Lung Cancer

Treatment Planning

An increasing number of potential treatment options are available for people diagnosed with lung cancer, providing hope to many patients and their families. These treatments are the result of advances in research conducted in clinical trials. The most recent approvals have been for certain types of drug therapy, but advances continue to be made in other treatment types, including radiation therapy and surgery.
Many of the new drug therapies are based on testing a person’s tumor for biomarkers, which is the foundation of precision medicine. Understanding a tumor’s specific mutations and alterations can indicate the possibility of cancer or can be used to measure a response to treatment, allowing doctors to choose therapies targeting those mutations specifically. The result is increased progression-free survival and improved quality of life during treatment.

To determine if you qualify for one of these new therapies, your doctor typically will test your tumor for biomarkers during the diagnosis phase. Biomarkers are substances that can be tested in the blood, urine or tissue. If your tumor does not have biomarkers for newer therapies that have been developed, more traditional routes of treatment including surgery, chemotherapy and radiation therapy are available.

With so many advancements in lung cancer treatment, it’s important to understand the basics of each so you can discuss them with your health care team and, in turn, make the best choices for you and your desired quality of life.

Understanding Treatment Options

As you begin to learn about your type of cancer and the treatments available, it is important to understand some of the terms your doctor may use.

  • First-line therapy is the first treatment used.
  • Second-line therapy is given when the first-line therapy doesn’t work or is no longer effective.
  • Standard of care refers to the best treatment known for the type and stage of cancer you have. It can be a first-line therapy.
  • Neoadjuvant therapy is given as a first step to shrink a tumor before the primary treatment (usually surgery or radiotherapy).
  • Adjuvant therapy is additional cancer treatment given after the primary treatment (usually surgery) to destroy remaining cancer cells and lower the risk that the cancer will come back.
Treatments are described as either local or systemic.
  • 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.
You will be monitored closely so that your therapy can be adapted as needed. As a result, treating your cancer may be a fluid process, changing periodically to offer you the best level of care. Therefore, communicating regularly with your health care team and keeping follow-up appointments are crucial.

The following therapies may be used alone or in combination.

Surgery, also known as 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.
Any of 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 makes small incisions and inserts scopes through the 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 is used to prevent, diagnose, treat or relieve symptoms of a disease or abnormal condition. The types of drug therapy approved for lung cancer include chemotherapy, immunotherapy, molecular therapy and targeted therapy.

Chemotherapy is systemic drug therapy that is typically part of the treatment plan for most stages of NSCLC and is the primary treatment for all stages of 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) to help shrink the tumor, after surgery (adjuvant) 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 that you take at home or as a solution injected intravenously (IV) through a vein in your arm or hand or a port in your chest (see Figure 1). Injections and IV treatments may take place at your doctor’s office or an outpatient cancer center. During a treatment session, you will likely receive additional fluids and medication, which are usually given with IV chemotherapy to prevent side effects.

Treatment plans vary but generally follow 21- or 28-day cycles for four to six cycles. A rest period follows each cycle to allow your body to recover. Discuss scheduling options with your treatment team.

Periodic appointments for physical exams and imaging will help your doctor monitor the effectiveness of your treatment. 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 fight cancer. It may be used alone or in combination with other types of immunotherapy or with chemotherapy.

Immunotherapy is standard first-line therapy for Stage IV NSCLC without specific molecular alterations. It is standard after chemotherapy and radiotherapy for unresectable Stage III NSCLC and is 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. Two checkpoint receptors that slow down the immune system have been identified for their roles 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.
Cancer cells try to outsmart the immune system by producing PD-L1 and using it as camouflage so that the T-cells of the immune system will see them as normal cells. T-cells expect only normal cells to produce PD-L1, so when a T-cell encounters PD-L1 on a cancer cell, it is tricked into signaling the immune system to slow down. This is how cancer can hide from the immune system.

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 drugs prevent these connections by targeting and blocking PD-1 or PD-L1, and the immune cells continue fighting the cancer. This treatment is given by IV only.

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, targeted therapy is designed to affect only cancer cells.

This therapy targets a specific molecular (genetic) abnormality in a tumor. The abnormalities most commonly tested for that have treatments available are epidermal growth factor receptor (EGFR) abnormalities and anaplastic lymphoma kinase (ALK) rearrangements. Other abnormalities include certain BRAF mutations as well as MET exon 14 skipping mutations, neurotrophic tyrosine receptor kinase (NTRK) fusions, RET fusion-positive alterations and ROS1 fusions.

The drugs that treat these abnormalities are called 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 types of cancer cells. Blocking them may help keep cancer cells from growing.

TKIs have been developed for EGFR mutations, ALK fusions, NTRK fusions, KRAS mutations, ROS1 fusions, MET exon 14 skipping mutations, RET fusions and certain BRAF mutations. TKIs for other molecular abnormalities are currently under investigation. It is possible for the cancer to become resistant to a particular molecular therapy, but more than one drug has been developed, which may offer flexibility. If the first one isn’t effective, another one may be considered.

To determine if you’re a candidate for this type of therapy, a tissue sample from your tumor must be tested at a specialized lab to find out if any known molecular biomarkers are present. This should be done before your treatment begins. Ask your doctor if tissue from a previous biopsy can be used.

Molecular therapy has been associated with higher response rates, longer-lasting benefits and far fewer side effects than chemotherapy in NSCLC.

Many tumors do not test positive for biomarkers for which approved therapies currently exist. However, clinical trials are underway to find effective treatments for additional genetic abnormalities, including KRAS, HER2 and others. If your tumor tested positive for a biomarker that does not have an approved targeted treatment, ask your doctor if you may be eligible to participate in a clinical trial. Researchers are continuing to identify new biomarkers for lung cancer so additional treatments can be developed.

Targeted therapy is systemic drug therapy directed at proteins involved in making cancer cells grow but that do not have proven biomarkers. The types of targeted therapy approved for lung cancer are monoclonal antibodies (mAbs) and angiogenesis inhibitors, which are given intravenously (by IV).
  • Monoclonal antibodies (mAbs) are laboratory-made antibodies that are 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. Monoclonal antibodies approved to treat lung cancer block the EGFR or vascular endothelial growth factor (VEGF) abnormality or its receptor; these are always given with chemotherapy. A specific type of mAb known as an antibody-drug conjugate may also be used. 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 used with other treatment types and may also be used as palliative care to help relieve pain when cancer spreads to the bone. The most common form of radiation therapy used in lung cancer is external-beam radiation therapy (EBRT). Multiple forms of EBRT are options to direct radiation to the tumor site:
  • 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 lungs’ airways.

Photodynamic therapy kills cancer cells with drugs that become active when exposed to light. A drug that has not yet been exposed to light is injected 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, it is given directly 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 give you the chance to try a cutting-edge treatment before it is widely available and help others who have lung cancer.

Areas of research include improving existing treatments, such as surgery and radiation therapy, while reducing side effects; discovering new biomarkers that may be used to diagnose or treat lung cancer; finding improved methods to quit smoking; identifying better ways of reducing symptoms of cancer and its treatment; and improving a person’s quality of life.


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)
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)
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 pembrolizumab (Keytruda) 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 3/10/22

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.

The Benefits of Stopping Smoking

It is never too late to stop using tobacco products. Although you may not see the point after you receive a lung cancer diagnosis, there are multiple benefits to quitting. You may notice some immediately, and others will appear later. The most important benefit is that your treatments will be more effective when you no longer use tobacco. The cancer-fighting effects of chemotherapy and radiation therapy are reduced while a person continues to smoke.


Immediate benefits:
  • Reduces lung inflammation that can lead to cancer progression
  • Boosts the immune system so it can better fight disease and infections
  • Improves wound healing to speed recovery after surgery
  • Increases a person’s antioxidant capacity

Long-term benefits:

  • Improves the chances of survival after cancer treatment
  • Decreases the risk of secondary cancers and other conditions linked to tobacco use
  • Lowers blood pressure and decreases heart rate
  • May improve senses of smell and taste

Even if you tried quitting before, try again. You have shown a desire to stop, and you may just need the right tools this time. Nicotine is a very addictive chemical, and the thought of stopping may feel overwhelming. 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 quit using tobacco. Other resources are available, such as smoking cessation programs, local support groups, call lines, text-based help and online assistance. The following resources may also help:

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