Lung Cancer

Types of Treatment

Treatment options for lung cancer include surgery, radiation therapy and systemic therapy. Systemic therapies are delivered intravenously or orally so they get into the blood and exert their effects throughout the body. Systemic therapies include chemotherapy, molecular therapy, targeted therapy and immunotherapy. Clinical trials that test new therapies for one or more of these treatment types may also be an option. Your doctor will recommend one, or a combination, of these treatments based on several factors, including the type and stage of your lung cancer, the location of the tumor, biomarker testing results, your overall lung function and your general health. Understanding as much as possible about your cancer will help you be a more informed and active partner in your treatment plan.

Surgery

Surgery is typically the primary treatment option for most early-stage adenocarcinomas and squamous cell and large cell lung cancers. The extent of surgery will depend on your overall health and how much of the lung is affected by cancer. The main surgical procedures include the following:

  • Wedge resection/segmentectomy is removal of a small part of the lung containing cancerous tissue (wedge resection) or a large portion of the lung (segmental resection).
  • Lobectomy /sublobar resection is removal of an entire lobe of the lung. (The left has two and the right has three.)
  • Pneumonectomy is removal of one entire lung.
  • Sleeve resection is removal of part of the bronchus (the main airway) or part of the pulmonary artery (artery to the lung), along with a lobe to save other portions of the lung.
  • Radiofrequency ablation is treatment in which a needle is placed directly into the lung tumor to deliver a high-frequency electrical current into the tissue, causing heat that destroys the cancer cells.

Some doctors use a technique known as video-assisted thoracic surgery (VATS) to perform a lobectomy or wedge resection. With VATS, the surgeon makes several small incisions to remove the tumor(s) instead of opening up the chest.

Surgery for lung cancer

Type of surgery Description
Wedge/segmental resection Removal of a small part of the lung containing cancerous tissue (wedge resection) or a large portion of the lung (segmental resection)
Lobectomy Removal of an entire lobe of the lung (the left lung has two and the right has three)
Pneumonectomy Removal of one entire lung
Sleeve resection Removal of part of the bronchus (the main airway) or part of the pulmonary artery (artery to the lung), along with a lobe in order to save other portions of the lung

Chemotherapy

Traditional chemotherapy is known as systemic treatment because the drugs travel through the bloodstream to all parts of the body. Chemotherapy is typically the primary treatment for all stages of small cell lung cancer and may be combined with surgery or radiation therapy for early-stage disease. It is also included in treatment regimens for most stages of adenocarcinoma, squamous cell lung cancer and large cell lung cancer and can be used as maintenance therapy, which is treatment given after the end of standard chemotherapy to help delay the progression of the cancer.

Chemotherapy may be given before surgery to shrink a tumor. This treatment is known as neoadjuvant therapy. Chemotherapy may also be used as adjuvant therapy, or treatment given after surgery, to kill any cancer cells that may remain. Chemotherapy can also be combined with radiation therapy, which is known as chemoradiation therapy. Chemoradiation therapy is sometimes used to shrink tumors to an operable size or to manage symptoms. Several chemotherapy drugs are available to treat lung cancer, and the choice depends primarily on the type of cancer. For example, some drugs may be less effective for squamous cell lung cancer than for the other subtypes of non-small cell lung cancer. Other factors in choosing a chemotherapy drug are how it will be used (for adjuvant treatment, for advanced disease or with radiation therapy) and how the benefits compare with the risks. Talk with your treatment team about which regimen is best for you.

Chemotherapy is usually given intravenously (IV) through a vein in your arm, but some drugs may be taken by mouth. You may be able to receive IV chemotherapy in your doctor’s office or in an outpatient clinic, and it typically takes 30 minutes to three hours for the chemotherapy to be completely infused. Chemotherapy is given in cycles, which refers to treatment on specific days over a period of time (usually 21 or 28 days). Sometimes different chemotherapy schedules can be used, and you can discuss the choice of schedule with your treatment team. Treatment plans may vary but usually consist of four to six cycles, and each cycle is followed by a rest period to allow your body to recover from the effects of the drug. Drugs to prevent side effects as well as additional fluids are often given intravenously. Your treatment team will discuss each of these with you.

To monitor whether treatment is working, physical exams and imaging studies may be done after two and four cycles of chemotherapy. The results may also contribute to the decision to stop or change treatment if your current regimen is no longer effective. When the tumor is no longer shrinking, chemotherapy is usually stopped. Maintenance therapy may then be considered.

Molecular Therapy

Molecular therapy is a targeted systemic therapy but it differs from chemotherapy in that it attacks the source of a tumor’s growth by focusing on certain parts of cells and the signals that cause cancer cells to grow uncontrollably or prevent the cells from dying. These signals are often sent by proteins known as tyrosine kinases. A genetic analysis of your tumor is conducted to determine if it has one of several genetic alterations for which oral therapies called tyrosine kinase inhibitors are available.

Researchers have found that the growth of some forms of the three types of non-small cell lung cancer (NSCLC) is driven by certain molecular abnormalities activating related tyrosine kinases. These changes are known as molecular drivers of lung cancer. Researchers also have learned that these molecular drivers cause the three types of NSCLC to respond differently to different types of treatment. Knowing this, doctors no longer treat adenocarcinoma, squamous cell lung cancer and large cell lung cancer in the same way. Instead, targeted therapy drugs are selected according to any molecular drivers that are identified in a lung cancer. In these cases, molecularly targeted therapy is preferred over chemotherapy as first-line treatment because targeted therapy is associated with higher response rates, longer duration of benefit and far fewer side effects.

Biomarker molecular testing will help determine if targeted therapy is right for you. Before your treatment begins (if possible), a sample of your tumor tissue will be sent to a special lab to be tested for molecular biomarkers. Ask your doctor if tissue from a previous biopsy can be used. Following are the most common molecular drivers in adenocarcinoma, squamous cell and large cell lung cancer and some common drugs that are effective at treating them:

  • Epidermal growth factor receptor (EGFR) mutation. Lung cancers with the most common EGFR mutations can be treated with targeted therapy drugs known as EGFR inhibitors, such as afatinib (Gilotrif), erlotinib (Tarceva), gefitinib (Iressa), and osimertinib (Tagrisso).
  • Anaplastic lymphoma kinase (ALK ) rearrangement. Lung cancers with this abnormality can be treated with an ALK inhibitor, such as alectinib (Alecensa), brigatinib (Al), ceritinib (Zykadia) and crizotinib (Xalkori).
  • ROS1 fusions. Lung cancers with this abnormality can be treated with a ROS1 inhibitor, such as crizotinib (Xalkori).
  • BRAF, HER2, KRAS, MET, RET and TRK abnormalities. Researchers are still studying targeted therapy options for these abnormalities in lung cancer. If your lung cancer has one of these abnormalities, ask your doctor if you are eligible for any appropriate clinical trials or for treatments approved for these abnormalities in other cancer types.

Not all tumors will test positively for a molecular change or driver. If your tumor does test positively for one or more molecular changes, you may be treated with an approved targeted therapy or one that is being studied in a clinical trial.

Researchers have not yet found targetable changes in small cell lung cancer, so molecular therapy is used only to treat adenocarcinoma, squamous cell lung cancer and large cell lung cancer.

Targeted Therapy

Some targeted therapies are directed at proteins involved in initiating cancer but for which there are no proven biomarkers to select patients who will most likely benefit. Currently these include monoclonal antibodies that are directed to the epidermal growth factor receptor (EGFR) or to the vascular endothelial growth factor (VEGF) or its receptor. These antibodies are always given with chemotherapy. The anti-EGFR antibodies include cetuximab (Erbitux) and necitumumab (Portrazza). Necitumumab is approved for use only for squamous cell lung cancers in combination with first-line chemotherapy. Cetuximab is not currently approved by the FDA as a standard treatment for lung cancer, but is being testing in clinical trials. Talk to your doctor about whether you might be eligible to receive these targeted treatments by participating in a clinical trial.

Angiogenesis inhibitors (or antiangiogenesis drugs) are another type of targeted therapy, but their use does not depend on the results of biomarker testing. Angiogenesis inhibitors stop the VEGF protein, which has an important rolein the process of angiogenesis (the formation of blood vessels). Without blood vessels to carry blood to the tumor, it stops growing. The angiogenesis inhibitor bevacizumab (Avastin) that inhibits VEGF is approved for use with platinum-doublet chemotherapy but only as first-line treatment and only in non-squamous NSCLC. Ramucirumab (Cyramza), which inhibits the vascular endothelial growth factor receptor, is also approved for use.

Immunotherapy

Immunotherapy uses the body’s own immune system to slow the growth of and kill cancer cells by using substances made either by the body or in a laboratory. This allows the immune system to identify cancer cells as a threat and target them for destruction.

Different types of immunotherapy exist, including immune checkpoint inhibitors, cytokines, oncolytic viruses, cancer vaccines and nonspecific immune stimulators. Each works in a unique way to slow and stop the growth of cancer cells, stop cancer cells from spreading to other parts of the body and help the immune system work better overall at destroying cancer cells. Some types of immunotherapy boost the body’s immune system, and others train the immune system to attack cancer cells. Although certain immunotherapies work well when given alone, others work better in combination with additional treatments.

Immune checkpoint inhibitors are an effective strategy for treating lung cancer. Your doctor may recommend the immunotherapy drugs atezolizumab (Tecentriq), nivolumab (Opdivo) or pembrolizumab (Keytruda) as part of your treatment plan.

Radiation Therapy

Radiation therapy is the use of high-energy X-rays to kill cancer cells or keep them from growing. External-beam radiation therapy (EBRT) is the type of radiation used most often for treating lung cancer and may be considered as primary treatment for individuals with small tumors who are unable to have surgery. EBRT is delivered from a machine outside of the body. Several techniques can accurately target and deliver radiation to the tumor site:

  • Three-dimensional conformal radiation therapy (3D-CRT) uses precise mapping to shape and aim the radiation beams at the tumor(s) from multiple directions, typically causing less damage to normal tissue.
  • Stereotactic body radiotherapy (SBRT) delivers high doses of radiation through radiation beams aimed at the tumor from multiple directions for more precise delivery. This technique is often used for smaller tumors or early-stage cancers when surgery is not an option. Stereotactic brain radiation is frequently used for brain metastases.
  • Intensity-modulated radiation therapy (IMRT) delivers radiation from a machine that moves around the patient. Beams are shaped and aimed at the tumor in varying strengths for increased precision.

Treatment-related words to know

Term Definition
Adjuvant therapy Treatment given after the primary therapy to help prevent recurrence (usually chemotherapy after surgery).
Chemoradiation therapy The use of both chemotherapy and radiation therapy. Chemoradiation therapy is described as either concurrent (when both treatment modalities are given during the same time period) or as sequential (when one modality is given after the other).
Combined-modality treatment The use of more than one type of treatment in the overall treatment plan (i.e., surgery, radiation therapy and/or chemotherapy); also known as multimodality treatment.
Curative intent Treatment given with the goal of curing the disease.
Doublet A chemotherapy regimen consisting of two drugs.
First-line therapy The initial treatment given; if the cancer does not respond, a different treatment regimen or second-line therapy can be tried. Third-line therapy may be given if second-line therapy fails.
Inoperable Unable to treat with surgery, either because of the stage or location of the disease or a person’s health status; also known as unresectable.
Local therapy Treatment directed at the site of the tumor; surgery and radiation therapy are local therapies.
Maintenance therapy Treatment given after the end of standard chemotherapy to help prevent disease from progressing.
Margin (surgical) The edge of the specimen removed during surgery. If the pathologist finds cancer cells in the margin (known as a positive margin), additional treatment may be needed.
Neoadjuvant therapy Treatment given before the primary therapy to help shrink the tumor (usually chemotherapy before surgery).
Primary therapy The initial treatment given with the intention to cure or prolong life.
Resection Surgical removal.
Surgical candidate A person healthy enough to have surgery. If a person has poor lung and/or heart function or other medical conditions, he or she may not be a candidate for lung cancer surgery, and other treatment options must be used.
Systemic therapy Treatment with chemotherapy or targeted therapy; the drugs travel throughout the body via the bloodstream.

 

Questions to Ask Your Doctor

GENERAL QUESTIONS

  • What treatment plan do you recommend? Why?
  • Are there any other treatment options available to me?
  • What is the goal of my treatment?
  • What are the possible side effects of this treatment?
  • How will this treatment affect my daily life and routine activities?
  • What clinical trials are open to me?

QUESTIONS ABOUT SURGERY

  • What type of surgery will I have?
  • How long will the operation take?
  • How long will I be in the hospital?
  • What should I expect during recovery from surgery?

QUESTIONS ABOUT CHEMOTHERAPY AND TARGETED THERAPY

  • What are the names of the drugs and how are they given?
  • Where will I receive treatment (in the doctor’s office, in a clinic)?
  • Will I need another person to help me get home after treatment?
  • How long will each treatment session last?
  • What are the side effects of each drug?
  • What can be done to decrease these side effects?

QUESTIONS ABOUT RADIATION THERAPY

  • How often will I receive radiation therapy?
  • How much time will each treatment take?
  • How much of the normal lung will be included in the area to receive radiation?
  • Will I need another person to help me get home after treatment?
  • What are the possible side effects of treatment?

 

Additional Resources

 

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