgery. Radiation therapy can also be used to palliate (relieve), symptoms of lung cancer such as pain, bleeding, difficulty swallowing, and problems caused by brain metastases.

Side effects of radiation therapy may include mild skin problems, nausea, vomiting, and fatigue. Often these go away after a short while. Radiation may also make the side effects of chemotherapy worse. Chest radiation therapy may cause lung damage and lead to difficulty breathing and shortness of breath. Side effects of radiation therapy to the brain usually become most serious one or two years after treatment, and include headaches and difficulty with thinking.

Lung Cancer Clinical Trials
(see Lung Cancer Clinical Trials)

Studies of promising new or experimental treatments in patients are known as clinical trials. A clinical trial is only done when there is some reason to believe that the treatment being studied may be of value to the patient. Treatments used in clinical trials are often found to have real benefits. There are three phases of clinical trials that study a treatment before the treatment is eligible for approval by the FDA (Food and Drug Administration).

The purpose of a Phase I study is to find the best way to give a new treatment and how much of it can be given safely. Physicians watch patients carefully for any harmful side effects. The research treatment has been well tested in laboratory and animal studies, but the side effects in patients are not completely predictable.

Phase II trials determine the effectiveness of a research treatment after safety has been evaluated in a Phase I trial. Patients are closely observed for an anticancer effect by careful measurement of cancer sites present at the beginning of the trial. In addition to monitoring patients for response, any side effects are carefully recorded and assessed.

Phase III trials require entry of large numbers of patients. Some trials enroll thousands of patients. One of the groups may receive standard (the most accepted) treatment, so the new treatments can be directly compared. The group that receives the standard treatment is called the "control group." For example, one group of patients (the control group) may receive the standard chemotherapy for a certain type of cancer, while another patient group may receive a different type of chemotherapy, that may or may not contain an investigational drug, to see if this improves survival. All patients in Phase III trials are monitored closely for side effects, and treatment is discontinued if the side effects are too severe.

Researchers conduct studies of new treatments to answer the following questions:

Is the treatment likely to be helpful?
Does this new type of treatment work?
Does it work better than other treatments already available?
What side effects does the treatment cause?
Do the benefits outweigh the risks, including side effects?
In which patients is the treatment most likely to be helpful?

However, there are some risks. No one involved in the study knows in advance whether the treatment will work or exactly what side effects will occur. That is what the study is designed to discover. While most side effects will disappear in time, some can be permanent or even life threatening. Keep in mind that even standard treatments have side effects. Depending on many factors, a patient may decide that a clinical trial will be beneficial.

Enrollment in any clinical trial is completely up to you. Your doctors and nurses will explain the study to you in detail and will give you a form to read and sign indicating your desire to take part. This process is known as giving your informed consent. Even after signing the form and after the clinical trial begins, you are free to leave the study at any time, for any reason. Taking part in the study does not prevent you from getting other medical care you may need.

To find out more about clinical trials, ask your cancer care team. Among the questions you should ask are:

What is the purpose of the study?
What kinds of tests and treatments does the study involve?
What does this treatment do?
What is likely to happen in my case with, or without, this new research treatment?
What are my other choices and their advantages and disadvantages?
How could the study affect my daily life?
What side effects can I expect from the study?
Can the side effects be controlled?
Will I have to be hospitalized?
If so, how often and for how long?
Will the study cost me anything?
Will any of the treatment be free?
If I am harmed as a result of the research, what treatment would I be entitled to?
What type of long-term follow-up care is part of the study?
Has the treatment been used to treat other types of cancers?

You can get a list of current clinical trials by calling the National Cancer Institute's Cancer Information Service toll free at 1-800-4-CANCER or visiting the NCI clinical trials website for patients (cancertrials.nci.nih.gov) or healthcare professionals (cancernet.nci.nih.gov/trialsrch.shtml).

Treatment Choices by Stage and Type
(see Lung Cancer Staging)

Non-small cell lung cancer

Stage 0:
Because stage 0 cancers are limited to the lining layer of air passages and have not invaded the nearby lung tissue, they are curable by surgery alone. No chemotherapy or radiation therapy is needed. They are usually treated by segmentectomy or wedge resection (surgical removal of defined segments or small wedges). Cancers in some locations (where the windpipe divides into the left and right main bronchi) are difficult to remove completely by surgery without also removing an entire lung. Endoscopic photodynamic therapy (killing cancer cells by sensitizing them with an injected chemical and activating the chemical by shining a bright light directly on the cancer) is being tested in this situation, and may be a useful alternative to surgery for stage 0 cancers.

Stage I:
Most patients with stage I NSCLC have their cancer surgically removed by a lobectomy (removal of one lobe). The value of additional (adjuvant) chemotherapy after surgery for stage I NSCLC is being studied in clinical trials. Segmentectomy or wedge resection are compromise resection for stage I cancers in patients with other medical conditions that make removing the entire lobe dangerous.If cancer is present at the edge of the lung tissue removed during surgery, doctors assume that some cancer cells have been left behind. Radiation therapy may be used to destroy these cells.Radiation therapy is also used as the primary (main) treatment for some patients with serious medical problems that prevent them from undergoing surgery. Photodynamic therapy is being studied in clinical trials as an option for these patients. This treatment involves a drug that accumulates in the cancer and makes malignant cells very sensitive to a powerful light aimed through a bronchoscope. The combination of the drug and light kills cancer cells with minimal damage to normal brochical cells.Chemoprevention trials (drugs studied to prevent tumors in subjects at high risk) for these patients are also in progress. These are being done in patients whose stage I NSCLC is curable but who are at risk for developing a second lung cancer.The greatest risk for patients with stage I NSCLC is that micrometastases (deposits of cancer too small to be detected by imaging tests) are present even when surgeons believe that the lung tumor has been completely removed. The value of adjuvant chemotherapy after surgical removal of stage I NSCLC or after primary radiation therapy has not been proven, but clinical trials with new medications continue to study this area in order to destroy micrometastases.Five year survival rates for NSCLC in this stage average about 65%.

Stage II:
As in stage I NSCLC, most patients with stage II NSCLC have their cancer surgically removed by lobectomy.As with stage I NSCLC, radiation therapy may be used to destroy cancer cells left behind after surgery if cancer cells are present at the edge of the tissue removed by surgery. Even if the edges of the sample have no detectable cancer cells, some doctors may recommend additional radiation therapy.Radiation therapy alone can be used for patients who cannot undergo surgery due to other serious health problems.Adjuvant chemotherapy may be used after surgery and or radiation therapy.Five-year survival rates are about 40%.

Stage IIIA:
Treatment of stage IIIA NSCLC depends on the location of the cancer in the lung and whether hilar or mediastinal lymph nodes are involved.Rarely, surgery may be used alone. Most often surgery follows chemotherapy and/or radiation therapy. Chemotherapy is often given before surgery, with the goal of shrinking the tumor enough that it can be completely removed by surgery. If surgery is not performed, either because chemotherapy did not shrink the cancer enough or because the patient has other serious medical conditions and could not withstand surgery, the cancer can be treated by radiation therapy or by both radiation therapy and additional chemotherapy. Brachytherapy is sometimes used. In some cases, a laser can be passed through a bronchoscope to destroy part of the cancer within the airway.Average five-year survival rates vary in the range of 10% to 20%, but some stage IIIA patients (such as those who respond well to chemotherapy and/or radiation) may have a much better outlook.

Stage IIIB:
Stage IIIB NSCLC has spread too widely to be completely removed by surgery. Overall five-year survival is about 5%, but patients in relatively good health can undergo combined chemotherapy and radiation therapy that offers a five year survival rate of about 10% to 20%. In selected cases, surgery may be done after chemotherapy or radiation therapy.

Stage IV:
A cure is not possible because Stage IV NSCLC has spread to distant organs. If any aggressive therapy is used, the goal of treatment should be clear to the patient and family. In patients in otherwise good health, chemotherapy can extend survival. Blockage of an airway by cancer may be treated by interstitial radiation therapy or by using a laser passed through a bronchoscope to destroy the part of the cancer within the airway. External beam radiation therapy can also treat complications of cancer in the lungs as well as problems from metastatic growth such as bone pain and nervous system symptoms.Clinical trials of new chemotherapy drugs or other new treatments such as immunotherapy or gene therapy are a worthwhile option that may benefit the individual patient as well as future patients.

For some patients, supportive care may be the preferred choice, often in the setting of a good hospice program. Pain is a significant concern for patients with lung cancer. Growth of the cancer around certain nerves may cause severe pain. However, it is possible to effectively relieve this pain by medications. It is important that patients do not hesitate to take advantage of these treatments.

Small Cell Lung Cancer (SCLC)

This type of cancer is usually staged as either limited or extensive. Studies show that this type of lung cancer has usually spread by the time it is found (even if that spread is not shown by x-rays and other imaging tests) so SCLC cannot be cured by surgery.

Limited stage:
Most cases of limited stage SCLC are treated first with chemotherapy in which two or more chemotherapy drugs are given to kill cancer cells throughout the body. This is usually followed by either more chemotherapy and chest radiation therapy at the same time, or by chest radiation therapy alone.Chest radiation therapy is not given to patients with severe lung diseases (in addition to their cancer) or some other types of serious health problems. These patients' have a worse prognosis (outlook) than those who can tolerate both chemotherapy and chest radiation therapy. In a few patients whose SCLC is very localized, a lung or lobe is removed by surgery, followed by combination chemotherapy. The brain is a common place where SCLC spreads. For this reason, patients who have a good response to initial treatment may be given head radiation therapy before evidence of a brain metastasis appears. This can prevent or delay complications due to brain metastasis, but may not increase overall survival time.When most SCLC patients are treated with chemotherapy, with or without radiation therapy, their tumors will shrink and they experience remission. Sooner or later, though, most small cell lung cancer becomes resistant to treatment and the cancer begins to grow again.The two-year survival rate for limited stage SCLC is about 40% to 50% but it goes down from 10% to 20% by 5 years. Because standard treatment does not work very well, doctors are studying other methods of treating these cancers. Clinical trials of new chemotherapy drugs or other new treatments such as immunotherapy or gene therapy are a worthwhile option that may benefit the individual patient as well as future patients.

Extensive stage:
Extensive SCLC has a very poor outlook when left untreated. Chemotherapy may be used to treat symptoms and to extend short-term survival. Chemotherapy with two or more drugs can shrink tumors for about 70% to 80% of these patients. However, this cancer often becomes resistant to treatment. Radiation therapy is sometimes used to control symptoms of growth within the lung or spread to the bones or brain. Preventive brain radiation therapy is sometimes given.Less than 4% of people with extensive SCLC survive five years after the cancer is found. Clinical trials of new chemotherapy drugs or other new treatments such as immunotherapy or gene therapy are a worthwhile option that may benefit the individual patient as well as future patients.

For patients too ill to have chemotherapy, the best plan may be to provide supportive care. This would include treatment of pain, breathing problems, weight loss, and other symptoms. Pain is a significant concern for patients with lung cancer. Growth of the cancer around certain nerves may cause severe pain. However, it is possible to effectively relieve this pain by medications. It is important that patients do not hesitate to take advantage of these treatments.

Questions to ask Your Physician

It is important for you to have honest, open discussions with your cancer care team. They want to answer all of your questions, no matter how trivial you might think they are.

What kind of lung cancer do I have?
Has my cancer spread beyond the primary site?
What is the stage of my cancer and what does that mean in my case?
What treatment choices do I have?
What do you recommend and why?
Based on what you've learned about my cancer, how long do you think I'll survive?
What is my expected survival rate, based on my cancer as you view it?
What risks or side effects are there to the treatments you suggest?
What are the chances of recurrence of my cancer with these treatment plans?
What should I do to be ready for treatment?

In addition to these sample questions, be sure to write down some of your own. For instance, you might want more information about recovery times so you can plan your work schedule. Or, you may want to ask about second opinions or about clinical trials for which you may qualify.