Non-Small Cell Lung Cancer Treatment (PDQ®) 2/3 —Patient Version - National Cancer Institute

Non-Small Cell Lung Cancer Treatment (PDQ®)—Patient Version - National Cancer Institute

After lung cancer has been diagnosed, tests are done to find out if cancer cells have spread within the lungs or to other parts of the body.

The process used to find out if cancer has spread within the lungs or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. Some of the tests used to diagnose non-small cell lung cancer are also used to stage the disease. (See the General Information section.)

Other tests and procedures that may be used in the staging process include the following:

• MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body, such as the brain. This procedure is also called nuclear magnetic resonance imaging (NMRI).
• CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, such as the brain, abdomen, and lymph nodes, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
• PET scan (positron emission tomography scan): A procedure to find malignanttumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.

  ENLARGE

  PET (positron emission tomography) scan. The patient lies on a table that slides through the PET machine. The head rest and white strap help the patient lie still. A small amount of radioactive glucose (sugar) is injected into the patient's vein, and a scanner makes a picture of where the glucose is being used in the body. Cancer cells show up brighter in the picture because they take up more glucose than normal cells do.

• Bone scan : A procedure to check if there are rapidly dividing cells, such as cancer cells, in the bone. A very small amount of radioactive material is injected into a vein and travels through the bloodstream. The radioactive material collects in the bones with cancer and is detected by a scanner.
• Pulmonary function test (PFT): A test to see how well the lungs are working. It measures how much air the lungs can hold and how quickly air moves into and out of the lungs. It also measures how much oxygen is used and how much carbon dioxide is given off during breathing. This is also called lung function test.
• Bone marrow aspiration and biopsy : The removal of bone marrow, blood, and a small piece of bone by inserting a hollow needle into the hipbone or breastbone. A pathologist views the bone marrow, blood, and bone under a microscope to look for signs of cancer.

There are three ways that cancer spreads in the body.

Cancer can spread through tissue, the lymph system, and the blood:

• Tissue. The cancer spreads from where it began by growing into nearby areas.
• Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
• Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.

Cancer may spread from where it began to other parts of the body.

When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from where they began (the primary tumor) and travel through the lymph system or blood.

• Lymph system. The cancer gets into the lymph system, travels through the lymph vessels, and forms a tumor (metastatic tumor) in another part of the body.
• Blood. The cancer gets into the blood, travels through the blood vessels, and forms a tumor (metastatic tumor) in another part of the body.

The metastatic tumor is the same type of cancer as the primary tumor. For example, if non-small cell lung cancer spreads to the brain, the cancer cells in the brain are actually lung cancer cells. The disease is metastatic lung cancer, not brain cancer.

metastasis: how cancer spreads

Many cancer deaths are caused when cancer moves from the original tumor and spreads to other tissues and organs. This is called metastatic cancer. This animation shows how cancer cells travel from the place in the body where they first formed to other parts of the body.

The following stages are used for non-small cell lung cancer:

Occult (hidden) stage

In the occult (hidden) stage, cancer cannot be seen by imaging or bronchoscopy. Cancer cells are found in sputum or bronchial washings (a sample of cells taken from inside the airways that lead to the lungs). Cancer may have spread to other parts of the body.

Stage 0

In stage 0, abnormal cells are found in the lining of the airways. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 may be adenocarcinoma in situ (AIS) or squamous cell carcinoma in situ (SCIS).

Stage I

In stage I, cancer has formed. Stage I is divided into stages IA and IB.

• Stage IA:
  The tumor is in the lung only and is 3 centimeters or smaller. Cancer has not spread to the lymph nodes.
• Stage IB:
  The tumor is larger than 3 centimeters but not larger than 4 centimeters. Cancer has not spread to the lymph nodes.
  or
  The tumor is 4 centimeters or smaller and one or more of the following is found:
  • Cancer has spread to the main bronchus, but has not spread to the carina.
  • Cancer has spread to the innermost layer of the membrane that covers the lung.
  • Part of the lung or the whole lung has collapsed or has developed pneumonitis.
  Cancer has not spread to the lymph nodes.

Stage II

Stage II is divided into stages IIA and IIB.

• Stage IIA:
  The tumor is larger than 4 centimeters but not larger than 5 centimeters. Cancer has not spread to the lymph nodes and one or more of the following may be found:
  • Cancer has spread to the main bronchus, but has not spread to the carina.
  • Cancer has spread to the innermost layer of the membrane that covers the lung.
  • Part of the lung or the whole lung has collapsed or has developed pneumonitis.
• Stage IIB:
  The tumor is 5 centimeters or smaller and cancer has spread to lymph nodes on the same side of the chest as the primary tumor. The lymph nodes with cancer are in the lung or near the bronchus. Also, one or more of the following may be found:
  • Cancer has spread to the main bronchus, but has not spread to the carina.
  • Cancer has spread to the innermost layer of the membrane that covers the lung.
  • Part of the lung or the whole lung has collapsed or has developed pneumonitis.
  or
  Cancer has not spread to the lymph nodes and one or more of the following is found:
  • The tumor is larger than 5 centimeters but not larger than 7 centimeters.
  • There are one or more separate tumors in the same lobe of the lung as the primary tumor.
  • Cancer has spread to any of the following:
    • The membrane that lines the inside of the chest wall.
    • Chest wall.
    • The nerve that controls the diaphragm.
    • Outer layer of tissue of the sac around the heart.

Stage III

Stage III is divided into stages IIIA, IIIB, and IIIC.

• Stage IIIA: The tumor is 5 centimeters or smaller and cancer has spread to lymph nodes on the same side of the chest as the primary tumor. The lymph nodes with cancer are around the trachea or where the trachea divides into the bronchi. Also, one or more of the following may be found:
  • Cancer has spread to the main bronchus, but has not spread to the carina.
  • Cancer has spread to the innermost layer of the membrane that covers the lung.
  • Part of the lung or the whole lung has collapsed or has developed pneumonitis.
  or
  Cancer has spread to lymph nodes on the same side of the chest as the primary tumor. The lymph nodes with cancer are in the lung or near the bronchus. Also, one or more of the following is found:
  • The tumor is larger than 5 centimeters but not larger than 7 centimeters.
  • There are one or more separate tumors in the same lobe of the lung as the primary tumor.
  • Cancer has spread to any of the following:
    • The membrane that lines the inside of the chest wall.
    • Chest wall.
    • The nerve that controls the diaphragm.
    • Outer layer of tissue of the sac around the heart.
  or
  Cancer may have spread to lymph nodes on the same side of the chest as the primary tumor. The lymph nodes with cancer are in the lung or near the bronchus. Also, one or more of the following is found:
  • The tumor is larger than 7 centimeters.
  • There are one or more separate tumors in a different lobe of the lung with the primary tumor.
  • The tumor is any size and cancer has spread to any of the following:
    • Trachea.
    • Carina.
    • Esophagus.
    • Breastbone or backbone.
    • Diaphragm.
    • Heart.
    • Major blood vessels that lead to or from the heart.
    • Nerve that controls the larynx (voice box).
• Stage IIIB: The tumor is 5 centimeters or smaller and cancer has spread to lymph nodes above the collarbone on the same side of the chest as the primary tumor or to any lymph nodes on the opposite side of the chest as the primary tumor. Also, one or more of the following may be found:
  • Cancer has spread to the main bronchus, but has not spread to the carina.
  • Cancer has spread to the innermost layer of the membrane that covers the lung.
  • Part of the lung or the whole lung has collapsed or has developed pneumonitis.
  or
  The tumor may be any size and cancer has spread to lymph nodes on the same side of the chest as the primary tumor. The lymph nodes with cancer are around the tracheaor where the trachea divides into the bronchi. Also, one or more of the following is found:
  • There are one or more separate tumors in the same lobe or a different lobe of the lung with the primary tumor.
  • Cancer has spread to any of the following:
    • The membrane that lines the inside of the chest wall.
    • Chest wall.
    • The nerve that controls the diaphragm.
    • Outer layer of tissue of the sac around the heart.
    • Trachea.
    • Carina.
    • Esophagus.
    • Breastbone or backbone.
    • Diaphragm.
    • Heart.
    • Major blood vessels that lead to or from the heart.
    • Nerve that controls the larynx (voice box).
• Stage IIIC: The tumor may be any size and cancer has spread to lymph nodes above the collarbone on the same side of the chest as the primary tumor or to any lymph nodes on the opposite side of the chest as the primary tumor. Also, one or more of the following is found:
  • There are one or more separate tumors in the same lobe or a different lobe of the lung with the primary tumor.
  • Cancer has spread to any of the following:
    • The membrane that lines the inside of the chest wall.
    • Chest wall.
    • The nerve that controls the diaphragm.
    • Outer layer of tissue of the sac around the heart.
    • Trachea.
    • Carina.
    • Esophagus.
    • Breastbone or backbone.
    • Diaphragm.
    • Heart.
    • Major blood vessels that lead to or from the heart.
    • Nerve that controls the larynx (voice box).

Stage IV

Stage IV is divided into stages IVA and IVB.

• In stage IVA, the tumor may be any size and cancer may have spread to the lymph nodes. One or more of the following is found:
  • There are one or more tumors in the lung that does not have the primary tumor.
  • Cancer is found in fluid around the lungs or the heart.
  • Cancer has spread to one place in an organ not near the lung, such as the brain, liver, adrenal gland, kidney, bone, sac around the heart, or to a lymph node that is not near the lung.
• In stage IVB, cancer has spread to multiple places in one or more organs that are not near the lung.

Recurrent Non-Small Cell Lung Cancer

Recurrent non-small cell lung cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the brain, lung, or other parts of the body.

Treatment Option Overview

KEY POINTS

• There are different types of treatment for patients with non-small cell lung cancer.
• Ten types of standard treatment are used:
  • Surgery
  • Radiation therapy
  • Chemotherapy
  • Targeted therapy
  • Immunotherapy
  • Laser therapy
  • Photodynamic therapy (PDT)
  • Cryosurgery
  • Electrocautery
  • Watchful waiting
• New types of treatment are being tested in clinical trials.
  • Chemoprevention
  • Radiosensitizers
  • New combinations
• Treatment for non-small cell lung cancer may cause side effects.
• Patients may want to think about taking part in a clinical trial.
• Patients can enter clinical trials before, during, or after starting their cancer treatment.
• Follow-up tests may be needed.

There are different types of treatment for patients with non-small cell lung cancer.

Different types of treatments are available for patients with non-small cell lung cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Ten types of standard treatment are used:

Surgery

Four types of surgery are used to treat lung cancer:

• Wedge resection: Surgery to remove a tumor and some of the normal tissue around it. When a slightly larger amount of tissue is taken, it is called a segmental resection.

  ENLARGE

  Wedge resection of the lung. Part of the lung lobe containing the cancer and a small amount of healthy tissue around it is removed.

• Lobectomy: Surgery to remove a whole lobe (section) of the lung.

  ENLARGE

  Lobectomy. A lobe of the lung is removed.

• Pneumonectomy: Surgery to remove one whole lung.

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  Pneumonectomy. The whole lung is removed.

• Sleeve resection: Surgery to remove part of the bronchus.

After the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given chemotherapy or radiation therapy after surgery to kill any cancer cells that are left. Treatment given after the surgery, to lower the risk that the cancer will come back, is called adjuvant therapy.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy:

• External radiation therapy uses a machine outside the body to send radiation toward the cancer.
• Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer.

Stereotactic body radiation therapy is a type of external radiation therapy. Special equipment is used to place the patient in the same position for each radiation treatment. Once a day for several days, a radiation machine aims a larger than usual dose of radiation directly at the tumor. By having the patient in the same position for each treatment, there is less damage to nearby healthy tissue. This procedure is also called stereotactic external-beam radiation therapy and stereotaxic radiation therapy.

Stereotactic radiosurgery is a type of external radiation therapy used to treat lung cancer that has spread to the brain. A rigid head frame is attached to the skull to keep the head still during the radiation treatment. A machine aims a single large dose of radiation directly at the tumor in the brain. This procedure does not involve surgery. It is also called stereotaxic radiosurgery, radiosurgery, and radiation surgery.

For tumors in the airways, radiation is given directly to the tumor through an endoscope.

The way the radiation therapy is given depends on the type and stage of the cancer being treated. It also depends on where the cancer is found. External and internal radiation therapy are used to treat non-small cell lung cancer.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy).

The way the chemotherapy is given depends on the type and stage of the cancer being treated.

See Drugs Approved for Non-Small Cell Lung Cancer for more information.

Targeted therapy

Targeted therapy is a type of treatment that uses drugs or other substances to attack specific cancer cells. Targeted therapies usually cause less harm to normal cells than chemotherapy or radiation therapy do. Monoclonal antibodies and tyrosine kinase inhibitors are the two main types of targeted therapy being used to treat advanced, metastatic, or recurrent non-small cell lung cancer.

Monoclonal antibodies

Monoclonal antibody therapy is a cancer treatment that uses antibodies made in the laboratory from a single type of immune system cell. These antibodies can identify substances on cancer cells or normal substances in the blood or tissues that may help cancer cells grow. The antibodies attach to the substances and kill the cancer cells, block their growth, or keep them from spreading. Monoclonal antibodies are given by infusion. They may be used alone or to carry drugs, toxins, or radioactive material directly to cancer cells.

There are different types of monoclonal antibody therapy:

• Vascular endothelial growth factor (VEGF) inhibitor therapy: Cancer cells make a substance called VEGF, which causes new blood vessels to form (angiogenesis) and helps the cancer grow. VEGF inhibitors block VEGF and stop new blood vessels from forming. This may kill cancer cells because they need new blood vessels to grow. Bevacizumab and ramucirumab are VEGF inhibitors and angiogenesis inhibitors.
• Epidermal growth factor receptor (EGFR) inhibitor therapy: EGFRs are proteins found on the surface of certain cells, including cancer cells. Epidermal growth factor attaches to the EGFR on the surface of the cell and causes the cells to grow and divide. EGFR inhibitors block the receptor and stop the epidermal growth factor from attaching to the cancer cell. This stops the cancer cell from growing and dividing. Cetuximab and necitumumab are EGFR inhibitors.