Lung Cancer - Non-Small Cell: Types of Treatment
The types of treatments that are the standard of care for NSCLC are discussed here. "Standard of care" means the best treatments known. When making treatment plan decisions, you are encouraged to consider clinical trials as an option. A clinical trial is a research study that tests a new approach to treatment. Doctors want to learn whether the new treatment is safe, effective, and possibly better than the standard treatment. Clinical trials can test a new drug, a new combination of standard treatments, or new doses of standard drugs or other treatments. Clinical trials are an option to consider for treatment and care for all stages of cancer. Your doctor can help you consider all your treatment options.
Treatment overview
In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. Cancer care teams include a variety of other health care professionals, such as physician assistants, nurse practitioners, oncology nurses, social workers, pharmacists, counselors, dietitians, and others.
There are 5 main ways to treat NSCLC:
Surgery
Radiation therapy
Chemotherapy
Targeted therapy
Immunotherapy
Descriptions of these common types of treatments used for NSCLC are listed below, followed by an outline of the common treatment plans by stage. Your care plan also includes treatment for symptoms and side effects, an important part of cancer care.
Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the patient’s preferences and overall health. Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Talk with your doctor about the goals of each treatment and what you can expect while receiving the treatment. These types of talks are called "shared decision making." Shared decision making is when you and your doctors work together to choose treatments that fit the goals of your care. Shared decision making is particularly important for NSCLC because there are different treatment options.
Surgery
The goal of surgery is to completely remove the lung tumor and the nearby lymph nodes in the chest. The tumor must be removed with a surrounding border or margin of healthy lung tissue. A “negative margin” means that when the pathologist examined the lung or a piece of lung that was removed by the surgeon, no cancer was found in the healthy tissue surrounding the tumor. A surgical oncologist is a doctor who specializes in treating cancer using surgery. A thoracic surgeon is specially trained to perform lung cancer surgery.
The following types of surgery may be used for NSCLC:
Lobectomy. The lungs have 5 lobes, 3 in the right lung and 2 in the left lung. A lobectomy is the removal of an entire lobe of the lung. It is currently thought to be the most effective type of surgery, even when the lung tumor is very small.
A wedge resection. If the surgeon cannot remove an entire lobe of the lung, the surgeon can remove the tumor, surrounded by a margin of healthy lung.
Segmentectomy. This is another way to remove the cancer when an entire lobe of the lung cannot be removed. In a segmentectomy, the surgeon removes the portion of the lung where the cancer developed.
Pneumonectomy. If the tumor is close to the center of the chest, the surgeon may have to remove the entire lung.
The time it takes to recover from lung surgery depends on how much of the lung is removed and the health of the patient before surgery. Before surgery, talk with your health care team about the possible side effects from the specific surgery you will have.
Additional treatments can be given before and after your surgery to help lower the risk of recurrence.
Neoadjuvant therapy, also known as induction therapy, is a therapy given before your surgery. In addition to treating the primary tumor and lowering your risk of recurrence, this type of therapy is also used to help reduce the extent of surgery.
More commonly, you will receive adjuvant therapy. Adjuvant therapy is treatment that is given after surgery. It is intended to get rid of any lung cancer cells that may still be in the body after surgery. This helps lower the risk of recurrence, though there is always some risk that the cancer will come back.
These types of adjuvant therapy used for NSCLC include radiation therapy and systemic therapies, such as chemotherapy, targeted therapy, and immunotherapy. Each therapy is described below.
Radiation therapy
Radiation therapy is the use of high energy x-rays or other particles to destroy cancer cells. If you need radiation therapy, you will see a specialist called a radiation oncologist. A radiation oncologist is the doctor who specializes in giving radiation therapy to treat cancer. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. A radiation therapy regimen, or schedule, usually consists of a specific number of treatments given over a set period of time. This can vary from just a few days of treatment to several weeks.
Like surgery, radiation therapy cannot be used to treat widespread cancer. Radiation therapy only destroys cancer cells directly in the path of the radiation beam. It also damages the healthy cells in its path. For this reason, it cannot be used to treat large areas of the body.
Sometimes, CT scans are used to plan out exactly where to direct the radiation beam to lower the risk of damaging healthy parts of the body. This is called intensity modulated radiation therapy (IMRT) or stereotactic body radiation therapy (SBRT). It is not an option for all patients, but it may be used for early-stage disease and small tumors when surgery is not an option.
Some people with Stage I NSCLC or people who cannot have surgery may be treated with radiation therapy as an alternative treatment to surgery.
Side effects of radiation therapy
People with lung cancer who receive radiation therapy often experience fatigue and loss of appetite. If radiation therapy is given to the neck or center of the chest, side effects can include a sore throat and difficulty swallowing. Patients may also notice skin irritation, similar to sunburn, where the radiation therapy was directed. Most side effects go away soon after treatment is finished.
If the radiation therapy irritates or inflames the lung, patients may develop a cough, fever, or shortness of breath months and sometimes years after the radiation therapy ends. About 15% of patients develop this condition, called radiation pneumonitis. If it is mild, radiation pneumonitis does not need treatment and goes away on its own. If it is severe, a patient may need treatment for radiation pneumonitis with steroid medications, such as prednisone.
Radiation therapy may also cause permanent scarring of the lung tissue near where the original tumor was located. The scarring does not usually cause symptoms. However, severe scarring can cause a permanent cough and shortness of breath. For this reason, radiation oncologists carefully plan the treatments using CT scans of the chest to lessen the amount of healthy lung tissue exposed to radiation.
Therapies using medication
Systemic therapy is the use of medication to destroy cancer cells. This type of medication is given through the bloodstream to reach cancer cells throughout the body. Systemic therapies are generally prescribed by a medical oncologist, a doctor who specializes in treating cancer with medication.
Common ways to give systemic therapies include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally).
The types of systemic therapies used for NSCLC include:
Chemotherapy
Targeted therapy
Immunotherapy
Each of these types of therapies are discussed below in more detail. A person may receive 1 type of systemic therapy at a time or a combination of systemic therapies given at the same time. They can also be given as part of a treatment plan that includes surgery and/or radiation therapy.
The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. It is also important to let your doctor know if you are taking any other prescription or over-the-counter medications or supplements. Herbs, supplements, and other drugs can interact with cancer medications.
Chemotherapy
Chemotherapy is the use of drugs to destroy cancer cells, usually by keeping the cancer cells from growing, dividing, and making more cells. It has been shown to improve both the length and quality of life for people with lung cancer of all stages.
A chemotherapy regimen, or schedule, usually consists of a specific number of cycles given over a set period of time. The type of lung cancer you have, such as adenocarcinoma or squamous cell carcinoma, affects which drugs are recommended for chemotherapy.
Common drugs used to treat lung cancer include either 2 or 3 drugs given together or 1 drug given by itself. Some common drugs include:
Carboplatin or cisplatin (both are available as generic drugs)
Docetaxel (Taxotere)
Gemcitabine (Gemzar)
Nab-paclitaxel (Abraxane)
Paclitaxel (Taxol)
Pemetrexed (Alimta)
Vinorelbine (Navelbine)
Chemotherapy may also damage healthy cells in the body, including blood cells, skin cells, and nerve cells. The side effects of chemotherapy depend on the person and the dose used, but they can include fatigue, low numbers of blood cells, risk of infection, mouth sores, nausea and vomiting, loss of appetite, diarrhea, numbness and tingling in the hands and feet, and hair loss. Some lung cancer chemotherapy treatments do not cause significant hair loss.
Your medical oncologist can often prescribe drugs to help relieve many of these side effects. Hormone injections may be used to prevent white blood cell counts from becoming too low. Nausea and vomiting are also often avoidable. In many cases, side effects usually go away after treatment is finished.
Targeted therapy
Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells and limits damage to healthy cells.
Not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in the tumor. For some lung cancers, abnormal proteins are found in unusually large amounts in the cancer cells. This helps doctors better match each patient with the most effective treatment whenever possible. In addition, research studies continue to find out more about specific molecular targets and new treatments directed at them.
Targeted therapy for NSCLC includes:
Epidermal growth factor receptor (EGFR) inhibitors. Researchers have found that drugs that block EGFR may be effective for stopping or slowing the growth of lung cancer when the cancer cells have EGFR mutations. This medication is a pill that can be taken by mouth. The side effects of EGFR inhibitors often include a rash that looks like acne and diarrhea.
Osimertinib (Tagrisso) is a first treatment option for some people with NSCLC whose tumors have EGFR mutations. Osimertinib is also approved for the treatment of metastatic NSCLC with an EGFR mutation when other drugs listed above no longer work.
Erlotinib (Tarceva) has been shown to work better than chemotherapy if the lung cancer has a mutation in the EGFR gene. It is an option for patients with locally advanced and metastatic NSCLC. This medication is a pill that can be taken by mouth. The side effects of erlotinib include a rash that looks like acne, and diarrhea.
Afatinib (Gilotrif) is an initial treatment option for NSCLC. It may also be an option for patients who have already received other treatments for squamous NSCLC. It is a type of drug called a tyrosine kinase inhibitor (TKI).
Dacomitinib (Vizimpro) is approved as an initial treatment for NSCLC that has an EGFR mutation. However, it is not frequently used.
Gefitinib (Iressa) is a first generation EFGR inhibitor that is not widely used in the United States. It is more commonly used in Asia and some other parts of the world.
Anaplastic lymphoma kinase (ALK) inhibitors. ALK is a protein that is a part of the cell growth process. When present, this mutation helps cancer cells grow. ALK inhibitors help stop this process. Mutations in the ALK gene are found in about 5% of people with NSCLC. The following drugs are currently available to target this genetic change:
Alectinib (Alecensa)
Brigatinib (Alunbrig)
Cretinib (Zykadia)
Crizotinib (Xalkori)
Lorlatinib (Lorbrena)
Drugs targeting ROS1 genetic changes. Rare mutations to the ROS1 gene can cause problems with cell growth and cell differentiation, the process by which cells change from one type of cell into another. Drugs targeting changes to the ROS1 gene include:
Crizotinib (Xalkori)
Entrectinib (Rozlytrek)
Drugs targeting NTRK fusion. This type of genetic change is found in a range of cancers, including lung cancer, and causes cancer cell growth. Larotrectinib (Vitrakvi) is used to treat NTRK fusion for people with NSCLC.
Drugs targeting BRAF V600E mutations. The BRAF gene makes a protein that is involved in cell growth and can cause cancer cells to grow and spread. A BRAF V600E mutation can be targeted with a combination of dabrafenib (Tafinlar) and tremetinib (Mekinist).
Drugs targeting MET Exon 14 Skipping. MET Exon 14 Skipping is a genetic mutation found in over 3% of NSCLC. Capmatinib (Tabrecta) has been approved to target this genetic change.
Drugs targeting RET fusion. Up to 2% of all NSCLC cases are RET fusion positive. Selpercatinib (LOXO-292) is approved to treat these genetic changes involving RET, which lead to uncontrolled cell growth.
Anti-angiogenesis therapy. Anti-angiogenesis therapy is focused on stopping angiogenesis, which is the process of making new blood vessels. Because a tumor needs the nutrients delivered by blood vessels to grow and spread, the goal of anti-angiogenesis therapies is to "starve" the tumor. The following anti-angiogenic drugs may be options for lung cancer:
Bevacizumab (Avastin, Mvasi) is an anti-angiogenic drug given along with chemotherapy for lung cancer. It may also be used along with chemotherapy and the immunotherapy drug atezolizumab for metastatic NSCLC.
The risk of serious bleeding for patients taking bevacizumab is about 2%. However, it is more common for patients with squamous cell carcinoma, so bevacizumab is not recommended for patients with this type of NSCLC.
Ramucirumab (Cyramza) is approved for NSCLC along with the chemotherapy drug docetaxel.
Ramucirumab (Cyramza) is also approved in combination with the targeted therapy drug erlotinib as a first-line treatment of NSCLC for people with an EGFR mutation.
Treatment with targeted therapy for NSCLC is changing rapidly due to the pace of scientific research. New targeted therapies are being studied in clinical trials now. Talk with your doctor about additional options that may be available to you.
Side effects of targeted therapy depend on the drug(s) you've been prescribed. Talk with your doctor about possible side effects for a specific medication and how they can be managed.
Immunotherapy
Immunotherapy, also called biologic therapy, is designed to boost the body's natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function.
For example, the PD-1 pathway may be very important in the immune system’s ability to control cancer growth. Blocking this pathway with PD-1 and PD-L1 antibodies has stopped or slowed the growth of NSCLC for some patients. The following immunotherapy drugs block this pathway:
Atezolizumab (Tecentriq)
Durvalumab (Imfinzi)
Nivolumab (Opdivo)
Pembrolizumab (Keytruda)
Another immune pathway that may be targeted is the CTLA-4 pathway. In lung cancer, this pathway is often blocked in combination with a drug blocking the PD-1 pathway. The FDA has approved the combination of the anti-CTLA-4 antibody ipilimumab (Yervoy) and nivolumab as a first-line treatment for people with metastatic NSCLC who have levels of PD-L1 greater than or equal to 1%. This combination can also be used with chemotherapy for people with metastatic or recurrent NSCLC with no EGFR or ALK mutations.
For most people with advanced NSCLC that cannot be treated with a targeted therapy, immunotherapy or immunotherapy plus chemotherapy is often the preferred initial treatment.
Different types of immunotherapy can cause different side effects but, in general, severe side effects are less common than with chemotherapy. Common side effects include skin reactions, flu-like symptoms, diarrhea, lung inflammation causing shortness of breath, and weight changes. Talk with your doctor about possible side effects for the immunotherapy recommended for you.
Physical, emotional, and social effects of cancer
Cancer and its treatment cause physical symptoms and side effects, as well as emotional, social, and financial effects. Managing all of these effects is called palliative care or supportive care. It is an important part of your care that is included along with treatments intended to slow, stop, or eliminate the cancer.
Palliative care focuses on improving how you feel during treatment by managing symptoms and supporting patients and their families with other, non-medical needs. Any person, regardless of age or type and stage of cancer, may receive this type of care. And it often works best when it is started right after a cancer diagnosis. People who receive palliative care along with treatment for the cancer often have less severe symptoms, better quality of life, and report that they are more satisfied with treatment.
Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional and spiritual support, and other therapies. You may also receive palliative treatments similar to those meant to get rid of the cancer, such as chemotherapy, surgery, or radiation therapy.
The following treatments may be given to help relieve the symptoms of NSCLC:
A tumor in the chest that is bleeding or blocking the lung passages can be shrunk with radiation therapy.
During a bronchoscopy, lung passages blocked by cancer can be opened to improve breathing.
A surgeon or pulmonologist can place a stent to prop open an airway or use a laser to burn away a tumor.
Medications are used to treat cancer pain. Most hospitals and cancer centers have pain control specialists who provide pain relief, even for severe cancer pain. Many drugs used to treat cancer pain, especially morphine, can also relieve shortness of breath caused by cancer.
Medications can be used to stop a cough, open closed airways, or reduce bronchial secretions.
Prednisone or methylprednisolone (A-Methapred, Depo-Medrol, Medrol, Solu-Medrol) can reduce inflammation caused by lung cancer or radiation therapy and improve breathing.
Extra oxygen from small, portable tanks can help make up for the lung’s reduced ability to extract oxygen from the air.
Medications are available to strengthen bones, lessen bone pain, and help prevent future bone metastases.
Appetite stimulants and nutritional supplements can improve appetite and reduce weight loss.
Before treatment begins, talk with your doctor about the goals of each treatment in the treatment plan. You should also talk about the possible side effects of the specific treatment plan and palliative care options.
During treatment, your health care team may ask you to answer questions about your symptoms and side effects and to describe each problem. Be sure to tell the health care team if you are experiencing a problem. This helps the health care team treat any symptoms and side effects as quickly as possible. It can also help prevent more serious problems in the future.
Treatment by stage of NSCLC
Different treatments may be recommended for each stage of NSCLC. Your doctor will recommend a specific treatment plan for you based on the cancer's stage and other factors. Detailed descriptions of each type of treatment are provided earlier on this page. Clinical trials may also be a treatment option for each stage.
Stage I and II NSCLC
In general, stage I and stage II NSCLC are treated with surgery. Surgeons cure many people with an operation.
Before or after surgery, a patient may also meet with a medical oncologist. Some people with a large tumor or signs that the tumor has spread to the lymph nodes may benefit from chemotherapy. Chemotherapy may be given before the surgery, called neoadjuvant chemotherapy or induction chemotherapy. Chemotherapy may also be given after surgery, called adjuvant chemotherapy, to reduce the chance that the cancer will return.
Adjuvant chemotherapy with cisplatin is not recommended for patients with stage IA NSCLC that was completely removed with surgery. Patients with stage IB cancers should talk with their doctors about whether chemotherapy is right for them after surgery. Adjuvant cisplatin-based chemotherapy is recommended for patients with stage II NSCLC that has been completely removed with surgery. Patients with stage II NSCLC should talk with their doctor about whether this treatment is right for them.
For patients with stage I or II lung cancer who cannot undergo surgery, radiation therapy, such as stereotactic ablative radiotherapy (SABR) or stereotactic body radiotherapy (SBRT), may be offered.
Stage III NSCLC
More than 30,000 people are diagnosed with stage III NSCLC every year, and there is no single best treatment for all of these patients. Treatment options depend on the size and location of the tumor and the lymph nodes that are involved. The options generally include:
Radiation therapy
Chemotherapy
Immunotherapy
Surgery
In general, people with stage III NSCLC receive 3 different types of treatment. A combination of chemotherapy and radiation therapy followed by immunotherapy is usually recommended for NSCLC that cannot be removed with surgery. Chemotherapy and radiation therapy may be given together, which is called concurrent chemoradiotherapy. Or, they may be given one after the other, called sequential chemoradiotherapy.
Surgery may be an option after initial chemotherapy or chemotherapy with radiation therapy. Sometimes, surgery may be the first treatment, particularly when cancer is found in the lymph nodes unexpectedly after a person has originally been diagnosed with stage I or stage II cancer. If this occurs, surgery is generally followed by chemotherapy and often radiation therapy.
Adjuvant cisplatin-based chemotherapy is recommended for people with stage IIIA lung cancers that have been completely removed with surgery. Patients should talk with their doctor about the best treatment options for them.
Metastatic or stage IV NSCLC
If cancer spreads to another part in the body from where it started, doctors call it metastatic cancer. If this happens, it is a good idea to talk with doctors who have experience in treating it. Doctors can have different opinions about the best standard treatment plan. Clinical trials might also be an option.
Patients with stage IV NSCLC typically do not receive surgery or radiation therapy as the main treatment. Occasionally, doctors may recommend surgery or radiation therapy for a metastasis in the brain or adrenal gland if that is the only place the cancer has spread. Radiation therapy may also be used to treat a localized area that may be causing pain. People with stage IV disease have a very high risk of the cancer spreading or growing in another location. Most patients with this stage of NSCLC receive systemic therapies, such as chemotherapy, targeted therapy, or immunotherapy. Palliative care will also be important to help relieve symptoms and side effects.
Systemic therapy for metastatic or stage IV NSCLC
The goals of systemic therapies are to shrink the cancer, relieve discomfort caused by the cancer, prevent the cancer from spreading further, and lengthen a patient’s life. These treatments can occasionally make metastatic lung cancer disappear. However, doctors know from experience that the cancer will usually return. Therefore, patients with stage IV disease are never considered “cured” of their cancer no matter how well treatment works. Treatment often continues as long as it is controlling the cancer’s growth.
Systemic therapy and palliative care have been proven to improve both length and quality of life for patients with stage IV NSCLC. If the cancer worsens or causes too many severe side effects, the treatment may be stopped. Patients would continue to receive palliative care and may be offered treatment in a clinical trial.
The first drug or combination of drugs a patient takes is called “first-line” treatment, which may be followed by "second-line" and "third-line" treatment. No specific treatment or combination of treatments works for every patient. If the first-line treatment causes too many or dangerous side effects, does not appear to be working, or stops working, the doctor may recommend a change in treatment. All patients should also receive palliative care.
First-line treatment. First-line systemic therapy for NSCLC often depends on the genetic changes found in the tumor.
For patients with tumors that do not have changes in the EGFR or ALK genes, the options include:
For people with non-squamous cell carcinoma with high PD-L1 expression: Pembrolizumab alone; a combination of pembrolizumab, carboplatin, and pemetrexed; a combination of atezolizumab, carboplatin, paclitaxel, and bevacizumab; or a combination of atezolizumab, carboplatin, and nab-paclitaxel.
For people with non-squamous cell carcinoma and low PD-L1 expression: Pembrolizumab combined with carboplatin and pemetrexed; a combination of atezolizumab, carboplatin, paclitaxel, and bevacizumab; or a combination of atezolizumab, carboplatin, and nab-paclitaxel. In those who cannot receive immunotherapy, a combination of 2 chemotherapy drugs is recommended. Pembrolizumab alone may be recommended for people who cannot receive a combination of pembrolizumab with a platinum chemotherapy.
For people with non-squamous cell carcinoma and no PD-L1 expression: Pembrolizumab combined with carboplatin and pemetrexed; a combination of atezolizumab, carboplatin, paclitaxel, and bevacizumab; or a combination of atezolizumab, carboplatin, and nab-paclitaxel. In those who cannot receive immunotherapy, a combination of 2 chemotherapy drugs is recommended.
For people with squamous cell carcinoma and high PD-L1 expression: Pembrolizumab alone, a combination of nivolumab and ipilimumab, or a combination of pembrolizumab, carboplatin, and paclitaxel or nab-paclitaxel.
For people with squamous cell carcinoma and low PD-L1 expression: A combination of pembrolizumab, carboplatin, and paclitaxel or nab-paclitaxel should be recommended when it is possible. In those who cannot receive immunotherapy, a combination of 2 chemotherapy drugs is recommended. Pembrolizumab alone may be recommended for people who cannot receive chemotherapy.
For people with squamous cell carcinoma and no PD-L1 expression: A combination of pembrolizumab, carboplatin, and paclitaxel or nab-paclitaxel should be recommended when it is possible. In those who cannot receive immunotherapy, a combination of 2 chemotherapy drugs is recommended.
For patients with tumors that have genetic changes on the EGFR gene, the following targeted therapies called TKIs may be options:
Afatinib
Dacomitinib
Erlotinib
Gefitinib
Osimertinib
For patients with tumors that have a genetic change on the ALK gene, targeted therapy options are alectinib, brigatinib, ceritinib, or crizotinib.
For patients with tumors that have a genetic change on the ROS1 gene, crizotinib is an option.
Second-line treatment. Second-line treatment for NSCLC depends on the gene mutations found in the tumor and the treatments patients have already received.
For patients with tumors that do not have changes in the EGFR, ALK, or ROS1 genes, the options include:
Nivolumab, pembrolizumab, or atezolizumab if they have a high level of PD-L1, received chemotherapy for first-line treatment, and have not received immunotherapy.
Nivolumab, atezolizumab, or chemotherapy if they have a low or unknown level of PD-L1 and have already received chemotherapy.
Chemotherapy for patients who have already received immunotherapy.
Docetaxel or docetaxel plus ramucirumab for patients who had severe side effects from immunotherapy and have already received prior platinum doublet chemotherapy or cannot tolerate a combination of chemotherapy drugs.
Pemetrexed for patients with non-squamous cell carcinoma who did not receive it during first-line treatment.
For patients with tumors that have an EGFR gene mutation, the best treatment option depends on how the cancer worsened and whether the cancer developed a mutation called T790M, which makes it resistant to the TKI. Options include:
Osimertinib
Additional chemotherapy
Continued treatment with a TKI, plus surgery or radiation therapy to the areas where the cancer has spread
For patients with tumors that have an ALK gene mutation, options are:
Alectinib
Brigatinib
Ceritinib
Lorlatinib
For patients with tumors that have a ROS1 gene mutation, treatment options depend on the treatments received previously:
Crizotinib or entrectinib, if patients have not already received it
Chemotherapy, which may be given along with bevacizumab
For patients with tumors that have a BRAF mutation, options depend on whether they have already received immunotherapy:
Atezolizumab, nivolumab, or pembrolizumab for patients who have not already received any of these immunotherapies
Dabrafenib or a combination of dabrafenib and trametinib for patients who have already received immunotherapy
Third-line treatment. Third-line treatment for NSCLC is usually chemotherapy with pemetrexed or docetaxel.
In all cases, patients and their doctors should discuss any reasons why some patients may not be able to receive immunotherapy.
Radiation therapy for brain metastases
Chemotherapy is often not as effective as radiation therapy or surgery to treat NSCLC that has spread to the brain. For this reason, NSCLC that has spread to the brain is usually treated with radiation therapy, surgery, or both. This can cause side effects such as hair loss, fatigue, and redness of the scalp. With a small tumor, a type of radiation therapy called stereotactic radiosurgery can focus the radiation only on the tumor in the brain and lessen the side effects.
Newer targeted therapies, such as osimertinib and alectinib, have shown that they can work well to treat brain metastases. In addition, immunotherapy may also be an option. This may allow many patients to have a systemic therapy for brain metastases and avoid the side effects that come from chemotherapy and radiation therapy to the brain.
Palliative care
As described above, palliative care will also be important to help relieve symptoms and side effects. Radiation therapy or surgery may also be used to treat metastases that are causing pain or other symptoms. Bone metastases that weaken major bones can be treated with surgery, and the bones can be reinforced using metal implants.
For most people, a diagnosis of metastatic cancer is very stressful and difficult. You and your family are encouraged to talk about how you feel with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.
Remission and the chance of recurrence
A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having “no evidence of disease” or NED.
A remission may be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. While many remissions are permanent, it is important to talk with your doctor about the possibility of the cancer returning. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return.
If the cancer returns after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence). Most often, when there is recurrence, it is stage IV disease.
When this occurs, a new cycle of testing will begin again to learn as much as possible about the recurrence. After this testing is done, you and your doctor will talk about the treatment options. Often the treatment plan will include the treatments described above such as surgery, chemotherapy, and radiation therapy, but they may be used in a different combination or given at a different pace. Your doctor may suggest clinical trials that are studying new ways to treat this type of recurrent cancer. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.
And Also:
Lung Cancer Treatment
Lung Cancer Pulmonary Lung and Respiratory System
Treatment for lung cancer varies according to age, type of cancer, extent of disease, tolerance to medication and patient preference.
Treatment options include a combination of surgery, radiation, chemotherapy, immunotherapy and targeted therapy.
Specific treatment for lung cancer will be determined by your doctor based on:
Age, overall health and medical history
The type of lung cancer
Extent of the disease
Your tolerance for specific medications, procedures or therapies
Expectations for the course of the disease
Your opinion or preference
Depending on its type and stage, lung cancer may be treated with surgery, chemotherapy or other medications, radiation therapy, local treatments such as laser therapy, or a combination of treatments. Combination treatment or multimodality treatment refers to having more than one type of treatment.
Treatment for lung cancer includes one or more of the following approaches.
Surgery
Surgery is part of the treatment for early-stage lung cancers. The type of surgery depends on the size and location of the tumor in the lung, the extent of the cancer, the general health of the patient and other factors. Many surgeries are done with a long incision in the side of the chest, known as a thoracotomy. Some early stage tumors may be treated with video-assisted thoracic surgery (VATS), which uses several small incisions (instead of one large one) and special long surgical tools.
Types of surgery include:
Segmental or wedge resection: Removal of only a small part of the lung
Lobectomy: Removal of an entire lobe of the lung
Pneumonectomy: Removal of an entire lung
Sleeve resection: Removal of a piece of bronchus, after which the lung is reattached to the remaining part of the bronchus
Radiation Therapy
Radiation therapy is the use of high-energy radiation to kill cancer cells and to shrink tumors. Radiation may also be used with chemotherapy to treat lung cancer. The following techniques are used to deliver radiation therapy:
External radiation (external beam therapy): A treatment that precisely sends high levels of radiation directly to the cancer cells. The machine is controlled by the radiation therapist. Because radiation is used to kill cancer cells and to shrink tumors, special shields may be used to protect the tissue surrounding the treatment area. Radiation treatments are painless and usually last a few minutes.
Chemotherapy
Whereas surgery and radiation treatment are focused at only one area of the body, chemotherapy goes throughout the body to search for tumor cells. Chemotherapy is given through an IV infusion, in most cases. chemotherapy works by interfering with the cancer cells’ ability to grow or reproduce. Different groups of drugs work in different ways to fight cancer cells. The oncologist will recommend a treatment plan for each individual.
Chemotherapy may be given before other treatments, after other treatments or alone for lung cancer.
Targeted Therapy
Targeted therapy is like chemotherapy in that it goes throughout the body in search of tumor cells. These are drugs that target specific parts of cancer cells or nearby cells that help them grow. So far, these drugs have only been found to be useful for some non-small cell lung cancers. For example, as cancers grow, they form new blood vessels that nourish them. It is used with the standard chemotherapy regimen. Medications with other specific targets, such as crizotinib, erlotinib and cetuximab, may also be useful.
There are specific names for the order in which treatment is given. Neoadjuvant treatment refers to having radiation or chemotherapy before surgery. Having one or both of these before surgery may help shrink the tumor, as a smaller tumor is easier to take out in surgery.
Chemotherapy or radiation soon after surgery is called adjuvant treatment. The goal of adjuvant treatment is to kill any cancer cells that may be left after the surgery. Even if there is no sign of cancer cells, your doctor may suggest adjuvant treatment, as it may lower the risk that the cancer will come back or spread.
Clinical trials are being conducted on prevention and treatment options for lung cancer, including photodynamic therapy and chemoprevention.
Immunotherapy
Immunotherapy is a new cancer treatment approach that uses drugs, vaccines and other therapies to activate the immune system’s natural defenses so it can fight cancer. One type of immunotherapy drug, called “anti-PD-1” has been shown to cause significant tumor regression in a quarter of patients who receive it after a round of chemotherapy.Three immunotherapy drugs—pembrolizumab, atezolizumab and nivolumab—have been approved to treat certain non-small cell lung cancers.