There are a number of different treatment options for lung cancer. Standard treatment options include surgical resection, chemotherapy, and radiation therapy. Newer lung cancer treatment approaches include photodynamic therapy, electrocautery, cryosurgery, laser surgery, targeted therapy and internal radiation. Each lung cancer treatment has its own specific ability to fight cancer and its own set of side effects and possible complications. Therefore while there are many options, lung cancer treatment needs to be performed judiciously and only after very careful consideration of a number of factors.
Lung cancer treatment is tailored to the needs and wishes of the individual patient. General guidelines exist to direct medical professionals as they make their decisions; though each treatment plan is designed with a particular patient in mind. Even so, it is important for people diagnosed with lung cancer to understand their options. It is useful to know which cancer treatment has the greatest chance of success in a particular situation, which treatments are more experimental in nature, which treatments are likely to be ineffective, and which treatments are aimed at reducing symptoms (palliative) rather than achieving a cure.
As with most cancer treatments, the choice of therapy is dictated mostly by the cancer type and the stage of the disease. In lung cancer there are two main types, non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). While there are several different stages and subdivisions of NSCLC differentiated by numbers and letters, SCLC has only two stages: limited and extensive disease. As oncologists are considering choices in therapy, the stage and type of lung cancer factor heavily on the decision.
For occult and stage 0 NSCLC, surgery is generally curative without the need for radiation or chemotherapy. This is because these stages do not represent invasive lung cancer—the lung cancer is completely contained within the primary tumor. Therefore when the tumor is surgically removed, the cancer is gone for good. Obviously the success rate in this case, as with all stages, depends on the quality and accuracy of the lung cancer staging. If cancer cells have migrated away from the tumor, these stages no longer apply and additional treatment is necessary.
|Treatment Guidelines for Non-Small Cell Lung Cancer|
|Stage||Standard Treatment||Alternate Theraphy, clinical trials, for symptom control, or palliation|
|Stage 0||Surgical resection||Endoscopic surgery, laser therapy, electrosurgery, cryosurgery|
|Stage IA||Surgical resection||Chemotherapy (adjuvant), radiation therapy|
|Stage IB||Surgical resection||Chemotherapy (adjuvant), radiation therapy|
|Stage IIA||Surgical resection||Chemotherapy (adjuvant), radiation therapy (primary or adjuvant)|
|Stage IIB||Surgical resection||Chemotherapy (adjuvant), radiation therapy (primary or adjuvant)|
|Stage IIIA||Surgery then chemotherapy
Chemotherapy and radiation
|Neoadjuvant chemotherapy and radiation|
|Stage IIIB||Chemotherapy and radiation|
|Stage IV||Chemo therapy
Radiation therapy (palliative)
Surgical resection (palliative)
|Combination therapy, internal radiation, targeted therapy, laser therapy|
Surgery is indicated for stages I, II, and III of NSCLC. It may also be used for palliation in stage 4. Palliative therapy, it should be mentioned, is intended to relieve symptoms and improve quality of life with no real goal of cure or cancer remission. For stages I and II of NSCLC, surgery is the primary treatment of choice. (See page on staging of lung cancer.)
The surgery that is used to treat the lung cancer is tailored to the patient based on the extent of the disease. Since the lung is essential for respiration and for life, preserving as much functional lung tissue as possible is a primary concern to thoracic surgeons. Surgeons consider how well the patient will be able to breathe after a portion of lung is removed. At the same time, a sufficient amount of tumor and surrounding lung must be removed in order to assure that the cancer has been eliminated. Pulmonary function tests (breathing tests) are performed before cancer surgery to assess the patient’s overall lung capacity. An estimate is made of the level of lung function that would exist after the proposed surgery. If the patient will be left with too little lung capacity, either a less aggressive surgery will be performed or the surgery will not be done at all and alternate treatment will be given. Since people with lung cancer often have other lung diseases such as emphysema, lung capacity is a very important issue.
There are five lobes of lung, three on the right side of the chest and two on the left. Within these lobes, the lung is further subdivided into segments according to how the bronchi and bronchioles supply them with air. This organization is important when planning lung resection surgery.
There are several approaches available to thoracic surgeons. A wedge resection preserves the most lung tissue but provides the least room for error (meaning there is a reasonable chance of the cancer recurring). A wedge resection is suited to small primary tumors, usually of the Stage 0 and I variety. A segmental resection is a bit more aggressive, taking more lung tissue. However, the segmental resection is often well suited to stage I and II disease. Again, the risk of missing cancer cells is weighed against the resulting lung capacity.
A lobectomy is a procedure in which one of the five lobes is completely removed. The largest lung cancer resection surgery, a pneumonectomy (or hemi-pneumonectomy), is when an entire lung is removed, either the left or the right lung. In general, lobectomy and pneumonectomy are used to treat stage II NSCLC in patients with excellent reserve capacity of the lungs.
There are a number of chemotherapeutic regimens that can be used to treat NSCLC. These are usually reserved 1) for higher stages of lung cancer (stages III and IV) or 2) as adjuvant therapy, that is, to be used after surgery or 3) as neoadjuvant therapy, which is treatment before surgery. Neoadjuvant therapy is done to make the tumor smaller so that surgery will be easier or more effective. Adjuvant therapy is performed to kill cancer cells that may have been missed in the surgery or spread from the primary tumor.
The standard of care in the treatment of NSCLC is to use a platinum-based chemotherapeutic agent, especially in advanced disease (stages III and especially IV). Most studies have shown that two agents are better than one. Three agents used in combination do not provide much additional benefit but do cause a number of additional, unpleasant side effects. Therefore chemotherapy regimens usually include two drugs. Often this combination regimen includes a platinum drug like cisplatin along with either an older (etoposide) or newer (docetaxel, gemcitabine, pemetrexed (Alimta) or vinorelbine) chemotherapeutic drug.
Non-small cell lung cancer tumors are not very sensitive to most chemotherapy regimens, unfortunately. Chemotherapy alone is not considered a curative treatment for NSCLC. Often chemotherapy is combined with radiation therapy—an approach that is sometimes referred to as chemoradiation therapy. When the two treatment modalities are combined, the rates of disease clearance and survival are better than with either treatment alone. Otherwise chemotherapy is combined with surgery (either as neoadjuvant or adjuvant)
Radiation therapy alone is sometimes used for stage I and II NSCLC when surgery is not possible due to too little lung capacity. If that stage I or II tumor is resectable, surgery would be used rather than radiation therapy.
In stage IIIA NSCLC, surgery is still considered first line therapy. When surgery is possible, it is usually combined with adjuvant chemotherapy. If surgery is not possible in stage IIIA disease, chemoradiation therapy is used. Some specific stage IIIA tumors, like Pancoast tumors or tumors that have invaded the chest wall, have special treatment approaches.
In stage IIIB, chemoradiation therapy is considered first line. Radiation therapy alone may be used if patients are concerned with the toxic effects of chemotherapy; however outcomes are better if both treatment modalities are used. In this stage of NSCLC, surgery is not considered a curative intervention or effective treatment and is rarely performed. Radiation therapy may be used for palliation of symptoms when tumor invades certain tissues and causes troublesome symptoms.
Chemotherapy is really the only treatment modality used in stage IV NSCLC. Radiation therapy and surgery are used to relieve symptoms rather than change the course of the disease or improve survival. Treatment for stage IV disease most likely will include a platinum-based chemotherapeutic agent and a non-platinum chemotherapeutic drug. When three drugs are used, the third is not technically a chemotherapeutic agent but rather “targeted therapy.”
Targeted therapy includes drugs, antibodies or other proteins that target and disrupt specific proteins within the cancer cell. These disrupted proteins are critical for the cancer cell’s survival so the treated cell dies or stops multiplying. The use of targeted therapy in stage IV disease along with two other chemotherapeutic drugs may improve overall survival.
The treatment options in SCLC are less complex than NSCLC, mostly because studies have repeatedly shown that treatment outcomes are not affected by detailed staging. In other words, placing SCLC in four different stages does not influence treatment choices or outcomes to any appreciable degree. Thus treatment of SCLC is based mainly on two different stages, limited and extensive.
|Treatment Guidelines for Small Cell Lung Cancer|
|Stage||Standard Treatment||Alternate Theraphy|
Chemotherapy (single drug or combination)
Chemotherapy (combination of drugs)
| Radiation therapy to the brain prophylactically
Fortunately SCLC is very sensitive to radiation therapy. Radiotherapy is the treatment modality used in virtually all cases of limited SCLC disease. Radiation therapy is more effective and causes fewer side effects in limited disease because, by definition, limited disease can be treated through a single, external radiation port. In extensive SCLC disease, radiation therapy may be reserved for patients that have not responded to chemotherapy. This is because in extensive disease, radiation would need to been applied to large areas of the body. As a palliative intervention in extensive SCLC (and sometimes limited SCLC), certain organs like that brain may be irradiated prophylactically (in case there is spread).
Chemotherapy is used to treat both limited and extensive SCLC. In limited disease, patients have been successfully treated with a single chemotherapeutic drug (when combined with radiation). In most cases though, two drugs are used rather than one. These two drugs are commonly a platinum drug and etoposide. In extensive SCLC, two chemotherapeutic drugs are used. The specific chemotherapeutic agents used in extensive SCLC vary.
In both NSCLC and SCLC, it may be possible to enroll in a clinical trial of lung cancer treatments. These trials usually compare new therapies against older ones to see if outcomes can be improved. Targeted therapies, radiosensitizers, internal radiation sources, and newer combination treatment regimens are just some of the treatment tools being tested in research and clinical studies. These new treatments may improve survival or may lead to future breakthroughs.