The first thing to know about treatment of early non-small-cell lung cancer, or eNSCLC, is that it doesn’t mean “early” in the conventional sense.
“You can have 'early' non-small-cell lung cancer through stage III,” says Karen Reckamp, MD, director of medical oncology at Cedars Sinai Cancer. There are four stages of NSCLC.
The key factor, Reckamp says, is whether the cancer is curable. In this instance, curable means the cancer goes away completely after treatment. And with a good treatment plan, especially in stages I and II, there is a pretty good chance this will happen. But as with any cancer, there is no guarantee.
There are two main factors that help determine whether NSLC is early or curable:
The cancer can’t have spread outside the lung. Some nearby lymph nodes may also have some signs of cancer.
The cancer must be surgically removable or “resectable.” This is when your doctor takes out a tumor and some of the surrounding tissue that might have cancer cells, too.
Whether these two things hold true is not always an easy call to make, especially when the cancer is more advanced, Reckamp says.
“At stage III, you typically need a multidisciplinary team that includes your surgeon, pulmonologist, radiologist, radiation oncologist -- all involved in discussing the case,” Reckamp says.
That’s because stage III can mean so many things.
“There are stage IIIs that are more advanced and stage IIIs that are less advanced and more curable.”
For example, sometimes the cancer may have spread to organs outside the lung, in which case it’s no longer considered early or curable. In that case, it’s still possible that your medical team will be able to effectively control the spread of cancer in your body. But, Reckamp says, it is less likely that the cancer will disappear forever after initial treatment.
It’s All About the Stage
For eNSCLC, treatment depends in large part on the stage. In stage I, the disease is limited to a single small tumor within the lung, she says. That limits the treatment as well.
“In stage I, lung cancers are generally cured, either by local radiation therapy or surgical resection and don't need any other therapies,” Reckamp says.
Stage II means there’s a large tumor in a single area of the lung or a smaller tumor that has spread to nearby lymph nodes. Here, the treatment would include surgery, followed by chemotherapy and/or radiation therapy to hopefully keep the cancer from coming back.
Early stage III could be a really large tumor that’s growing into nearby tissue, perhaps with some growth into nearby lymph nodes. As long as surgery could remove the cancer and it hasn’t spread to tissue and organs far from the lungs, most doctors would still call it early, Reckamp says.
Treatment would be largely the same as for stage II: surgery followed by chemo and/or radiation. It may also include immunotherapy. That’s certain drugs that help your immune system recognize and destroy cancer cells.
The Effects of Genes and Biomarkers
There’s little in your genes -- the ones you inherit from your biological parents -- that would change your doctor’s treatment approach. But the tumor itself may hold some clues, Reckamp says.
If your doctor can get a sample of the tumor, called a biopsy, they can test it for certain gene changes or mutations. Surgery to remove the tumor may be the first opportunity to get a big enough sample to do this test, she says.
The most common of these tumor gene mutations is EGFR. Those with the EGFR mutation have better outcomes after surgery if they take a drug that targets the mutation, which can lessen chances of the cancer's return. About 10% to 15% of lung cancers have the EGFR mutation, says Reckamp. And EGFR isn’t the only mutation. There are at least seven others that could help your medical team guide treatment. They include:
- ALK
- ROS1
- RET
- MET
- BRAF
- NTRK
- HER2.
Any biological sign or symptom that guides treatment, including a gene mutation, is called a biomarker.
Another such biomarker is PD-L1, or the amount of certain proteins found in some tumor cells and immune cells. High PD-L1 means immunotherapy might be successful. But it’s not always a good idea to jump into immunotherapy for high PD-L1, says Reckamp. If you get treatment for certain mutations, like EGFR, immunotherapy for PD-L1 can sometimes cause serious side effects.
It’s another example of just how complex treatment can be for eNSCLC. That’s why it’s helpful to have a team if doctors to make calls about treatment, especially if the cancer is further along.
Other Factors
It’s not just the tumor itself that determines whether a cancer is curable or not. Your general health also makes a difference, Reckamp says. An identical tumor may be curable in one person and not in another, depending on other health factors.
Your health care team will decide whether you’re healthy enough to get surgery. They’ll look at your age and health history and do a full physical examination to try and figure this out. It may be that your lung function -- your ability to take in oxygen and get rid of CO2 -- is simply too low for you to survive having a part of it taken out.
If you smoke, your team may ask you to stop to improve lung capacity and raise your chances for a successful surgery.
New Treatments
New protocols for treatment of eNSCLC are getting close to FDA approval, Reckamp says. The new approach involves new immunotherapy drugs (cemiplimab, for example) used both before and after surgery, with or without chemotherapy and radiation.
In some cases, doctors were able to shrink lung cancer tumors to what Reckamp calls “pathologic complete response.” That means doctors could no longer see any tumor -- before the surgery. Though surgery is typically still required, it’s usually much less serious.
Reckamp is optimistic about the future of treatment. The definition of early for NSCLC may start to stretch, she says.
“We're in a new era now with the use of immunotherapy in lung cancer. We are likely curing more people both in the early stage and the locally advanced stage.”
