Researchers from Boston University School of Medicine have developed a new 'clinicogenomic model' to accurately test for lung cancer. The model combines a specific gene expression for lung cancer as well as clinical risk factors. These findings currently appear on-line in the journal Cancer Prevention Research
Lung cancer is the leading cause of cancer death in the United States and the world, with more than one million deaths worldwide annually. Eighty-five to 90 percent of subjects with lung cancer in the United States are current or former smokers with 10 to 20 percent of heavy smokers developing this disease.
A previous study by the same researchers reported a gene expression biomarker capable of distinguishing cytologically normal large airway epithelial cells from smokers with and without lung cancer. However, the biomarker has limited sensitivity depending on the stage and the location of the cancer.
Studying current and former smokers undergoing bronchoscopies for suspicion of lung cancer, the researchers compared the likelihood of the subjects having lung cancer using the biomarker, the clinical risk factors and a combination of the two -- clinicogenomic model. They found patients using the clinicogenomic model had increased sensitivity, specificity, positive value and negative predictive value of their cancer compared to the other methods.
"Our data suggests that the clinicogenomic model might serve to identify patients who would benefit from further invasive testing, thereby expediting the diagnosis and treatment for their malignancy," said senior author Avrum Spira, MD, an assistant professor of medicine and pathology at Boston University School of Medicine.
According to the researchers, it is hoped this prediction model will expedite more invasive testing and appropriate therapies for smokers with lung cancer as well as reduce invasive diagnostic procedures for individuals without lung cancer.
Funding for this study was provided by the Doris Duke Charitable Foundation and National Institutes of Health and National Cancer Institute grants.
Spira is a pulmonary and critical care medicine physician at Boston Medical Center and is one of the founders of Allegro Diagnostics Inc., a molecular diagnostics company that plans to market the gene expression biomarker.
Researchers from Boston University School of Medicine have developed a new "clinicogenomic model" to accurately test for lung cancer. The model combines a specific gene expression for lung cancer as well as clinical risk factors. These findings currently appear on-line in the journal Cancer Prevention Research.
Lung cancer is the leading cause of cancer death in the United States and the world, with more than one million deaths worldwide annually. Eighty-five to 90 percent of subjects with lung cancer in the United States are current or former smokers with 10 to 20 percent of heavy smokers developing this disease.
A previous study by the same researchers reported a gene expression biomarker capable of distinguishing cytologically normal large airway epithelial cells from smokers with and without lung cancer. However, the biomarker has limited sensitivity depending on the stage and the location of the cancer.
Studying current and former smokers undergoing bronchoscopies for suspicion of lung cancer, the researchers compared the likelihood of the subjects having lung cancer using the biomarker, the clinical risk factors and a combination of the two -- clinicogenomic model. They found patients using the clinicogenomic model had increased sensitivity, specificity, positive value and negative predictive value of their cancer compared to the other methods.
"Our data suggests that the clinicogenomic model might serve to identify patients who would benefit from further invasive testing, thereby expediting the diagnosis and treatment for their malignancy," said senior author Avrum Spira, MD, an assistant professor of medicine and pathology at Boston University School of Medicine.
According to the researchers, it is hoped this prediction model will expedite more invasive testing and appropriate therapies for smokers with lung cancer as well as reduce invasive diagnostic procedures for individuals without lung cancer.
For more details on treatment options -- including some that may not be addressed in this document -- the National Cancer Institute (NCI) and the National Comprehensive Cancer Network (NCCN) are good sources of information.
The NCI provides treatment guidelines via its telephone information center (1-800-4-CANCER) and its Web site (www.cancer.gov). Detailed guidelines intended for use by cancer care professionals are also available on www.cancer.gov.
The NCCN, made up of experts from many of the nation's leading cancer centers, develops cancer treatment guidelines for doctors to use when treating patients. These are available on the NCCN Web site (www.nccn.org).
Treatment Choices by Stage for Non-Small Cell Lung Cancer
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.
When you have cancer you are likely to hear about ways to treat your cancer or relieve symptoms that are different from mainstream (standard) medical treatment. These methods can include vitamins, herbs, and special diets, or methods such as acupuncture or massage—among many others. You may have a lot of questions about these treatments. Here are some you may have thought of already:
How do I know if a non-standard treatment is safe?
How do I know if it works?
Should I try one or more of these treatments?
What does my doctor know/think about these methods? Should I tell the doctor that I'm thinking about trying them?
Will these treatments cause a problem with my standard medical treatment?
What is the difference between "complementary" and "alternative" methods?
Where can I find out more about these treatments?
The terms can be confusing
Not everyone uses these terms the same way, so it can be confusing. The American Cancer Society uses complementary to refer to medicines or methods that are used along with your regular medical care. Alternative medicine is a treatment used instead of standard medical treatment.
Complementary methods: Complementary treatment methods, for the most part, are not presented as cures for cancer. Most often they are used to help you feel better. Some methods that can be used in a complementary way are meditation to reduce stress, acupuncture to relieve pain or peppermint tea to relieve nausea. There are many others. Some of these methods are known to help, while others have not been tested. Some have been proven not be helpful. A few have even been found harmful. However, some of these methods may add to your comfort and well-being.
There are many complementary methods that you can safely use right along with your medical treatment to help relieve symptoms or side effects, to ease pain, and to help you enjoy life more. For example, some people find methods such as aromatherapy, massage therapy, meditation, or yoga to be useful.
Alternative treatments: Alternative treatments are those that are used instead of standard medical care. These treatments have not been proven safe and effective in clinical trials. Some of these methods may even be dangerous and some have life-threatening side effects. The biggest danger in most cases is that you may lose the chance to benefit from standard treatment. Delays or interruptions in your standard medical treatment may give the cancer more time to grow.
Deciding what to do
It is easy to see why people with cancer may consider alternative methods. You want to do all you can to fight the cancer. Sometimes mainstream treatments such as chemotherapy can be hard to take, or they may no longer be working.
Sometimes people suggest that their method can cure your cancer without having serious side effects, and it's normal to want to believe them. But the truth is that most non-standard methods of treatment have not been tested and proven to be effective for treating cancer.
As you consider your options, here are 3 important steps you can take:
Talk to your doctor or nurse about any method you are thinking about using.
Check the list of "red flags" below.
Contact the American Cancer Society at 1-800-ACS-2345 (1-800-227-2345) to learn more about complementary and alternative methods in general and to learn more about the specific methods you are thinking about.
Red flags
You can use the questions below to spot treatments or methods to avoid. A "yes" answer to any one of these questions should raise a "red flag."
Does the treatment promise a cure for all or most cancers?
Are you told not to use standard medical treatment?
Is the treatment or drug a "secret" that only certain people can give?
Does the treatment require you to travel to another country?
Do the promoters attack the medical or scientific community?
The decision is yours
Decisions about how to treat or manage your cancer are always yours to make. If you are thinking about using a complementary or alternative method, be sure to learn about the method and talk to your doctor about it. With reliable information and the support of your health care team, you may be able to safely use the methods that can help you while avoiding those that could be harmful.
As researchers have learned more about the gene changes in cells that cause cancer, they have been able to develop newer drugs that specifically target these changes. These targeted drugs work differently than standard chemotherapy drugs. They often have different (and less severe) side effects. At this time, they are most often used either along with chemotherapy or in cases where chemotherapy is no longer working.
Drugs that target tumor blood vessel growth (angiogenesis)
For tumors to grow, they must form new blood vessels to keep them nourished. This process is called angiogenesis. Some newer targeted drugs block this new vessel growth.
Bevacizumab (Avastin) is a type of drug known as a monoclonal antibody (a manmade version of a specific immune system protein). It targets vascular endothelial growth factor (VEGF), a protein that helps new blood vessels to form. This drug has been shown to prolong survival of patients with advanced lung cancer when it is added to standard chemotherapy regimens as part of first-line treatment.
Bevacizumab is given by infusion into a vein every 2 to 3 weeks.
The possible side effects of this drug are different from those of chemotherapy drugs. Some of these effects can be serious. It can cause bleeding, which limits its use to some extent. It is not used in patients who are coughing up blood, who have cancer that has spread to the brain, or who are on "blood thinners" such as aspirin or warfarin (Coumadin). Most current guidelines do not recommend using bevacizumab in patients with squamous cell cancer, because it may lead to serious bleeding from this type of lung cancer. However, studies are under way to see if bevacizumab is safe as long as the squamous cell cancer is not located near large blood vessels in the center of the chest cavity.
Other possible effects include high blood pressure, loss of appetite, delayed wound healing, and an increased risk of blood clots.
Drugs that target EGFR
Epidermal growth factor receptor (EGFR) is a protein found on the surface of cells. It normally receives signals telling the cells to grow and divide. Some lung cancer cells have too many copies of EGFR, which help them grow faster.
Erlotinib (Tarceva): Erlotinib is a drug that blocks EGFR from signaling the cell to grow. It has been shown to help keep some lung tumors under control, especially in women and in people who never smoked. It is most often used for advanced lung cancers if initial treatment with chemotherapy is no longer working.
This drug is taken daily as a pill. The most common side effects of erlotinib include an acne-like rash on the face and chest, diarrhea, loss of appetite, and feeling tired.
Cetuximab (Erbitux): Cetuximab is a monoclonal antibody that targets EGFR. For patients with advanced lung cancer, some doctors may add it to standard chemotherapy as part of first-line treatment.
Cetuximab is given by IV infusion, usually once a week. A rare but serious side effect of cetuximab is an allergic reaction during the first infusion, which could cause problems with breathing and low blood pressure. You may be given medicine before treatment to help prevent this. Other, less serious side effects may include an acne-like rash, headache, tiredness, fever, and diarrhea.
Chemotherapy is treatment with anti-cancer drugs injected into a vein or taken by mouth. These drugs enter the bloodstream and go throughout the body, making this treatment useful for cancer that has spread (metastasized) to distant organs. Depending on the type and stage of lung cancer, chemotherapy may be given as the main (primary) treatment or as an addition (adjuvant) to surgery or radiation therapy.
Doctors give chemotherapy in cycles, with each period of treatment followed by a rest period to allow the body time to recover. Chemotherapy cycles generally last about 3 to 4 weeks, and initial treatment typically involves 4 to 6 cycles. Chemotherapy is often not recommended for patients in poor health, but advanced age by itself is not a barrier to getting chemotherapy.
Most often, initial treatment for advanced lung cancer uses a combination of 2 chemotherapy drugs. Studies have shown that adding a third chemotherapy drug doesn't add much benefit and is likely to cause more side effects. The drugs most frequently used for initial chemotherapy for NSCLC are:
cisplatin
carboplatin
paclitaxel
docetaxel
gemcitabine
vinorelbine
irinotecan
etoposide
vinblastine
pemetrexed
The most common combinations include either cisplatin or carboplatin plus one other drug, although some studies have found that using combinations with less severe side effects, such as gemcitabine with vinorelbine or paclitaxel, may be just as effective for many patients.
For people whose cancers meet certain criteria, targeted therapy drugs such as bevacizumab (Avastin) or cetuximab (Erbitux) may be added to initial treatment as well (see "Targeted therapies" section).
Single-drug chemotherapy is sometimes used for people who might not tolerate combination chemotherapy well, such as those in poor overall health.
If the initial chemotherapy treatment is no longer working, second-line treatment usually consists of a single drug such as docetaxel or pemetrexed. Another option may be the targeted therapy erlotinib (Tarceva) (see "Targeted therapies" section).
Again, advanced age is no barrier to receiving these drugs as long as the person is in good general health.
Possible side effects
Chemotherapy drugs work by attacking cells that are dividing quickly, which is why they work against cancer cells. But other cells in the body, such as those in the bone marrow, the lining of the mouth and intestines, and the hair follicles, also divide quickly. These cells are also likely to be affected by chemotherapy, which can lead to side effects.
The side effects of chemotherapy depend on the type and dose of drugs given and the length of time they are taken. These side effects can include:
hair loss
mouth sores
loss of appetite
nausea and vomiting
increased chance of infections (due to low white blood cell counts)
easy bruising or bleeding (due to low blood platelet counts)
fatigue (due to low red blood cell counts)
These side effects are usually short-term and go away after treatment is finished. There are often ways to lessen these side effects. For example, there are drugs that can be given to help prevent or reduce nausea and vomiting.
Some drugs such as cisplatin, vinorelbine, docetaxel, or paclitaxel can damage nerves. This can sometimes lead to symptoms (mainly in the hands and feet) such as pain, burning or tingling sensations, sensitivity to cold or heat, or weakness. (This is called peripheral neuropathy.) In most cases this goes away once treatment is stopped, but it may be long lasting in some people. You should report this, as well as any other side effects or changes you notice while getting chemotherapy, to your medical team so that they can be treated promptly. In some cases, the doses of the chemotherapy drugs may need to be reduced or treatment may need to be delayed or stopped to prevent the effects from getting worse.
At times, treatments other than surgery or radiation therapy may be used to destroy lung cancer cells at a specific location.
Radiofrequency ablation (RFA)
This technique is being studied for small lung tumors that are near the outer edge of the lungs, especially in people who can't have or don't want surgery. It uses high-energy radio waves to heat the tumor. A thin, needle-like probe is placed through the skin and moved along until the end is in the tumor. Placement of the probe is guided by ultrasound or CT scans. Once it is in place, an electric current is passed through the probe, which heats the tumor and destroys the cancer cells. RFA is usually done as an outpatient procedure, using local anesthesia (numbing medicine) where the probe is inserted. You may be given medicine to help you relax as well.
Major complications are uncommon, but they can include the partial collapse of a lung (which often resolves on its own) or bleeding into the lung.
Photodynamic therapy (PDT)
Photodynamic therapy is sometimes used to treat smaller lung cancers near airways when other treatments aren't appropriate, or to help open up airways blocked by tumors to help people breathe better.
For this technique, a light-activated drug called porfimer sodium (Photofrin) is injected into a vein. Over the next couple of days, the drug is more likely to collect in cancer cells than in normal cells. A bronchoscope is then passed down the throat and into the lung. This may be done with either local anesthesia (where the throat is numbed) or general anesthesia (where you are in a deep sleep). A special red light on the end of the bronchoscope is aimed at the tumor, causing the cells to die. The dead cells are then removed a few days later during a bronchoscopy. This process can be repeated if needed.
Some of this drug also collects in normal cells in the body, such as skin and eye cells. This can make you very sensitive to sunlight or strong indoor lights. Too much exposure can cause serious skin reactions, which is why doctors recommend staying out of any strong light for 4 to 6 weeks after the injection.
Radiation therapy uses high-energy rays (such as x-rays) or particles to kill cancer cells. There are 2 main types of radiation therapy -- external beam radiation therapy and brachytherapy (internal radiation therapy).
External beam radiation therapy
External beam radiation therapy (EBRT) uses radiation delivered from outside the body that is focused on the cancer. This is the type of radiation therapy most often used to treat a primary lung cancer or its metastases to other organs.
Before your treatments start, the radiation team will take careful measurements to determine the correct angles for aiming the radiation beams and the proper dose of radiation. Radiation therapy is much like getting an x-ray, but the radiation is more intense. The procedure itself is painless. Each treatment lasts only a few minutes, although the setup time -- getting you into place for treatment -- usually takes longer. Most often, radiation treatments are given 5 days a week for 5 to 8 weeks.
Standard (conventional) EBRT is used much less often than in the past. Newer techniques allow doctors to be more accurate in treating lung cancers while reducing the radiation exposure to nearby healthy tissues. These techniques may offer better chances of increasing the success rate and reducing side effects.
Three-dimensional conformal radiation therapy (3D-CRT): 3D-CRT uses special computers to precisely map the location of the tumor(s). Radiation beams are shaped and aimed at the tumor(s) from several directions, which makes it less likely to damage normal tissues. Most doctors now recommend using 3D-CRT when it is available.
Intensity modulated radiation therapy (IMRT): IMRT is an advanced form of 3D therapy. It uses a computer-driven machine that moves around the patient as it delivers radiation. Along with shaping the beams and aiming them at the tumor from several angles, the intensity (strength) of the beams can be adjusted to minimize the dose reaching the most sensitive normal tissues. This technique is used most often if tumors are near important structures such as the spinal cord. Many major hospitals and cancer centers are now able to provide IMRT.
Stereotactic radiation therapy: A newer form of treatment, known as stereotactic body radiation therapy (SBRT), is sometimes used to treat very early stage lung cancers. It is described in more detail in the section, "What's new in non-small cell lung cancer research and treatment?"
Another type of stereotactic radiation therapy can sometimes be used instead of surgery for single tumors that have spread to the brain. Using a machine called a Gamma Knife®, many beams of high-dose radiation are focused on the tumor from different angles over a few minutes to hours. The head is kept in the same position by placing it in a rigid frame.
Brachytherapy (internal radiation therapy)
Brachytherapy is used most often to shrink tumors to relieve symptoms caused by the cancer, although in some cases it may be part of a larger treatment regimen trying to cure the cancer. It involves placing a small source of radioactive material (often in the form of pellets) directly into the cancer or into the airway next to the cancer. This is usually done through a bronchoscope, although it may also be done during surgery. The radiation travels only a short distance from the source, limiting the effects on surrounding healthy tissues. The radiation source is usually removed after a short time. Less often, small radioactive "seeds" are left in place permanently, and the radiation gets weaker over several weeks.
When is radiation therapy used?
External beam radiation therapy is sometimes used as the main treatment of lung cancer (sometimes together with chemotherapy), especially if the lung tumor cannot be removed by surgery because it is close to large blood vessels or the person's health is too poor. Brachytherapy is most often used to help relieve blockage of large airways by cancer.
After surgery, radiation therapy can be used (alone or along with chemotherapy) to try to kill very small deposits of cancer that may have been missed by surgery.
Radiation therapy can also be used to relieve (palliate) symptoms of lung cancer such as pain, bleeding, trouble swallowing, cough, and problems caused by brain metastases.
Possible side effects
Side effects of external radiation therapy might include sunburn-like skin problems where the radiation enters the body, nausea, vomiting, and fatigue. Often these go away after treatment. Radiation might also make the side effects of chemotherapy worse. Chest radiation therapy may damage your lungs and cause problems breathing and shortness of breath. Your esophagus, which is located in the middle of your chest, may be exposed to radiation, which could cause trouble swallowing during treatment. This usually improves after treatment is over.
Radiation therapy to large areas of the brain can sometimes cause changes in brain function. Some people notice memory loss, headache, trouble thinking, or reduced sexual desire. Usually these symptoms are minor compared to those caused by a brain tumor, but they can reduce your quality of life. Side effects of radiation therapy to the brain usually become most serious 1or 2 years after treatment.
Depending on the type and stage of a lung cancer, surgery may be used to remove the cancer along with some surrounding lung tissue. Surgery is usually recommended (often along with other treatments) for early stage lung cancers. If surgery can be done, it provides the best chance to cure NSCLC.
If your doctor thinks the lung cancer can be treated with surgery, pulmonary function tests will be done beforehand to determine whether you will have enough healthy lung tissue remaining after surgery.
Types of surgery
Several different operations can be used to treat (and possibly cure) non-small cell lung cancer:
pneumonectomy: the entire lung is removed in this surgery.
lobectomy: a section (lobe) of the lung is removed in this surgery.
segmentectomy or wedge resection: part of a lobe is removed in this surgery.
With any of these operations, lymph nodes are also removed to look for possible spread of the cancer.
These operations require general anesthesia (where you are in a deep sleep) and a surgical incision between the ribs in the chest (thoracotomy). You will generally need to spend 5 to 7 days in the hospital after the surgery.
Video-assisted thoracic surgery (VATS): Recently, some doctors have begun to use a less invasive procedure for treating some early stage lung cancers called video-assisted thoracic surgery (VATS). During this operation, a thin telescopic tube with a tiny video camera on the end is placed through a small hole in the chest to help the surgeon see the chest cavity. One or two other small holes are created in the skin, and long instruments passed though these holes are used to remove the tumor. Because only small incisions are needed, there is a little less pain after the surgery. Another advantage of this surgery is a shorter hospital stay -- usually around 4 to 5 days. Most experts recommend that only early stage tumors smaller than 3 to 4 centimeters (about 1 1/2 inches) be treated this way. The cure rate after this surgery seems to be the same as with older techniques. But it is important that the surgeon performing this procedure is experienced since it requires a great deal of technical skill.
Surgery for cancers with limited spread to other organs: If the lung cancer has spread to the brain or adrenal gland and there is only one tumor, you may benefit from removal of the metastasis. This surgery should be considered only if only if the tumor in the lung can also be completely removed. Even then, not all lung cancer experts agree with this approach, especially if the tumor is in the adrenal gland.
For tumors in the brain, this is done by surgery through a hole in the skull (craniotomy). It should only be done if the tumor can be removed without damage to vital areas of the brain that control movement, sensation, and speech.
Possible side effects of surgery
Possible complications depend on the extent of the surgery and a person's health beforehand. Serious complications can include excessive bleeding, wound infections, and pneumonia. While it is rare, in some cases people may not survive the surgery, which is why it is important that surgeons select patients carefully.
Because the surgeon must spread ribs to get to the lung in patients undergoing a thoracotomy, the incision will hurt for some time after surgery. Your activity will be limited for at least a month or two.
If your lungs are in good condition (other than the presence of the cancer) you can usually return to normal activities after a lobe or even an entire lung has been removed. If you also have non-cancerous diseases such as emphysema or chronic bronchitis (which are common among heavy smokers), you may become short of breath with activities after surgery.
Surgery to relieve symptoms of NSCLC
If you can't have major surgery because of reduced lung function or other serious medical problems, or if the cancer is widespread, other types of surgery may be used to relieve some symptoms. For example, laser surgery can be used to relieve blockage of airways that may be causing pneumonia or shortness of breath. Other techniques, such as photodynamic therapy (described later in the document) may also be used.
Sometimes fluid can build up in the chest cavity (outside of the lungs) and interfere with breathing. To remove the fluid and keep it from coming back, doctors sometimes perform a procedure called pleurodesis. A small cut is made in the skin of chest wall, and a hollow tube is placed into the chest to remove the fluid. Either talc or a drug such as doxycycline or a chemotherapy drug is then instilled into the chest cavity. This causes the linings of the lung (visceral pleura) and chest wall (parietal pleural) to stick together, sealing the space and preventing further fluid buildup. The tube is generally left in for a day or two to drain any new fluid that might accumulate.
For more general information about surgery, please see our separate document, Surgery.
This information represents the views of the doctors and nurses serving on the American Cancer Society's Cancer Information Database Editorial Board. These views are based on their interpretation of studies published in medical journals, as well as their own professional experience.
The treatment information in this document is not official policy of the Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help you and your family make informed decisions, together with your doctor.
Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don't hesitate to ask him or her questions about your treatment options.
The first part of this section describes the various types of treatments used for non-small cell lung cancer. This is followed by a description of the most common approaches used for these cancers based on the stage of the cancer.
Making treatment decisions
If you have non-small cell lung cancer (NSCLC), your treatment options may include surgery, radiation therapy, chemotherapy, targeted therapy, or some combination of these, depending on the stage of your cancer and other factors.
After the cancer is found and staged, your cancer care team will discuss your treatment options with you. It is important to take time and think about your options. In choosing a treatment plan, one of the most important factors is the stage of the cancer. For this reason, it is very important that your doctor order all the tests needed to determine the cancer's stage. Other factors to consider include your overall health, the likely side effects of the treatment, and the probability of curing the disease, extending life, or relieving symptoms. One thing to remember is that age alone should not be a barrier to treatment. Older people can benefit from treatment as much as younger people, as long as their general health is good.
In considering your treatment options it is often a good idea to seek a second opinion, if possible. This may provide you with more information and help you feel more confident about the treatment plan you have chosen. Your doctor should not mind that you want to get a second opinion. 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.
