Top Questions to Ask Your Doc About NSCLC Treatment
Let’s start with the truth: A diagnosis of advanced non-small cell lung cancer (NSCLC) is scary. You likely feel overwhelmed and maybe even a little hopeless. After all, there is no cure for NSCLC. But there are actually quite a few reasons to be very hopeful now, starting with the fact that treatment for advanced NSCLC has changed drastically in the last few years. Learning which options are available and what to expect will help give you a sense of control. Start with these questions you’ll want to ask your doctor.
Which Treatment Should I Try First?
If your tumor has a “driver mutation” (cells that have a genetic mutation that is driving them to divide and spread), the first-line treatment is a drug in a category called targeted therapy, says Afshin Dowlati, M.D., a professor of medicine and oncology at Case Western Reserve University in Cleveland, OH. These drugs target that mutation and aim to halt cancer-cell growth. For example, osimertinib is the standard of care targeting an EGFR mutation, adds Dr. Dowlati.
What If I Don’t Have a Driver Mutation?
Immunotherapy is the go-to treatment in patients without driver mutations, says Marina Chiara Garassino, M.D., director of the Thoracic Program at University of Chicago Medicine. Immunotherapy utilizes your immune system to battle cancer. For instance, the drug Opdivo (nivolumab) activates your body’s special immune cells (known as T cells) so they can attack cancer cells in your body. In other treatments, immunotherapy drugs help block certain proteins, thereby slowing or stopping tumor growth, especially in people who have a high percent of tumor cells with this particular protein.
What Is Combination Therapy?
Combination therapy involves prescribing multiple drugs together. These have a synergistic effect that makes treatment more effective than either drug alone in battling the tumor cells. For example, your doctor may prescribe two immunotherapy drugs or one of them plus chemotherapy, says Naomi Fujioka, M.D., a medical oncologist at the University of Minnesota Medical School in Minneapolis. Research shows that in some cases, immunotherapy drugs given with chemo have a better chance of a faster response and of the cancer shrinking compared with when immunotherapy is given alone.
How Will My Doctor Know Which Is Right for Me?
“There are three main things oncologists need to know before selecting treatment,” says Amy Cummings, M.D., a clinical instructor of hematology/oncology at the David Geffen School of Medicine at UCLA. First, your doctor will want to know the extent of the cancer (or where the cancer is in the body). Next, what are the characteristics of the cancer? (I.e., what does it look like under the microscope and what mutations does it have?) And finally, is this course of treatment is safe for you as a patient?
Will I Need Additional Tests?
Aside from a tumor biopsy, Dr. Cummings says scans (CT or MRI) and other tests, including blood tests to assess kidney and liver function and blood cells, are needed to determine the location and size of the tumor, and whether your body can adequately deal with drug therapy. Adds Dr. Cummings, “We want to be sure there are not any features that would put someone unduly at risk to receive the treatment we think is best.” These tests will be repeated after you’ve started therapy to make sure the treatment is not causing any issues and to see how the tumor is responding.
What Side Effects Can I Expect?
Every medication comes with a side effect. Both targeted therapy and immunotherapy can cause diarrhea or a skin rash; immunotherapy may also cause fever, fatigue, or nausea. Reducing your dosage or prescribing other medications may help diminish the side effects. “Even though serious side effects are rare on targeted therapy and immunotherapy, if something happens that is life-threatening, or if there is a side effect that is debilitating and affecting the quality of your life, the treatment should be discontinued,” says Dr. Cummings.
How Long Will I Need Treatment?
“The most important factor is how you feel on the treatment,” says Dr. Cummings. Also, your doctor will consider how long the therapy keeps the cancer under control. “There are plenty of people I know with advanced cancer who are still on the same drug and thriving several years later,” says Dr. Cummings. As far as we know, he adds, “there is no maximum time limit that someone can receive this type of treatment as long as they are feeling well and their cancer is under control.”
What Does “Maintenance Therapy” Mean?
“Maintenance therapy is meant to be tolerable long-term treatment that can be continued for years as long as you’re feeling well and your cancer is under control,” says Dr. Cummings. If, for example, you were taking a combination of drugs at first for a max effect, “continuing the same combination for months or years could lead to significant side effects with little additional benefit.” In those situations, your doctor may choose to continue one or two drugs from the initial combination if they think there’s a chance of the cancer returning quickly off therapy.
When Should I Consider Surgery?
In advanced non-small cell lung cancer, surgery usually does not play a role in management. But radiotherapy is a whole other thing. “We use localized radiation quite a bit for pain,” says Dr. Fujioka. That includes if the cancer has spread to bones. “[Furthermore], sometimes we treat specific lesions—one or two spots that are growing and other spots have stopped—with radiation. We troubleshoot individual spots,” adds Pradnya Patil, M.D., an associate staff at the Taussig Cancer Institute at the Cleveland Clinic in Ohio.
Immunotherapy: Molecular Cancer. (2020.) “Overcoming Immunotherapy Resistance in Non-Small Cell Lung Cancer (NSCLC): Novel Approaches and Future Outlook.” https://molecular-cancer.biomedcentral.com/articles/10.1186/s12943-020-01260-z
Combination Therapy: Cancer Discovery. (2021.) “Paradigms on Immunotherapy Combinations with Chemotherapy.” https://cancerdiscovery.aacrjournals.org/content/candisc/early/2021/03/12/2159-8290.CD-20-1312.full.pdf
Maintenance Therapy: The Patient - Patient-Centered Outcomes Research. (2019.) “Treatment Decisions for Advanced Non-Squamous Non-Small Cell Lung Cancer: Patient and Physician Perspectives on Maintenance Therapy.” https://link.springer.com/article/10.1007/s40271-018-0327-3