Lung Cancer Overview
Lung cancer is the most frequently diagnosed cancer in the United States. If you have been diagnosed with advanced (also called late-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 patient treatment summary, which is based on the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™), will help you understand the best available treatments for non-small cell lung cancer that has spread beyond the lungs. 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 I, II, or IIIA non-small cell lung cancer, please see the separate summary for early-stage non-small cell lung cancer
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Background
Non-small cell lung cancer is the most common type of lung cancer. Several different types of lung cancer 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.
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Adenocarcinomas: the most common type of non-squamous cell cancer, which means they arise in glandular tissue that lines parts of the lungs that make mucus and other substances
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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 advanced non-small cell lung cancer.
Lung cancer most often occurs in people who currently 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 at an advanced or 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 (for example, current or past smokers). Lung cancer has a better chance of being cured when it is found at an early stage. However, treatments are available for even advanced lung cancer to enable you to live a longer, higher-quality life.
Diagnosing Lung Cancer
Many lung cancers are found accidentally when a patient has a chest x-ray or CT scan for another reason. Although lung cancer can have few symptoms, some patients may experience a cough that does not go away, wheezing, chest discomfort, streaks of blood in mucus they cough up, hoarseness, weight loss, or fatigue, and see their doctors for these problems.
It is important that your doctor confirm the type of lung cancer you have (non-small cell or small cell) because different types of lung cancer require different treatments.
Non-small cell lung cancer that has spread (metastasized) to your bones, brain, or other organs in the body is still lung cancer. If you were previously diagnosed with non-small cell lung cancer, any signs of cancer in your liver, bones, brain, or other sites are much more likely to be caused by lung cancer that has recurred than to be new cancers at those sites.
It is also important that all sites of metastasis are identified, because this can influence treatment recommendations.
Likewise, some cancers, such as breast cancer and prostate cancer, can metastasize to the lung; these are treated according to the site where the cancer originated, rather than being treated as lung cancer. Therefore, if your cancer has spread to the lung from another location, you will receive different treatment than that given to people whose cancer started in the lung.
To diagnose lung cancer, your doctor will usually start with tests, 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 or sites to which the cancer has spread.
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 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 answer a number of questions, which your doctor needs to know to develop a treatment plan:
- 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 elsewhere in the body and spread to the lungs, in which case different treatment will be required.
- 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 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 cancers 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 found to be more extensive than initially thought or if it recurs after treatment.
Your doctor will also do tests to find out whether the cancer has spread to other organs. One of these tests is a PET/CT scan to locate possible spread of the cancer. If the PET scan shows a suspicious area, your doctor will likely recommend a biopsy to see whether it is cancer because there can be other less serious causes of a positive PET scan like inflammation. The doctor probably will also recommend an MRI of the brain to find out whether the cancer has spread there; the brain is a common site for lung cancer to spread.
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. 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, and 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 that your cancer can be cured. Even with late stage lung cancer, however, new treatments may be available to help you live a longer, higher-quality life.
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, also called advanced). The 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. The system used for staging has recently changed. The most significant change for people with advanced lung cancer is that pleural effusions which were formerly considered stage IIIB disease are now classified as stage IV.
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. Locally advanced lung cancer refers to stage III non-small cell lung cancer.
A diagnosis of stage IIIB lung cancer means the cancer has not spread to distant organs, but it does involve:
- Tumors that extend into other structures in the chest
- More than one tumor in the lung with or without lymph node spread
- Cancer in the lymph nodes on the other side of the chest from the original lung tumor
A diagnosis of stage IV lung cancer means the cancer has spread to other parts of the body; the size of the tumor is not relevant for a diagnosis of stage IV.
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.
A team of doctors will work together to manage your cancer. Usually, a medical oncologist, radiation therapist, surgeon, pathologist, and a radiologist will be involved at some point during your treatment. Good communication among your doctors is essential to ensure that your various treatments are coordinated in ways that make them most effective.
The goal of treatment for patients with advanced disease is to reduce the amount of cancer, slow its growth, and minimize symptoms associated with the disease and its treatment to let you live a longer, higher-quality life. Some patients with stage IIIB cancer may even be cured if all the cancer can be removed. Frequently, several treatments working together are needed to control your cancer and reduce the symptoms of advanced disease.
Most patients with advanced disease will have some form of systemic therapy; that is, drug therapy that goes throughout your body to kill or slow the growth of cancer cells. Some people may have a specific type of systemic therapy called targeted therapy, which is discussed below, to disrupt processes that encourage the growth of cancer cells.
Depending on your particular situation, you may also receive local therapies, such as surgery or radiation therapy, to remove or kill the tumor in the lung and possibly remove isolated tumors in other places in your body.
Stage IIIB lung cancers have a high risk for recurrence; therefore, local therapies are used to remove the tumor and are combined with systemic therapies such as chemotherapy to reduce the chance of recurrence or spread to other parts of the body. Because the disease has already spread to other parts of the body in patients with stage IV lung cancer, these patients are also treated with systemic therapy, sometimes in combination with local therapies.
The treatments that are best for you will be influenced by your general health. Your doctor will determine your performance status, which assesses how many normal physical activities you are able to perform. For example, performance status 1 indicates that you cannot do heavy physical work but can do almost anything else. If you can do most of your regular activities, you will probably be able to stand more intensive treatment. If you are unable to perform many normal activities, you will need milder treatments. If the restrictions on your activities are caused by the cancer and not from some other health problem, these milder treatments may help you to become well enough to handle the more intensive treatments later. To make the best decision, you will want to discuss the benefits, risks, and possible side effects of each treatment with your doctor.
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.
People with advanced lung cancer may need some or all of the types of treatments discussed below.
Surgery
Most people with stage IIIB lung cancer are not able to have surgery; however, sometimes the cancer can be removed surgically, either as a first treatment or after preoperative chemoradiation (using certain types of chemotherapy drugs to make radiation therapy more effective) or chemotherapy alone. Surgery will be followed by chemotherapy with or without sequential radiation therapy (that is, radiation given before or after chemotherapy, but not at the same time) or by chemoradiation and chemotherapy to reduce the high risk for recurrence.
Surgery may also be considered for patients with stage IV disease if the cancer is isolated and can be completely removed. For example, some patients with one or two cancer growths in the brain are candidates for surgery to remove these tumors and the lung tumor if they have no other spread of cancer. These patients are also treated with chemotherapy to kill any small amounts of cancer that may remain but cannot be seen.
Radiation Therapy
Radiation therapy involves the use of high-energy beams that kill cancer cells, shrink the tumor, and/or decrease obstruction of major blood vessels or bronchi. It can also be used to relieve pain and stop internal bleeding.
Chemotherapy
Chemotherapy is a single drug or a combination of drugs (called a regimen)—such as carboplatin and paclitaxel—used to destroy or slow the growth of cancer cells throughout your body. It is especially useful for late-stage cancer that has spread beyond the lungs. It is also used to shrink locally advanced lung cancer with the goal of making surgery possible, and used after local therapies to kill any cells that remain after treatment. Some chemotherapy drugs also can be used to make radiation therapy more effective; this type of treatment is called chemoradiation.
Chemotherapy may be given through injection into a vein (intravenously) or taken orally, depending on the drug. It is usually given in cycles over a period of months.
If you are to receive chemotherapy intravenously, you will probably go to your doctor’s office for treatment. You likely will have blood drawn beforehand so that your doctor can make any necessary adjustments in your chemotherapy. You also may be given drugs to decrease the side effects of your chemotherapy. These drugs do not alter the effectiveness of your chemotherapy; they simply make you feel better during treatment.
The chemotherapy cycles are usually given several weeks apart. While you are on therapy, you will have periodic tests and scans to monitor the progress of your treatment. If one type of chemotherapy becomes ineffective over time, you and your doctor may decide on a different course of therapy using different drugs. Over time, you may have several different chemotherapy regimens, taking each one until it becomes ineffective and then moving on to another. See the Guide to Chemotherapy.
Chemoradiation
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 surrounding the tumor to which cancer may have spread—can be difficult to remove and still preserve good lung function. Chemoradiation is used to help shrink the lung tumor so that it can be more effectively removed during surgery.
After surgery, chemoradiation may be given to kill any remaining tumor cells in the area where the tumor was removed and to prevent 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.
Targeted Therapy
Some treatments attack certain markers on tumor cells or certain processes occurring in tumor cells. For example, Avastin (bevacizumab) attacks a substance that helps blood vessels grow. Bevacizumab is believed to help decrease the production of new blood vessels supplying the tumor or tumors, thereby helping to "starve" the tumor of nutrients. Other drugs, such as Erbitux (cetuximab) or Tarceva (erlotinib), interfere with cancer growth processes occurring in tumor cells. Combinations of chemotherapy and targeted therapy are used frequently for advanced non-small cell lung cancer.
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.After radiation therapy, people often feel fatigued or unusually tired; some may experience shortness of breath. Your health care provider can use the NCCN Guidelines
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for Cancer-Related Fatigue (see NCCN Guidelines ) to help you reduce fatigue caused by cancer treatments. Also, see Fighting Cancer Fatigue.
- After chemotherapy or chemoradiation, people may develop intestinal disturbances, 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 101o, 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 Guidelines for Antiemesis can help your physician determine the most appropriate antiemetic regimen for your situation.
- Targeted therapies (such as bevacizumab or cetuximab) can also cause side effects. For example, bevacizumab can cause a rise in blood pressure or internal bleeding. Cetuximab may cause skin rash.
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 that they can reassure you that the effects are normal, take steps to relieve them, or investigate them further if necessary.
Your doctor may recommend that you receive treatment to relieve disease- or treatment-related symptoms and to control pain. See Palliative Care Gets New 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.
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 type and stage of cancer you have
- Your response to the treatment(s) being used
New therapies and combinations of therapies are enabling people with lung cancer to live longer, better-quality lives than ever before. Ask your doctor which treatment(s), in his or her judgment, will give you the best life expectancy and quality of life. You may want to see whether you are eligible to participate in a clinical trial, in which new and experimental therapies are compared with standard therapies.