The most common treatments for lung cancer are surgery, radiation therapy and chemotherapy. Some patients also may be prescribed targeted therapy, which includes drugs that “target” cancer cells. There also are some new treatment options being tested in clinical trials. Be sure to talk with your doctor if you are interested in participating in a clinical trial.

Multiple organizations have physician treatment guidelines for lung cancer, including:

• The National Comprehensive Cancer Network (NCCN): NSCLC, SCLC
• The American College of Chest Physicians (CHEST)
• The American Society of Clinical Oncology (ASCO)

Surgery
Radiation therapy
Chemotherapy
Targeted therapy: New lung cancer treatments
Targeted therapy drugs
Treatments by stage of cancer
Managing your pain
Supportive care

Surgery

Surgery, or having an operation, is the physical removal of the cancer tumor and any lymph nodes that may contain cancerous cells. Ideally, a thoracic surgeon, who is an expert in lung cancer surgery, should perform the operation. Seek out a surgical center that does a lot of lung cancer surgeries. Don't be afraid to ask whether your recommended surgeon is a thoracic surgeon and how many lung cancer surgeries he or she does each year.

Whether you can be treated with surgery depends on:

• The type and stage of your cancer. Surgery is generally not recommended if the cancer has spread to other organs (Stage IV NSCLC) or for SCLC.
• The location and size of your tumor. If the surgeon cannot get to or safely remove your tumor, the disease is called inoperable, or unresectable, and surgery may not be an option (Stage IIIB and some Stage IIIA NSCLC patients).
• Whether you are otherwise healthy enough to have surgery. If you have heart or lung disease in addition to lung cancer, you may not be able to have surgery.

If you have traditional lung surgery, it usually takes six to eight weeks to fully recover. Depending on the size and location of your tumor, you may be able to have a newer type of lung surgery with a shorter recovery time: video-assisted thoracic surgery (VATS). This type of surgery is less invasive because it uses a video camera to guide the surgeon. Recovery time will vary depending on your particular surgery, your general health and how well you heal.

Types of surgery: If you are a candidate for surgery, it is best when only the lobe where the tumor is located needs to be removed. This is called a lobectomy. In more difficult cases, the tumor may be located in the largest airway, very near the trachea or involve more than one lobe of the lung. In these cases, the whole lung may need to be removed. This is called a pneumonectomy.

Radiation therapy

Radiation therapy (also sometimes referred to as radiotherapy, x-ray therapy or irradiation) is the use of x-rays to damage cancer cells and stop them from growing or multiplying. Because radiation also affects normal cells, this therapy is aimed only at the cancer tumor. Like surgery, radiation is a local form of therapy and not a systemic treatment, such as chemotherapy. High doses of radiation are given when the tumor is confined to the chest, with the hope that it will kill all of the tumor cells in that area. This might involve daily doses of radiation for up to six weeks or longer.

When the cancer has spread from the lungs to other parts of the body, radiation may be given in smaller doses to relieve symptoms to affected areas, such as the brain or bones. Radiation, given for periods ranging from one day to four weeks, can kill enough cancer cells to bring relief from symptoms such as pain, breathing difficulties and headaches.

Side effects from radiation therapy depend upon where the radiation is focused and how much radiation is given. Radiation treatment can make you tired, for example, or give you a painful sore throat. For more details about the side effects you can expect from your treatment, talk with your oncology nurse or radiation oncologist. Click here to watch a video on managing the side-effects of radiation treatment for lung cancer.

Specialized Radiation Therapy: Your radiation oncologist may recommend a specialized type of treatment for you called stereotactic body radiation therapy (SBRT). SBRT uses radiation from multiple angles, allowing higher doses of radiation to be focused on the tumor, avoiding normal tissues. You may hear about Gamma-Knife or CyberKnife treatments, which are methods of delivering SBRT.

Other advances in radiation therapy are being developed, and will be added here when they are available.

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Chemotherapy

Chemotherapy drugs are used to kill cancer cells. Unlike surgery and radiation, which are used to treat local disease, chemotherapy is usually systemic, that is, it goes through the whole body and therefore should affect cancer cells anywhere they may be. There are a number of different chemotherapy drugs that are used for lung cancer. They are administered intravenously (IV) or taken as pills by mouth. Usually two drugs are given for four to six “cycles.” Each cycle is a treatment followed by about a three week rest period. Therefore, if you are prescribed four cycles, it usually means you will receive the chemotherapy drugs four times, each given about three weeks apart, for a total of 12 weeks of therapy.

Chemotherapy interferes with the DNA of cancer cells. Because cancer cells divide rapidly, many chemotherapy drugs target these cells in an attempt to stop them from dividing. In the course of attacking the cancer cells, these drugs also can affect normal cells that also grow rapidly, such as hair cells, cells lining the stomach, and blood cells. This is why chemotherapy may cause side effects such as hair loss; an upset stomach, nausea or vomiting; or weaken or suppress the immune system.

Many people are concerned about the side effects of chemotherapy. It is important to know that different types of cancers are treated with different types of chemotherapy, and that chemotherapy has changed a lot over the years. If someone tells you what they or a friend went through, remember that your experience may be very different, particularly if the other person did not have lung cancer or received different chemotherapy drugs than you are prescribed. The good news is that today’s chemotherapy drugs for lung cancer patients have fewer side effects than ever.

Typical side effects of chemotherapy may include (but are not limited to):

• Hair loss. Not all types of chemotherapy cause hair loss. If this is important to you, be sure to ask your oncologist about your treatment options.
• Severe nausea/vomiting. This is largely a thing of the past due to the newer anti-nausea medicines that are available.
• Lowering the blood cell count. Chemotherapy affects all of the blood cells in your body and your blood count (the number of these cells) generally goes down. Your blood count is likely to go down about one to two weeks after your treatment and should return to normal about a week later.
  • Red blood cells: Low red blood cell counts can cause you to feel more tired than usual or short of breath.
  • White blood cells: Having a low white blood cell count means you may not be able to fight off infections, colds or the flu as easily, so you will want to protect yourself from other illnesses during your treatment. Avoid being around people who are sick. Wash your hands often.
  • Platelets: Having a low platelet count puts you at risk for bleeding, although complications from this are rare.

Each individual chemotherapy drug has its own side effects. For more details about the possible side effects of your chemotherapy, ask your oncologist or nurse. If chemotherapy drugs are recommended for you, discuss the pros and cons of the different drugs with your medical oncologist. You will want to discuss potential side effects and how they can be treated. You may also want to ask your doctor if there are any new drugs you can try as part of a clinical trial.

Here are some questions to ask about your chemotherapy:

• What is the goal of chemotherapy for my cancer?
• How often will I receive my chemotherapy?
• How will I know if the chemotherapy is working?
• What side effects might I have?
• How can I help cope with side effects?
• Will I need to change my diet?
• Will my sexual function or fertility be affected by the drugs?
• If the chemotherapy does not work, are there other options for me?

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Targeted therapy: New lung cancer treatments

Over the past decade, scientists have made many discoveries about what makes cancer cells multiply out of control. They are developing drugs that “target” only cancer cells. There are different types of targeted therapy. For example, some drugs stop substances called growth factors from working. These growth factors are made by tumor cells and “tell” other tumor cells to multiply. Blocking these growth factors from working can stop the cancer from growing and/or spreading. Some other types of targeted therapy drugs can stop the tumor from making new blood vessels, a process known as angiogenesis. Choking off the blood supply to a tumor can prevent it from getting needed oxygen and nutrients. There are different types of targeted therapies, but all are designed to target cancer cells and stop or limit the growth and spread of cancer.

Currently, there are targeted therapies available to treat NSCLC in certain cases. Some of these treatments work best in people whose tumors have specific genetic mutations, so testing the tumor tissue for these mutations can be important. Many more drugs are being tested in clinical trials to see if they will help people with NSCLC and SCLC. Even more drugs are in development.

Targeted therapy drugs

Cancer cells make growth factors. Vascular epithelial growth factor (VEGF) is a growth factor that tells blood vessels to grow into the cancer tumor. Blood vessels are needed to “feed” the cancer. Blood vessels also can serve as a “highway” for tumors to spread cancer cells through the body. The forming of new blood vessels is known as angiogenesis or neovascularization. A number of anti-angiogenic drugs are being developed to interfere with the formation of blood cells in a cancer tumor. One anti-angiogenic drug that has been approved for the treatment of non-small cell lung cancer is bevacizumab (Avastin®). Click here to watch a podcast on how bevacizumab interferes with the process of angiogenesis.

Another important growth factor is epidermal growth factor (EGF), which also encourages cells to divide. Erlotinib (Tarceva®) is a drug that blocks the action of EGF, to keep cancer cells from multiplying in the body. It is approved for second-line therapy of non-small cell lung cancer – treatment that is used if the first treatment you were given did not cure your cancer, and maintenance therapy - treatment given immediately after the first line of treatment. Recent expert opinions recommend that patients whose tumors have particular genetic changes in the epidermal growth factor receptor (EGFR) should receive erlotinib as a first course of therapy. A similar drug, gefitinib (Iressa®), is available to treat these lung cancers in countries outside of the US.

A new target for lung cancer therapy has recently been discovered. In some NSCLC patients, their tumor growth appears to be driven by a fusion of the ALK gene with another gene. This fusion makes the ALK gene constantly “on”, encouraging cells to continue to divide. A drug, Crizotinib (Xalcori®), was approved by the FDA in late 2011 to treat tumors with the ALK gene fusion.

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Treatment by stage of cancer

Non-small cell lung cancer (NSCLC) treatment by stage
Stage I
The ideal treatment for Stage I NSCLC is surgery. New research is helping doctors predict which Stage I NSCLC patients will need chemotherapy after their surgery and which will not.

Stage II
The optimal treatment for Stage II NSCLC is surgery followed by chemotherapy.

When Stage I or Stage II NSCLC is treated with surgery and chemotherapy, it is called adjuvant chemotherapy. Chemotherapy may be given because the doctor thinks there is the possibility that cancer cells may have spread to other parts of the body. In many patients, this does not happen and the cancer can be cured with surgery alone. In others, the cancer will come back even when the surgeon removes all the cancer that can be seen during surgery and the surrounding lymph nodes.

There are a number of good resources to help you understand adjuvant chemotherapy:

• Patients & experts discussing their experiences with adjuvant chemotherapy
• An archived teleconference with experts on adjuvant chemotherapy
• A decision tool for the use of adjuvant chemotherapy
• Expert discussion on the data surrounding the use of adjuvant chemotherapy

Since it is very difficult to be sure who will be cured with surgery alone, chemotherapy often is given for about eight to 12 weeks following surgery. Adjuvant chemotherapy does not guarantee that a cancer never will recur, but studies show it reduces the chances of a cancer coming back.

Not everyone who has stage I or II lung cancer can have surgery. In those cases, radiation therapy may be used instead. Click here for an interview with an expert on the use of radiation therapy in early-stage lung cancer treatment.

Stage III
For Stage IIIA cancer, chemotherapy is the standard treatment, either in conjunction with radiation therapy or surgery. Research is under way to help doctors decide the best timing for these different treatments. Your treatment team will develop a plan based on your needs and their best experience in fighting this disease. Stage IIIB cancer is usually treated with chemotherapy and radiation therapy; surgery is generally not recommended.

Stage IV
Because Stage IV cancer has spread to other parts of the body, surgery is not usually recommended. Chemotherapy is used because it fights the cancer throughout the body. Targeted therapy, such as bevacizumab (Avastin®), also may be prescribed, depending on the type, size and location of the tumors, and whether you are on other medications. Radiation may be used to shrink tumors that are causing symptoms.

Recent expert opinions recommend that patients whose tumors have particular mutations in the epidermal growth factor receptor (EGFR) should receive an EGFR-targeting therapy, such as erlotinib (Tarceva®) or gefitinib (Iressa®; available outside the US) as a first course of therapy. If you don't know if your tumor has an EGFR mutation, ask your doctor about whether further tumor testing is right for you.

When chemotherapy is used to treat NSCLC, two drugs are usually given for four to six cycles, three weeks apart. These drugs usually include a platin (cisplatin or carboplatin) and another, non-platin drug such as paclitaxel (Taxol®), docetaxel (Taxotere®), gemcitabine (Gemzar®), or pemetrexed (Alimta®). Pemetrexed (Alimta®) is only recommended for people with NSCLC that is not of the squamous sub-type. Studies have found that two non-platins probably work as well as one platin and one non-platin. In general, all of these treatments are different in terms of side effects, cost and how frequently they must be given. They do not, however, appear to be much different in how well they work at treating the tumor.

Studies have recently shown that using pemetrexed (Alimta®) after the initial course of chemotherapy - often called maintenance therapy - helped patients with NSCLC that is not of the squamous sub-type live longer. Erlotinib (Tarceva®) is also approved for maintenance therapy in all types of NSCLC. However, not every person will be able to manage the side effects of another drug so soon after their initial chemotherapy, so the decision to go on maintenance therapy will be individual to you and your experience. Other drugs are being tested for their ability to improve survival when given as maintenance therapy.

Recurrent NSCLC
If your cancer has progressed after one type of chemotherapy, other chemotherapy and targeted therapy drugs may be recommended. These drugs include pemetrexed (Alimta®) and docetaxel (Taxotere®), which are chemotherapy drugs, and erlotinib (Tarceva®), which is a targeted therapy drug. Many people experience great improvement with additional treatment, even after their cancer has recurred. Additional therapies are in testing through clinical trials.

Small Cell Lung Cancer (SCLC) Treatment by Stage
Limited Stage
Limited stage SCLC is typically treated with radiation and chemotherapy. Prophylactic cranial irradiation (PCI) is radiation to the whole brain. PCI is sometimes given to SCLC patients who have done well with chemotherapy. The brain is a common site for cancer to come back in patients with SCLC because chemotherapy does not get to the brain as well as other tissues. PCI is recommended for SCLC patients who have gone into remission (the cancer has gone away) as a result of their initial chemotherapy.

Extensive Stage
Individuals with extensive stage SCLC are treated with chemotherapy. Should remission occur, PCI also will be used. For extensive SCLC, the chemotherapy most often given is a platin (cisplatin, carboplatin) plus the drug etoposide (VP 16, Vespid®). Additional therapies are in testing through clinical trials.

Managing your pain

You may experience pain from your cancer, surgery or radiation therapy. There are many effective pain medicines available. Pain medicines are much better at keeping pain away than they are at reducing pain after it occurs, so talk with your doctor or nurse about ways to treat your pain early in your treatment process. Although many people may fear getting addicted to or “hooked” on pain medications, research has shown that is unlikely to occur when the medications are used correctly for pain.

Supportive care

Your treatment team may recommend drugs that do not treat your cancer, but can help you maintain your overall health during treatment. These drugs are referred to as supportive care agents. You may receive suggestions to take any or all of the following:

• A drug to strengthen your bones, if your cancer has spread to the bones. These drugs are called bisphosphonates and some have been approved for use in cancer patients, including pamidronate (Aredia®) and zolendronate (Zometa®).
   
• Drugs to prevent you from becoming nauseous when you receive chemotherapy treatments. There are many types of these drugs, called anti-emetics. Some examples include aprepitant (Emend®), cyclizine (Valoid®) granisetron (Kytril®), ondansetron (Zofran®) and Prochlorperazine (Compazine®). For optimum nausea control, more than one of these may be prescribed at the same time.
   
• A drug to prevent you from becoming constipated. Among the many drugs available are bisacodyl (Dulcolax®), docusate (Colace®, Dialose®, Surfak®), lactulose (Cephulac®, Chronulac®, Enulose®), polyethylene glycol 3350 (Miralax®) and sennosides (Senokot®, Senna-Lax®).
   
• A drug to treat anemia (a low red blood cell count). The drugs most commonly prescribed are epoetin alfa (EPOGEN®, Procrit®) and darbopoetin alfa (Aranesp®).
   
• A drug to treat low counts of white blood cells (the cells that fight off disease). Drugs used to increase white blood counts are called colony-stimulating factors (CSF), and include G-CSF (Neupogen®), pegfilgrastim (Neulasta®), and GM-CSF (Leukine®).

Ask your oncology nurse, nurse practitioner, physician assistant or doctor to talk with you about how these or other agents may help you manage your cancer and side effects of your treatments.

You also may find that massage can help you feel better. Click here for information on how caregivers can provide effective massage for you.

For more information on typical side effects of cancer treatments, click here.
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This information is not designed to be a substitute for medical advice provided by your treatment team.

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