Chemotherapy is the use of drugs to destroy cancer cells, usually by stopping the cancer cells’ ability to grow and divide. It has been shown to improve both the length and quality of life for people with lung cancer of all stages. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication.
Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. Common ways to give chemotherapy include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally). Most chemotherapy used for lung cancer is given by IV injection.
A chemotherapy regimen usually consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of different drugs at the same time. The type of lung cancer you have (adenocarcinoma or squamous cell carcinoma) will affect which drugs are used for chemotherapy. Newer chemotherapy regimens cause fewer side effects and are as effective as older treatments.
The side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite, diarrhea, and hair loss. Nausea and vomiting are often avoidable; learn more about preventing nausea and vomiting caused by cancer treatment. These side effects usually go away once treatment is finished.
Chemotherapy may also damage normal cells in the body, including blood cells, skin cells, and nerve cells. This may cause low blood counts, an increased risk of infection, hair loss, mouth sores, and/or numbness or tingling in the hands and feet. Your medical oncologist can often prescribe drugs to help relieve many of these side effects. Hormone injections are also used to prevent white and red blood cell counts from becoming too low.
Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells.
Recent studies show that not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in your tumor. For some lung cancers, abnormal proteins are found in unusually large amounts in the cancer cells. Running tests to find these proteins can help doctors better match each patient with the most effective treatment whenever possible. In addition, many research studies are taking place now to find out more about specific molecular targets and new treatments directed at them.
Most people with lung cancer receive more than one type of treatment from more than one specialist. This is called a multidisciplinary team approach. For example, chemotherapy can be given before or after surgery or before, during, or after radiation therapy. Patients should have a sense that their doctors have a coordinated plan of care and are working effectively with one another. If patients do not feel that the surgeon, radiation oncologist, and/or medical oncologist are communicating effectively with them or each other about the goals of treatment and the plan of care, patients should discuss this with their doctors or seek additional opinions before treatment.
Cancer and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate the cancer, an important part of cancer care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.
Palliative care can help a person at any stage of illness. People often receive treatment for the cancer and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.
Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, and other therapies. You may also receive palliative treatments similar to those meant to eliminate the cancer, such as chemotherapy, surgery, and radiation therapy. Talk with your doctor about the goals of each treatment in your treatment plan.
The following treatments may be given to help relieve the symptoms of lung cancer:
Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and supportive care options. And during and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem so it is addressed as quickly as possible.
Stage I and II. In general, stage I and stage II NSCLC are treated with surgery. Surgeons cure many patients with an operation. Before or after surgery, a patient may be referred to a medical oncologist. Some patients with large tumors or signs that the tumor has spread to the lymph nodes may benefit from chemotherapy before the surgery, called neoadjuvant chemotherapy or induction chemotherapy, or adjuvant chemotherapy to reduce the chance the cancer will return. Radiation therapy may be used to treat and cure a lung tumor when surgery is not recommended.
Stage III. Stage III NSCLC has spread to the point that surgery or radiation therapy alone is usually not enough to cure the disease for most people. Patients with stage III disease also have a high risk of the cancer returning, either in the same place or distantly, even after successful surgery or radiation therapy. For this reason, doctors generally do not recommend immediate surgery, and sometimes suggest chemotherapy before surgery.
After chemotherapy, patients with stage III NSCLC may still have surgery, especially if chemotherapy is effective in shrinking the cancer. However, some patients with stage III NSCLC do not receive surgery. Instead, they may be given a combination of chemotherapy and radiation therapy. Chemotherapy may be given either before or at the same time as the radiation therapy. This method has shown to improve the ability of radiation therapy to shrink the cancer and to lower the risk of the cancer returning.
Chemotherapy given at the same time as radiation therapy is more effective than chemotherapy given before radiation therapy, but causes more side effects. Patients who have received both chemotherapy and radiation therapy for stage III disease may still go on to have surgery. However, there is debate among doctors whether surgery is needed for patients when radiation therapy has worked well, and if radiation therapy is needed in patients whose cancer disappears after chemotherapy.
For most patients with stage III NSCLC, the tumor is unresectable, meaning it cannot be removed with surgery. This may be because the surgeon feels that an operation would be too risky, or that the tumor cannot be removed completely. For patients with unresectable NSCLC, with no signs of spread of cancer to distant sites or to the fluid around the lung, a combination of chemotherapy and radiation therapy can still be used to try to eliminate the cancer.
Stage IV NSCLC. Patients with stage IV NSCLC typically do not receive surgery or radiation therapy. Occasionally, doctors may recommend surgery for a brain or adrenal gland metastasis if that is the only place the cancer has spread. Radiation therapy can also be used to treat a metastasis located in only one area, such as the brain. However, patients with stage IV disease have a very high risk of the cancer spreading or growing in another location. Most patients at this stage of NSCLC receive only chemotherapy.
The goals of chemotherapy are to shrink the cancer, relieve discomfort caused by the cancer, prevent the cancer from spread further, and lengthen a patient’s life. Chemotherapy can rarely make metastatic lung cancer disappear. However, doctors know from experience that the cancer will usually return. Therefore, patients with stage IV disease are never considered “cured” of their cancer no matter how well chemotherapy works. Treatment often continues as long as it is controlling the cancer’s growth. Chemotherapy has been proven to improve both length and quality of life for patients with stage IV NSCLC. If the cancer worsens or causes too many severe side effects, the treatment may be stopped, and patients would continue to receive palliative care.
To help patients talk with their doctor about chemotherapy for stage IV NSCLC, ASCO has created several decision aids. These tools provide information on the risks and benefits of chemotherapy, help for thinking through the decision, and other issues for patients to consider. Use these decision aids to begin a discussion with your doctor: First-line chemotherapy, second-line chemotherapy, second-line or third-line chemotherapy with erlotinib, or third-line or fourth-line chemotherapy.
As with NSCLC, the treatment of small cell lung cancer depends on the stage. Small cell lung cancer spreads quickly, so chemotherapy is the primary treatment for all patients. You may hear your doctor refer to limited stage, which means there are no signs that the cancer has spread, or extensive stage, which means that the cancer that has spread, to describe your small cell lung cancer.
For patients with limited stage small cell lung cancer, chemotherapy plus radiation therapy to the chest is given twice a day. Radiation therapy is best when given during the first or second month of chemotherapy. Patients with extensive stage cancer receive chemotherapy for three to six months.
Surgery is rarely used for patients with small cell lung cancer and is only considered for patients with very early-stage disease, such as cancer in a small lung nodule. In those situations, chemotherapy, with or without radiation therapy, is given after surgery.
In patients whose cancer has shrunk after chemotherapy, radiation therapy to the head lessens the risk that the cancer will spread to the brain. This is called prophylactic cranial irradiation (PCI), and it has been shown to lengthen the lives of these patients.
Like patients with later-stage NSCLC, patients with small cell lung cancer of any stage face the risk that their cancer can return, even when its growth is controlled. All patients with small cell lung cancer should have regular follow-up care with their doctors, including x-rays, scans, and check-ups.
If cancer has spread to another location in the body, it is called metastatic cancer. Patients with this diagnosis are encouraged to talk with doctors who are experienced in treating this stage of cancer, because there can be different opinions about the best treatment plan. You may want to seek a second opinion before starting treatment so you are comfortable with the treatment plan chosen. This discussion may include clinical trials.
Chemotherapy is not as effective as radiation therapy or surgery to treat lung cancer that has spread to the brain. For this reason, lung cancer that has spread to the brain is treated with radiation therapy, surgery, or both. Most patients with brain metastases from lung cancer receive radiation therapy to the entire brain. This can cause side effects such as hair loss, fatigue, and redness of the scalp. With a small tumor, a type of radiation therapy called stereotactic radiosurgery can focus radiation only on the tumor in the brain and lessen the side effects.
Supportive care will also be important to help relieve symptoms and side effects. Radiation therapy or surgery may also be used to treat metastases that are causing pain or other symptoms. Bone metastases that weaken major bones can be treated with surgery, and the bones can be reinforced using metal implants.
For most patients, a diagnosis of metastatic cancer is very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.
A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called “no evidence of disease” or NED.
A remission can be temporary or permanent. This uncertainty leads to many survivors feeling worried or anxious that the cancer will come back. While many remissions are permanent, it’s important to talk with your doctor about the possibility of the cancer returning. Understanding the risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.
If the cancer does return after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence).
When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence, including whether the cancer’s stage has changed. After testing is done, you and your doctor will talk about your treatment options. Often the treatment plan will include the therapies described above such as surgery, chemotherapy, and radiation therapy, but they may be used in a different combination or given at a different pace. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer.
People with recurrent cancer often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope.
Recovery from cancer is not always possible. If treatment is not successful, the disease may be called advanced or terminal cancer.
This diagnosis is stressful, and this is difficult to discuss for many people. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Making sure a person is physically comfortable and free from pain is extremely important.
Patients who have advanced cancer and who are expected to live less than six months may want to consider a type of palliative care called hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to think about where you would be most comfortable: at home, in the hospital, or in a hospice environment. Nursing care and special equipment can make staying at home a workable alternative for many families.
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