The type of treatment will vary depending on your overall health and the type and stage of your lung cancer.
- Non-small cell lung cancer (NSCLC): For non-small cell lung cancers that have not spread beyond the lung, surgery is often used to remove the cancer. Surgery may also be used in combination with radiation therapy and chemotherapy in cancers that are more advanced. These treatments can be given prior to surgery to shrink tumors or afterward to kill cancer cells that surgery may not have excised.
- Small cell lung cancer (SCLC): Surgery is used less frequently in small-cell lung cancer because it tends to spread more rapidly to other parts of the body and so rarely is found when it is still confined to a single lung. Chemotherapy is the most common treatment for small-cell lung cancer, as these medicines circulate in the blood, killing lung cancer cells throughout the body. Chemotherapy may be used to shrink lung tumors, slow their growth, slow the growth of cancer that has spread to other parts of the body, or ease pain and other symptoms. Radiation therapy also may be used in conjunction with chemotherapy. Radiation therapy may be used to treat tumors that are confined to the lung or other areas in the chest. And because SCLC often spreads to the brain, your doctor may also recommend brain radiation to kill off tiny bits of cancer that may have spread to the brain but are not yet evident on brain scans. In addition to causing nausea and fatigue, brain radiation can lead to problems with short-term memory, so it's important to weigh carefully the costs and benefits of this therapy with your healthcare providers.
- Mesothelioma: Chemotherapy, radiation, and surgery can all be part of the treatment for mesothelioma. Combined approaches that utilize these therapies together, particularly using chemotherapy prior to surgery, as well as new drugs that specifically target mesothelioma cells, are currently being tested.
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For lung cancers that have not spread widely and are confined to a portion of the lungs, surgical removal of the malignancy gives the best chance of long-term survival or cure. Very early-stage cancers (Stage I) are usually treated with surgery alone although there are a subset of stage 1 tumors that now are being recommended to be treated with chemotherapy after surgery. With Stage II cancers, chemotherapy often is given after surgery. Treatment becomes more aggressive with advanced cancers, such as Stage IIIa, in which there is considerable spread to the lymph nodes. In these patients, chemotherapy and sometimes radiation therapy are offered first. If there is a good response to these treatments, surgery may be proposed as well. Called "induction" or "neoadjuvant" therapy, this approach requires a multidisciplinary team working closely together. For patients with Stage IV disease, surgery is appropriate only in very rare instances, such as when the malignancy in the lung can be removed surgically and the organ or site to which the cancer has traveled also can be treated, surgically or otherwise.
Increasingly, surgery is offered to patients regardless of their age. Many reports now suggest that elderly individuals with early-stage lung cancer get as much benefit from aggressive surgery as do younger patients. In general, complications are low among the elderly, although older patients in good health obviously do better than those in poor health.
To get to and remove the affected area, surgeons typically make a small incision in one side of the chest in between the ribs. This procedure, known as a thoracotomy, usually doesn't involve breaking or removing ribs. Once inside, surgeons can pursue one of four options:
- Wedge resection: In this operation, a wedge, or pie-shaped, section of the cancerous lung is excised.
- Lobectomy: This operation involves removing the entire lobe in which the cancer is located. In many cases, this will be the treatment of choice.
- Segmentectomy: A segment of the lobe containing the cancer is removed in this procedure, which typically is done when lung function is poor.
- Pneumonectomy: In this operation, the entire lung with the cancer is removed. This is only done if the location of the malignancy makes it difficult to remove a portion of the lung and a patient has sufficient lung capacity to survive with just one remaining lung.
In any of these cases, some lymph nodes in the chest are removed and tested to make sure there is no evidence of further spread. The results of this testing and the size of the tumor determine whether additional therapy, like chemotherapy or radiation therapy, is needed.
Any of the above is a major operation. The hospital stay is typically from three to five days. All patients are encouraged to be as active as possible once they get home, with only minor limitations on what they can do for two to three weeks after surgery. Most of the pain goes away after two to three weeks, and people often return to work soon thereafter.
At some hospitals, thoracic surgeons are now able to use in selected patients minimally invasive techniques, including video-assisted or robotic surgery. The robot has a 20-mm camera for "eyes," and inside the chest cavity the "arms" have the complete rotating capabilities of a human wrist. The surgeon sits at a console, and using his fingers to control the two robotic arms, makes three ½ inch incisions and one 5-to-6-inch incision below the shoulder blade. With this device, there is generally less scarring, along with less postoperative pain. Also, recovery time is a little shorter. This is still a new technology, and these techniques aren't appropriate for every patient with lung cancer.
Finally, irrespective of the surgical approach, it is very important that your surgeon be well versed in the care of lung cancer patients as well as familiar with all potential treatment options. Just as with other major surgeries, lung cancer operations are typically better handled by specialists—in this case, thoracic surgeons—than by surgeons who do only the occasional lung operation.
Chemotherapy uses drugs to stop the growth of cancer cells, either by killing them or by interfering with their division. This type of treatment may be given after surgery to attack cells that may have spread beyond the tumor (adjuvant therapy) or before surgery to shrink a tumor before removing it (neoadjuvant therapy).
The drugs are taken orally or injected into a vein, and they travel throughout the body. This method of delivery means that they affect not only malignant cells but healthy ones as well, leading to the unpleasant side effects for which chemo is known. For more on this see our section on managing chemo's side effects.
There are a variety of drugs used to treat lung cancer. The first therapies to be used are typically two drugs in combination: a platinum drug such as cisplatin or carboplatin along with another class of drugs such as a taxane. Chemotherapy agents are usually given in combination with one another (each agent usually has a different mechanism of action) over the course of months with breaks between treatments to give your body a chance to recuperate. Recent studies have also shown a benefit in adding a drug that cuts off the blood supply to a tumor, bevacizumab (brand name Avastin), as the first therapy in certain cases of advanced (Stage IV) lung cancer. The drugs you are given will depend on the type and stage of lung cancer you have.
In radiation therapy, precisely targeted X-rays are used to destroy cancer cells in a localized area. Radiation therapy often is used to treat tumors in patients who are not candidates for surgery because their cancer has spread to lymph nodes or because it is situated adjacent to vital parts of the body such as the heart or key arteries. It can also be used along with chemotherapy to shrink tumors prior to surgery or to mop up stray cancer cells after surgery and so prevent tumor recurrences Finally, radiation can be used to treat cancer that has spread to other parts of the body and is causing pain or other symptoms.
Radiation damages genes or DNA of both healthy and cancerous cells. But radiation generally does more damage to cancer cells because when normal cells are hit with radiation, they stop to repair the damage and, once that's fixed, are able to continue replicating. Cancer cells, on the other hand, are in such a hurry to grow, they don't take the time to correct irradiated DNA, so lose the ability to replicate and subsequently die.
Radiation therapy may be delivered "internally," by means of a needle or catheter packed with tiny seeds of radioactive material inserted into the chest near the tumor. It may also be delivered "externally" via a machine that beams the radiation at the cancer. Recently, sophisticated new techniques, such as stereotactic body radiation therapy, have given doctors the ability to target lung tumors with greater accuracy than ever before. This accuracy allows physicians to safely deliver very high doses of radiation, and is especially beneficial when killing tumors that are close to sensitive areas, such as the heart and spinal cord.
Chemotherapy drugs attack healthy cells as well as cancerous ones, leading to toxic side effects. Recently, researchers have been exploring drugs that specifically target cancer cells by interfering with proteins and receptors involved in their growth. One of these targeted therapies used against lung cancer is erlotinib (brand name Tarceva). Erlotinib has been shown both to extend survival and to improve quality of life for patients with recurrent non-small-cell lung cancer who have already undergone one or two therapies. Erlotinib is particularly effective in some groups of patients, including nonsmokers, women, those of Asian descent, and those with adenocarcinoma.
Bevacizumab (brand name Avastin) is another targeted agent. It is an antibody, similar to proteins your body's immune system makes. Bevacizumab does not directly target the tumor but targets the blood vessels that supply tumors with nutrients, oxygen and glucose that the cancer needs to grow. Bevacizumab has been shown to increase the effectiveness of standard chemotherapy drugs used to treat non-small-cell lung cancers other than squamous-cell cancer. It has also been shown to prolong survival in this group of patients. Bevacizumab is associated with increased risk of bleeding and is not used in patients on anticoagulants ("blood thinners") or whose cancer has spread to the brain, among other patient groups.
Surgical removal of the malignancy is the preferred primary treatment for many lung cancer patients. For those patients for whom surgery is not a good option, a procedure known as radio-frequency ablation (RFA) offers some hope—for treating both the tumor in the lung and the organ or site to which the lung cancer has spread.
RFA is a minimally invasive procedure in which imaging tools such as CT scanning are used to direct a special probe to the site of disease. From these probes, a series of prongs are deployed in an umbrellalike fashion into the malignancy. Radio-frequency energy, which heats and kills cells, is then delivered directly into the tumor. In some patients, 100 percent of the tumor is destroyed. In others with tumors smaller than 5 centimeters, tumor growth can be halted or controlled, which can bring symptom relief, among other benefits. This technique is still in its infancy, however, and cannot substitute for other, standard treatment options, including chemotherapy and radiation therapy.
Last reviewed on 7/28/09
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