Non-Small Cell Lung Cancer: When You Need More Than One Treatment

From the WebMD Archives

Treating Lung Cancer Is a Multidisciplinary Approach

“We work in a team when it comes to planning care for a lung cancer patient,” says Steven E. Schild, MD, professor and chairman of the department of radiation oncology at the Mayo Clinic in Scottsdale, Ariz. This means that you will be working with one or more of the following specialists:

  • Pulmonologist – a lung specialist
  • Medical Oncologist – a doctor who specializes in cancer treatments
  • Thoracic Surgeon – a doctor who specializes in chest surgery
  • Radiation Oncologist – a doctor who specializes in radiation therapy

“Because of recent advances in all fields of cancer care, treatment for lung cancer has become more technical and nuanced,” says Christopher Azzoli, MD, medical oncologist on the lung cancer service at the Memorial Sloan-Kettering Cancer Center in New York City. “We now take a multidisciplinary approach to fighting the disease. This allows us to work together to decide on the best approach for each patient.”

Staging Non-Small Cell Lung Cancer

What type and combination of treatments you receive is based on several factors, which can include:

  • The type of NSCLC cancer you have
  • Your overall health and other conditions you may have
  • Your lung function and any symptoms you are having, such as difficulty breathing
  • How your cancer is staged

Staging lung cancer is usually done at the same time that you are diagnosed. Your doctors will perform physical exams, biopsies, and tests such as CT scans or X-rays to determine where the cancer is located. Cancers are staged according to:

  • Size of the tumor
  • Whether cancer has spread into nearby lymph nodes
  • Whether cancer has spread, or metastasized, into other areas of the body

Cancers are staged into groups I, II, III, and IV, and are further subdivided within those groupings. Cancer tumors staged at a lower value tend to be smaller and haven’t spread as far. Staging a cancer helps doctors plan your course of treatment. “How your cancer is staged will determine whether you get chemotherapy, radiation, or surgery,” Azzoli says.

Treatment Options for Non-Small Cell Lung Cancer

Your medical team will plan a course of treatment that will provide the best option to cure your lung cancer, if possible, or to keep it in check for as long as possible. Because treatment is individualized, most lung cancer patients receive a combination of therapies.

  • Surgery provides the best chance of a cure for lung cancer. This is the general approach for stages I and II, and sometimes for stage III and IV. Surgery may be followed by a course of radiation or chemotherapy.

  • Radiation is used instead of surgery for lung cancer patients who aren’t as healthy or whose tumors can’t be removed surgically. Radiation combined with chemotherapy is generally used to treat Stage III lung cancers.

  • Chemotherapy alone won’t cure lung cancer. But used with radiation therapy and surgery, it improves the rates of cure. “Chemo is the icing on the cake when it comes to NSCLC treatment,” says Azzoli. When chemotherapy is used in addition to surgery, it is called adjuvant therapy. The goal of adjuvant therapy is to lower the chance of cancer returning. For Stage IV lung cancers, the goal of chemotherapy usually is not to cure the lung cancer, but to relieve symptoms to make the patient more comfortable.

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Lung Cancer Surgery

You may hear your doctor refer to this type of lung cancer surgery as a resection. Some or all of the lung, or sections of the lung called lobes, may be removed depending on the size and location of the tumor:

  • Segmentectomy or wedge resection removes part of a lobe.
  • Lobectomy removes an entire lobe.
  • Pneumonectomy removes an entire lung.
  • Sleeve resection removes part of a lung and the remaining tissue is reattached.

During surgery, lymph nodes near the tumor will also be removed so that doctors can determine how far the cancer has spread. Cancer can travel to other parts of the body by invading the lymph system.

Lung cancer surgery is a serious operation. In most cases, surgeons need to open the rib cage in order to remove the cancer and some surrounding tissue. Most patients spend 5 to 7 days in the hospital after lung cancer surgery, and recovery takes 4 to 8 weeks. A new type of surgery called video-assisted thoracic surgery is less invasive. In this procedure, a small video camera is inserted through a small hole in the chest to help surgeons remove small tumors near the outside of the lung.

If you are generally in good health, you should be able to return to normal activities after you recover from lung cancer surgery, even if you had a lung removed. However, if you have a lung disease such as emphysema, you may become short of breath more often after surgery.

If the cancer has spread to another part of your body, or if your cancer recurs, you may have surgery or other procedures to help control it. In people with late stage cancer, surgery may be used to help relieve symptoms and make the patient more comfortable. For example, if a tumor is blocking an airway, laser surgery may be used to make it smaller. In this instance, surgery will not cure the cancer, but can help relieve discomfort or pain. This is called palliative surgery.

Radiation Therapy for Lung Cancer

Radiation therapy can be external or internal. Both use high-energy X-rays or other types of radiation to kill cancer cells or to help keep them from growing. External radiation therapy is delivered from a machine. Internal radiation therapy requires small radioactive “seeds” to be placed in or near a cancerous tumor to help shrink it. Most people with NSCLC receive external radiation therapy.

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External radiation may be used to treat NSCLC in several ways, depending on the type and stage of the lung cancer.

  • It can be used in place of surgery for patients who are not healthy enough for surgery or if the tumor can’t be removed by surgery.
  • It may be used with chemotherapy to treat Stage III cancers. Chemotherapy and radiation therapy may be given at the same time. If a patient is not healthy enough to have combination therapy, then treatments will be given one after another.
  • It can also be used as palliative therapy in late stage cancer to lessen symptoms and relieve pain.

External beam radiation therapy will not make you radioactive. However, some healthy tissue may be harmed along with cancer cells during treatment, so you may notice some side effects. These include:

Most of these side effects go away after treatment ends.

A new form of radiation therapy, called stereotactic body radiation (SBRT), is becoming widely used in patients with early stage cancer who are not able to have surgery. This treatment uses highly targeted, high-dose radiation that kills cancer cells while sparing normal tissue. “SBRT is a more precise therapy, and it has few side effects. It’s becoming a standard of care for early stage NSCLC,” says Schild.

Chemotherapy for Lung Cancer

Chemotherapy uses drugs to kill cancer cells. Usually given by injection, the drugs travel throughout the body in the bloodstream, so chemo is useful for metastasized cancers.

“In the last 6 or 7 years, there has been a revolution in how chemotherapy is used for treatment of NSCLC,” says Azzoli. “In 2003, studies first reported the benefits of using chemotherapy as adjuvant therapy. Prior to that, chemotherapy was not routinely given to patients with stage I or stage II cancer. Now medical oncologists see more early stage lung cancer patients. We discovered that by adding chemotherapy to surgery or to radiation treatment at earlier stages, more patients can be cured.”

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Depending upon a person’s health, the stage of lung cancer, and the type of cancer, chemotherapy may be used in several ways:

  • After surgery as adjuvant therapy to help kill any remaining cancer cells
  • Before surgery to control the disease prior to surgery. This is called neoadjuvant therapy.
  • With radiation therapy, either one after another or at the same time. Chemotherapy given simultaneously with radiation therapy is called chemoradiation.
  • As a single therapy
  • With a targeted therapy (drugs that inhibit cancer growth and development)

Chemotherapy treatment should begin within two months after lung cancer surgery. The decision about which chemotherapy drugs to use is based on a number of factors. Usually, two chemo drugs are used together. This is called combination chemotherapy. For people in poor health, only one drug may be used. For patients with advanced cancer who meet certain requirements, a targeted therapy may be added to combination chemotherapy treatment.

Chemotherapy is given in cycles of 3 to 4 weeks, with time off between cycles to allow your body to recover. In general, you will receive 4 to 6 cycles of chemotherapy.

Chemotherapy works by killing rapidly growing cancer cells. But the drugs can’t tell the difference between cancer cells and other cells in the body that also divide quickly. These types of cells occur in hair follicles, bone marrow, and the lining of the intestines and mouth. As a result, these healthy cells may become damaged, leading to side effects such as:

Advances in chemotherapy drugs and in the drugs used to treat side effects have eliminated certain side effects for people receiving chemotherapy for NSCLC. In many cases, you won’t lose your hair. Tell your doctor if you feel nauseous, as there are effective treatments to help. Often, patients receiving chemotherapy can continue to work and remain active. In most cases, side effects from chemotherapy go away after therapy has stopped.

Clinical Trials for Non-Small Cell Lung Cancer

“Over the years, treatment for NSCLC has steadily improved,” says Schild. “But we aren’t where we want to be yet. So we frequently recommend that lung cancer patients consider participating in a clinical trial.”

These research studies use volunteer patients to test new treatments and procedures. Ask your doctor if there are studies for which you may be eligible.

Your health care team can help you weigh all the treatment options so you can make the best choice for you.

WebMD Feature Reviewed by Brunilda Nazario, MD on March 26, 2010

Sources

SOURCES:

Steven E. Schild, MD, professor and chairman of the department of radiation oncology at the Mayo Clinic, Scottsdale, Ariz.

Christopher Azzoli, MD, medical oncologist on the lung cancer service at the Memorial Sloan-Kettering Cancer Center, NYC.  

George R Simon, MD, FACP, FCCP, director of Thoracic Oncology, Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia.

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