Your cancer treatment team likely uses the National Comprehensive Cancer Network (NCCN) cancer treatment guidelines to determine your treatment and care. For more information, visit nccn.org. Your specific treatment options will be based on your cancer’s particular type and stage, location, molecular characteristics, and your overall health. The most common treatments for lung cancer are surgery, radiation therapy and chemotherapy. Some patients with specific gene mutations in their tumors may be prescribed immunotherapy and targeted therapy drugs.
New treatment options are also being tested in clinical trials. If you are interested in learning more about clinical trials, talk with your doctor about the possibility of participating in one.
Surgery
Surgery, or having an operation, is the physical removal of the cancer tumor and any nearby lymph nodes that may contain cancerous cells. Ideally, a thoracic surgeon, an expert in lung cancer surgery, should perform this operation. If you need surgery, find a surgical center that performs a lot of lung cancer surgeries. Don’t be afraid to ask whether your recommended surgeon is a thoracic surgeon and how many lung cancer surgeries he or she does. Surgeons performing one or more lung cancer surgeries per week are recommended.
Whether you can be treated with surgery depends on:
- The type and stage of your cancer. Surgery is generally not recommended for cancer that has spread to other organs (stage IV NSCLC) or for SCLC.
- The location and size of your tumor. If the surgeon cannot safely remove your tumor, the disease is called inoperable, or unresectable, and surgery may not be an option (stage IIIB and some stage IIIA NSCLC).
- If you are otherwise healthy enough to have surgery. If you have heart or lung disease in addition to lung cancer, you may not be able to withstand surgery.
Traditional Surgery: If you have lung cancer surgery through the traditional, opened-chest approach, full recovery usually takes 6 to 8 weeks.
Less Invasive Surgical Approaches: Depending on the size and location of your tumor, you may be able to have lung surgery by a minimally invasive approach, either video-assisted thoracic surgery (VATS) or robotic-assisted thoracic surgery (RATS). This type of surgery is less invasive because it uses smaller openings and a video camera to guide the surgeon. This procedure results in less injury to your bones and muscles, and a shorter recovery time. Recovery time will vary depending on your particular surgery, your general health and how well you heal.
Types of surgery:
- Wedge resection: The surgeon removes a small wedge-shaped section of the lung containing the tumor and a small amount of healthy tissue around the cancer. This procedure allows you to maintain a majority of your lung function.
- Segmentectomy: One or more segments (regions supplied by distinct blood and air supply) of the lung that is affected by the lung cancer are removed. Typically, the amount of lung tissue and lymph nodes removed in a segmentectomy is more than in a wedge resection, but less than in a lobectomy.
- Lobectomy: The entire lobe (portion) of the lung affected by lung cancer is removed. The right lung has three lobes, and the left lung has two, so having a lobectomy allows you to maintain most of your lung function. This is generally the preferred procedure, although it depends on your unique situation.
- Pneumonectomy: The surgeon completely removes the lung with cancer. This must be done when the tumor is located in the lung’s largest airway or very near the trachea (wind pipe), or when the cancer affects more than one lobe of the lung. This procedure can significantly reduce lung function, but most people find they can get back to nearly normal activities with the help of physical and respiratory therapy.
Removal of Lymph Nodes: If you have surgery, your surgeon will likely also remove some lymph nodes from the lung and the center of the chest (your mediastinum) to check them for cancer cells. This will help your doctors determine if your cancer has spread elsewhere in your body and may change your staging and treatment plan. If cancer cells are found in the lymph nodes, chemotherapy may be recommended after your surgery.
Myth-Buster: Cancer Surgery
You may hear that cancer can spread if it is exposed to air during surgery, but this is not true. Some people may get this idea if the doctor finds more cancer during the surgery than was previously expected. Although doctors can usually get a very good understanding of the extent and location of cancer from scans and tests, these methods are not perfect. Occasionally, a surgeon will find more cancer than expected. In these cases, the cancer was already there, but wasn’t seen on previous scans or tests. Delaying or refusing surgery because of this myth could make it significantly harder for your cancer care team to treat your cancer.
Radiation Therapy
Radiation therapy (also referred to as radiotherapy, x-ray therapy, or irradiation) is the use of x-rays or other high-energy beams (such as protons) to damage cancer cells and stop them from growing or multiplying. Radiation treatment machines are directed to the tumor and the surrounding area and are “on” for a few minutes, delivering radiation that can kill tumor (as well as normal) cells. Like surgery, radiation is a local form of therapy and not a systemic (whole-body) treatment like chemotherapy or targeted therapy. High doses (amounts) of radiation are given when the tumor is confined to one area of the body, with the hope that the radiation will kill all of the tumor cells in that area. This treatment might involve daily doses of radiation for six weeks or longer.
If the cancer has spread from the lungs to other parts of the body, radiation may be given in smaller doses to relieve symptoms in affected areas, such as the brain, lungs or bones. Radiation given for periods ranging from one day to four weeks can kill enough cancer cells to bring relief from symptoms such as pain, breathing difficulties and headaches. A very focused form of radiation therapy, called radiosurgery, is sometimes offered if the cancer has spread to the brain or bones.
You may also hear the term stereotactic radiosurgery or SRS. This type of radiation therapy might be given in only one session. It can be used instead of or along with surgery for single tumors that have spread to the brain. Gamma Knife® is one example of a machine that focuses radiation on the tumor from different angles.
Specialized radiation therapy
Your radiation oncologist may recommend a special type of treatment called Stereotactic Body Radiation Therapy (SBRT) or Stereotactic Ablative Radiotherapy (SABR); these terms mean the same thing. SBRT/SABR uses radiation from multiple angles, which allows higher doses of radiation to be precisely focused on the tumor, avoiding healthy tissue. SBRT/SABR can be used totreat some localized tumors in people who cannot have surgery due to other health conditions or to treat some tumors that cannot be surgically removed because they are in a difficult location. SBRT/SABR can be performed with many different types of machines, and different options may be presented to you depending on the machines available at a given treatment location.
CyberKnife® is the brand name for a system that uses high-precision radiosurgical and SBRT procedures.
Endobronchial brachytherapy is another specialized form of radiation that may be recommended when tumors are present in the airway (bronchi or trachea). A small catheter (tube) placed via a bronchoscopy delivers highly localized radiation to the tumor while sparing nearby healthy tissue.
Chemotherapy
Chemotherapy drugs are medications that travel through the bloodstream to kill cancer cells throughout the body. Unlike surgery and radiation, which are used to treat disease locally, chemotherapy is systemic; it can affect cancer cells throughout the body.
A number of different chemotherapy drugs are used for lung cancer, including, but not limited to:
- cisplatin
- carboplatin
- docetaxel (Taxotere®)
- etoposide (VP16, Vepesid®)
- gemcitabine (Gemzar®)
- nab-paclitaxel (Abraxane®)
- irinotecan
- paclitaxel (Taxol®)
- pemetrexed (Alimta®)
- topotecan (Hycamtin®)
- vinoblastine
- vinorelbine (Navelbine®)
Generally, one platinum-containing agent (cisplatin or carboplatin) is combined with a non-platinum drug. Additional or different combinations of therapies may be prescribed by your doctor depending on her/his expert opinion on what is likely to work best for you. Still more drugs are in development, and these may be available after the printing of this booklet.
These drugs are administered through the veins (intravenously or through an IV) or taken orally as pills. Usually, chemotherapy drugs are given for four to six “cycles.” Generally, each cycle is about three to four weeks in length and chemotherapy may be given one or several days within the cycle. However, depending on your particular cancer and overall health, your doctors may recommend a different schedule for your treatment.
Continuing a drug or using a different drug after the initial course of chemotherapy, often called maintenance therapy, can help treat the cancer and may prevent it from spreading. However, not every person can manage the side effects of these drugs so soon after initial treatment. Your treatment team will work with you to decide whether maintenance therapy is right for you.
Many people are concerned about theside effects of chemotherapy. It is important to know that different types of cancers are treated with different types of chemotherapy, and that chemotherapy has changed a lot over the years. If someone tells you what they or a friend went through, remember that your cancer and your treatment — and therefore your experience — may be very different.
Targeted therapy
Scientists have made many discoveries about what makes cancer cells multiply out of control. One way in which cancer cells differ from normal cells is that they often have abnormalities or mutations in their DNA. To help fight cancer, scientists have developed drugs that specifically target cancer cells that have these mutations. By targeting mutations of cancer cells, these drugs can stop or limit the growth and spread of cancer. These drugs are also called “targeted therapies/drugs” or “precision medicines” because they precisely target the mutation that is causing the cancer.
At the time of this printing, the FDA has approved drugs to treat lung cancer by targeting mutations or gene abnormalities in
- ALK
- BRAF
- EGFR
- HER2
- MET
- NTRK
- RET
- ROS1
- VEGF
NSCLC patients with ALK mutations may be treated with:
- ceritinib (Zykadia®)
- crizotinib (Xalkori®)
- alectinib (Alecensa®)
- brigatinib (Alunbrig®)
NSCLC patients whose tumors have the BRAF V600E mutation may be treated with:
- combination of dabrafenib (Tafinlar®) and trametinib (Mekinist®)
- vemurafenib (Zelboraf®)
Patients with NSCLC who have EGFR mutations may be treated with:
- erlotinib (Tarceva®)
- afatinib (Gilotrif®)
- gefitinib (Iressa®)
- osimertinib (Tagrisso®)
NSCLC patients with the HER2 mutation may be treated with afatinib (Gilotrif®).
NSCLC patients with the MET mutation may be treated with crizotinib (Xalkori®). For a specific kind of MET mutation, known as the MET exon 14 skipping mutation, NSCLC patients may be treated with capmatinib (Tabrecta®).
NSCLC patients with the NTRK mutation may be treated with:
- entrectinib (Rozlytrek®)
- Larotrectinib (Vitrakvi®)
NSCLC patients with the RET mutation may be treated with selpercatinib (Retevmo®).
NSCLC patients with the ROS1 mutation may be treated with:
- crizotinib (Xalkori®)
- brigatinib (Alunbrig®)
- ceritinib (Zykadia®)
- entrectinib (Rozlytrek®)
NSCLC patients with the VEGF mutation may be treated with:
- bevacizumab (Avastin®)
- ramucirumab (Cyramza®)
Because targeted therapies work best for people whose tumors have specific gene mutations or changes, testing your tumor is very important. These tests can be called molecular, biomarker, genetic or mutation testing. See page 30 for more information about testing.
Unfortunately, tumors can develop new mutations that cause targeted therapies to stop working (a process known as resistance). For example, the most common mutation that causes resistance to EGFR-targeted drugs is called T790M. Some doctors recommend another biopsy or a blood test (liquid biopsy) to see if your tumor has the T790M mutation. You should talk to your doctor about whether your tumor should be biopsied to test for T790M. The FDA has approved two targeted therapies to treat patients with the EGFR T790M mutation, which are osimertinib (Tagrisso®) or afatinib (Gilotrif®).
Necitumumab (Portrazza®) is a therapy that targets EGFR differently than other approved EGFR-targeting drugs and is given through an IV. Necitumab is FDA-approved for squamous cell NSCLC patients with the EGFR mutation and is used in combination with two other chemotherapy drugs.
Many other drugs are being tested in clinical trials to see if they can target other types of mutations or can overcome resistance. Some of these drugs under development may be approved soon. Even more drugs are in earlier stages of development. Biomarker testing is often needed to see if you are eligible for clinical trials of targeted therapies.
Immunotherapy
Immunotherapy is one of the most exciting new approaches for treating lung cancer. Immunotherapies work by boosting your body’s own natural defenses to fight cancer.
The immune system is the body’s defense against disease. It has the ability to recognize and destroy not only infections like bacteria and viruses, but also abnormal cells like cancer cells. But, cancer cells are sometimes able to hide from or weaken the immune system so they are not recognized and not destroyed. If cancer cells escape the immune system, they can continue to grow and spread. Scientists have been making breakthrough discoveries about how cancer cells evade the immune system. These discoveries have led to new therapies that may stimulate the immune system to attack cancer or counteract the ways cancer cells hide from or suppress the immune system.
At the time of this publication, the immunotherapies approved to treat NSCLC are:
- atezolizumab (Tecentriq®)
- durvalumab (Imfinzi™)
- nivolumab (Opdivo®)
- combination of nivolumab (Opdivo®) and ipilumumab (Yervoy®)
- pembrolizumab (Keytruda®)
These immunotherapies are given into the vein (intravenously or IV), but differ in how often they are given. It is common that these immunotherapy treatments are used in combination with one or more chemotherapy drugs or other treatments like radiation. In other cases, these immunotherapy treatments are used alone.
Before deciding if immunotherapy is an option for you, your doctor may recommend that your tumor be tested for a protein called PD-L1. This particular protein helps your immune system by preventing it from attacking non-harmful cells in the body. However, if a cancer cell has high amounts of PD-L1, the cancer cell “tricks” the immune system into recognizing it as a non-harmful cell. Immunotherapy works best with cells high in PD-L1 by helping boost your immune system in recognizing and fighting harmful cells. Your doctor will test the tumor by taking a biopsy, or a small tissue sample.
More immunotherapies are being developed and tested in clinical trials for a variety of lung cancer types and stages. Keep in mind that immunotherapy for lung cancer is still relatively new. Research to figure out how best to use them – and which people are most likely to benefit – is ongoing. Immunotherapy does not work for everyone, even if your tumor is high in PD-L1. Ask your doctor if immunotherapy treatments or clinical trials might be options for you.
Because immunotherapy drugs work on the immune system, they work differently from chemotherapy. The side effects of immunotherapy drugs are also different from those of chemotherapy. Overall, immunotherapy treatments tend to have less side effects than other treatments. The most common side effects experienced tend to be mild and can include fatigue, itching, skin rashes, muscle, joint or bone pain, and nausea. Rarely, these drugs can cause the immune system to become too active. This may cause the body to react against normal tissues, such as your lungs, liver, colon, or thyroid.
Be sure you talk to your doctor about any concerns or side effects that you experience during your treatment.
Biomarker testing
Scientists continue to learn more and more about the molecular changes and mutations that turn normal cells into cancer cells, thus “driving” cancer growth. Testing your tumor for these changes (also called biomarker testing) is key to helping your cancer care team decide which treatments are most likely to work for you. Patients with adenocarcinoma of the lung may have mutations such as EGFR, ALK (or ELM4-ALK), ROS1, BRAF, or NTRK mutations. If you have adenocarcinoma, your tumor may be tested to see if drugs that target EGFR, ALK, or ROS1 mutations are likely to work for you. If your doctors have enough tissue from your initial biopsy, this tissue can be tested.
If not, you may need to undergo a second biopsy to obtain enough tissue for a biomarker test. Blood tests, sometimes called “liquid biopsies,” can also be used to test for certain EGFR mutations. If you are taking an EGFR-targeted therapy and it stops working, your doctor might recommend a biopsy or blood test to see if your tumor has developed the T790M mutation.
Your doctor might also recommend testing your tumor for PD-L1 to see if immunotherapy is an option for you.
If your doctor doesn’t recommend biomarker testing, itis okay for you to ask, “Why not?” Testing may not be appropriate in all cases, but it is best for you to know as much as possible about your disease so that you and your doctors can be full partners in your care.
Fertility considerations for young people with lung cancer
Most lung cancer patients are over age 60. However, a large number of young people, even those under 40, get lung cancer. If preserving your ability to have children is important to you, be sure to talk with your doctor about your options before you start treatment.
Alternative therapies
After a lung cancer diagnosis, you mayhear about “alternative therapies,” suchas herbal remedies, dietary supplements, massage therapy, acupuncture or chiropractic treatments. While some of these therapies may be helpful in managing pain or side effects of treatment, they are never a substitute or replacement for proven medical treatments prescribed by the specialists on your cancer care team. Additionally, some of these alternative treatments may harm you; they may cause problems with the treatment you are receiving, or prevent the treatment from working. Always talk with your cancer specialists before starting any alternative therapy plan.
If you smoke
It is important to work with your treatment team to quit smoking. Quitting smoking will help you breathe more easily, put less stress on your heart and lungs and help your treatments work better. Studies have shown that quitting smoking helps you live longer, even once you have lung cancer. Talk with your oncology social worker, case manager, or psychologist to find out about programs to help you develop a plan and quit smoking. This plan may include counseling and medications designed to make quitting easier. It is not too late to quit.
To create a quit plan today, call (800) QUIT-NOW or visit smokefree.gov or becomeanex.org.
Getting a second opinion
Understanding all of your treatment options before beginning therapy can help you feel confidentthat you are making the best decisions you can. Getting a second opinion is one way to gain this confidence. The additional experts you consult may tell you the same thing as your original cancer care team, or they may suggest new options or clinical trials that you may want to consider. Consider going to a National Cancer Institute–designated Comprehensive Cancer Center or other major medical center to seek a second opinion. These centers are ideally suited to provide you with the treatment you need.
Non-small cell lung cancer (NSCLC) treatments by stage
Because new treatments are rapidly becoming available, please visit LCRF.org/treatment-advances for the most up-to-date information.
Stage I
The ideal treatment for stage I NSCLC is surgery to remove the tumor. New research is helping doctors predict which patients with stage I NSCLC will need chemotherapy before or after their surgery and which will not. High-dose radiation therapy may also be used if you or your doctors feel that you would not tolerate surgery.
Stage II
The optimal treatment for stage II NSCLC is surgery followed by chemotherapy.
Stage III
Treatment options may differ if surgery can be utilized in combination with chemotherapy and radiation. Although surgery is generally not recommended for stage III lung cancer, it may be considered in specific cases for patients with stage IIIA disease. Treatment for most patients with stage IIIA and for all patients with stage IIIB or IIIC usually include chemotherapy and radiation therapy. Chemotherapy and radiation therapy may be given at the same time or one after the other. In some cases immunotherapy may be given after a combination of chemotherapy and radiation therapy.
Stage IV
Because stage IV cancer has spread to other parts of the body, surgery is only recommended in very select cases and usually is for palliation (relief) of certain symptoms. Radiation may be used to shrink tumors that are causing symptoms. Chemotherapy is used because it fights the cancer throughout the body. Immunotherapy is another option for some patients. If your tumor has a specific mutation, a targeted therapy might be a good option for you. If the cancer has spread to your bones, you may be given a medication such as denosumab (Xgeva®), pamidronate (Aredia®) or zolendronic acid (Zometa®) to help strengthen your bones.
Recurrent NSCLC
If your cancer first responded to one type of therapy, but then progressed, your cancer is called recurrent. In these cases, other chemotherapy or targeted therapy may be recommended. Immunotherapy is another potential option for the treatment of recurrent NSCLC. Many people experience great improvement with additional treatment, even after their cancer has recurred.
Small-cell lung cancer (SCLC) treatments by stage
LIMITED-STAGE
Limited-stage SCLC is typically treated with radiation to the chest and chemotherapy. Prophylactic cranial irradiation (PCI), radiation to the whole brain, may also be offered. The brain is a common site for cancer to come back in patients with SCLC because chemotherapy does not treat cancer that has spread to the brain as effectively as it treats cancer in other parts of the body. PCI is recommended for SCLC patients whose cancer appears to be in remission (no current sign of cancer) as a result of treatment. The treatment uses a lower-dose radiation, and is used to prevent the cancer from recurring. It is important to discuss PCI with your oncologist.
EXTENSIVE-STAGE
Individuals with extensive-stage SCLC are treated with chemotherapy or immunotherapy such as atezolizumab (Tecentriq®), durvalumab (Imfinzi®), or nivolumab (Opdivo®). Should remission occur, PCI will also be considered for some patients. At the time of this publication, there are no FDA approved targeted therapy options for SCLC. However, research is ongoing to identify potential targeted therapies.
Personalized cancer care plan
You may wish to work with your doctor and/or nurse to develop a personalized cancer care plan, which serves as a one-stop reference for information relating to your treatment and care. This plan will include your initial treatment plan, which is a listof your cancer treatments; other medicines or therapies you will need to help your treatments work best; possible side effects; and symptoms to watch for. Once your initial treatment is complete, you may wish to update your care plan with information on any medicines you are continuing to take, any ongoing medical issues that need to be addressed and when to return for check-ups.
A basic outline for a personalized care plan includes the following:
- Treatment provided
- Treatment purpose (cancer treatment,bone strengthener, ease of breathing, etc.)
- When to take (daily, weekly, specific dates)
- How to take (after meals, before bed, with water, etc.)
- When and where you need to go for treatments
- Reactions to look out for
- Follow-up needed
- Follow-up date(s)
Your cancer care team may have a more detailed version to share with you. If you are not given a personalized cancer care plan, you can download or order a printed copy of a care plan – as well as other free materials – at LCRF.org/resources. The care plan is available in both English and Spanish.
Ongoing care
Once your treatment is over, it is important that you receive regular follow-up care. Visit your doctor as prescribed to monitor for any return of the cancer. You should feel free to schedule more frequent appointments if you are experiencing symptoms that worry you, or if you have other healthcare concerns. Ask your oncologist what symptoms you should be on the lookout for. If symptoms occur, report them promptly.