Your Guide to Non-Small Cell Lung Cancer Treatment
According to the NCCN Guidelines for Patients™
After a diagnosis of non-small cell lung cancer, there will be a lot to think about. Your oncologist will help you decide the best way to treat or manage cancer. Lung cancer treatment planning is very complex, and there may be more than one treatment to choose from. The basic options for treatment include surgery, chemotherapy, radiation therapy, and targeted therapy. Treatment may include various combinations of these therapies. A team of cancer care professionals should be available to discuss your options.
You should not feel rushed into making a decision; in fact, you should feel free to get a second opinion on the proposed treatment plan or to find a cancer care team that you feel most comfortable with. (However, before making plans, it can be wise to check with your health insurance company’s policy regarding second opinions.) If the first doctor has done tests, the results can be sent to the second doctor so you will not have to undergo them again.
One of the first considerations of treatment is whether or not the lung tumor can be removed with surgery. Determination of surgical eligibility and type of surgery should be completed by a board-certified thoracic surgeon with extensive experience performing lung cancer surgery. The surgeon will determine surgical eligibility based on the size and location of the tumor and if nearby lymph nodes are involved. In general, surgery is not an option if the tumor has spread beyond the lungs to distant organs, such as the bones, brain, or liver. If the tumor is large or involves the adjacent lymph nodes, surgery may be delayed until after an initial cycle of chemotherapy and radiation therapy (chemoradiation) to shrink the tumor.
The extent of surgery will also depend on the tumor size and the overall health of your lungs. A wedge resection (segmental resection) removes the portion of the lung that includes the tumor and some surrounding tissue. If a lobe (section) of the lung is removed, the surgery is called a lobectomy. If the entire lung is removed, the surgery is called a pneumonectomy. Video-assisted thoracic surgery is a relatively new minimally invasive surgical procedure that is done primarily at large academic cancer centers.
You should not feel rushed into making a decision; in fact, you should feel free to get a second opinion.
Surgery may not be an option if breathing problems, such as emphysema, are present. Pulmonary function tests are always done before surgery to determine if the person’s lungs can tolerate surgery. The lung tissue that is removed is called the surgical specimen, which is sent to a pathologist for examination. The pathologist will check to see whether all the tumor has been removed by looking at the edge, or margin, of the specimen. If the tumor is present at the margin, it is likely that not all the tumor was removed. The status of the surgical margins is an important part of treatment planning after surgery.
Lung operations are performed while you are asleep under general anesthesia, and a hospital stay of about one week is usually needed. You will have some pain after the surgery because the surgeon will have to cut or spread the ribs to reach the lungs. There are many ways to control this pain.
After surgery, people who do not have lung problems other than the cancer can often return to their normal activities after a lobe or even an entire lung is removed. However, if they have other diseases, such as emphysema or chronic bronchitis (common among heavy smokers), they may find that their shortness of breath gets worse.
Radiation therapy uses high-energy rays, such as X-rays, to kill or shrink cancer cells. The radiation may come from outside the body (external-beam radiation therapy) or from radioactive materials placed directly in the tumor (internal or implant radiation, also called brachytherapy). External radiation is most often used to treat lung cancer.
Different chemotherapies attack tumor cells in different ways; therefore, several drugs are often combined for a multi-pronged attack.
Radiation therapy is often part of the initial treatment of lung cancer, either before or after surgery. Before surgery, it is used to shrink the tumor so that surgery can remove the entire tumor, or if the tumor is near other organs or blood vessels. After surgery, radiation therapy may be considered if there is concern that the surgery did not remove all the tumor. The radiation therapy will then be aimed directly at the tumor and does not have widespread antitumor effects. This contrasts with chemotherapy, which circulates throughout the body. For this reason, radiation therapy is called a local therapy.
Chemotherapy refers to the use of drugs to kill cancer cells. The drugs are usually injected intravenously while a few drugs are given by mouth, called oral chemotherapy. Once the drugs enter the bloodstream, they can reach all parts of the body, which is why chemotherapy is referred to as systemic therapy. Thus, chemotherapy can be used not only to shrink the tumor in the lung but also to treat tumor cells that have spread outside the lung.
Different chemotherapies attack tumor cells in different ways; therefore, several drugs are often combined for a multi-pronged attack (combination chemotherapy). A specific drug combination is called a chemotherapy regimen. Doctors who prescribe these drugs (called medical oncologists) give chemotherapy in cycles, with each period of treatment followed by a recovery period. Chemotherapy cycles generally last about 21 to 28 days, and multiple cycles are typically given. For example, when chemotherapy is used as part of the initial treatment, treatment usually lasts for four to six cycles. When chemotherapy is used to treat lung cancer that has spread outside the lungs, the treatment can continue until there is no further improvement. Chemotherapy is not recommended for people in poor health. Advanced age is not a barrier to treatment, as long as the person is not in poor health.
When given as part of the initial treatment, the timing of chemotherapy in relationship to surgery is given specific names. When chemotherapy is given before surgery to shrink the size of the tumor, the therapy is referred to as induction therapy or neoadjuvant chemotherapy. Adjuvant therapy is given after surgery to reduce the risk that the cancer will recur or spread outside the lung. Chemotherapy may also be combined with radiation therapy in a variety of ways.
Chemotherapy can also be given after initial therapy has been completed if the tumor recurs or spreads outside the lungs. Different chemotherapy regimens may be used; the first regimen used is called first-line therapy, followed by second-line therapy, if necessary. Chemotherapy may also be administered as maintenance therapy for people who have received four to six cycles of chemotherapy and have had a good response and/or stable disease, and whose cancer has not progressed. There are two types of maintenance therapy: continuation maintenance and switch maintenance therapy. Continuation maintenance therapy refers to the use of at least one of the agents given in first-line therapy. Switch maintenance refers to the initiation of a different agent, not included as part of the first-line treatment.
The drug combinations, or regimens, most frequently used for therapy immediately before or after surgery are cisplatin (Platinol®) combined with one of the following: docetaxel (Taxotere®), etoposide (Toposar®; Vepesid®), gemcitabine (Gemzar®), vinblastine, vinorelbine (Navelbine®), or pemetrexed (Alimta®). When appropriate, some people will receive carboplatin, another platinum-based drug, instead of cisplatin.
If the lung cancer recurs or metastasizes, chemotherapy is the principle treatment. People are given first-line chemotherapy, and this is continued until the tumor no longer responds, at which point a new combination of drugs will be considered, known as a second-line therapy. Drugs commonly used for first-line chemotherapy are similar to the ones used for initial therapy at surgery and include cisplatin or carboplatin in combination with any of the following drugs: docetaxel, etoposide, gemcitabine, irinotecan (Camptosar®), paclitaxel (Taxol®), vinblastine, or vinorelbine.
Erlotinib (Tarceva®), a type of targeted therapy, is also an option for first-line therapy. In people who cannot tolerate combination chemotherapy, single-agent chemotherapy (using just one drug) can be used. However, chemotherapy is not recommended for people in poor general health.
Second-line chemotherapy includes all the drugs discussed above, and also docetaxel alone, erlotinib alone, and pemetrexed alone.
In the past few years, lung cancer research has focused on a new class of drugs called targeted therapy, which are drugs designed to specifically attack cancer cells and interfere with their ability to grow. Targeted therapy can be combined with chemotherapy for lung cancer that has spread beyond the lungs. One such drug is erlotinib, which is unique because the tumor tissue can be tested first to see if the tumor cells have the target that predicts successful treatment with erlotinib. Erlotinib is taken by mouth, and common side effects include skin rash and diarrhea.
Bevacizumab (Avastin®) is another targeted therapy that specifically targets blood vessels and is designed to choke off the blood supply to the tumor. A side effect of bevacizumab is bleeding, which means it should not be used in people who are coughing up blood. Care must be taken when this drug is given to those whose cancer has spread to the brain or who are on blood thinners (anticoagulants). Other rare but serious side effects include blood clots and high blood pressure. Bevacizumab is given intravenously every three weeks along with chemotherapy.
Cetuximab (Erbitux®) is designed to interrupt the growth of tumor cells and, similar to other targeted therapies, is combined with chemotherapy. It is given intravenously, and common side effects include skin rash or diarrhea.
Lung cancer is often initially treated with combination therapy; that is, the combination of surgery with chemotherapy, or radiation therapy, or both, given either before or after surgery. Chemotherapy and radiation therapy can be combined together in several different ways, referred to as chemoradiation. For example, chemotherapy and radiation therapy can be given sequentially. Typically, the chemotherapy is given before the radiation therapy, but sometimes the radiation therapy may come first. Occasionally, additional chemotherapy alone will be given after chemoradiation. Concurrent chemoradiation is when chemotherapy and radiation therapy are given together.
Treatment recommendations should be made after a joint consultation and/or discussion by a multidisciplinary team including thoracic surgeons, radiation oncologists, medical oncologists, pulmonologists, pathologists, and diagnostic radiologists.
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To view the full version of the NCCN Guidelines for Patients™: Non-Small Cell Lung Cancer, go to nccn.com.
Reproduced with permission from the NCCN Guidelines for Patients™: Non-Small Cell Lung Cancer. © 2010 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines for Patients™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines for Patients™, go online to nccn.com. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES™, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.
This article was published in Coping® with Cancer magazine, November/December 2010.