Lung Cancer

Treatment Options by Stage

Choosing the best treatment plan for lung cancer can be challenging and requires the expertise of a multidisciplinary care team, which works together to determine the best treatment plan for your particular tumor. Even once a plan has been made, it may change, depending on the results of staging procedures and other test results.

The options listed here by stage provide basic information about how your cancer may be treated. Many other details are involved in making treatment decisions, and your doctors will discuss these details with you.

Non-small cell lung cancer

Stage 0 (carcinoma in situ)

Stage 0 cancer is usually treated with surgery (removal of the tumor with a wedge or segmental resection). Additional treatment is not generally needed but careful follow-up is important.

Stage I

Surgery – often a sublobar resection – is usually the primary treatment for Stage IA or IB disease. Lymph nodes in the mediastinum (area between the lungs) must be removed – or a sample must be taken from a node – during the surgery to see if cancer cells have spread to lymph nodes. Lymph node metastases will determine your prognosis and whether additional treatment is given after surgery. In most cases, no further therapy is given after surgery, but if the risk for recurrence is high (if the tumor is large, usually 4 centimeters [about 1½ inches] or more), chemotherapy after surgery may be offered. It’s difficult, however, to determine who is at highest risk for recurrence, so talk to your doctor about the risks and benefits.

If the pathologist found cancer cells in the surgical margin of the normal tissue removed with the tumor, a second surgery to remove additional tissue may be needed. Chemotherapy and/or radiation therapy are other options for destroying cancer cells that may remain.

Radiation therapy can be used to treat disease in people who are not surgical candidates, and stereotactic ablation radiotherapy (SABR) is available at many treatment centers for people with small tumors that are not close to vital organs. Standard radiation may be given if SABR is not possible.

Stage II

Treatment for Stage II cancer depends on the location of the tumor. In general, surgery is the primary treatment. People who are not surgical candidates are often offered radiation therapy with or without chemotherapy. Chemotherapy after surgery is usually recommended for Stage II disease because it improves overall survival. On rare occasions, chemoradiation therapy or chemotherapy may be given before surgery to shrink a larger tumor so that it’s easier to remove.

Stage IIIA

Making treatment decisions for Stage IIIA is complex and depends on many factors, including the location of the tumor, what tissues or structures it invades, whether cancer has spread to lymph nodes and, if so, the number and size of the involved lymph nodes. If cancer was not suspected in the lymph nodes but the pathologist detects cancer cells in these nodes after a potentially curative operation, additional treatment after surgery is recommended. This usually involves some combination of chemotherapy, radiation and surgery, or all three.

Chemoradiation therapy is often the first treatment option. If a limited number of lymph nodes with cancer cells are found on the same side as the tumor (staged as N2) – or if the tumor is bulky – then chemotherapy, with or without radiation, can be considered as the first treatment given before surgery. If the response to treatment is good – that is, the tumor shrinks and the involved lymph nodes are free of cancer – surgery (removal of part or the entire lung) may be done if the surgeon believes the remaining cancer can be removed entirely. Additional chemotherapy, alone or with radiation, may then be given after surgery.

Chemotherapy after surgery has been shown to improve survival for people in whom the cancer was considered to be Stage I or II before cancer was found in lymph nodes removed during surgery. If cancer cells are found in the surgical margins or in the removed lymph nodes, concurrent chemoradiation therapy may be given.

If surgery isn’t an option, additional chemotherapy and/or radiation may help to further shrink the tumor and reduce the risk of the cancer coming back. If your doctors don’t suspect that your cancer is Stage III at the time of your surgery but find positive lymph nodes during surgery, you may be given chemotherapy or chemoradiation therapy after your surgery.

Stage IIIB

Surgery is not usually an option for Stage IIIB because the disease has spread too far. Therefore, treatment usually consists of concurrent chemoradiation therapy. In some centers, additional chemotherapy is given after radiation has been completed.

Stage IV

Stage IV (advanced) non-small cell lung cancer has been typically treated with chemotherapy, which cannot cure the cancer but can lengthen survival and improve quality of life. Studies have shown that if the disease is stable (not growing) after first-line chemotherapy, immediate second-line treatment with a different chemotherapy drug (known as “switch maintenance”) can improve the outcome. Surgery and radiation therapy are used in some instances to relieve symptoms and improve quality of life or to prevent further complications.

Targeted therapy now offers an additional option for many people with advanced cancer. In order for it to be used, however, genetic testing must be done on the tumor sample, and the treatment depends on the results:

  • If the tumor tests positively for the EGFR mutation, options for targeted therapy include afatinib (Gilotrif), erlotinib (Tarceva) and gefitinib (Iressa).
  • If the tumor tests positively for ALK rearrangement, treatment with crizotinib (Xalkori) is recommended; ceritinib (Zykadia) can be used if the disease fails to respond to crizotinib.
  • If the tumor tests negatively for the EGFR mutation and ALK rearrangement, a platinum-based chemotherapy combination is recommended for people healthy enough to tolerate the drugs. People who are not healthy enough may receive a single drug or palliative therapy with radiation therapy, surgery or other supportive measures. If the cancer is a type other than squamous cell carcinoma, bevacizumab (Avastin) added to the platinum-based chemotherapy is an option.

If you have Stage IV lung cancer, talk to your doctor about supportive care. Studies have shown that supportive care not only enhances your quality of life but also extends survival.

Small cell lung cancer

Stage I-IIIB

Surgery followed by chemotherapy is often given with curative intent for Stage I or IIA disease (although small cell lung cancer is rarely detected at this early stage). Concurrent chemoradiation is typically given with curative intent to people who have Stage I or IIA disease but are not surgical candidates, or to people who have Stage IIB, IIIA or IIIB disease. If the cancer responds to treatment, radiation to the brain is given to prevent the return of lung cancer in the brain and to prolong survival.

Stage IV

Chemotherapy is the primary treatment for Stage IV disease or for earlier-stage disease that recurs after initial therapy. If the tumor responds to therapy, radiation therapy to the brain is given to prevent the return of cancer in the brain and to prolong survival. Radiation to the brain may also be given after chemotherapy if there is a good response to chemotherapy. Other types of radiation and surgical therapies may be used as palliative treatment to relieve symptoms and to improve quality of life.

Recurrent disease after surgery

In some instances, early-stage cancer recurs (comes back). The recurrence may be at a local site in the chest or at a site distant from where the primary tumor was found. If cancer recurs in or around the lungs and it’s considered resectable, surgery may be done, followed by radiation therapy with or without chemotherapy. If the recurrence includes lymph nodes in the chest, concurrent chemoradiation therapy is an option. If the recurrence is outside the original lung cavity, the treatment choices are the same as the options for cancer that is Stage IV at the time of diagnosis.

Metastatic disease

Two of the most common sites of metastasis from lung cancer are the brain and bone.

Brain metastasis – Chemotherapy may not be effective for cancer that has spread to the brain because of the blood-brain barrier, which is a membrane (thin lining of tissue) that protects the brain by preventing substances in the blood, such as drugs, from entering the brain. Therefore, local therapies are often used, and the choice of treatment depends on the number and location of the metastatic tumors. If there is a single metastatic site in the brain, surgery followed by whole-brain radiation therapy may be done. Another option is stereotactic radiosurgery (also known as Gamma Knife or CyberKnife). This approach is primarily used only when no more than three small metastatic tumors are present. Because the radiation is delivered precisely to the metastatic site, side effects are less likely to occur with stereotactic radiosurgery than with whole-brain radiation therapy.

Whole-brain radiation therapy is usually the treatment of choice for people with more than three metastatic brain tumors. Corticosteroids are usually given with the radiation to limit swelling in the brain, and the drugs may be discontinued after the treatment effects are over. If a person has had any type of seizure, medications are given to prevent future seizures. If the metastases are small and cause no symptoms, chemotherapy or targeted therapy may be used because enough of the drug may cross the blood-brain barrier to be effective.

Bone metastasis – The spread of cancer to bone can cause the loss of bone mass. This condition occurs when the bone cells that help rebuild bone don’t get replaced at the same rate as bone cells that naturally break down bone. Bones become thin and full of tiny holes and are more likely to break or cause pain and disability.

Radiation therapy can be used to relieve pain and help prevent or treat fractures, especially if the involved bone is a weight-bearing one. Radiation beams are targeted to the area of the metastasis, and relief of symptoms is usually immediate and complete. If you’ve had a fracture or your doctor thinks you’re at a high risk for one, orthopedic surgery may be recommended.

Two drugs are also available to help prevent this loss of bone mass: zoledronic acid (Zometa) and denosumab (Xgeva). Treatment with either of these drugs will help prevent bone fractures and can reduce the need for radiation to alleviate bone pain. These medications are usually given with each cycle of chemotherapy and are sometimes given to maintain bone health in people who no longer need chemotherapy.

Importance of clinical trials

Clinical trials are essential for evaluating new treatments that will improve outcomes for people with lung cancer. Clinical trials are safe and conducted under the care of physicians and other research professionals. They’re sponsored by government agencies, such as the National Cancer Institute, by individual doctors and health care groups, or by the pharmaceutical or biotechnology companies that developed the treatments.

People who volunteer for a clinical trial gain access to new treatments before they’re available to the general public, and they can take an active role in their own health care and help others by participating in medical research.

To find a clinical trial that may be right for you, first ask your treatment team if they can suggest a trial that might benefit you. In addition, a number of government and private groups have listings of clinical trials and information.

 

 

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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