The most common options for lung cancer treatment are surgery, chemotherapy, and radiation therapy. The treatments can be used alone or in combination. The choice depends on the size and location of the tumor, whether the cancer is small cell or non-small cell, the physical condition of the person being treated, and whether the cancer has spread to or beyond the lymph nodes.
Because of the complexity of treatment, you should discuss your options with a multidisciplinary team of experts, including a pulmonologist, a thoracic surgeon, medical and radiation oncologists, and other health professionals.
Everyone who has lung cancer should be evaluated for possible surgery because that is the most effective treatment for non-small cell lung cancer (NSCLC). The major factors that affect whether someone is a good candidate for surgery are how resectable the tumor is and whether the operation is even possible considering the condition of the person who has the cancer.
A resectable tumor is one that can be removed in its entirety. If the tumor has spread extensively or involves vital structures, such as the heart or major blood vessels, it is no longer resectable. The decision that a tumor is not resectable is usually based on information from the biopsy and scans.
Before an operation can take place, the patient must be deemed capable of undergoing the surgery safely and of tolerating the extent of resection necessary for a cure, taking into account other key factors such as lung function and the presence of other diseases.
Surgery may involve removal of a lobe or an entire lung. If the tumor is very small, the surgeon may remove a wedge-shaped piece of the lung, an operation called a wedge resection. A hospital stay of up to one week is usually required. People with otherwise healthy lungs can often resume normal activities after a period of recuperation. Most people need two to six months to recover.
Video-assisted thoracoscopic surgery (VATS) is a type of surgery for people with early-stage lung cancer. A tiny camera is placed through a small hole in the chest to help the surgeon see the tumor. The surgeon then makes one or two additional small holes in the skin and passes instruments through these openings to remove the tumor. Because only small incisions are needed, patients generally experience less pain after surgery. The cure rate appears to be the same as that for standard surgery.
Recent research indicates that survival in people with early-stage non-small cell lung cancer is slightly improved when surgery is followed by chemotherapy.
Chemotherapy drugs work by killing cells that are actively dividing, a process that occurs more frequently in cancer cells than in most other cells; the goal is to kill the cancer cells without doing too much damage to healthy cells.
Undergoing chemotherapy is a highly individualized process and may involve taking a combination of drugs given in four to six cycles. Platinum-based chemotherapy, which entails using cisplatin (Platinol) or carboplatin (a less toxic platinum drug), prolongs survival and improves symptom control in patients with non-small cell lung cancer.
In addition to one of these, a second drug may be included in the regimen. Possibilities include pemetrexed (Alimta), which is for a specific type of non-small cell lung cancer known as adenocarcinoma; gemcitabine (Gemzar); vinorelbine (Navelbine); paclitaxel (Taxol); or docetaxel (Taxotere).
Chemotherapy regimens usually cause temporary but sometimes severe side effects that may include nausea, vomiting, loss of appetite, hair loss, mouth sores, diarrhea, fatigue, low resistance to infection, and possible bleeding. Some of the newer chemotherapy drugs and the combinations in which they are used caused fewer and less distressing side effects than those administered in the past.
For small cell lung cancer, cisplatin or carboplatin plus etoposide (VePesid, Etopophos) is usually considered the optimal chemotherapy regimen, but researchers are studying other combinations. Some studies have found that combinations with fewer severe side effects, such as gemcitabine with vinorelbine or paclitaxel, may be just as effective for many patients.
The search continues for better alternatives, and researchers have been making some progress with targeted therapy and immunotherapy.
3. Targeted therapy drugs
Unlike standard chemotherapy, which kills some healthy cells, targeted therapies are designed to attack cancer cells specifically—the cells of a particular tumor. At present, only about 20 percent of patients can benefit from targeted therapy, and the only way to tell which patients can do so is to conduct a molecular profile of their cancer cells.
Targeted therapies involve taking a daily pill. They can come with side effects, including an acne-like rash on the face and back, tiredness, mouth sores, and diarrhea.
If your doctor thinks you might benefit from targeted therapy as a lung cancer treatment, he or she will send a sample of your tumor to be analyzed for certain genetic or protein biomarkers on the cancer cells.
For example, the targeted therapy drug erlotinib (Tarceva) has been shown to modestly prolong survival in people with non-small cell lung cancer having a mutation in the epidermal growth factor gene (EGFR). Erlotinib can be used as a first-line therapy in EGFR mutation–positive patients.
Crizotinib (Xalkori), another targeted therapy approved for treating non-small cell lung cancer, is indicated as a first- or second-line therapy in patients who have a genetic mutation known as echinoderm-microtubule-associated protein-like 4 and anaplastic lymphoma kinase (EML-4 ALK) rearrangement. In a 2010 study published in The New England Journal of Medicine, over half of 82 patients taking crizotinib experienced tumor shrinkage, and in one patient, the tumor disappeared completely.
Another targeted therapy, ceritinib (Zykadia), was approved by the Food and Drug Administration in 2014. Ceritinib is indicated for the treatment of patients who have ALK-positive metastatic non-small cell lung cancer and whose disease has progressed while taking Xalkori or who are intolerant to it.
Bevacizumab (Avastin), in combination with standard chemotherapy, is approved as an initial treatment for advanced nonsquamous non-small cell lung cancer. When added to standard chemotherapy regimens as part of first-line lung cancer treatment, Avastin has been shown to prolong survival in individuals with advanced lung cancer. Because Avastin can cause internal bleeding, it cannot be used by people at high risk for that condition, such as patients using blood thinners. Research suggests that combining Tarceva and Avastin improves survival compared with that of patients taking Avastin plus standard chemotherapy or chemotherapy alone.
Cetuximab (Erbitux), used in addition to standard chemotherapy, is another first-line treatment for some individuals who have advanced lung cancer. Like Tarceva, Erbitux works by targeting a mutation in the EGFR gene.
Some other targeted therapy drugs approved for treating lung cancer include ramucirumab (Cyramza), necitumumab (Portrazza), afatinib (Gilotrif), gefitinib, (Iressa), osimertinib (Tagrisso), and alectinib (Alecensa).
Like any cell, cancer cells can evolve, and they sometimes develop resistance to the drugs used to fight them. When this happens with targeted therapy, chemotherapy or other targeted drugs may be used.
External beam radiation therapy is the main form of treatment for people who are unable to tolerate surgery and for those whose cancer has spread beyond the reach of surgical removal. The standard course of radiation treatment for lung cancer is five days a week for four to eight weeks.
Radiation may be directed to areas of cancer in the lung that cannot be removed with surgery, or it may be used to treat cancer that has spread to the brain or bones, or that compresses the spinal cord. Side effects of external beam radiation therapy include nausea and vomiting, local skin irritation, and fatigue.
Immunotherapy is one of the newest approaches in the cancer treatment arsenal. The job of the body’s immune system is to kill cancer cells, but sometimes the cancer cells manage to evade the immune system (cells involved in the immune system response are called T-cells). Rather than using drugs to kill cancer cells, immunotherapy uses drugs to help your own immune system identify and kill your cancer cells.
Two drugs—nivolumab (Opdivo) and pembrolizumab (Keytruda)—were recently approved by the FDA for use in a very select group of patients with non-small cell lung cancer that has spread in spite of other treatments. They are typically given by intravenous infusion every two or three weeks. More common side effects are cough, fatigue, rash, nausea, joint pain, and diarrhea. But side effects can sometimes be more severe.
Bob T. Li, M.D., a medical oncologist and lung cancer specialist at Memorial Sloan Kettering Cancer Center in New York City, explains: “Immunotherapy revs up the immune system, so it can cause autoimmune-like reactions, conditions like colitis, dermatitis, hepatitis, and thyroiditis. In these cases, we may have to give steroids to calm the immune system. When these reactions are severe and life-threatening, we have to stop the treatment. Fortunately, that isn’t common.”
Researchers have been studying a lung cancer vaccine known as human melanoma antigen-A3 (MAGE-A3) Antigen-Specific Cancer Immunotherapeutic (ASCI), which appeared to trigger the patient’s immune system to identify and attack cancer cells without harming normal cells. Preliminary results from a clinical trial of this vaccine, called MAGRIT (MAGE-A3 as Adjuvant, Non-Small Cell Lung Cancer Immunotherapy), were promising. However, more recent results were disappointing and the trial was discontinued. Investigators plan to review the accumulated data with the hopes of identifying a subgroup of patients that may have benefited from this lung cancer treatment.