Lung Cancer

Treatment Planning

To determine the most effective approach and one that will help you achieve your desired quality of life, your doctor will look at the characteristics that make your diagnosis unique, such as your staging and pathology results, the presence of biomarkers and the potential response to treatments that may be prescribed.

This information will enable your doctor to develop a treatment plan that will be most effective for you. As strides continue to be made through research, it is beneficial to work with a doctor who is aware of the latest advances in lung cancer treatment.

Getting Started

You will hear a lot of new information as you learn about your treatment options. Some of the terms your medical team uses may be confusing. These explanations may help you feel more informed as you make the important decisions ahead.

First-line therapy is the first treatment used.

Second-line therapy is given when the first-line therapy does not work or is no longer effective.

Standard of care refers to the widely re-commended treatments known for the type and stage of cancer you have.

Neoadjuvant therapy is given to shrink a tumor before the primary treatment (usually surgery).

Adjuvant therapy is additional cancer treatment given after the primary treatment (usually surgery or radiotherapy) to destroy remaining cancer cells and lower the risk that the cancer will come back.

Local treatments are directed to a specific organ or limited area of the body and include surgery and radiation therapy.

Systemic treatments travel throughout the body and are typically drug therapies, such as chemotherapy, molecular therapy, targeted therapy and immunotherapy (see Figure 1).

Making your Plan

Your doctor will develop your treatment plan using one or more types of therapy. The goal is for you to receive the best level of care possible. For that to happen, the plan you start with may change if test results or symptoms indicate the need. Your doctor will monitor you regularly, and you will be responsible for communicating regularly with your health care team and keeping follow-up appointments.

Surgery, also called a resection, is typically the primary treatment for early-stage (Stages I, II and some IIIA) lung tumors. Ideally, a board-certified thoracic surgeon experienced in lung cancer should determine whether the tumor(s) can be successfully removed. The procedure selected will depend on how much of your lung is affected, tumor size and location, and your overall health.

  • Wedge resection removes the tumor with a triangular piece of a lobe of the lung.
  • Segmental resection (segmentectomy) removes a larger section of a lobe.
  • Lobectomy removes one of the lungs’ five lobes.
  • Pneumonectomy removes an entire lung.
  • Sleeve resection (sleeve lobectomy) removes part of the bronchus (main airway) or pulmonary artery to the lung along with one lobe to save other portions of the lung.

These types of resection may be done by open thoracotomy (a large incision in the chest wall that requires separation of the ribs) or by less invasive procedures, such as video-assisted thoracoscopic surgery (VATS) with or without robotic surgery. These are performed as the doctor inserts scopes through small incisions. These VATS procedures may help preserve muscles and nerves, reduce complications and shorten recovery time.

Some early-stage tumors may be removed with robotic surgery. Special equipment provides a three-dimensional view inside the body while the surgeon guides a robotic arm and high-precision tools that can bend and rotate much more than the human wrist. Finding a surgeon with extensive training and experience in robotic surgery is highly recommended.

Drug therapy for lung cancer includes chemotherapy, immunotherapy, molecular therapy and targeted therapy. Drug therapies may be used alone or in combination.

Chemotherapy is systemic drug therapy that is typically part of the treatment plan for most stages of non-small cell lung cancer (NSCLC) and is the primary treatment for all stages of small cell lung cancer (SCLC).

It may be given alone or in combination with surgery, radiation therapy or immunotherapy. In early stages, it may be used before surgery (neoadjuvant therapy) to help shrink the tumor, after surgery (adjuvant therapy) to kill remaining cells, as maintenance therapy following standard chemotherapy to prevent recurrence, or as palliative care to help relieve symptoms.

Chemotherapy may be given in pill form or as a solution injected intravenously (IV) through a vein in your arm or hand, or a port in your chest. Injections and IV treatments may take place at your doctor’s office or an outpatient cancer center. Additional fluids and medication are usually given with IV chemotherapy to prevent side effects.

Treatment plans vary but generally occur in cycles with a rest period after each cycle to allow your body to recover. Discuss scheduling options with your treatment team.

Your doctor will monitor the effectiveness of your treatment by conducting periodic physical exams and imaging tests. Chemotherapy is usually stopped when the tumor is no longer shrinking, at which point maintenance chemotherapy may be recommended.

Immunotherapy is systemic drug therapy that stimulates your immune system to find and attack cancer. It may be used alone or in combination with other types of immunotherapy or with chemotherapy.

It is standard first-line therapy for Stage IV NSCLC without specific molecular alterations and is approved in combination with chemotherapy as neoadjuvant therapy for early-stage NSCLC. It is standard after chemotherapy and radiotherapy for unresectable Stage III NSCLC and standard with chemotherapy for extensive-stage SCLC.

Immune checkpoint inhibitors are the type of immunotherapy approved to treat NSCLC and SCLC. These drugs prevent the immune system from slowing down, allowing it to keep up its fight against the cancer.

Checkpoints keep the immune system “in check,” preventing an attack on normal cells by using regulatory T-cells. When the correct proteins and cell receptors connect, a series of signals is sent to the immune system to slow down once an immune response is finished. Three checkpoint receptors that slow down the immune system have a role in lung cancer treatment:

  • PD-1 (programmed cell death protein 1) is a receptor involved with telling T-cells to die and to reduce the death of regulatory T-cells (suppressor T-cells). Both slow down an immune response. PD-1 can tell the immune system to slow down only if it connects with PD-L1.
  • PD-L1 (programmed death-ligand 1) is a protein that, when combined with PD-1, sends a signal to reduce the production of T-cells and enable more T-cells to die. When PD-1 (the receptor) and PD-L1 (the protein) combine, the reaction signals that it is time to slow down.
  • CTLA-4 (cytotoxic T-lymphocyte-associated protein 4) is another checkpoint like PD-1. CTLA-4, however, can connect with more than one protein.

The goal of immune checkpoint inhibitors is to prevent PD-1 and PD-L1 from connecting so that the immune system does not slow down. These IV drugs prevent these connections by targeting and blocking PD-1, PD-L1 or CTLA-4 so the immune cells can continue fighting the cancer.

Some immune checkpoint inhibitors are also approved as tumor-agnostic treatment, which means they are approved to treat any type of cancer that has the molecular alterations known as microsatellite instability-high (MSI-H), deficient mismatch repair (dMMR) or tumor mutational burden-high (TMB-H). When cancer cells have any of these features, they are more sensitive to destruction by immune checkpoint inhibitors. MSI is also tested to determine which tumors may have developed because of a deficiency in correcting cellular errors made when the cancer cells divide.

Molecular therapy is systemic personalized treatment that may be available if the tumor contains a known abnormality. It is given orally as a pill and is recommended as first-line therapy for NSCLC. If the first-line therapy is not effective, another one may be considered. Unlike chemotherapy, which attacks healthy cells as well as cancer cells, it is designed to affect only cancer cells.

This therapy targets a specific molecular (genetic) abnormality in a tumor. The most common abnormalities with available treatments are epidermal growth factor receptor (EGFR) abnormalities and anaplastic lymphoma kinase (ALK) rearrangements.

Others include certain BRAF mutations, KRAS mutations, MET exon 14 skipping mutations, neurotrophic tyrosine receptor kinase (NTRK) fusions, RET fusion-positive alterations and ROS1 fusions.

Some drugs that treat these abnormalities are tyrosine kinase inhibitors (TKIs). In a healthy cell, tyrosine kinases are enzymes that are responsible for certain functions such as cell signaling (communication between cells) and cell growth and division. These enzymes may be too active or found at high levels in some cancer cells. Blocking them may help keep cancer cells from growing.

TKIs have been developed for EGFR mutations, ALK fusions, NTRK fusions, ROS1 fusions, MET exon 14 skipping mutations, RET fusions and certain BRAF mutations. TKIs for other molecular abnormalities are currently being researched. Another molecular therapy has been approved for KRAS mutations.

It is possible for the cancer to become resistant to a particular molecular therapy. With some mutations, more than one drug has been developed, which may offer flexibility. If the first one is not effective, another one may be considered.

In NSCLC, molecular therapy is associated with higher response rates, longer-lasting benefits and far fewer side effects than chemotherapy.

To determine whether you are a candidate for molecular therapy, a tissue sample from your tumor must be tested at a specialized lab to detect any known molecular biomarkers. This should be done before your treatment begins. Ask your doctor whether tissue from a previous biopsy can be used.

Many tumors do not have biomarkers for which approved therapies currently exist. However, clinical trials are underway to find effective treatments for additional genetic abnormalities. If your tumor tested positive for a biomarker that does not have an approved targeted treatment, ask your doctor about participating in a clinical trial.

Targeted therapy is systemic drug therapy directed at proteins involved in making cancer cells grow that do not have proven biomarkers. Monoclonal antibodies (mAbs) and angiogenesis inhibitors, which are given intravenously (by IV), are the types of targeted therapy approved to treat lung cancer.

  • Monoclonal antibodies (mAbs) are laboratory-made antibodies designed to target specific tumor antigens, which are substances that cause the body to make a specific immune response. They can work in different ways, such as flagging targeted cancer cells for destruction, blocking growth signals and receptors, and delivering other therapeutic agents directly to targeted cancer cells. The mAbs approved to treat lung cancer block the EGFR or vascular endothelial growth factor (VEGF) abnormality or its receptor and are always given with chemotherapy. A specific type of mAb known as an antibody-drug conjugate (ADC) may also be used. A new ADC was recently approved to treat the human epidermal growth factor receptor-2 (HER2) mutations. It contains a mAb linked to a drug. The mAb binds to specific proteins or receptors found on certain types of cells, including cancer cells. The linked drug enters these cells and kills them without harming other cells.
  • Angiogenesis inhibitors shut down VEGF, a protein that is essential for creating blood vessels. With no vessels to supply blood, the tumor eventually “starves” and dies. Angiogenesis inhibitors are often given in combination with chemotherapy.

Radiation therapy, also called radiotherapy, is often combined with other treatment types. It may also be used as palliative care to help relieve pain when cancer spreads to the bone.

External-beam radiation therapy (EBRT) is the most common form of radiation therapy used to treat lung cancer. EBRT comes in multiple forms:

  • Three-dimensional conformal radiation therapy (3D-CRT) uses precise mapping to shape and aim radiation beams at the tumor(s) from multiple directions, typically causing less damage to normal tissue.
  • Stereotactic body radiotherapy (SBRT) is a form of 3D-CRT offering precision delivery of high-dose radiation through beams aimed at the tumor from multiple directions. SBRT may be the primary treatment for small tumors or early-stage cancers when a person cannot undergo surgery or makes the decision not to have surgery.
  • Intensity-modulated radiation therapy (IMRT) is an advanced form of 3D-CRT that delivers radiation from a machine that moves around the person, aiming beams at varying strengths for increased precision. This technique may be used to treat tumors located near sensitive areas such as the spinal cord.
  • Proton beam therapy destroys cancer cells by using charged particles called protons. This treatment typically results in less damage to healthy tissue and fewer side effects than traditional radiation therapy.

Radiofrequency ablation (RFA) may be used to treat small tumors when surgery is not an option. A needle placed directly into the tumor passes a high-frequency electrical current to the tumor that destroys cancer cells with intense heat.

Cryosurgery, also called cryoablation and cryotherapy, kills cancer cells by freezing them with a probe or another instrument that is super-cooled with liquid nitrogen or similar substances. An endoscope, which is a thin tube-like instrument, is used for this procedure to treat tumors in the airways of the lungs.

Photodynamic therapy kills cancer cells by injecting a drug that has not yet been exposed to light into a vein. The drug is drawn to cancer cells more than normal cells. Fiber optic tubes are then used to carry a laser light to the cancer cells, where the drug becomes active and kills the cells. It is used mainly to treat tumors on or just under the skin or in the lining of internal organs. When the tumor is in the airways, therapy is directed to the tumor through an endoscope. It may help relieve breathing problems or bleeding in NSCLC and can also treat small tumors.

Clinical trials may offer the opportunity to try an innovative treatment that is testing drug therapies or types of surgery or radiation therapy before it is widely available. Other trials evaluate new methods for improving disease prevention, patient screening and diagnostic tools and procedures, along with reducing side effects and identifying genetic risk factors or behavioral changes that may contribute to a healthy lifestyle. Some are even underway to find improved methods to quit smoking.


Finding Support

Facing a lung cancer diagnosis is overwhelming, but help and support are available. Start by asking for a patient navigator or nurse navigator who can connect you to the right specialists and resources available within the complicated health care system. Not all cancer centers have one available. If yours does not, contact a cancer advocacy group for recommendations on finding a navigator.

Explore the Convenience of Telehealth

Your doctor’s office may offer visits by telehealth, a form of health care delivery from a distance using technology such as computers, cameras, video conferencing, the internet and smartphones.

Although it is not a substitute for an in- person visit, it may be a convenient option, especially if you live far from your doctor’s office, do not feel well enough to come in, are at risk for infection, do not have transportation or have other challenges. Ask whether telehealth is available for you and whether it is covered by your insurance.

Join the Lung Cancer Registry

The Lung Cancer Registry is a database of patient information that is donated by patients themselves or by a loved one of someone who faced lung cancer. It is a direct way to improve the future of lung cancer treatment by simply sharing insights and experiences.

Participants provide data by answering questions from a home computer or mobile device. No medical visits are required, and no biopsies or specimens need to be submitted. And, it is free to join. To get involved, go to www.lungcancerregistry.org.


Common Drug Therapy for Lung Cancer
Drugs are listed depending on your unique diagnosis, such as the presence of a biomarker.
Chemotherapy
carboplatin (Paraplatin)
cisplatin (Platinol)
docetaxel (Docefrez, Taxotere)
etoposide (Etopophos)
gemcitabine (Gemzar)
lurbinectedin (Zepzelca)
methotrexate
nab-paclitaxel (Abraxane)
paclitaxel protein-bound (Abraxane)
paclitaxel (Taxol)
pemetrexed (Alimta)
topotecan (Hycamtin)
vinorelbine (Navelbine)
Immunotherapy
Immune checkpoint inhibitors
atezolizumab (Tecentriq)
cemiplimab-rwlc (Libtayo)
durvalumab (Imfinzi)
ipilimumab (Yervoy)
nivolumab (Opdivo)
pembrolizumab (Keytruda)
Molecular therapy
Anaplastic lymphoma kinase (ALK) rearrangement
alectinib (Alecensa)
brigatinib (Alunbrig)
ceritinib (Zykadia)
crizotinib (Xalkori)
loratinib (Lorbrena)
BRAF mutation
dabrafenib (Tafinlar)/trametinb (Mekinist)
Epidermal growth factor receptor (EGFR) mutation
afatinib (Gilotrif)
amivantamab-vmjw (Rybrevant)
dacomitinib (Vizimpro)
erlotinib (Tarceva)
gefitinib (Iressa)
mobocertinib (Exkivity)
osimertinib (Tagrisso)
KRAS mutation
sotorasib (Lumakras)
MET exon 14 skipping mutation
capmatinib (Tabrecta)
tepotinib (Tepmetko)
Neurotrophic receptor tyrosine kinase (NTRK) gene fusion
entrectinib (Rozlytrek)
larotrectinib (Vitrakvi)
RET fusion-positive alteration
pralsetinib (Gavreto)
selpercatinib (Retevmo)
ROS1 fusion
crizotinib (Xalkori)
entrectinib (Rozlytrek)
Targeted Therapy
Epidermal growth factor receptor (EGFR) inhibitor
amivantamab-vmjw (Rybrevant)
necitumumab (Portrazza)
HER2 mutation
fam-trastuzumab deruxtecan-nxki (Enhertu)
Vascular endothelial growth factor (VEGF) inhibitors (angiogenesis inhibitors)
bevacizumab (Avastin)
bevacizumab-awwb (Mvasi)
bevacizumb-bvzr (Zirabev)
ramucirumab (Cyramza)
Some Possible Combinations
atezolizumab (Tecentriq) with bevacizumab (Avastin) with carboplatin (Paraplatin) and paclitaxel (Taxol)
atezolizumab (Tecentriq) with paclitaxel protein-bound (Abraxane) and carboplatin (Paraplatin)
bevacizumab (Avastin) with carboplatin (Paraplatin) and paclitaxel (Taxol)
bevacizumab-awwb (Mvasi) with carboplatin (Paraplatin) and paclitaxel (Taxol)
bevacizumab-bvzr (Zirabev) with carboplatin (Paraplatin) and paclitaxel (Taxol)
cemiplimab-rwlc (Libtayo) in combination with platinum-based chemotherapy
docetaxel (Taxotere) with cisplatin (Platinol)
docetaxel injection with cisplatin (Platinol)
durvalumab (Imfinzi) with etoposide (Etopophos) and either carboplatin (Paraplatin) or cisplatin (Platinol)
etoposide (Etopophos) with cisplatin (Platinol)
gemcitabine (Gemzar) and cisplatin (Platinol)
ipilimumab (Yervoy) with nivolumab (Opdivo)
necitumumab (Portrazza) with gemcitabine (Gemzar) and cisplatin (Platinol)
nivolumab (Opdivo) plus platinum-doublet chemotherapy
nivolumab (Opdivo) with ipilimumab (Yervoy)
nivolumab (Opdivo) with ipilimumab (Yervoy) and two cycles of platinum doublet chemotherapy
paclitaxel protein-bound (Abraxane) with carboplatin (Paraplatin)
paclitaxel (Taxol) with cisplatin (Platinol)
pembrolizumab (Keytruda) with carboplatin (Paraplatin) and either paclitaxel (Taxol) or paclitaxel protein-bound (Abraxane)
pembrolizumab (Keytruda) with pemetrexed (Alimta) and platinum chemotherapy
pemetrexed (Alimta) with cisplatin (Platinol)
ramucirumab (Cyramza) with docetaxel (Taxotere)
ramucirumab (Cyramza) with erlotinib (Tarceva)
vinorelbine (Navelbine) with cisplatin (Platinol)

As of 11/14/22

Palliative Care Improves Quality of Life Throughout Treatment

The side effects of cancer and its treatment can affect your quality of life, and palliative care services are designed to make living with or beyond cancer easier.

Palliative care focuses on addressing disease symptoms, minimizing treatment side effects and managing pain. It is a medical specialty designed to help people living with serious or life-threatening illnesses and their families meet their physical, emotional, psychological, social and spiritual needs.

Also called supportive care, comfort care or symptom management, palliative care services are often confused with hospice care. Palliative care is available at any time after diagnosis, whereas hospice care is reserved for end-of-life care.

These services are beneficial at any stage of cancer, but they are especially encouraged for people with metastatic disease. Over time, continual treatment can take a heavy toll physically and emotionally on patients, as well as their loved ones. Your palliative care specialist/team is there to provide strategies and resources to help you cope.

To access palliative or supportive care, start with your doctor’s office. You may receive these services from an advanced practice nurse, physical therapist, dietitian or palliative medicine specialist who is specially trained in symptom management. These services may be offered at the hospital, cancer center or medical clinic and are often covered by individual insurance plans, Medicare and Medicaid. To learn more, talk with the hospital’s social worker, financial counselor or your health insurance representative.

It’s never too late to stop smoking

A common misconception is that it isn’t necessary for people who have lung cancer to quit smoking or stop using tobacco. On the contrary, studies show there are multiple benefits, starting with one of the most basic—being able to breathe easier.

What other benefits might you see right away?

  • More effective treatment from chemotherapy and radiation therapy
  • Improved wound healing and a speedier recovery after surgery
  • Reduced lung inflammation that can lead to cancer progression
  • Boosted immune system to better fight disease and infections

What are some long-term benefits to look forward to?

  • Improved chances of survival after cancer treatment
  • Decreased risk of secondary cancers and other conditions linked to tobacco use
  • Lowered blood pressure and decreased heart rate
  • An improved sense of smell and taste

Habits can be hard to break – especially with something as addictive as nicotine – and they're even harder to do on your own. The most successful approach combines medications, counseling and support. Ask your health care team about the options your treatment facility and community may offer to help people stop using tobacco. Other resources are available, such as smoking cessation programs, local support groups, call lines, text-based help and online assistance.

Explore these resources, and congratulate yourself on taking a proactive role in improving your health: