| Treatment Choices by Stage for Non-Small Cell Lung Cancer | |
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If you smoke, one of the most important things you can do to be ready for treatment is to quit. Studies have shown that patients who stop smoking after a diagnosis of lung cancer have better outcomes than those who don't.
Occult cancer
For these cancers, malignant cells are seen on sputum cytology but no obvious tumor can be found with bronchoscopy or imaging tests. They are usually early stage cancers. Bronchoscopy is usually repeated about every 3 months to look for a tumor. If a tumor is found, treatment will depend on the stage.
Stage 0
Because stage 0 non-small cell lung cancer (NSCLC) is limited to the lining layer of air passages and has not invaded deeper into the lung tissue or other areas, it is curable by surgery alone. No chemotherapy or radiation therapy is needed.
If you are healthy enough for surgery, you can usually be treated by segmentectomy or wedge resection (removal of defined segments or small wedges). Cancers in some locations (such as where the windpipe divides into the left and right main bronchi) may be hard to remove completely by surgery without removing a lobe or even an entire lung.
In some cases, photodynamic therapy, laser surgery, or brachytherapy may be useful alternatives to surgery for stage 0 cancers. If you are truly stage 0, these treatments will probably cure you.
Stage I
If you have stage I NSCLC your treatment may be only surgery -- removal of the tumor either by taking out one lung lobe (lobectomy) or taking out part of a lung by doing a segmentectomy or wedge resection. At least some lymph nodes within the lung and outside the lung in the mediastinum will be removed to check them for cancer cells.
Segmentectomy or wedge resection is recommended only for treating the smallest stage I cancers and for patients with other medical conditions that make removing the entire lobe dangerous. This is the stage that is most suited for video-assisted thoracic surgery (VATS). Still, most surgeons believe it is better to perform a lobectomy if the patient can tolerate it, as it offers the best chance for cure.
For some people with stage I NSCLC, adjuvant chemotherapy after surgery may lower the risk that cancer will return. But doctors aren't sure how best to determine in which people the benefits outweigh the downsides. New lab tests that look at the patterns of certain genes in the cancer cells appear promising and may help with this. Studies are now under way to see if these tests are accurate.
After surgery, chemotherapy and/or radiation therapy may also be recommended if the pathology report shows that there were cancer cells at the edge of the surgery specimen. This means that some cancer may have been left behind. Another approach would be to have a second surgery to try to ensure that all the cancer has been removed. (This might be followed by chemotherapy as well.)
If you have serious medical problems that would prevent you from having surgery, you may receive only radiation therapy as your main treatment.
Stage II
People who have stage II NSCLC and are healthy enough for surgery usually have the cancer removed by lobectomy or, less often, segmentectomy. Sometimes removing the whole lung (pneumonectomy) is needed.
Any lymph nodes likely to have cancer in them are also removed. The type of lymph node involvement and whether or not cancer cells are found at the edges of the removed tissues are important factors when planning the next step of treatment.
After surgery, chemotherapy (with or without radiation therapy) is typically recommended to try to destroy any cancer cells left behind. As with stage I cancers, newer lab tests now being studied may allow doctors to tell which patients need this adjuvant treatment and which are less likely to benefit from it.
If cancer cells are found at the edge of the tissue removed by surgery, chemotherapy and radiation therapy may be used. Additional surgery followed by chemotherapy may be another option.
If you have serious medical problems that would prevent you from having surgery, you may receive only radiation therapy as your main treatment.
Stage IIIA
Treatment for stage IIIA NSCLC may include radiation therapy, chemotherapy, surgery or some combination of these. For this reason, planning treatment for stage IIIA NSCLC will often require input from a medical oncologist, radiation oncologist, and surgeon. Treatment options will depend on the size of the tumor, where it is located in your lung, which lymph nodes it has spread to, your overall health, and how well you are tolerating treatment.
For patients who can tolerate it, treatment usually starts with chemotherapy, with or without radiation therapy. Surgery may be an option at this point if the doctor thinks any remaining cancer can be removed and the patient is healthy enough. (In selected T3N1 cases, where the cancer has not reached the lymph nodes in the middle of the chest, surgery may be an option as the first treatment.) This is often followed by chemotherapy, and possibly radiation therapy if it hasn't been given before.
For people who can't tolerate chemotherapy or surgery, radiation therapy is usually the treatment of choice.
Stage IIIB
Stage IIIB NSCLC has usually spread too widely to be completely removed by surgery. If you are in fairly good health you may be helped by chemotherapy and radiation therapy. In selected cases where all of the cancer may be removable (such as certain T4N0 tumors), you may be able to have surgery. Chemotherapy (with or without radiation therapy) is often given first. After surgery, chemotherapy and radiation (if not given before surgery) is recommended.
For stage IIIB cancers that have caused a malignant pleural effusion (fluid in the space around the lungs), the fluid may be drained and pleurodesis may be done to help prevent it from coming back. Treatment is then generally the same as for stage IV disease (see below).
Again, treatment depends on a person's overall health and how well they are tolerating it. For people who can't have chemotherapy or surgery, radiation therapy is usually the treatment of choice.
Because treatment is unlikely to cure these cancers, taking part in a clinical trial of newer treatments may be a good option. Several clinical trials are in progress to determine the best treatment for people with this stage of lung cancer.
Stage IV
Stage IV NSCLC is widespread when it is diagnosed. Because these cancers have spread to distant organs, they are very hard to cure. Treatment options depend on the site of the distant spread, the number of tumors, and your overall health. If you are in otherwise good health, treatments such as surgery, chemotherapy, and radiation therapy may help you live longer and make you feel better by relieving symptoms, even though they aren't likely to cure you. In any case, if you are going to receive treatment for advanced NSCLC, the goals of treatment should be clear to you before you start.
Cancer that has spread widely throughout the body is treated with chemotherapy, as long as the person is healthy enough to tolerate it. The targeted therapy bevacizumab (Avastin) is FDA-approved for use with chemotherapy in people who are not at high risk for bleeding (that is, they do not have squamous cell NSCLC, do not have cancer spread to the brain, have not coughed up blood, and are not taking "blood thinning" medicine). However, some doctors consider bevacizumab to be safe for certain patients with squamous cell cancer as long as the tumor is not located near large blood vessels in the center of the chest. (Studies are now under way to try to confirm this.) Adding the targeted drug cetuximab (Erbitux) to chemotherapy may be another option, especially in people who cannot get bevacizumab.
Cancer that is limited in the lungs and has only spread to one other site (such as the brain) is not common but can sometimes be treated with surgery or radiation therapy. For example, a single tumor in the brain may be treated with surgery or stereotactic radiation (such as the Gamma Knife), followed by radiation to the whole brain.
As with other stages, treatment depends on a person's overall health and how well they are tolerating it. For example, some people not in good health might get only one chemotherapy drug instead of two. For people who can't tolerate chemotherapy or surgery, radiation therapy is usually the treatment of choice.
Because treatment is unlikely to cure these cancers, taking part in a clinical trial of newer treatments may be a good option.
Cancer that progresses or recurs after treatment
If cancer continues to grow during treatment or comes back, further treatment will depend on the extent of the cancer, what treatments have been used, and a person's health and desire for further treatment. Again, it is important to understand the goal of any further treatment -- whether it is to try to cure the cancer or to help relieve symptoms -- as well as the likelihood of benefits and risks.
If cancer continues to grow during initial treatment such as radiation therapy, chemotherapy may be tried. If a cancer continues to grow during combination chemotherapy, second line treatment most often consists of a single chemotherapy drug such as docetaxel or pemetrexed, or the targeted therapy erlotinib (Tarceva).
Smaller cancers that recur locally in the lungs can sometimes be retreated with surgery or radiation therapy (if it hasn't been used before). Cancers that recur in the lymph nodes between the lungs are usually treated with chemotherapy, possibly along with radiation if it hasn't been used before. For cancers that return at distant sites, chemotherapy and/or targeted therapies are often the treatments of choice.
At some point, it may become clear that standard treatments are no longer controlling the cancer. If you want to continue anti-cancer treatment, you might think about taking part in a clinical trial of newer lung cancer treatments. While these are not always the best option for every person, they may benefit you as well as future patients.
Even if you have incurable lung cancer you should be as free of symptoms as possible. If curative treatment is not an option, treatment aimed at specific sites can often relieve symptoms and may even slow the spread of the disease. Symptoms such as shortness of breath or coughing up blood caused by cancer in the lung airways can often be treated effectively with radiation therapy, brachytherapy, laser therapy, photodynamic therapy, or even surgery if needed. Radiation therapy can be used to help control cancer spread in the brain or relieve pain in a specific area if cancer has spread.
Many people with lung cancer are concerned about pain. As the cancer grows near certain nerves it can sometimes cause pain, but this can almost always be treated effectively with pain medicines. Sometimes radiation therapy will help as well. It is important that you talk to your doctor and take advantage of these treatments.
Deciding on the right time to stop treatment aimed at curing the cancer and focus on care that relieves symptoms is never easy. Good communication with doctors, nurses, family, friends, and clergy can often help people facing this situation.
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