Treatment for lung cancer


Treatment for lung cancer will depend on the type of lung cancer you have, the stage of the cancer, how well you can breathe (your lung function) and your general health. NSCLC and SCLC are treated in different ways, as shown in the table below.

Treatment options by type and stage

Non-small cell lung cancer (NSCLC)

  • Early (stage I or II): Usually treated with surgery to remove the cancer and nearby lymph nodes. If surgery is not an option, radiation therapy is offered. Sometimes, chemotherapy may be given after surgery or with radiation therapy.
  • Locally advanced (stage III): Can be treated with surgery and chemotherapy or with radiation therapy and chemotherapy. Treatment will depend on the number and location of lymph nodes with cancer.
  • Advanced (stage IV): Depending on the symptoms, palliative chemotherapy and/or palliative radiation therapy may be offered. New targeted therapy and immunotherapy drugs may also be an option.

Small cell lung cancer (SCLC)

  • Early or locally advanced (stages I–III): Usually treated with chemotherapy and radiation therapy. Surgery is not used.
  • Advanced (stage IV): Mainly treated with palliative chemotherapy. Palliative radiation therapy may also be given to the brain, spine, bone or other parts of the body where the cancer has spread.

Understanding the aim of treatment

For early or locally advanced lung cancer (stages I–III), treatment may be given with the aim of making all signs and symptoms of the cancer go away (curative treatment).

Because lung cancer rarely causes obvious symptoms in the early stages, many people are diagnosed when the cancer is advanced (stage IV). This means the cancer has spread outside the lung to other parts of the body. The goal of treatment will be to maintain quality of life by controlling the cancer, slowing down its spread and managing any symptoms (palliative treatment). Specific treatments to improve breathing are covered in the Managing symptoms section.

Surgery

People with early non-small cell lung cancer (stage I or II) will generally be offered surgery to remove the tumour. How much of the lung is removed depends on the location of the cancer, its size, your general wellbeing and fitness, as well as your lung function.

Lung cancer is usually diagnosed at a later stage once it has caused symptoms, so most people with lung cancer will not have surgery.

Removing lymph nodes

During surgery, nearby lymph nodes will also be removed to see whether the cancer has spread. Knowing if the cancer has spread to the lymph nodes also helps the doctors decide whether you need further treatment with chemotherapy or radiation therapy.

Types of lung surgery

Surgery for lung cancer may remove all or part of a lung.

Lobectomy

A lobe of the lung is removed.

Pneumonectomy

One whole lung is removed.

Wedge resection

Only part of the lobe is removed.

How the surgery is done

The surgery can be done in different ways. Talk to your surgeon about the best approach in your case.

Thoracotomy

If a cut is made between the ribs in the side of the chest, the operation is called a thoracotomy. You will need to stay in hospital for 3–7 days.

VATS

It's becoming more common for lung surgery to be done with a keyhole approach. This is known as video-assisted thoracoscopic surgery (VATS). The surgeon makes a few small cuts in the chest wall, inserts a tiny video camera and operating instruments, and performs the operation from outside the chest. A keyhole approach usually means a shorter hospital stay, faster recovery and fewer side effects.

What to expect after surgery

Tubes and drips

You will have several tubes in place, which will be removed as you recover. A drip inserted into a vein in your arm (intravenous drip) will give you fluid, medicines and pain relief. There may be one or two temporary tubes in your chest to drain fluid and/or air from your chest cavity.

Pain

Some degree of pain or discomfort is common after surgery, but this can be controlled. Managing the pain will help you to recover and move around more quickly, and allow you to do your breathing exercises. Pain relief may also help clear phlegm from your chest.

Recovery time

You will probably go home after 3–7 days, but it may take 6–12 weeks to resume your usual routine and activities. Your treatment team will explain how to manage at home. Walking can improve fitness, clear your lungs and speed up recovery.

Breathlessness

Gentle exercises as part of a pulmonary rehabilitation program will help improve breathlessness and reduce the risk of developing a chest infection. The hospital physiotherapist will show you how to do these exercises. To continue with a pulmonary rehabilitation program after you leave hospital, talk to your surgeon or visit lungfoundation.com.au.

See Understanding Surgery for more information about surgery and recovery.

Thermal ablation

Some people with very early lung cancer may be offered thermal ablation as an alternative to surgery. Thermal ablation involves inserting needles or probes into the cancer to destroy the cancer cells with heat. Only one treatment is needed. A CT scan is used to guide the needles into the right position. Thermal ablation is not painful, but you may have a general anaesthetic to make you more comfortable during the procedure.

Radiation therapy

Also known as radiotherapy, radiation therapy is the use of targeted radiation to kill or damage cancer cells so they cannot grow, multiply or spread. For lung cancer, the radiation is usually in the form of x-ray beams that come from a machine outside the body. This is called external beam radiation therapy (EBRT) and it can be delivered in different ways (see below).

Radiation therapy may be offered on its own or in combination with surgery or chemotherapy, and may be recommended:

  • to treat an early lung cancer if you are unable to have surgery
  • to treat locally advanced (stage III) NSCLC or stages I–III SCLC
  • after surgery if tests show cancer in the mediastinal lymph nodes, to reduce the risk of the cancer coming back in the mediastinum
  • as palliative treatment to improve quality of life by relieving pain or other symptoms.

The radiation oncology team will plan your treatment, explain the treatment schedule and discuss possible side effects.

Types of external beam radiation therapy

Radiation therapy can be used for all types of lung cancer, but may be delivered in different ways depending on the type of lung cancer.

Standard external beam radiation therapy (EBRT)

  • This is usually given every weekday over several weeks.
  • A curative course may involve a series of 20–33 treatments over 4–5 weeks.
  • Palliative radiation therapy usually involves 1–10 treatments.

Stereotactic body radiation therapy (SBRT)

  • This is a way of giving highly focused radiation therapy to small NSCLC tumours, while the surrounding tissue receives a low dose. It is delivered from multiple beams that meet at the tumour.
  • SBRT often involves four treatment sessions over a couple of weeks.
  • This type of radiation therapy is only suitable for tumours that are not close to major airways, blood vessels or the spinal cord.

Hyperfractionated radiation therapy

  • This means having a slightly higher dose of radiation therapy each day so that the entire course is delivered over a shorter period of time.
  • The total dose of radiation is roughly the same as the total dose you would have for standard radiation therapy.
  • Hyperfractionated radiation therapy is mostly used for SCLC.

Concurrent chemoradiation

  • This means having chemotherapy and radiation therapy at the same time.

Having radiation therapy

During treatment, you will lie on an examination table, and a radiation therapy machine will be aimed at the chest area. A radiation therapist will place you and the machine in the correct position and then leave the room. You will not feel anything during the treatment, but may hear a buzzing sound from the machine. The treatment itself takes only a few minutes, but the full session may last 10–20 minutes.

Side effects of radiation therapy

The side effects of radiation therapy vary depending on the dose of radiation and the number of treatments.

Difficulty swallowing and heartburn

These side effects may occur during the treatment period and continue for up to four weeks after treatment ends. Until they improve, you may need to change to a soft food diet and avoid hot drinks, such as tea and coffee.

Skin changes

The skin on your chest and back may become red or dry, like sunburn. A moisturising cream should be applied to the skin when treatment starts – talk to your medical team about which products they recommend.

Fatigue

Feeling tired is common after radiation therapy. Plan your daily activities so you can rest regularly. It may also help to talk to your family, friends or employer about how they can help you.

Shortness of breath and cough

Radiation therapy may cause inflammation of the lungs, known as radiation pneumonitis. This may cause shortness of breath and/or a cough, sometimes during treatment but more likely one to six months after treatment ends. Radiation pneumonitis is usually temporary and can be treated with steroid (cortisone) tablets.

Side effects can change from one period of radiation therapy to the next and may build up over time. Tell the radiation oncology team about any side effects you have, as most can be managed. See Understanding Radiation Therapy and listen to our " Managing Cancer Fatigue" podcast episode.

Chemotherapy

Chemotherapy is the treatment of cancer with drugs that kill cancer cells or slow their growth. It can be used at different times:

  • before surgery to try to shrink the cancer and make the operation easier (neoadjuvant chemotherapy)
  • before or during radiation therapy to make radiation therapy more effective (chemoradiation)
  • after surgery to reduce the risk of the cancer returning (adjuvant chemotherapy)
  • when cancer is advanced – to reduce symptoms and improve quality of life ( palliative chemotherapy).

Having chemotherapy

Chemotherapy is usually delivered into a vein (intravenously). Each chemotherapy treatment is called a cycle and is followed by a rest period to give your body time to recover. The number of cycles will depend on the type of lung cancer you have and the side effects you experience. You will probably have chemotherapy as an outpatient, which means you won't have to stay overnight. Ask your doctor about the treatment plan recommended for you. Some types of chemotherapy come in tablet form and can be taken by mouth (orally). These are sometimes used on an ongoing basis.

Side effects of chemotherapy

Chemotherapy works on cells that are dividing rapidly. Cancer cells divide rapidly, as do some healthy cells such as the cells in your blood, mouth, digestive system and hair follicles. Side effects occur when chemotherapy damages these normal cells. Unlike cancer cells, normal cells can recover, so most side effects are temporary. Side effects vary depending on the drugs used and from person to person.

Anaemia

A low red blood cell count is called anaemia. This can make you feel tired or breathless. Your treatment team will monitor your red blood cell levels and suggest treatment if necessary.

Risk of infections

Chemotherapy drugs lower the number of white blood cells that fight infections, so you will be more likely to develop colds or flu. If you feel unwell or have a temperature above 38°C, call your doctor immediately or go to the hospital emergency department.

Mouth ulcers

Some chemotherapy drugs cause mouth sores, ulcers and thickened saliva, which make it difficult to swallow. Your treatment team will explain how to take care of your mouth.

Hair loss

You may lose hair from your head and chest, depending on the chemotherapy drugs you receive. The hair will grow back after treatment is completed, but the colour and texture may change.

Nausea or vomiting

You will usually be prescribed anti-nausea medicine with your chemotherapy drugs, but some people still feel sick (nauseous) or vomit. Let your treatment team know if you feel nauseous, as they may be able to offer another anti-nausea medicine. See Understanding Chemotherapy, Mouth Health and Hair Loss, and listen to our " Appetite Loss and Nausea" podcast episode.

Targeted therapy

New types of drugs known as targeted therapy target specific mutations within cancer cells. These drugs can be highly effective, but they will only work if the cancer contains the particular target, and even then, they do not work for everyone.

Targeted therapy is currently available for the most common gene mutations associated with non-small cell lung cancer ( NSCLC). Approved drugs include afatinib, alectinib, ceritinib, crizotinib, erlotinib and gefitinib. At this stage, targeted therapy drugs are generally available only for NSCLC that is advanced or has come back. Targeted therapy drugs for small cell lung cancer are being tested in clinical trials.

This area of science is changing rapidly, and it's likely that new mutations and targeted therapy drugs will continue to be discovered. Talk to your oncologist for more information about new drug trials.

Cancer cells often become resistant to targeted therapy drugs over time. If the first-line treatment stops working, your oncologist will suggest trying another targeted therapy drug. This is known as second-line treatment.

Side effects of targeted therapy

Although targeted therapy drugs cause fewer side effects compared with standard chemotherapy drugs, they can still have side effects. These vary depending on the targeted therapy drugs used – some may cause an acne-like rash or other skin changes and diarrhoea, others may cause nausea and vomiting or swelling. Less commonly, some targeted therapy drugs affect the way the heart and lungs work, which can be life-threatening, so it's important to report any side effects to your medical team. For a detailed list of side effects for a particular targeted therapy, visit eviq.org.au. See Understanding Targeted Therapy.

Immunotherapy

Some cancers produce particular proteins, such as PD-1 or PD-L1, that stop immune cells from recognising and destroying the cancer cells. Immunotherapy drugs known as checkpoint inhibitors block these proteins. Once the proteins are blocked, the immune cells can attack the cancer.

Checkpoint inhibitors that have been approved for some types of advanced NSCLC include atezolizumab, durvalumab, nivolumab and pembrolizumab. Several other checkpoint inhibitors are currently being tested in clinical trials for lung cancer. Checkpoint inhibitors do not work for all lung cancers, but some people have had very encouraging results.

Side effects of immunotherapy

Immunotherapy drugs have different side effects to chemotherapy drugs and most people have few if any side effects. However, immunotherapy can cause inflammation in any of the organs in the body and this sometimes leads to side effects such as fatigue, shortness of breath and diarrhoea. See our Understanding Immunotherapy fact sheet.

Palliative treatment

If the cancer is advanced when it is first diagnosed or comes back after treatment, your doctor will discuss palliative treatment for symptoms caused by the cancer, such as pain or breathlessness. Palliative treatment aims to manage symptoms without trying to cure the disease. It can be used at any stage of advanced lung cancer to improve quality of life and does not mean giving up hope. Rather, it is about living for as long as possible in the most satisfying way you can.

Chemotherapy, radiation therapy, surgery and targeted therapy may be used palliatively to slow the spread of cancer and/or control symptoms. If you are experiencing a build-up of fluid in the lungs, various procedures can drain the fluid and help prevent it building up again. See Managing symptoms for more details.

Palliative treatment is one aspect of palliative care, in which a team of health professionals aim to meet your physical, practical, emotional, spiritual and social needs. The team also supports families and carers. See Understanding Palliative Care and Living with Advanced Cancer.

Key points about treating lung cancer

Choice of treatment

Treatment will depend on the type of lung cancer, its stage, and your general fitness, lung function and suitability for the treatment.

Treatment for early lung cancer

Treatment for early lung cancer may involve:

  • surgery - a whole lung, a lobe or part of a lobe may be removed. Effective pain management, gentle breathing exercises as part of a pulmonary rehabilitation program, and being active will help your recovery after surgery
  • radiation therapy – uses targeted radiation to damage or kill cancer cells and may be offered on its own or together with surgery or chemotherapy. Side effects may include difficulty swallowing and heartburn, red or dry skin, fatigue, or shortness of breath or cough
  • chemotherapy – uses drugs to kill cancer cells or slow their growth. Side effects can include anaemia, risk of infections, mouth ulcers, hair loss from head and chest, and nausea or vomiting.

Treatment for advanced lung cancer

The goal of treatment for advanced lung cancer is to slow the spread of the cancer and manage symptoms. Treatment may include:

  • chemotherapy and radiation therapy – can relieve symptoms such as pain
  • targeted therapy – uses drugs that target specific mutations within cancer cells
  • immunotherapy – uses drugs that remove barriers to the immune system attacking the cancer.

Expert content reviewers:

Dr Henry Marshall, Thoracic Physician, The University of Queensland Thoracic Research Centre, The Prince Charles Hospital, QLD; Dr Naveed Alam, Thoracic Surgeon, St Vincent's Melbourne and Epworth Richmond Hospitals, VIC; A/Prof Martin Borg, Radiation Oncologist, GenesisCare, SA; Dr Lisa Briggs, Consumer; Kirsten Mooney, Thoracic Cancer Nurse Coordinator, WA Cancer & Palliative Care Network, WA; Claire Mulvihill, Lung Cancer Support Nurse, Lung Foundation Australia; Caitriona Nienaber, 13 11 20 Consultant, Cancer Council WA; A/Prof Nick Pavlakis, President, Australasian Lung Cancer Trials Group, President Elect, Clinical Oncology Society of Australia, and Senior Staff Specialist, Department of Medical Oncology, Royal North Shore Hospital, NSW.

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