Lung cancer is the most frequently diagnosed cancer in the United States. If you have been diagnosed with early-stage non-small cell lung cancer, you probably have many questions and concerns about your disease, how it is likely to be treated, and what happens when treatment is completed. This summary for patients, which is based on the NCCN Clinical Practice Guidelines in Oncology™, will help you understand the best available treatments for non-small cell lung cancer that is confined to the lungs (in other words, has not spread beyond the lungs; early stage). Talk to your doctor about these options so that together you can decide on a treatment plan that is right for you.  

If you have been diagnosed with stage IIIB or IV non-small cell lung cancer, please see the summary for advanced (late-stage) non-small cell lung cancer.

Background

Non-small cell lung cancer is the most common type of lung cancer. Several different types of cells are collectively called non-small cell lung cancer.  They are grouped this way because their characteristics are very different from those of small cell lung cancer, which is discussed in a separate summary. Non-small cell lung cancers are divided into two main categories: non-squamous cell (most common) and squamous cell.

• Adenocarcinomas: the most common type of non-squamous cell cancer, which means they arise in glandular tissue that lines parts of the lungs and makes mucus and other substances
• Squamous cell cancer: arises in scalelike cells that cover the lining of the lungs 
• Large cell: arises in several types of large cells in the lungs

Knowing the specific cell type of the lung cancer is important, because it will help your doctor select the exact types of treatment that are right for you. This summary discusses the treatments for early-stage lung cancer.  

Lung cancer most often occurs in people who currently smoke or previously smoked cigarettes or cigars. However, it can also occur in people who have never smoked or have not been exposed to other risk factors, such as second-hand smoke, asbestos, radon, or other environmental hazards.

If you currently smoke, it is very important that you stop because smoking can further reduce your lung function, which is already impaired by lung cancer. Smoking also delays healing after surgery.

Non-small cell lung cancer is often diagnosed in a late stage (for example, stage IV), when it has spread beyond the lungs. Thus, scientists are working to develop screening tests to detect early-stage lung cancer in people who do not have symptoms but are at high risk (such as current or past smokers).  Lung cancer has a better chance of being cured when it is found at an early stage.

Diagnosing Lung Cancer

Many early-stage lung cancers are found accidentally when a patient has a chest x-ray or CT scan for another reason.  Although very early-stage lung cancer usually has few symptoms, some patients experience a cough that does not go away, wheezing, or chest discomfort and see their doctor for these problems.

To diagnose lung cancer, your doctor will usually start with tests (including imaging such as a chest x-ray or CT scan) to see whether you have a mass in your lungs. 

If an abnormality is noted, the only sure way to confirm or rule out cancer is to perform a biopsy, a procedure in which a sample of tissue from the suspicious area in the lung is removed and examined under a microscope to identify disease. A sample of tissue also may be taken from nearby lymph nodes. 

Lymph node biopsy can be performed using different methods depending on the location and accessibility of your cancer.  In some cases, the lymph nodes can be examined and removed using bronchoscopy.  In this procedure a thin, tube-like instrument with a light and a lens and a cutting tool is inserted through the mouth, through your trachea (windpipe), and into your lungs.  The doctor is able to look at your lungs and remove abnormal looking tissue for examination.  In other cases, the lymph nodes are viewed using mediastinoscopy, a procedure in which an incision is cut above your breast bone and a thin, tube-like instrument with a light source, a lens, and a cutting tool is inserted so that your doctor can examine areas that are not accessible using a bronchoscope.

All of these samples are sent to a pathologist to determine whether the abnormal area is in fact cancer and, if so, the type of cancer and whether there is evidence that the cancer has spread to the lymph nodes. 

The pathology findings provide number of answers that your doctor needs to develop a treatment plan, such as:

• Whether the cancer started in the lung or some other part of the body: tests on the tumor will help distinguish between lung cancer that started in the lungs and another type of cancer (such as breast or kidney cancer) that started somewhere else and spread to the lungs, in which case different treatment will be needed
• Where the lung cancer began, for example, in the bronchi (tubes from the trachea [windpipe] to the lungs) or alveoli (air-filled sacs in the lungs where the body takes in oxygen)
• Whether the cancer is noninvasive (localized to the layer of tissue where the tumor started) or invasive (has spread into the lung tissue and perhaps beyond)
• The grade of the tumor cells; that is, how much the cancer cells resemble healthy cells under a microscope. Generally, grade 1 lung cancer looks more like normal lung cells, whereas grade 3 does looks very different from normal lung cells.  The higher the grade, the more aggressive the cancer is likely to be
• Whether important lung cancer tumor markers are present in or on the tumor cells, especially EGFR (epidermal growth factor receptor) mutations. Because cancer cells with different markers respond differently to different drugs, the presence or absence of certain tumor markers helps determine the type of treatment that is most likely to be effective for you. These tests are important for selecting treatment for advanced disease but are also done in early-stage disease so that the information is available if your cancer is later found to be more extensive than initially thought or if your cancer recurs after treatment

Your doctor will also need to know about your general health and will recommend tests to determine how well your lungs and other vital organs are functioning.  This information will help your doctor recommend the treatments that are likely to be safest and most effective for you.

Staging

Staging is a formal system for identifying how localized or widespread your cancer is.  For non-small cell lung cancer, the stages range from stage 0 (most localized) to stage IV (spread to distant organs in your body). 

The  stages describe whether the cancer is confined to the lung (early-stage) or has spread to other organs (late-stage, which is also called advanced). Stage is determined from the sample of tissue obtained from your lung or lymph nodes and from imaging studies that show whether cancer has (or has not) spread to other organs. The stage of a tumor is described with a numbering and lettering system. For example, people with stage IIB lung cancer have more extensive disease (larger tumor size) than those with stage IIA lung cancer. See the Cancer Staging Guide for more information. 

Stage 0 is noninvasive lung cancer; that is, it has not grown into the lung tissue and has not had an opportunity to spread.  It is very uncommon.  Stages I to IIIA are considered early-stage lung cancer; stages IIIB and IV are late stages. Note that locally advanced lung cancer refers to stage III non-small cell lung cancer.

Staging is an important part of developing the best treatment plan for you. In general, the lower the stage of disease, the better the chance is that your cancer can be cured; the higher the stage, the less likely it is that your cancer can be cured.  Staging is used both to help your doctors make treatment decisions and to provide you and your doctors with information about what typically happens to patients with cancers most like yours.

For a more detailed discussion of staging, see the Cancer Staging Guide.

Treatment of Lung Cancer

No single lung cancer treatment is right for everyone. People with very similar cancers may require or choose different types or combinations of treatments. In addition, certain treatment options may be appropriate at one point but not another.

You can make the best treatment decision by discussing the benefits, risks, and possible side effects of each treatment described below with your physician. 

The goal of treatment for patients with local disease is to cure the cancer.  Sometimes several treatments working together are needed to increase the chance that you can be cured. 

Treatment for stage 0 non-small cell lung cancer involves surgical removal of the tumor or removal through an endoscope using photodynamic therapy. 

Stages I, II, and IIIA lung cancers are managed by several different physicians working together and using a variety of treatments to make sure you have the best chance for a full recovery.  Treatments used for early-stage non-small cell lung cancer are:

• Surgery: removing diseased parts of your lung
• Chemotherapy: using drugs to kill or slow the growth of cancer cells including any that have broken away from the original tumor
• Radiation therapy (or radiotherapy): using high-energy beams to kill tumor cells
• Chemoradiation: using certain types of chemotherapy drugs to make radiation therapy more effective. These drugs are also effective against tiny metastases outside the radiation therapy field

These treatments are frequently used in combination to give you the best possible chance that your lung cancer can be cured and to enable you to live a longer, healthier life.

Your doctor should provide you with a written care plan explaining what treatments you will have, when they will occur, how often (if you will have chemotherapy or radiation), and what side effects you may experience.  Some side effects can be anticipated, and you can have treatment to reduce their severity. 

You will be asked to sign an informed consent document indicating that you have been told about your treatment and what to expect.  

It is very important that you ask your doctor or nurse every question you have.  Lung cancer and its treatment are complicated, and most patients have questions.

Surgery

Whether surgery is appropriate for you depends on your general health (for example, surgery may not be appropriate for people with severe heart disease) and on the specific location and characteristics of the tumor.  If cancer has not spread to your lymph nodes, your doctor may recommend surgery as your initial treatment.  Deciding when surgery should be performed is a complex decision; good communication is essential among you, your surgeon, your medical oncologist, and your radiation oncologist.

The goal of surgery is to remove the entire tumor (and surrounding tissue that may contain cancer cells).  If the initial surgery does not produce “clear margins” (an area of cancer-free tissue around the entire site where the tumor was removed), a second surgery may be needed.  Removing all the cancer surgically provides a good chance of curing it.  If possible, surgery may be your first treatment.

Thoracic (chest) surgeons dedicate much of their practice to cancer therapy. If a skilled surgeon believes it will be difficult (but potentially possible) to remove the entire tumor and have clear margins, radiation therapy may be used in combination with chemotherapy (usually called chemoradiation) to shrink the tumor before surgery. This makes it easier to completely remove the tumor. 

After surgery, even with clear margins, your doctor may recommend radiation, chemoradiation, or chemotherapy alone to kill any cancer cells that may remain after surgery or that have broken away from the main tumor and gone elsewhere in your body, before they can grow into new tumors.  The NCCN Non-Small Cell Lung Cancer Guidelines (see NCCN Clinical Practice Guidelines in Oncology™) can help your physician determine which of these therapies could be beneficial for you.

Types of Surgery

Generally, one of two types of surgery is used for lung cancer: conventional open surgery or minimally invasive surgery.

• Conventional open surgery (involving a large incision in the chest to expose the diseased part of the lung) is used either to remove the tumor from the lung (segmentectomy, or removal of the diseased portion of tissue) or to remove the part of the lung that contains the tumor (lobectomy, or removal of the entire lobe where cancer is found), or removal of the entire affected lung (pneumonectomy).
• Minimally invasive surgery is used if the cancer is stage I or II.  In this procedure, tiny incisions are made in the chest, and the doctor views the chest and lung with a small video camera during surgery. This type of surgery results in a quicker recovery time than conventional surgery, and people experience less pain after surgery. However, this procedure is not appropriate for everyone and is not available at every treatment facility.  

In either case, your surgeon’s experience is very important.  Overall, thoracic surgeons who perform many lung cancer surgeries each year have better outcomes than those who perform only a few. 

Adjuvant Therapy

Although surgeons try to remove the entire visible tumor, they sometimes cannot see very small areas of cancer.  After surgery, adjuvant therapy, or therapy to help or assist, is given in addition to surgery to kill any cancer cells that may have spread beyond the tumor and reduce the risk that cancer will recur (that is, come back after treatment). Depending on the size and characteristics of your lung cancer, your doctor may recommend adjuvant chemotherapy, radiation therapy, or chemoradiation.

Some form of adjuvant therapy is recommended for most patients to reduce the chance of recurrence. However, your doctor may not recommend adjuvant therapy if your tumor is very small, no cancer was found in the lymph nodes, and the cancer has not spread to other sites.

Sometimes the tumor cannot be removed with surgery, or an operation may be too risky if you have certain health problems.  In this situation, your doctor may recommend combined chemotherapy and radiation to kill the tumor. 

Radiation and Chemotherapy

Combining chemotherapy and radiation into a single treatment is called chemoradiation. In this treatment, external-beam radiation therapy (radiotherapy) uses high-energy beams to kill cancer cells and shrink the tumor. Certain chemotherapy drugs (such as cisplatin and etoposide) are used to make the radiation therapy more effective.  Chemoradiation can be used before, after, or instead of surgery; it usually lasts about 5 weeks.

Chemoradiation, when administered before surgery, is especially effective in the treatment of lung cancer. A lung cancer tumor—and the lymph nodes around the tumor to which cancer may have spread—can be difficult to remove without damaging how your lung functions. Chemoradiation is used to help shrink the lung tumor so that it can be more effectively removed during surgery. It also is given to help prevent return of the cancer in the lungs and its spread to more distant sites.

Sometimes the tumor is in a place that it cannot be safely removed with surgery, or you may be unable to have surgery for medical reasons.  In this case, chemoradiation may be used as the primary therapy without any surgery. 

After surgery, chemoradiation is used as adjuvant therapy.  This is recommended when  your surgeons was able to remove the bulk of the tumor but could not get clear margins, or when you are at a high risk for recurrence based on the size or characteristics of your tumor.

A list of the chemoradiation therapy regimens that are recommended by the NCCN Lung Cancer Panel is available in the NCCN Non-Small Cell Lung Cancer Guidelines (see NCCN Clinical Practice Guidelines in Oncology ™).

Chemotherapy

Chemotherapy drugs are given to destroy or slow the growth of cancer cells. A single drug or combination of drugs, such as cisplatin and docetaxel, is given through injection into a vein (intravenously).

If you have chemotherapy after surgery, it will be called adjuvant. Studies have shown that adjuvant chemotherapy for lung cancer may increase the likelihood of long-term survival by preventing the recurrence of cancer.  Specific combinations of drugs have been tested in many patients with early-stage non-small cell lung cancer, and been found to be beneficial.  Adjuvant chemotherapy is usually given for about 3 to 4 months.

Although most patients with non-small cell lung cancer will need adjuvant therapy, not everyone with early-stage lung cancer will need to undergo chemotherapy.

Chemotherapy recommendations according to lung cancer stage for patients whose initial therapy was surgery are:

Stage I Lung Cancer

• Chemotherapy is usually not recommended for those with stage I lung cancer. 

Stage II Lung Cancer

• Chemotherapy after surgery is recommended for stage II cancer that has a low risk for recurrence (that is, clear margins). 
• Either chemotherapy or chemoradiation is recommended for patients with high-risk factors for recurrence, such as margins that are not clear (that is, there is some cancer around the entire area where the tumor was removed) or when cancer has been found in many lymph nodes.   

Stage IIIA Lung Cancer

• Chemotherapy is recommended followed by radiation therapy for stage IIIA lung cancer that was removed with clear margins. 
• Chemoradiation followed by chemotherapy is recommended if the margins are not clear, that is if there is not a complete layer of normal lung tissue around the entire area where the tumor was removed.

More information is available in the Guide to Chemotherapy. 

A list of the chemotherapy regimens recommended by the NCCN Lung Cancer Panel can be seen in the Non-small Cell Lung Cancer NCCN Clinical Practice Guidelines in Oncology ™.)

Radiation Therapy

Radiation therapy, which is usually given for a period of weeks, uses high-energy beams to kill cancer cells.  When given after surgery, it is usually preceded by chemotherapy.  Sometimes, if chemoradiation was given before anticipated surgery but surgery is still impossible, more radiation therapy will be given followed by more chemotherapy. 

Side Effects of Lung Cancer Treatment

Lung cancer treatments may result in uncomfortable side effects. Talk to your doctor about what to expect from each treatment and how to manage the possible effects. For example:

• After conventional surgery, people often experience pain. There is also a potential for wound infections, bleeding, pneumonia, and shortness of breath. Ask your doctor in advance how these can be avoided or minimized and what will be done to treat them if they occur. Although the side effects of minimally invasive surgery are generally mild, any troubling side effect should be reported to your doctor or oncology nurse.
• After radiation therapy, people often feel fatigued; some may experience shortness of breath. Your health care provider can use the NCCN Cancer-Related Fatigue Guidelines (see NCCN Clinical Practice Guidelines in Oncology™) to help you reduce fatigue caused by cancer treatments. Also, see Fighting Cancer Fatigue.
• After chemotherapy or chemoradiation, people may develop mouth sores, hair loss, fatigue, and/or loss of appetite.  You may also be prone to infections because chemotherapy drugs can reduce your infection-fighting white blood cell counts.  Your doctor may prescribe growth factors to help to maintain your white blood cell levels during therapy.  However, regardless of whether you are taking growth factors, if you have a fever over 101^o, contact your doctor or nurse immediately. 
• Nausea and vomiting are the most common side effects of chemotherapy and chemoradiation. Your doctor may give you antiemetic (anti-vomiting) drugs to decrease or prevent this symptom. The NCCN Antiemesis Guidelines can help your physician determine the most appropriate antiemetic regimen for your situation.

Talk to your doctor or oncology nurse about the best ways to manage side effects. It is important for you to discuss any possible side effects as soon as they occur so you can get help quickly.

Prognosis

In determining a prognosis—the likely course or outcome of a disease and its treatment—your doctor may look at lung cancer survival statistics taken from studies of large groups of patients. However, such statistics:

• Are estimates only
• Can vary widely with each cancer stage
• Are sometimes based on older data that do not reflect recent advances in early detection and treatment
• Cannot be used to precisely predict your survival

Your individual prognosis will be affected by many factors, including:

• Your age
• Your overall health
• The stage and grade of your cancer 
• Your response to the treatment(s) being used

Ask your doctor which treatment(s), in his or her judgment, will give you the best life expectancy and quality of life.

Clinical Trials

New therapies and combinations of therapies are enabling people with cancer to live longer, better-quality lives than ever before.  You may want to find out whether you are eligible to participate in a clinical trial, in which new and experimental therapies are compared with standard treatments.  More information is available in the Guide to Clinical Trials and Demystifying Common Clinical Trial Myths.

Life After Treatment

After completion of your treatment, you will begin a period called follow-up.  During this period, you will visit your doctor at regular intervals.  The doctor will perform a physical exam, ask how you are feeling, and order tests to ensure your continued good health.  If your cancer recurs (comes back), these visits will help your doctor to find the recurrence so that you can begin treatment as soon as possible. These visits to your doctor will give you a chance to ask questions and share your concerns.