Types of Treatment for Lung Cancer

There is a lot for you to think about when choosing the best way to treat or manage your cancer. There may be more than one treatment to choose from. Lung cancer treatment planning is very complex. A team of cancer care professionals should be available to discuss all of the options. Combinations of chemotherapy, radiation therapy targeted therapy, or surgery may be of greater value than any single treatment alone. You may feel that you need to make a decision quickly. But give yourself time to understand your options. Talk with your doctor. Look at the list of questions on page 5 to get some ideas. Then add your own.

You may want to get a second opinion. Your doctor should not mind your doing this. In fact, some insurance companies require you to get a second opinion. If your first doctor has done tests, the results can be sent to the second doctor so that you will not have to have them done again. If you are in an HMO (health maintenance organization), find out about their policy concerning second opinions.

The treatment options for lung cancer are surgery, radiation therapy, chemotherapy, and targeted therapy either alone or in combination, depending on the stage of the tumor.

Surgery

Depending on the type and stage of the cancer, surgery may be used to remove the tumor and some of the lung tissue around it. 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. These operations are done with the patient asleep under general anesthesia. A hospital stay of about 1 week is usually needed. The patient will have some pain after the surgery because the surgeon has to cut through the ribs to get to the lungs. There are several ways to control pain. See the ACS/NCCN Cancer Pain Treatment Guidelines for Patients).

People who do not have any other 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 also have diseases such as emphysema or chronic bronchitis (common among heavy smokers), then they may find that their shortness of breath gets worse. For people who can’t have the usual surgery because they have lung disease or other medical problems or because the cancer is widespread, other types of surgery (for example, laser surgery) can be done to relieve symptoms.

Surgery may be the first step in treating your lung cancer. Or, surgery may be considered after chemotherapy and radiation therapy. In either case, your initial work-up before beginning any treatment should include evaluation by a surgeon.

Chemotherapy

Chemotherapy refers to the use of drugs to kill cancer cells. Usually the drugs are given into a vein or by mouth. Once the drugs enter the bloodstream, they reach all parts of the body. Often several drugs are given at the same time. Depending on the type and stage of lung cancer, chemotherapy may be given as the main treatment or in addition to surgery and/or radiation therapy. Chemotherapy is referred to a adjuvant therapy when it is used along with surgery or radiation therapy. It is used like this to reduce the risk that the cancer will recur (come back) or spread outside the lung. Doctors who prescribe these drugs (medical oncologists) generally use a combination of medicines that have proven to be more effective than a single drug. Doctors give chemotherapy in cycles, with each period of treatment followed by a recovery period. Chemotherapy cycles generally last about 21 to 28 days, and initial treatment typically involves 4 to 6 cycles. Chemotherapy is not recommended for patients in poor health (performance status 3–4). Advanced age is not a barrier, as long as the patient is not in poor health.

The drug combinations most frequently used for initial chemotherapy for non-small cell lung cancer are cisplatin or carboplatin combined with 1 of the following:

• Paclitaxel
• Docetaxel
• Gemcitabine
• Vinorelbine
• Irinotecan
• Etoposide
• Vinblastine
• Bevacizumab (targeted therapy used in combination)

IIn patients who cannot tolerate combination chemotherapy, single agent chemotherapy can be used.

Chemotherapy or targeted therapy used for second-line treatment (medicines used if the cancer continues to grow during or after initial chemotherapy) for non-small cell lung cancer include:

• Docetaxel alone
• Erlotinib
• Pemetrexed

The drug combinations most frequently used for initial chemotherapy for small cell lung cancer are:

• Limited Stage
  • Cisplatin and etoposide
  • Carboplatin and etoposide
• Extensive Stage
  • Cisplatin and etoposide
  • Carboplatin and etoposide
  • Cisplatin and irinotecan

Chemotherapy drugs used if there has been a relapse of the small cell lung cancer include:

• Ifosfamide, paclitaxel, docetaxel, or gemcitabine, if the relapse occurred within 2 to 3 months
• Topotecan, irinotecan, cyclophosphamide/doxorubicin/vincristine (CAV), gemcitabine, paclitaxel, docetaxel, oral etoposide, methotrexate, or vinorelbine if the relapse occurred from 2 to 3 months to 6 months
• For relapses after 6 months, the original chemotherapy can be repeated

All chemotherapy agents have side effects. Temporary side effects might include loss of appetite, nausea and vomiting, mouth sores, and hair loss. Because chemotherapy can damage the blood-producing cells of the bone marrow, a drop in white blood cells can increase a patient’s risk of infection; a shortage of blood platelets can cause bleeding or bruising after minor cuts or injuries; and a decrease in red blood cells (low blood hemoglobin levels) can lead to fatigue (see ACS/ NCCN Cancer-Related Fatigue and Anemia Treatment Guidelines for Patients).

But treatment can prevent or lessen these side effects. For example, several drugs are available that can prevent or reduce nausea and vomiting (see ACS/NCC Nausea and Vomiting Treatment Guidelines for Patients with Cancer). A group of drugs called growth factors can help bone marrow recover after chemotherapy and reduce the period of time that a person’s blood counts are low.

Patients can also experience long-term effects from anticancer drugs such as premature menopause, infertility, or heart or lung damage.

Your doctor or nurse will discuss possible side effects and what can be done to reduce these effects, with you and your family before you start treatment. Once treatment is started, your doctor and nurse will expect you to keep them informed about any effects that you experience.

Targeted therapy
In the past few years, much lung cancer research has focused on drugs that are specifically targeted at cancer cells and interfere with their ability to grow. For example, erlotinib (Tarceva®) has been recently approved by the Food and Drug Administration (FDA) for use in patients with NSCLC who are no longer responding to chemotherapy (this is usually determined after 1 or 2 different chemotherapy combinations). The drug is taken by mouth. Common side effects of erlotinib include skin rash and diarrhea.

Bevacizumab (Avastin®) is another targeted therapy that has been most commonly used to treat colon cancer, but has also been studied as a treatment for NSCLC. Bevacizumab causes bleeding, which means it cannot be used in patients who are coughing up blood, whose cancer has spread to the brain, or who are on “blood thinners” (anticoagulation therapy). It also cannot be used in patients with squamous cell cancer, because it leads to bleeding from this type of lung cancer. Other rare but serious side effects include blood clots and high blood pressure. Bevacizumab is given intravenously every 2–3 weeks.

Gefitinib (Iressa®) is a targeted therapy used to treat patients in good health, but with NSCLC that begins to grow after initially responding to treatment. Gefitinib is taken by mouth and common side effects include diarrhea or skin reactions.

Radiation Therapy

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 radiation) or from radioactive materials placed directly in the tumor (internal or implant radiation, also called brachytherapy). External radiation is the type most often used to treat lung cancer.

External beam radiation is sometimes used as the main treatment of lung cancer, for example, for those who may not be healthy enough to have surgery or whose cancer has spread too far to be removed by surgery. For other patients, radiation might be used after surgery to kill small areas of cancer that can’t be seen and removed during surgery. Radiation can also be used to relieve symptoms such as pain, bleeding, or blockage of air passages by the cancer; or as a treatment of lung cancer that has spread to other organs, such as the bone or brain.

External beam radiation therapy is usually given in daily doses, 5 days per week, for a period of 4 to 8 weeks. The exact duration and timing of therapy will depend on the type and stage of the cancer.

Side effects of external radiation therapy to the chest area may include mild skin reactions, nausea, tiredness, pain on swallowing, and a cough. Often these go away after a short while. Radiation to the chest may also cause lung damage and difficulty breathing. Side effects of radiation therapy to the brain usually become most serious 1 or 2 years after treatment and include headaches and trouble thinking.

Brachytherapy, also known as internal radiation therapy, involves placing a small pellet of radioactive material inside the lung. It is rarely used as the initial treatment for a lung cancer, but is sometimes recommended if cancer has returned and is blocking one of the airways.

Combination Therapy

Lung cancer is often initially treated with combination therapy; that is, the combination of surgery with chemotherapy, or radiation therapy, or both, either before or after the surgery. Chemotherapy and radiation therapy may be used before surgery to shrink the tumor so that it can be removed surgically. Chemotherapy and radiation therapy may be given after surgery if there is a chance that the entire tumor was not removed at surgery. The T and N status of the tumor are used to determine whether combination therapy is needed.

Palliative and Supportive Care

Most of these guidelines identify ways to cure some people with lung cancer and to help others live longer by removing or destroying lung cancer cells. But it is important to realize that controlling symptoms and helping you continue to do the things important to you is another important goal. Don’t hesitate to discuss your symptoms or how you are feeling with your cancer care team. There are effective and safe ways to treat pain, most other symptoms of lung cancer, and most of the side effects caused by lung cancer treatments. Care to help relieve symptoms is sometimes called palliative care, or supportive care.

Pain is a significant concern for patients with lung cancer. Growth of the cancer around certain nerves may cause severe pain. It is important that patients do not hesitate to tell their doctors if they have pain. Otherwise the doctor can’t help. For most patients, treatment with morphine or other opioids (also called narcotics, these prescription medicines are the strongest pain relievers available) will reduce the pain considerably. For more information on the treatment of cancer pain, refer to the Cancer Pain Treatment Guidelines for Patients or contact the ACS or NCCN to request a copy.

In addition to the supportive care measures for people with advanced cancer, you may also benefit from specific measures that relieve some symptoms of lung cancer that are relatively rare with other cancers. For example, some small cell lung cancers may secrete a hormone (called antidiuretic hormone). Small amounts of this hormone are normally produced by the pituitary gland, but high levels produced by a cancer result in a collection of fluid in the body. Limiting your fluid intake may help. Drug therapy with demeclocycline may also help. Other hormone-like substances produced by lung cancer cells can cause high levels of hormones produced by the adrenal glands . These hormones cause a condition known as Cushing’s syndrome. Patients with this problem may note weight gain (especially around the chest and abdomen), fat deposits behind the neck and shoulders, fatigue, easy bruising, depression and/or moodiness, and weakened bones. This condition may be treated with a drug called ketoconazole. Other hormone-like substances that may be produced by NSCLC can alter blood calcium levels, leading to muscle weakness and other nervous system problems. Intravenous fluids and medications can help relieve some of these symptoms.

Sometimes patients may be given cancer treatment that is intended to reduce or prevent symptoms but is not expected to cure the cancer. Palliative care may include radiation or chemotherapy treatments that relieve symptoms by shrinking the tumor. Some other palliative treatments for lung cancer include laser surgery and photodynamic therapy .

Complementary and Alternative Therapies

Complementary and alternative medicines are a group of different types of health care practices, systems, and products that are not part of your usual medical treatment. They may include Chinese herbs, special supplements, acupuncture, massage, and a host of other types of treatment. You may hear about different treatments from your family and friends. People will offer all sorts of things, such as vitamins, herbs, stress reduction, and more as a treatment for your cancer or to help you feel better.

The American Cancer Society defines complementary medicine or methods as those that are used in addition to your regular medical care. If these treatments are carefully managed, they may add to your comfort and well-being. Alternative medicines are defined as those that are used instead of your regular medical care. Some of them have been proven harmful, but are still promoted as “cures.” If you choose to use these alternatives, they may reduce your chance of fighting your cancer by delaying or replacing regular cancer treatment.

There is a great deal of interest today in complementary and alternative treatments for cancer. Many are being studied to find out if they are truly helpful to people with cancer.

Before changing your treatment or adding any of these methods, it is best to discuss this openly with your doctor or nurse. Some methods can be safely used along with standard medical treatment. Others, however, can interfere with standard treatment or cause serious side effects. That is why it’s important to talk with your doctor. More information about complementary and alternative methods of cancer treatment is available through the American Cancer Society’s toll-free number at 1-800-ACS-2345 or on the ACS Web site at www.cancer.org.

Other Things to Consider During and After Treatment

During and after treatment for your lung cancer you may be able to hasten your recovery and improve your quality of life by taking an active role. Learn about the benefits and disadvantages of each of your treatment options and ask questions of your cancer care team if there is anything you do not understand. Learn about and look out for side effects of treatment and report these promptly to your cancer care team so that they can take steps to reduce them.

Remember that your body is as unique as your personality and your fingerprints. Although understanding your cancer’s stage and learning about the effectiveness of your treatment options can help predict what health problems you may face, no one can say precisely how you will respond to cancer or its treatment.

You may have special strengths such as a history of excellent nutrition and physical activity, a strong family support system, or a deep faith, and these strengths may make a difference in how you respond to cancer treatment. There are also experienced professionals in mental health services, social work services, and pastoral services who may assist you and your family in coping with your illness.

You can also help in your own recovery from cancer by making healthy lifestyle choices. If you use tobacco, stop now. Quitting will improve your overall health, and the full return of your sense of smell may help you enjoy a healthy diet during recovery. If you use alcohol, limit how much you drink. Have no more than 1 or 2 drinks per day. Good nutrition can help you get better after treatment. Eat a nutritious and balanced diet, with plenty of fruits, vegetables, and whole grain foods. If you are having nutrition problems, ask your cancer care team if you may benefit from talking with a dietician. Also ask about beginning or continuing your regular program of exercise.

A cancer diagnosis and its treatment is a major life challenge, with an impact on you and everyone who cares for you. Before you get to the point where you feel overwhelmed, consider attending a meeting of a local support group. If you need assistance in other ways, contact your hospital’s social service department or the American Cancer Society.

About Clinical Trials

Studies of promising new or experimental treatments in patients are known as clinical trials. A clinical trial is only done when there is some reason to believe that the treatment being studied may be valuable to the patient. Treatments used in clinical trials are often found to have real benefits. Researchers conduct studies of new treatments to answer the following questions:

• Is the treatment helpful?
• How does this new type of treatment work?
• Does it work better than other treatments already available?
• What side effects does the treatment cause?
• Are the side effects greater or less than the standard treatment?
• Do the benefits outweigh the side effects?
• In which patients is the treatment most likely to be helpful?

There are 3 phases of clinical trials:

Phase I clinical trials
The purpose of a phase I study is to find the best way to give a new treatment and how much of it can be given safely. Doctors watch patients carefully for any harmful side effects. The treatment has been well tested in laboratory and animal studies, but the side effects in patients are not completely known. Doctors conducting the clinical trial will start by giving very low doses of the drug to the first patients and increasing the dose for later groups of patients until side effects appear. Although doctors are hoping to help patients, the main purpose of such a phase I study is to test the safety of the drug.

Phase II clinical trials
These are designed to see if the drug works. Usually, patients with a single form of cancer are given the highest dose that doesn’t cause unacceptable side effects (determined from the phase I study) and closely watched for an effect on the cancer. The doctors also look for side effects and benefits.

Phase III clinical trials
Phase III studies involve large numbers of patients. Some clinical trials may enroll thousands of patients. One group (the control group) receives the standard (most accepted) treatment. The other groups receive the new treatment. Usually doctors study only 1 new treatment to see if it works better than the standard treatment, but sometimes they test 2 or 3. All patients in phase III studies are closely watched. The study will be stopped early if the side effects of the new treatment are too severe or if one group has had much better result than the others.

If you are in a clinical trial, you will receive excellent care. You will have a team of experts looking at you and monitoring your progress very carefully. The study is especially designed to pay close attention to you.

There are, however, some risks. No one involved in the study knows in advance whether the treatment will work or exactly what side effects will occur. That is what the study is designed to discover. While most side effects disappear in time, some can be permanent or even life threatening. Keep in mind, though, that even standard treatments have side effects. Depending on many factors, you may decide to enroll in a clinical trial.

Deciding to enter a clinical trial
Enrollment in any clinical trial is completely up to you. Your doctors and nurses will explain the study to you in detail and will give you a form to read and sign indicating your desire to take part. You should read the consent form very carefully and be certain that all of your questions about the clinical trial are answered before you sign it. Even after signing the form and after the clinical trial begins, you are free to leave the study at any time, for any reason. Taking part in the study will not prevent you from getting other medical care you may need.

To find out more about clinical trials, talk to your cancer care team. Among the questions you should ask are:

• Is there a study I would be eligible for?
• What is the purpose of the study?
• What kinds of tests and treatments does the study involve?
• What does this treatment do?
• What is likely to happen in my case with, or without, this new research treatment?
• What are my other choices and their advantages and disadvantages?
• How could the study affect my daily life?
• What side effects can I expect from the study? Can the side effects be controlled?
• Will I have to be hospitalized? If so, how often and for how long?
• Will the study cost me anything? Will any of the treatment be free?
• If I am harmed as a result of the research, what treatment would I be entitled to?
• What type of long-term follow-up care is part of the study?
• Has the treatment been used to treat other types of cancers?

The American Cancer Society offers a clinical trials matching service for patients, their family, and friends. You can gain access to this service through the ACS cancer information center (1-800-ACS-2345) or our Web site (www.cancer.org). Based on the information you provide about your cancer type, stage, and previous treatments, this service compiles a list of clinical trials that match your medical needs. In finding a center most convenient for you, the service can also take into account where you live and whether you are willing to travel.

You can also get a list of current clinical trials by calling the National Cancer Institute’s Cancer Information Service toll free at 1-800-4-CANCER or by visiting the NCI clinical trials Web site at www.cancer.gov/clinical_trials/.

LUNG CANCER STAGES

For more information on these treatment guidelines, or on cancer in general, call the NCCN at 1-888-909-NCCN or the American Cancer Society at 1-800-ACS-2345. Or you can visit these organizations’ web sites at www.cancer.org (ACS) and www.nccn.org (NCCN).

©2007, by the National Comprehensive Cancer Network (NCCN) and the American Cancer Society (ACS). All rights reserved. The information herein may not be reprinted in any form for commercial purposes without the expressed written permission of the NCCN or the American Cancer Society. Single copies of each page may be reproduced for personal and non-commercial uses by the reader.