NSCLC: When You Need More Than One Treatment

Standard chemotherapy (chemo) was once the only treatment for advanced non-small-cell lung cancer (NSCLC). Now, you’re likely to get chemo plus a targeted medicine or immunotherapy, says Karen Reckamp, MD, co-director of the lung cancer and thoracic oncology program at City of Hope in Duarte, CA.

She says most people need more than one therapy, and often, they get all three at some time during their treatment. Combined treatments may work better because they attack cancer in different ways. And while they aren’t likely to cure advanced NSCLC, they may help you live longer with fewer symptoms.

Targeted Therapies

These block gene changes that cause tumors to grow and spread. The meds are more precise in targeting tumors than chemo, so side effects may not be as tough to deal with.

The problem is they often work for a while and then stop.  This may be because the gene changes again, so it’s no longer a good target. Or, cancer might find a way around the therapy. Either way, you’ll probably need to add another medicine -- usually chemo or a different targeted drug.

Immunotherapy

This treatment works in a different way. It triggers your immune system to attack your cancer. If your tumor has a high level of the protein PD-L1, immunotherapy medicines called checkpoint inhibitors may be your best treatment. These often work better when combined with chemo.

You May Still Need Chemo

If you don’t have the PD-L1 protein or a gene target, immunotherapy plus chemo is likely to be your main treatment. Reckamp says that fact disappoints some people.

“But we’re not at the point where we can do without [chemo],” she says. “In an era where we have all these new therapies, chemo is still helpful and will be part of most people’s treatment.”

That’s because chemotherapy can mop up cancer cells that other treatments leave behind.

“Metastatic cancer has spread through the lymph and blood to other places in the body,” Reckamp says. “That’s billions of cells. There’s always some cancer left, no matter what the treatment.”

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Dealing With Side Effects

Cancer medicines can have serious side effects. What happens when you get two at the same time, or one right after the other? It can be tough, Reckamp says, especially since therapies can cause so many different problems.

For example, platinum-based chemo -- the kind used for advanced NSCLC -- damages all your fast-growing cells, even the healthy ones. Common side effects are:

  • Nausea
  • Diarrhea
  • Hair loss
  • Anemia
  • Bleeding

Chemo also can cause liver and kidney damage. If your side effects are severe, you may need a lower dose, or to stop treatment completely. Reckamp says many people can predict how they’re going to feel on certain days and plan around it. And since chemo is given in cycles, you have a chance to rest during the breaks.

You may not get a break from certain targeted medicine, though.  Many targeted medicines are taken every day. That makes you more likely to have constant, but manageable symptoms, like rashes and diarrhea.

“You might have one really bad day of diarrhea with chemo and mild diarrhea every day with a targeted therapy,” Reckamp says.

Targeted medicines usually won’t make you as tired as chemo. Other side effects are usually easier on your body, too, but they still need to be dealt with.

“All these drugs are attacking cancer, so there is a level of not feeling like yourself,” Reckamp says. “Most people get used to that feeling. When they stop treatment, they remember what they’re supposed to feel like.”

What about side effects from immunotherapy, which can be pretty unpredictable?

“That’s anyone’s guess,” Reckamp says. “It can cause inflammation anywhere in your body at any time, even after you stop treatment. You can get inflammation in the brain, colon, thyroid gland, liver, bladder, kidneys, or heart.

“We can predict when you’ll feel bad with chemotherapy, but with immunotherapy, we can’t.”

She says people who get both immunotherapy and chemo need to be on high alert. The number of possible side effects is high, and some can come without warning.

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“If you’re not feeling like yourself, call your doctor, and they can help guide you what to do next,” she advises. “Also, [very serious] problems like colitis and pneumonitis [lung inflammation] can happen quickly and suddenly. We need to hear about that right away.”

Scott Gettinger, MD, an expert in immunotherapy and targeted therapy at Yale Cancer Center in New Haven, CT, also warns about pneumonitis. It’s inflammation of lung tissue that can cause cough and shortness of breath. For people with NSCLC, it can be deadly.

“When you suspect pneumonitis, you need to start steroids right away,” he says.

High-dose steroids can bring down life-threatening inflammation. Lower doses may help treat less serious symptoms.

Despite the intense side effects, Reckamp says most people do pretty well with combined treatments.

“You can work, travel, and live a fairly normal life, but you need to adjust for days when you don’t feel well,” she explains. “Hospitals and treatment centers have social workers and many other resources to help you get back into life.”

But, Reckamp says, you’ll also need help you can’t get from a hospital.

“You also need strong social support from your family,” she says.  “And it can be helpful to join a group of like-minded people or talk to a therapist or counselor.

“Patients are living longer, so it’s important to help them figure out how to frame what they want for their lives and how to do what they want to do.”

WebMD Feature Reviewed by Laura J. Martin, MD on December 19, 2018

Sources

SOURCES:

Karen Reckamp, MD, co-director, lung cancer and thoracic oncology program, City of Hope, Duarte, CA.

Scott Gettinger, MD, associate professor of medicine, Yale Cancer Center, New Haven, CT.

American Cancer Society.” Targeted Therapy Drugs for Non-Small Cell Lung Cancer.”

National Cancer Institute. “Targeted Cancer Therapies”

The New England Journal of Medicine: “Pembrolizumab plus Chemotherapy in Metastatic Non–Small-Cell Lung Cancer.”

Dalton Transactions: “The side effects of platinum-based chemotherapy drugs: A Review for chemists.”

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